Thursday, August 15, 2019

Hospitals for the Holy Land

It is widely believed that Arab/Muslim medicine was far superior to Western/Christian medicine, yet when Saladin captured Jerusalem in 1187, he was so impressed with the Hospital of the Knights of St. John that he allowed it to remain open for another year. Indeed a visitor from the West shortly before the fall of Jerusalem described it as a "palace" with beautiful buildings, "rich in the means of refreshing the poor."(1)

I want to first consider why hospitals are considered one of the greatest innovations of Outremer.


At the time of the First Crusade, Western Europe did not know hospitals in the sense of places where acutely ill patients received professional medical treatment. There were, of course, infirmaries in monasteries and convents to treat the sick members of the community, but they were not established for the benefit of the general public. Furthermore, the infirmarer and his assistants were first and foremost a monks/nuns, not trained doctors/nurses. There were also almshouses for the infirm and aging, hospices for the dying, and various forms of charitable institutions to look after the chronically and incurably ill such as lepers, the blind, and the seriously disabled. In general, however, if the rich got sick, they sent for a physician to treat them in their homes; if the poor got sick they treated themselves or sought the services of a barber or other informally trained medical practitioner.
 
Another feature of 11th century Western medicine was that all care was centered around religious institutions, and even in those cases where wealthy secular benefactors had taken the initiative to found or endow a house for the poor/sick/ aged/blind/leprous etc, care was almost invariably provided by members of the clergy (secular or monastic).  In addition, an important component of the “treatment” was hearing Mass and saying prayers regularly. While men and women patients were separated by a partition or by being housed on separate floors, there was little to no attempt to separate patients based on type of illness at this time.



The Byzantine tradition was quite different. Although initially care of the sick had been provided at monasteries, already by the 7th century AD most hospitals were both financially independent and employed paid, professional staff rather than relying on members of a monastic institution providing care and treatment of patients. Most Byzantine hospitals were small to modest in size, ranging from ten to a hundred beds, although there were larger hospitals which boasted a large and highly specialized staff. In the most prestigious hospitals in Constantinople, for example, physicians and surgeons (some of these further specialized by the type of operations they predominantly performed such as hernias, appendices, eyes, etc.), pharmacists, attendants (nurses), instrument sharpeners, priests, cooks, and latrine cleaners are all listed on the payroll. The administration of these institutions was in the hands of the senior medical staff, and the patients were divided up into wards based on both sex and medical condition. Notably, there is documentary evidence of a small number of female doctors as well as female nurses for the women’s wards.

Equally important, the medical staff worked in the hospitals for very small salaries, but only for six months of a year; presumably, they earned the bulk of their income from private practice in the alternating months in which they did not work in the hospital. This suggests that Byzantine hospitals, although no longer run by the Church, were nevertheless viewed as charitable places accessible it the middle and poorer classes. Furthermore, most junior doctors earned no salary at all since they were considered apprentices in their craft (the equivalent of modern interns). In the larger hospitals, however, there were libraries and teaching staff, making these the equivalent of modern “teaching hospitals.”



In the Muslim world, in contrast, there is no evidence of hospitals until the end of the eighth century. Furthermore, the idea of an institution dedicated to healing sick appears to have been inspired by contact with the Eastern Roman Empire following the conquest of Syria and the Levant. It soon became a matter of prestige, however, for Muslim rulers to establish and endow hospitals so that by twelfth-century most major cities in the Middle East boasted at least one and often more hospitals. The staff of these hospitals was all paid medical professionals and they could be drawn from any faith so that the doctors could be Muslim, Christian or Jewish. Although nursing staff for the women’s wards was female, doctors were invariably male. The famous Adudi hospital in Baghdad (and presumably other hospitals) was also a training institution with library and a staff that wrote medical texts as well. 

The administration of most hospitals in the Muslim world, however, was in the hands of a bureaucrat appointed by the ruler; in short, even in the age of the crusades, these hospitals were “public” in the sense of being state-run. The salaries were small, and again the doctors worked only half time (in the Muslim world, half-days rather than alternating months) in the hospital in order to be free to earn “real” money with private patients. (This practice is still common in Egypt today, by the way.) Hospitals in the Muslim world were large, often having several thousand beds. Perhaps because of this, it was also usual to divide patients up based on the diagnosis, so that there were separate wards for the mentally ill, people with fevers, stomach ailments, eye or skin conditions, etc. Patients were also segregated by sex, of course.



Possibly due to the nomadic past of both Arab and Turkish Muslims, the Muslim world appears to have been very progressive with respect to the establishment of mobile hospitals. These traveled with the Sultan’s armies as early as 942. They also provided care to outlying, rural areas not serviced by the large central hospitals in the urban centers of the Middle East. 

With the establishment of the crusader states in the Levant following the First Crusade, pilgrims from across the Latin West started flooding into the Holy Land on pilgrimage. The journey, whether by land or sea, was arduous and fraught with dangers from pirates and highway robbers to unfamiliar foods, snakes, scorpions, and accidents. Many pilgrims arrived in the Holy Land with injuries and/or in poor health. Being far from home, these pilgrims had no families, guilds or other networks of support; they needed assistance. Their plight sparked the foundation of one of the most important religious orders of the Middle Ages: the Hospitallers. (See separate entry.) But not just the Hospitallers. Pilgrims were coming from across Europe and they spoke different languages; they needed care-takers who could understand them. In consequence, a number of early hospitals were established by monks speaking the same language as the pilgrims, but most of these were later absorbed into the Hospitaller’s network as it became increasingly wealthy and powerful. A few, like the German hospital established during the siege of Acre in Third Crusade, evolved into independent orders. The German hospital became the Teutonic Knights, and the establishments for lepers were taken over by the Knights of St. Lazarus, to mention just two examples. Notably, all hospitals in the crusader states were run by religious/military orders; there were no secular hospitals in the Byzantine and Muslim tradition.


Furthermore, it is fair to say that the medical landscape of Outremer was dominated by the Hospitallers or Knights of St. John, and it is from this Order that we have the most complete information about care for the sick in the Crusader period. The hospitals of the Knights of St. John retained many features of Western medical institutions but adopted others from Byzantine and Muslim examples.



For example, being a religious order, the Hospitaller retained the Western emphasis on prayer as a means to recovery. The wards were usually situated to enable patients to hear Mass being read in an adjacent chapel or church.  Furthermore, patients were required to confess their sins on admittance to the hospital because it was believed that sin (and God’s displeasure) could cause illness. That said, however, eye witness accounts report that Muslims and Jews were also treated in the hospitals; we can only presume that they were exempt from confession at admittance.

Breaking with Western tradition, however, the hospitals run by the Knights of St. John employed professionally trained doctors and surgeons at least by the second half of the 12th century. There is at least one case of Jewish doctor being employed and taking the oath required of all doctors on the “Jewish book” rather than the bible. In contrast to both Byzantium and the Muslim world, the doctors of the Order of St. John were well-paid and worked full-time in the hospitals. The attendants or care-givers, on the other hand, were brothers and sisters of the Order of St. John, i.e. monks and nuns and as such neither salaried nor professionally trained, although they would certainly have rapidly gained extensive on-the-job training. The male care-givers are listed as “sergeants” in the records of the Order. The Rule of the Order of St. John required the nursing staff (male and female) to serve the sick “with enthusiasm and devotion as if they were their Lords.”



Following the Muslim more than the Byzantine tradition, the Hospitallers maintained very large establishments in major cities such as Jerusalem, Nablus, and Acre. The Hospital in Jerusalem had more than 2,000 beds, for example, and was divided into eleven wards for men and an unknown number of wards for women. (Our source for this information is male patients reporting on the hospital, who did not have access to the women’s wards.) Patients appear to have been segregated not only by sex but by type of illness, although this may not have been possible at smaller institutions in more provincial towns. The larger hospitals, such as that in Jerusalem, Nablus, and Acre, are described as very well-appointed by eyewitnesses that stressed there was adequate room for beds and for personnel to move between patients and adequate windows for fresh air and light. Archaeological evidence testifies to the Hospital in Jerusalem’s proximity to a major aqueduct and no less than five large cisterns providing ready water and a network of drains made it possible to flush out refuse and human waste.

Diet formed an important part of the treatment in Hospitaller establishments, possibly because so many of the patients were pilgrims suffering more from malnutrition than disease. Food poisoning and various forms of dietary problems were likewise also common. Furthermore, medieval medicine was based on the premise that illness resulted from an imbalance between the “humors” (e.g. blood, bile). Certain foods, notably lentils, beans, and cheese, were completely prohibited in the hospitals of St. John, but white bread, meat, and wine were daily fare. Patients also benefited from the wide variety of fruits available in the Holy Land: pomegranates, figs, grapes, plums, pears, and apples are all mentioned. 


 

The Hospitallers were able to provide such extensive and professional care to large numbers of patients because of the enormous endowments left to them ― often from former patients. Grants were also made in kind, for example, obligating a town or distant estate to provide set quantities of, say, sugar cane (used in medicines), almonds, or linen sheets on an annual or more frequent basis.

1) Susan Edgington, "Oriental and Occidental Medince in the Crusader States,"  The Crusades and the Near East: Cultural Histories, ed. Conor Kostick (London: Routledge, 2011)206.

Principal source: Medicine in the Crusades: Warfare, Wounds and the Medieval Surgeon, by Piers D. Mitchell, Cambridge University Press, 2004.


Throughout my Award-winning "Jerusalem" trilogy and my newer books lifestyle in Outremer is depicted as realistically as possible.

                                                                                                                               Best Biography 2017

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Dr. Helena P. Schrader holds a PhD in History.

She is the Chief Editor of the Real Crusades History Blog.
She is an award-winning novelist and author of numerous books both fiction and non-fiction. Her three-part biography of Balian d'Ibelin won a total of 14 literary accolades. Her current series describes the civil war in Outremer between Emperor Frederick andthe barons led by John d'Ibelin the Lord of Beirut. Dr. Schrader is also working on a non-fiction book describing the crusader kingdoms. You can find out more at: http://crusaderkingdoms.com

Thursday, August 8, 2019

Medical Care in the Crusader States

It has long been thought that "Saracen" medicine was far superior to Western medicine, and film and fiction often contrast "barbaric" (not to say sadistic) Western/Christian ignorance to sophisticated and enlightened Saracen/Muslim practice. Yet recent scholarship has demonstrated that the differences between "Eastern" and "Western" medicine were far less significant than was assumed. A closer examination of the sources has also revealed that most "Eastern" physicians and practices praised by contemporaries were native Christians rather than Muslims. Perhaps most surprising of all: the standard of treatment was remarkably sophisticated and included highly complex procedures from hernia and cataract operations to (limited) brain surgery.  Below is a short comparison of Eastern and Western medicine followed by a summary of contemporary practices based Piers D. Mitchell’s seminal work Medicine in the Crusades: Warfare, Wounds and the Medieval Surgeon. Piers D. Mitchell is an osteoarchaeologist.


  
East meets West: Medicine in the Crusader States

Before turning to the state of medical knowledge in the crusader era, it is important to understand where it came from. On the one hand, "Saracens and Christians shared the same conceptual framework for medical science, which they inherited from the classical world." (1) On the other hand, both East and West had a body of practical knowledge for treating wounds particularly based not on theory but on experience, i.e. empirical knowledge. Whereas both Christian and Muslim physicians based their theories of medicine on classical Greek texts about the four "humors" of the body, their treatment of concrete cases of injury and illness varied based more on climate, availability of pharmaceuticals, and tradition.

It has frequently been noted by crusades historians, that the residents of Outremer were quick to turn to "Eastern" doctors, leading most commentators to assume a superiority on the part of "Muslim" doctors. There are several weaknesses to this approach. First, some of the presumed superiority was due simply to greater familiarity with both the diseases common in the Middle East and the ingredients (most derived from locally available products) available for treatment. 

More important, however, is the fact that many of these "Eastern" doctors were not Muslims at all, but rather native Christians. The fact that many native Christians of the Levant spoke Arabic by the time the Crusaders arrived and had adopted Arab-sounding names has misled students of the crusades to assume the physicians named and praised were also Muslims and their knowledge of medicine derived from Arab rather than Greco-Roman traditions. Yet, in fact, "when [contemporary] Western sources referred to 'oriental' or even 'Saracen' doctors, it usually meant only that they were natives of Outremer, and their language was Arabic. Most were probably Eastern Christians."(2)  For example, the famous and influential medical scholar Ibn Butlan was a Christian who spent most of his life in Byzantine Antioch. 


Negative views of crusader medicine have also been derived from Muslim sources. Yet, it is important to remember that the Islamic world in this period looked down on Christians as "backward" and "barbaric" based not on specific examples but rather on a fundamental world view of Islam  -- and so all aspects of Muslim society -- as inherently superior to all other religions. As the newer religion, it was understood "as being...a corrective to the misunderstandings that had crept into the religious practices of the earlier recipients of the religion of Abraham."(3)

Famously, Usama ibn Munqidh's memories highlight two examples in which European medical treatment resulted in the death of the patient. Yet these anecdotes do not prove that the procedures were standard, nor can we know if the patient died because of the treatment was inherently incorrect or incorrectly executed by the practitioner. Furthermore and often overlooked is the fact that Usama also notes two "effective cures the orientals learned from the occidentals: the use of wine to disinfect wounds, and an ointment for scrofula."(4) 

With that let me turn to a brief description of common medical procedures in the crusader states. 




Treating Trauma

Based on available records, it has been calculated that between 15 and 20 of knights on crusade died in battle or as a result of wounds obtained there; the proportion of foot soldiers lost due to military engagement was probably higher.  Nevertheless and surprisingly for modern readers, very many more survived their wounds due to competent medical treatment.

In the 12th and 13th centuries, the weapons employed produced first and foremost puncture wounds (from arrows, lances and swords), followed by cuts/amputations caused by swords and axes, fractures/crushed bones caused by maces and stones thrown from siege engines, and, last but not least burns from Greek fire, boiling pitch and water. The fundamental treatment for each of these kinds of wounds does not differ significantly from what is recommended today.

Medieval medical practitioners and soldiers, for example, understood the essential fact that a man can bleed to death. When treating puncture wounds, stopping hemorrhaging was, then as now, the primary concern. The difference between arteries and veins was likewise understood, and the need to stop arterial bleeding as rapidly as possible recognized. The use of the tourniquet and precise cauterizing were both known, and surgeons were expected to be able to close off arterial bleeding with their fingers long enough to apply a cautery.  Not only is the procedure for this carefully described in medical texts of the period, but there are also numerous recorded instances of men surviving this treatment and recovering so completely that they could fight again without impediment.

While amputations were likewise cauterized and cuts were bound, or if necessary, sewn back together, arrows presented additional problems. Although it would have been rare for an arrow to hit an artery, the arrow itself often remained in the wound and the need to remove it was paramount. But many arrows were designed to do more damage if pulled backwards (out the way they went in) by the addition of barbs or the shape of the arrowhead itself.  Medieval surgeons, therefore, had the option of pushing it through the injured man and out the other side or waiting for the wound to putrefy and the surrounding tissue to become soft enough to make it easier to remove.  Horrible as this sounds, the fact that many knights are described fighting with multiple arrows stuck into their armor suggests that it may have been comparatively rare for an arrow to become so deeply embedded that it was life-threatening ― without killing outright as in the case of arrows to the throat, eyes, armpits, etc.

In the case of broken bones, the need to set bones to ensure they mended straight and functional was likewise recognized. Bones were held in place by splints, bandaging or plaster ― or a combination thereof. In the case of burns, the primary concern was to prevent blisters from forming and the wound from completely drying. Moist cooling the wound was thus the recommended treatment, whether by means of placing the affected limb in a bowl of liquid, applying wet compresses soaked in herbs or the application of ointments.
 
Anesthetics

Surprisingly (at least for me), the use of anesthetics during operations or the treatment of wounds was common.  An anesthetic was given to the patient either in a drink (usually wine) or placed on a sponge that was then held to his/her nose. Mitchell notes that the various plants recommended for preparing anesthetics (e.g. henbane, hemlock, poppy, deadly nightshade, mandragora root and lettuce seed to name a few) have been demonstrated to have pain-killing and or sedative effects. He hypothesizes that “cocktails” combining several of the recommended ingredients could have been very potent ― and dangerous if the dose was miscalculated or the extracts improperly prepared. Patients in the crusader states were lucky to have ready access to one of the most effective narcotics known to man: opium. Mitchell writes that there is evidence of its use for medicinal (rather than recreational) purposes by the Franks in the crusader states.
Infection

While the fatal danger of infection was widely recognized and feared, the cause was not understood. As a result, some medieval medical practices contributed to infection. Once infection occurred, however, medieval doctors attempted to cure it. The successful use of vinegar, which has strong antiseptic properties, is recorded in treating festering wounds and severe burns, for example. Medieval doctors also understood the need to drain festering wounds.  Mitchell notes no significant differences between crusader treatment for infection that standard practice elsewhere.
 
Next week I will address the evolution of hospitals, something Edgington describes as the most impressive development in crusader medical care. (5)


1. Susan B. Edgington, "Oriental and Occidental Medicine in the Crusader States," in The Crusades and the Near East: Cultural Histories (London: Routledge, 2011), 189. 
2. Edgington, 197.
3. Niall Christie, Muslims and Crusaders: Christianity's Wars in the Middle East, 1095-1382, from the Islamic Sources (London: Routledge, 2014), 77.
4. Edgington, 201.
For the description of contemporary medical treatments, the principal source is Medicine in the Crusades: Warfare, Wounds and the Medieval Surgeon, by Piers D. Mitchell, Cambridge University Press, 2004.
5. Edgington, 208.

Throughout my award-winning, "Jerusalem" trilogy and my newer books lifestyle in Outremer is depicted as realistically as possible.

                                                                                                                               Best Biography 2017

 Buy now!                                       Buy now!                                               Buy now!


                                                                   
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Dr. Helena P. Schrader holds a PhD in History.

She is the Chief Editor of the Real Crusades History Blog.
She is an award-winning novelist and author of numerous books both fiction and non-fiction. Her three-part biography of Balian d'Ibelin won a total of 14 literary accolades. Her current series describes the civil war in Outremer between Emperor Frederick and the barons led by John d'Ibelin the Lord of Beirut. Dr. Schrader is also working on a non-fiction book describing the crusader kingdoms. You can find out more at: http://crusaderkingdoms.com

Thursday, August 1, 2019

Byzantinum and the Crusades Part IV: Humiliation and Reconcilation



It is easy to conceive of the crusades as a conflict between Latin Christian West and the Muslim Middle East, forgetting that between these two geographic/

religious groupings was the Orthodox Christian Byzantine Empire. Yet the latter both triggered the crusades and became a victim of them. Today I conclude my four-part series on the complex role played by Byzantium in the era of the crusades by looking at the Fourth Crusade and its aftermath.


 

Ironically, while the first three crusades had never been aimed at the capture of Constantinople, persistent Byzantine suspicious that Constantinople was the “real” target of Western armies became a self-fulfilling prophecy at the start of the 13th century. From the perspective of the West, the first hundred years of crusading history had been littered with examples of Byzantine betrayal -- from the failure of the Byzantine Empire to come to the aid of the crusaders at Antioch to Isaac II’s treaty with Saladin at the moment of Jerusalem’s fall. With the notable exception of Manuel I — who contemporary Western chroniclers universally praised — the “Greeks” were seen as treacherous and cowardly. This had led to repeated calls for the seizure of Constantinople starting with Bohemond of Taranto in 1107.  Throughout the 12th century, however, the voices calling for an attack on the "treacherous" and "heretical" "Greeks" had been firmly silenced by crusader leadership.



The start of the 13th century, however, saw a new constellation of factors. On the one hand, Jerusalem had been lost to the Sultan and a massive crusade to recapture it had ended in only partial success. This discouraged Western interest in a new crusade on the part of the land-owning, military class that needed to provide both the resources and the manpower for such an undertaking — although the tragic “Childrens’ Crusade” soon showed that popular sentiment still favored efforts to regain control of the Holy City. Meanwhile, in the Holy Land itself, the resources of Cyprus were beginning to bolster the local nobility and feed an economic recovery that laid the foundation for a partial recovery that would last a half-century. In short, at the start of the century, retrenchment was the order of the day. 

Yet, Venice had neither forgotten the injuries done it by the Byzantines nor recovered from the commercial losses that resulted from their expulsion from Constantinople. When some overly optimistic noblemen failed to raise either the troops or the funds they anticipated for a new crusade, Venice took advantage of the assembly of fighting men on its doorstep to launch that has gone down in history as the "Fourth Crusade."



I have described the course of the so-called Fourth Crusade elsewhere. (See: https://defendingcrusaderkingdoms.blogspot.com/2019/02/the-hijacked-crusade.html) What I wish to highlight here is that the Fourth Crusade did not, in fact, either destroy the Byzantine Empire (it first fractured, with several competing successors jostling for the title of heir, they reconquered Constantinople in 1261 and survived nearly two-hundred years) — nor Byzantine ties to the West. 

Chris Wright in his fascinating article “On the Margins of Christendom” even highlights the extent to which the fall of Constantinople to the crusaders in 1204 forced the Byzantines to face facts and recalibrate their policies in a more realistic manner. No longer were the great monarchs of Western Europe dismissed as “barbarians.” No longer were  Western culture and politics dismissed as irrelevant. The arrogance that placed Constantinople at the center of the world was shattered. While rightly feeling outraged and unjustly attacked, Byzantine elites for the first time recognized that the earlier crusades had indeed been genuine efforts to liberate the Holy Land, rather than cynical plots to destroy the Byzantine Empire.

Mystra - A Byzantine Outpost in the Frankish Peloponnese
Now, defeated by the mercenaries of Venice, the spokesmen for the fragmented Byzantine empire skillfully evoked crusader rhetoric to condemn both what had happened and the Pope’s continued self-serving calls for new crusades to defend Latin control of Constantinople. With the papacy increasingly declaring “crusades” for its own political aims — against heretics in the Languedoc, against the Hohenstaufens in Italy and Sicily, against the successors of the Byzantine Empire — the concept of crusading for Jerusalem became a Byzantine rather than a Latin theme, a rod with which to beat the Latins with their own hypocrisy. 

It was in no small measure the disgust of the lay population with the papal misuse of crusading rhetoric and privileges that led to a decline in crusading enthusiasm until St. Louis revived it through his own passionate commitment. Certainly, the repeated papal calls for “crusades” to defend Latin conquests in the former Byzantine Empire fell largely on deaf ears. By 1261 the embarrassment was over. Constantinople was back in Orthodox hands.



It was during the period of “exile” from Constantinople, however, that Byzantine intellectuals started to differentiate themselves from contemporary Rome (i.e. the Pope’s Rome) by focusing more on their Greek roots. For the first time, some of the Byzantine elites began to call themselves Greeks (Hellenes), rather than Romans -- although the majority of the population continued to identify themselves as Romans. 


Furthermore, far from destroying all trust and cooperation between the Byzantine Empire and the Western “barbarians,” the interlude of Western control of the Eastern Roman Empire forced the restored Byzantine Emperors to recognize their fellow monarchs in the West as equals rather than inferiors. Furthermore, as the Turkish threat grew, the Byzantines were forced again to seek Western aid and support, with only partial success. Yet it is one of the ironies of history that one of the most harmonious periods in West European-Byzantine relations was when cooperation between the two power centers was already too late.



Sources and recommended reading:

Angold, Michael, “The Fall of Jerusalem (1187) as Viewed from Constantinople,” in The Crusader World, ed. Adrian Boas (London: Routledge, 2016), 289-309.

Chrissis, Nicolaos, “Byzantine Crusaders: Holy War and Crusade Rhetoric in Byzantine Contacts with the West (1095-1341),” in The Crusader World, ed. Adrian Boas (London: Routledge, 2016), 259-277.

Papayianni, Aphrodite, "Memory and Ideology: The Image of the Crusades in Byzantine Historiography, Eleventh - Thirteenth Centuries," in The Crusader World, ed. Adrian Boas (London: Routledge, 2016), 278-288.

Wright, Chris, "On the Margins of Christendom: The Impact of the Crusades on Byzantium," in ed. Conor Kostick (London: Routledge, 2011), 55-82.


Balian d'Ibelin married a Byzantine princess and their sons retained an exceptional appreciation of Byzantium's role in the Eastern Mediterranean.


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Dr. Helena P. Schrader holds a PhD in History.
She is the Chief Editor of the Real Crusades History Blog.
She is an award-winning novelist and author of numerous books both fiction and non-fiction. Her three-part biography of Balian d'Ibelin won a total of 14 literary accolades. Her current series describes the civil war in Outremer between Emperor Frederick andthe barons led by John d'Ibelin the Lord of Beirut. Dr. Schrader is also working on a non-fiction book describing the crusader kingdoms. You can find out more at: http://crusaderkingdoms.com