Target Health Blog

Sultan Saladin

July 15, 2019

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History of Medicine
Source:

A possible portrait of Saladin, found in a work by Ismail al-Jazari, circa 1185
Graphic credit: by Ismail al-Jazari (1136-1206) - This file has an extracted image: File:Portrait of Saladin (before A.D. 1185).jpg., Public Domain,
https://commons.wikimedia.org/w/index.php?curid=47091613

The most famous Crusader castle, the Krak des Chevaliers in Syria survives to this day. The loss of Jerusalem after the defeat of a large Crusader army at Hattin resulted in the launch of the Third Crusade (1187-1191). The Third Crusade is perhaps history's most famous Crusade due mainly to the charismatic leaders of the opposing Christian and Muslim forces. Salah ad-Din Yusuf ibn Ayyub, or to the Western world, Saladin (1137/38-1193), was the famous Kurdish leader who founded the Muslim Ayyubid Dynasty. Saladin defeated the Crusaders at the strategic battle of Hattin in 1187. Saladin consolidated control over Egypt; defeating rival Muslim Fatimids and expanded his Ayyubid Sultanate to include Syria, Mesopotamia, Yemen, Hejaz and parts of North Africa.

Christian forces during the Third Crusade were commanded by Emperor Frederick Barbarossa, King Phillip of France and King Richard I of England, also known as Richard the Lionheart. During the Battle of Arsuf, King Richard's forces defeated Saladin's army and recaptured the strategic city of Jaffa. Christian control of the area was recovered and allowed Richard to sign a peace treaty with Saladin. The Kingdom of Jerusalem was reestablished and the Third Crusade ended. It was widely discussed and recorded throughout both the Christian and Muslim worlds that both leaders, Richard and Saladin, demonstrated noble and chivalrous behavior during their battles and consequent peace negotiations. Rather than becoming a hated figure in Europe, Saladin became a celebrated example of the principles of chivalry. Richard became a feared but respected symbol of Christian power and chivalry.

Dynastic infighting among different Muslim sultanates and the invasions of the ferocious Mongol hordes distracted Muslim forces from the remaining Crusader Kingdoms. Additionally, Christian infighting, the decline of Byzantine power, political intrigue and the decline of Papal authority impacted the fervor and power of consequent Crusader campaigns. Saladin may not be well known in the West, but even 800 years after his death, he remains famous in the Middle East. Born in 1137, he rose to become the Sultan of an enormous area that now includes Egypt, Syria, parts of Iraq, Lebanon, Yemen and other regions of North Africa. He successfully led armies against the invading Crusaders and conquered several kingdoms. Historians have described him as the most famous Kurd ever. Saladin died of a fever on 4 March 1193, at Damascus, not long after King Richard the Lionheart's departure. Even today, however, Saladin's death remains a mystery.

Of all the warriors who fought in the Crusades, none cast a larger shadow over the era than this patient. He was the one who annihilated King Guy's army at the Horns of Hattin in 1187 and reclaimed Jerusalem for Islam after it had been ruled for nearly a century by a Christian coalition of “Franks.“ And yet, he became a figure of myth and legend more for his image as a “noble enemy“ than for his victories on the battlefield. Only fragments of the patient's medical history are known.

Salah ad-Din Yusuf Ayyub was born in Tikrit in 1138 to a Kurdish family originating from a highland village in Greater Armenia. His first serious illness apparently began in December 1185, when he was 47 and besieging Mosul. The illness lasted more than two months and was so severe his associates thought he would die. No records exist of its signs or symptoms, though some have speculated that fever was a prominent feature of the illness. The patient improved, though his health seems to have waxed and waned with recurrent bouts of “fever and colic“ in the months that followed. Although sufficiently recovered to lead his troops in battle in July 1190, by October of that year, he was again ill with an attack of what was called “bilious fever,“ which confined him to bed for a month. A close associate was similarly affected with “two successive fevers,“ suggesting that both his illness and the patient's involved periodic fevers. The patient then seems to have done well until overtaken by his final illness at age 56.

He was feeling old then, and complained of loss of appetite, weakness, lassitude, and indigestion. Though the weather was damp and cold, he eschewed the quilted tunic he always wore in public and “seemed like a man awakening from a dream.“ In the evening, his lassitude increased, and “a little before midnight he had an attack of bilious fever, which was internal rather than external.“ The next day his fever was worse. However, when it was suppressed (by unknown means), he seemed to improve and to take pleasure in conversation with associates. However, from that time, his illness grew more and more serious, with headaches of mounting intensity. Those in attendance began to despair for his life. After being bled on the fourth day of his illness, the patient “grew seriously worse, and the humors of the body began to cease their flow.“ On the sixth day, he was propped into a sitting position and given lukewarm water “as an emollient after the medicine he had taken.“ During the next two days his “mind began to wander.“ By the ninth day of illness, he was stuporous and “unable to take the draught that was brought to him.“ On the 10th day, a clyster was applied twice, which seemed to give him relief. He took a few sips of barley-water. That night, he began to perspire, which his attendants regarded as a hopeful sign. The next day, “the perspiration was so profuse that it had gone right through the mattress and the mats, and the moisture could be seen on the floor.“ On the 12th night, the patient grew weaker, wavering in and out of consciousness. His attendants expected him to die. However, he lingered on until the 14th day of illness. On Wednesday, the 27th of Safer in the year 589 (March 4, 1193), after the hour of morning prayer, the patient died.

After closely examining a range of evidence about Saladin's condition, Stephen J. Gluckman, MD, professor of medicine at the University of Pennsylvania School of Medicine, developed a diagnosis. Dr. Gluckman theorizes that typhoid, a bacterial disease that was very common in the region at the time, is the most likely culprit. Today of course, antibiotics could have greatly helped Saladin. But in the 12th century these medicines did not exist. Dr. Gluckman delivered his diagnosis at the 25th annual Historical Clinicopathological Conference, held at the University of Maryland School of Medicine. The conference is devoted to the diagnosis of disorders that afflicted historical figures; in the past, experts have focused on the diseases of luminaries such as Lenin, Darwin, Eleanor Roosevelt and Lincoln. Dr. Gluckman, an expert on parasitic disorders, has provided care and taught in many countries around the world. He carefully reviewed what is known about the Sultan's medical history. “Practicing medicine over the centuries required a great deal of thought and imagination,“ he says. “The question of what happened to Saladin is a fascinating puzzle.“

Saladin is known for destroying King Guy's army at the Horns of Hattin in 1187 and reclaiming Jerusalem for Islam after it had been ruled for nearly a century by Christian crusaders. He is also famed for treating his enemies generously.

19th-century depiction of a victorious Saladin, by Gustave Dore
Graphic credit: by Gustave Dore -
http://pages.usherbrooke.ca/croisades/big_images/_images_en.htm, Public Domain, https://commons.wikimedia.org/w/index.php?curid=4645401

Gluckman had few details upon which to make the diagnosis, but he was able to rule out several illnesses. Plague or smallpox probably didn't kill Saladin, he said, because those diseases kill people quickly. Likewise, it probably wasn't tuberculosis, because the records didn't mention breathing problems. And it likely wasn't malaria, because Gluckman couldn't find any evidence that Saladin was shaking from chills, a common symptom of the disease. But the symptoms did fit with typhoid, a disease that was very common in that region at that time, Gluckman said. Symptoms of typhoid include high fever, weakness, stomach pain, headache and loss of appetite. The bacterial condition still exists today; every year, about 5,700 people in the United States (75% of whom get the illness abroad) and 21.5 million people worldwide come down with the bacterial infection, according to the Centers for Disease Control and Prevention. Today, antibiotics are prescribed for people with typhoid, but, of course, those weren't available during the 12th century. Still, there is cause for concern going forward, as antibiotic resistance among typhoid bacteria is growing

Typhoid fever is a potentially deadly disease spread by contaminated food and water. Symptoms of typhoid include high fever, weakness, stomach pain, headache, and loss of appetite. It is common in most parts of the world except in industrialized regions such as the United States, western Europe, Australia, and Japan. About 300 people get typhoid fever in the United States each year, and most of them have recently traveled. Globally, typhoid infects about 22 million people a year, and kills 200,000.

Isle of Graia Gulf of Akabah Arabia Petraea, depicting the Pharaoh's Island in the northern Gulf of Aqaba off the shore of Egypt's eastern Sinai Peninsula.
Graphic credit: by David Roberts - This is a retouched picture, which means that it has been digitally altered from its original version. Modifications: Dirt and smudges removed. Banding corrected. Histogram adjusted and colors balanced, with localized adjustments to brightness and color balance.. The original can be viewed here: Isle of Graia.tif. Modifications made by GerardM., Public Domain, Wikipedia Commons

Sources: medschool.umaryland.edu/; Wikipedia

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