lauren kuffler's seminar paper

8/6/2019 Lauren Kuffler's Seminar Paper

1/29

HST 325, SPRING 2011

Medieval Understanding

and Treatment of HeadTraumaDepictions and Prescriptions in Medieval

Tales, Medical Manuals, and Archaeology

Lauren Kuffler

5/4/2011


2/29

In the mid to late medieval period, likely in Coventry, an assailant struck down a man with

two vicious blows to the head. They might have been bandit and victim, violently

quarreling neighbors, or soldiers in a war, there are no records, besides the rent and

ruined skull that would be found hundreds of years later in a Coventry churchyard. But

archaeologists could tell clear enough from the bone itself the sequence of events that

befell the man: An assailant, wielding a heavy sword or axe, came up behind the man, and

dealt him a vicious blow to the left side of his targets head, cutting through the bone and

almost certainly bringing the man down to the ground. Grievously injured, but still alive,

the man was defenseless against the second blow, the weapon biting in deep near its first

impact, this time shattering weakened bone and pressing the fragments of skull down into

the delicate protective layers surrounding the brain. After this, all evidence indicates the

mangled and no doubt prone victim was left for dead on the bloodied ground, his enemy

satisfied with or distracted from his work. An ally or passing charitable soul found him, still

breathing, despite all that had happened to him.

The man's survival was remarkable; he survived not one, but two blows by a heavy

weapon to the head, one of which could have killed him within minutes. But what was truly

remarkable was what happened next: The man continuedto survive. The wounds did not

become infected, or at least not enough to reach the brain, and in time, the wounds closed

to scars, and the sharp edges left in the bone from the weapon's bite began to heal. At the

time of his death, he'd survived as much as twenty years after the blows that should have

killed him.1 His skeleton, interred at St. Mary's Cathedral, survived for much longer still,

the cracked bone to be found hundreds of years later by excited archaeologists.

Injuries of the skull and brain were common results of any number of unfortunate

1 Trever Anderson, Ian Hodgins. Healed Cranial Weapon Injury from Medieval Coventry, England.Neurosurgery 50

(2002): 870.

2


3/29

events in medieval times, from combat to a hard kick from a bucking horse's hoof. This is

reflected in many tales and legends of the time, which recount the blows in gruesome

detail, often seeming to relish the description of brains being thrown from a sundered

skull. But what might even be more interesting is the medieval physician's understanding

of head injury, and how it might be treated, or whether they treated it at all. As historical

record seems to suggest, the intimate details of these injuries were well-known by many,

but specialized treatment was only considered useful in a small spectrum of injuries,

particularly those involving depressed skull fractures.

Establishing Terminology

In writing on injuries of the skull and brain, the importance of precision in use of terms

cannot be underestimated. Even modern medical texts can sometimes conflict with each

other with regards to terminology, a confusion that could have serious consequences.

Certainly no life will ever be at stake here (unless the reader decides that pounding their

head against the closest solid object to be more stimulating than this paper), but to better

ground the discussion, certain common terms must be established.

First, and at a most basic level, head injuries can be divided into two categories:

closed and open. Closed head injuries do not pierce any of the protective tissues inside

the skull, though the bone itself may be cracked. Open head injuries breach these

defenses, and are generally more serious for this obvious reason. These are often caused

by depressed skull fractures, which occur when bone is dislodged and pressed down out

of place. Linear skull fractures are slightly less severe, resulting from a blunt force trauma

to the head spread out over a wide area, and usually characterized by a straight crack in

the bone. While they are not as dangerous, they can still create complications if they are

close to or cross a suture (line at which the skull is knit together in adult bones), or other

3


4/29

sensitive structures2. When depressed skull fractures are also open head injuries, they are

classed as compound skull fractures.

Within the skull, there are several layers of membranes, which envelop the brain. Just

beneath the bone lies the dura mater (Lat. hard mother), a leathery layer that protects the

brain and the cerebrospinal fluid, among other functions. For a head injury to be

considered open, then the dura mater must be breached. Below it lies the thin webbing of

the arachnoid mater (Lat. spider(web)-like mother), which also acts as protection for the

brain. Below this and the bulk of the cerebrospinal fluid lies the pia mater (Lat. tender

mother), a thin, fluid-impermeable layer that is imbued with capillaries that nourish the

brain itself, which lies directly beneath it. The severity of head injuries often depend on

2 Jan E. Leestma, Forensic Neuropathology. (Boca Raton: CRC Press 2009) 443

4

Figure 1. Illustration of depressed and compound fractures.

DAM, NIH,

http://www.nlm.nih.gov/medlineplus/ency/article/000060.htm


5/29

what tissues were damaged, and the chance of infection raises greatly if the dura mater is

breached, as contagions can then enter the cerebrospinal fluid.

Concussion is an entirely different kind of injury, and one likely seen commonly in

medieval battles among those with adequate helmets. Rather than a direct injury to the

skull or brain, concussions are caused by the brain itself striking the inside of the skull. As

previously mentioned, the cerebrospinal fluid takes up space within the skull, allowing the

brain some ability to drift within it. If shaken hard enough, usually due to an impact, the

brain slams against the inside of the skull, temporarily impairing brain function. The effects

of concussion usually only last for a few days at most, but a strong enough impact or

multiple concussions can cause permanent brain damage.

Contusions of the scalp often accompany head and brain injuries, and in less than

precise medieval accounts, it can become difficult to determine whether the bleeding is a

part of the main injury or cause of death, or merely a side-effect. These will therefore be

5


6/29

referred to as operative or incidental, if we know the injury's full extent, to clarify the kind

of injury and appropriate treatment required.

These terms, though largely derived from Latin, are relatively modern inventions,

used for the precise terminology of modern medicine and science. Concussion, for

example, was not given a distinct name until the 14th century, when Guy de Chauliac used

the term 'commotion' to describe shaking of the brain, as opposed to skull fracture3.

Medieval terminology becomes particularly confused in identification of medicinal

herbs, as often the colloquial name could refer to several species, or multiple names could

be ascribed to the same plant4. Therefore, when dealing with prescribed herbal medicines

recommended in medieval medical manuals, it is important to examine the mixtures on a

case-by-case basis, and their effectiveness considered, as well as any dangers or

potential side effects. Furthermore, modern understanding of herbal remedies remains

muddy, and sources are difficult to find, simply because so many of those who publish

information on the efficacy and uses of natural remedies either have a monetary or

ideological stake in their use. Therefore, this paper will only draw information on medicinal

uses of herbs from the German government's Commission E monographs, a

comprehensive study of available data by a source less likely to be biased. This will,

however, necessarily limit the scope of discussion, as most of the ingredients mentioned in

a medical manual such as Roger Frugard's Chirurgia are either not approved for use, or

not within the scope of Commission E's already massive amount of data. The herbs

themselves are identified via a glossary within the newest translation of the Chirurgia, and

both common and Latin names for each will be given where possible.

3 Paul R. McCrory and Samuel F. Berkovic,Concussion: The history of clinical and pathophysiological concepts and

misconceptions.Neurology 57(2001): 2284.

4 Roggero Frugardi, The Chirurgia of Roger Frugard, trans. Leonard D. Roseman (USA: Xlibris Corporation, 2002), 151.

6


7/29

Theory and Practice: Medicine in the Middle Ages

Despite the loss of past culture and scientific knowledge amassed during the much-lauded

classical period, Western Europe maintained a canon of Latin works, still accessible to

academic readers, bolstered by waves of translation from other languages into the

scholarly tongue. Medical theory maintained a large portion of its body of works through

an effort to translate a portion of the texts kept at the medical school of Alexandria during

the 6th century, for example, while practical medical knowledge persisted through a more

diverse and consistent repackaging of therapeutic traditions.5

Medical theory at the time included many concepts that have long since fallen by

the wayside, but were then central to the medieval understanding of disease and general

pathology of the body, such as the four humors. These concepts likely originated in

Ancient Egypt6 or Mesopotamia,7 though medieval scholars would have traced them to

Greek medical thinking, which was the first to systemize the concepts.8The four humorsthemselves, blood, yellow bile, black bile, and phlegm, were thought to be the basis for

human health and illness only occurred if they fell out of balance.9 These humors were in

turn tied to the four elements, and the four qualities that made them, these being air, fire,

earth, water, and hot, dry, cold and wet, respectively. Though head wounds themselves,

being a surgical matter, were not treated in ways that were as heavily tied to these

concepts, the symptoms that followed an injury, and the substances and herbs used in

5 Faith Wallis, ed. Medieval Medicine: a reader. (Toronto: University of Toronto Press Incorporated, 2010), 3.

6 Ivan van Sertima, ed. The Golden Age of the Moor. (New Brunswick: Transaction Publishers, 1992), 17.

7 Karl Sudhoff.Essays in the History of Medicine . (New York: Medical Life Press, 1926), 67, 87, 104.8 Hippocrates. The Nature of Man, in Medicine and Western Civilization, ed. David J. Rothman, Steven Marcus,

Stephanie A. Kiceluk, The Medical Works of Hippocrates, trans. John Chadwick and W. N. Mann (Springfield: Charls

C. Thomas, 1950), 43.

9 Wallis, Medieval Medicine, 7.

7


8/29

medicines could be classified under this system, and therefore saw some use in

discussion of treatments and diagnosis.

Medicine itself at this time had a mythic history validated by Greek origin, believed

to first be taught by Apollo, then his son, Asclepius, then revived by Hippocrates after

centuries of falling into disservice.10 Three schools of medical thought attributed each

founder to themselves during the medieval period: Methodists, who studied only the

property of diseases themselves and tied themselves to Apollo, Empiricists, inheritors of

Asclepius, who disregarded theory and relied on factual experience alone, and the

Logical school of medical thought, which rely on theory and rational investigation of cures.

However, even among this structure, there was still little room for another important group:

surgeons.

Medicine was seen as a noble art, combining the individual subjects of literature,

rhetoric, dialectic and arithmetic,11 but surgery was for much of the medieval period

considered less of an art and more of a handicraft, to be performed as a trade. In the early

middle ages, most healing was performed by members of the clergy. For much of the

period, in fact, most saw prayer as the firstaction to be taken, not a last resort.12 However,

following a papal decree and followed by the Fourth Lateran Council in 1215, priests were

prohibited from spilling blood, even in a medical setting. Therefore, the job of handling a

razor went to the next most experienced: barbers.13


11 Isidore of Seville. Etymologiae, in Medieval Medicine: a reader, ed. Faith Wallis, Isidore of Seville: The MedicalWritings, Transactions of the American Philosophical Society, trans. William D. Sharpe, 54 pt. 2 (1964), 9.


13 Sven Med Tidskr, From barber to surgeon- the process of professionalization. Svensk medicinhistorik tidskrift11

(2007): 70.

8


9/29

These tradesmen were not given university training as physicians were, and were held in

much lower esteem, until Roger Frugard composed his Chirurgia, the foundation for

scholarly medical manuals of surgery. Even for some time after, it is known that surgery

was not often trusted or attempted beyond a few routine procedures such as drawing

blood, or in life-threatening cases or acutely painful conditions, where the urgency of the

condition outweighed the pain or fear of the surgeons knife,14 which at the time had

regressed from previous classical sophistication to a few less specialized tools, as

14 Nancy G. Siraisi, Medieval and Early Renaissance Medicine: an introduction to knowledge and practice. (Chicago: The

University of Chicago Press, 2010) 154.

9

Figure 3. "De chirug": A Barber Surgeonopperates on a patient. Engraving by

Lucan van Leyden, 1542.


10/29

illustrated in 15th century versions of Guy de Chauliacs Chirurgia Magna, and

contemporary miniatures within a version of Frugards Chirurgia. 15

Given the contemporary limitations of theory and practice, understanding of cerebral

anatomy was far from complete. Though Roger Frugard knew and identified the dura

mater and pia mater surrounding the brain16, theoretical medicine went further, attempting

to imagine the anatomy and function of areas of the brain. Most oddly to modern

observers, they theorized that the functional portion of the brain was not the solid mater,

but the ventricles within it, to which they assigned the functions of imagination, reason and

memory.17 The brain does contain a ventricular system, but their function is mainly to

contain cerebrospinal fluid, and therefore protect the brain. However, medieval doctors

were convinced that the ventricles could be influenced by imbalanced, windy humors,18

which would block the ventricles and create epilepsy.19

These misconceptions illustrate just how difficult it was to diagnose and treat

neurological problems and, by extension, injuries, given that anatomy of the affected area

remained so misunderstood. As a result of this and the simplistic tools available to

surgeons, many books of surgery, including Frugards Chirurgia, warned specifically

against intervention in cases when the outcome of intervention could easily be death or

greater pain. This will be expanded upon later.

15 Siraisi, Medieval and Early Renaissance Medicine, 156-157.

16 Ruggero Frugardo, Super Chirurgiam in Collectio Salernitana , ed. Salvatore de Ferenzi et al, (Napoli: Sebezio,1852), 506


18 Bernard of Gordon, Lilium medicinae, in Medieval Medicine: a reader, ed. by Faith Wallis, Bernard de Gordon on

Epilepsy trans Adrian P. English, ed. William G. Lennox,Annals of Medical History, vol 3, (Publisher unknown, 1941),265

19 Arnau of Vilanova, Breviarium practicae medicinae, in Medieval Medicine: a reader, ed. Faith Wallis, Arnold of

Villanova on Epilepsy, Annals of Medical History, vol 10, 252-54, trans. Edna P. Von Storch, Theo J. C. von Storch, 54

pt. 2 (1964), 264.

10


11/29

Salerno: Progenitor and Medical Center

Primary in the development of practical medicine and spread of accurate surgical

prescriptions in western Europe was the school at Salerno, the Schola Medica

Salernitana. Unconventional and unique in its development, many regard the schola as

the earliest example of the university model in Europe. However, due to its unorthodox

structure and slow growth, some refer to it as more of a proto-university20. Only in the last

forty years it has become evident when the school may have come into being, as founding

records for the schola are lost. Likely founded in the late eleventh century, the school did

not receive legal status until the fourteenth century, finally given authority by Emperor

Frederick II to grant medical licenses valid for the entire kingdom it lay within.21 By that

time, mythology concerning its founding had popularly circulated, including the concept

that the schola was founded by four masters: a Greek, a Latin Christian, a Jew, and an

Arab. Although this is surely not true,22 given the schola's start as an out-branching of the

local church, it reflects the confluence of traditions that were in evidence in the schola's

works. As a southern Italian coastal city, Salerno was able to benefit from an influx of

knowledge from Arab lands, including ancient Greek works that had been translated into

Arabic. Salerno became the place that made much of these texts accessible to western

Europe, most prominently with the translations of Constantine the African. A man of Arabic

descent, Constantine's work at the end of the eleventh century set off a flourishing of

medical thought, as evidenced in over fifty medical works in Europe over the next hundred

years, and his translations of Arabic surgical texts allowing some among his successors to

20 Alan B. Cobban, The Medieval Universities: their development and organization. (London: Methuen & Co Ltd,1975), 37.21 Jacques, Verger. Patterns, inA History of the University in Europe, vol 1: Universities in the Middle Ages, ed. Hilde

Ridder-Symoens et al., (Cambridge: Cambridge University Press, 1992) 52.

22 Roger French. Medicine before Science: The Business of Medicine from the Middle Ages to the Enlightenment.

(Cambridge: Cambridge University Press, 2003), 72.

11


12/29

focus on this practical art.23 Among those was Roger Frugard, a twelfth century Salernitan

surgeon, whose work on head injuries and skull fractures would become authoritative for

the period. His work will be discussed later in this paper.

Bias and counterballance

In many fields, there has been an anti-medieval bias for centuries, and medicine has not

been spared. Though the majority of the relevant texts confined themselves to analysis of

their topic without judgmental statements, some seemed unable to help themselves,

mostly those working in a broad historical context, especially those with a high regard for

the Roman empire. A modern overview of the history of military medicine held particular

scorn for the medieval period, bemoaning the decline of Roman battlefield medicine and

leaving only a short section for the medieval period, concluding that Military medicine

regressed to the Bronze Age and that collapse of any central political authority made it

impossible to establish any institutional mechanisms for teaching, preserving, and passing

on medical knowledge24, and focuses only on the barber-surgeons and changes in

medicine brought about by the crusades.25 This obviously ignores the beginnings of the

university movement, a rather glaring omission, given the foundational role taken on by

the school at Salerno, a medical institution that will be discussed in depth later within this

paper.

Despite lingering prejudice against medieval understanding of medicine and

battlefield injuries, folk tales and legends of western Europe are not only filled with

descriptions of skull-destroying imagery that can also be seen in historical accounts , but

also descriptions proving at least a limited understanding of less fatal injuries. However,

23 Siriasi, Medieval and Early Renaissance Medicine, 162.

24 Richard A. Gabriel and Karen S. Metz,A History of Military Medicine: Volume I: From Ancient Times to the MiddleAges, (New York: Greenwood Press, 1992), 210.

25 Gabriel et al.,A History of Military Medicine, Vol I, 207.

12


13/29

there seems to have been little middle ground between blows causing mild to severe

concussions, and instantly fatal blows within these stories. For the purposes of this paper,

we will only examine those blows that are not immediately fatal, as the most relevant class

of damage in understanding of medieval treatment and recognition of head injury. The

stories in question lend support to the hypothesis that most head injuries went largely

untreated, so that contemporary tales considered time the only healer that could help the

stricken in these situations. We shall draw examples from a comprehensive survey

conducted by the doctor Cyril B. Courville, a now-deceased professor of neurology and

director of the Cajar Laboratory of Neuropathology in Los Angeles. He approached the

relevant episodes mostly as a chronicler, but he often expounded on the injuries

described, only occasionally lamenting the lack of specificity of a source26. Overall,

however, the doctor seems quite pleased with the texts27.

Among the texts examined in Courville's overview is the episode of the famous

Nibelungenlied, in which Iring is slain by Gieselher. During their battle, Giselher gives Iring

a concussion, with descriptions of how he was struck so that he could not stir a step, but

sank before his hands down in the blood, that his wits had grown so weak that the brave

knight no longer thought of life, and that his daze was shaken off When now the ringing

gan leave his head,28 a description which Courville interprets as a typical sequence of

concussion,29 in which he is struck on the helmet with a sword, falls unconscious,

recovering in a state of confusion, and then gradual clearing of the head.

26 Cyril Brian Courville,Injuries of the Skull and Brain As Described in the Myths, Legends and Folk-talkes of the Various

Peoples of the World, with Some Comments on the Significance and Reliability of this Information in Evaluating

Contemporary Concepts As to Their Nature and Lethality, (New York: Vantage Press, 1967) 51.27 Courville,Injuries of the Skull and Brain, 53.

28 Unknown. The Nibelungenlied, trans. Daniel Bussier Shumway. (Salt Lake City: Project Gutenberg, 2008),

http://www.gutenberg.org/files/1151/1151-h/1151-h.htm

29 Courville,Injuries of the Skull and Brain, 44.

13


14/29

A related Germanic tale described a further example of concussion resulting from

head injury centering on Dietrich of Bern, the Eckenlied, in which the giant Fasold strikes a

blow to Dietrich's head, and Dietrich fell from his horse and lay in a swoon, Fasold

leaving his fallen enemy for dead.

30Dietrich soon regained consciousness, mirroring

Iring's recovery. This sequence of events lies only just outside of the realm of the possible

a fairly realistic aspect of an otherwise fantastic tale. By current CDC guidelines, anyloss

of consciousness or failure to respond requires a visit to the emergency room, and

sustained unconsciousness is more likely a sign of a more serious brain injury.31 Despite

the legendary aspects of both tales, the tellers of each still remained moderately

restrained in the description of the severity of Iring's and Dietrich's symptoms compared to

the more immediately fatal blows seen elsewhere in the text, or rebounding instantly from

a heavy blow with no side effects.

When protagonists are not mythical figures, however, Germanic folklore often treats

head injuries quite seriously and realistically. The story of the Bell-founder of Stolberg (A

medieval tale, but I can track down no hard dates, as there seem to be no discussions of

the story in English), 32 recounts a jealous bell-founder striking his journeyman apprentice

on the head, [giving] the youth such a powerful blow on his head that he sank bleeding,

with glass eyes, on the grass. The bell-founder soon regrets his actions, and tries to aid

the boy. However, any head injury severe enough to cause unconsciousness can be fatal,

especially in children,33 and the apprentice dies shortly thereafter. However, as Courville

laments, the teller does not specify whether the bleeding was incidental or operative in the

30 Donald A. MacKenzie, Teutonic Myth and Legend: An Introduction to the Eddas & Sagas, Beowulf, The Nibelungenlied,

etc. [Charelston: Forgotten Books, 2009], http://www.forgottenbooks.org/info/9781605067261.

31 Concussion and Mild TBI, last modified April 8, 2011, www.cdc.gov/concussion.32 Courville,Injuries of the Skull and Brain, 51.

33 Elie Elovic and Ross Zafonte, Prevention, in Textbook of Traumatic Brain Injury., ed. Jonathan M Silver et al.

(Washington DC: American Psychiatric Association, 2005), 74.

14


15/29

boy's death.

Among Arthurian legend as well, multiple instances of concussion occur, can be

attributed to the large, flat-topped great helms favored by knights during the period of the

tales writing, stretching from the Third Crusade to the mid-16

th

century. The first and

simplest designs completely cylindrical form transferred the entirety of a blow over the

head directly downwards onto the skull or shoulders, a problem that was obviously evident

at the time, as this early design was eventually discarded in favor of a low conical design

to replace the flat top34. Arthurian legend shows the reasons why, with concussion afflicting

many characters. In the text Courville brings forth, The Story of King Arthur and his

Knights, The Black Knight receives a blow from King Arthur that is so severe that he

groaned and staggered, and ran about in a circle as though he had gone blind and knew

not whither to direct his steps, and was later thrown unconscious by Arthur by impact with

the ground.35


35 Howard Pyle,King Arthur and his Knights (New York: Charles Scribners Sons, 1903) http://books.google.com/books?

id=4Z8mP8XKagYC&source=gbs_navlinks_s

15Figure 4. Arthur versus the greathelmed Black Knight. Illustration by

Howard Pyle, 1903.


16/29

The same befalls Sir Balamorgineas during a fight, wherefore his brains swam so light it

was necessary for him to hold to the horn of his saddle to save himself from falling. This

particular description was consistently used throughout the source material Courville

draws from, where both Sir Dinador of Montcalm and the Knight of the Sparrow Hawk, that

their brains swam like water, immediately followed by lack of coordination and weakness.

The mythical description of a head injury sustained by Thor in the Prose Edda

combines an understanding of skull and brain injury with a cultural assumption of whether

such wounds were operable. In this collection of older myths compiled by Snori Sturluson

in the 1220s, Thor fights the Jotunn Hrunger, and by chance when the god's hammer

meets the flint weapon in the giant's hand, a splinter of flint flies from the weapon and is

lodged within his skull. Courville hypothesizes that the immediate reactions that follow

indicate that the early Norse considered head injuries to be inoperable36. After Thor's and

his wife's attempts to dislodge the shard by simply tugging at it fail, Thor turns to a

sorceress, Groa, who attempts to remove the flint through incantations. Distracted at a

critical moment, she is unable to continue, leaving Thor's skull permanently perforated by

the flint shard.

Coventry Skull: (Non)-Medical Miracle

Despite the propensity of medieval stories towards the fantastic and deadly,

archaeologists have found some evidence that grievous, open head injuries might

sometimes survivable during this period, despite limited surgical knowledge at the time.

The previously mentioned skull of a Coventry native found within the last decade provides

one such piece of evidence: estimates from the journal Neurosurgeryregarding the


16


17/29

rounded, healed edges of the rents in his skull point to the man surviving up to twenty

years after his wounding.37

His survival seems remarkable, given the fact that for much of the Middle Ages, infection

and inflammation were seen as a necessary and healthy part of healing, some sources

even confusing thepus bonum et laudible described in Greek and Galenic texts, a natural

emanation from a healing wound, with infected, unhealthypus malignum3839. A less benign

build-up of fluid in the skull or under the scalp could also be mistaken for healthy pus,

which will be expanded upon in the next section of this paper. If the blow had breached the

dura mater and allowed infection to take hold within the confines of the man's skull, he

would have almost certainly died. It remains unclear whether this practice of encouraging

pus was still in effect in Coventry at the time of the man's death, given that the churchyard

had been disturbed many times over the centuries, but he likely had to do without the

good advice of Roger Frugard, the best Salernitan expert on cranial surgery.

Roger Frugard and his Chirurgia

37 Anderson, Hodgins. Healed Cranial Weapon Injury from Medieval Coventry, England., 870.

38 Gabriel and Metz.A History of Military Medicine,190.

39 Plinio Prioreschi.A History of Medicine, Vol. VMedieval Medicine, 316

17

Figure 5. Photograph of the Coventry

Skull, displaying its healed injuries.

Neurosurgery, (50)4, 2002, 870.


18/29

Among the most well-received of the original works of Salerno by medieval physicians was

Roger Frugard's Chirurgia, a medical manual his students compiled some time during the

1170s, likely during Roger's lifetime. Later editions of the manual included commentaries

by others, with the first major example appearing in 1250, by Roland Cappelluti. The

Chirurgia became the foundation for Latin instruction in surgery for the late twelfth and

thirteenth centuries, taught widely and expanded upon with glosses by those working at

other schools. The manual was even translated from Latin to local vernaculars, including

an Anglo-Norman translation into Middle English at the close of the thirteenth century, and

through such interpretations continued to be incorporated into general use from the

fourteenth to fifteenth centuries.40 The most readily available and recent translation into

modern English is by a Dr. Leonard Rosenman. Dr. Rosenman uses multiple manuscripts

for his translation: A Latin edition including Roland's addenda, two medieval Italian

versions of the text, and the Middle English translation, mostly referenced for its

occasional deviance from the others, especially in certain medicinal preparations. Roger's

text remains uncommon in that it does not quote great historical sources, as was

traditional. He states in his Proem to Book I of the Chirurgia that I have decided to set

down in writing that practice as if it comes from me alone, therefore obscuring any

sources he drew from as a conscious stylistic choice, not an indication that he wrote an

original work. Indeed outwardly in the section on skull fractures, Frugard does not seem to

be drawing on any identifiable classical sources, though he may have been drawing on the

unrecorded experience of other medieval surgeons who came before him.

Roger divided the text itself to four parts, by anatomy: Head, neck, torso, and limbs.

He devotes the greatest part of the section on the head to injuries of the skull and brain,


18


19/29

making his work notable among the many treatises that made their way from Salerno41,

which would follow his lead in diagnosis and treatment. However, he limits his attention

mostly to injuries that fracture the skull, and therefore could be surgically operated upon.

Despite seeming to understand much of the symptoms of traumatic brain injury without

skull fracture, he often did not give any direct recommendation for treatment in these

cases: much of the symptoms he gives are for levels of brain injury he deems to be fatal42.

Indeed, Frugards lack of willingness or ability to intervene on these injuries

persisted in the minds of later surgeons, such as Dino del Garbo, who in 1308 explained

that in choosing the appropriate treatment in individual cases of skull fracture the surgeon

should take into consideration the risks inherent in each of two possible procedures, the

patients general health, and the precise nature of the injury.43 During this period, there

was a very definite understanding of the limitations of skill and materials, and these were

expected to be taken into consideration by any intelligent surgeon.

Combined with this caution, there was also public fear of surgical measures, or

ignorance on the part of medical professionals. Dino del Garbo noted that it was widely

believed that skull fractures could be cured by the use of plasters alone, rather than

undergoing surgical procedures identifiable as those spelled out by Frugard,44 a belief

either attributed to the extreme willingness of the public to believe in such cures and to

the ignorance or deceit of empirics.

With this in mind, Roger starts with symptoms of an injury he calls fatal: damage of

the dura or pia mater, both of which he seems to understand The symptoms listed do not

all a function of damage to the structures mentioned, however: He lists among the

41 Cobban, The Medieval Universities, 45.

42 Frugardo, Chirurgia, 33.



19


20/29

symptoms of a fatal injury to the dura mater wide-open eyes, which can be interpreted as

fixed, dilated pupils, a veryserious sign of damage to major cranial nerves, stemming from

the opthalmic arteries and nerves, and modern medicine still uses to declare a patient

medically dead.

45

However, this shows that Roger Frugard was working from actual

observations either from direct experience or that of others and attempting to determine

their source.

However, both in passing mention in Roger's text and expanded upon in Roland's

addenda is mention of celestial bodies' effect on the injuries: Roger declares that When

the damage in the meninges is extensive, death will ensue at the time of the next full

moon, and Roland expands on this claim, asserting that he believed the waxing moon

caused an increase of fluid buildup within the skull. While this not true, Roland does show

an important understanding: If the brain cannot vent the fluid the patient will die.46 A true

statement, and an important fact for those treating head injuries to know. Roland is

describing cerebral edema, a build-up of excess fluid within the skull. This can cause loss

of consciousness, brain damage and death, as blood flow to the brain is cut off by brain

swelling caused by the edema.47 Therefore, treatment is imperative.

Once Roger establishes the majority of what he considers to be fatal symptoms, he

moves to surgery, and again shows his knowledge of appropriate treatment, and the

limitations of medieval medical technology. He describes surgery performed to remove

fragments of bone and foreign matter from where they lie on the dura mater from a wound

that is large and open, such as made by a sword48, likely in the event of a closed head injury

45 Julian Kuffler, in discussion with the author, April 2011.46 Frugardo, Chirurgia, 34.

47 Ahmed Raslan and Anish Bhardwaj, Medical Management of Cerebral Edema,Neurosurgical Focus, 22 (2007): 1.

http://thejns.org/doi/pdf/10.3171/foc.2007.22.5.13


20


21/29

with a depressed fracture, although he does not specify whether the wound breaches the

dura mater, which would increase the chance of losing the patient.. He advocates for a

meticulous style of work, removing fragments by lifting them slowly via a soft cloth threaded

between the fragment and the dura mater. Roger ensures that care is taken to keep the dura

mater clean, separating out open edges of the wound and the dura mater with cloth, and the

discharge from the scalp wound blotted with a sea sponge. As disinfectants were not

available during this time, and nothing such as alcohol would be in anywas appropriate for

cleaning a head injury, Roger instructs the surgeon to pack the wound with linen that had

been soaked in egg-white, with the dressing to be changed twice per day in winter, and three

times in the summer, the Anglo-Norman source noting that this is due to wounds during

summer being more likely to discharge pus in greater quantities.

Roger interestingly recommends the use of egg-whites for wound irrigation and

bandage dressing: given the lack of sterile water, egg-whites are a good alternative, as the

eggshell acts as a preservative, designed to keep a developing embryo free of infection. The

relative appropriateness of the chemical makeup of the egg-white versus yolk is also worth

noting: egg-whites are composed almost entirely protein, while the yolk contains cholesterol

and fat, substances deleterious to the dura mater. Therefore, combined with dried egg-whites'

ability to form a hard, relatively impermeable surface, they stand out as an excellent choice

for bandaged head wounds, when no other options are available49.

However, Roland's addenda again mixes sound medical advice with an incorrect

classical theory behind it: Roland states that the sea sponge must be washed thoroughly

before use to ensure removal of sea salt, as the salt can harm the dura mater. This is true, but

he goes on to say in explanation that All astringent substances are hot, and corrosives are

49 Kuffler, discussion.

21


22/29

hot as well as dry50. This expresses the classical theoretical system of categorization of

substances, organs and even organisms into categories of hot, cold, wet and dry. A Hellenic

concept in nature, and tied to the concept of the four elements of fire, earth, air and water, as

well as the four humors, blood, black bile, yellow bile, and phlegm. While farfrom useful in

any practical sense, the classification system expressed a wish to impose some order on the

various, then-mysterious qualities that substances could possess. In absence of any

formalized understanding of elements, molecular structure or chemical interaction,

philosophers still an attempted to provide theoretical explanation, not simply generate

unsourced statements of fact.

Roger continues on, becoming more specific as he does so in his recommendations

and observations. In discussion of depressed fractures coupled with small scalp wounds, he

recommends exploration of the affected area by touch to determine the extent of the

fracture.51 Then, once the surgeon makes these observations, they were to make a cross-

shaped incision and peel back the scalp with the aid of a scraper, so that the fracture could be

directly observed and fragments removed as previously recommended. However, he

recommends delay of operation if the patient develops other symptoms (one of the Italian

sources suggests loss of consciousness), or if bleeding seems too great. Once the surgeon

removed the fragments, the flaps were folded together, with bandages beneath to protect the

dura mater. At this point he also recommends a mixture for pain relief, made of boiled what

flower and saffron. Wheat flower acts to thicken the mixture, while the notably expensive

saffron (Crocus sativus) is not at this time approved for use by Comission E, though they note

that currently unsupported studies claim its usefulness as a sedative for nerve spasms and



22


23/29

asthma.52 He specifically mentions that edema of the corner flaps is a good sign after one

day.53 Roland's addenda notes [t]he edema indicates that the nature can provide nutrition,

which is true to a certain extent. If bleeding accompanies edema or the fluid is red, then the

discharge is not a good indicator, but otherwise shows that nerves in the area are still alive,

and blood flow is nourishing the wounded area54. This is placed in contrast to if the flaps are

shriveled and retracted, which Roland notes indicates a blockage of the vital substances,

which is once again true. It indicates that blood vessels and nerves in the area are no longer

functional, and the cells in the are dying off. Furthermore, the addenda notes that the early

appearance of pus is a good sign; a late appearance is bad55. This is also true: pus acts as a

sign that white blood cells are working to disinfect an area and flush it of any foreign matter,

as can be readily observed in less serious injuries, such as a splinter that pierces the skin.

However, pus appearing late in the process shows that the body is fighting an established

infection, and is losing the struggle. It may also indicate that the infection is deep within the

tissue, as the pus was delayed in its appearance, which is also a bad sign 56.

Despite mostly limiting his attention to depressed fractures, Roland also turns his

attention to linear fractures for one chapter, a more difficult subject. As infection always

remained a risk of operation, the risks of leaving the wound untreated would have to outweigh

the obvious dangers. Therefore, if the fracture is not depressed, Roger instructs the physician

order the patient to pinch his nostrils and close his mouth while he exhales strongly57. If this

produces something (the Anglo-Norman text suggests fumes) around the wound in the

52 Blumenthal, Mark, Busse, Werner, Bundesinstitut fur Arzneimittel und Medizinprodukte (Germany). The Complete

German Commission E Monographs: therapeutic guide to herbal medicines. (Austin: American Botanical Council,

1998) 371.

53 Frugardo, Chirurgia, 38.54 Kuffler, discussion.


56 Kuffler, discussion.


23


24/29

scalp, then, he states, the fracture goes the full thickness of the skull, and a fluid build-up may

be occurring within, which, as noted before, is potentially fatal. Roger then recommends

trepanning holes into the skull parallel to the fracture along its whole length, then sawing, or,

as the Anglo-Norman text states, chiseling, from one hole to the next, creating an opening for

fluid to drain from where it is likely collecting on the dura. After packing the opening with

cotton or linen, the wound was then to be treated with our usual methods.

Ontop of these previous measures, Roger also recommends several plasters to place

on the wound during different seasons. While at first this may seem like more classical

elements-based quackery, the very practical effect of temperature and seasonal disease on

an open wound seems to have been taken into consideration in this case. For the winter,

Roger recommends a plaster that contains malva (Althea officianalis), a currently unapproved

herbal remedy used for a wide variety of ailments, including external ulsers and

inflammation,58 flaxseed (Linum usitassimum), proven to ease external local inflammation,59

and fenugreek (Trigonella foenum-graecum), effective for the same, as well as posessing a

mild antiseptic effect.60 While the efficacy of the five other ingredients cannot be determined,

these three seem to all indicate the effectiveness of this medicine in keeping down swelling.

For the summer months, Roger prescribes a different poultice. Oddly, with information

available, the poultice described for use in summer seems most effective if one were treating

a gastronintestinalproblem, not a head injury. Wild Celandine (Betonica officinalis) and

henbane (Hyoscyamus niger) are both approved for use in treating various afflictions to the

gastrointestinal tract.61The rest have no provable effectiveness, although studies in rats have

58 Blumenthal, et al. The Complete German Commission E Monographs, 164.



61 Blumenthal, et al. The Complete German Commission E Monographs, 105, 146.

24


25/29

shown that nightshade can stabilize heart arythmias, with no other effects documented.62

For contusions exhibiting swelling and no underlying fracture, Roger does not prescribe

any surgery, but instead recommends a mixture involving absinthe (an aqueous extract of

wormwood,Absinthii herba), yet another anomalous ingredient effective for gastro-intestinal

tract problems,63 vinegar, a good anti-inflammatory and promotes bone health, artemisia

(Artemesia vulgaris) and onions (Allium cepa), both posessing anti-bacterial functions.64 In

combination, these ingredients would in fact work quite well for Frugard's intended purpose.

Roger also remains sure to warn physicians that fractures may not always be so

obvious, such as when a blow strikes the head and causes only swelling but no cuts, a

fracture may still be lurking beneath.65 When a surgeon can feel displaced bone, Roger

recommends the same treatment as for fractures with small wounds, i.e. cruciate incision and

fragment removal.66 However, an impalpable fracture would not be treated, unless after five to

seven days after injury, the patient cannot eat or drink, meaning they are nauseous, and his

digestion is bad; he is sleeplesss; his urine and feces are scanty and he is feverish, therefore

surgery should be performed in the manner described previously. However, this implies that

in the case of an asymptomatic fracture, it would go untreated or treated as another illness.

The addenda further adds that if the swelling caused by the initial injury is old and the wound

therefore not fresh, diaphoretics and maturatives should be employed. These are both

classes of substances whose purpose is to draw fluids from an area, and a sound move: the

swelling would likely be due to a hematoma (a build-up of blood within tissue, outside of blood

vessels), and persistent hematomas must be drained when the body cannot reabsorb it.67


63 Blumenthal, et al. The Complete German Commission E Monographs, 232.64 Blumenthal, et al. The Complete German Commission E Monographs, 352, 176.



67 Kuffler, discussions

25


26/29

Despite the limits of his surgical ability and materials, Roger was able to create a

largely accurate medical manual, based heavily on observable phenomena, and if followed

could positively impact a patient's chances of survival and continued good health. This

composed part of a marked shift in medical understanding and serious schollarly examination

of practical medicine, starting with Salerno's confluence of traditions and experience, which

allowed serious head injuries to be operated upon, and symptoms of hidden problems to be

diagnosed. With this, historical fact diverges from the popular stereotype, and the foundations

of further advancements could be laid.

Bibliography

Anderson, Trevor, Ian Hodgins.

Healed Cranial Weapon Injury from Medieval Coventry, England. Neurosurgery

(2002) 50, no. 4: 870-873.

Blumenthal, Mark, Busse, Werner, Bundesinstitut fur Arzneimittel und Medizinprodukte

(Germany).The Complete German Commission E Monographs: therapeutic guide to

herbal medicines. Austin: American Botanical Council, 1998.

CDC. Concussion and Mild TBI. Last modified April 8, 2011. www.cdc.gov/concussion

Cobban, Alan B. The Medieval Universities: their development and organization. London:

26


27/29

Methuen & Co Ltd., 1975.

Courville, Cyril Brian. Injuries of the Skull and Brain As Described in the Myths, Legends

and Folk-tales of the Various Peoples of the World, with Some Comments on the

Significance and Reliability of this Information in Evaluating Contemporary

Concepts As to Their Nature and Lethality. New York: Vantage Press, 1967.

Elovic, Elie and Zafonte, Ross. Prevention. In Textbook of Traumatic Brain Injury., ed.

Jonathan M Silver, Thomas W. McAllister, Stuart C. Yudofsky. Washington DC:

American Psychiatric Association, 2005.

French, Roger. Medicine before Science: The Business of Medicine from the Middle Ages to

the Enlightenment. Cambridge: Cambridge University Press, 2003.

Frugardo, Ruggero. The Chirurgia of Roger Frugard. Translated by Leonard D. Rosenman,

MD. USA: Xlibris Corporation, 2002.

Frugardo, Ruggero. Super Chirurgian in Collectio Salernitana , ed. Salvatore de Ferenzi,

Salerno Medical School, 497-548. Napoli: Sebezio, 1852.

Gabriel, Richard A. and Karen S Metz.

A History of Military Medicine: Volume I: From Ancient Times to the Middle Ages.

New York, NY: Greenwood Press, 1992.

Gordon, Bernard of. Lilium medicinae, In Medieval Medicine: a reader, edited by Faith

Wallis, 265-267. Toronto: University of Toronto Press Incorporated, 2010. Originally

published in Adrian P. English, trans., William G. Lennox, Bernard de Gordon on

Epilepsy (trans by Adrian P. English),Annals of Medical History, volume 3, 373-74.

Publisher unknown, 1941.

Haskins, Charles Homer. The Rise of Universities. Ithaca: Cornell University Press, 1923.

Hippocrates. The Nature of Man, in Medicine and Western Civilization, David J.

27


28/29

Rothman, Steven Marcus, Stephanie A. Kiceluk, 43-47 New Brunswick: Rutgers

University Press, 1995. Originally published in John Chadwick and W. N. Mann,

trans., The Medical Works of Hippocrates,. (Springfield: Charls C. Thomas, 1950).

Leestma, Jan E. Forensic Neuropathology. Boca Raton: CRC Press, 2009.

MacKenzie,Donald A. Teutonic Myth and Legend: An Introduction to the Eddas & Sagas,

Beowulf, The Nibelungenlied, etc. Charelston: Forgotten Books, 2009.

http://www.forgottenbooks.org/info/9781605067261.

McCrory, Paul R. and Samuel F. Berkovic.

Concussion: The history of clinical and pathophysiological concepts and

misconceptions. Neurology(2001) 57, no. 12: 2283-2289.

Prioreschi, Plinio.A History of Medicine Volume VMedieval Medicine. Omaha: Horatius

Press, 2003.

Pyle, Howard. The Story of King Arthur and his Knights. New York: Charles Scribners

Sons, 1903. http://books.google.com/books?

id=4Z8mP8XKagYC&source=gbs_navlinks_s

Raslan, Ahmed and Bhardwaj, Anish. Medical Management of Cerebral Edema,

Neurosurgical Focus, 22 (2007). http://thejns.org/doi/pdf/10.3171/foc.2007.22.5.13

Seville, Isidore of. Etymologiae, In Medieval Medicine: a reader, edited by Faith Wallis,

5- 10. Toronto: University of Toronto Press Incorporated, 2010. Originally published in

William D. Sharpe, trans., Isidore of Seville: The Medical Writings, Transactions of

the American Philosophical Society, 54 pt. 2 (1964), 55-64.

Siraisi, Nancy G. Medieval and Early Renaissance medicine: an introduction to knowledge

and practice. Chicago: The University of Chicago Press, 1990.

28


29/29

Unknown. The Nibelungenlied. Translated by Daniel Bussier Shumway. Salt Lake City:

Project Gutenberg, 2008. http://www.gutenberg.org/files/1151/1151-h/1151-h.htm

Verger, Jaques. Patterns inA History of the University in Europe, Volume 1: Universities

in the Middle Ages, edited by Hilde Ridder-Symoens, Walter Regg, 35-65.

Cambridge: Cambridge University Press, 1992

Vilanova, Arnau of. Breviarium practicae medicinae, In Medieval Medicine: a reader,

edited by Faith Wallis, 264-265. Toronto: University of Toronto Press Incorporated,

2010. Originally published in Edna P. von Storch and Theo J. C. von Storch, trans.,

Arnold of Villanova on Epilepsy,Annals of Medical History, vol. 10, 252-54. New

York: Paul B. Hoeber, Publisher.

Wallis, Faith, ed. Medieval Medicine: a reader. Toronto: University of Toronto Press

Incorporated, 2010.

lauren kuffler's seminar paper

Documents