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The Seigneur dc Joinville's Cure
By Josephine Cummins*

The medieval crusades to the eastern Mediterranean which established and maintained the Latin States in the Holy Land lasted some two hundred years: from the proclamation of the first crusade by Pope Urban II in 1095 until the fall of the city of Acre in 1291. Huge companies of men, women and children of every social class migrated east as soldiers and pilgrims. There were significant threats to their health from the hazards of rough travel and warfare, especially in an environment foreign to their immune system. The medical practitioners who accompanied the armies were either appointed by municipalities to accompany its citizenry on crusade or the personal physicians of noblemen who were obliged to follow their patrons to war. In the Kingdom of Jerusalem and the other crusader states, European and native practitioners mingled. The idea has emerged that the crusaders regarded Middle Eastern medics as superior to their own. One example of this esteem is an anecdote in a chronicle written by the Seigneur Jean de Joinville who followed King Louis IX of
France on crusade from 1248-1254. (1) Lord John claims that while he was on campaign he developed symptoms, which convinced him that he had cancer of the throat. He despaired of recovery but records that a Muslim prescribed a mysterious drink, which cured him within two days. This article explores certain of Joinville's remarks elsewhere in the same chronicle, which indicate that the true nature of his complaint was not oesophageal cancer but an oro-antral fistula.

A disastrous crusade
John of Joinville (a town on the Marne) was born sometime between June 1224 and May 1225. As Seneschal of Champagne, he took the cross in 1248 and sailed from Aigues-Mortes on 25 August in the same year, reaching Limassol in Cyprus on 17 September. The army departed for Egypt the following May. They landed at Damietta and routed the Muslims there but this was to be the only major victory of the crusade. They marched south along a branch of the Nile halting near Mansourah where the Egyptians cut them to pieces in the narrow streets. Despite the French losses the king
remained in the Holy Land for another four years negotiating truces and strengthening the defences of crusader strongholds. He returned to France in July 1254, accompanied by the faithful Joinville.

A medieval travelogue
Lord John wrote his engaging account of the crusade almost fifty years later. It is a political history and a military memoir but he was also an inquisitive traveller, an observer who enjoyed describing the habits and customs of the locals, especially the Bedouin. He was concerned about his health, and included in his chronicle descriptions of his own afflictions and those of his companions-in-arms.
" [I]f a physician but comes from a distant land and speaks in a foreign tongue, not understood, the multitude will think him enlightened. (2)
The practitioners who accompanied the crusades were either educated in the liberal arts and the theory of medicine at universities such as Montpellier and Bologna or those who had learned a skill by apprenticeship. Unusually for this period a female practitioner named Hersende, attended Louis. In a document dated at Acre in 1250, which records her salary at twelve deniers a day she is described as physica (a term which usually denotes a university education).(3)
Anecdotes in certain chronicles of the crusades and evidence arising from medical licensing legislation of the crusader states suggests that the patient management skills of the Muslims were superior to those of the Latin practitioners. The Livre des Assises de la Cour des Bourgeois comments on the expected standard of medical care in the Latin east. Incoming doctors were required to be examined by established practitioners and a bishop before they were licensed to practise. This would indeed suggest a lack of confidence in Europeans but ignores the fact that local doctors from neighbouring Muslim lands were also examined.(4)
The medieval Islamic writer Usama ibn Munqidh contributes to the debate by recording the story of a local physician called Thabit, who was appointed by a Muslim ruler, to treat a knight with an abscess on his leg. Thabit opened the abscess allowing it to drain. A European physician intervened. He advised the patient that Thabit knew
nothing and asked him: "Which would you prefer, to live with one leg or to die with two?" (5) The knight preferred to live. The doctor sent for an axe-man. It took two blows to amputate the leg, whereupon "the marrow spurted out and the knight died instantaneously." Thabit remarks dryly that he: "came away, having learnt things about medical methods that I never knew before." (6) This incompetence would seem to justify the superiority of Middle Eastern practitioners. But some historians believe that the anecdote is no true indication of the state of western medicine at the time. Usama also wrote of exemplary practice by Europeans. In rehearsing Thabit's experience he was simply using a popular literary device (didactic dichotomy) that describes a topic by using extreme examples, which contradict one another.(7)

Constant fear of death

If hacking and penetrating wounds from axe, sword and lance were the most obvious danger to a crusader, starvation was a clear and present threat for rich and poor alike. The Muslims blockaded the river depriving the French of fresh food. The only fish available in camp were eels, which had fed on the accumulations of gall-bloated corpses in the river (8). The dietary mainstay appears to have been salt pork. Consequently Louis' crusaders were deprived of vitamin C and prone to scurvy (9).

The army disease.

Joinville writes: "[A] disease spread through the army, [scurvy] of such a sort that the flesh on our legs dried up, and the skin became covered with black spots and turned a brown earthy colour like an old boot. With those who had this disease the flesh on the gums became gangrened; and no one who fell a victim to it could hope to recover, but
was sure to die. An infallible sign of death was bleeding from the nose" (10).

Joinville was himself a victim and complains of the condition of his mouth and legs. His priest had the same symptoms, making him prone to fainting during the celebration of mass and even the king was brought low. Louis' condition was complicated by dysentery. Lord John shares the observation that the king's need to visit the privy was so urgent and frequent that the lower part of his drawers had to be cut away. (11)

Like the cry of a woman in labour
.
A distressing sign of scurvy is acute ulcerative gingivitis with its accompanying haemorrhage and periodontal bone loss making dental extractions advisable (12) : "The sickness that had stricken the army now began to increase to such an alarming * extent, and so many people suffered from mortification of the gums that the barber surgeons had to remove the gangrenous flesh before they could either chew their food or swallow it. It was pitiful to hear around the camp the cries of those whose dead flesh was being cut away; it was just like the cry of a woman in labour." (13). Lord John's personal circumstances were exacerbated by capture and the development of a new symptom:
" [O]n account of the sickness that troubled me, I was seized with a terrible fit of trembling. So I asked for a drink, and they brought me some water in a pitcher. But no sooner had I put the pitcher to my mouth than the water spurted out of my nostrils. When I saw this happen, I sent for my men and told them I was a dying man, since I had a tumour in my throat. They asked me how I knew it, so I showed them. As soon as they saw the water spurting from my throat and nostrils, they began to weep." (14) When the Saracens asked why Lord John's men were weeping, one man replied: "[t]hat he understood I had a tumour in my throat and so could not hope to recover. Then one of the Saracen knights told [him] to bid us take comfort, for he would give me something to drink that would cure me within two days. And this, I may say, he did." (15)
Joinville lived into his eighties. He was not therefore suffering from terminal cancer. It is interesting, however, that he was quick to associate the reflux of liquid from nose and mouth with cancer of the throat, suggesting that he had experience of someone who had suffered in this way.

Conclusion

He describes the work of the barber surgeons in performing oral surgery on the men who had scurvy but he does not record that they treated him. He does say that he suffered from the same disease and complained of the oral symptoms, which would have been gingivitis and loose teeth. It is likely that the surgeons did try to relieve his pain as they had for lesser men and in so doing removed a mobile upper molar or premolar. Indeed it is not impossible in a case of scurvy that a tooth was lost without surgical intervention. The creation of a minor fistula between the oral cavity and the maxillary antrum after a dental extraction would account for the apparently sudden a ability of the patient to eject fluid through his nostrils more satisfactorily than oesophageal cancer. Furthermore, if the extraction socket remained clean, sufficient clotting and healing could have taken place within two days, even in an unhealthy man, to close a small fistula and prevent further symptoms. It is likely that the mysterious drink prescribed by the Muslim, if it had any effect at all, was simply an infusion of antiseptic herbs and not an amazing cure, as Lord John believed.

* Josephine Cummins, BDS, MA, PhD, dentist and historian, Glasgow
(1) Shaw MRB, trans. Joinville and Villehardouin: Chronicles of the Crusades. London: Penguin, 1963,
passim.
(2) Isaac the Israeli. Fifty Admonitions to Physicians. 9th century. In: Bar-Sela and Hoff,. Journal. of the
History of Medicine, 17, 1962,245-57.
(3) Daumet G. Une femme-medecin au xiiie siecle. In: Revue des Etudes Historique, 84, 1918, 69-71.
Joinville says that at times food was so scarce that an egg cost twelve deniers, which gives some
indication of the value of Hersende's salary, at least locally. Shaw. 237.
(4) Mitchell PD. Medicine in the Crusades: warfare, wounds and the medieval surgeon. Cambridge:
Cambridge University Press, 2004,214
(5) Gabrieli F, Costello EJ, trans. Arab Historians of the Cnisades.New York:Dorset Press, 1989, 76
'(6) lbid.77
(7)
(8) Shaw.236-237
(9)Carpenter KJ. The History of Scurvy and Vitamin C. Cambridge: Cambridge University Press, 1986.
(10) Shaw. 237
(11) Ibid. 238, 239,240
(12) AUG appears to be the form of periodontal disease associated with scurvy. See Laumann A. et al. Scurvy. In: emedicine (www.emedicine.com) July 27, 2005, p.4. Also the entry for scurvy in: Blacks Medical Dictionary, 18th edition, Comrie JD ed., Adam and Charles Black, London, 1945, p. 794. "[t]he gums are livid, spongy, ulcerated and bleeding; the teeth are loosened and drop out; and the breath is excessively fetid."
(13) Shaw. 239
(14) Ibid.244
(15) Ibid.