Thursday, October 20, 2016

Hospitals in the Holy Land: Innovations at the Cross-Roads of Civilization

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 1th 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.

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.”

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. 

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."

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Friday, October 14, 2016

War by Other Means: Diplomacy of the Third Crusade – Part I: Testing the Limits

The German military philosopher, Carl von Clausewitz, famously described war as “the continuation of politics by other means” and as “an act of force to compel the enemy to do our will.” Diplomacy on the other hand is the attempt to obtain political objectives without the use of force. War and diplomacy, however, are intimately related because every military leader seeks to obtain his objectives (both military and political) with the minimum casualties. A diplomatic victory that delivers an important military objective bloodlessly ― whether it’s as small as a bridge or as big as a kingdom ― is always preferred over a bloody battle or all out war.

Thus, both methods of obtaining political objectives (war and diplomacy) are as old as history itself. The crusades ― despite often being characterized as acts of mindless barbarism ― were no exception. In addition to the battles familiar to most students of the crusades, there were frequent, complex and often highly successful diplomatic maneuvers as well. 

The Third Crusade was the first (but not the last) of the crusades that ended with a truce, and as such was concluded diplomatically rather than militarily. It is therefore an interesting case-study in diplomacy at the interface between Christendom and the Dar al-Islam. It is particularly interesting because the principle actors, Richard the Lionheart and Salah ad-Din, are more famous as men of war than men of peace. In two entries I wish to examine the diplomacy of the Third Crusade. Today’s entry looks at diplomacy in the first six months of the crusade; a period in which both sides were probing the other more than seeking agreement.

The political objectives of the Third Crusade were crystal clear: the restoration of Christian rule over the Holy Land. The later was defined roughly as the land in which Christ had lived and died, most especially the site of his execution, burial and resurrection: Jerusalem. All the crusaders that embarked upon the Third Crusade understood this as their goal ― and Saladin knew it. His political objective was quite simply to defend the status quo: Muslim control over the territory coveted by the crusaders.

The Christian forces making up the Third Crusade first encountered the forces of Salah ad-Din at Acre. The choice of venue was not strategic and had not been chosen by any of the commanders. Rather, it was imposed on both parties by Guy de Lusignan’s questionable decision to lay siege to Acre two years earlier (See Siege of Acre). (One can’t help but speculate what Richard the Lionheart’s choice venue for an assault would have been if the siege of Acre had not already been in place; I suspect Jaffa or Ascalon.)

After nearly two years of stalemate, the arrival of the fleets commissioned and commanded by the powerful European kings Philip II of France and Richard I of England immediately tipped the scales at the siege of Acre in favor of the crusaders. I say the fleets and not the armies because it was ultimately the airtight blockade of the city of Acre that forced the Egyptian garrison of Acre to seek terms. 

So the first diplomatic move in the Third Crusade was made by the Saracens (the garrison of Acre) seeking very generous terms of surrender. The newly arrived crusaders, still fresh and cocky, rejected the terms. Instead, they continued their assaults and finally forced the garrison, which was now quite desperate, to surrender on less favorable terms. The terms included the return of the relic captured at the Battle of Hattin and believed to be a piece of the cross on which Christ was crucified (True Cross), a large payment in gold (200,000 gold pieces) and the liberation of a large number of Christian captives, most probably a number equal to the number of hostages. Two-thousand five hundred hostages (by some accounts more, but a number equal to the captives to be released) from the garrison were surrendered to the crusaders as surety for the fulfillment of the terms of the treaty. In short, the first round of diplomatic maneuvering went to the Christians.

Salah ad-Din, however, had either not been involved in the negotiations at all, or only at the last moment, when the desperate garrison begged him to sanction the terms they had already obtained. He was almost certainly not pleased with the terms, which may well have placed him in an awkward position. Salah ad-Din’s problem was that he: 1) may not have had the True Cross in his possession (Islam considers reverence for objects idolatry and had little reason to keep the Christian relic intact), 2) may have been short of ready cash, and 3) would have needed to buy back the captive Christians from the men who had captured them or purchased them since. In short, Salah ad-Din may have had difficulty fulfilling the terms of the agreement. Equally or possibly even more important, Salah ad-Din had every reason to drag out the fulfillment of the agreement. The campaign season in the Holy Land lasts only through the summer and ends when the rains start in November or December. It was already July when Acre surrendered. The longer Salah ad-Din dragged out the negotiations, the less time the crusaders would have to make an assault somewhere else.

Salah ad-Din as portrayed by a artist in the West

Salah ad-Din chose to play for time, missing at least two deadlines for the delivery of the True Cross, the captives and the gold. This inaction on the part of Salah ad-Din now put Richard of England in the awkward position of having to respond. The campaign season was ticking away, his troops were getting fractious, the Saracens hostages were consuming food and required guards. Most important of all: Salah ad-Din appeared to be mocking and belittling him. Aside from the fact that Salah ad-Din appeared to have made a fool of him in the eyes of many of his own followers, Richard had to wonder what Salah ad-Din would think of him if he meekly accepted the excuses and delays. The military objective, the surrender of Acre to the crusaders, had already been achieved. What was now at stake were only secondary, not to say marginal objectives: money, the symbolic True Cross, and captives, who were not Richard's own men but natives of Outremer, men that Richard at this time may have more-or-less looked down on.

Since Salah ad-Din had not fulfilled the terms of the agreement, Richard was completely within his rights to execute the hostages according to the customs of war at this time. His decision to do so, however, had little to do with what was his “right,” and more to do with what impact he thought his action would have. The execution of the hostages was of negligible military value; 2,500 men were a drop in the bucket of what Salah ad-Din could conscript or recruit. The execution of the hostages served, rather, the diplomatic objective of increasing Salah ad-Din’s respect for Richard as a negotiating partner. The diplomatic message was: this English king is not to be trifled with. Whether we like it or not, Richard got his message across.

Significantly, it was Richard that made the next diplomatic move. Shortly after the crusading army had left Acre and before the battle of Arsuf, Richard sought a meeting with Salah ad-Din. His apparent objective at this time appears to have been no more than meeting him face-to-face so he could take the measure of him. Richard, remember, had up to now fought men he knew well ― his father, his brothers, his vassals, his would-be brother-in-law Philip of France. Salah ad-Din was known to him only from hear-say and it is understandable that he wanted to meet. 

Richard I's Tomb at Fontevrault

Salah ad-Din rebuffed him. He said kings only met after an agreement has been hammered out. (The same is true today: treaties are negotiated at the working-level, and only signed ― when ready ― at summits.) Richard lost this round.

After the Battle of Arsuf, Richard made a renewed attempt to open diplomatic channels and Salah ad-Din agreed to let his brother al-Adil meet with Richard. Richard opened the negotiations with a demand that Salah ad-Din turn over all territories that had ever belonged to the Kingdom of Jerusalem (i.e. even territory lost decades earlier) and, furthermore, do homage to the restored Christian King of Jerusalem for Egypt. The fact that al-Adil mildly characterized these demands as “excessive” but indicated willingness to continue talking is highly significant. 

At the same time that Saladin was negotiating with Richard, he was also negotiating with Conrad de Montferrat. Conrad’s initial proposal was that the Sultan recognize him as Count of Tyre and in addition restore Sidon and Beirut, with their surrounding territory, to him in exchange for Montferrat recognizing the Sultan’s right to everything south of Tyre (i.e. from Acre to Ascalon and including the heartland of the former Kingdom of Jerusalem ― Nazareth, Galilee and Jerusalem.) While on the surface this offer was a hundred times better than Richard's, Salah ad-Din called Conrad’s bluff by pointing out that he could not give away what he did not control. This diplomatic exchange is significant because it exposed Conrad the Montferrat’s greed and weakness. Thereafter, the Sultan knew that his only serious opponent was Richard the Lionheart and he focused his attention on driving Richard out of the Holy Land. 

But “driving him out” did not have to be by military means and so he pursed the diplomatic contacts established by Richard. What followed were a series of meetings, the exact number and date of which we can no longer reconstruct, between Richard and/or his representatives and al-Adil as Salah ad-Din’s ambassador. At one of these, al-Adil put forward the preposterous idea that he marry Richard's sister, Joanna Plantagenet, Dowager Queen of Sicily. (See A Curious Proposal) Both sides, however, treated the proposal as a joke. By the end of November it was clear that the negotiations with Richard were going nowhere and had yielded nothing concrete. The diplomatic back-and-forth broke down and was replaced by a renewed military offensive directed at Jerusalem.

Yet the diplomatic contacts established in 1191 were not unimportant. They laid the groundwork for successful negotiations the following year. If nothing else, they enabled Richard and al-Adil to establish a degree of trust and rapport that had been singularly lacking at the start of the summer, when Richard had felt he had to execute thousands of prisoners to demonstrate his resolve. While the exchange of gifts should not be exaggerated into “friendship,” they were nevertheless an indication of a degree of “normalization” of relations that kept the door to a diplomatic solution open.

Balian d’Ibelin was directly involved in much of the diplomatic maneuvering, serving in one instance as Conrad de Montferrat’s envoy. The diplomatic game is a major plot factor in “Envoy of Jerusalem.”

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