14 April, 2010

Early medieval surgical knowledge

Occasionally I get asked whether the medical details in Paths of Exile have any basis in history. As is often the case for the seventh century, direct evidence is thin on the ground, though surviving evidence from other areas provides a starting point for inference and extrapolation.*

I suppose I should add a disclaimer: this article is for historical and literary interest only, and in no way represents any medical advice of any kind. If you are looking for medical help, consult a qualified medical practitioner.

Evidence

Bede
In his Ecclesiastical History, Bede tells us that Saint Etheldreda (Aethelthryth), Abbess of Ely, underwent surgery for a tumour on her neck:

…the physician Cynifrid, who was present at both her death and exhumation. Cynifrid used to relate that during her last illness she had a large tumour under the jaw. “I was asked,” he said, “to open the tumour and drain away the poisonous matter in it. I did this, and for two days she seemed somewhat easier […]
There I saw the body of the holy virgin taken from its grave […] and when they had uncovered her face, they showed me that the incision which I had made had healed [….] there remained only the faint mark of a scar.”
--Bede, Ecclesiastical History, Book IV, Ch. 19

The matter-of-fact tone of Bede’s account indicates that surgery was accepted as normal. The apparent healing of a surgical scar after death is treated as a miracle (I can think of natural explanations, not all of them unpleasant), but the surgery itself is treated as a routine procedure with nothing magical or mystical about it. Etheldreda died in 660, and Bede was writing in 731. From this we can reasonably conclude that surgery was known and practised in the late seventh and early eighth century in England, although how widely is a matter for conjecture. It may have been confined to the religious and social elites; Etheldreda was a king’s daughter and a queen before she became an abbess. Unfortunately (perhaps because it was routine), Bede gives no details of the techniques used.

Leechbook of Bald

The Leechbook of Bald is an Old English medical textbook, compiled in the late ninth or early tenth century possibly as a result of Alfred the Great’s encouragement of learning and scholarship. Some of the information contained in it may also have been in circulation in earlier centuries. The Leechbook does not have very much to say on surgery, but does mention it in a couple of places:

For hare lip, pound mastic very small, add the white
of an egg, and mingle as thou dost vermillion, cut
with a knife the false edges of the lip, sew fast with
silk, then smear without and within with the salve,
ere the silk rot. If it draw together, arrange it with
the hand ; anoint again soon.
--Leechbook of Bald, Book I chapter 13, translated by Cockayne, 1860, searchable online

If someone’s bowels be out [….] put the bowel back into the man, sew it together with silk
--Leechbook of Bald, Book III chapter 73, translated in Pollington 2000

Again, there is not much in the way of detail, perhaps because a surgeon or medic of the time would be expected to know the techniques. Silk sutures have a long history in surgery, although they have now been largely displaced by modern synthetic materials (Kuijjer 1998). It can reasonably be inferred from these terse references that surgery was known and practised when the Leechbook was compiled. The instructions for hare lip indicate that plastic surgery was in use at this date, and also suggest that surgery was not necessarily confined to trauma or life-threatening conditions. This may further imply that the success rate was reasonable, making the surgical risk worth taking for the benefit of repairing a hare lip.

Celsus, De Medicina

De Medicina (‘On Medicine’) is a Roman medical textbook dating to about the first century AD and attributed to an author called Celsus.

Celsus provides a detailed description of abdominal surgery techniques:

Sometimes the abdomen is penetrated by a stab of some sort, and it follows that intestines roll out. When this happens we must first examine whether they are uninjured, and then whether their proper colour persists. If the smaller intestine has been penetrated, no good can be done, as I have already said. The larger intestine can be sutured, not with any certain assurance, but because a doubtful hope is preferable to certain despair; for occasionally it heals up. Then if either intestine is livid or pallid or black, in which case there is necessarily no sensation, all medical aid is vain. But if intestines have still their proper colour, aid should be given with all speed, for they undergo change from moment to moment when exposed to the external air, to which they are unaccustomed. The patient is to be laid on his back with his hips raised; and if the wound is too narrow for the intestines to be easily replaced, it is to be cut until sufficiently wide. If the intestines have already become too dry, they are to be bathed with water to which a small quantity of oil has been added. Next the assistant should gently separate the margins of the wound by means of his hands, or even by two hooks inserted into the inner membrane: the surgeon always returns first the intestines which have prolapsed the later, in such a way as to preserve the order of the several coils. When all have been returned, the patient is to be shaken gently: so that of their own accord the various coils are brought into their proper places and settle there. This done, the omentum too must be examined, and any part that is black is to be cut away with shears; what is sound is returned gently into place in front of the intestines. Now stitching of the surface skin only or of the inner membrane only is not enough, but both must be stitched.
[detailed instructions on stitching technique follow]
--Celsus, De Medicina, Book VII Ch. 16, available online

Having said that a wound to the small intestine is hopeless, Celsus also provides instructions for diagnosis:

The signs when the small intestine and the stomach have been wounded are the same; for food and drink come out through the wound;
--Celsus, De Medicina, Book V Ch. 26, available online

The standard antiseptic appears to have been honey, which Celsus recommends in many places for the cleaning of wounds (e.g. after draining an abscess):

…a little honey will be infused into the cavity to clean it...

-- Celsus, De Medicina, Book V Ch. 2, available online

Honey has antiseptic properties due to its high sugar concentration. When bacteria are exposed to a high concentration of sugar (or anything with a high osmolarity), water is drawn out of the bacterial cells and they become dehydrated and die. Honey may have some specific antibacterial properties in addition to the effect of its high sugar concentration, though this has not been confirmed (Moore et al 2001). Honey and/or sugar paste are sometimes used for the treatment of wounds in modern surgical practice (Moore et al 2001; Newton 2000) and in veterinary medicine (Matthews and Billington 2002).

Celsus clearly had detailed and practical knowledge of surgery, including the treatment of stab wounds to the abdomen. I wonder if he was a retired Roman army surgeon, or had access to someone who was.

A specialist military medical corps was introduced by Emperor Augustus in the first century AD, when the Roman Army became a professional standing army composed of trained (and therefore expensive) soldiers (Jackson 1988). Roman military doctors were highly respected, and probably also treated civilians living near army bases. Jackson (1988) suggests that the Roman army was probably the most powerful single agency in spreading Roman medicine around the empire. Some Roman army doctors may have settled locally and continued in civilian practice after their retirement (Jackson 1988), thus potentially establishing a source of Roman medical techniques that could continue independently of the army, if, for example, the local army unit was transferred to another base. Medical expertise has obvious utility in any society, and it would be reasonable for at least some medical knowledge to be handed down as doctors trained their successors. How much knowledge could have been transmitted, for how long, and how garbled it got, is open to question. Nevertheless, it does not seem unreasonable to me that at least some of the skills in Celsus’ textbook could have been handed down to early medieval Britain. The Christian Church, with its Latin literacy and respect for learning, is the most obvious method of transmission, but not necessarily the only one.

Heimskringla

Heimskringla is a collection of sagas about the kings of Norway, written by the Icelandic poet Snorri Sturluson in the thirteenth century. The saga of King Olaf Haraldson (St Olaf) describes how the king’s skald Thormod was treated for his wounds after the battle of Stiklestad in 1030:

The girl said, "Let me see thy wound, and I will bind it."
Thereupon Thormod sat down, cast off his clothes, and the girl
saw his wounds, and examined that which was in his side, and felt
that a piece of iron was in it, but could not find where the iron
had gone in. In a stone pot she had stirred together leeks and
other herbs, and boiled them, and gave the wounded men of it to
eat, by which she discovered if the wounds had penetrated into
the belly; for if the wound had gone so deep, it would smell of
leek.
--Heimskringla, available online

This is consistent with Celsus’ method for diagnosing a perforated intestine (see above); if the intestine has been pierced, food (or in this case the smell of food) will come out of the wound. So the same knowledge was being applied in eleventh-century Norway (if the account is an accurate description of the battle; or in thirteenth-century Iceland if it is something that Snorri added from his own experience) and in first-century Rome. This could reflect continuity in the transmission of knowledge, as suggested above, or it could reflect empirical discoveries made independently. A warlike society has plenty of opportunity for studying wounds, and skills that increased the recovery rate from battlefield trauma would have been of obvious value to kings and warlords. It’s also worth noting that in the Norse saga it is a woman who examines the wounds and makes the diagnosis. Nursing is a traditional female occupation, and it seems that in the Norse world at least it could extend into specific medical treatment.

Archaeology

Usually the only part of a body that survives to be discovered by archaeology is the skeleton, so any soft tissue surgery would have disappeared without trace. Only surgery that directly affects the bones would leave evidence on the skeleton, and then only if the bones are sufficiently well preserved. So one would expect the archaeological record to under-report surgery, perhaps to a large extent.

Nevertheless, various archaeological excavations have found evidence for surgery in pre-Norman Britain. For example:

  • evidence of brain surgery in a young woman in Donegal in around 800 AD. Her skull had a hole cut in it, and bone growth around the hole showed that she had survived the operation (reported in the Irish Times, 10 November 2009)

  • evidence of surgical treatment of a fractured skull in a man in Wharram Percy, Yorkshire, in 960-1100. The man was aged about 40 and had suffered a depressed fracture of the skull caused by a blow from a blunt weapon. Left untreated, the depressed bone fragments would have pressed on the brain and proved fatal. Surgery had removed the bone fragments, and the fracture had healed (reported in BBC News, October 2004)


By their nature, reports such as these are sporadic; they show us that cranial surgery happened at those times and places but do not say how widespread it was. However, Wharram Percy is an ordinary village, not an elite settlement. Unless the man at Wharram Percy was unbelievably lucky that a skilled healer happened to be passing through the area at just the time he had his skull fractured (which is possible), this may suggest that high levels of medical skill were more widely available than popular stereotype would suggest.

Interpretation

Surgical knowledge and techniques with a sound basis, sometimes still reflected in current or recent practice, were clearly known in first-century Rome, early medieval Britain and eleventh-century Norway. Whether these represent the same body of knowledge being handed on, or the independent empirical discovery of effective techniques, or both, is open to question.

Surgical treatment of trauma tends to be an acute procedure, in which the cause of the problem is clearly identifiable (the injury or lesion) and the link between treatment and outcome is direct and likely to be apparent fairly quickly. These features support the empirical development of new skills and the evaluation of old ones; when the link between cause and effect is readily recognisable, you can see what works and what doesn’t. A warlike society has plenty of opportunity to observe wounds and gain experience in treating them, and veterinary experience may provide additional knowledge that can be applied. It is therefore quite possible that the same or similar techniques were invented independently at different times and places. Continuity of transmission is possible, but not necessary.

Skilled surgery may have been confined to the military, religious and social elite. Bede and Heimskringla both describe surgery in high-status contexts, a royal abbess and a king’s warband, respectively. It is impossible to say how far access to skilled surgeons extended into the wider population. However, the man at Wharram Percy may indicate that high levels of surgical skill were widely available (although he may just have been very lucky), and unless the girl at Stiklestad was attached to the king’s household (which is possible) her medical skills were presumably available to her local community. Access to skilled and effective surgery may have been more widespread than popular stereotypes about the ‘Dark Ages’ would like to believe.

References

Bede, Ecclesiastical history of the English people. Translated by Leo Sherley-Price. Penguin Classics, 1968, ISBN 0-14-044565-X.
Celsus, De Medicina, available online
Heimskringla, available online
Jackson R. Doctors and diseases in the Roman empire. British Museum Press, 1988, ISBN 0-7141-1398-0
Kuijjer PJ. History of healing: wound suturing. Ned Tijdschr Geneeskd 1998;142:473-479. English-language abstract available online on PubMed
Leechbook of Bald. Translation by Cockayne, searchable online
Matthews KA, Billington AG. Wound management using sugar. Veterinary Compendium 2002;24:41-50, available online. Note: some of the photographs in this article may be upsetting. If you’re squeamish, consider yourself warned.
Moore OA, Smith LA, Campbell F, Seers K, McQuay HJ, Moore RA. Systematic review of the use of honey as a wound dressing. BMC Complementary and Alternative Medicine 2001;1:2, available open-access online
Newton 2000. Using sugar paste to heal postoperative wounds. Nursing Times 2000;96:15, available online
Pollington S. Leechcraft: Early English charms, plantlore and healing. Anglo-Saxon Books, 2000, ISBN 978-1-898281-23-8.


*If you’ve read Paths of Exile, you may recognise the sources of some of the medical techniques used in the story.

13 comments:

Doug said...

So Thormod was diagnosed using Severa's technique! No doubt it was always worth a try cutting somebody open and sewing them up, if the alternative was death, although I am surprised that they repaired hare lips, which are not fatal when an operation might have been. Feeding the patient smelly herbs to see if the smell escaped is quite a sophisticated notion, however. The major advances in surgery in recent times are usually thought to be antisepsis and anaesthetic, and it is fascinating to see that they had antiseptic techniques. I believe the standard anaesthetic was to have the patient hopelessly drunk, which must have had risks of its own.

Bernita said...

I've always been of the opinion that surgery has been practised in some form from the time we've had sharp things and needles.
The widening of the intestinal wound to facilitate repair indicates considerable practise.

Carla said...

Doug - Yes, he was :-) Or, if you prefer, Eadwine was diagnosed using the girl at Stiklestad's technique. As Celsus says, a doubtful hope is preferable to certain despair, so I would imagine that surgery for traumatic injuries was often worth a try. The mention of repairing hare lips, which as you say are not fatal, suggests to me that the success rate from surgery of that type was pretty good and the risk low.

Agreed, the major technical advances that made modern surgery possible are antisepsis and anaesthesia. Applying honey to a wound is probably nothing like as effective as Lister's carbolic spray, let alone modern antibiotics, but it would be a good deal better than nothing. Pre-anaesthesia surgery relied largely on speed, and complicated procedures would have been out of the question, as would most deep surgery in the absence of muscle relaxants. A trauma patient might be unconscious from shock, which could be a very crude approximation to general anaesthesia (!), and there were sedatives like henbane and opium as well as alcohol that might have taken the edge off the pain, but they would have been terribly hit and miss.

Bernita - indeed. Isn't there evidence of trepanning from way back in the Neolithic?

Annis said...

Fascinating stuff, Carla.

Re operating on patients without anaesthesia, results of examinations at the medieval Augustinian monastery and hospital at Soutra shows that the monks used opium, black henbane and hemlock, presumably to deaden pain and during surgical procedures, and it seems to me quite possible that earlier healers would also have known of and used herbs in similar ways.
Article here

Gabriele C. said...

Trepanning goes long back into history. And suffering from the occasional bout of migraine, I can understand that you may reach a point where the idea that someone drills a hole into your skull to let the evil spirit out sounds pretty good.

Roman medicine is a fascinating topic. It's amazing how much they already knew, and a pity how much of it got lost during the Middle Ages - though it seems you were still better off in the 7th century than the 13th. ;) Another interesting aspect is the fact that there must have been female physicians in Rome. Two burials have been found at the Rhine, and if you consider how few burials get discovered in the first place, the must have been some girls around. :)

Carla said...

Annis - many thanks for the link! I've come across the Soutra research before (though not the Bitter Vetch - that was a new one on me! I wonder if anyone's researching it for modern use?). I agree, it seems entirely possible that the medicinal uses of plants may extend back to earlier times. Medieval Islamic medicine made great advances in surgery. Maintaining the delicate balance between being sufficiently unconscious not to feel (or at least not to remember) pain while still being able to breathe unaided must have been quite a feat!

Gabriele - Roman surgery seems fairly practical and solidly based, but I can't say I have much faith in the four humours :-) There unquestionably were female medical practitioners in the Roman empire, as the tombstones prove. Whether they were the equivalent of moden obstetrics and gynaecology specialists or practiced medicine more generally, or both, seems to be uncertain.

Rick said...

I wonder how this fits in with the perception, which we discussed here not long back, that premodern medicine was worse than worthless.

It may be a matter of different branches of medicine, and perhaps different classes of patients. I don't know how it was in either imperial Rome or AS England, but in the Renaissance surgeons were basically craftspeople, with much lower status than formally educated physicians.

The irony of humble barber-surgeons knowing what they were doing, while physicians were practicing sheer quackery, is so rich that it triggers a warning light that we might be stereotyping the past, a sophisticated version of 'medieval people never took baths.'

For one thing, the practice of formal physicians was pretty much confined to the elite, pushing them toward 'celebrity medicine.' The king, like Michael Jackson, got the treatment he wanted, not the treatment an independent doctor would recommend.

It would be interesting to know the health outcomes in well educated monastic orders, where medical care presumably followed the theories of the time, but the doctors weren't the patients' servants.

Carla said...

Rick - I'd say that the effectiveness or otherwise of treatment depends on the nature of the condition, the ability to make an accurate differential diagnosis, and the tools available to treat it. If the patient has an obvious injury - a broken bone, a dislocated joint, or a wound - the problem is easily identified. The effect of the intervention is likely to be apparent - the wound heals up, the bone mends, the joint becomes functional again, or doesn't - so it's possible to observe a direct link between intervention and effect. This makes it possible to build up and test a body of practical knowledge based on some sort of empirical evidence, even if imperfect.
In contrast, a symptom like, say, difficulty in breathing could arise from many different underlying causes. Off the top of my head I can think of: viral infection, bacterial infection, cancer (primary or secondary), chronic inflammation e.g. asbestosis, allergic reactions, bronchoconstriction, pulmonary oedema secondary to congestive heart failure. There are probably plenty more. A treatment that was effective against any one of these underlying causes would work in patients in whom the symptom was due to that cause but have no useful effect in the others - e.g. bronchodilators work fine in asthma but not in lung cancer, digitalis might help congestive heart failure but won't do anything for cancer. Furthermore, some of the conditions may be self-limiting and get better by themselves without, or despite, intervention - e.g. infection may be cleared by the immune system, allergic reactions resolve if exposure to the allergen is removed or reduced. Chronic conditions that take years to build up may be impossible to reverse once they have passed a certain stage. This makes it very difficult to disentangle the effect of intervention from all the other factors that influence the patient's condition, and consequently difficult to tell the difference between treatments that improve the patient's condition, treatments that have no effect either way, and treatments that make the patient worse. If the patient gets better, you can't tell if it was because the treatment worked or because they had a self-limiting condition that resolved itself. If the patient dies, you can't tell if it was because they were beyond help, because the treatment didn't work, or because the treatment was toxic. Without differential diagnosis you can't tell if a treatment that appeared to work in one patient will also work in another with similar symptoms. (As an example in modern practice, it's only just becoming possible with imaging to tell the difference between an occlusive stroke, which you treat with a clot-dissolving agent, and a haeorrhagic stroke, which a clot-dissolving agent is likely to make worse). All of which makes it very difficult for a physician to identify treatments that are useful, harmful or neutral (and in which patients) until the placebo-controlled trial was invented. So a barber-surgeon may be dealing with an inherently simpler problem than a physician, because it's much easier to identify what's gone wrong - you can see the injury. A medieval physician, on the other hand, is facing a problem rather more like trying to fix a Swiss watch that's stopped ticking, without being able to take the back off, without a map of what all the components do, and probably blindfolded into the bargain.

Carla said...

[continued]
On top of this, the tools available to a premodern physician were very much more limited than his modern counterpart. No antibiotics, for a start - honey may be a reasonable antiseptic for topical application to a wound, but it won't do anything for a lung infection or septicaemia. Whereas the tools for simple surgery - a sharp knife, needle and thread - were all known technology thousands of years ago.
So although there may be a grain of truth in the idea that the low-status barber-surgeon might have been a better bet than the high-status physician, that's perhaps more a reflection of the different problems they were trying to solve and the tools they had available, rather than a comment on the practitioners themselves. It might be fairer to say that the sort of condition a barber-surgeon would treat was inherently more treatable with premodern technology than the sort of condition a physician would treat. Does this make sense?

Rick said...

Yes, it does make sense. Very roughly it corresponds to injuries, which tend to be straightforward, versus diseases, whose symptoms may have no obvious connection to the underlying cause.

I've read that until well into last century, there wasn't a lot a physician could actually do about most diseases other than give a prognosis - whether it was time to get your affairs in order, or a week of bed rest and you'd probably be fine.

Thinking about the theory of humors, though worthless substantively, it is all about balance, and might have produced a lot of generally good health advice. Eat a varied diet, and in moderation, yada yada.

On the other hand, how did people ever convince themselves that bleeding patients was a good idea?

Carla said...

Good question. Bleeding might conceivably have been of some temporary help in high blood pressure, I suppose, but that's about the only rationale I can come up with. I imagine it was so persistent because it comes directly from the flawed four humours model and there was no way of testing it (if you even wanted to) until someone came up with scientific method and the randomised controlled trial. It also looks frightfully dramatic and impressive, so you could see the physician was Doing Something. And sometimes the patient would get better (from a self-limiting condition), in which case the treatment and physician probably got, or at least claimed, the credit.

The healthy living advice proposed by classical doctors - varied diet, moderation, regular physical exercise, get plenty of sleep, not too much alcohol, staying mentally active, etc - has hardly changed at all.

Re your earlier point, I dimly recall that monastic cemeteries indicate that monks did fairly well in the longevity stakes, though how much of that is attributable to monastic physicians and how much to efficient sanitation, good diet and a peaceful existence (pace Viking raiders) is a different question.

Elizabeth Chadwick said...

Very interesting post thank you Carla. I remember reading a few years ago about an anaesthetic called Dwale. I think it was related to Annis' mention in terms of ingredients, although the entire list was uncertain as were the quantities.

Carla said...

Elizabeth - thanks. There are various recipes for dwale from the Middle Ages, and I think they generally feature hemlock, henbane, opium and various other ingredients. Somewhere around I have an article from the BMJ on the subject.