Last month I noted that
the crusader states (collectively known as Outremer) had benefited from the
hygienic traditions of the civilizations that had preceded them in the Levant,
namely the Greeks, Romans, Byzantines, Arabs and Turks. Another area in which the crusader states
benefited from being at the cross-roads of civilizations was with respect to medical care. This was not as simple as having access to Arab medical knowledge, since
both Western and Arab medicine of this period was based on false premises. Rather, it was the
exposure to medical practices from the Eastern Roman Empire, India, Persia, Arabia,
Egypt and the West that gave medicine in the Levant a degree of sophistication
and flexibility unknown elsewhere at this time. Before looking at medical
practices, however, I want to first consider one of the greatest innovations of
Outremer: the hospital.
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 infirmerer and his assistants were first and foremost monks/nuns, not trained doctors/nurses. There were also alms houses 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 attempt to separate patients based
on type of illness at this time.
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| Fontfroid Monastery in Southern France |
The Byzantine tradition
was quite different. Although, as in the West, care of the sick had initially 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 to provide the 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 to the middle and
poorer classes. Furthermore, the 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.”
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| Source: Ahmed Ragab, Harvard Divinity School |
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 the 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 the twelfth century
most major cities in the Middle East boasted at least one and often more
hospitals. The staff of these hospitals were 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 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 or Knights of St. John.
(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 the Knights of St. John became
increasingly wealthy, powerful, and international.
A few, such as the establishments for lepers and the German hospital established during
the siege of Acre in Third Crusade, evolved into independent orders. The leper hospitals were taken over by the Knights of St. Lazarus and German
hospital became the Teutonic knights, 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, 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.
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| Hospitaller Complex, Acre |
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, 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) "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 were 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 eye
witnesses 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, while 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 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.
Principal source:
Medicine in the Crusades: Warfare, Wounds and the Medieval Surgeon, by Piers D.
Mitchell, Cambridge University Press, 2004.
Daily life in the crusader states is depicted as accurately as possible in my "Jerusalem Trilogy."
