This range of explanations for the major epidemics put forward by people writing very early in the crusading period is very similar to causes proposed by the eleventh-century Islamic physician Ibn Ridwan.42 It suggests that the writers, and probably the crusading leadership, did not lag behind in their scientific understanding of disease, even before they settled among the natives of Outremer. No matter how they described the reasons for epidemics, there was little practically that could be done to limit or counteract them. Pragmatically, the leaders survived the major epidemic at Antioch by leaving the scene and taking refuge in Edessa or the port of St Symeon: they were very aware of the limitations of medical knowledge and capability.
Neither knowledge nor capability had improved a great deal by the time of the Third Crusade. Malnutrition was certainly a problem – even King Richard suffered from ‘ leonardie’ during the siege of Acre.43 Mortality was very high among the common soldiers right from their arrival at Acre: ‘No small number of them died soon afterwards from the foul air, polluted with the stink of corpses, worn out by anxious nights spent on guard, and shattered by other hardships and needs.’44 An epidemic took even more of them during the siege; it was ascribed to the famine and the excessive rain.45 In all, said the author of the Itinerarium, ‘300,000
pilgrims and more died from infection and from hunger, both during the siege of Acre and afterwards within the city.’46 Although medieval numbers are not to be trusted, this, which is part of the author’s summing up of the crusade, reflects the scale of the loss. The Turks also blamed corruption of the air for promoting disease, and they tried to reduce the danger: ‘[Following the great Battle of Acre, 4 October 1189] the Sultan ordered the withdrawal of the baggage-train back to 194
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a place called al-Kharru
¯ba, fearing the smells from the corpses and the unhealthy
effects of the battlefield on the troops.’47
It is interesting that the sources make no mention of Richard receiving medical attention during his illness. We know that he was accompanied by a physician (see above), and there is a passing reference to his being bled, which Nicholson interprets as a general health measure rather than for any specific ailment.48
Possibly the physician’s prescription for the king is to be read in Richard’s constant requests to Saladin for fruit and snow, to which the sultan acceded.49 But overall, it is likely that the physician’s responsibility was conceived as advising on the maintenance of health. Illness was an act of God and recovery was in God’s hands, so medical intervention was necessarily limited.
In the same way, St Louis is known to have had medics in attendance, and early in his narrative Joinville reported a discussion with the king as to whether wine should be watered or not; Joinville claiming that his doctors ( sic) had told him he did not need to dilute his wine.50 Once on crusade more serious matters were in question. In Egypt the river became polluted by corpses; it was Lent, and the only fish available were from the same river:
On account of this evil circumstance, and because of the unhealthy
climate . . . a disease spread throughout the army, of such a sort that the flesh on our legs dried up, and the skin became covered with black spots and turned a brown earthy colour like an old boot. With those who had this disease the flesh on the gums became gangrened; and no one who
fell a victim to it could hope to recover, but was sure to die.51
Within a short time, ‘so many people suffered from mortification of the gums that the barber surgeons had to remove the gangrenous flesh before they could either chew their food or swallow it’.52 Joinville himself was ill, but the king was in a worse state, ‘suffering from the sickness that had attacked the army, and from very bad dysentery as well . . . That night he fainted several times, and because the dysentery from which he suffered continually obliged him to visit the privy, they had to cut away the lower part of his drawers’.53 When Joinville lay ill at Acre, suffering from a fever, he prayed to be delivered from his sickness, and the prayer was granted.54
Thus on three crusading expeditions, generations apart, the pattern of medical care seems to have been similar. The leaders were prepared for battle casualties and they took along numbers of surgeons and barber surgeons, who had the practical skills necessary to deal with wounds. The conditions on campaign, and particularly siege warfare, inevitably promoted diseases, both endemic and epidemic, and these were explained rationally according to Hippocratic theory.
But it was accepted that recovery from disease was out of human hands. The armies resorted to penance and prayer; avoidance and endurance. Many died. It is anachronistic to assume that physicians would take any responsibility for combating infectious disease on this scale: the few educated doctors were in the 195
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employ of the elite, and their primary role was to advise their lords on the maintenance of health. This was the heyday of the regimen sanitatis – rules for health, usually addressed to a king or noble. There is a good example from 1335, written by Guido da Vigevano for Philip VI of France and entitled The Treasury of the King of France for the Recovery of the Holy Land beyond the Sea, and for the Health of his Body and the Prolongation of his Life, and Also with a Safeguard against Poisons. It comprised nine folios of medical advice, subtitled Regimen sanitatis senis, or Rules of Health for an Old Man.55 The rules were to do with keeping the body’s humours in balance, conforming closely with accepted theories about human physiology and pathology. In brief, medical practice in the crusading armies of the twelfth and thirteenth centuries was empirical and probably as effective as it could be in the circumstances. There is little evidence as to how far practice was informed by theory, although surviving manuscript evidence confirms that Islamic writers were more advanced than western ones.
In Outremer – medical theory
Recent research in medieval Islamic medicine has stressed the distinction between medical theory and medical practice: because a procedure was described in medical literature, it should not be assumed it was carried out in practice.56 Many Islamic cities were centres of scholarship, and Antioch, which the first crusaders captured in 1098, was a flourishing intellectual centre with a tradition of medical writing and translation.57 A major Roman city, Antioch had been captured from the Byzantines by the Persians and then occupied by the Arabs, and it was not until CE 969 that it returned to Byzantine hands. By now the population was speaking Arabic, and it was during this Byzantine occupation that a major and influential medical theoretician lived in Antioch. Ibn Butlan’s career illustrates the cosmopolitan nature of the city: he was a Christian, born in Baghdad, who first visited Antioch in the 1040s, and his vivid description indicates why he chose to settle there towards the end of his life:
In the middle of the town is the citadel . . . a palatial building . . . and round the palace are halls in which are accommodated the judges of the
[Byzantine] government, and the teachers of grammar and language
. . . There is an innumerable amount of churches; they are all adorned with gold mosaic work, coloured glass and mosaic pavement. In the town is also a hospital in which the patients are under the personal care of the Patriarch. In the town are, moreover, agreeable and excellent baths . . .
In Antioch is a shaikh who is known as Abu Nasr ibn al-’Attar (‘the son of the druggist’). He is chief judge of the town, has some knowledge in sciences, and is of agreeable conversation and understanding.58
Ibn Butlan travelled widely and engaged in a notorious dispute with a rival physician, Ibn Ridwan of Egypt.59 This obliged him to leave Cairo, and after 196
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visiting Constantinople he returned to Antioch, where he became a monk and where he died (c.1066). According to his biographer, he was entrusted with the building of a hospital in the city, and for this institution he wrote a discourse on how Greek
rules of treatment had been modified by Arab physicians.60 For his monastic community, he wrote a compendium: On the Management of Diseases for the Most Part through Common Foodstuffs and Available Medicaments, Specifically for the Use of Monks of the Monasteries and Whoever is Far from the City.61 This has not yet been translated, although another relevant work has now appeared in print: Le banquet des médecins is structured as a symposium, where medics put forward competing medical theories.62 Ibn Butlan is better known for an earlier work, Taqwim al-sihhah, or Almanac of Health, which was translated into Latin in the later Middle Ages as Tacuinum sanitatis in medicina.63 He wrote in Arabic but acknowledged the influence of Hippocrates, Galen and other Greek physicians, as well as Arabic sources.64 His career illustrates the dynamism of Antiochene intellectual life, which survived at least the early period of Latin occupation. Note too that, because Ibn Butlan was a Christian, his works and those of others like him were potentially more acceptable to the Franks. When 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.
The early princes of Antioch were Normans from southern Italy: the captor Bohemond of Taranto, his nephew Tancred and their kinsman Roger of Salerno.
Their provenance (particularly Salerno) may also have contributed to Antioch’s continued importance as a translation centre. Antioch continued to attract travellers from near and far. Walter the Chancellor refers to ‘Latins, Greeks, Syrians, Armenians, strangers and pilgrims’ in the town during the earthquake of November 1114,65 and we know that one of these strangers was Adelard – author of the popular Quaestiones Naturales – who had been born in Bath (England), had spent time in Laon (northern France), and had journeyed to Syria via southern Italy, Sicily and Greece: he described being shaken by the quake as he crossed a bridge at Mamistra.66 Adelard’s modern biographer has made much of the possibility that he learned his Arabic in Antioch, since he spoke of Arab masters and also mentioned an old man of Tarsus who explained methods of dissection for the study of anatomy. He could equally well have learned the language in Sicily, but his choosing to travel thereafter to Antioch does suggest that he expected to find it a centre of scientific learning.67 Burnett has made a persuasive case for Adelard’s having brought manuscripts back from Antioch to Bath.68
Another translator working in Antioch at this time was Stephen of Pisa, who made the first complete translation into Latin of al-Majusi’s kitab al-malaki, which Stephen called Regalis dispositio. He also compiled a catalogue and glossary of Greek materia medica.69 Stephen’s activities show that important Arabic texts were available in Antioch. His translation of al-Majusi was made in 1127 and it is known to have been used by a physician in Hildesheim before 1140.70 It was to 197
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be immensely influential in western medicine.71 More than a century later, in the 1240s, Bar Ebroyo was living in Antioch. A prolific writer in Syriac and Arabic, among his works was a condensed version of the materia medica of Dioscorides and Ahmed al-Ghafiqi – evidence of his linguistic range.72 In short, the first generations of settlers were brought into contact with a flourishing tradition of Islamic medical theory in Outremer, but how far was this reflected in practice?
In Outremer – medical practice
As is the case for the army on the march, there are few contemporary records of medical treatment in the early years of Frankish settlement. The most detailed is an account by Guibert of Nogent of a wound sustained by Baldwin I (1100–18), probably in 1103:73
[Baldwin] sustained a very severe wound in battle. The doctor whom he had summoned made a diagnosis but he feared to cover the wound outside by applying poultices, knowing that the wound had reached the insides of the body quite deeply, and while the surface of the skin might heal
smoothly, on the inside a build-up of pus would be encouraged. So he proposed a wonderful expedient from his praiseworthy opinion and
experience. He asked the king that he might order one of the Saracens he was holding in custody (for it would be wicked to ask for a Christian) to be wounded in such a position and place as the king himself had been wounded, and then to order him to be killed, so that the doctor might investigate freely upon the dead body and examine certainly from looking at it what the king’s wound was like on its inside. The pious prince was utterly horrified at this . . . saying that he was not going to be the cause of anyone’s death whatsoever, even a person of the worst sort, for the sake of repairing his own health, when even that was in the balance. Then the doctor said: ‘If you draw a line at depriving anyone of life for the sake of repairing your own health, then at least order that the bear, which is useless enough except as a sideshow, be brought; command that it be killed with a weapon when it is upright with its front paws stretched out on high; and when I examine the dead beast’s internal organs afterwards, I shall be able to make a sound judgement one way or the other from how far it has
penetrated, how great also is your wound.’ The king said to him: ‘Since it is necessary, the beast is no problem; consider it done.’ Therefore, when the experiment had been carried out on the wild beast to please the doctor, he ascertained that, as we have hinted above, it would be troublesome to the king if a covering were applied too quickly to the wound without the pus being drained first and the torn part brought together.74
This is an intriguing episode: if it was indeed 1103 (and it must have been before 1109, when Guibert’s Dei Gesta was completed), then it is all but inconceivable 198
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that Baldwin had a relationship of trust with any doctor but a Frank, and this is supported by the doctor’s casual proposal that a Saracen prisoner-of-war be used in the experiment. The medic in question was fully aware of the danger of infection and the probable necessity to drain the wound – though, of course, his understanding of pus ( purulentia) was humoral.75 Assured by the autopsy on the bear that his fears were justified, the practitioner drained the wound and possibly sutured it. (Among unanswered questions is how the king survived the long wait for the outcome of the experiment.) Other historians described more briefly the near-fatal wounding in 1103. There is some disagreement as to the site of the wound, whether ‘through the thigh and kidneys’ (Albert); ‘in the back, near the heart’ (Fulcher); or ‘from behind through the ribs near the heart’ (William).76
However, all three agree that Baldwin was saved through ‘the skill and experience of very able doctors’ (Albert); ‘after an incision’ (Fulcher); by ‘the care of physicians . . . with their use of incisions and cautery’ (William).77 The substantial agreement between the three independent and contemporary writers – Albert, Fulcher (who was the king’s chaplain) and Guibert of Nogent – enables us to say with some certainty that the King of Jerusalem had at least one medical practitioner in his retinue very early in the settlement period. The context suggests he was a Western European, and the king’s survival that he was knowledgeable in theory and practice.
Unfortunately, this case study is a unique survival, and of course it tells us only what medical resources were available to the royal household, and nothing about the rest of the Latin population. It does, however, challenge received wisdom about the inferiority of western practical medicine early in the twelfth century.
Later, it appears that there was a fashion among the Frankish nobility for employing oriental doctors:
Desiring to take a physic before the approach of winter, as was his
custom, [King Baldwin III] obtained certain pills from Barac, the
physician of the count [of Tripoli], a part of which were to be taken at once and the rest after a short interval. For our Eastern princes, through the influence of their women, scorn the medicines and practice of our Latin physicians and believe only in the Jews, Samaritans, Syrians and Saracens. Most recklessly they put themselves under the care of such practitio
ners and trust their lives to people who are ignorant of the science of medicine.78
Some months later Baldwin III died.
Baldwin’s successor also consulted oriental doctors as a first resort, though he considered he knew more about medicine than they did:
On the way home [from the siege of Banyas, Amalric] complained to
those about him that he was feeling rather ill . . . He dismissed his forces and went on with his personal retinue to Tiberias, where he began to 199
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suffer from a severe attack of dysentery. Fearing . . . illness, he [went on]
to Jerusalem. There he continued to grow worse, and a violent fever
came on, although the dysentery yielded to the physician’s skill. After suffering intolerably from the fever for several days, he ordered physicians of the Greek, Syrian and other nations to be called and insisted that they give him some purgative remedy. As they would not consent to this, he had Latin physicians called and made the same request of them, adding that whatever the result might be he would take the responsibility upon himself. They administered medicines which [purged him several times and] seemed to give him some relief. But before he could take nourish-ment to strengthen his body which had been weakened by the violent
remedy, the usual fever returned, and he yielded to his fate.79
The unwitting testimony of these passages from William of Tyre is the coexistence of competing Latin and oriental doctors. William’s own prejudices are very clear, but it is also interesting that in both cases the king took a great interest in his own treatment: Baldwin III was accustomed to take a tonic before winter, and Amalric insisted that he needed a purgative. They are behaving according to their own understanding of the theory of the four humours. According to the (admittedly prejudiced) author of the Itinerarium, this attitude of the patient knowing best was taken to an unfortunate extreme by Conrad of Montferrat soon after his arrival at Tyre in 1189:
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