Wound Treatment in the Crusader Era

Today guest blogger Fermin Person provides us an expert insight into injuries and their treatment during the crusader era.

A careful look at this medieval manuscript illustration shows a variety of battlefield injuries.

The most common types of injuries in the crusader era were fractures, cuts, puncture wounds, burns and head injuries. Below, is a look at the treatment of these injuries in the crusader era individually:

Fractures

Evidently fractures were quite common during the medieval period in peacetime as well as in wartime. If a long bone of the human body, like the upper arm bone (Humerus) is broken it is important that the broken bone is adjusted in a position so that the bone can heal straight, without forming an angle. To fixate the broken limb in such a position the arm or leg was put into a splint made from several wood sticks or into a plaster made from flour and egg white. Apparently this was considered a simple procedure, since the Laws of the Kingdom of Jerusalem punished the improper use of splints or plaster resulting in the crippling of the patient.

Cuts/Blade injuries

Blade injuries were probably very common during the crusading age.  According to Arabic texts such as Albucasis and its translation into western languages bleeding could be stopped by cauterisation or surgical sutures, however, it was not possible to suture fine structures like blood vessels. Afterwards bandages were applied. In some texts poultices soaked with wine and vinegar are also mentioned. 

In severe wounds or in case of infection, however, an amputation was considered necessary ― but only as a last resort. Albucasis describes a reasonable method. The limb was placed on a wooden block. Ligatures were placed above and under the site of the amputation. Afterwards the soft tissue was cut and the bleeding from the blood vessels was stopped. Thereafter the bone was sawn trough. Finally, the stump was bandaged and left to heal. There is no evidence regarding the length of time needed for amputation.

Spear or bow injuries

Individuals were often hit by several arrows during one engagement. Lances or spears could cause similar wounding patterns. If arrows could not be removed trough their initial point of entry it was recommended to push them through the tissue, completing their way out. 

If the arrow could not be removed immediately, it was possible to wait some days until the swelling around the wound went down.  A further complication resulted from parts of the armour being nailed to the body by the arrow. Afterward the removal of the missile, the wounds were cared for using bandages or poultices.

Burning

Burning was common in medieval warfare, particularly during sieges, and also due to accidents with fire, candles etc.. A source that was exceptional to the Middle East was Greek fire, which could not be extinguished by water, vinegar being needed. Medieval medical texts recommend keeping the wound from drying out by applying  oil, wax, fat or vinegar mixed with other ingredients such as opium or herbs. Additionally, the development of blisters was to be prohibited by applying oil, vinegar or rose oil.

Head injuries

Head injuries were common during medieval warfare. Medieval physicians were aware of seriousness of such wounds, and that many of the victims died. Still an adequate treatment was specified in the legal text of the Kingdom of Jerusalem Livre des Assis de la Cour des Bourgeois.  The phycisian/surgeon had to clean the head wound, search for bone fragments and remove them. From archaeological evidence, such as the skull finding in Jacobs Ford, we know that skull fractures were survived by some individuals.

Excurs: Was there exchange between medieval Arabic and Christian medicine during the crusades? It is not clear to what extent knowledge was transferred between the Islamic world and the Christian west during the crusades in the Holy Land. We do know, however,  there was extensive translation of medical texts in Sicily and Spain. Numerous medical and astrological works (the border between the two areas was in the medieval period fluent) were translated from Arabic into Latin. Several lost Greco-Roman works that had been lost to the West were re-discovered through their translation into Arabic. The actual impact on western medicine of these available translations is, however, difficult to trace or document. Regarding the standards of care there is also little knowledge, no survival rates are reported to compare the different health care standards. There are frequent stories in the literature of the time such as in the autobiography of Usama Ibn Munqidh. But they are often allegoric in nature and do not allow any certain conclusions. According to Edgington (1994), Eastern Roman, Muslim and Western Christian practitioners had a similar standard regarding the practical knowledge of surgery.

Sources

Mitchel, Piers D.  (2007) Medicine during the crusades, Cambridge University press

Tony Hunt (1999) The Medieval Surgery, Boydell & Brewer Inc

Edgington, S. (1994) Medical knowledge of the crusading armies: the evidence of Albert of Aachen and others. In M Barber, The Military Orders: Fighting for the Faith and caring for the Sick, (Aldershot, Ashgate)

Keda, B (1998) A twelfth century description of the Jerusalem Hospital, In H. Nicholson (ed.). The Military Orders. II Welfare and Warfare (Aldershot: Ashgate), pp. 3-26.

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 13^th 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.

 

Medical Practitioners in the Crusader Era

It is often assumed that the people who practiced medicine in the Middle Ages were ignorant, untrained, guided by “pure superstition” and accountable to no one. In today’s post, the second in a series of guest essays by German scholar Fermin Person, we look at medical practitioners and standards in the Crusader States.

In today’s world, the permission to practice medicine (prescribe medication, operate etc.) is usually closely regulated by the state. 

In the west during 11^th – 13^th century several distinctions were made between the grades of knowledge and practical training a medical practitioner had. 

A rather small group were called physicus / fisicien. They had a high degree of knowledge for their time, combining the study of liberal Arts at a university with medical education. The title of physicus/fisicien usually implied the degree of magister because of the received education in liberal Arts. The centres for learning in the Latin west were Salerno, Montpellier, Paris, Bologna, Cambridge, Oxford or Padua. It was at these universities that the physicus/ficicien were trained.

Notably, there are examples of female physicians such as Hersende. Hersende was physician to Louis IX and accompanied him during the crusade to Egypt (1248-50).

The term medicus/ miege /mire was used for all types of doctors during the medieval period. They would take the patients history, examine them and treat them, for example with diet, medication or bloodletting. To some degree they also practiced surgery.

The profession of cyrurgicus (surgeon) was considered a trade rather than a profession. It was learned via an apprenticeship, until the end of the 13^th century when it started to be studied on the universities of the Latin west. Cyrurgici were commonly seen as less well educated, were worse paid and had a lower social status than physici. Surgery was seen by medici as a manual trade along the line of carpentry or stone masonry. During the late 13^th century cyrurgici with the title of master, indicating their academic education started to appear. Their task was the treatment of wounds as well as the treatment of illnesses that could be seen from the outside (like leprosy or venereal diseases) or might require a surgical treatment.

The profession of berberus /rasorius was likewise a trade learnt via an apprenticeship. Their task was to shave as well as to care for wounds in time of need.

Similarly, the minutor/phlebotomus/sangunator was a specialist tradesman that only did bloodletting. He was also educated during an apprenticeship and would follow the orders of a physician or blood-let on the request of a patient.

The apothecarius/ herbolarius/ spicer prepared medicine according to the orders of a medicus or he could sell the medicine directly to the patients. 

Despite the restrictions that were placed on medical education of clergyman during the council of Tours many physicians (physicus/fisicien) were clergyman. Apart from minor restrictions by the fourth Lateran council for subdeacons, deacons and priests, clergyman could practise surgery to the full extant.

The known sources suggest a strong influx of European physicians and surgeons as well as barbers to Outremer. However, there is also documentary evidence for local Christian and Jewish physicians. Furthermore, there seem to have been Muslim physicians as in the hospital of St John in 12^th century Jerusalem there were two versions of an oath for newly hired surgeons, supposedly allowing also non-Christians to practise. In addition, a decree of the Frankish church of Nicosia forbade their employment in a church run hospital. Note, however, that we have no comprehensive records of the overall numbers and qualifications of medical practitioners, but are instead dependent on predominantly juridical documents where physicians stood witness for testaments etc.

Medical Standards in the Crusader States

The crusader states seem to have adopted and modified the Muslim system of hisbah.

In the Muslim system of hisbah an official called the muhtasib (in Frankish mahteseb) controlled quality standards of crafts. In the Frankish adoption of the system (found in the commentaries of the legislation of the kingdom of Jerusalem the “Assis de la Cour de Bourgeois” from 1240-44) a council of the best doctors of a town under the provost of the local bishop licensed a physician.

Therefore a thorough examination was conducted by the council of physicians. If a candidate did not show sufficient knowledge he was forbidden to practice medicine.

If he practiced medicine without a license he was beaten out of town. A similar system developed about the same time in the kingdom of Sicily.

Excurs: Medical negligence in the Laws of the Kingdom of Jerusalem The Assis de la Cour des Bourgeois from 1240-44 is our principal source about medical legislation in the crusading states. It lays out the mechanisms of medical licensing and punishment for medical negligence.  In case of medical negligence, a distinction is made if the victim is a slave or a free man. Furthermore, a distinction is made if the illness can be realistically healed by a physician (like a bone fracture) or not (like measles). If a physician crippled or killed a slave because of medical negligence he was bound to pay compensation to the owner. If a physician killed or crippled a free man because of medical negligence he was submitted to various physical punishments such as the amputation of the right thumb or even hanging.

Sources 

Mitchel, Piers D.  (2007) Medicine during the crusades, Cambridge University press

Tony Hunt (1999) The Medieval Surgery, Boydell & Brewer Inc

Edgington, S. (1994) Medical knowledge of the crusading armies: the evidence of Albert of Aachen and others. In M Barber, The Military Orders: Fighting for the Faith and caring for the Sick, (Aldershot, Ashgate)

Keda, B (1998) A twelfth century description of the Jerusalem Hospital, In H. Nicholson (ed.). The Military Orders. II Welfare and Warfare (Aldershot: Ashgate), pp. 3-26.

Medical the Jerusalem Trilogy the comparatively high standard of medical care in the crusader states is recognized.

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The Human Body, Illness and Death in the Crusader Era

It is often assumed that the people who practiced medicine in the Middle Ages were ignorant, untrained, guided by “pure superstition” and accountable to no one. Today’s post, the first in a series of guest essays by German scholar Fermin Person, looks at medical practitioners and standards in the Crusader States.

The medieval concept of illness was different from our current understanding. In the medieval period, medical theory (common to both East and West) explained illness as an imbalance of the four humours (body fluids), as divine punishment, as astrology or as the working of evil entities.

These basic concepts existed parallel to each other and mixed to some degree during the medieval period. There already existed the notion of infectious diseases and of epidemics, but with the very limited diagnostic capabilities of the period (seeing, smelling, tasting, feeling), it was not possible to differentiate infectious diseases from auto-immune disease or poisoning.

Excurs: Bloodletting Following the works of Galen bloodletting was practised extensively both in the western as well in the Islamic world since the antiquity. Bloodletting was used prophylactically in healthy persons as well as during illnesses. The statutes of the Templars and of the order of St John specified, for example, the possibilities and the treatment of members of the Orders that had been bloodlet. The laws of Outremer specifically demanded that a physician use bloodletting, if a patient was suffering from fever.

Ergotism (called “holy fire” or “St. Anthonies Fire”) for example, caused by alkaloids produced by fungus that befall cereals during wet weather, broke out in epidemics.

There was some understanding that blood loss from wounds was an important factor in the death from injuries, but there was still no understanding of the pathophysiology of haemorrhagic shock.

Another point of discussion was whether pus in wounds was something negative or positive. Medieval western (and Arabic) physicians lacked an understanding of infectious diseases and microbiology. 

Similarly, the exact function of many organs was unknown or was misinterpreted, and the working of the circulatory system was also wrongly understood. For example, based on the classical scholar Galen, medieval physicians considered the liver to be the place of blood production.

Excurse: Galens teaching of Humours Galenos of Pergamon (129/131 – 200/215 a.C.) was a Greco-Roman physician and anatomist. His works were translated into the Arabic language. He influenced heavily both western Christian, eastern roman and Arabic medicine. He applied the teaching of humors to medicine. According to him there were four body fluids blood, black bile, yellow bile and phlegm. If the four humors were in misbalance illnesses could result from that. Through diet, appropriate medication and bloodletting the body fluids could be brought into balance again.

Additionally, physicians generally had only had a rudimentary understanding of the internal anatomy. Knowledge of the anatomies resulted most probably from animal corpses, practical experience with wounds and from antique literature. Autopsies started in the western world only at the beginning of the Renaissance at the end of the 14^th century. This is in contrast to the Eastern Roman Empire, where it is reported that in 1110 a contingent of Scandinavians that had taken up the cross fell ill in Constantinople. Autopsies were performed on the dead to clarify the cause of their death.

The medieval attitude to death was likewise different.

About 1/3 of the children born in the medieval west died before the age of five. Overall life expectancy varied significantly based on period, location and social strata a great deal. Based on archaeological and genealogical evidence it can be assumed that life expectancy was as low as 25-30 years during the medieval period. No exact data was available on the live expectancy in Outremer. 

In short, death was much more present in the medieval world than in the modern period. During the medieval period the average human had a strong belief in an afterlife and the later bodily resurrection of the dead. It was considered ideal to have a period of illness before death in order to prepare as a good Christian for death. A sudden unprepared death, in contrast, was considered something terrible.

Sources:

Mitchel, Piers D.  (2007) Medicine during the crusades, Cambridge University press

Tony Hunt (1999) The Medieval Surgery, Boydell & Brewer Inc

Edgington, S. (1994) Medical knowledge of the crusading armies: the evidence of Albert of Aachen and others. In M Barber, The Military Orders: Fighting for the Faith and caring for the Sick, (Aldershot, Ashgate)

Keda, B (1998) A twelfth century description of the Jerusalem Hospital, In H. Nicholson (ed.). The Military Orders. II Welfare and Warfare (Aldershot: Ashgate), pp. 3-26.