The marquis falls ill and kills his own doctors. Meanwhile the marquis was struck down by a familiar and recurring illness; but because this time it happened to be worse than usual he supposed that he had drunk a deadly potion. So a harsh edict went out against the doctors who make potions. Because of an unjust suspicion the innocent were
destroyed, although their profession does not bring death but health to the sick.80
William’s descriptions of the terminal illnesses of the two kings are usually cited to demonstrate the fashion for non-Latin doctors, and this is indeed a feature which is borne out by other evidence. Amalric is known to have employed an oriental Christian doctor, Abu Sulayman Da’ud, to treat his leprous son, the future Baldwin IV.81 Abu Sulayman had been born in Frankish Jerusalem, but had moved to Egypt, where he served the caliph. Amalric met him there, and induced him to move back to Jerusalem. Abu Sulayman made the young Baldwin an
‘appropriate theriac’ for his leprosy, although unfortunately, as William observed:
‘Repeated fomentations, ointments, and even drugs were employed without result in the attempt to help the prince.’82 Abu Sulayman was the first of a dynasty: one son succeeded him as Amalric’s physician, and another became Baldwin IV’s carer and riding teacher. When Jerusalem was recaptured in 1187 the family entered the service of Saladin and his successors.83
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The way in which doctors worked across the cultural divide, as well as Usama ibn Munqidh’s personal fascination with medical matters, is illustrated in his
‘memoirs’. He records two cases where the barbarous intervention of a Frankish doctor had fatal consequences: one was on a knight who had an abscess on his leg and the doctor amputated; the second was on a woman with ‘consumptive fever’, whose head he cut open and rubbed with salt.84 But Usama also notes two effective cures the orientals learned from the occidentals: the use of wine to disinfect wounds, and an ointment for scrofula.85 These examples are too well known to need quoting in full, and anyway, as Hillenbrand observes, they should be used with caution: ‘Usama’s work . . . [has] been overexploited, often rather too simplistically, by scholars.’86 It is worth adding that Usama’s ‘memoirs’ cover his long life, 1095–1188, and his anecdotes cannot be closely dated. Therefore, they cannot, or should not, be used to make judgements about the comparative
‘progressiveness’ of medical science in the twelfth century.
Medical regulation
By the middle of the thirteenth century, however, there is some fairly secure evidence concerning the licensing, regulation and legal status of medical practitioners in the kingdom of Jerusalem. Le livre des Assises de la Cour des Bourgeois de Jérusalem was formerly thought to record the laws for non-nobles as they were during the first kingdom of Jerusalem (1099–1187), but Prawer showed that in fact the book was written as a private treatise in Acre, almost certainly between 1240 and 1244.87 The author was himself a burgess, and had practical experience of the law, but he was not an academic lawyer. Prawer concluded that the two chapters on medicine and surgery were added by the author to show off his own knowledge of the medical profession, not taken from any previous treatise.88 The whole collection comprises 278 chapters and is a chaotic mixture of property, criminal, civil and commercial laws. The ‘medical’
chapters are towards the end, among the commercial regulations.
These two chapters contain a wealth of information about the circumstances in which a doctor would be called, and the treatments he might administer. The cases within each chapter follow a formula: if my slave is sick in such a way, and I call a doctor, and he does this when he should have done that, and so the slave dies, then the following penalty is due – usually the price of the slave. The first chapter contains surgical remedies; the second concerns the work of the physician.
They are separated by a chapter on doctoring horses, and the repeated references to slaves ( serf ou serve) in the medical chapters may be why they were put in the
‘commercial’ section of the Assises. Slaves were unfree, usually non-Christian, and in certain circumstances could be bought and sold, so, like the horses in the intervening chapter, they could be viewed as property.89
Cases in the surgery chapter90 exhibit a mixture of empirical treatment and humoral theory. For example, wounds ‘in a hot place’ or a place where the doctor should put hot things – for example, the brain, the nerves or the joints – ‘which 201
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are of a cold nature’ must not be treated with cold things. An abscess should be treated with cold and moist remedies ‘to soften and ripen and draw the badness out’; if the doctor put hot and dry things on it, the badness might burst inside and the patient die. Skull fractures had to be cleaned ‘with instruments’, otherwise the broken bone might pierce the brain and the patient die. The doctor might fail by leaving wounds without dressings, or by applying ‘too many hot things as a result of which the cut arm or thigh goes bad’, or the wound might stink, or he might neglect to attend to it every day, any of which could be fatal. In all of these cases where wounds proved fatal, compensation to the value of the slave was due to the owner, and the doctor was banned from practice in the city. However, if the patient was a free man or woman, then the doctor was to be hanged. Another case in the same chapter indicates the procedure for a broken arm or leg. The doctor’s treatment, pulling the patient about and applying ‘useless’ plasters, might result in the slave being crippled, in which case the doctor had to take the slave and pay his master his purchase price; or, if he could not do this, then pay compensation for the slave’s loss in value. If he treated a Christian (i.e., free) patient in a similar manner, then his right hand was forfeit.
Thus the work of the surgeon – dealing with wounds, broken bones and swellings, such as abscesses – was practical, and this, along with the focus on treating slaves (with references to free people seemingly secondary), might suggest that the surgeon was seen as an artisan and comparatively uneducated. It should be noted, however, that the entries relating to surgeons and those relating to physicians are structured in exactly the same way, and furthermore the surgeon, like the physician, was expected to advise on regimen in accordance with prevailing theory. The case reads:
Item: if a doctor can show in court, on good evidence, that the person he was treating lay with a woman, or drank wine, or ate any bad food which the doctor had forbidden him, or did anything which he ought
not to have done so soon, judgement is and should be that even though the doctor might have treated him otherwise than he should, the doctor is under no obligation to pay compensation, because more obvious
opinion is that the patient died because he should not have done that which was forbidden to him, rather than from bad treatment, and this is the law and judgement of the assize. But if the doctor did not forbid him to eat anything, or drink, or touch a woman, and he touched, or ate or drank what he should not have done, and he died of it, the sentence is that the doctor is obliged to pay compensation for him, by law; for the doctor is obliged, by law, as soon as he sees the patient, to tell him what he should eat, and what he should not eat; and if the doctor does not do this and something goes wrong, this is the doctor’s responsibility. But if the doctor, even though he has undertaken to administer a course of
treatment, has the misfortune to be captured by Saracens, or an illness befalls him, or some other mischance as a result of which he cannot come 202
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afterwards to see the patient, opinion is that the doctor is not obliged to pay any compensation at all, by law.91
In view of this evidence of theoretical knowledge, it is possible that the Assises are not dealing with different occupational groups at all, but different areas of expertise: that is, that the same ‘doctor’ was called upon to deal with surgical and physical illnesses. The Assises d
o, however, preserve the distinction between external and internal complaints in the structuring of the chapters. Humoral theory also pervades the chapter on physic.92 In the case of diarrhoea, the doctor should give ‘cold and binding things’ and not ‘laxative things or hot things’. In the case of fever it might be fatal to bleed the patient excessively, or before the right time. The doctor was expected to recognise when a patient had a chill from looking at the urine, and not to bleed him. For dropsy, controlled draining via an incision was recommended. A quotidian fever, which was marked by fluctuations in temperature in the course of the day, seems to have been treated by administering a purgative containing the herb scammony, an overdose of which could lead to death: ‘He goes so much to the privy that before it is daylight he has voided everything he had in his body, both liver and lungs, and dies.’93 Diseases of the bowel might be treated with drugs – ‘some powder or strong herb to drink’
– or by cautery. There is a graphic description of how the latter might go wrong.
In all these cases the penalty was high: the price of a slave; or, if a free person died, the doctor responsible was to be beaten around the town, urine-flask in hand, and then hanged ‘to deter others from this malpractice’.
There is one exception to these high penalties, and that is when the illness caused spots:
Item: if I have one of my slaves ill with spots, or with a dry rash, or with any other illness, and I come to a doctor and I make an agreement with him that if he cures him, then half of what the slave shall be sold for will be his and the other half go to his lord who bought him, and the doctor takes him for treatment, and does for him what he can, but it does not work, and the slave dies, opinion is that on this account the doctor is not obliged by law to pay compensation for the slave, first of all because he lost his work, and everything he should have received; and this is the law and opinion of the assize.94
It appears that the Assises recognised that doctors were powerless when faced with certain infectious diseases. This is consonant with the findings above, regarding epidemics on campaign. Another feature of this chapter is the preponderance of cases of dysentery, which may be taken to reflect the realities of life in Outremer.
These two types of illness are the only ones to feature elsewhere in the Assises : if a purchased slave should develop dysentery within a year and a day, then the vendor was obliged to take him or her back and refund the price. Similarly, if the 203
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slave developed ‘ mezele’ (leprosy, or spots), the same applied, and this seems to have been a ‘frequent occurrence’ ( Mainte feis avientque).95
In view of the high price of failure, it is a wonder that doctors were prepared to practise in Outremer. One possible explanation is that success was more usual than failure, and another is that the rewards were high enough to compensate for the risks. There was some protection in the law, in that the doctor could not be convicted on unsupported testimony.96 But who were these doctors who risked their lives every time they undertook to treat a patient? In both chapters they are referred to as mièges ( medici) – no distinction is made between surgeons and physicians, and indeed the distinction may not have existed, as suggested above.
There was a formal procedure for licensing these mièges, which went as follows: Item: no foreign doctor, that is one who comes from overseas or from pagan lands, should practise as a urine-doctor to anyone until he has been tested by other doctors, the best in the land, in the presence of the bishop of the land, before whom this should be done. And if it is
ascertained that the doctor knows how to practise medicine properly, the bishop, before whom he is examined, should give him a licence to
practise in the town henceforth, wherever he will, by letters from the bishop which he will have as testimony, that the doctor has been
examined and can practise, by law, as a urine-doctor. And this is the law and opinion of the assize of Jerusalem . . . And if it happens that he does not know good medicine, that he cannot cure, opinion judges that the bishop and the court should order him to leave the city, or if not, that he stay in the land without treating anyone. And if it should happen that any doctor practises in the town, without leave of the court and the bishop, the court should take him and have him beaten out of town, by law and by the assize of Jerusalem.97
Note that the bishop was responsible for overseeing the examination of doctors and for granting their licences, although it is clear that the same regulations applied to all foreign doctors, whether from Western Europe (‘Outremer’) or from ‘Païnime’ (lands under Muslim rule). Bearing in mind the passages from William of Tyre and Usama, above, it is probable that not all these doctors were Christian, although the majority probably were.
This testimony of the Assises with regard to the licensing of doctors is relevant to a wider debate about the development of the medical profession. The licensing of medical practitioners is earliest recorded in Arabic sources, including al-Razi in the ninth century CE. The first known example in Western Europe dates from Sicily in 1140, but there is no other example until 1231, again in Sicily, as part of legislation issued by Emperor Frederick II.98 This was soon followed by enactments in other regions, and the Assises, dating from the early 1240s, could be related to these – or it could be independent and influenced by practice in Outremer.
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The clue to the inclusion of these medical chapters in the Assises, and their position in the ‘commercial’ section is found in an accompanying document entitled ‘ un abrégé ’, or abridgement.99 The relationship of this document with the Assises is by no means clear, but it is certainly more than a précis. Among the court officers in the abrégé is the ‘ mathessep’, who is further identified as a ‘master-sergeant’. Prawer realised that this was an attempt to render in French the Arabic word ‘ muhtasib’.100 The muhtasib was an official in Syrian towns who had responsibility for enforcing fair trade in the markets, upholding public morality, and ensuring the maintenance of standards in various crafts and professions.
Some manuals survive which describe the role of the muhtasib in detail.
One available in English translation is The Book of the Islamic Market Inspector.101
Its author, al-Shayzari, was based in Syria in the twelfth century and wrote for Saladin, so it could scarcely be better suited for comparison with our medical chapters.102 In fact, the manual gives regulations for all sorts of trades, including butcher and baker. There are chapters on apothecaries, phlebotomists and cuppers, physicians, eye doctors, bone setters and surgeons. The book includes a definition of physician and the knowledge he needed, and the information that all physicians had to take the Hippocratic oath before the muhtasib. He was also to examine them on Galen and a book by Hunayn b. Ishaq (d. 873), The Trial of the Physician. The medical instruments the physician should have were itemised, and included several we should call surgical. Eye doctors were also to be tested, as were bone setters and surgeons. All were expected to have considerable book-learning as well as a knowledge of anatomy.103
With this insight into the role of the muhtasib, the inclusion of the medical chapters in the Assises seems a great deal less arbitrary. The thirteenth-century author may well have been showing off his knowledge by expanding the content to include details of treatments and maltreatments (as Prawer thought), but the chapters were included as a matter of course within that part of the collection which dealt with the various aspects of the muhtasib’s role. We cannot assume that the knowledge required of doctors who treated the Franks was the same as in Islamic lands, but we can see that their practice was probably regulated as a craft or trade in a similar way. The regulation of medical practice and practitioners does appear to be one aspect of medicine where crusaders and settlers learned from the natives of Outremer.
Hospital development
An institution that underwent significant change in Outremer w
as the hospital. It is relatively easy to describe the development, but more difficult to decide whether it was the result of Islamic influence.
Institutions called hospitals (‘ hospitales’ or ‘ hospitalia’ in Latin) were well established across Europe before the time of the crusades. They originated as guest-houses of monasteries (‘ hospites’ means guests or strangers), and provided accommodation for travellers and others in need. Those on pilgrimage routes 205
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were especially in demand, and attracted the poor and the infirm in great numbers.
It would be more accurate to call them hostels or hospices – two other English words derived from the same Latin root (and no doubt the wealthy used them as hotels, a third derived word). It was in this spirit that a group of merchants from Amalfi, Italy, set up a small hostel/hospice in Jerusalem in the middle of the eleventh century, confiding it to the care of a group of Benedictine monks. The hostel was sited conveniently close to the church of the Holy Sepulchre, and it was dedicated to St John the Baptist. When Jerusalem was in Christian hands after 1099, it became even more attractive as a pilgrimage centre, and the buildings were expanded to meet the need for accommodation. Administration of the hospital was placed in the hands of the new Order of St John, which developed into a military order, but always had the care of the sick as its primary concern.
Excavations early in the twentieth century revealed a major building programme in the 1140s.104 By 1169, when the German pilgrim Theoderich visited, the buildings were palatial:
Unless he has had the opportunity of seeing it with his own eyes, no one can credibly tell another how beautiful its buildings are, how abundantly it is supplied with rooms and beds and other material for the use of the poor, and sick people, how rich it is in the means of refreshing the poor, and how devotedly it labours to maintain the needy. Indeed we passed through this palace, and were unable by any means to discover the
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