Dr. John J. Turner
University Hospital Aintree, Liverpool, United Kingdom
The young King Baldwin
William of Tyre discovers Baldwin's first symptoms of leprosy
1250s, from Estoire d'Eracles (French trans. of William of Tyre's Historia)
British Library, London
Medieval teen king, precocious politician, and successful battlefield commander, Baldwin IV not only surmounted disabling neurological impairment but challenged the stigma of leprosy, remarkably continuing to rule until his premature death aged twenty-three. His coronation as sixth king of Jerusalem at age thirteen coincided with the seventy-fifth anniversary of the Crusader Latin Kingdom in July, 1174. Twelfth-century Jerusalem, with a population larger than any European city, carried enormous cross- cultural significance. Just as today, it contained the revered Judaic, Muslim, and Christian (Catholic and Byzantine) holy sites in a delicate tripartite relationship. Medieval map makers depicted Jerusalem as the literal and symbolic center of the known world, a convention that persisted for centuries.1 The borders of the kingdom were more or less co-terminus with modern Israel, Lebanon, and the Palestinian territories.
Baldwin’s tutor, archbishop and historian, William of Tyre, observed Baldwin’s insensitivity to pain in his arm when he was only nine: “Half his arm and right hand were dead … he could not feel if pinched or even bitten.” 2Leprosy was likely suspected, but the implications were so serious that the consulting physicians, including eminent, Egyptian-educated, Arab-Christian Abu Sulayman Dawud, cautiously awaited the appearance of more clinical signs before committing to the diagnosis.3
Young Baldwin’s academic and practical education proceeded well. Contemporary accounts report that he had “an excellent memory, quick understanding, [and was] skilled at controlling horses and riding at a gallop.”4 Good at taking advice, Baldwin ruled with a regent until deemed no longer a minor at age fifteen. Under the rules, Livre au Roi, a regent was appointed from eligible blood relatives, who included Henry II of England, grandson of Melisende, Queen of Jerusalem. The high court, presided over by Baldwin himself, in joint session with the patriarch and bishops, appointed Prince Raymond of the crusader principality of Tripoli, site of the most famous of the crusader castle Crac des Chevaliers.
Despite the diagnosis of his disease, Baldwin was never segregated, causing surprise among Muslim observers: “The Franks were concerned to keep him in office but took no notice whatsoever of his leprosy.”5 This striking overturning of convention suggests an appreciation of Baldwin’s character and qualities and also reflects the semi-divine status of medieval Christian kings. Leprosy, feared by many and deemed incurable, with an exaggerated belief of high infectivity, must have felt intensely threatening to the tight circle of the royal court. However, they loyally supported Baldwin in the face of his illness. Perhaps they felt that divine intervention would provide a cure in the end and offer them protection. Contemporary chronicles do not record leprosy in any of the king’s close contacts.
Leprosaria and the roadmap to elimination
In the Middle Ages, misconceptions of leprosy as highly contagious were reflected in traditional vivid images of warning bells and leper horns. Furthermore, shouts of “unclean” exposed misplaced beliefs in society that leprosy was either a sexually transmissible disease or a punishment for sins requiring penance.6 The onset of the disease at the age of nine meant that neither could have applied to Baldwin and, in the prevailing culture, strengthened the case for his acceptance. In certain cases, leprosy caused highly visible claw hands, facial disfigurement, and multiple ulcers, provoking fear in many individuals.7 Baldwin had no noticeable disfigurement in his early years of kingship but developed multiple skin ulcers, deformities of face, hands and feet, and became blind.8
The Military and Hospitaller Order of Saint Lazarus, founded in the 1140’s in Jerusalem, is one of the most ancient of the European orders of chivalry. It was dedicated to aid those suffering from leprosy, providing a sanctuary. Its second role was to defend the Christian faith.9 Endowed by charitable nobility, it attracted non-leper volunteers to give care to knights and sergeants diagnosed with leprosy. Imprecision in medieval diagnosis inevitably resulted in some non-lepers being confined to the “Lazar House,” which was adopted internationally as a name for leprosaria.
Leprosy, caused by mycobacterium leprae, has much lower infection rates than many other infectious diseases such as measles, cholera, or smallpox. Repeated droplet infection is considered the main mode of transmission. Although leprosy was understood as highly contagious in the Middle Ages, ninety-five percent of even close habitation contacts did not develop clinical leprosy. Yet segregation and life-long quarantine were seen as essential protective public health measures. Stigmatization led to the continued existence of leprosaria in Asia and Africa even after curative multidrug therapy became available.
The World Health Organization’s (WHO) ambitious program for elimination of leprosy has provided free multi-drug therapy worldwide since 1985, while encouraging accurate diagnosis, the closure of leprosaria, and an integrated healthcare system for leprosy treatment.10 This push resulted in a dramatic reduction in global cases, from 5.2 million in 1985 to 213,000 cases by late 2008. The US Department of Health and Human Services recorded 137 new cases across thirty states in 2006, slightly higher than in 2001 and most likely a reflection of global air travel. 11
Baldwin and the looming crisis in Jerusalem
Military prowess in Frankish society was a highly regarded attribute and prerequisite for kingly respect and authority. Baldwin, by training and temperament, was a knight, implying physical courage and a sense of honor, always focused on his paramount duty to defend the Holy Land. He not only adapted to the progression of his disabling neurological disability but continued to execute his political duties astutely and perform successfully as a battlefield warrior king. This was of utmost importance in the prevailing conditions of Baldwin’s royal domain, threatened by invasion from Saladin’s coalition of Muslim forces, in an arc from Syria to Egypt.12
Baldwin used all military and diplomatic channels to deal with the crisis in the Kingdom and appealed for help from Catholic Western Europe, known collectively as the “Latin West” (Jerusalem and the other Crusader states, intimately linked by religion and culture, were known as the “Latin East”). A desperate plea for help came in 1184 in Paris when Heraclius Patriarch of Jerusalem (the most senior member of the clergy), accompanied by both Grand Masters of the Templars and Hospitallers Orders, presented the keys of Jerusalem and the Tower of David to King Philip, who rejected them.13 Moving on to London, the delegation begged Henry II to lead an army to the Holy Land, but he offered them gold instead. The delegation responded:
“We have come in search of a sovereign not a subsidy.” 14
Baldwin, as king and overall commander, could have delegated military leadership to Jerusalem’s Constable, the chief military officer of the royal household. Instead he chose to lead the army from the front, despite the fact he was effectively one-handed and needed help mounting his horse and putting on armor. Baldwin’s greatest triumph came at Mont Gisard, Gaza, close to the Egyptian border, where he inflicted a crushing defeat on Saladin’s larger invading force. As regional tensions mounted, Baldwin repeatedly responded to border raids even when severely disabled.15 Eventually immobilized, he was transported on a litter slung between the horses of two knights. Blindness followed shortly after, probably from corneal ulceration after neuropathic impairment of his blink reflex. Intellectually sharp, but aware of his physical limitations, he offered abdication, but in tribute to his leadership, this was rejected. The terminal phase, marked by fevers and death in 1185, may have been recurrent sepsis from multiple limb ulcers.
Baldwin IV was succeeded by his sickly nine-year-old nephew Baldwin V, “the Child King.” Baldwin V died within a year, and the kingdom spiralled into a bitter, factional, succession crisis. Queen Sybil further inflamed the situation when she crowned her new husband, Guy de Lusignan, who became the last King of Jerusalem. Saladin’s invasion of Galilee came in 1187, two years after Baldwin IV’s death, resulting in the Fall of Jerusalem and the contraction of the kingdom to a foothold around the port of Tyre.16
The effect on the “Latin West” was electrifying. Pope Urban reputedly died of grief after hearing the news, and the shockwaves triggered the Third Crusade. Richard the Lionheart, after defeating Saladin at Arsuf, reached the walls of Jerusalem, but, in one of the most controversial moments in crusading history, he turned his army around and chose not to enter the Holy City.17
Earlier scholars assume Baldwin must have been open to manipulation by advisors and unfairly apportioned blame for the later catastrophe of the Fall of Jerusalem. Physical vulnerability was overridden by his intellect, strength of character, and leadership. Historical interpretation by Hamilton, Riley-Smith, Phillips, and others persuasively argues that Baldwin marshalled his resources effectively, as he demonstrated in successes at Mont Gisard, Gaza, where he repelled the invasion threat and played a “dynamic role” in the affairs of the Kingdom.18 The Fall of Jerusalem did not occur on Baldwin’s watch, but resulted two years later from the constitutional crisis, political vacuum, and divisive factionalism of his heirs to the kingdom.19
The political, cultural and religious legacy of the medieval Kingdom of Jerusalem continues to resonate. On the termination of the British Palestinian mandate in 1948 and the birth of the new state of Israel, the London Times commented: “Here the political temperature never falls below the danger mark.”20 This view was echoed by Tony Judt, Professor of Modern History at New York University and controversial commentator on the polarization of contemporary Arab-Israeli relations.21 Judt, like Baldwin, suffered an incapacitating neurological disease (Lou Gehrig or amyotrophic lateral sclerosis) and also remained intellectually active to the end.
To Dr. John Doran, Senior Lecturer, University of Chester for opening the door to the surprises of Medieval History and Dr. Keith McLay, Head of History, for encouraging his mature students to blossom. To wise physicians everywhere who teach the art as well as the science of Medicine.
- James Hannam, “The T-O Mappae Mundi” in God’s Philosophers: How the Medieval World Laid the Foundations of Modern Science (London: Icon Press, 2009) pp. 36-37.
- William of Tyre, XXI,1, pp.114-115.
- Mitchell Piers, “An Evaluation of the Leprosy of King Baldwin IV of Jerusalem in the context of the Medieval World” in Bernard Hamilton, The Leper King and his Heirs (Cambridge: Cambridge University Press, 2000) pp. 245-258.
- William of Tyre, XXI, 1, p. 962.
- Imad ad-Din al-Isfahani, La conquête de la Syrie et de la Palestine par Saladin, tr. H. Masse, DRHC 10 (Paris, 1972), p.18.
- A reference to the Seven Penitential Psalms, as in the Gordon Collection, University of Virginia.
- Robert Schenck, “A Trip to the Leprosarium: Forgotten People and their Hope for Treatment,” Hektoen International, Vol. 1, 4 (2009).
- P. D. Mitchell, “The Leprosy of King Baldwin IV of Jerusalem: Mycobacterial Disease in the Crusader States of the 12th and 13th Centuries.” International Journal of Leprosy 61(2) (1993), pp. 283-91.
- M. Barber, “The Order of Saint Lazarus and The Crusades,” Catholic Historical Review 80 (1994), pp. 439-56.
- World Health Organization, Epidemiology of Leprosy in Relation to Control, Technical Reports Series no. 716 (Geneva, 1985).
- National Hansen’s Disease (Leprosy) Program Data and Statistics, 2006.
- Jonathan Phillips, “Saladin, The Leper King and The Fall of Jerusalem” in Holy Warriors; A Modern History of the Crusades (London: Bodley Head, 2009) pp. 115-8.
- Phillips, Holy Warriors, p.123.
- Roger of Howden, Gesta Henrici, pp. 335-7.
- John France, “The Revival of Latin Christendom and the Crusades in the East” in The Medieval World at War, ed. Matthew Bennett (London: Thames and Hudson, 2009) pp. 101-2.
- R.C. Smail, “The Latin Field Army in Action” in Crusading Warfare, 1097-1193 (Cambridge and New York: Cambridge University Press, 2005) pp. 189-199.
- Jonathan Riley-Smith, “The Third Crusade” in The Crusades 2nd ed., (London and New York: Continuum, 2005) p. 145.
- See reviews of Crusader State sources and historiography in Riley Smith, Phillips. and especially Hamilton, “Prologue and Sources for Baldwin IV’s Reign” in Leper King, pp. 2-20.
- Hamilton, “The Heirs of the Leper King” in Leper King pp. 225-230.
- London Times, August 30, 1948.
- New York Times, August 7, 2010, William Grimes, “Tony Judt Chronicler of History,” Obituary
DR. JOHN J. TURNER is a consultant physician at University Hospital Aintree in Liverpool in the United Kingdom and former Clinical Director and Head of Medicine. After training at St. Mary’s Hospital, Imperial College, London, he held posts at St. Vincent’s University Hospital in Dublin, Ireland and the Nuffield Department of Medicine, University of Oxford. He is a Fellow of the Royal College of Physicians of London and Fellow of the Royal Society of Medicine, currently balancing hospital work with an MA in History at the University of Chester England.