Tudor Health Reform

22 June 2011

Tudor Health Reform Symposium

Medical and Surgical Therapeutics:

Scientific Advances in the Tudor Era

Dr Allan Chapman

Let us begin by firmly contradicting the still pervasive myth that medicine in the Middle Ages was little more than witchcraft, and that surgery was butchery.  For as is as clear as day to anyone who cares to examine medieval medical records, there was a very considerable sophistication of medical understanding.  Indeed, to take a Doctorate in Medicine degree from one of Europe’s great universities, such as Paris, Oxford, Montpellier, or Bologna in c. 1350, one had to display a sound understanding of both classical and contemporary medical knowledge.  This would have included Hippocrates, Dioscorides, Galen, and other medical writers from the Graeco-Roman world, 450 BC to AD 200, along with ‘modern’ Arab doctors in Latin translation.  One has only to read Geoffrey Chaucer’s Canterbury Tales (c. 1381) to be aware of the rich medical knowledge that a scientifically-minded civil servant like Chaucer could easily come to possess, for the Tales are peppered with contemporary medical and psycho-clinical ideas; while the Pardoner’s Tale makes explicit reference to the early-eleventh-century-AD Arab writer Avicenna’s Canon, or ‘rule of medicine’.  (Indeed, Chaucer displayed a far wider and deeper knowledge of contemporary science and medicine than did Shakespeare, 250 years later.)

And well before the end of the Middle Ages, there was an impressive and growing body of surgical literature.  TheChirurgia Magna, 1363, of the Frenchman Guy de Chauliac is a work of immense clinical sophistication, showing a detailed knowledge of anatomy, and exhorting the practitioner to act with the greatest of humanity towards his naturally terrified patients.  And nothing suggests that Guy’s book was exceptional in what it taught and advised.  Indeed, one stunning testimony to the sophistication of medieval surgery is that skull of the man killed in the Battle of Towton, south Yorkshire, in 1461.  For while we do not know what injury killed Towton Man in 1461, we do know that this experienced soldier had suffered a frightful maxillo-facial injury some years before: probably from a sword-slash down the left side of his face, smashing skull bone, jaw, teeth, and perhaps eye socket, and inevitably severing several major muscles and blood vessels, so it is a wonder that he did not die from haemorrhage on the spot.  Yet Towton Man’s slash had been staunched and the bones beautifully re-set by an unknown surgeon, and healed perfectly.  His face must have been hideously scarred, it is true, yet he obviously made a full physical recovery, enabling him to fight again – and die – at Towton.

Medieval Europe also had a large network of hospitals, mostly run by monks and nuns.  Indeed, between the formally-trained doctors and surgeons, and the monks and nuns who largely ran the hospitals, one had an astonishingly compassionate and efficient ‘health service’.  For while it is true that the medical arts were therapeutically feeble by modern clinical standards, they catered for a society with very different expectations and values.  For as the physician had a ‘cure of the body’, so the priest had a ‘cure of the soul’, in an age where everyone, from Popes to swineherds, had an active, vivid sense of an afterlife to come; and hence the religious dimension of these hospitals was fundamental.  For should one’s disease be painful, or terminal, then the patient would be spiritually comforted and prepared to leave this world and enter the next, and the saying of Mass at altars in hospital wards and the administration of the Sacraments to patients could give a deep comfort and spiritual reassurance that was in stark contrast to a modern diagnosis: ‘Sorry, you have a month to live; we can provide information about hospice care.’

And in stark contrast with the circus-treatment of mental patients in the subsequent ‘Age of Reason’ Bedlam, medieval ‘asylums’ (quite literally, sanctuaries) displayed a humanity that was a million miles removed from the bleak, disciplined, scrubbed, ‘alienist’ institutions of the twentieth century, especially those where unfortunate souls were enmeshed in the labyrinthine negatives of Freudian theory.  For medieval doctors and priests not only knew on a practical level the differences between clinical insanity and ‘disturbances of the soul’, but they tended to be kinder to the mentally ill.  For had not St Paul, in I Corinthians 10:4, said that those who sought after Christ were deemed ‘fools’ by the worldly, and had not Jesus loved and cured the deranged?  Indeed, in medieval thinking there could be a fine line between the visionary, the prophet, and the ‘madman’, and one needed compassion and discernment in dealing with them.  For might not a socially troublesome person – such as the fifteenth-century visionary Margery Kempe – have been truly touched by God?

(1)  Tudor medical changes

So where was the great distinction between medieval and Tudor or Renaissance medicine and health care?  Quite simply, I do not think that there is one.  What I believe did happen, however, is that a variety of cultural, scientific, technological, and spiritual changes were brought about by non-medical circumstances, to which healers had to respond.  These were as diverse as the Reformation dissolution of monastic hospitals, new diseases and drugs that came into Europe as a result of the great oceanic voyages after c. 1470, and the necessity of coping with the horrific wounds inflicted by the increasing use of firearms and gunpowder during the fifteenth century.  And while there are little precise statistical data, circumstantial evidence suggests that by the time of King Henry VIII, and certainly by that of Queen Elizabeth I, the population of England was rapidly increasing – perhaps getting back to, and then exceeding, its pre-1348 Black Death levels, in spite of regular returns of the plague.  And without doubt, increasing land enclosure for sheep-farming – less labour-intensive than arable – combined with the population displacements brought about by the monastic dissolution created a rural unemployment crisis that occasioned a drift to the towns.  And nowhere more than the great drift to London and its growing suburbs, the population of which probably quadrupled during the reigns of the Tudor monarchs.  In the forty years from 1565 to 1605, for instance, modern estimates based on surviving records suggest that the population increased from 85,000 to 155,000, with perhaps another 20,000 in Southwark, Westminster, and the other surrounding ‘liberty’ districts.   [see below, Ackroyd, p.102.]

All of these changes brought their own burden of healthcare, from dealing with the elderly and infirm to treating ‘new’ diseases such as syphilis, and coping with that multiplicity of accidents and injuries implicit within a growing and often ill-nourished industrial society.  For London did it all, from gun-founding to ship’s rigging; indeed, all the trades – except mining – prone to accident and injury, not to mention social overcrowding, poor sanitation and crime.

It was this overall burgeoning of London that also gave rise to a growing professionalism.  Numerous branches of legal practice – centred on the Inns of Court in the Temple, and the Courts at Westminster – boomed as never before, as monastic estates were sold off, and the Crown insisted that disputes be settled peaceably before His Majesty’s Justices and Judges, rather than via feuds and private armies.  And medicine followed suit.  The old, more loosely-organised bodies of physicians and surgeons of medieval London sought a new professional identity under Henry VIII, as Thomas Linacre and his medical colleagues won privileges for the elite Oxford and Cambridge degree-carrying doctors with the incorporation of the Royal College of Physicians in 1518.  The surgeons followed later, in 1540, when the black-gowned and velvet-capped Master Thomas Vicary and his colleagues obtained Worshipful Company status for surgeons and barbers.  Then in 1617 the apothecaries and druggists obtained incorporation as a livery company.  For such professional territorialism made it clear in law who were the medical sheep and who were the quack goats!

(2)  Therapeutics

(a)  Humoral physiology

The problem with practical healing in 1545, however, be the attendant practitioner a D.M., F.R.C.P., or a liveried incorporated surgeon, was that it still remained a lottery.  A lottery, in fact, where unlicensed quacks could not infrequently win successes and a qualified man lose his patient; for the whole nature of the disease process remained a mystery, and treatment was often based upon academic premises which we now know to be completely wrong!

Medical theory in Tudor times still rested upon the theory of the four humours, which had passed from classical Greek times, especially from Hippocrates and Aristotle in the fifth and fourth centuries BC, into medieval Christian and Arabic medicine.  In this way of interpreting health and disease, each human being contained a mixture of the humours Yellow Bile (hot, dry, ‘choleric’), Black Bile (cold, dry, ‘melancholic’), Blood (hot, moist) and Phlegm (cold, moist).  They formed medical cognates to the four elements of physics, Fire, Earth, Air, and Water.  Each person’s humoral balance was unique to the individual, giving that person his or her particular personality and ‘disease profile’.  A dominant ‘Blood’ humoral mix made a person ‘sanguine’ (Latin, sanguis = blood), or basically happy and easy-going.  A dominantly ‘Black Bile’ – ‘melancholic’ or ‘bilious’ – person was likely to be reclusive, peevish, depressive and essentially unhappy and prone to worry.  (Scholars, academics, and schoolmasters were thought to be predominantly of this humour.  The Oxford scholar and learned medical ‘amateur’, Robert Burton, gave the definitive Renaissance analysis of this ‘temperament’ in his Anatomy of  Melancholy in 1621.)  But each one of us contained all the humours in one mix or another, making us the people we were.  The humours could also incline one to disease: ‘Yellow Bile’ people, for instance – irritable and fiery-tempered – were more susceptible to violent tendencies, and those diseases associated with hastiness, such as sudden paralysis, purple countenances, or shortness of breath.  ‘Phlegmatics’ – or dominant Phlegm types – might be philosophical, but could also be inclined to respiratory disorders, bad headaches, and running sores, as the excessive phlegm clogged up or oozed out of the body.  Indeed, every disease of the human frame, from insanity to swollen feet, from cancerous tumours to blindness, could be explained by surfeits or deficiencies of the humours.

Irrespective of one’s humoral type or inclination, illness of pretty well all kinds was thought of as some sort of blockage or obstruction.  Diagnosis and therapy, therefore, hinged upon the physician correctly identifying the blockage, and then prescribing the appropriate purgative to unblock it, and restore the natural, healthy humour flow.  For virtually all classical and Renaissance therapy involved purgation of one kind or another: the purging of the bowels or the stomach (with an emetic), for example, could create a ‘sympathetic’ chain of unblockings, as stagnant, corrupt, or poisoned humours were made to flow away.  Blood-letting was seen as removing over-heated, excessive blood, and allowing (in pre-Harveian circulatory physiology) a congested vein to ‘breathe’ and return to normality.  ‘Diaphoretics’ encouraged copious sweating and aimed to remove deep-seated poisons to the outer parts of the body, to be disgorged as sweat. Cordials assisted in treatment by seeming to strengthen the patient and lift the spirits—usually because most cordials were well-laced with alcohol.

And while we now know that such therapies were based upon theories of anatomy and physiology that were completely wrong, they could sometimes work, for reasons which practitioners did not necessarily understand.  A person suffering from high-blood-pressure-related disease could enjoy some short-term relief from losing a pint of blood by phlebotomy; while a seriously-disturbed schizophrenic just might sleep quietly for a day or so after being bodily exhausted by a powerful purge.  And in an age quite innocent of knowledge about germs and microbes, plagues and other infectious diseases were, just as in classical Greek times, believed to derive from foul wind-blown ‘miasmas’ originating in decomposing matter.  Or perhaps the hand of God was even at work, punishing a person or a city for sinful conduct.

(b) Astrology

In Tudor and Stuart times, moreover, astrology was routinely enlisted by both the academic healer and the quack to explain an illness, for in that age astrology made good sense.  For did not human beings live on a planet at the centre of the universe (Heaven being beyond the eighth sphere of the stars, and Hell at the centre of the world), around which the entire cosmos rotated?  This was neither an ignorant nor a superstitious belief, but one that accorded with the best commonsense physical evidence available at the time.  For in c. 1550 there was far more physical and observational evidence against the Copernican theory of the spinning and moving earth than there was for it.  For would not a dropped object fly off into space rather than falling to the ground if the earth were spinning on its axis?  Would there not be a constant great gale blowing if we were whirling through space?  And did not the earth simply feel rock-solid and firm on its foundations?  Indeed, those who assert that Tudor people only paid lip-service to a fixed, immobile earth because of a fear of the Church only display a glaring ignorance of sixteenth-century physical ideas (to say nothing about an ignorance of sixteenth-century ecclesiastical priorities), compounded with a dogmatic modernist hindsight view of history.

And in this earth-centred classical cosmology, were not the planets imbued with particular properties?  Was not fast-moving Mercury – spinning round the earth in 88 days – a significator of nimble intelligence, whereas did not Saturn – taking 29½ years to complete his circuit against the zodiac stars – epitomise old age, dullness, and melancholy?  And between them, ancestral wisdom had ascribed fruitful changeability to the fast-moving moon, beauty and femininity to Venus, warlikeness to blood-red Mars, ‘Joviality’ to Jupiter, and positive life-giving force to the Sun.  The same classical attributes, moreover, that Gustav Holst explored musically in his Planets Suite of 1914-16 (Uranus, Neptune, and Pluto were not discovered until after 1781).

Furthermore, these seven planets moved against the zodiac band of twelve constellations of stars, which themselves had had qualities attributed to them from time immemorial.  Taurus, for example, epitomised bullish perseverance, Leo confidence, Libra justice, and Scorpio passion.

Interpreting the changing geometrical patterns produced by the moving planets against the fixed zodiac signs was the business of the horoscope-caster, or astrologer.  A diagnosing physician, in trying to understand his patient’s disease, would want to know the ‘birth time’ of the disease, or hora decumbitus (the precise time at which the patient ‘took to his bed’).  And as the doctor believed that the astrological forces beaming down from the heavens upon the earth affected the four humours of the human body, he perceived a genuine connection.  For stars and planets affected humours, to produce body changes, illness, and death.  And not only could astrology help to diagnose; the horoscope could also be calculated into the future, to prognose the likely outcome of a disease, as the planets moved.  Was, by way of example, the patient strong enough to survive until the life-giving Sun, or Jupiter, moved into his currently malign zodiac configuration to bring in positive, life-giving influences?

Astrology is scientifically meaningless today because scientific discoveries have shown that we are not really at the centre of the universe, but on a planet spinning around the sun.  Subsequent chemical and biochemical discoveries, moreover, have made it abundantly clear that the earth is not made up of four elements, and that our bodies and their infirmities are not the product of four humours.  Quite simply, the whole physical and physiological basis of astrology has been undermined by subsequent scientific discovery, and that is why we do not give it any serious credibility today.  But this was most emphatically not the case in Tudor times, when pretty well everyone, from the Royal Court physician to Snug the Joiner in Shakespeare’s A Midsummer Night’s Dream consulting  his  almanac to check the moon’s phase, would have accepted astrology as a fact of life no less than we today might accept evolutionary genetics or DNA.  (Astrological almanac booklets, costing a few pennies for their usual 32 pages of predictions and assorted information – the ancestor of the pocket diary – were very popular by Elizabethan times, as Shakespeare’s character Snug makes clear.)

(c) Medication

From Hippocrates onwards, most academic physicians, in both the European and the Arab worlds, would have regarded healing as properly a gentle, gradual, humour-changing, process.  Medicine was, by definition, an innately conservative art, where wise forefathers were revered, and crass modern innovations despised.  For curing a serious illness demanded a wholesale changing of the body’s ‘regime’, including diet, clothing, exercise, administration of herbal medication, and spiritual taking stock.  For human beings were innately sinful, and disease was often seen as a divine punishment for wrong-doing.  Yet as Christ Himself was the supreme healer, and the Gospel writer St Luke, a non-Jewish Greek doctor, ‘the beloved physician’, the healing art in the Christian context had impeccable credentials, both as a spiritual and as a physical activity.

In the sixteenth century, however, new drugs began to come into use, in a big way – though some had been employed in a more limited context for centuries.  The Swiss physician who styled himself ‘Paracelsus’ (‘Greater than Celsus’, the famous c. AD 30 Roman medical writer) became, medically-speaking, a true ‘cat among the pigeons’.  Inspired by astrology, the supposed writings of the Greek mystic who was known as Hermes, and a few esoterics besides, Paracelsus made noisy warfare against conservative classical medical practice, causing ructions in Basle (upon his appointment as Town Physician) and elsewhere.  Noisy, brash, heavy-drinking and a born showman, Paracelsus made public bonfires of the classical Greek writers’ works to demonstrate his contempt for medicine’s conservative tradition.  He exclaimed that the whole rationale of classical medicine was wrong, and that its slow, gentle, herbal therapies needed to be replaced by powerful, drastic, mineral drugs.  Mercury was his favourite: a drug, moreover, that did seem to have a genuinely retarding effect upon gonorrhoea and syphilis, although there are examples of mercury having been used to treat leprosy in late medieval times.  (As the very astrologically- and alchemically-minded Paracelsus was all too well aware, the drug mercury and the Venus connection of sexual diseases formed a powerful occult symmetry that was far too good to miss, for it seemed only logical that the sins of Venus should be cured by the painful salivation induced by mercury compounds.)

Mercury, and subsequently-used antimony, lead, arsenic, gold, and other metallic compounds demanded a new mode of preparation beyond that of simple herbal pharmacy.  The mineral acids, sulphuric, nitric, and hydrochloric, and other powerful corrosives came to link the radical ‘Paracelsian’ medicine with the alchemical laboratory, as intense furnace heat, distillation, and other processes were necessary to prepare them.  ‘Paracelsianism’, though a growing force in the Tudor period, really came to its full fruition in the seventeenth century.  Firmly opposed as it was by the Royal College of Physicians and other conservative, Europe-wide medical faculties, Paracelsianism nonetheless did two things.  Firstly, it began the enduring association of medicine with complex laboratory processes; and secondly, it suggested that medicine should be driven by experimental research, rather than by a respectful acquiescence in what had been done for centuries.

But beyond its capacity to inspire future generations, Paracelsian ‘Iatro-chemical’ medicine had little practical impact upon Tudor or Stuart medical practice, and very little indeed upon the actual business of healing.  For while mercury could retard the progress of sexual diseases, many other Iatro-chemical therapies could have done little other than produce even more vicious purges that in many cases probably did permanent damage to the stomachs, intestines, and livers of the patients who were dosed with them.  On the other hand, they produced a fast reaction.

(3)  Infectious disease 

Without doubt the biggest single category of malady against which any Tudor physician would have done battle was infectious disease.  In an age of relatively sparse washing, when the harsh climate of ‘mini-Ice-Age’ northern Europe made even the rich reluctant to take off  too many clothes between October and May, and where large quantities of hot water were a luxury, personal uncleanliness, not to mention lousiness, was a fact of life.  Microbial insect-borne disease was the common lot of humanity, especially as urban drinking water was likely to be routinely polluted by what had drained into the water-table, and on into urban domestic wells, from over-crowded graveyards and leaking privy pits.  Indeed, it was eminent good sense that led Cardinal Wolsey’s engineers to bring drinking water to Hampton Court from a distant fresh spring via a lead conduit.

Irrespective of how individual strains of bacteria entered the body, however, there were a large number of illnesses which manifested themselves as fevers or debilitating diseases in the sixteenth century.  Especially feared in King Henry VIII’s time was the ‘sweating sickness’ which could kill within days or even hours of onset.  Then there was ‘ague’, a malarial disease common before the drainage of the several hundred square miles of marshland that England still had in Tudor times, some of which survived even into the early nineteenth century, harbouring as it did a mosquito that could survive cold weather.  Ague, or the ‘Quakes’ or ‘Shivers’, could either kill or debilitate in recurring bouts.  A ‘tertian’ ague had a three-day recurrent crisis pattern and a ‘quartan’ a four.  And then there was typhoid, typhus, smallpox (on the increase), tuberculosis in its myriad complications, enteric fever, and the fever whose very name indicated its astrological source: ‘Influenza’.  Yes, ’flu was often ascribed, as its original Italian name indicates, to a malign planetary configuration.

For reasons of which we still cannot be sure, epidemiologically the ancient Biblical disease leprosy seemed on the decline.  We know this because leper hospitals were closing for lack of patients, or else turning into more general local hospitals.  Was this because aggressive new diseases, such as the fast-killing Bubonic Plague, were gobbling up people who were not living long enough to develop slow-maturing leprosy, or because medieval physicians in Europe and the Arab world were developing better diagnostic criteria that were more precise in separating the true lepers from the more acute but non-infectious dermatological cases?  It is hard to be sure.  The Biblical book of Leviticus (chapter 13), however, goes into remarkable detail regarding the visual signs of what ancients cultures understood to be leprosy.

But without any doubt, the real bogey of Tudor disease was Bubonic Plague which, from its first appearance in southern Europe in the autumn of 1347, after previously visiting the Arab world, had decimated populations: killing off, it has been reckoned, between one-third and one-half of the population groups it entered.  It arrived in England in the early summer of 1348.  And worst of all, plague, or pestilence, kept coming back, with a major epidemic roughly four or five times a century, so that the population only slowly returned to its pre-1348 level.  London, for example, suffered a succession of major plague epidemics during the reigns of the first four Tudor monarchs, sometimes compounded with outbreaks of the baffling ‘sweating sickness’; and major Bubonic attacks occurred in 1563, 1581, 1593, 1603, and1625, until the disease mysteriously disappeared, for good, after the Great Plague of London in 1665.

No matter whether it was smallpox, the ‘sweating sickness’, typhus, tuberculosis, or plague, however, each of which could be fairly accurately diagnosed (but not necessarily at their onset) by an experienced doctor or surgeon by 1550, the treatment was no more than palliative.  If you were fit and strong when Bubonic Plague struck your community, it was best to flee.  But if you went down with it, even if you could get a doctor or a nurse to tend you, there was little that could be done beyond basic nursing.  Give the patient plenty of liquid or broth, pile on the bedclothes and ‘sweat the fever out’, let blood, cool the forehead to take down the temperature, perhaps try a favourite nostrum such as aromatic ‘plague water’, and pray. The late Elizabethan and Jacobean surgeon and advocate of Paracelsian chemical pharmaceuticals, John Woodall (of whom more will be said presently), tells us that he personally survived the Plague twice, in two separate epidemics, during his long professional career: ‘I had it twice, namely at two severall Plague times, in my Groyne’ (i.e. the lymphatic swellings, or buboes).  Woodall proudly asserts that his ‘Cordiall Powder made of Gold’, aurum vitae, produced many cures and saved many lives.  But how this very Paracelsian metal cure could possibly be effective against such a virulent disease is impossible to say.  In Paracelsian theory, of course, its potency derived from the noble, sun-related, astrologically-powerful gold, although in modern chemical terms this is therapeutically meaningless. One suspects that Woodall and his surviving patients pulled through due to a combination of tough constitutions and good basic nursing.  For plague struck such terror into society that relatives and loved ones not infrequently fled, and one suspects that many patients died of neglect who, with some care and attention, warm bedding, and a few gallons of gradually-administered clean water or small beer would have survived.

Yet perhaps the greatest and most enduringly useful Tudor medical innovations were administrative.  The first of these was the creation of a births, marriages, and deaths registry system in each parish church after 1536, the surviving registers of which give us our first demographic insights into their communities.  The second, after the major plague epidemic of 1563, and more formally by 1593, was the institution of weekly-published Bills of Mortality for London.  A response to the plague epidemics in 1581, the registration process required the appointment of two matrons in each of the 100 or so London parishes.  Experienced older women who had, no doubt, witnessed a great deal of sickness during their lives: but not qualified doctors.  Their job was to inspect the corpses of persons who had died that week in their parish, and search for the dreaded black ‘buboes’ in the neck, armpit, and groin – telltale signs of the plague – and tender their weekly report to the magistrates each Tuesday.  Appropriately, they were called ‘Searchers’.

A ‘healthy’ London was one in which there were no plague deaths, and where death returns were fairly stable.  Concern and alarm set in, however, when plague deaths began to appear, and spread from one congested parish to another.  All that could be done ‘in time of plague’ was to impose a primitive quarantine, usually by shutting up ‘plague houses’, complete with still-healthy inmates, prepare mass graves, and, if you could afford it, flee.  One old aphorism said that the only sure preventative against plague was a good pair of boots: to get as far away from London as possible!  And as the rich living in London would naturally flee to their country homes, so most of the physicians would go with them, leaving the poor to do as best they could.  John Woodall, rich businessman as well as medical professional, was exceptional in staying in the plague-stricken City, and one wonders whether his clear sense of Christian duty was the deciding factor.

Although plague mysteriously left London of its own will after 1665, and mainland Europe in the early 1720s (after a brief re-introduction into Marseilles by an infected ship from the Levant, causing the death of 60,000), the other infectious diseases mentioned above – and quite a few more – would remain menacingly active right down to Victorian times.

(4)  Surgery

Impotent as medical men were in the face of fevers, cancer, tuberculosis, diabetes, mental illness, and a whole range of further afflictions, there was one branch of the healing arts which really did begin to make significant advances in late medieval and Tudor times: surgery.

(a)  Pre-Tudor advances

There was a known documented body of surgeons in London active long before Thomas Vicary and his Worshipful Company of 1540.  John of Arderne had been a leading London surgeon in the early fourteenth century, and headed the medical team that King Edward III took to accompany his army to the Battle of Crecy in 1346.

These men, moreover, were not the rough-and-ready butchers of popular stereotype.  They would, given the limitations imposed by a lack of anaesthetics, antiseptics, and trauma control drugs, have been capable of performing a wide range of surgical procedures upon the broadly external parts of the body: resetting and splinting broken bones, dental extractions, draining ulcers, stitching wounds (it is a myth that Ambrose Paré invented surgical stitching), occasional amputations but probably not of complete limbs, some breast surgery, inserting catheters for urinary problems, joint massage and manipulation, couching for cataract (very much a specialist skill), and battle surgery, including attempts to close haemorrhaging wounds with needle or cautery.

But one of the most – to us – breathtaking pieces of medieval military surgery, of which we possess a detailed and even illustrated account – comes from 1403.  In that year, the 16-year-old Prince Hal (Shakespeare’s future Henry V) was hit in the left cheek by a clearly spent long-bow arrow (an arrow shot at shorter range would have gone right through his head).  The arrow was pulled out, but the iron point remained in the wound, embedded in his inner skull.

Prince Hal was operated on by John Bradmore of London, and it was his assistant, Thomas Morsted, who left us the detailed account of the surgical procedure, and of the arrow head extractor used by Bradmore.

As the flesh was already closing in where the arrow had been pulled out by the time that Bradmore saw the young Prince, he was obliged to prepare a series of wooden probes – apparently lubricated with honey – to gradually re-open the wound to full arrow-shaft width.  Bradmore then inserted a beautifully-made arrow-head extractor – made in ‘the manner of tongs’ – into the resulting cavity, gently seating its closed semi-cylindrical jaws inside the hollow tube in the arrow-head into which the shaft would have been originally inserted.  Then operating the tong mechanism, he opened, or expanded, the jaws, until they firmly gripped the arrow-head tube from the inside.  Then Bradmore gently worked the arrow-head loose from the bone, and skilfully extracted it from the Royal face, after which the wound was treated with salves.  Prince Hal made a full recovery.  So much for the hoary tale that medieval surgeons were ignorant brutes!

(b)  Gunpowder wounds

I would argue, however, that a massive stimulus to surgical ingenuity and experimentation developed as operators came to be increasingly faced with soldiers who had hideously complex gunshot injuries, buried bullets, smashed joints, horrible burns, and unprecedented trauma.  Of course, John of Arderne and his colleagues would no doubt have witnessed some very early such cases, for gunpowder weapons were used in a limited way at Crecy (but the English longbowmen were by far the most devastating force on that battlefield).  By the fifteenth century, however, firearms were coming to be used increasingly, and it was Hieronymus Brunschwig in the 1490s who first began to publish illustrated accounts of military surgical procedures, using the printing  press’s ability to reproduce not only text, but also technical pictures.

Gunshot wounds were assumed by the earlier surgical writers, such as John de Vigo, to be by their very nature poisoned and in need of cleansing.  Boiling oil was often used to cauterise and ‘cleanse’ them.  Treating gunshot wounds, therefore, became a frightful business, for not only had the already traumatised patient to endure probing for the bullet inside the musculature, and its extraction, but then the pouring in of the boiling oil!  The Frenchman Ambrose Paré in his military practice began to abandon the oil and replace it with cold salves, yet knowing what we now do about bacteria, dirty hands and instruments, not to mention the inevitable dirtiness of soldiers on campaign, one wonders whether the boiling oil did, inadvertently, have a sterilising effect.

It was the Elizabethan surgeon William Clowes, however, who performed what might be called the first ‘controlled’ experiment in the clinical investigation of gunshot wounds.  Doubting the orthodoxy of the chemically poisoned bullet, around 1580, Clowes got an arquebusier (or musketeer) to load his piece not with a lead ball but with a heavy war arrow, and then fire it at the Dover town gate.  On carefully inspecting the embedded arrow, he found that the flight feathers were wholly undamaged and unsinged by being shot from a gun.  So if the arrow had left the arquebus barrel faster than the flames of the explosion (thus avoiding singeing), was it not likely that it (or a lead ball) had left it before it could be touched by the presumably poisonous fumes that came from the gunpowder?

By the late sixteenth century, both the pragmatic necessities of military surgery and a more widespread practice of human and animal dissection led to the development of more daring and complex operations.  The amputation of a gangrenous limb following an injury had always been a frightful business, not only because of the pain inevitably inflicted on the patient and the likelihood of infection, but also due to massive haemorrhage.  For quite simply, many surgeons were not sure which major blood vessels lay beneath the skin at a given part of the lower arm or thigh.  But statutory dissections at the Physicians’ College and Surgeons’ Company Hall by the 1560s, supplemented in many cases by private dissections, along with the study of the detailed plates in Andreas Vesalius’s  De Fabrica Humani Corporis (1543), began to give a new anatomical confidence to surgeons.  And it was sometime before 1588 (when he published his account) that William Clowes performed an extraordinarily dangerous operation upon a ‘mayde of Hygate’, London.  We are not told the woman’s name, nor the cause of her obviously non-military injury: only that Clowes and his well-drilled team of assistants removed one of her legs above the knee, with successful control of haemorrhage, and that she made a full and rapid recovery.  Thigh amputations would still be horrendous affairs 250 years later, but would have been little short of a death sentence in 1500.

Indeed, the deeply spiritual caution with which a Tudor or early Jacobean physician or surgeon approached his patient should never be lost sight of, be they pre-Reformation Roman Catholic or Elizabethan Protestant, for these men possessed an acute awareness that a patient stood in the image of God.  Indeed, nowhere else was this spelled out more clearly than when the Elizabethan military and naval surgeon, the above-mentioned John Woodall, who as a young man in 1589-90 had served in Lord Willoughby’s campaign against the Catholic league, wrote up his extensive medical experiences in The Surgeon’s Mate (1617).  He does not appear to have served much, if at all, at sea, however, although he was widely-travelled, and as an influential East India Company stockholder he became responsible for the provisioning of medical and surgical chests both to that Company and to the early Royal Navy.  For in addition to being a very successful medical man, Woodall became a wealthy and influential businessman in the City of London, and as a fluent German speaker, he even served on diplomatic expeditions to Eastern Europe .  Indeed, Woodall, who was clearly a learned, religious, and deeply humane military and sea doctor, lays the world of practical medicine and surgery before us.  And while amputation was sometimes necessary, as a result of battle or shipboard or campaign ‘industrial accident’ injury, one should approach it with extreme caution, ‘for it is no small presumption to Dismember the Image of God’.  Indeed, Woodall describes treatments for hernia (very common amongst soldiers and sailors with their heavy manual work), gunshot wounds and bad cuts, scurvy (best prevented by regularly taking on board fresh meat, fruit, and vegetables, and most of all ‘Lemmons, Limes, Tamarinds, Oranges, and other choice of good help in the Indies’), and a variety of diseases.  He also provides a horrendous account of the precise symptomology of what would later be called appendicitis and acute peritonitis, with its complete blockage of the gut.  A fatal condition, known as the ‘Illiac Passion’.

Woodall’s religious caution regarding ‘Dismembering the Image of God’, or a human being, during amputation certainly produced practical results, however; for in the 1639 edition of his magnum opus he tells us that when later working as senior hospital surgeon at St Bartholomew’s, London, out of just over 100 amputations of dead gangrenous tissue he lost only 20 patients.  An 80% success record that many a pre-anaesthetics, pre-antiseptics Victorian surgeon of 200 years later would have been proud of!  How on earth did he achieve it?

By the end of the Tudor age, with the death of Queen Elizabeth I in 1603, the range of practical surgery had increased greatly beyond what had been possible at the time of the Battle of Bosworth Field in 1485, which had brought the Tudors to the throne.  The skills, insights, and confidence gained by young surgeons from the life-and-death circumstances of battlefield surgery were carried over into civilian practice, as a man who had become good at bullet extractions might reasonably try his hand at the removal of bladder stones, and a man who was a skilled wound stitcher might also win a civilian reputation for using other needles to couch cataracts in the eyes of the blind.

(5)  Discoveries

Mention has already been made of the great Belgian anatomist working in Padua, Andreas Vesalius.  Indeed, it is hard to calculate the impact which he and his writings (and published anatomical drawings) had on European practice after 1543, other than to say that it was colossal.  Vesalius transformed dissection from a theatrical ritual – a corpse dissected and demonstrated in accordance with the recited second-century-AD writings of Galen before an academic audience – to a hands-on affair that encouraged students to dissect and study for themselves.  Indeed, not just humans, but to dissect, when available, pigs, monkeys, dogs, or cattle, as an exercise in comparative anatomy, and to study how they shared similar, yet different, parts; how the skeleton was like a set of ‘tent-poles’ from which the muscles, tendons, and veins hung, to provide a chamber to house the vital organs; how the heart, lungs, and brain were believed to interact; and how the various types of joint facilitated locomotion and stability.

Vesalius’s approach to dissection, both as a scientific research technique and as a method of teaching, was to have an enormous impact.  Padua, moreover, became a magnet for medical students, and created an intellectual and technical style and tradition, combined with a concern with published discoveries, and with illustrating them, as Vesalius himself first did, with detailed fine-art engravings, to establish what would become the ‘anatomical atlas’ of the body.  Vesalius’s disciples went on to make their own discoveries, and some of their names are still remembered in the anatomical structures which they first described.  Gabriele Falloppia, for example, first described those tubes in the female reproductive system that still bear his name; while Bartolomeo Eustachio described the tube which runs from the throat to the middle ear.  And it was Hieronymus Fabricius ab Aquapedente’s description of the valves in the veins that was to play a major part in what was not only the greatest single discovery to come from the Vesalian tradition at Padua, but a discovery without which modern scientific physiology, and its myriad ensuing therapies, could never have come about: William Harvey’s circulation of the blood.

A ‘grand-student’ of Vesalius, Harvey was one of several English doctors who studied at Padua.  Born at Folkstone in 1578, he first went to Cambridge University as an undergraduate, then on to Padua to take his medical doctorate, which he received in 1602.   Returning home to Cambridge after the best clinical training in Europe to be incorporated Doctor of Medicine in his home university, he was all set for a gilded professional career.  On a purely professional level, he became a Fellow, and later Lumleian Lecturer and Censor, of the Royal College of Physicians, Physician to St Bartholomew’s Hospital, and a very successful Society doctor, and crowned it all as Physician to King Charles I.  Indeed, he was more than just a Royal doctor: he seems to have become a trusted friend of the Royal Family, accompanying the King to war, and even crouching under a hedge to give some lessons to the young Prince of Wales and Duke of York (the future King Charles II and King James II) at Edgehill, as the first battle of the English Civil War thundered around them!

Harvey became intrigued by Fabricius’s vein valves, first encountered at Padua, for they must, inevitably, prevent the blood from going down the veins from the heart, contrary to what Galen and the classical anatomists had taught.  Over a series of meticulous dissections and experiments, on human cadavers and living and dead animals, he came to fundamentally ‘re-plumb’ the bodies of man and the animals.  For as Harvey said in his published De Motu Cordis (1628), the blood came into the heart from the vena cava: a fact also known by the classical anatomists.  But then the right-hand chambers of the heart, the atrium and the ventricle, successively drove the blood first into the lungs, via the pulmonary artery. Then, leaving the lungs by the pulmonary vein, the blood entered the left cardiac atrium and ventricle (tracing its path by the direction in which the valves opened) and from there moved into the aorta, and on into the arteries, not the veins!  As Vesalius and other anatomists were fully aware, the veins and the arteries seemed to mirror each other structurally, and each broke down into increasingly fine capillary vessels, although the exact function of the arteries (as opposed to the veins) was a matter of puzzlement and dispute to classical and later anatomists.

Harvey, as a thoroughgoing experimentalist and guided by the Aristotelian idea that structures and functions within an organism should be correlated with each other, was all too much aware that he could not, with the research technology of the 1620s, unequivocally demonstrate the artery to vein passage via the capillaries, and the critics of his blood circulation theory rounded upon him because of it.  But then, in 1661, some three years after Harvey’s death at the age of eighty, Marcello Malphigi in Bologna, using that relatively new research tool, the microscope, observed the capillary transition in the lung of a vivisected frog.  And as the established comparative anatomy tradition saw the relevance, structure- and function-wise, of applying discoveries from one species to another, the Harveian theory now carried all before it.

So one might, therefore, claim that Harvey’s discovery of blood circulation under the systolic, contractive, force of the heart was the last, and greatest, achievement of Tudor medicine.  Yet like pretty well all of the other medical discoveries of the Tudor age, blood circulation would have to wait a long time before it could migrate from the lecture hall or laboratory to the hospital ward, for so many additional things had still to be discovered to take Tudor medical practice out of the realm of hit and miss and make it efficient and reliable on a daily basis.  Further centuries of discovery still awaited in 1600: bacteriology, trauma and pain control, diet, organic and bio-chemistry, cellular pathology, a germ-based model of infection transmission, blood transfusion, and many more besides.

Perhaps the first great discovery that began immediately to save lives was Edward Jenner’s realisation in 1796 that a mild cowpox dose introduced into the bloodstream via a small cut in the skin, vaccination, could prevent a fatal bout of smallpox.  Jenner’s discovery played a significant role in the great European and American population explosions of the nineteenth century, the reduction in smallpox deaths giving opportunity to reproduce to millions who would otherwise have died young.  And the rest of that transformative avalanche of discoveries which led to direct, practical, clinical consequences also came about in the nineteenth and twentieth centuries.

Yet what happened in the Tudor age did much to create a foundation, both institutional and technical, for what would come later.

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©Dr Allan Chapman, Gresham College 2011