number of sick people lying there; but we saw that the beds numbered more than one thousand.105
John of Würzburg, writing at about the same time, put the number of patients at two thousand, and the daily mortality as high as fifty.106 Nevertheless, when Saladin captured Jerusalem in 1187, he was so impressed by the hospital that he allowed it to remain open for a year so that it could dispose its affairs in good order.
Records from the early 1180s give an insight into the running of the hospital.
These include an Old French translation of the Statutes entitled Des viandes as malades et des mieges et de lordenement qui a este uzei au palais des malades a Jerusalem ( Concerning food for the sick and doctors and the organisation of the palace of the sick in Jerusalem).107 There is also a description by a German pilgrim of his experience in the hospital in the 1170s.108 He not only noted down his observations, but questioned staff and patients. These two sources confirm the exceptional size of the hospital, though its maximum capacity may have been achieved only at the expense of the brothers’ own beds. There were eleven wards: ten were general and one was for the weakest patients. All had comfortable beds, sheepskin covers and dressing-gowns. Salaried staff comprised four ‘doctors’, a physician for the weakest patients, and three or four surgeons, plus blood-letters.
The hands-on nursing was done by serjeants of the Order of St John, though the regulations also stipulated that the knights should be prepared to take on menial tasks.
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In terms of treatment, the most important recourse was to ‘celestial medicine’, or the power of prayer. Patients were part of the daily liturgical life and there were also special processions. Second only to religion was dietary regulation (regimen).
Patients were prescribed strengthening foods to counteract the ‘cold, moist’
humours of old age and infirmity. Their diet included luxuries such as wine, sugar and almonds, as well as meat, vegetables and white bread. Much less is known about which medicines were administered, though electuaries, syrups and a sweet–sour tonic called oxymel are all recorded. (The hospital seems to have used at least two hundredweight of sugar a year.) Surgery was important after battles, and the German pilgrim claims the knights had first-aid stations on the battlefield, from which the wounded were brought back to the hospital. There was a separate hospital alongside for women, with wards for lying-in and for the care of foundlings. This was dedicated to St Mary Magdalene and the attendants were female.
The references in the sources to special facilities for the weakest patients and the low ratio of medical staff to patients suggest that the majority of inmates were not ill at all; they were pilgrims, perhaps aged and infirm, who needed nursing care. However, salaried medical staff were employed, further identified in the Statutes of the Hospitallers, 1182: ‘for the sick in the Hospital of Jerusalem there should be engaged four wise doctors, who are qualified to examine urine, and to diagnose different diseases, and are able to administer appropriate medicines’.109
In a decree of 1184/5 Pope Lucius III stipulated ‘that in the house of the hospital there should always be five doctors and three surgeons, at whose disposition should be administered those things which are necessary for the sick, both foodstuffs and other things’.110 The German pilgrim text further says that the doctors were learned in physic, salaried, employed exclusively in the hospital, and bound by oath. They were to know the nature of the sick and to use electuaries and other medicines, with which they were fully supplied. They visited the sick every morning and evening to check their urine and pulse, accompanied by two serjeants (‘ clientes’) from the ward concerned, one of whom carried syrups, a vinegar–honey mixture, electuaries and other medicines; the other held up the urine samples, discarded them when they had been seen and cleaned the urinals, and recorded the doctor’s dietary instructions or arranged for the blood-letter to attend. These blood-letters (‘ minutiores’) were also waged. On the advice of the doctors and the superintendent, they also used foods to treat patients.
The hospital of St John in Jerusalem was both less and more than a hospital in any modern sense. There has been debate about its antecedents, but contemporary institutions like the Pantokrator in Constantinople and the Nur ed-Din hospital in Damascus were institutions both on a vastly smaller scale and with a more specialised medical mission. Much of the work of the Jerusalem hospital was caring rather than curing, and in this context it is significant that Raymond du Puy’s Rule for the order, which dates from the middle of the twelfth century (before 1153), has been shown to draw on the Augustinian Praeceptum, a document with much emphasis on good food and comfortable conditions for the 207
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infirm, and reliance on the advice of doctors in these matters.111 Lucius III, confirming the Rule in 1184/5, certainly believed that the order followed St Augustine: ‘canonicis regularibus beati Augustini regula concessa est’.112 This means that the hospital looked for its organisation and ethos to a model popular in more northerly parts of Europe.113 Even in the 1180s it still functioned as a hostel/hospice as well as offering medical care according to the ideas of the time, with their emphasis on regimen. It was an institution which could have developed only in Jerusalem, where the influx of needy pilgrims coincided with the professionalisation of medical occupations, and the organisation of institutional care.
Writers on medical matters in Outremer have often started with preconceptions about the superiority of oriental medicine, with the implication that the occidentals had much to learn. It is uncontestable that Islamic writings on medicine were both more prolific and more sophisticated: translations into Latin were as yet few in Western Europe. However, the interchange of medical ideas was facilitated by the two peoples sharing the same classical heritage, and it is impossible to state categorically that it took place in Outremer rather than elsewhere. A study of the crusading armies suggests that they brought with them surgeons who were well up to the demands of battlefield surgery. There may also have been educated physicians with the armies, but their role was to keep the leaders healthy rather than to deal with such medical emergencies as epidemic disease. Once settled in Outremer, occidentals seem to have been prepared to consult oriental doctors – probably mostly Christians – and even to employ them in the hospital in Jerusalem and its successors. A system of licensing medics was developed which was probably influenced by Islamic models, but the most impressive development was the hospital of St John in Jerusalem, and this was a religious institution rather than a medical one.
Notes
1 I am grateful to Piers Mitchell for reading and commenting on a draft of this chapter.
For more detail on every aspect of this subject, see his Medicine in the Crusades: Warfare, Wounds and the Medieval Surgeon, Cambridge: Cambridge University Press, 2004.
2 The Old French Crusade Cycle: La Chanson de Jérusalem, Nigel Thorp (ed.), Tuscaloosa: University of Alabama Press, 1992, pp. 191–2:
Ains que Pieres eüst finee se raison
Li covint a pasmer en mi le pavellon.
Quant l’amirals le voit s’apela Lucion –
C’ert li plus sages mires c’onques veïst nus hom.
‘Or tost,’ dist li Soudans, ‘faites une puison.
Garisiés moi cest Franc sans grant demorison!’
Cil desfrema.I. cofre s’en trait marabiton –
C’est une saintime herbe de l’argut Simeon,
Qui jeta les .VII. sages del cartor en prison.
Pui que Pieres en ot trespassé le menton,
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Li sana sa grans plaie dont parut li pomon:
Plus fu sains enesleure qu’espreviers ne faucon.
My thanks to Carol Sweetenham for help with translation. (‘ Marabiton’ is usually used for Arabic gold coins ( maravedis). Here it is an exotic word chosen to
fit the metre, and perhaps because it echoes both the Arabic word and ‘ marathrum’, or fennel, a Mediterranean herb which had many pharmaceutical uses.)
3 S.B. Edgington, ‘Pagans and “others” in the Chanson de Jérusalem’, in Liz James and S.D. Lambert (eds), Languages of Love and Hate: Conflict: Communication and Identity in the Medieval Mediterranean, International Medieval Research 15, Turnhout: Brepols, forthcoming.
4 See, for example, Jacques Jouanna, Hippocrates: Medicine and Culture, M.B.
DeBevoise (tr.), Baltimore: Johns Hopkins University Press, 1998.
5 For the ‘non-naturals’, see Manfred Ullmann, Islamic Medicine, Edinburgh: Edinburgh University Press, 1978, pp. 97–103.
6 ‘A doctour of phisik’. For a modern translation, see Geoffrey Chaucer, The Canterbury Tales, Neville Coghill (tr.), Harmondsworth: Penguin, 1951, pp. 30–1.
7 See the essays in Peregrine Horden and Emilie Savage-Smith (eds), The Year 1000: Medical Practice at the End of the First Millennium, Social History of Medicine 13, 2000, pp. 197–321.
8 P.E. Pormann and Emilie Savage-Smith, Medieval Islamic Medicine, Edinburgh: Edinburgh University Press, 2007, pp. 24–35.
9 Pormann and Savage-Smith, Medieval Islamic Medicine, p. 164.
10 A.F. Woodings, ‘The medical resources and practice of the crusader states in Syria and Palestine 1096–1193’, Medical History 15, 1971, 268–77.
11 Woodings, ‘The medical resources’, 268.
12 The exception was the Assises (see n. 87 below), in Old French.
13 Mitchell, Medicine in the Crusades.
14 The eyewitness accounts are: GF; FC; RA; letters: Heinrich Hagenmeyer (ed.), Epistolae et chartae ad historiam primi belli sacri spectantes (reprint), Hildesheim: G. Olms, 1973 [1901].
15 RM 764.
16 AA 144–5; GN 285–6.
17 AA 144–5: ‘sanguis incessabili unda proflueret’.
18 AA 144–5: ‘medicos peritissimos ad sanandum ei’.
19 GN 286: ‘usque ad finem plane Antiochenae obsidionis egre prorsus nisi lecticia devehi potuit’.
20 WT 220.
21 Lambert: Regesta Regni, p. 2, no. 16; Geffroi: in Mitchell, Medicine in the Crusades, p. 17, citing Cartulaires du Bas-Poitou, Paul Marchegay (ed.), Vendée: L. Gasté, 1877, pp. xv, 7–8.
22 See Mitchell, Medicine in the Crusades, pp. 17–30, for a much fuller and more detailed list.
23 Mitchell, Medicine in the Crusades, pp. 21–3, citing Gilbertus Anglicus, Compendium Medicine, Michael de Capella (ed.), Lyon: In vico Mercuriali sub intersignio Angeli
[Impressum per Jacobu[m] Saccon[um] expensis Vincentij de Portonarijs], 1510, fol.
137a.
24 Mitchell, Medicine in the Crusades, p. 23, citing Matthew Paris, Historia Anglorum, Frederic Madden (ed.), Rolls Series 44, 3, London: Longman, 1866–9, II.37.
25 Mitchell, Medicine in the Crusades, p. 23, citing La Continuation de Guillaume de Tyr 1184–1197, M.R. Morgan (ed.), Paris: Librairie orientaliste P. Geuthner, 1982; P.W. Edbury (tr.), The Third Crusade: Sources in Translation, Aldershot: Ashgate, 1996, pp. 11–145, at 108–9.
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26 See Mitchell, Medicine in the Crusades, pp. 24–5, for details and sources.
27 See Mitchell, Medicine in the Crusades, pp. 26–7, for details and sources.
28 Mitchell, Medicine in the Crusades, p. 19. See also Régine Pernoud, La femme au temps des croisades, Paris: Stock, 1990, pp. 227–8.
29 Jean Joinville, The Life of St Louis, in M.R.B. Shaw (ed. and tr.), Chronicles of the Crusades, Harmondsworth: Penguin, 1963, pp. 262–3.
30 S.B. Edgington, ‘A female physician on the Fourth Crusade? Laurette de Saint-Valery’, in Norman Housley (ed.), Knighthoods of Christ: Essays on the History of the Crusades and the Knights Templar, Presented to Malcolm Barber, Aldershot: Ashgate, 2007, pp. 77–85.
31 AA 228–9: ‘clademque mortalitatis in populo [principes] considerantes, ex peccatorum multitudine hec fieri asserebant’.
32 AA 342–5.
33 AA 354–5: ‘in pestifero mense Augusto’.
34 AA 366–7: ‘ex loci infirmitate’.
35 Hippocratic Writings, G.E.R. Lloyd (ed.), John Chadwick and W.N. Mann (trs), Harmondsworth: Penguin, 1978, pp. 148–69.
36 RC 663.
37 WT 344: ‘aliis vero id pro causa assignantibus quod populus, longo tempore famis acerbitate vexatus, postquam alimentorum attigit opulentiam cibos cum aviditate sumens nimia, preteritos defectus querens redimere sibi ipsi causam mortis inmoderata gulositate inferebat’.
38 WT 344: ‘dicentibus aliis quod ex occultis quibusdam aeris passionibus hoc accideret’.
39 GN 134–5.
40 EA 160.
41 BD 80: ‘Sileamus ergo et quiescamus; et vulneratos et infirmos nostros reparemus; et interim pauperum nostrorum misereamur. Expectemus humida solstitia et declinemus Cancri et Leonis nocivos successus. Kalendris Novembribus, tempus refrigerabitur, et tunc congregati, unanimiter condictum iter aggrediamur. Alioquin totum populum intempestivis ardoribus affligeremus.’
42 Pormann and Savage-Smith, Medieval Islamic Medicine, p. 58.
43 Or ‘ arnaldia’: see Itinerarium peregrinorum et Gesta Regis Ricardi, in Chronicles and Memorials of the Reign of Richard I, William Stubbs (ed.), Rolls Series 38, 2, London: Longman, 1864–65, translated as The Chronicle of the Third Crusade: The Itinerarium Peregrinorum et Gesta Regis Ricardi, H.J. Nicholson (tr.), Aldershot: Ashgate, 2001, p. 204 and n. 14. See also D.S. Richards (tr.), The Rare and Excellent History of Saladin or al-Nawadir al-Sultaniyya wa’l-Mahasin al-Yusufiyya by Baha’ al-Din Ibn Shaddad, Aldershot: Ashgate, 2001, pp. 153–5.
44 Itinerarium peregrinorum et Gesta Regis Ricardi, p. 74: ‘non minor pars in brevi decessit, tum foetore cadaverum, aere corrupto, tum vigiliis sollicitis consumptis, aliis injuriis et penuriis afflicta’; Nicholson (tr.), The Chronicle of the Third Crusade, p. 83.
45 Nicholson (tr.), The Chronicle of the Third Crusade, pp. 126–34; see also pp. 278–9.
46 Itinerarium peregrinorum et Gesta Regis Ricardi, p. 440: ‘Item revera novimus et infirmitatis corruptione et famis inedia decessisse peregrinorum trecenta millia et amplius, et in obsidione Achonensi, et post in ipsa civitate’; Nicholson (tr.), The Chronicle of the Third Crusade, p. 380.
47 Richards (tr.), The Rare and Excellent History of Saladin, p. 105; Woodings, ‘The medical resources’, 272.
48 Nicholson (tr.), The Chronicle of the Third Crusade, p. 273 and n. 87.
49 Richards (tr.), The Rare and Excellent History of Saladin, pp. 159, 227–8.
50 Joinville, The Life of St Louis, Shaw (tr.), p. 168.
51 Jean de Joinville, Histoire de Saint Louis: texte original, Natalis de Wailly (ed.), Paris: Hachette, 1874, p. 160: ‘Et pour ce meschief, et pour l’enfermetei dou païs . . . nous 210
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vint la maladie de l’ost, qui estoit teix, que la chars de nos jambes sechoit toute, et li cuirs de nos jambes devenoit tavelés de noir et de terre, aussi comme une vieille heuse; et à nous qui aviens tel maldie, venoit chars ourrie es gencives; ne nulz ne eschapoit de celle maladie, que mourir ne l’en couvenist.’ Joinville, The Life of St Louis, Shaw (tr.), p. 237. Shaw identified the disease as scurvy.
52 Joinville, Histoire de Saint Louis, Wailly (ed.), p. 166: ‘il venoit tant de char morte es gencives à nostre gent, que il couvenoit que barbier ostassent la char morte, pour ce que il peussent la viande maschier et avaler aval’. Joinville, The Life of St Louis, Shaw (tr.), p. 239.
53 Joinville, Histoire de Saint Louis, Wailly (ed.) p. 168: ‘li roys, qui avoit la maladie de l’ost et menoison mout fort . . . Le soir, se pasma par plusours foiz; et pour la fort menuison que il avoit, li couvint coper le font de ses braies, toutes les foiz que il descendoit pour aler à chambre’. Joinville, The Life of St Louis, Shaw (tr.), p. 240.
54 Joinville, The Life of St Louis, Shaw (tr.), p. 26
8.
55 Paris, BN lat. 11015.
56 Pormann and Savage-Smith, Medieval Islamic Medicine, pp. 75, 115–43; Cristina Álvarez-Millán, ‘Practice versus theory: tenth-century case histories from the Islamic Middle East’, in Horden and Savage-Smith (eds), The Year 1000, pp. 293–306; Emilie Savage-Smith, ‘The practice of surgery in Islamic lands: myth and reality’, in Horden and Savage-Smith (eds), The Year 1000, pp. 307–21.
57 S.B. Edgington, ‘Medieval Antioch as an intellectual centre, and its influence on Western European medicine’, in Nil Sari et al. (eds), Proceedings of the 38th International Congress on the History of Medicine, Ankara: Türk Tarih Kurumu, 2005, pp. 481–7.
58 Joseph Schacht and Max Meyerhof, The Medico-Philosophical Controversy between Ibn Butlan of Baghdad and Ibn Ridwan of Cairo: A Contribution to the History of Greek Learning among the Arabs, Cairo: The Egyptian University, 1937, pp. 54–5, quoting Ibn al-Qifti, Tarikh al-Hukama.
59 Schacht and Meyerhof, The Medico-Philosophical Controversy; Medieval Islamic Medicine: Ibn Ridwan’s Treatise ‘On the Prevention of Bodily Ills in Egypt’, M.W. Dols (tr.), Berkeley: University of California Press, 1984; Lawrence Conrad, ‘Scholarship and social context: a medical case from the eleventh-century Near East’, in Don Bates (ed.), Knowledge and the Scholarly Medical Traditions, Cambridge: Cambridge University Press, 1995, pp. 84–100; Pormann and Savage-Smith, Medieval Islamic Medicine, pp. 92–3.
60 See Schacht and Meyerhof, The Medico-Philosophical Controversy, p. 65.
61 Translation of title from http://www.nlm.nih.gov/hmd/arabic/mon2.html accessed 2 February 2010.
62 Ibn Butlan, Le banquet des médecins: une maqa
¯ma médicale du XIe siècle, Joseph
Dagher and Gérard Troupeau (trs), Paris: Geuthner, 2007.
63 Le Taqwim al-Sihha (Tacuini Sanitatis) d’Ibn Butlan: un traité médical du XIe siècle, Hosam Elkhadem (ed.), Louvain: Peeters, 1990. See also Pormann and Savage-Smith, Medieval Islamic Medicine, p. 50.
64 M.W. Adamson, Medieval Dietetics: Food and Drink in Regimen Sanitatis Literature from 800 to 1400, Frankfurt am Main: P. Lang, 1995, p. 90.
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