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 7^th 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 12^th 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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The Knights of St. John of Jerusalem

Of the most famous "militant orders," the Knights Templar and the Knights Hospitaller, the latter proved both more enduring and more Christian. Today's entry is a tribute to them.

The roots of the Knights of St. John of Jerusalem go back before the First Crusade. In about 1070, a hospice for pilgrims was established near the Church of the Holy Sepulcher with funds from Italian merchants and staffed by Benedictine monks and nuns. Although the Benedictines were expelled from Jerusalem before the arrival of the first crusaders, they returned after Jerusalem was in Christian hands, and with help from the Christian secular authorities, re-established a hospital. Soon, further grants of money and land from the Christian lords enabled the monks to establish a chain of hospitals throughout the Holy Land and to set up hospices at the embarkation ports for pilgrims setting out from Europe or returning from Outremer. The monks and nuns running these hospitals and hospices soon became known as the “Hospitallers.”

In 1113, the monks of the Hospital (also referred to as the Brothers of St. John and the Brothers of the Holy Sepulcher) requested and received from the Pope the right to become an order in their own right. This new order, as with the Templars a decade later, was made directly subordinate to the Pope, and in or about 1130 it adopted the Augustine Rule. Meanwhile this new order was rapidly acquiring significant donations in land and treasure in both the West and in the Holy Land, a reflection of the undiminished support for a Christian-controlled Holy Land.

THe "Hospital" in Acre is still massive and impressive; the Hospital in Jerusalem was much larger.
Photo by H. Schrader 

Nevertheless, the Hospital of St. John remained a traditional monastic order. Although it had been granted the explicit right to defend its properties and pilgrims, members of the Order were prohibited from bearing arms. As a result, throughout the 12th century the Hospital was dependent for its protection on knights who owed feudal duty to the Hospital via their landholdings, voluntarily offered their services, or were hired mercenaries. These defensive forces, whatever their source, must have been substantial, however, because the Hospital was given very powerful fortresses, notably the most impressive crusader castle of them all: Krak des Chevaliers.

Krak de Chevaliers in Modern Day Syria. Photo by H Schrader

It would have been pointless to turn over such vitally important military resources to an order incapable of maintaining and defending them, but the exact status of the Hospital’s fighting men remains obscure until 1206, when the Hospitaller Rule was changed to allow for fighting monks. Thereafter, the Hospitallers began to recruit fighting men, probably starting with those who were already associated with it in some way, and like the Templars they had both knights (men of noble birth) and sergeants. Within a very short time, the knights dominated the Order. The Hospitallers, however, continued to have priests, monks, and nuns devoted solely to the care of the sick, and the network of hospitals was not abandoned. At about this time, the entire Order adopted black robes (reminiscent of their Benedictine origins) adorned with a white cross. One notable difference with the Templars, however, was that there was no distinction in dress between the knights and the sergeants of the Hospital.

The Hospitallers, like the Templars, warned new recruits that “… when you desire to eat, it will be necessary for you to fast, and when you would wish to fast, you will have to eat. And when you would desire to sleep, it will be necessary for you to keep watch, and when you would like to stand on watch, you will have to sleep. And you will be sent this side of the sea and beyond, into places which will not please you, and you will have to go there. It will be necessary for you, therefore, to abandon all your desires to fulfill those of another and to endure other hardships in the Order, more than I can describe to you.” (Barber, Malcolm, The Knight and Chivalry, p. 275) Like the Templars, the Hospitallers vowed poverty and chastity as well as obedience.

Austere Monastic Accommodation; in this case the Cistercian Monastery of Fontfroid

The similarity between the two powerful militant orders led to open rivalry between them for recruits, resources, and power in the first half of the 13th century. This led on occasion to open fighting between members of the orders on the streets of Acre and Tripoli, but more often to subtle maneuvering behind the scenes. For decades, the Hospitallers and Templars consistently backed rival claimants to the throne of Jerusalem and rival Italian trading communities. As the end of Christian Palestine neared, however, the Hospitallers and Templars put aside their differences and jealousies to rally to the now lost cause. In the last decades of Christian Palestine, Hospitallers and Templars fought side by side, ferociously and futilely, at Antioch, Tripoli, and finally Acre.

After the fall of Acre, the Hospital also relocated its headquarters to Cyprus, but conflict with the King of Cyprus convinced the leadership of the Hospital (evidently more flexible, imaginative, and analytical than the tragic Jacques de Molay) of the necessity for independence from secular authority. The Hospitallers undertook the capture of the island of Rhodes from Turkish forces in 1306, finally seizing the capital city in 1309. With this move the Hospitallers removed themselves, and the bulk of their movable treasure, from the grasp of Philip IV – or any king inclined to follow his example. Even more important, however, from this island base the Hospitallers built up a powerful fleet capable of challenging the naval power of the Turks and of launching hit-and-run raids into Saracen territory. The Hospitallers had “reinvented” themselves and had found a new justification for their existence.

Hospitaller Castle at Kolossi, Cyprus. Photo by HSchrader

The Hospitaller fleet remained a significant force protecting Christian shipping and commerce throughout the next two and a half centuries, and the base of this fleet on Rhodes, so close to the Turkish coast, was a constant provocation to Saracen, particularly Turkish, rulers. Numerous attempts were made to capture Rhodes, notably in 1440, 1444, 1480, and 1522. During the first 3 sieges, the Hospitallers withstood vastly superior numbers, in one case (1444) driving off the enemy with a daring sortie from within the city, and twice rescued by the timely arrival of a relieving fleet from the West. In 1522, an army allegedly 100,000 strong attacked a force of just 600 knights and 4,500 local auxiliaries. After 2 months of bombardment a breach in the landward wall was made, yet 3 assaults through the breach, carried out with complete disregard for casualties, failed. Sultan Suleiman called off the costly assaults and settled down for a long siege, cutting Rhodes off from all relief. Recognizing the hopelessness of their situation, the surviving Hospitallers, now more commonly called Knights of St. John, surrendered on honorable terms.

When the Hospitallers withdrew on their ships from Rhodes, they were effectively homeless, but Emperor Charles V offered them the island of Malta as their new headquarters. From here they continued to operate their fleet so effectively that Sultan Suleiman decided he had to dislodge them from their new home. In 1565 he again assembled a large siege force. The Knights of St. John had 500 knights of the Order and 10,000 other troops. The Turks launched their first attack in May and after a month of fighting captured an outlying fort, slaughtered the garrison, and floated their mutilated bodies across the harbor to the main fortress as a warning of what was to come. The Hospitallers replied by executing Turkish prisoners and catapulting their heads into the Turkish camp. A Turkish assault on the main fortifications was undertaken on July 15, and a breach in the walls effected by August 7. Yet two assaults through the breach, on August 19 and 23, both failed. On September 7 a Spanish fleet arrived from the West and scattered the demoralized Turkish forces. The defense of Malta had cost the Hospitallers half their knights and 6,000 of the other defenders.

Melodramatic 19th Century Depiction of the Fight at Malta

Thereafter, the Knights of St. John focused again on making the seaways of the Mediterranean safe for Christian shipping, a task that became increasingly easy as Turkish naval power declined. But this victory, like the defeat in Acre 300 years earlier, robbed them of their raison d’être. The Knights of St. John, now commonly known as the Knights of Malta, slid into a slow decline. They became more involved in commerce than warfare, and their fortresses turned into palaces. When Napoleon laid siege to Malta in 1798, the last frail remnants of the once mighty Hospitaller Order surrendered in just two days.

The Hospitallers played an important role in the Holy Land in the 12th century and so also figure in my biographical novel about Balian d'Ibelin and the fall of the Kingdom of Jerusalem.

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King Henry's Treasure and the Kingdom of Jerusalem

Henry II's Effigy on his Tomb at Frontevralt.

Henry II of England is one of England’s most colorful, fascinating and controversial kings.  He is usually remembered for forging the Angevin Empire, for his tempestuous relationship with his strong-willed and powerful queen, Eleanor of Aquitaine, for the murder of Thomas Becket, and – among more serious scholars – for laying the foundations of English Common Law.

He is not remembered as a crusader. This is because, although he took crusader vows, he never actually went to the Holy Land. Indeed, most historians credit Henry II with disdaining crusading in preference to building an empire at home. Certainly, his refusal to accept the keys of the Holy Sepulchre from the Patriarch of Jerusalem in 1185, reflected a preference for holding on to what he had over seeking glory and salvation “beyond the sea” in “Outremer.”

Yet a focus on Henry’s legacy in the West obscures the fact that his ties to the Holy Land were much closer than is commonly remembered. First of all, his grandfather, Fulk d’Anjou, had turned over his inheritance to his son Geoffrey in order to go to the Holy Land and marry the heiress to the Kingdom of Jerusalem, Melisende. Geoffrey d’Anjou was thus the half-brother of Kings Baldwin III (reigned 1143 – 1162) and Amalaric I (1162-1174) of Jerusalem. This made Henry II first cousin to the ill-fated Baldwin IV of Jerusalem. 

The Arms of the Kingdom of Jerusalem

Baldwin IV suffered from leprosy and could not sire an heir. As his condition worsened and the armies of Saladin drew stronger, he looked desperately for a successor capable of defending his inheritance. He did not see this either in his five year old nephew, or in the husbands of his sisters. It is before this incipient succession crisis, with Saladin beating the drums of jihad at his doorstep, that the mission of the Patriarch of Jerusalem and the Grand Masters of the Knights Templar and Knights Hospitaller of 1185 must be seen. Baldwin IV sent these emissaries to offer the keys to the Holy Sepulchre and the Tower of David first to Philip II of France and then to Henry II of England. By all accounts, Baldwin’s real hopes lay with Henry II – a powerful monarch, who had proved his abilities on the battlefield again and again. The Patriarch’s plea was for Henry II – or one of his sons – to come to Jerusalem and, implicitly, take the crown itself. Baldwin IV, many historians believe, wanted Henry II to end the succession crisis and restore the House of Anjou in the East.

The Tower of David in Jerusalem, Seat of the Kings of Jerusalem

Henry II, as I noted above, declined to follow in his grandfather’s footsteps and surrender his hereditary lands for the Kingdom of Jerusalem. But he was far from indifferent to the fate of his cousin or the Holy Land. As early as 1172, when Henry II had become reconciled with the Church for his role in the murder of Thomas Becket, he had taken the cross and started accumulating “large sums” of money in Jerusalem. This money, historian Malcolm Barber writes in The Crusader States, (Yale University Press, New Haven, 2012) was “intended for use when he eventually travelled to the East.” In 1182, Henry II made a will which left an additional 5,000 marks silver to both the Knights Templar and the Knights Hospitaller for the defense of the Holy Land, and another 5,000 marks was bequeathed for the general “defense of the Holy Land.” That is a total of 15,000 marks silver, an enormous sum, which he intended for the defense of the Holy Land.

Manuscript Illustration of a 12^th Century King

Since he did not die in 1182, this money never reached the crusader kingdom, but three years later, although Henry felt he dare not leave his kingdom in 1185 (at a time when the French and his sons were trying to tear it apart), he did agree to a special tax (often referred to as the “Saladin Tax”) the proceeds of which were also to go to the Kingdom of Jerusalem.

Finally, when the news reached him in 1187 of the fall of Jerusalem and the desperate straits of the Kingdom, Henry II again took a crusader vow. While many historians (and even more novelists) disparage this as a ploy, it is just as possible that he was sincere – so long as those who coveted his kingdom and threatened his crown, Philip II of France and his son Richard – went on crusade with him! We will never know how sincere his intentions were because he died before the Third Crusade got underway.

Meanwhile, however, his treasure had already played a crucial role in the history of Jerusalem. There are no figures for just how large King Henry’s treasure was, but it was undoubtedly more than the 15,000 silver marks mentioned in his will of 1182 because there had been money deposited prior to this, and the “Saladin Tax” that came afterwards. Significantly, the money had been entrusted to the militant orders for safe keeping. This means that the money could be deposited in London, and paid out in Jerusalem through the networks of the Templars and Hospitallers. Furthermore, based on the testament of 1182, it would appear that Henry carefully distributed the funds between the two militant orders, rather than favoring one over the other. This, unintentionally, resulted in his treasure having two very different uses.

In 1187, as Saladin prepared to launch an all-out offensive against the Christian kingdom of Jerusalem, King Guy had little choice but to call-up a levee en masse to put the largest force possible in the way of the invaders. Against a force of 45,000 including some 12,000 cavalry, King Guy could muster only about 1,000 knights, 4,000 light horse and some 15,000 infantry. In light of this, the Grand Master of the Templars, Gerard de Ridefort, handed over King Henry’s treasure to finance more fighting men. It is unclear from the sources whether these were mercenaries, light troops, or, as some say, the outfitting of 200 additional knights. In any case, Henry II’s money helped contribute to the army that marched out to meet Saladin – and was destroyed on the Horns of Hattin on July 4, 1187.

The Grand Master of the Hospitallers, however, did not release King Henry’s treasure in advance of the Battle of Hattin. The money Henry II had deposited with the Hospitallers for the Holy Land was still in Jerusalem when the city surrendered to Saladin in October 1187. The terms of the surrender allowed the residents 40 days to raise a ransom of 10 dinars per man, 5 dinars per woman and 2 dinars per child. Those who failed to pay the ransom, became slaves by right of conquest at the end of the 40 days.

At the time these terms were negotiated, the Christian defender of Jerusalem, Balian d’Ibelin, knew that there were some 40,000 (some sources say 100,000) Latin Christian refugees in the city.  He knew that many of these were destitute, having lost all they owned to Saladin already. They were in no position to pay their ransom. Ibelin therefore negotiated the release of 18,000 poor for a lump sum of 30,000 dinars. 

Sources differ, however, on where this money was to come from. Some suggest that it came from King Henry’s treasure, but others suggest the initial sum was paid from the treasury of the Kingdom of Jerusalem, but that it soon became evident that there were many more poor in the city than Ibelin had estimated – or had the resources to ransom. (He’d lost all his lands to Saladin already too.) It was at this juncture, they say, that the Hospitallers handed over King Henry’s treasure to ransom as many of the poor as they could. In the end, even Henry’s treasure was not enough and some 15,000 Christians were sold into slavery. Nevertheless, King Henry of England played an important role in ransoming thousands of Christians trapped in Jerusalem, minimizing the number sold into slavery. His son, of course, played an even greater role in rescuing the Kingdom from complete obliteration, but that is another story….