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Tuesday, August 22, 2023

Life in the Crusader States: Medical Care

 For all their other significant contributions to social welfare, it was with respect to medical care that the Hospitallers made the greatest impact not just on the Holy Land but on all of Western Europe.

It is important to recall that prior to the First Crusade Western Europe did not have a network of hospitals where acutely ill patients received professional medical treatment. There were, of course, infirmaries in religious houses for the care of ailing members of the community, but they were not established for the benefit of, nor available to, the general public. Furthermore, the infirmarer (the person in charge of an infirmary in a medieval monastery) and his assistants were first and foremost monks and nuns, rather than trained doctors and nurses. There were also almshouses for the infirm and ageing, hospices for the dying, and various 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 were 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 eleventh-century Western medicine was the emphasis on spiritual healing through prayer. While men and women patients were separated, there was little to no attempt to separate patients based on the type of illness that afflicted them.

The Byzantine tradition was quite different. Already by the seventh century, most hospitals in the Eastern Roman Empire were financially independent. They employed paid, professional staff rather than relying on members of a monastic institution to provide care and treatment to patients. Most Byzantine hospitals were modest in size, ranging from ten to a hundred beds. Only the most prestigious hospitals in Constantinople were larger. These employed multiple physicians and surgeons (further specialised by the type of surgery performed), pharmacists, attendants (nurses), instrument sharpeners, priests, cooks and latrine cleaners. The administration of these institutions was in the hands of the senior medical staff, and the patients were housed in wards based on gender and medical condition. Notably, female doctors are recorded working in the women’s wards as well as female nurses.

Equally important, the medical staff of Byzantine hospitals were paid only low salaries, and served only for six months of a year; presumably, they earned the bulk of their income from private practice in the six months when they did not work in the hospital. This suggests that Byzantine hospitals, although no longer run by the Church, were nevertheless viewed as charitable institutions accessible to the poor. While most junior doctors earned no salary because they were considered apprentices in their craft, the larger hospitals contained libraries and teaching staff, making these comparable to modern teaching hospitals. 

In the Muslim world, the concept of an institution dedicated to healing the sick appears to have been adopted after contact with the Eastern Roman Empire, i.e., following the conquest of Syria and the Levant. It soon became a matter of prestige, however, for Muslim rulers to establish and endow hospitals. By the twelfth century, most major cities in the Middle East boasted at least one, if not more, hospitals. The staff of these hospitals was all paid medical professionals and could be drawn from any faith — Muslim, Christian or Jewish. Although nursing staff in the women’s wards were female, doctors were invariably male. The famous Adudi hospital in Baghdad (and presumably other hospitals) was also a training institution with a library and a staff that wrote medical texts. 

The administration of most hospitals in the Muslim world 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 of the time (half-days rather than alternating months), enabling them to earn ‘real’ money with private patients. Hospitals in the Dar al-Islam were large, often having several thousand beds. Patients were separated by sex and condition. Possibly due to the nomadic past of Arab and Turkish Muslims, the Muslim states were extremely progressive regarding the establishment of mobile hospitals. These traveled with the Sultan’s armies as early as 942. Mobile hospitals also provided care to outlying, rural areas. 

The hospitals of the Order of St. John drew on Byzantine and Muslim traditions while retaining some features of Western medical care. Unsurprisingly for a religious order, the Hospitallers maintained 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 expected to confess their sins on admittance to the hospital because it was believed that sin (and God’s displeasure) could cause illness. That said, since Muslims and Jews were treated in the hospitals, we must presume that confession was an option as opposed to a requirement. 

Breaking with Western tradition, the hospitals run by the Order of St. John employed professionally-trained doctors and surgeons by the second half of the twelfth century, at the latest. Jewish doctors were also employed, taking the oath required of doctors on the ‘Jewish book’ rather than the bible. In contrast to both Byzantine and Muslim practice, the doctors of the Order of St. John were well-paid and worked full-time in the hospitals. On the other hand, the attendants or caregivers were predominantly brothers and sisters of the Order of St. John, i.e., monks and nuns. As such, they had no formal medical training, although they presumably gained extensive on-the-job training. The male caregivers are listed as ‘sergeants’ in the order’s records, a comparatively high status. 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’.

Like the Muslims, the Order of St. John maintained exceptionally large hospitals 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. (All contemporary accounts were written by male patients, 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 those in Jerusalem, Nablus and Acre, are described as ‘palaces’ by eyewitnesses, who stress they were built to provide adequate room for patients and personnel to move between beds. Furthermore, they had large windows that let in fresh air and light. Archaeology has brought to light an aqueduct apparently leading to the flagship hospital of the Order in Jerusalem. In addition, no less than five large cisterns provided water, and a network of drains made it possible to flush out refuse and human waste. 

Diet formed an essential part of the treatment in Hospitaller establishments, possibly because so many patients were pilgrims suffering more from malnutrition than disease. Food poisoning and various forms of dietary problems were common in this period. Furthermore, medieval medicine was based on the premise that illness resulted from an imbalance between the ‘humours’ (e.g., blood and bile), and that proper diet could restore a healthy ‘balance’. Certain foods, notably lentils, beans and cheese, were prohibited in the hospitals of St. John, but white bread, meat and wine were daily fare. Patients also benefitted from the wide variety of fruits available in the Holy Land: pomegranates, figs, grapes, plums, pears and apples are all mentioned in Hospitaller records. 

Finally, in addition to following the Muslim example of mobile field hospitals, the Hospitallers created the first known ambulance service. The brothers of St. John combed the streets for those in need of care and carried them back to their hospitals. Likewise, during a military campaign, the Hospitallers scoured the battlefields for the injured and brought them to their hospital tents. Those who needed further care were transported to an urban hospital — even if the knights of the order had to surrender their warhorses to ensure transport. It is, therefore, particularly appropriate that one of the most active and successful successors of the Hospitallers is St. John’s Ambulance corps.

The bulk of this entry is an excerpt from Dr. Schrader's comprehensive study of the crusader states.

Dr. Helena P. Schrader is also the author of six books set in the Holy Land in the Era of the Crusades.


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