Crusades to the Holy Land and elsewhere, as well as settlement in the East, exposed western Europeans to a number of health risks over and above those they faced at home. At the beginning of the crusade movement, the basis of the understanding of health and disease was still essentially that of the ancient Greeks: the body was believed to be made up of four “humors”: blood, yellow bile, black bile, and phlegm. These were linked to the four elements (air, fire, earth, and water) and the four seasons (spring, summer, autumn, and winter). There were also four qualities—hot, dry, cold, and wet—that related in opposing pairs to each of the humors, elements, and seasons. Thus summer (like fire and yellow bile) was hot and dry, while winter (like water and phlegm) was cold and wet. When a person was unwell, this was because the humors were out of balance. The patient was to be carefully observed and, taking the season and the weather into account, a treatment administered that would restore the proper balance, either by removing an excess humor, for example, by blood letting or giving an emetic, or by making up a deficiency, perhaps by prescribing foods and drinks with the required qualities (something hot and dry to counteract an excess of phlegm in winter, for instance), or by advising a change of lifestyle, such as more fresh air. Although its theoretical basis was flawed, this approach to medicine at its best encouraged careful observation of the patient and offered a range of holistic remedies that would have done little harm and possibly some good. In the wrong hands or when poorly understood, it could lead to harmful excesses, as in the common practice of routinely bleeding monks in the spring.
These beliefs about the body and health were already 1,500 years old by the time of the crusades. They had persisted through the period of the Roman Empire, usually applied by Greek physicians, and survived in the eastern Mediterranean area even after the collapse of Rome. Thus the Byzantines had a more or less unbroken tradition of medical care, and the Muslims adopted the ancient theories and preserved many of the old texts by translating them into Arabic. By the eleventh and twelfth centuries, translators in southern Italy and Spain were turning these same texts into Latin, along with original works in Arabic that elaborated the humoral system. One of these was the influential Liber pan- tegni of ‘Alī ibn al-‘Abbās al-Majūsī (called Haly Abbas by Westerners), which was partially translated at Salerno, but translated in its entirety by Stephen of Pisa in Antioch in 1127. These complexities mean that when Arabic influence is discerned in medicine in Outremer, it cannot be assumed to be a result of immediate cross-cultural relationships; the links may be via Salerno or even Cordoba.
There are no references in the sources to named doctors accompanying the earlier crusades, and only fleeting mentions of the activities of physicians and surgeons, for example, when Godfrey of Bouillon was wounded by a bear. Medicine at the time was only beginning to develop as a profession in western Europe, so it is likely that the leaders took physicians with them, but that these were not academically trained and that their status was similar to others who had learned their craft through apprenticeship, such as farriers. Even at the time of the Third Crusade (1189-1192), although there is evidence that the French and English kings were attended by physicians, it cannot be established with any certainty which, if any, went on crusade. Only in the thirteenth century are crusading physicians eminent enough to be recorded, and this reflects the increasing professionalization of medicine: most had the title Master (Lat. magister), which implies a university education. At one of the centers of learning, such as Paris or Montpellier (or later Oxford or Cambridge), they would have completed a degree in the seven liberal arts before being permitted to study the theory and practice of medicine. Their main textbooks were by the Greco-Roman Galen on anatomy and physiology, and the Arab Avicenna (Ibn Sīnā) on physics.
Meanwhile, from as early as 1102 there is evidence of Western physicians in Outremer, noted as witnesses to charters and even as owning property. Their activities are also recorded in Arabic sources, notably the memoirs of Usāma ibn Munqidh. Some Western commentators deplored the fashion among the settlers for using the services of Eastern Christian and Muslim physicians. When King Amalric of Jerusalem despaired of finding a cure for his leper son, the future Baldwin IV, he sent to Egypt for a physician, Abū Sulaymân Dâwûd, who was a Jerusalem-born Christian then in the service of the Fātimid caliph. Abû Sulaymân’s sons also served Amalric, but after the conquest of Jerusalem in 1187, they joined Saladin’s service. This facility of movement between cultures, also known in Spain and Sicily at the same period, identifies Outremer as an area potentially at the forefront of medical development at the time.
By the later twelfth century, salaried physicians were employed at the hospital of St. John in Jerusalem, and it is clear from the provision for physicians to take an oath by the saints or “to vow” that they were not necessarily Christian. The same sources reveal that there were general doctors, surgeons, and a physician who was to take care of the minority of sick patients: most inmates of the hospital were “infirm” rather than ill. It is probable that all of these individuals were licensed, but the earliest evidence for this dates from the 1240s. The bylaws written for Acre (mod. ‘Akko, Israel) at that date state that physicians, whether “from overseas or from pagan lands,” had to be tested by the best physicians in the land, in the presence of the bishop, before they were awarded licenses to practice [“Assises des Bourgeois de Jérusalem,” in Recueil des Historiens des Croisades: Lois, 2 vols. (Paris: Académie des Inscriptions et Belles-Lettres,1841-1843), 2: 169]. The licensing of physicians is another procedure that may show Muslim influence: the earliest known example in western Europe is from Sicily, about a century before the date of the Assises, but it was recorded in Persia as early as the ninth century.
Crusaders on campaign sustained a range of injuries in sieges, in ambushes, in battles and skirmishes, and also in accidents such as collapsing siege towers and, no doubt, falls. For the early period little is said in the sources about the treatment of such wounds, but indications are that after first aid, casualties were taken to the camp or into town for further care. While the leaders probably had the services of surgeons, it is likely that other ranks and noncombatants were assisted by empirics such as barbers and bonesetters, and by others who had no formal training or education. In any case, treatment was straightforward and limited to practical measures such as stanching blood flow and immobilizing fractures. For deep penetrating wounds, such as that sustained by King Baldwin I of Jerusalem in ambush in 1103, his physician recognized the necessity to drain the wound, and later Usāma recorded an ulcerous leg wound being successfully cured by the application of strong vinegar. By the 1180s the Order of St. John was responsible for dealing with battle casualties; it set up field hospitals that administered first aid and, presumably, a triage system, since after preliminary treatment casualties were taken to its hospital in Jerusalem.
Woodcut print in a medieval apothecary shop, fifteenth century. (Stapleton Collection/Corbis)
If the sources are to be believed, then many more crusaders succumbed to epidemic disease, particularly on the First Crusade (1096-1099). This was an inevitable result of siege conditions, when the blockaders lived for weeks or months in close quarters, in camps with poor sanitation. Malnutrition and polluted water supplies added to their miseries. Leaders were not immune from illness (both Tancred in 1099 and Louis IX of France in 1250 suffered from dysentery), but were more likely to survive because they were better fed and had the option (which Godfrey of Bouillon took in 1098) of escaping to more healthy surroundings. For the rest there was no effective prevention or treatment because there was no understanding of how diseases were spread. The first reaction was to blame the epidemic on the people’s sinfulness, and penance, prayer, and fasting were prescribed. Natural causes were also sought, and the unaccustomed heat and “corruption of the air” were proposed. It was widely thought in the Middle Ages that bad smells caused diseases, and, although the causative link was wrong, if the misunderstanding led to an effort to eliminate bad smells, then this may have done some good.
Once crusaders became settlers, they had to cope not only with the same range of illnesses and injuries, but also with leprosy, a disease that was endemic in Outremer and that they feared, perhaps disproportionately, partly because it was believed to be the result of licentiousness and partly because its later stages were disfiguring. Although treatments were available, including bathing in hot springs, ointments, and dietary modification, none was successful, and the usual resort was social exclusion (the exception to this was the young king Baldwin IV). For example, a knight who joined the Order of the Temple not knowing he was a leper would be permitted to leave and join the Order of St. Lazarus, while a knight who had deceived the authorities by concealing his symptoms was to be expelled. Others who contracted the disease were accommodated in leprosaria (leper houses) maintained by charity.
An insight into some aspects of civilian medicine is provided by the Assises des Bourgeois de Jérusalem, written in Acre in the 1240s. Two chapters deal with case law relating to suits for malpractice. The earlier contains information about the work of the surgeon, which includes skull fractures as well as broken arms and legs, and the treatment of abscesses and wounds. The surgeon was also expected to advise on diet, for he was absolved from responsibility if the patient disobeyed his instructions. The work of the physician is the subject of a second chapter; he treated internal complaints, such as fevers and chills, diarrhea, skin rashes, and dropsy. He was expected to balance the humors in the patient, and there are references to bloodletting and to strong purgatives. The penalties for failure were high: the price of a slave, or public humiliation if a freeman died; effectively, the physician was barred from practice. An interesting aspect of these chapters is that they were included in the section of the Assises dealing with commercial matters, and it appears that their enforcement was overseen by an official who regulated trade in Acre and whose antecedent was the Muslim market inspector. Although we cannot assume that the knowledge required of physicians and surgeons who treated Franks was the same as in Islamic lands, this method of enforcement suggests that their practice was probably regulated as a craft or trade in a similar way.