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The crusaders did not only perish in battles, but also fell victim to invisible foes – diseases and injuries. How did they attempt to combat epidemics, by enforcing honesty and preventing theft? Was Eastern medicine truly superior to Western medicine during that period, and should we regard the Crusades as a form for cultural exchange?
Let us begin by clarifying that we are discussing a specific interpretation of the term “Crusades”: the military campaigns undertaken between 1096 and 1272 in Palestine under the authority of the Catholic Church. Their official aim was to liberate the Holy Sepulchre and other Christian holy sites from non-believers, thereby enabling Christian pilgrims to visit without hindrance (although the list of political reasons is considerably longer). Consequently, it was imperative to conquer the territories where these sites were situated. Subsequently, the term “Crusades” was used to refer to other military-religious expeditions, such as those to the Baltic territories inhabited by pagans. However, it was the campaigns in the Holy Land that served as a template for subsequent military expeditions of this nature. By exploring the medical practices of the time of the Crusades, we can glean insights into medical knowledge in the Middle Ages, and into how people during that era perceived the world.
Sword and Fist: Wounds and Injuries according to Archaeology
The Holy War, like any other conflict, resulted in wounds. Scholars researching the injuries and trauma endured by the Crusaders frequently compare data from written sources and archaeology. Nonetheless, both sources should not be accepted without question. In the hot climate of the Middle East, human remains, which archaeologists and paleopathologists rely on to assess past injuries, do not preserve well. Sometimes, those who perished in battle were not interred immediately, further impacting the remains’ state. Additionally, few complete skeletons are found in the mass graves of that era. It is conceivable that the bodies of those killed in battle were dismembered before burial. Given these limitations, it is challenging to determine which injuries were most common in Palestine during that period, or at what age most individuals incurred injuries – there is insufficient archaeological material for such statistics.
The statistics on the number of individuals who returned from the campaign alive are somewhat less ambiguous.
After scrutinizing the rosters of those who participated in the First, Third, and Fifth Crusades, historians concluded that approximately 15-20% of knights and clergy died from disease and malnutrition, while another 15-20% of knights died from injuries. Unfortunately, simple soldiers were excluded from these lists. Their living conditions during the campaign were harsher, so they likely perished more frequently.
All forms of injuries and trauma that could be sustained in the battles of that time are visible on the remains of individuals who perished in combat in the Holy Land. Bones or their surroundings contain arrowheads, and sometimes small metal rings remain in such wounds – indicating that the arrow penetrated through the chainmail. Other injuries were undoubtedly inflicted by swords: such a blow could sever an opponent’s hand or pierce the skull. Only a few managed to survive such injuries. Nevertheless, there were also “peaceful” injuries in the Holy Land, as many remains bear evidence of injuries that could result from a fight or falling from a height. Such proof is frequently discovered during the excavation of urban cemeteries – likely, those interred there did not partake in the battles.
God’s wrath and miasma: epidemics against the Crusaders
Disease outbreaks caused just as much agony as wounds, claiming the lives of both Crusaders and their adversaries. The circumstances of campaign life fostered a fertile ground for the spread of epidemics, which posed a significant threat to Europeans owing to the unfamiliar climate. However, the most horrific outbreaks transpired during prolonged sieges. Thousands of individuals died during the epidemic that erupted after the Crusaders’ siege of Antioch (1097-1098).
Historians attribute typhoid fever to the soldiers who settled in the captured city. However, contemporaries of the campaign provided various explanations for this disaster. According to the traditional medieval view, the epidemic was a manifestation of God’s wrath caused by the sins of someone among the city’s inhabitants. To improve the moral character of their subordinates, the command strictly prohibited theft, fraud, cheating or deception in trade, and sex outside of marriage. Violators were stripped, beaten with whips, and forced to display their wounds to the whole city. Despite this, the disease returned and became even stronger.
Another explanation for the epidemic was the unfavorable local climate. Warriors suffered from unbearable heat, drank stale water, and breathed in “miasmas” from decomposing dead bodies. Some believed in “seeds of disease, invisibly carried in the air.” Hunger, which besiegers suffered from, was another cause. Priest Raoul de Caen suggested that the lack of familiar food forced the crusaders to eat unfamiliar plants, some of which were poisonous. Chronicler Guillaume de Tyr blamed the quantity of food, stating that warriors who had long suffered from hunger would gorge themselves at the first opportunity and perish from lack of self-restraint. Eastern doctors – both Muslims and Christians – also offered similar rational explanations.
Regardless of how the participants in the siege explained the outbreak of the disease, the result remained the same: they were likely unable to do anything about it. Attempting to get rid of the epidemic ahead of time would have gone against God’s will if it was sent by Him. If hunger was the cause, there was no guarantee that it wouldn’t return. And if the climate of the “unfavorable place” was the culprit, the only solution would be to abandon the captured city after the long siege – meaning to lose it.
A few people, including one of the leaders of the First Crusade, managed to escape. Albert of Aachen recounts that Godfrey of Bouillon left the city when he saw the epidemic gaining strength in Antioch. The chronicler does not assign blame to the commander, as he had a valid reason. Godfrey had already encountered a similar disease many years ago, in the mid-1080s in Rome, where he accompanied King Henry IV. At that time, during the “plague month of August,” several hundred of the strongest warriors died, and the king himself departed Rome. To avoid a similar fate, Godfrey left Antioch and went to the mountains – perhaps believing that the clean air would protect him from the disease. However, not all the leaders of the crusaders fled. According to Albert, many “princes” perished together with commoners.
The Black Teeth of the King: What Destroyed Louis the Saint
Illnesses sometimes do not spare even kings, and this was the case for Louis IX the Saint, the leader of the Seventh and Eighth Crusades. Chroniclers reported that he experienced several ailments during his journey. The king endured fevers and stomach disorders, which were so severe that he had to cut his pants from the bottom, according to his companion and biographer Jean de Joinville. However, Louis and his entourage were mainly affected by a disease that the chronicler referred to as “the army’s disease”.
De Joinville describes the army’s disease as follows: Throughout Lent, we had only bourbete to eat, a fish that feeds on the bodies of the dead since it is so voracious. Because of this calamity, which caused the bodies of the slain to float to the surface of the nearby river, and the inhospitable climate where rain never falls, the army’s disease struck us. This disease caused the muscles in our legs to dry up, the skin on our calves to turn black, like an old boot with earthy spots, and our teeth to begin to rot. No one could be cured of this disease, except through death. The sign of impending death was the flow of blood from the nose.” The sick received no assistance as nobody knew how to help them. The writer mentioned only one treatment method: “…the flesh on people’s swollen gums would die, and the barbers had to remove it to allow them to chew and swallow food.
The soldier’s disease was not necessarily a death sentence, contrary to popular belief. The chronicler himself survived the disease, although it was not easy for him. “Due to the wounds I received at the very beginning, the soldier’s disease also struck me. My gums and legs became inflamed, I developed a fever, and a strong runny nose flowed from my nose. Due to these ailments, in the middle of Lent, I had to lie down in bed.”
Scientists believe that the soldier’s disease was likely scurvy, which is caused by a severe deficiency of vitamin C, leading to disrupted collagen protein synthesis and a loss of tissue strength. Researchers who studied Louis’s preserved jaw confirmed this “diagnosis”. They believe that Louis’s unusual selectivity in food led to his illness. Although he was an extremely pious person who observed all dietary restrictions prescribed by the church, he did not trust unfamiliar food, which may have caused him to refuse local fruits that could have enriched his diet with vitamin C. Thus, killing a European in the Holy Land could be caused not only by gluttony, as chroniclers wrote, but also by abstinence.
“Surgeons” vs. “Doctors”: Physicians in the Holy Land
Everyone who undertook the Crusades knew that they were risking their lives and health. The Lord provided some hope, and to some extent, the physicians accompanying the army. However, how did they organize medical care during the Crusade?
The lists of those who went on expeditions to the Holy Land also contained information about physicians. A nobleman, including the king, or one of the orders, such as the Order of St. John (whose brothers are known as hospitallers), could hire a doctor. Italian city-states paid doctors to provide assistance to their citizens traveling abroad, and they could also employ doctors for the entire city.
It is worth delving deeper into the representation of medical professionals at all levels during campaigns.
During medieval times, physicians were informally categorized based on their objectives, status, and goals.
At the top of the hierarchy were the “physicians” who practiced therapy and possessed theoretical knowledge, understanding of “Hippocratic medicine.” These doctors not only provided assistance during sudden illness or injury but also had to consistently maintain the patient’s body in a healthy state. They regularly balanced the patient’s bodily fluids, which included blood, phlegm, yellow bile, and black bile, as per medieval beliefs. Physicians also monitored their patients’ breathing, movement, sleep, and diet. Ideally, their patients should not have gotten sick at all, as balance ensured good health. However, highly educated doctors faced practical challenges during military campaigns and had to solve them, sometimes successfully, sometimes not.
The second place in the hierarchy belonged to “apothecaries,” who prepared medicines either for themselves or on the orders of “physicians.” “Surgeons,” surprisingly, occupied the bottom of the hierarchy. They mainly performed various surgical interventions on the body, but also carried out other tasks like haircuts, shaves, and tooth extractions. They even removed the gingivitis-affected gum of Louis IX’s companions. Their profession was considered “dirty” and significantly different from the elegant art of balancing the body’s internal equilibrium. Hence, surgeons occupied a lower level in the hierarchy of medieval doctors. Interestingly, during the era of the first Crusades, they only resorted to surgery when other methods failed. The medieval fascination with bloodletting began much later.
Women who delivered babies occupied a similar position in the hierarchy as the surgeons and also accompanied the Crusaders to the south. However, a midwife’s status could vary depending on who she helped deliver. The documents of the Seventh Crusade mention Hersende, a female medic who accompanied King Louis IX the Saint to Egypt. Historians believe that Hersende was not the personal physician of His Majesty as it was unlikely for a woman to obtain the necessary education for such a position during that era. It is more likely that she served as a midwife to Queen Margaret of Provence. Regardless, Hersende returned to Paris and married an apothecary there after helping Margaret deliver her son, Jean Tristan. Hersende’s relatively high status was well paid for her services, and sources respectfully referred to her as magistre.
East vs. West: Whose doctors are better?
Historians in the 20th century believed that Western medicine lagged significantly behind Eastern medicine during the first Crusades, both in theory and practice. They believed that it was the encounter between European doctors and the knowledge preserved in the East that finally helped Western medieval medicine begin to develop.
Sources from both European and Eastern perspectives appear to support the idea of the low level of European doctors. The scene from “The Book of Admonition” by Usama ibn Munqidh, a diplomat, poet, and participant in several battles against the Crusaders, became famous. A Frank once turned to Usama’s uncle requesting a good doctor for two of his subjects – a knight with an abscess on his leg and a woman with a “debilitating fever”. The same doctors could work for both Christians and Muslims – it was normal for doctors to constantly cross religious and social boundaries. The writer’s uncle sent the Christian doctor Sabit to the Franks, who began with relatively gentle methods such as prescribing poultices for the man and a special diet for the woman to restore the balance of fluids in the body. The patients were already recovering, but then Sabit was replaced by a Frankish doctor who preferred much harsher therapy.
The knight’s leg was ordered to be chopped off with an ax, and a cross-shaped incision was made on the head of the female patient, with salt being rubbed into it to expel the demon that had entered her head. As a result, both unfortunate patients died almost immediately.
This situation reveals a conflict between different levels of the medical hierarchy, rather than between regional traditions. Sabit is clearly a “physician” who follows the concept of balancing the humors and avoids invasive procedures on the body. On the other hand, the Frank clearly prefers “surgery” and sincerely believes that such intervention will help. He explains to the knight that the leg should be amputated to prevent the disease from spreading to the entire body. It is important to note that both “physicians” and “surgeons” existed in both the West and the East, and this division has existed since ancient times.
Legal documents in the Crusader states were often cited to argue for the inferiority of Western doctors. For instance, Le Livre des assises de la cour des bourgeois was used in courts that dealt with cases of common inhabitants of the cities of the Kingdom of Jerusalem. It required any doctor who arrived in the Holy Land to obtain permission to practice medicine. His skills were then evaluated by a bishop and several local doctors, without specifying their origin. Some researchers believed that this pointed to the incompetence of Western doctors.
However, most contemporary scientists disagree with this view. Firstly, all arriving doctors, whether from the West or the East, had to be licensed. Secondly, this norm was not introduced by the Crusaders; such rules were already in place in local cities long before the Franks’ arrival.
Perhaps Europeans simply did not know how to choose the right specialists? In the case that Usama describes, this may be the case, but this was not always true. In fact, immediately after this episode in Usama’s book, there are examples of how Frankish medicine helped people.
The expertise of Western doctors in treating injuries was apparent. For instance, a knight who suffered from 14 wounds on his leg that would repeatedly heal and then reopen was successfully treated by a Frankish doctor. The doctor removed the bandages and washed the wounds with a solution of “strong vinegar”. The patient fully recovered and was described by Usama as “one of the most cursed and disgusting Franks.”
However, despite Usama’s negative perception of the Frankish knight, he acknowledges the success of the Frankish doctor who treated his injuries. Additionally, Usama shares a story of a Frankish man who shared an effective recipe for an ointment to treat skin diseases with a Muslim craftsman, under the condition that the craftsman would not charge others for the recipe.
There is some evidence to suggest that there was a trend among the Crusaders for seeking medical treatment from Eastern doctors. Guillaume de Tyr writes:
“our eastern princes, influenced by their women, neglect the medicines and work of our Latin doctors and trust only Jews, Samaritans, Syrians, and Saracens.” However, he also criticized this practice, calling it “extremely reckless” to entrust one’s life to doctors who may not be knowledgeable in the science of medicine”
Recent research by medical historians suggests that the preference for Eastern doctors among the crusaders may have been influenced by trends and fashions, rather than being solely indicative of the incompetence of Frankish doctors.
Medical theory: cultural exchange or cruel takeover?
However, the aforementioned examples only pertain to practical skills, whereas in terms of medical theory, the West was indeed lagging behind. This was largely attributed to the fact that the Eastern centers of knowledge, unlike most European cities, had a developed book tradition that preserved much of the knowledge of Antiquity, including medical knowledge, such as the theory of humors. These cities attracted educated individuals from all over the East.
The city of Antioch gradually became a point of interest for European intellectuals. The transfer of power in Antioch made it easier for Europeans to gain knowledge from the East. These educated Europeans wanted to personally explore the vast libraries and make copies of valuable manuscripts to translate into Latin.
One of these scholars was Benedictine monk Stephan of Pisa, who spent several years in Antioch working on the translation of Al-Majusi’s “Royal Book” (Al-Kitāb al-Malakī). Prior to Stephan’s translation, the medical treatise was only known in fragments in Europe. Stephan’s translation, called the “Royal Decree” (Regalis Dispositio), was copied and spread throughout Europe in multiple copies. Sometimes the text was copied entirely, while other times only fragments were used. The book quickly made its way to the north by medieval standards. Stephan translated it in the late 1120s, and by 1140, a physician from Hildesheim, Germany, was already utilizing its teachings.
Stephan of Pisa, a Benedictine monk, spent several years in Antioch translating Al-Majusi’s “Royal Book” (Al-Kitāb al-Malakī). Prior to Stephan’s work, this medical treatise was only partially known in Europe. Stephan’s translation, referred to as the “Royal Decree” (Regalis Dispositio), quickly spread throughout Europe in various forms, with some copies containing the complete text and others only fragments. The book made its way northward through Europe at a relatively rapid pace, given the time period. Stephan completed the translation in the late 1120s, and by 1140, a physician from Hildesheim, Germany, was already using it.
Another method of obtaining books for European libraries during this time was through the spoils of war taken by Crusaders. Albert of Aachen recounted how in one battle, the Europeans seized many books from an abandoned enemy camp that contained what he called “unholy charms of [Eastern] soothsayers and diviners.” In 1145, the Franks also captured the library of Usama ibn Munqidh, who not only wrote about medicine and described medical cases, but was also a practicing physician. His collection was estimated to be around four thousand volumes, which presumably contained valuable medical texts.
Given these events, it may be argued that the West was culturally enriched in the field of medical theory. However, it is important to acknowledge that such access to knowledge was obtained through violent means and at the expense of many human lives on both sides of the conflict.
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