Friday, June 16, 2017

Hospital Care in the Crusader Era

In his final guest post, Fermin Person talks about hospitals in the crusader era.

A hospital in a modern sense is a place where ill or wounded people go to be treated for their illness. Persons from all social strata use hospitals equally. In the medieval world, this was different.

The medieval Latin word hospitalia or hospite meant a variety of things. It could mean an institution along the basic idea of a modern hospital but it also meant hospice, guest house or hostel. It also could be charitable institution caring for old or poor people. This is largely because it was mostly poor people who needed and made use of these institutions, while wealthier people were cared for and treated at home.

The word domus infirmorum or firmaria meant “house of the sick”, but did not imply the attendance of physician. Usually a monk or a servant cared for the inmates there, although a physician or surgeon could be called on from the outside.

In the crusader states, because so many pilgrims were far from home and unable to avail themselves of “the family doctor,” there were several institutions that cared for the sick and wounded and had, exceptionally, had physicians and surgeons caring for their patient. These were predominantly run by religious orders such as the Order of St John (Hospitalers), the Teutonic order (from about 1200 onward) and by the order of St Thomas of Canterbury from the start of the 13th century on. The orders of St Anthony and of St Lazarus also ran probably institutions for the specific chronic illnesses (Ergotism and Lepra) that were under their focus. The Templars, in contrast, appear to have run infirmaries only for their own members.

The biggest and best researched hospital in the crusading states is the hospital of St John in Jerusalem. According to estimates by Piers Mitchel and by B. Kedar the capacity of the hospital ranged from 400-900 beds under normal circumstances to as many as 2500 under extreme circumstances, for example after battles.

Under normal circumstances the hospital of St John in Jerusalem would house a mixture of exhausted pilgrims, sick, wounded or dying patients. On arrival, the guests had to confess, following that they were clothed by the hospital and fed, segregated by sex. Physicians, surgeon and bloodletters were employed by the hospital and paid a good salary to provide treatment to patients if necessary daily, while sergeants and sisters took care of non-medical needs of the patients.

Patients whose conditions made it dangerous, impossible or unsustainable to keep them with the other guests were separated from them. A classic example for this is diarrhoea or delirium because of a fever. 

Excursus: Medieval western urine-diagnostic
Before the development of modern laboratory medicine there were only few possibilities to diagnose illnesses. One of those was the urine-diagnostics.
It was an obligatory part of the medical treatment by a physician to inspect, smell and taste the urine of the patient.
The smell or taste of urine could indicate metabolic disease of a patient such as diabetes or liver failure.
Similarly, could the colour and the amount of the urine indicate several other diseases.

The guests / patients were given a diet that was seen to be healthy for them, but great emphasis was also placed on the spiritual cleaning of the patients. Prayers and mass were thus a fixed part of the treatment. Other than in big byzantine or Muslim hospitals the patients were not distributed at their admission per their conditions onto different wards, but members of the Order of St John had separate infirmaries in case of falling ill or getting wounded.

Little is known about the actual quality of the big hospitals in the crusade states, especially about the death rates etc. John of Würzburg (c 1170) reports that up to 50 dead per day were being carried out of the St Johns hospital in Jerusalem, he named 2000 inmates of the hospital. It is unclear if his numbers are exaggerated or if the hospital was at that moment particularly filled with patients. Similarly, without knowing the composition, the age and the general physical state of the inmates of the hospitals we can only guess about the quality of the medical caring.

Theoderich, a pilgrim that saw the hospital of St John in 1169 praised the equipment and the caring work of the hospital. Judging by the composition of the personal there was by the standards of time probably an adequate care for the sick and dying.

Field hospitals during the crusades

Little is known about field hospitals of the armies of the crusader states, however, there are various references to the wounded being carried to the army camp or the nearest city to be cared for. Examples of this is after the Battle of Antioch in 1119, the ambush of a Christian caravan on the 17 June 1192, and January 1192, when Richard I organised for the sick to be transported to Ramla. 

The first clear mention of something comparable to a field hospital is from the 1180s. According to the text of an anonymous cleric the Hospitallers set up a field hospital in the army’s camp, transporting wounded if needed back to Jerusalem. Similarly, German sailors from Bremen and Hamburg set up an improvised hospital during the siege of Acre in 1190, dismantling their ships to build it. During the same siege, English sailors also set up a field hospital dedicated to St Thomas Becket.

Thursday, June 8, 2017

The Battle on the Litani: June 1179

The Battle on the Litani has not received much attention in the history of the crusader states. It is often completely ignored or acknowledged with no more than a passing mention. While it is true that this battle was only one in a series of indecisive engagements between Salah ad-Din and the forces of the Kingdom of Jerusalem in the decade before the disaster at Hattin in July 1187, it was a sad precursor of things to come and is not entirely uninteresting.

The battle was allegedly provoked by Saracen “raiding,” of cattle and crops in the lordships of Beirut and Sidon. However, it seems highly unlikely that the King of Jerusalem would personally respond to mere raiding, particularly if it was conducted by Bedouins as some accounts suggest. Certainly, accounts of the engagement make clear that both Farukh Shah, a nephew of Salah ad-Din, and the Sultan himself were on hand with large cavalry, but notably no infantry, forces. This smells far more like a “reconnaissance in force” similar to the raid of 1187 that led to the disaster at the Springs of Cresson.

In any case, King Baldwin IV, now aged 18, responded by mustering a powerful cavalry force of his own. This included not only his most important baron, Raymond, Count of Tripoli, as well as Baldwin, Lord of Ramla and Mirabel, but also the Templars under their Grand Master, Odo de St. Amand. As W. B. Bartlett astutely points out in his Downfall of the Crusader Kingdom, this composition of forces underlines the fact that the Kingdom was not divided at this time; the Templars and Tripoli fought together without suspicion or recriminations.  

While the exact sequence of events is not clear, it appears that the King and his forces succeeded in surprising and routing the forces of Farukh Shah. They drove the bulk of his cavalry back across the Litani and may have temporarily taken Farukh Shah himself captive.  Meanwhile, however, the Templars had separately encountered the larger, main force under Sultan Salah ad-Din. William of Tyre, who was not in the Kingdom at the time and based his account on reports of others, blamed the Templars for attacking this larger force injudiciously.  While that is possible, it should also be remembered that Tyre was a consistent critic of the Templars and inclined to think poorly of them regardless, while other participants may have been only too ready to pin the blame on someone other than themselves.

What is clear is that the Templars broke and fled back toward the main feudal army around the King. At this point in time, however, the feudal army was already scattered across the valley floor “mopping up” after their successful action against Farukh Shah. They were in no position to form a cohesive force. Salah ad-Din’s cavalry, hot on the heels of the Templars, fell upon the dispersed Christian forces, killing and capturing large numbers of Christian knights and nobles, including Baldwin, Baron of Ramla and Mirabel, Hugh of Tiberius, and, according to Arab sources, some 270 knights and nobles altogether.

The King’s household, however, rallied around him and extricated him from the field with help and reinforcements from Reginald of Sidon. This was, of course, vital, as his capture would have had even more serious consequences than the other losses incurred. But his escape is notable for another reason as well: Baldwin was unhorsed during the — evidently heated — engagement, but his leprosy had by this stage advanced so far that he no longer had the use of his hand and arms and was unable to remount. The King had to be carried off the field on the back of a Frankish knight.

Just two months earlier, in another skirmish with Saracen cavalry, King Baldwin’s horse had bolted and, without the use of his hands, he had been unable to regain control. Now, because he was unable to remount, he had come within a hair’s breadth of capture. The eighteen-year-old king, who just two years earlier had led his chivalry to a stunning victory over Salah ad-Din at Montgisard, was now forced to face the fact that he could no longer command his armies from horseback. In a society in which the mounted warrior, the knight, was the incarnation of manly virtue and prowess, it must have broken Baldwin’s heart.  Not that he surrendered to his disability entirely: in the future he would lead his armies from a litter.

Meanwhile, the sorry outcome of this obscure engagement had two additional detrimental consequences for the Kingdom of Jerusalem.  First, among the captives was the Templar Grand Master, Odo St. Amand. Whether he was to blame for an unnecessary defeat, as William of Tyre suggests, or not, he had the courage and honor (as his successor Gerard de Rideford did not ) to  refuse ransom in accordance with the Templar Rule. He died miserably in a Saracen dungeon — thereby paving the way, indirectly, for the election of the disastrous and unscrupulous Gerard de Rideford.

Equally wide-reaching in its effect was the capture of Baldwin, Baron of Ramla and Mirabel. Baldwin (often referred to as Baldwin of Ibelin because he was the son of the First Baron of Ibelin and older brother of Balian of Ibelin, the founder of the Ibelin dynasty) was considered such a valuable prisoner that Salah ad-Din set his ransom higher than the ransom once asked for King Baldwin II of Jerusalem; in short, the Saracen Sultan demanded “a king’s ransom” for a baron whose feudal holdings were only two thirds of that of the upper tier of barons (Tripoli, Caesarea, Sidon, Galilee, Jaffa-Ascalon).  

This is not logical — unless the Sultan had some reason to believe that Ramla was destined to become a king. According to the chronicler Ernoul, who had close ties to the Ibelin family and so can be considered an “insider” — Princess Sibylla of Jerusalem had at this time promised to marry Ramla. Such a marriage would have made Ramla the effective heir to the throne, and Salah ad-Din would have had every reason to both demand the high ransom and hope that the cost of paying it would discredit Ramla to his future subjects. Curiously, the ransom was paid not by the treasury of Jerusalem but by the Byzantine Emperor instead, suggesting that the latter too had reason to expect Ramla would become King of Jerusalem. Both Salah ad-Din and Emperor Manuel I appear to have been misinformed. That, or — as Ernoul suggests — Princess Sibylla changed her mind after Ramla was captured.

In the latter case, Ramla’s capture can be seen as a contributing factor in Sibylla transferring her affections to the young, recently arrived French adventurer Guy de Lusignan. The consequences of her infatuation and life-long love for Lusignan are the subject of another entry.

The Battle on the Litani is described in detail in Book II of my three-part biographical novel of Balian d’Ibelin:

A divided kingdom,

                             a united enemy,

                                                       and the struggle for Jerusalem.

Thursday, June 1, 2017

The Knights of St. Lazarus

The most famous of the “fighting orders” or militant orders were of course the Knights Templar, and the Knights Hospitaller (Knights of St. John), two orders founded in the Holy Land and, for their age, truly international in character. Although not powerful and largely forgotten, there was a third military order also founded in the Holy Land, the Order of St. Lazarus.

The Order of St. Lazarus evolved from a leper hospital that had existed in Jerusalem prior to the First Crusade. After the Christian Kingdom of Jerusalem was established, it became part of the Hospitaller network of hospitals, but by 1142 the Order of St. Lazarus broke away, and by 1147 it was known as the Leper Brothers of Jerusalem. The Leper Pool and the foundations of the leper hospital run by the Knights of St. Lazarus have been located just beyond the norther wall of Jerusalem.

Critical to understanding the Knights of St. Lazarus is the fact that leprosy was far more common in the East than in Western Europe and the influence of Greek Orthodox ideology on the territories of the crusader states. By the end of the 10th century, the Byzantine clergy had come to see leprosy as a "holy disease" -- its victims were not seen as particularly vile sinner but rather as men and women marked by God's favor. A number of Greek Orthodox legends entailed Christ appearing as a leper. Caring for lepers was therefore seen as an act of great charity that would gain a person credit in heaven.

It is probably not surprising, therefore, that the Order of St. Lazarus grew rapidly in the mid-12th century, eventually having houses in Tiberias, Ascalon, Acre, Caesarea, Beirut, and possibly other cities as well. More surprising, however, is the fact that it began to have military brethren.  

It appears that initially, the role of these armed monks was primarily the defense of the leper hospitals. Some of these military men were undoubtedly former Templars and Hospitallers who had contracted leprosy, because we know that both the Templar and Hospitaller Rules required members with leprosy to join the Order of St. Lazarus. However, secular knights of the crusader kingdoms who contracted the desease were also expected to join the Knights of St. Lazarus. 

Knights already afflicted with disease would have been facing a steady deterioration of their fighting capabilities, however, and it appears that just as some healthy monks and nuns devoted themselves to the care of the sick in the habit of the Knights of St. Lazarus, some healthy fighting men likewise chose to join the Knights of St. Lazarus rather than the more powerful (and arrogant) military orders of the Templars and Hospitallers. This supposition is supported by the fact that there are recorded incidents of the Order of St. Lazarus taking part in military operations – possibly at the Battle of Hattin, and certainly at the Battle of Gaza in 1244, at Ramla in 1253, and during the defense of Acre in 1291.

Meanwhile, in 1265 Pope Clement IV issued a papal bull that commanded all the prelates of the church to assist in transferring the care of all lepers -- male and female -- to leprosariums run by the Knights of St. Lazarus. Pope Clement had taken a strong interest in the care of lepers before he became pope, and had written a set of regulations for leprosariums while still Bishop of Le Puy that included such remarkable features as the right of lepers to elect their own superiors from among their members. As pope, however, he seems to have been most concerned with ensuring that lepers remained segretrated from the rest of society by putting them under the control of the Knights of St. Lazarus. 

Thus after the fall of Acre, the Order of St. Lazarus moved its headquarters to Cyprus, abandoned all military activities, and thereafter concentrated on its mission of providing comfort and care for the victims of leprosy until the mid-14th century. Of all the so-called militant orders, arguably this was the "most Christian."

Find more about life in the crusader states in The Jerusalem Trilogy:

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Review: "The Holy Lance" by Andrew Latham

This is a book that (finally!) describes Templars as they really were: devout Catholic fighting men, rather than as fantasy creatures and costumed, modern myths.  Andrew Latham has with this comparatively short, action-packed book done the much-maligned Order of the Poor Knights of the Temple of Solomon in Jerusalem a worthy service by pulling them out of the realm of mystery and romance and putting back into a historical context and perspective.

The book does not attempt to paint a panorama of the Third Crusade much less the Holy Land at the end of the 12th century. Instead, it follows a single Templar troop (or banner, as Latham calls it) on a fictional but completely plausible mission to try to recover from deep inside enemy territory a controversial relic found during the First Crusade, the “Holy Lance,” i.e the lance that pierced Christ’s side before the crucifixion. 

Historically, this relic discovered by a priest in Antioch inspired the Christians of the First Crusade, who were besieged in Antioch and suffering intense privation at the time, to successfully sortie out against the numerically superior enemy. Within the first decade after the establishment of the crusader states, however, the Holy Lance had been discredited and replaced by the True Cross as the most holy relic of Christendom. At the time of this novel, July/August 1191, the True Cross had been captured by the Saracens at the disastrous Battle of Hattin, and the crusader states reduced to the cities of Tyre, Tripoli and Antioch. It is completely plausible, therefore, that Richard the Lionheart and other Christian leaders would remember the Holy Lance and want to secure possession of it. A relic, even a dubious relic, would have been kept in a monastery, and every part of former Kingdom of Jerusalem except the above named cities was under nominal Saracen control, the recovery of the relic would inherently have entailed crossing into enemy controlled territory.

Based on this plausible mission into enemy-held territory, Latham has built a great war-story similar in structure to “Saving Private Ryan” about a small band of men on a dangerous mission with a guide of uncertain trustworthiness and unexpected enemies in their own ranks. Latham keeps his story focused and moving, with completely realistic situations and challenges, never once falling into the temptation of fantasy, legend or romance. His characters are fighting men: some of them mercenaries, others former mercenaries. They can be violent and brutal, but they remain men (not monsters) and they are grounded firmly in the 12th century, with 12 century motives and beliefs.

Latham is a master of suspense, not so much in the overall plot as in his ability to tease out each new danger and make the reader really sweat it out with the protagonists. The way time gets stretched to unbearable infinity when one is in danger or approaching danger is brilliantly conveyed. The dialogue is also convincing and comfortable, with neither unnecessary anachronisms that shatter the sense of time and place nor with stilted, artificially old-fashioned speech. The use of Latin is excellent as an anchor to the period, but always translated so the reader is not left feeling like the author is talking down to him. The descriptions of equipment, landscapes, clothing etc. reflect the author’s meticulous research, and this is by far the best description of Templar daily routines I have ever seen in a work of fiction. I particularly liked the fact that Lathum has given the Turcopoles and Sergeants of the Knight’s Templar a significant role, reflective of their significance in historical Order but almost always ignored in works of fiction that feature the Templars.

My only quibble with the book is the exaggeratedly negative portrayal of Conrad de Montferrat. Although this has become commonplace and Lathum's plot needed an antagonist, Lathum's Montferrat is more a caricature villain than a nuanced historical figure.

Friday, May 26, 2017

The Conquest of Cyprus -- Continued

There is no historical evidence that Richard Lionheart planned to conquer the Byzantine island of Cyprus when he set out on the Third Crusade. On the contrary, every indication suggests that he was intent upon reaching the Holy Land as expeditiously as possible and re-capturing Jerusalem for Christendom.
Cypriot Landscape
 Had there been no storm, he would have proceeded, as his fellow-crusader Philip II of France had done, without interruption all the way to Tyre/Acre. Only chance scattered his fleet, wrecked some of his ships on the shores of Cyprus and left his fiancé and sister stranded there.  Yet even that would not have resulted in a conquest had the ruler of Cyprus, the self-styled Emperor Isaac Comnenus, acted hospitably to Richard’s ship-wrecked men and ladies. Instead, Isaac plundered the ships, imprisoned the survivors, threatened the royal women, and insulted Richard himself (see The Conquest of Cyprus I: Chance and Passion). Richard’s response was to teach the Byzantine tyrant a lesson, which he did by storming ashore, capturing Limassol and then scattering Isaac’s army in a dawn attack. It all would have ended there if only Isaac had been willing to come on crusade with Richard. Instead he fled to the interior.

Richard responded not with rage but with hard-headed rationality. It was at this point that he appears to have conceived the plan of taking -- and holding -- Cyprus for the crusaders. He rapidly developed and executed a well-crafted strategic plan that made effective use of his large crusader force and fleet. First, he divided his army into three parts. He sent some troops overland to pursue and if possible capture Isaac. He sent part of his fleet to the west, and took the bulk of the fleet eastward. Both parts of the fleet secured ports and castles along the coast as they advanced.

The latter continued to be easy and bloodless due to the unpopularity Isaac. Even before he left Limassol, Richard had been receiving homage from many of the local elite, most notably the Italian merchants. But it wasn’t only the foreigners that evidently welcomed Richard. Many of the Byzantine nobility also appeared to prefer Richard to Isaac — perhaps because they believed he would not stay long and they would soon have the island to themselves.

Another Cypriot Landscape

Meanwhile, at Famagusta Richard disembarked his troops and advanced toward the inland city of Nicosia. Expecting an ambush, Richard personally commanded the rear-guard of his army. Isaac obliged, attacked and the Greek despot's army was handily defeated yet again by Richard’s superior troops and leadership. Isaac himself, however, escaped as he had on all the previous occasions, and this time he fled to the one of the nearly impregnable mountain fortresses, either Kantara or Buffavento.

These castles, perched on the top of a steep, rocky mountain ridge so narrow that it was not possible to build courtyards or wide halls, could be held with very small garrisons. Attackers had to climb near vertical slopes to reach them, continuously under fire from the defenders — or starve the defenders out with a siege. While a siege was by far the more rational military solution, sieges take time, and that was what Richard of England did not have. Isaac Comnenus clearly expected Richard to give up, continue with his crusade, and leave him to re-take his island at leisure. 

Mountain Fortress of St. Hilarion
He might even have gotten away with it, if Richard’s fleet (the part that had sailed west and reached the norther shore of the island) had not in combination with the forces sent overland captured the coastal city and castle of Kyrenia. As chance would have it, Isaac’s only child, a girl, was in Kyrenia.

The girl has remained nameless throughout history, referred to only as the “Maid of Cyprus” or as her father’s daughter. Fortunately for the crusader cause, her father, despite all his other faults, loved her. He loved her so much that despite his comparatively secure position in an all-but-unassailable castle, he abjectly surrendered on June 1. Isaac set only one condition: that he not be put in irons. According to legend, Richard of England agreed, only to have fetters made for him of silver.

If Isaac’s hope had been that surrender would enable him to be reunited with his daughter, it was a short-lived reunion. Isaac was handed over to the Hospitallers, who kept him in a dungeon in Marqub (Syria) until 1193 or 1194. The year after his release he was allegedly poisoned for trying to incite the Sultan of Konya to attack the Byzantine Empire. He was dead by 1196. As for his daughter, she was turned over to the care of Richard’s bride and sister and sailed with them first to Palestine and later to Europe. She was used (just like Richard's sister Joanna) as a diplomatic pawn by Richard, and eventually married to an illegitimate son of the Count of Flanders. (During the Fourth Crusade the couple tried to lay claim to Cyprus, but were rapidly sent packing without anyone taking them seriously.)

Thus, in less than a month and with the loss of only two men (according to the contemporary sources), Richard the Lionheart had taken complete control of the rich and strategically important island of Cyprus. The port of Famagusta is only 118 miles from Tripoli, the closest of the crusader cities, and just 165 miles from Acre.  On a clear day, it is possible to see the coast of Lebanon from Cyprus. Furthermore, Cyprus was a fertile island capable of producing grain, sugar, olives, wine and citrus fruits in abundance.  Its location made it an ideal staging place for future crusades and a strong base for ships to interdict any Saracen fleets intent on preying on the coast of the Levant. Cyprus was thus both a bread-basket and a military base for the existing crusader states.

Ruins of a 13th Century Sugar Mill at Kolosi, Cyprus
Richard of England profited immensely from his conquest. In addition to the plunder he took on the battlefield (that included rich tents, gold plate and armor according to tradition) he had also captured Isaac Comnenus’ treasury. Furthermore, he extracted a tax from the lords and burghers of Cyprus to support his crusade. All this replenished his coffers and enabled him to pursue the war for Jerusalem with sufficient resources to pay the men and purchase the materiel he needed. 

Richard was not, however, interested in retaining control of the island indefinitely. It was too far from home (Aquitaine). Richard’s goal in capturing Cyprus was purely strategic, not dynastic. Rather than holding it for himself, he instead sold the island (thereby further strengthening his financial position) to the Knights Templar for 100,000 pieces of gold. What happened next will have to be the subject of a later entry.

The capture of Cyprus is a minor episode in the third book of the Jerusalem Trilogy:

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