Projects
A Survey of the Archaeological and Art Historical Record of the Treatment of Traumatic Injury in the Medieval Period (Selection)
Anthropology 450
April 24, 2006
Chapter 4: Non-Surgical Medical Practices
4.1 Introduction
As in any society, the people of the medieval period attempted to find ways to treat traumatic injury to the skeleton. Using the tools and knowledge available to them, they came up with a variety of methods, both surgical and non-surgical. Many of these treatments were also recorded visually and in writing, in the illuminated manuscripts produced in the period. This chapter will begin by briefly exploring the difficulties in finding evidence of treatment for researchers working with skeletal collections from the late medieval period. It will continue with examples of non-surgical treatment of injury using select late-medieval images and case studies from the archaeological literature.
4.2 Limitations of Anthropological Study
It is important to note that there are limitations on what can be inferred by looking at the skeletal record. Although archaeology can provide material for researchers to hypothesise about the life ways of past peoples, no one can actually know exactly what these life ways were (Thomas and Kelly, 2006). One cannot go back in time to observe the period for one's self. Rather, researchers must compare modern day examples with the collections from the past. These modern day comparative populations, though useful in examining the skeletal record of the past, most likely did not experience the exact same living conditions as the people in the medieval period (Grauer and Roberts, 1996). This opens up the possibility for incorrect assumptions to be made about the historic population. In addition, the burials may have been disturbed by later human (and animal) activities. In the case of the medieval period, many of the settlements and cemetery sites were used for a long period of time. Later developments of these areas may have altered the original burial locations of individuals or destroyed evidence completely (Waldron, 1987). Researchers must take these limitations into account when studying the skeletal record.
4.3 Difficulties in Finding Physical Evidence of Treatment
One of the largest challenges facing researchers in regards to the investigation of medical practices in the medieval period is the poor preservation of materials. Bone is biodegradable, and depending on the conditions of burial, not all of the individuals buried in the medieval period will be available for study in the modern day (Boddington et al., 1987). The main factor that affects the survival of bone in the archaeological record is the composition of the surrounding material in which the bone is buried (Waldron, 1987). Waldron (1987) notes that highly acidic conditions can change the composition of the bone itself, leading to the degradation of the bone. In addition, decomposition occurs extremely quickly when bone is buried in environments with high temperatures and high humidity (Poinar, 1999). These two factors encourage the growth of micro-organisms which weaken the structural integrity of the bone (Haynes et al., 2002). Porosity of the bone itself also is a factor in degradation (Boddington et al., 1987). As the bones of both children and elderly tend to be more porous then those individuals in between, they may be under represented in a cemetery population (Roberts and Manchester, 1995).
In addition, the population that has been excavated for study may not be indicative of the population as a whole. For example, due to cultural practices, certain segments of the population (such as juveniles) may be buried in areas away from the main cemetery (Ortner, 2003; Roberts and Manchester, 1995). Another example of this misrepresentation in the archaeological record, given by Roberts and Manchester (1995), is a gravesite made up of individuals who perished in a battle. These individuals would likely demonstrate an increased frequency of injury caused by interpersonal violence, and the demographics would likely be skewed towards males. In addition, in terms of the study of fracture trauma, perimortem fractures can be easily mistaken for post-mortem damage, and are therefore excluded from studies, giving researchers inaccurate data.
The preservation of materials used in medical treatment itself is also problematic. For example, bones that have been treated with a splint or bandages are rarely found in the archaeological record (Grauer and Roberts, 1996). As Grauer and Roberts (1996) note, this is likely due to the fact that the materials used were generally biodegradable in nature. Such materials could include cloth or leather for the wrappings, and wood to provide stability to the injury and reduce mobility. Elements in soil that lend to the decomposition of these materials include insects, micro-organisms, mould, and worms (Allsopp et al., 2004). Moist and humid conditions also promote the decomposition of these natural materials, as they encourage the growth of the above biotic elements.
4.4 Reduction and Immobilization of Uncomplicated Fractures
In the medieval period, one common type of treatment (similar to the present times) was the setting of a fracture to promote proper healing of the bone. This treatment has been documented in the imagery produced in illuminated manuscripts. One example depicts the setting of a fractured arm (Figure 4.1). In this image, two attendants brace the patient as the medical practitioner sets the break. The accompanying text describes the process. MacKinney (1965) translates, "First restore the bones to their proper places. If the flesh is not broken, one ought to take each part of the bone and lightly and easily pull them, pressing with the hands. [T]he physician joins the bones and reduces them to their proper alignment". The action of setting the fracture is vital to the correct healing of the bones. Though there are many complications that can occur during the healing process, common forms include rotation, angulation, shortening, and non-union of the fractured bone. In addition, these processes can have soft tissue complications, such as the ossification of muscle attachments and can effect mobility and use of the limb. Lovell (1997) describes these complications. Rotation occurs when one half of the bone moves in a clockwise or counter-clockwise direction in relation to the other half. When healing is completed, rotation results in a bone that is no longer in its original alignment. Angulation arises when the distal half of a bone is displaced away from the midline of the proximal half (Lovell, 1997). The healed fracture appears as though the bone has been bent, as there is an angle formed at the fracture site. Shortening of the bone takes place when one half of the break moves to overlap the other half. After healing, the result is that the bone no longer is the same length that it was originally, and is a different length then its contralateral bone. Complications arising from this problem include stress on the joints that are effected by the fracture and possible development of osteoarthritis due to the added stresses (Lovell, 1997; Ortner, 2003). Lovell (1997) notes that it is also possible the opposite side of the body from which the injury occurred can develop, due to that side being required to compensate for the deficiency in the bone length of the side with the break. Finally, a complication that can arise from lack of, or incorrect, reduction of a fracture is non-union. This results when the two halves of a complete break fail to heal together and reattach to each other. In severe cases, if there is damage to the blood supply of the bone, this can result in necrosis of the bone (Ortner, 2003). In sub-adults, complications of fractures can also cause the metaphysis to fuse prematurely, resulting in a bone that does not reach its potential full size (Ortner, 2003).
The text that accompanied the image of the physician setting the bone (Figure 4.1) demonstrates that even in the late-medieval period, people were aware of the importance of correct reduction of fractured bone. In the 21st century, the actual process of setting an uncomplicated fracture of a long bone is similar to that depicted in the early 14th century manuscript, in that it is relatively simple. Though in the present, physicians have access to radiography to determine if the bone is in fact in the correct place and is healing properly, the basic method still remains the same.
Another basic treatment of fractures in long bones in the medieval period was the application of splints. This practice has also been visually documented in manuscripts produced in the period. One example comes from a manuscript produced in Europe, in the 13th century (Figure 4.2). In this image a physician appears to be wrapping a cloth strip around a several wooden pieces placed on the leg to immobilise the injured area. The main purpose of a splint is to reduce the mobility of the fracture, and associated joints, to promote healing. Providing support to the injured area also helps to reduce pain, and reduces the chance of additional injury to the soft tissues surrounding the fractured bone (Elstrom, 2006). Elstrom (2006) also notes that the pressure the splint places on an injury helps to reduce swelling. Presumably, these functions would have been similar in the late medieval period.
Evidence of these healing techniques can be observable in the archaeological record. Although it is rare to find physical evidence such the remains of a splint associated with a burial, due to decomposition of organic materials, evidence for treatment can be observed on the bones themselves. One example of a case study that found evidence for reduction of fractures is Grauer and Robert's 1996 study of the cemetery population of St Helen-on-the-Walls, York, England. In this study, the researchers examined the remains of 1014 adult specimens. Grauer and Roberts (1996) focused on the long bones of the specimens, namely the humerus, radius, ulna, femur, tibia, and fibula. They examined the bones that displayed evidence of shortening, rotation, and angular deformity, due to the fracture. The researchers then made the assumption that evidence of deformity indicated a lack, or ineffective attempt, of treatment of the fracture. Grauer and Roberts (1996), also inferred, "Alignment of the healed fracture bone was recorded as a means to recognise the practice of reduction and splinting," (533). To observe the type of fracture, and the extent of overlap, rotation, and angular deformity present, radiography was used on each fracture. They compared these radiographs with a modern sample population whose injuries were not caused by modern technology, were treated by conservative methods of reduction and splinting, and were declared by the physician to be correctly healed. As a measure of caution, Grauer and Roberts (1996) note that the modern comparative population was well nourished, and that proper healing of fractures in the archaeological population may have been effected by poor health.
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The study was able to detect 41 fractures in 30 individuals, with the most common fracture type being oblique, in the distal end of the bone. Evidence of linear displacement was observed in 26.8% of the cases; However, this type of deformity is the most difficult to set (Grauer and Roberts, 1996). The researchers note that in 61.0% of the cases, there was no observable deformity. They also did not observe any extreme cases of shortening in the 41 fractures. In addition, all but two of the fractures were well healed, and the researchers noted that this is indicative that the fractures occurred long before the deaths of the individuals (Grauer and Roberts, 1996). Grauer and Roberts (1996), conclude that treatment was likely administered to the individuals at St. Helen-on-the-Walls. In regards to fractures of the humerus, the researchers noted that some form of immobilisation of the limb must have been applied, as the degree of overall healing among the individuals displaying this injury was too great to have been left to heal without medical intervention. Fractures of the radius and ulna appear to have received some form of treatment when both of the bones were fractured. The researchers state, "The successful healing of these bones is particularly surprising in light of the instability that fractures of these two bones cause," (Grauer and Roberts, 1996:540). In other words, if left untreated it is unlikely the fractures would have healed as well as was observed in this sample. According to Grauer and Roberts (1996), fractures of the radius and ulna are particularly susceptible to complications of healing, especially rotational deformity, due to the supinating and pronating function of the radius around the ulna. The researchers did observe that in cases where only the radius was fractured, there is less evidence that treatment (if administered) was helpful, or that in these cases, splinting of the fracture was not practiced (Grauer and Roberts, 1996). With the lack of complications in cases where only the ulna was fractured, the researchers conclude that either effective treatment was administered, or that the radius acts as a natural splint for the ulna (as noted by Connolly, 1988 and cited by Grauer and Roberts, 1996). Finally, Grauer and Roberts (1996), discuss fractures occurring in the long bones of the leg. They note that no cases of injury to the fibula were observed without a corresponding fracture of the tibia. Four cases of fractures to the tibia with corresponding fracture to the fibula occurred in the population, and two fractures of the tibia were present. The researchers also note that 50% of the tibia and fibula fractures show evidence of deformity. Oddly, although they note that treatment of tibia and fibula fractures involve setting the bones and then applying splints to immobilize the injuries is standard practice, they do not mention how the specimens they observed do or do not show evidence of treatment. (However, based on their previous observations of the possible treatment of fractures, one can infer that some form of successful treatment took place in at least 50% of the cases). In addition, only one fracture to the femur was observed, with little evidence of complication, except for some mild linear deformity.
Overall, Grauer and Roberts conclude that there is evidence that treatment of fractures was practiced, in the form of reduction and immbolilization of the injury, in the medieval site of St. Helen-on-the-Walls. The images of reduction and splinting that were produced in the late-medieval period of manuscript illumination corroborate the evidence found in the case study.
In addition, there are a small number of cases in the archaeological record of metal plates being employed, both non-surgically and surgically, to treat long bone fractures (Mitchell, 2004). Though metal does corrode, and over time is degraded, it does tend to last longer then softer materials such as wood, cloth, and leather, which are more susceptible to decomposition due to organisms living in the soil (Allsopp et al., 2004). This could be why there are a few instances of metal medical objects preserved in graves. An instance of the non-surgical use of metal plates to treat traumatic injury will be discussed here, with an example of surgical treatment to follow in Chapter 4. The non-surgical example comes from the Gilbertine monastic institution of St. Andrews, York. Knusel and co-workers (1995) studied an individual who suffered a comminuted fracture on the lateral condyle of the right tibia.1 Directly associated with this fracture were two horseshoe-shaped pieces of a copper plate. In several places, attached to the corroded metal, are remains of leather (Knüsel et al., 1995). Presumably, based on the location of the copper plates in relation to the injury, the copper plate, padded with leather, and held in place either with leather straps or twine, would have performed a supportive function to the injured area. Knüsel et al. (1995) notes that the individual likely could still bear weight on the injured limb, based on the condition of the bones. The researchers note that at the time of publication, of the four known examples of medieval fracture treatment involving metal plates to treat an injury, three of the cases displayed the plate in relation to an injury of the upper limbs. The individual studied by Knüsel et al. (1995) was the only one to have the plate supporting a lower limb.
As demonstrated, treatment of long bone fractures through reduction and immobilization of the bone can be evident in the skeletal record. The reverse is also true, in that evidence for the lack of treatment of traumatic injury can be detected in the record. Stirland's 1996 study on Patterns of Trauma in a Unique Medieval Parish Cemetery is an example of a population that did not receive treatment, based on observations of fracture healing in the sample. Stirland (1996) examines 413 individuals from the cemetery population of St. Margaret Fyebridgegate, Norwich. The study examined cranial trauma, vertebral lesions, and fractures, though only the fractures to the long bones will be discussed here, as a comparison with the Grauer and Roberts 1996 study. A total of 29 individuals displayed evidence of fractures in the long bones of the skeleton. Detailing several of the relevant fractures discussed in the study, Stirland (1996) observed a fracture of the tibia displaying rotation, a shortened and linearly displaced radius, and three humeri showing evidence of fracture. The researcher notes that all the above fractures are healed and unreduced (Stirland, 1996). This is evident by the extent of the complications involved in fracture healing, as described in the Grauer and Roberts 1996 study, that would not be as evident if the treatment of setting the fractures had been performed.
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4.5 Uncomplicated Fractures of Short Bones
Thus far, this essay has excluded fractures in short bones from the discussion. The reason for this is twofold; First, I have been unable to locate any images of trauma to the short bones, and secondly, these bones were unlikely to have been treated. Grauer and Roberts (1996), assume that as fractures to the short bones (and the metacarpals and metatarsals) would not cause as crippling an injury as those to long bones; Therefore, treatment for these injuries would not be sought. It can also be hypothesised that an individual presenting these types of injuries would be in pain and would naturally keep them still, or perhaps use a piece of cloth to immobilise the injury without the aid of a medical practitioner.
4.6 Non-Surgical Exploration of injuries to the Cranium
The majority of images from the medieval period depicting wounds to the bones of the cranium involve surgical treatment. However, there are a few examples of non-surgical examination of cranial injuries. One such example is Figure 4.3. In this image, according to the text, the medical practitioner is directing the patient to cover his ears, nose, and mouth, and blow; the theory being that air will escape from a fracture in the cranium, and thereby allow the medical practitioner to diagnose the problem (Hunt, 1992). Hunt (1992) also notes that in this case, the patient is depicted with his legs braced apart, as a sign of the physical exertion required in this test. However, no mention is made of the effectiveness of this method.
There are also several texts that encourage the use of medicated cloths, ointments, and powders as a primary method of treatment in preference to surgical treatment, when possible (MacKinney, 1965). Detailed in one of the manuscripts written by Rogerius Salernitanus, MacKinney (1965), lists one particular treatment of open wounds to the skull: an ointment called apostolicon chirurgicon, the prescription for which is written in the original Latin of the manuscript. Though the treatment of open wounds raises the question of infection, this will be discussed in more detail in Chapter 4.
4.7 Secondary Fractures Due to Disease
Another aspect that must be considered when discussing traumatic injury to the skeleton is the predication of fractures due to other disease processes. This discussion is particularly relevant to the medieval period, due to the heavy presence of the infectious disease of leprosy (Figure. 4.4). I was unable to find any images of lepers with traumatic injuries, but that is likely due to the context in which images of leper patients were produced. These images are generally not found specifically in medical manuscripts, rather they are found in religious texts to promote charity (Richards, 1977). Figure 4.4 is an excellent example of a religious image depicting leprosy. Done in the traditional hierarchical scale2 for religious images, this scene depicts Jesus healing a leper, accompanied by Peter and two unidentified apostles (Brody, 1974). In terms of the art historical context of depictions of leprosy, these figures are depicted with spots because of literary descriptions of them (Brody, 1974). Brody (1974) observes that the written descriptions detail lepers as "being covered with nodules", which is visually translated into spots. It is not until the late 18th century that the actual physical effects of the disease are depicted with any attempt at accuracy (Richards, 1977).
Although leprosy does effect the skeleton, more importantly for the purposes of this essay, it also effects the eyes and the nerve endings, causing a reduction in vision and loss of sensation in the extremities (Roberts and Manchester, 1995; Judd and Roberts, 1998). These losses may lead to an individual having a higher incidence of falls, increasing the chances of sustaining traumatic injury. Judd and Roberts (1998) have studied the effects of this connection. In their study, Fracture Patterns at the Medieval Leper Hospital in Chichester, Judd and Roberts (1998) examine the frequency of long bone fractures at a known leper hospital, and compare the results with frequencies from other sites in England. To begin, the researchers examined 212 adult specimens for evidence of long bone fractures. Originally excavated in 1986-87, the specimens displayed a total of 41 fractures coming from 32 of the individuals (Judd and Roberts, 1998). The researchers radiographed each fracture and noted any evidence of complication, to study indications of treatment (as discussed at length in section 4.3 of this essay). It was determined that the frequency of fractures in the sample was 15.1% (Judd and Roberts, 1998). When compared to four other skeletal populations, it was found that this frequency was much higher than at the other locations. The frequencies of fractures found at these other sites were 5.6%, 5.0%, 6.6%, and 3.3% (Judd and Roberts, 1998). The researchers proposed that leprosy was in fact responsible for the discrepancy. They note that in addition to poor vision and reduced sensitivity, slow reaction-time and vertigo are also associated with the disease of leprosy, which could also increase the chances of accidental injury (Judd and Roberts, 1998).
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4.8 Evidence of Dislocation
When dislocations are properly reduced, not a lot of evidence appears in the skeleton. Lovell (1997) defines a dislocation as an injury to a joint, resulting in the displacement of one articular surface relative to another. A partial dislocation can also occur, in this case, the articular surfaces of the joint still have some connection, but have moved to some extent (Lovell, 1997). Lovell (1997) also notes that dislocations can also occur spontaneously or because of congenital predisposition, though as this essay focuses on traumatic injury, these conditions will not be explored further. When properly treated, though there can be complications visible in bone such as soft tissue ossification, osteoarthritis, and periosteal reaction, it can be difficult to identify these injuries in the skeletal record (Lovell, 1997; Ortner, 2003). If unreduced for an extended period of time, the dislocation can be visible in dry bone because a secondary articular surface is formed, as the joint adjusts to the new location of the bones (Ortner, 2003). However, despite the inability to easily observe the treatment of dislocation, the phenomenon undoubtedly occurred in the period. Evidence of this can be seen in the abundance of visual imagery documenting the treatment of this type of injury from the late medieval period. Figure 4.5 depicts a reduction of the glenohumeral joint, using a pole with a padded section in the centre, held by two assistants, to provide support as the physician pulls down on the patient's arm. Murray Jones (1998) writes that the text accompanying this image describes the procedure in a similar manner to other medieval texts, and also the Hippocratic texts from the 5th century BCE. This type of dislocation is fairly common, as the shoulder joint is designed to provide the widest range of motion possible, but this mobility decreases the stability of the joint (Lovell, 1997; Ortner, 2003). Ortner (2003) notes that the appearance of this type of dislocation in the archaeological record is more prevalent then other types, due to the mechanics of the joint that offers little resistance to traumatic injury. Figure. 4.6 depicts another type of treatment for dislocation: the reduction of a dislocated mandible. The physician pulls upward on the piece of cloth to reduce the patient's jaw, with his feet braced on the patient's shoulders to provide leverage (Murray Jones, 1998).
4.9 Summary
This chapter examined the practice of non-surgical treatment of traumatic injury in the late medieval period. It discussed the reduction and immobilization of long bone fractures and the increased frequency of fractures in individuals afflicted with leprosy, using both anthropological case studies and manuscript illuminations produced in the late-medieval period of image making. The chapter also used images to discuss dislocations and non-surgical exploration of cranial injuries, as these conditions do effect the skeleton, though evidence of treatment in these cases can be difficult to ascertain in the skeletal record.
Endnotes
1 For a more complete description of the injury and the observed osteological complications in relation to the injury, refer to Knüsel et al. 1995.
2 Hierarchical scale refers to the relative sizes of the figures in relation to one another, with the tallest figure being the most important (Stokstad, 2001). In this case, Jesus is the tallest, the apostles next, and finally the leper, being the smallest and, therefore, the least important figure in the religious hierarchy.
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Figures
Figure 4.1. Setting a fractured arm. C.1300.
Rome: Casanatense Library, MS 1382, folio 22. Rolandus Parmensis, Chirurgia III, 17. (Mackinney, 1965)
Figure 4.2. Application of a splint for an injury to the lower leg. C.13th century.
London: British Library, MS Sloane, 1977 folio 9R. Roger of Parma. Livres de Cyrugie. (Mitchell, 2004)
Figure 4.3. Test for a cranial fracture, c. 1250.
Cambridge: University of Cambridge, MS O.1.20, Book 1, 6; folio 243R. (Hunt, 1992).
Figure 4.4. Jesus, with three apostles, healing a leper, c. 1000.
Top register from the Gospel Book of Otto III. Munich: Bayerische Staatsbibliothek, MS Latin 4453, folio 97V. (Brody, 1974).
Figure 4.5 Reducing a dislocated shoulder, early 14th century.
London: British Library, Sloane MS 1977, folio 6. (Murray Jones, 1998).
Figure 4.6 Reducing a dislocated jaw, c. 1300.
Rome: Biblioteca Casanatense. MS 1382, folio 19. (Murray Jones, 1998).
Works Cited (Chapter 4 only)
Allsopp D, Seal K, and Gaylarde C. 2004. Introduction to biodeterioration. 2nd ed. Cambridge: Cambridge Univ. Pr.
Boddinton A, Garland AN, and Janaway RC. 1987. Flesh, bones, dust, and society. In Boddington A, Garland AN, and Janaway, RC, editors. Death, decay and reconstruction: Approaches to archaeology and forensic science. Manchester: Manchester Univ. Pr.
Brody SN. 1974. The disease of the soul: Leprosy in medieval literature. Ithaca, NY: Cornell Univ. Pr.
Grauer AL, and Roberts CA. 1996. Paleoepidemiology, healing, and possible treatment of trauma in the medieval cemetery population of St. Helen-on-the-walls, York, England. Am J Phys Anthropol 100:531-544. Wiley Interscience Online [Accessed November 12, 2005]
Haynes S, Searle JB, Bretan A, and Dobney KM. 2002. Bone preservation and ancient DNA: The application of screening method for predicting DNA survival. J Archaeol Sci 29(6):585-592
Hunt T. 1992. The medieval surgery. Woodbridge, Suffolk: Boydell Pr.
Judd MA, and Roberts CA. 1998. Fracture patterns at the medieval leper hospital in Chichester. Am J Phys Anthropol 105:43-55. Wiley Interscience [Accessed November 19, 2005]
Knüsel CJ, Kemp RL, and Budd P. 1995. Evidence for remedial medical treatment of a severe knee injury from the Fishergate Gilbertine monastery in the city of York. J Archaeol Sci 22:369-384.
Lovell NC. 1997. Trauma analysis in paleopathology. YB Phys Anthropol 40:139-170.
MacKinney LC. 1965. Medical illustrations in medieval manuscripts. London: Wellcome Historical Medical Library.
Mitchell PD. 2004. Medicine in the crusades: warfare, wounds and the medical surgeon. Cambridge UK: Cambridge Univ. Pr.
Murray Jones P. 1998. Medieval medicine in illuminated manuscripts. Revised edition. London: The British Library.
Ortner DJ. 2003. Identification of pathological conditions in human skeletal remains. Second edition. Amsterdam: Academic Pr.
Poinar,G. 1999. Ancient DNA. American Sci 87(5):446-457
Richards P. 1977. The medieval leper and his northern heirs. Cambridge: DS Brewer
Roberts C, and Manchester K. 1995. The archaeology of disease. 2nd ed. Ithaca NY: Cornell Univ. Pr.
Stirland A. 1996. Patterns of trauma in a unique medieval parish cemetery. Int J Osteoarchaeol 6:92-100.
Thomas DH, and Kelly RL. 2006. Archaeology. 4th ed. Belmont CA: Thomson/Wadsworth.
Waldron T. 1987. The relative survival of the human skeleton: Implications for palaeopathology. In Boddington A, Garland AN, and Janaway, RC, editors. Death, decay and reconstruction: Approaches to archaeology and forensic science. Manchester: Manchester Univ. Pr.
© 2006 Rosanne Lester
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4.1 Introduction
As in any society, the people of the medieval period attempted to find ways to treat traumatic injury to the skeleton. Using the tools and knowledge available to them, they came up with a variety of methods, both surgical and non-surgical. Many of these treatments were also recorded visually and in writing, in the illuminated manuscripts produced in the period. This chapter will begin by briefly exploring the difficulties in finding evidence of treatment for researchers working with skeletal collections from the late medieval period. It will continue with examples of non-surgical treatment of injury using select late-medieval images and case studies from the archaeological literature.
4.2 Limitations of Anthropological Study
It is important to note that there are limitations on what can be inferred by looking at the skeletal record. Although archaeology can provide material for researchers to hypothesise about the life ways of past peoples, no one can actually know exactly what these life ways were (Thomas and Kelly, 2006). One cannot go back in time to observe the period for one's self. Rather, researchers must compare modern day examples with the collections from the past. These modern day comparative populations, though useful in examining the skeletal record of the past, most likely did not experience the exact same living conditions as the people in the medieval period (Grauer and Roberts, 1996). This opens up the possibility for incorrect assumptions to be made about the historic population. In addition, the burials may have been disturbed by later human (and animal) activities. In the case of the medieval period, many of the settlements and cemetery sites were used for a long period of time. Later developments of these areas may have altered the original burial locations of individuals or destroyed evidence completely (Waldron, 1987). Researchers must take these limitations into account when studying the skeletal record.
4.3 Difficulties in Finding Physical Evidence of Treatment
One of the largest challenges facing researchers in regards to the investigation of medical practices in the medieval period is the poor preservation of materials. Bone is biodegradable, and depending on the conditions of burial, not all of the individuals buried in the medieval period will be available for study in the modern day (Boddington et al., 1987). The main factor that affects the survival of bone in the archaeological record is the composition of the surrounding material in which the bone is buried (Waldron, 1987). Waldron (1987) notes that highly acidic conditions can change the composition of the bone itself, leading to the degradation of the bone. In addition, decomposition occurs extremely quickly when bone is buried in environments with high temperatures and high humidity (Poinar, 1999). These two factors encourage the growth of micro-organisms which weaken the structural integrity of the bone (Haynes et al., 2002). Porosity of the bone itself also is a factor in degradation (Boddington et al., 1987). As the bones of both children and elderly tend to be more porous then those individuals in between, they may be under represented in a cemetery population (Roberts and Manchester, 1995).
In addition, the population that has been excavated for study may not be indicative of the population as a whole. For example, due to cultural practices, certain segments of the population (such as juveniles) may be buried in areas away from the main cemetery (Ortner, 2003; Roberts and Manchester, 1995). Another example of this misrepresentation in the archaeological record, given by Roberts and Manchester (1995), is a gravesite made up of individuals who perished in a battle. These individuals would likely demonstrate an increased frequency of injury caused by interpersonal violence, and the demographics would likely be skewed towards males. In addition, in terms of the study of fracture trauma, perimortem fractures can be easily mistaken for post-mortem damage, and are therefore excluded from studies, giving researchers inaccurate data.
The preservation of materials used in medical treatment itself is also problematic. For example, bones that have been treated with a splint or bandages are rarely found in the archaeological record (Grauer and Roberts, 1996). As Grauer and Roberts (1996) note, this is likely due to the fact that the materials used were generally biodegradable in nature. Such materials could include cloth or leather for the wrappings, and wood to provide stability to the injury and reduce mobility. Elements in soil that lend to the decomposition of these materials include insects, micro-organisms, mould, and worms (Allsopp et al., 2004). Moist and humid conditions also promote the decomposition of these natural materials, as they encourage the growth of the above biotic elements.
4.4 Reduction and Immobilization of Uncomplicated Fractures
In the medieval period, one common type of treatment (similar to the present times) was the setting of a fracture to promote proper healing of the bone. This treatment has been documented in the imagery produced in illuminated manuscripts. One example depicts the setting of a fractured arm (Figure 4.1). In this image, two attendants brace the patient as the medical practitioner sets the break. The accompanying text describes the process. MacKinney (1965) translates, "First restore the bones to their proper places. If the flesh is not broken, one ought to take each part of the bone and lightly and easily pull them, pressing with the hands. [T]he physician joins the bones and reduces them to their proper alignment". The action of setting the fracture is vital to the correct healing of the bones. Though there are many complications that can occur during the healing process, common forms include rotation, angulation, shortening, and non-union of the fractured bone. In addition, these processes can have soft tissue complications, such as the ossification of muscle attachments and can effect mobility and use of the limb. Lovell (1997) describes these complications. Rotation occurs when one half of the bone moves in a clockwise or counter-clockwise direction in relation to the other half. When healing is completed, rotation results in a bone that is no longer in its original alignment. Angulation arises when the distal half of a bone is displaced away from the midline of the proximal half (Lovell, 1997). The healed fracture appears as though the bone has been bent, as there is an angle formed at the fracture site. Shortening of the bone takes place when one half of the break moves to overlap the other half. After healing, the result is that the bone no longer is the same length that it was originally, and is a different length then its contralateral bone. Complications arising from this problem include stress on the joints that are effected by the fracture and possible development of osteoarthritis due to the added stresses (Lovell, 1997; Ortner, 2003). Lovell (1997) notes that it is also possible the opposite side of the body from which the injury occurred can develop, due to that side being required to compensate for the deficiency in the bone length of the side with the break. Finally, a complication that can arise from lack of, or incorrect, reduction of a fracture is non-union. This results when the two halves of a complete break fail to heal together and reattach to each other. In severe cases, if there is damage to the blood supply of the bone, this can result in necrosis of the bone (Ortner, 2003). In sub-adults, complications of fractures can also cause the metaphysis to fuse prematurely, resulting in a bone that does not reach its potential full size (Ortner, 2003).
The text that accompanied the image of the physician setting the bone (Figure 4.1) demonstrates that even in the late-medieval period, people were aware of the importance of correct reduction of fractured bone. In the 21st century, the actual process of setting an uncomplicated fracture of a long bone is similar to that depicted in the early 14th century manuscript, in that it is relatively simple. Though in the present, physicians have access to radiography to determine if the bone is in fact in the correct place and is healing properly, the basic method still remains the same.
Another basic treatment of fractures in long bones in the medieval period was the application of splints. This practice has also been visually documented in manuscripts produced in the period. One example comes from a manuscript produced in Europe, in the 13th century (Figure 4.2). In this image a physician appears to be wrapping a cloth strip around a several wooden pieces placed on the leg to immobilise the injured area. The main purpose of a splint is to reduce the mobility of the fracture, and associated joints, to promote healing. Providing support to the injured area also helps to reduce pain, and reduces the chance of additional injury to the soft tissues surrounding the fractured bone (Elstrom, 2006). Elstrom (2006) also notes that the pressure the splint places on an injury helps to reduce swelling. Presumably, these functions would have been similar in the late medieval period.
Evidence of these healing techniques can be observable in the archaeological record. Although it is rare to find physical evidence such the remains of a splint associated with a burial, due to decomposition of organic materials, evidence for treatment can be observed on the bones themselves. One example of a case study that found evidence for reduction of fractures is Grauer and Robert's 1996 study of the cemetery population of St Helen-on-the-Walls, York, England. In this study, the researchers examined the remains of 1014 adult specimens. Grauer and Roberts (1996) focused on the long bones of the specimens, namely the humerus, radius, ulna, femur, tibia, and fibula. They examined the bones that displayed evidence of shortening, rotation, and angular deformity, due to the fracture. The researchers then made the assumption that evidence of deformity indicated a lack, or ineffective attempt, of treatment of the fracture. Grauer and Roberts (1996), also inferred, "Alignment of the healed fracture bone was recorded as a means to recognise the practice of reduction and splinting," (533). To observe the type of fracture, and the extent of overlap, rotation, and angular deformity present, radiography was used on each fracture. They compared these radiographs with a modern sample population whose injuries were not caused by modern technology, were treated by conservative methods of reduction and splinting, and were declared by the physician to be correctly healed. As a measure of caution, Grauer and Roberts (1996) note that the modern comparative population was well nourished, and that proper healing of fractures in the archaeological population may have been effected by poor health.
The study was able to detect 41 fractures in 30 individuals, with the most common fracture type being oblique, in the distal end of the bone. Evidence of linear displacement was observed in 26.8% of the cases; However, this type of deformity is the most difficult to set (Grauer and Roberts, 1996). The researchers note that in 61.0% of the cases, there was no observable deformity. They also did not observe any extreme cases of shortening in the 41 fractures. In addition, all but two of the fractures were well healed, and the researchers noted that this is indicative that the fractures occurred long before the deaths of the individuals (Grauer and Roberts, 1996). Grauer and Roberts (1996), conclude that treatment was likely administered to the individuals at St. Helen-on-the-Walls. In regards to fractures of the humerus, the researchers noted that some form of immobilisation of the limb must have been applied, as the degree of overall healing among the individuals displaying this injury was too great to have been left to heal without medical intervention. Fractures of the radius and ulna appear to have received some form of treatment when both of the bones were fractured. The researchers state, "The successful healing of these bones is particularly surprising in light of the instability that fractures of these two bones cause," (Grauer and Roberts, 1996:540). In other words, if left untreated it is unlikely the fractures would have healed as well as was observed in this sample. According to Grauer and Roberts (1996), fractures of the radius and ulna are particularly susceptible to complications of healing, especially rotational deformity, due to the supinating and pronating function of the radius around the ulna. The researchers did observe that in cases where only the radius was fractured, there is less evidence that treatment (if administered) was helpful, or that in these cases, splinting of the fracture was not practiced (Grauer and Roberts, 1996). With the lack of complications in cases where only the ulna was fractured, the researchers conclude that either effective treatment was administered, or that the radius acts as a natural splint for the ulna (as noted by Connolly, 1988 and cited by Grauer and Roberts, 1996). Finally, Grauer and Roberts (1996), discuss fractures occurring in the long bones of the leg. They note that no cases of injury to the fibula were observed without a corresponding fracture of the tibia. Four cases of fractures to the tibia with corresponding fracture to the fibula occurred in the population, and two fractures of the tibia were present. The researchers also note that 50% of the tibia and fibula fractures show evidence of deformity. Oddly, although they note that treatment of tibia and fibula fractures involve setting the bones and then applying splints to immobilize the injuries is standard practice, they do not mention how the specimens they observed do or do not show evidence of treatment. (However, based on their previous observations of the possible treatment of fractures, one can infer that some form of successful treatment took place in at least 50% of the cases). In addition, only one fracture to the femur was observed, with little evidence of complication, except for some mild linear deformity.
Overall, Grauer and Roberts conclude that there is evidence that treatment of fractures was practiced, in the form of reduction and immbolilization of the injury, in the medieval site of St. Helen-on-the-Walls. The images of reduction and splinting that were produced in the late-medieval period of manuscript illumination corroborate the evidence found in the case study.
In addition, there are a small number of cases in the archaeological record of metal plates being employed, both non-surgically and surgically, to treat long bone fractures (Mitchell, 2004). Though metal does corrode, and over time is degraded, it does tend to last longer then softer materials such as wood, cloth, and leather, which are more susceptible to decomposition due to organisms living in the soil (Allsopp et al., 2004). This could be why there are a few instances of metal medical objects preserved in graves. An instance of the non-surgical use of metal plates to treat traumatic injury will be discussed here, with an example of surgical treatment to follow in Chapter 4. The non-surgical example comes from the Gilbertine monastic institution of St. Andrews, York. Knusel and co-workers (1995) studied an individual who suffered a comminuted fracture on the lateral condyle of the right tibia.1 Directly associated with this fracture were two horseshoe-shaped pieces of a copper plate. In several places, attached to the corroded metal, are remains of leather (Knüsel et al., 1995). Presumably, based on the location of the copper plates in relation to the injury, the copper plate, padded with leather, and held in place either with leather straps or twine, would have performed a supportive function to the injured area. Knüsel et al. (1995) notes that the individual likely could still bear weight on the injured limb, based on the condition of the bones. The researchers note that at the time of publication, of the four known examples of medieval fracture treatment involving metal plates to treat an injury, three of the cases displayed the plate in relation to an injury of the upper limbs. The individual studied by Knüsel et al. (1995) was the only one to have the plate supporting a lower limb.
As demonstrated, treatment of long bone fractures through reduction and immobilization of the bone can be evident in the skeletal record. The reverse is also true, in that evidence for the lack of treatment of traumatic injury can be detected in the record. Stirland's 1996 study on Patterns of Trauma in a Unique Medieval Parish Cemetery is an example of a population that did not receive treatment, based on observations of fracture healing in the sample. Stirland (1996) examines 413 individuals from the cemetery population of St. Margaret Fyebridgegate, Norwich. The study examined cranial trauma, vertebral lesions, and fractures, though only the fractures to the long bones will be discussed here, as a comparison with the Grauer and Roberts 1996 study. A total of 29 individuals displayed evidence of fractures in the long bones of the skeleton. Detailing several of the relevant fractures discussed in the study, Stirland (1996) observed a fracture of the tibia displaying rotation, a shortened and linearly displaced radius, and three humeri showing evidence of fracture. The researcher notes that all the above fractures are healed and unreduced (Stirland, 1996). This is evident by the extent of the complications involved in fracture healing, as described in the Grauer and Roberts 1996 study, that would not be as evident if the treatment of setting the fractures had been performed.
4.5 Uncomplicated Fractures of Short Bones
Thus far, this essay has excluded fractures in short bones from the discussion. The reason for this is twofold; First, I have been unable to locate any images of trauma to the short bones, and secondly, these bones were unlikely to have been treated. Grauer and Roberts (1996), assume that as fractures to the short bones (and the metacarpals and metatarsals) would not cause as crippling an injury as those to long bones; Therefore, treatment for these injuries would not be sought. It can also be hypothesised that an individual presenting these types of injuries would be in pain and would naturally keep them still, or perhaps use a piece of cloth to immobilise the injury without the aid of a medical practitioner.
4.6 Non-Surgical Exploration of injuries to the Cranium
The majority of images from the medieval period depicting wounds to the bones of the cranium involve surgical treatment. However, there are a few examples of non-surgical examination of cranial injuries. One such example is Figure 4.3. In this image, according to the text, the medical practitioner is directing the patient to cover his ears, nose, and mouth, and blow; the theory being that air will escape from a fracture in the cranium, and thereby allow the medical practitioner to diagnose the problem (Hunt, 1992). Hunt (1992) also notes that in this case, the patient is depicted with his legs braced apart, as a sign of the physical exertion required in this test. However, no mention is made of the effectiveness of this method.
There are also several texts that encourage the use of medicated cloths, ointments, and powders as a primary method of treatment in preference to surgical treatment, when possible (MacKinney, 1965). Detailed in one of the manuscripts written by Rogerius Salernitanus, MacKinney (1965), lists one particular treatment of open wounds to the skull: an ointment called apostolicon chirurgicon, the prescription for which is written in the original Latin of the manuscript. Though the treatment of open wounds raises the question of infection, this will be discussed in more detail in Chapter 4.
4.7 Secondary Fractures Due to Disease
Another aspect that must be considered when discussing traumatic injury to the skeleton is the predication of fractures due to other disease processes. This discussion is particularly relevant to the medieval period, due to the heavy presence of the infectious disease of leprosy (Figure. 4.4). I was unable to find any images of lepers with traumatic injuries, but that is likely due to the context in which images of leper patients were produced. These images are generally not found specifically in medical manuscripts, rather they are found in religious texts to promote charity (Richards, 1977). Figure 4.4 is an excellent example of a religious image depicting leprosy. Done in the traditional hierarchical scale2 for religious images, this scene depicts Jesus healing a leper, accompanied by Peter and two unidentified apostles (Brody, 1974). In terms of the art historical context of depictions of leprosy, these figures are depicted with spots because of literary descriptions of them (Brody, 1974). Brody (1974) observes that the written descriptions detail lepers as "being covered with nodules", which is visually translated into spots. It is not until the late 18th century that the actual physical effects of the disease are depicted with any attempt at accuracy (Richards, 1977).
Although leprosy does effect the skeleton, more importantly for the purposes of this essay, it also effects the eyes and the nerve endings, causing a reduction in vision and loss of sensation in the extremities (Roberts and Manchester, 1995; Judd and Roberts, 1998). These losses may lead to an individual having a higher incidence of falls, increasing the chances of sustaining traumatic injury. Judd and Roberts (1998) have studied the effects of this connection. In their study, Fracture Patterns at the Medieval Leper Hospital in Chichester, Judd and Roberts (1998) examine the frequency of long bone fractures at a known leper hospital, and compare the results with frequencies from other sites in England. To begin, the researchers examined 212 adult specimens for evidence of long bone fractures. Originally excavated in 1986-87, the specimens displayed a total of 41 fractures coming from 32 of the individuals (Judd and Roberts, 1998). The researchers radiographed each fracture and noted any evidence of complication, to study indications of treatment (as discussed at length in section 4.3 of this essay). It was determined that the frequency of fractures in the sample was 15.1% (Judd and Roberts, 1998). When compared to four other skeletal populations, it was found that this frequency was much higher than at the other locations. The frequencies of fractures found at these other sites were 5.6%, 5.0%, 6.6%, and 3.3% (Judd and Roberts, 1998). The researchers proposed that leprosy was in fact responsible for the discrepancy. They note that in addition to poor vision and reduced sensitivity, slow reaction-time and vertigo are also associated with the disease of leprosy, which could also increase the chances of accidental injury (Judd and Roberts, 1998).
4.8 Evidence of Dislocation
When dislocations are properly reduced, not a lot of evidence appears in the skeleton. Lovell (1997) defines a dislocation as an injury to a joint, resulting in the displacement of one articular surface relative to another. A partial dislocation can also occur, in this case, the articular surfaces of the joint still have some connection, but have moved to some extent (Lovell, 1997). Lovell (1997) also notes that dislocations can also occur spontaneously or because of congenital predisposition, though as this essay focuses on traumatic injury, these conditions will not be explored further. When properly treated, though there can be complications visible in bone such as soft tissue ossification, osteoarthritis, and periosteal reaction, it can be difficult to identify these injuries in the skeletal record (Lovell, 1997; Ortner, 2003). If unreduced for an extended period of time, the dislocation can be visible in dry bone because a secondary articular surface is formed, as the joint adjusts to the new location of the bones (Ortner, 2003). However, despite the inability to easily observe the treatment of dislocation, the phenomenon undoubtedly occurred in the period. Evidence of this can be seen in the abundance of visual imagery documenting the treatment of this type of injury from the late medieval period. Figure 4.5 depicts a reduction of the glenohumeral joint, using a pole with a padded section in the centre, held by two assistants, to provide support as the physician pulls down on the patient's arm. Murray Jones (1998) writes that the text accompanying this image describes the procedure in a similar manner to other medieval texts, and also the Hippocratic texts from the 5th century BCE. This type of dislocation is fairly common, as the shoulder joint is designed to provide the widest range of motion possible, but this mobility decreases the stability of the joint (Lovell, 1997; Ortner, 2003). Ortner (2003) notes that the appearance of this type of dislocation in the archaeological record is more prevalent then other types, due to the mechanics of the joint that offers little resistance to traumatic injury. Figure. 4.6 depicts another type of treatment for dislocation: the reduction of a dislocated mandible. The physician pulls upward on the piece of cloth to reduce the patient's jaw, with his feet braced on the patient's shoulders to provide leverage (Murray Jones, 1998).
4.9 Summary
This chapter examined the practice of non-surgical treatment of traumatic injury in the late medieval period. It discussed the reduction and immobilization of long bone fractures and the increased frequency of fractures in individuals afflicted with leprosy, using both anthropological case studies and manuscript illuminations produced in the late-medieval period of image making. The chapter also used images to discuss dislocations and non-surgical exploration of cranial injuries, as these conditions do effect the skeleton, though evidence of treatment in these cases can be difficult to ascertain in the skeletal record.
2 Hierarchical scale refers to the relative sizes of the figures in relation to one another, with the tallest figure being the most important (Stokstad, 2001). In this case, Jesus is the tallest, the apostles next, and finally the leper, being the smallest and, therefore, the least important figure in the religious hierarchy.
Rome: Casanatense Library, MS 1382, folio 22. Rolandus Parmensis, Chirurgia III, 17. (Mackinney, 1965)
London: British Library, MS Sloane, 1977 folio 9R. Roger of Parma. Livres de Cyrugie. (Mitchell, 2004)
Cambridge: University of Cambridge, MS O.1.20, Book 1, 6; folio 243R. (Hunt, 1992).
Figure 4.4. Jesus, with three apostles, healing a leper, c. 1000.
Top register from the Gospel Book of Otto III. Munich: Bayerische Staatsbibliothek, MS Latin 4453, folio 97V. (Brody, 1974).
Figure 4.5 Reducing a dislocated shoulder, early 14th century.
London: British Library, Sloane MS 1977, folio 6. (Murray Jones, 1998).
Figure 4.6 Reducing a dislocated jaw, c. 1300.
Rome: Biblioteca Casanatense. MS 1382, folio 19. (Murray Jones, 1998).
Allsopp D, Seal K, and Gaylarde C. 2004. Introduction to biodeterioration. 2nd ed. Cambridge: Cambridge Univ. Pr.
Boddinton A, Garland AN, and Janaway RC. 1987. Flesh, bones, dust, and society. In Boddington A, Garland AN, and Janaway, RC, editors. Death, decay and reconstruction: Approaches to archaeology and forensic science. Manchester: Manchester Univ. Pr.
Brody SN. 1974. The disease of the soul: Leprosy in medieval literature. Ithaca, NY: Cornell Univ. Pr.
Grauer AL, and Roberts CA. 1996. Paleoepidemiology, healing, and possible treatment of trauma in the medieval cemetery population of St. Helen-on-the-walls, York, England. Am J Phys Anthropol 100:531-544. Wiley Interscience Online [Accessed November 12, 2005]
Haynes S, Searle JB, Bretan A, and Dobney KM. 2002. Bone preservation and ancient DNA: The application of screening method for predicting DNA survival. J Archaeol Sci 29(6):585-592
Hunt T. 1992. The medieval surgery. Woodbridge, Suffolk: Boydell Pr.
Judd MA, and Roberts CA. 1998. Fracture patterns at the medieval leper hospital in Chichester. Am J Phys Anthropol 105:43-55. Wiley Interscience [Accessed November 19, 2005]
Knüsel CJ, Kemp RL, and Budd P. 1995. Evidence for remedial medical treatment of a severe knee injury from the Fishergate Gilbertine monastery in the city of York. J Archaeol Sci 22:369-384.
Lovell NC. 1997. Trauma analysis in paleopathology. YB Phys Anthropol 40:139-170.
MacKinney LC. 1965. Medical illustrations in medieval manuscripts. London: Wellcome Historical Medical Library.
Mitchell PD. 2004. Medicine in the crusades: warfare, wounds and the medical surgeon. Cambridge UK: Cambridge Univ. Pr.
Murray Jones P. 1998. Medieval medicine in illuminated manuscripts. Revised edition. London: The British Library.
Ortner DJ. 2003. Identification of pathological conditions in human skeletal remains. Second edition. Amsterdam: Academic Pr.
Poinar,G. 1999. Ancient DNA. American Sci 87(5):446-457
Richards P. 1977. The medieval leper and his northern heirs. Cambridge: DS Brewer
Roberts C, and Manchester K. 1995. The archaeology of disease. 2nd ed. Ithaca NY: Cornell Univ. Pr.
Stirland A. 1996. Patterns of trauma in a unique medieval parish cemetery. Int J Osteoarchaeol 6:92-100.
Thomas DH, and Kelly RL. 2006. Archaeology. 4th ed. Belmont CA: Thomson/Wadsworth.
Waldron T. 1987. The relative survival of the human skeleton: Implications for palaeopathology. In Boddington A, Garland AN, and Janaway, RC, editors. Death, decay and reconstruction: Approaches to archaeology and forensic science. Manchester: Manchester Univ. Pr.
© 2006 Rosanne Lester