Surgeons

The disciplines of medicine as practiced by Physickers and Surgery as practiced by Surgeons or “Barber-Surgeons” evolved almost independently of one another. Barbers, along with Midwives, are among the overwhelming majority of health care practitioners in the medieval milieu, but the majority also equates to a very common occurrence of mediocrity in practice, which is why their skills are limited in the manner seen in their descriptions.

Physickers or Physicians trained in the universities and Surgeons of exemplary knowledge and skill form elite bands of practitioners, by contrast. Physickers are primarily university-trained theorists. When put to the test, however, in times of epidemic illness’, it is the practical knowledge and skill of the Surgeons and their willingness to put themselves in harm’s way in the streets treating the sick that allows the best of them to outshine the highly esteemed and educated Physickers, leveling the playing field between them both professionally and socially.

It is from among the ranks of Surgeons that most of the nobility traditionally hire those they wish to tend to them and their men when they head off on campaign for battle.

Anglo-Saxon kings had surgeons, but didn’t take them to battle with them.

The Plantagenets took Surgeons to battle but rarely brought them to court.

Henry III instituted the office of Chief Surgeon, the “Sergeant-Surgeon” (1233-1254) in the royal party, at a time when the norm was to take a Physicker and an Apothecary.

Armies in the field were usually accompanied by physicians, surgeons, barbers or some combination of these. Great lords typically brought such men as part of their retinues, and infantry contingents often did the same. Medical personnel doubtless gave first priority to their own employers, but it was normally expected that wounded soldiers would eventually be tended by a physician if necessary: to say someone had been struck with such force that he would have no need of a doctor was to say that they had been killed outright.

Physickers and Apothecaries are the most common and influential among healers in royal service in the royal courts. That service provides instant protection and respectability. Surgeons just as commonly patronized by the oligarchs, who are in the habit of protecting them from being disturbed by the aspirations, machinations and politics of the Barbers.

Albeit late in period for the purposes of the game, it is interesting to note that by Henry VIII (dates), the medical practitioners at the royal court were dominated by Italians, university trained and practiced in a new surgery resulting from more accurate appraisals of anatomy and physiology and integrated with Physic. Thus, those PC’s equipping their characters as both Physickers and Surgeons – and perhaps Herbal, as well – are going to be “ahead of their time”, so to speak, prepared to provide the best in comprehensive medical care (even rivaling what is available in the modern day – exceeding it where magick is also employed). 

Surgeons are the gentlemen of the Healer Trades, following the Physickers who were granted dignity equal to knights on the social ladder. To the general population, both high and low, there is little difference between Barbers and Surgeons, however. Indeed, the name by which their trade is called is often conflated into “Barber-Surgeon”, only in some cases differentiated from “Barber-Tonsor” (barbers that cut hair), especially outside the great towns and cities. The distinction between them is considered a fine line among the less sophisticated, if known at all, much less acknowledged.

Most people in the period simply couldn’t afford to pay for a Physician or Surgeon, so a viable alternative would be to go and see a local wise woman (or sometimes a man) who were skilled in the prescribing Simples of herbal medicine, or might actually be qualified Herbals. A few Surgeons made themselves notable for their “charitable works” in providing their services free of charge for poor clients in dire need.

Like the Physickers, Surgeons jealously guard their knowledge, rank and privilege, and the wealthy patrons who provide it. Their wealthy patrons protect them from those who would trample on their prerogatives. That safety killed any interest they might have had in the political aspirations of forming a company or guild, historically.

In the context of a medieval game world, it provides the possibility of a noble patron “string” by which you, as GM, might rein in Surgeon characters. Any interest a Surgeon PC might have in involving himself in the political struggles for representation and quality control in the craft by means of instituting a local or national guild, or beefing up its standards and/or authority, could be hampered, even severely, by one or more noble patrons. This provides a nice bit of drama that can easily be woven into a campaign. 

As a result, the Surgeons stood aloof through most of the history of the forming of the guilds of Barbers in medieval England, and from all of the bickering and protestations of the practitioners (Leeches, Midwives, Barbers) “beneath them” that accompanied it.

When challenged by other trades infringing on their business, the Surgeons tried to merge in companies (guilds) with the Physickers due to this common ground they shared, but such attempts were few, and failed all too soon when they finally did come to fruition.

The trouble that most bedeviled the Surgeon trade historically, and likely should also in the game world, lies in the fact that their trade occupies a gray area between scholarship and the crafts that require only a skillful hand.

Indeed, in the 1300’s, the renowned surgeon Guy de Chauliac stated:

“If the surgeon has not learned geometry, astronomy, dialectics, nor any other good discipline, soon; the leather workers, carpenters and furriers will quit their own occupations and become surgeons.”

Because of the latter, ALL sorts of tradesmen who routinely cut into bodies in pursuing their trade, including butchers, skinners, tanners and tawyers, even chandlers, felt fully justified in engaging in surgery in spite of their lack of any knowledge of anatomy (much less physiology). These were typified as carving on bodies as blind men might carve a block of wood by the period medical luminary Guy de Chauliac.

A bit late in period for our purposes but still very illustrative of the persistent mindset of medieval craftsmen, the wax makers of Bristol insisted in 1430 they should be allowed to practice surgery by virtue of the lone fact that they, “like Barbers, use wax for embalming.”

The only remedy available against these charlatans is to haul them before the courts and put them and their knowledge of the Surgeons’ mystery on trial.

When you have a Barber, Midwife and/or especially a Surgeon in the party of PC’s, this historical conflict provides another, related source for a motivational subplot to weave into the background for a campaign. What side of the conflict are the PC(s) going to declare themselves for?

It wasn’t until 1492 that the Surgeons established their own guild in England, so it is quite possible that, as GM, you might rule that no such guild has yet been established in your game world. Alternately, in view of the essentially “perpetually medieval” nature of most game worlds, the establishing of Surgeons’ guilds might just as easily already be a general practice. Specialization among the trades was just as bad historically as it is in the modern world, especially when looking at the handicrafts, one of which surgery was considered to be.

An extensive understanding of how the human body works (anatomy and physiology) is far more important for the Surgeon than manual skill or experience. As surgeons generally came to this conclusion in the period of the game, de Chauliac’s work Chirurgia magna began to serve as a standard text on the subject.

The Surgeons’ primary concern about their field (historically) was for its dangerous lack of educated practitioners. Unlike the physicians’ practice of medicine which came solely from university education, surgeons stood/stand aloof, lacking any institutional structure. The surgeon’s guild became a separate institution in the medical community in England as early as 1368, but was ironically finally merged into the United Barber-Surgeons Company by Henry VIII in 1540, after their bid to join in a company with the physicians failed.

Historically, only a few Continental universities taught surgery as a specialized field of knowledge and, when they taught surgery at all, they focused mainly on the science and not the art of surgery itself, the actual skill of hand required. 

By the 1400s, England’s medical establishments were c.100 years behind those on the Continent, where medical universities were established at Paris and Salerno by the 12th and 13th centuries. England’s first medical university wasn’t established until 1423, only to be dissolved 18 months later. It wasn’t reestablished until 1518, almost 100 years later. Prior to 1423 – and then until 1518 – English students who desired to study medicine had only two options: either enroll in a medical university on the Continent and return to England with a degree, or study medicine as a component of the Bachelor of Arts degree in the truncated fashion available in England.

At this time, medicine in England was subsumed under the study of practical philosophy, a philosophy which centered on ars and scientia (arts and sciences). Medicine was considered a less virtuous pursuit, far beneath that of theology and law. Universities still offered degrees demonstrating the student’s knowledge as a doctor (of Physick), however, illustrating that medicine did, indeed, require education.

It is possible, and perhaps even advisable, that the state of medicine in the English corner of the your game world be just reaching the flowering of the 1400’s, as a part of arriving at the apex of accomplishments of High Medieval society. If there is no isolating factor as there is in the case of England’s geography, it is perfectly reasonable to presume that advances in the practices of medicine have kept pace with those on the Continent, with the establishment of the medical schools of Paris and Salerno in the 11-1200’s.

But Surgeons themselves provide the practical knowledge, training and experience needed for surgery through traditional apprenticeships, like those also served by Barbers and Midwives, from among whose ranks Surgeons commonly rise.

In both cases, traditional apprenticeships are the norm for the passing on these Trades.

The apprenticeship of a surgeon took 6 years, just as shown on the table for determine character age.

Unlike the other healthcare practitioners, however, the candidate for Surgeon’s apprentice must be literate. To reflect this, the character must be equipped with the Literatus and Scrivener skills, as well as the Scholar’s Tongue Linguist skill, at the very least.

Where they are organized into guilds (Barber-Surgeons are the most common), the guilds function as the professional organizations through which “registered apprenticeships” are arranged. The guild requirements are more stringent due to the prestige eventually gaining membership affords. Equipping the character with Grammar School (MGram degree) is the minimum education required for a registered guild apprenticeship, but a Bachelor of Arts or, even better, the Licentia Docendi of a Magister is preferred.

The surgeon’s guilds fill the need for trained surgeons without the aid of the universities. 

Each city’s guild keeps its own library holding the secrets of its mysteries, so all the students really needs to qualify for an apprenticeship are the Literatus & Scrivener skills.

To work as a common Clerk, even in the exalted ranks in the royal goverment, itself, no degree is needed at all, just a working knowledge of Latin and the ability to read and write, so it wasn’t a matter of simple literacy – this was most likely intended to emphasize the borders between class and/or station. Formal education to the point of obtaining even a BA takes money, whereas a commoner learning to simply read and write was not so difficult to come by in and around the towns and cities where the community of craftsmen made sure that basic education was available so they could at least keep the books for the family businesses.

Guy de Chauliac refers to himself as “cyrurgicus magister in medicine,” and he received his magister in medicina (master’s degree in medicine, equivalent to the M.D. of Bologna) from the much-respected University of Montpellier, under the tutelage of Raymond de Moleriis in a program that required 6 years of study. Same as the apprenticeship.

If the apprentice doesn’t assay and pass a (guild) surgical exam within 12 years from entering his apprenticeship, he is no longer allowed to ever become a master of surgery. 

As GM, you might reasonably waive this last restriction, but having that hanging over the head of a character poised to be a “perpetual student” provides a little low-grade background drama.

Skills & Abilities

Surgeons are relentlessly trained in surgical procedures and continue to study interior anatomy and physiology, even long after any certification or degree is in hand. This gives them a wider scope of experience to draw on.

The Surgeon is confident and knowledgeable when opening the body. He knows when things are out of place and generally how to fix them by his art, if they can be.

Where Physickers (doctors of physick; physicians) are regarded as safe-guarding the general health of the patient, tending to his diet and lifestyle preventatively as well as the obvious illnesses of his internal systems (maladies, dis-ease), Surgeons are perceived as limited to more external matters, from amputating a limb to cutting hair (due their firm association with Barber’s in the public mind/perception). Surgeons defy such limitations, but have a working knowledge of the humors as it affects proper diet, essential to client health and their practices, as well.

Due to the 100 Years’ War, England had the best practical, battle-trained surgeons in Europe by 1350.

The Surgeon’s tools represent a wide array for treating an equally broad array of maladies/injuries, ranging from scalpels, probes for wounds and fistulae, sounds, dilators, mallets, threphines, catheters, hooks, chisels, saws, clamps, forceps, to cups, bowls, cauteries, and a number of other shapes, rounded and flat needles for different sorts of wounds and suturing needs, bowls, pestles, mortars, spatulae and scales. Due to the importance of Astrology, an astrolabe is considered just as powerful a tool as a scalpel to a Surgeon in the medieval game world.

The repair of hemorrhoid, fistula, cancer, cataract, amputation, nasal polyp, bladder stone, depilation, tooth extraction, fracture setting or assorted traumas each requires different instruments. Practicing surgical authors like Henry de Mondeville, Guy de Chauliac, and Ambroise Paré innovated instrument design by necessity.

Despite the common belief to the contrary, Western European surgeons of the Middle Ages seem to have been roughly on a par with their Islamic, Byzantine and Jewish contemporaries.

The bleeding of a cut artery was stopped with pressure and cauterization.

They were no strangers to splinting broken arms or legs, and cracked/broken skulls were skillfully treated by means of a procedure called trepanning.

Metal tubes or goose quills were used to cover the barbs of nastily barbed arrowheads so they could be safely drawn out.

They could even suture intestines or severed jugular veins.

The eyeglasses that first appeared in the late 1200’s extended the useful life of craftsmen beyond the early 40’s, the age at which people still commonly suffer desiccation degeneration of the lens of the eyes, making close/detailed hand-work nearly impossible. This was a great boon to Surgeons as well, for the same reason.

Staunching Blood Loss

Any overt bleeding (GM’s discretion, based on the interaction of weapons, armor and flesh) must be staunched before those wounds can be cleaned or stitched closed – from any wounded BP area suffering bleeding losses from open wounds (as described in the rules for tactical play, where those optional rules are in play).

The rate at which open wounds taper off in blood loss and BP’s heal are detailed under the heading “Open Wounds & Bleeding” and the heading “The Aftermath: Tending Wounds & The Healing Process” in the rules for Tactical Play & Armed Combat. 

The att. mod for staunching bleeding is based on the character’s CRD and STR.

The DV for staunching wounds is equal to the number of points being lost when WND is deducted for that cause. The time required to do so is equal to the DV counted in Pulses, MINUS the practitioner’s (CRD and STR att. mod’s), with a bonus based on him SL, to a minimum of one (1) full action, according to his RoA.

IF the practitioner fails all the D100 checks his skills allow, he can still reduce the WND lost due to bleeding by (1 per 4 SL’s) points, or (CRD att. mod. + STR att. mod.), whichever is less. This is modified by +/- 1 per 2 points of healer’s STA above/below 20. The modified STA score is used for this purpose.

IF he is unable to staunch the bleeding completely, any remaining losses are only deducted every (CRD att. mod.) or (1 per ÷ 4 SL’s) minutes, whichever is greater, instead of every minute and the bleeding slows and tapers off normally. 

IF he is unable to completely staunch the bleeding, the remaining points of blood loss is added to the DV to clean and then close the wound, as well. 

The rate at which open wounds taper off in blood loss and BP’s heal are detailed under the heading “Open Wounds & Bleeding” and the heading “The Aftermath: Tending Wounds & The Healing Process” in the rules for Tactical Play & Armed Combat.

Once a character takes enough BP’s in damage indicating he is wounded to the “Mortal” degree in any given BP area, the blood loss suffered from that area does NOT taper off and clot on its own as it does for areas wounded to a lesser degree.

A character wounded to this degree whose bleeding is not stopped simply bleeds out and dies, unless he can be attended to by a Surgeon.

Treating Wounds

The Surgeon must Assess Wounds for every BP area wounded so he can determine their cause (blunt trauma, laceration, fire, frostbite) as well as their severity (Light, Serious, Grievous or Mortal) before he may begin to treat them.

He must also general Assess the patient’s health. This reveals to him whether he is weakened due to some condition that, if he is also wounded, further weakens him, raising the DV for performing any procedure(s) to patch him up.

To the DV, add the POT of any poison or venom in his system, and/or the POT of any disease with which he is contending, number of attribute points lost due to malnutrition, attribute points and/or BP’s due to hypothermia, and so on.

IF the Surgeon has the talent (Spirit Skill) of Reading, add the SL as a bonus to the AV.

IF the Surgeon is a practitioner of magic and casts the Read charm (assuming he has it in his portfolio), add the SL to the AV, plus a bonus based on the POT used.

The Surgeon may only attend to the wounds of one (1) BP area at a time (Head/Neck; Torso; Rt. Arm; Lt. Arm; Rt. Leg or Lt. Leg) for purposes of staunching blood loss, cleaning and then closing wounds. 

Wounds are washed with vinegar [soured wine or verjuice] or old wine that was strong in alcohol – both effective antiseptics – as a part of the cleaning process to remove possible sources of infection (dirt, cloth, etc.),

For cleaning wounds the att. mod. is based upon the character’s AWA and CRD

For repairing, closing, binding and dressing wounds the att. mod. is based on CRD.

Repairing, closing, binding and dressing are each treated as a separate task.

The DV for repairing and closing and binding & dressing wounds is equal to the number of BP’s of damage suffered in the BP area attended for Light and Serious category wounds.

For Grievous and Mortal wounds, the BP’s of damage suffered in those categories are multiplied by 2, i.e., a character with 40 Torso BP’s suffers from Grievous wounds when the BP’s of damage he takes there range from 21 to 30 and Mortal wounds when they range from 31 to 40 so, if he suffered 25 points of damage, he would have 5 points of Grievous wounding, adding 10 (5 x 2) to the DV, on top of the base DV of 20 from the (Light & Serious) damage taken to get him to the threshold of Grievous, for a total of 30. 

In the same vein, if he suffered 35 points of damage, he would have 5 points of Mortal wounding, adding 10 (5 x 2) to the DV, on top of the base DV of 20 from the (Light & Serious) damage and the added 20 from the Grievous damage taken to get him to the threshold of Mortal, for a total of 50.

Until he achieves the Journeyman Improver LoA, the Surgeon has a penalty to treat wounds of the Grievous or Mortal classifications.

Once he has reached Journeyman Proper LoA, all penalties for treating Grievous and Mortal wounds are erased.

Extracting splinters or stingers, shards of glass or pottery, darts, arrows, or other invasive objects from a patient’s body is considered a surgical procedure, especially when the foreign object is a large one and/or has inflicted damage that exceeds the “Light” threshold. Arrows and javelins that had not gone in too deeply were usually pulled out as quickly as possible, often by the injured person.

For this procedure, the att. mod. is based on CRD.

The DV for a Surgeon to extract a foreign object from the body is Progressive, based on the number of points of damage it caused on entry.

All piercing wounds being dutifully noted by both GM and player so they are not forgotten. This way they can be properly treated by the Healers in the aftermath.

This procedure takes (DV) minutes to accomplish, minus the practitioner’s CRD att. mod. + SL), with a minimum time requirement of one (1) minute

In addition to extracting shards or large splinters, darts, arrows, or other missiles, ranged weaponry, or invasive objects lodged in a patient without causing further damage or undue additional bleeding, a Surgeon can perform the amputations sometimes made necessary by the brutal form of warfare of the period of the game, and use cauterization to stop the massive bleeding that can result.

The AV for these procedures is the same as repairing and closing any other wound.

It is assumed that in the course of the procedure the BP’s of the area in question are reduced to zero for the purposes of determining the DV’s.

A Sentry/AWA check is needed at the end of any procedure, before it is bound and dressed, to determine if it was cleaned properly and a sufficient level of cleanliness was maintained throughout the treatment. 

A failure of this check indicates a failure to notice insufficient cleaning, or internal bleeding, either of which might progress and result in gangrene and septicemia ….

Success allows the Surgeon to detect any failure in that regard so he may then clean it properly before closing and thereby avoid complications of infection and worse.

Wounds are covered with moistened lint, plasters, sterile egg whites, or lard-based [Herbal] ointments, then bandaged, often with strips cut from a [muslin/linen] shirt. Sometimes herbal poultices are also be used. Honey is a preferred wound-dressing, and both modern science and the US army survival manual agree it was very effective.

Later, the wounds would be washed and re-bandaged frequently, with any corrupted flesh being trimmed away. Soaking bandages in old wine as an antiseptic, while not common in the period, was a practice that had a following, and it makes sense to include it as a common practice in the medieval game world.

As GM, you may well require the Healers in your game to carry a flask of old wine along with them to practice their craft, as well as an egg-bearing hen to provide the sterile egg whites commonly used to dress cuts and scrapes.

Medieval medicine was far more effective than the common conception allows; in one sample of over 300 skulls dating from the sixth through the eighth century, only 12% of the wounds showed any evidence of infection.

Analgesics & Anesthesia

To spare the patients their pain, Healers commonly make use of analgesics and anesthetics made with poppy milk (opium), coca leaves, and similar soporifics or narcotics as sedatives, cannabis and other less potent substances, though this must always be done with a judicious hand. Because of the danger, many Herbals insist on administering it in person, by their hand only, but this is not always possible due to circumstances, especially when a powerful peer or noble demands the purchase for another to administer.

But healthcare costs money and such niceties are not cheap. For many commoners surgery was a last resort due to the cost of anesthesia.

The Middle English word used to name one such anesthetic potion used from c. 1200 to 1500 A.D. in England was “dwale” (pronounced DWAH-leh). One can find records of dwale in numerous literary sources, including Shakespeare’s “Hamlet,” and John Keats poem “Ode to a Nightingale.”

Dwale is a concoction of lettuce juice*, gall from a castrated boar, briony, opium, henbane, hemlock juice and vinegar. This was mixed with wine [old wine, strong in alcohol OR the source of the vinegar] before being given to the patient.

*lactuca virosa, wild lettuce called “bitter lettuce” or “opium lettuce,” commonly found in England, cousin to the modern lettuce used for salads today. The juice is a white, milky substance derived from the leaves and stems that acts just like morphine on the central nervous system to suppress pain, despite not having any opiates in it.

The opium, henbane, hemlock juice alone have characteristics that make them good candidates for such use. Where properly dosed and administered, the anesthetic concoction induces a profound sleep, allowing the surgery to take place. The danger of poisoning the patient still exists, already written into the description of this preparation, especially in the hands of well-meaning amateurs.If it is too strong, the patient simply stops breathing.

Using an empirical approach to discover how they might be safely used clinically as must be the case in a medieval fantasy world, with the aid of magick, such a potion is likely to be commonly and safely administered by the hands of well-trained and experienced Herbals. This is one of the reasons dosing is detailed so thoroughly in the Herbals trade description (qv). It is the healer’s business to be able to dose his clients accurately.

The first prescription for a “spongia soporifica” was written in the 1200’s. This is a sponge soaked in the juices of unripe mulberry, flax, mandragora leaves, ivy, lettuce seeds*, lapathum, and hemlock with hyoscyamus.

*lactuca virosa, as above

After soaking up the treatment and/or storage, the sponge is heated for use, the vapors inhaled with anesthetic effect. De Chauliac’s Chirurgia magna contains a description of a similar narcotic inhalation to use as a soporific for patients undergoing surgery.

Most Surgeons prefer that the Herbal who made it administer his concoction/potion in person, by his own hand, because the POT can vary and only the maker knows his product best. On the other hand, all Surgeons are taught the proper method of administration and observation of the patient to ensure safe use.

The POT is up to the Surgeon or attending Herbal, and the choice is based on the patient’s size (STA ÷ 4) in POT – as usual for an effective POT of 1 – and state of health (CND).

The STA score used here has been modified for Build.

If an herbal concoction is to inhibit a particular sense or faculty of the patient, the POT must be equal to or greater than the score in the attribute governing it, 

such as AWA for sensory nerves,

The POT of these sorts of herbs should be measured against the patient’s AWA to determine if they are sufficient for the use to which he puts them.

To numb sensory nerves or knock the patient unconscious, the POT of the herbs’ effect must be equal to the patient’s AWA or greater. 

To deaden the motor nerves, the effective POT must equal or outweigh the patient’s  AGL or STR for motor nerves (whichever is greater or more appropriate according to the nature of the toxin), or AGL + STR att. mod. or vice versa (GM’s discretion).

IF the patient’s CND is less than his AWA or AGL, the poisonous nature of these substances must begin to hit the patient before he is rendered unconscious or completely immobile.

Those substances which affect the motor nerves, if the effective POT exceeds [(AGL) + (CND ÷ 4)] the autonomic functions such as breathing are suppressed – stopped, and the patient descends into asphyxia, leading to death if not reversed.

These herbal treatments endure for [(POT of herbs’ effect) x 10] in minutes, minus (CND att. mod.). Subtracting a negative number is the same as adding the positive integer. Low CND dictates a slower metabolism, dictating the substance move more slowly through the body. Once that time has passed, the POT of the herbs’ effect drops by one (1) every (40 – CND) minutes.

IF the practitioner is simply trying to suppress or numb the sensory nerves, the patient’s effective P-RES for any checks vs. pain due to a patient’s injuries are raised by (POT of herbs’ effect), to a maximum of the patient’s CND. 

IF the patient’s AWA is lower than his CND, he is rendered completely numb without the need to make any sorts of P-RES checks vs. pain once the POT of the herbs’ effects in his body have reached (AWA).

The Surgeon or attending Herbal can apply a preparation of this sort as a topical to affect only one BP area in the same way, or so as to paralyze that BP area, rather than rendering the patient completely unconscious as above. For these cases, the amount of herbs in grams/drams are divided by the fraction of BP’s the area(s) so treated are awarded, according to the rules for combat and tactical play. If more than one area is to be treated, but not the whole body, only the fraction of BP’s of the largest BP area are applied this way.

This can be maintained for [(STA) – (CND att. mod.)] minutes per application, but the patient can tolerate no more than (CND) such applications. More than this is treated as poisoning. The effect wears off at a rate of one (1) point of P-RES bonus per (CND att. mod.) minutes. This can be easily prorated down to Pulses for tactical situations.

The uses to which a Surgeon puts his knowledge and skills must necessarily affect his scores in Virtue and Vice.

Surgeons roused the sleeping patients by rubbing vinegar and salt on their cheekbones.

Ether (diethyl ether) was discovered in 1275 by a Spanish alchemist named Raymundus Lullius, or Ramon Llull, and known as “sweet vitriol” (until 1730). While ethyl ether was first synthesized in a laboratory in 1540 by a German scientist named Valerius Cordus , who noted some of its medicinal properties. He called it oleum dulce vitrioli (“sweet oil of vitriol”) a name that reflects the fact that it is synthesized by distilling a mixture of ethanol and sulfuric acid (known at that time as oil of vitriol).

Aureolus Theophrastus Bombastus von Hohenheim (1493–1541), better known as Paracelsus, was the first to observe the anesthetic/analgesic qualities of “sweet vitriol” (diethyl ether).

“… [sweet vitriol] quiets all suffering without any harm and relieves all pain, and quenches all fevers, and prevents complications in all disease.”

He observed that chickens enjoyed sweet vitriol then “undergo prolonged sleep, awake unharmed”. However, for whatever reason(s), he never applied this discovery to people. For his human patients, he concocted laudanum, a bitter tincture of opium.

Cutting hair & Shaving

The [historically] unbreakable association between Barbers and Surgeons makes cutting hair and shaving clients an onerous burden that Surgeons (or “Barber-Surgeons”) fight daily to divorce themselves from. Their wealthy patrons can’t be bothered with such fine distinctions, however. In spite of the heights to which they might be appointed in a given noble household, a Surgeon is still expected to provide grooming services like a common Barber. This attitude persisted well into the 18th century.

The DV for cutting hair, the att. mod. is based only on the character’s CRD score.

The DV for cutting hair is equal to the number of inches of hair to be cut off, + patron’s [(CHM att. mod.) + (HRT att. mod.)]. The higher these scores the more definite the patron’s sense of style and idea of what they want and the more fussy and difficult to please and adamant they are about getting what they want.

The time required to do so is (DV) minutes.

In practice, individual (Barber-) Surgeons were themselves diversified into other trades, according to local economic conditions and opportunities, and there is usually a very real relationship behind these apparently odd combinations.

Many surgeons were also expert craftsmen in metals. 

This is evident in Henry’s second expedition in 1416 in which he commissioned Morstede to indenture as many surgeons as he wanted (23 surgeons were too few to handle the wounded in the previous year’s campaign) and to also bring along makers of surgical equipment. Doubtless, the surgeons must have been delayed by crafting surgical instruments to the detriment of the care of the wounded in the first campaign. By bringing along smiths to make tools, the surgeons on the second campaign were freed to attend to performing their medical duties.

This is why “Silver/Gold-Smith” appears on the roster of Allied Trades for Surgeons.

Trade Skills
Assessing Health/Wounds
Cleaning & Dressing Wounds
Repairing & Closing Wounds
Extracting Objects
Set Bones/Restore Dislocations
Cosmetic Surgery
Cutting Hair  

Notable Practitioners

During the Middle Ages, scientific discoveries were few and far between in much of Europe, medicine included. The scientific culture flourished in other parts of the world, however.

In 1000, Abu al-Qasim al-Zahrawi (936-1013), an Arab who lived in Al-Andalus, published the 30-volume Kitab al-Tasrif, the first illustrated written work on surgery. In this book, he wrote about the use of general anesthesia for surgery.

c. 1020, Ibn Sīnā (980–1037) described the use of inhaled anesthesia in “The Canon of Medicine.” The Canon described the “soporific sponge”, a sponge imbued with aromatics and narcotics, which was to be placed under a patient’s nose during surgical operations.

Ibn Zuhr (1091–1161) was another Arab physician from Al-Andalus. In his 12th century medical textbook Al-Taisir, Ibn Zuhr describes the use of general anesthesia.

These three physicians were among many who performed operations under inhaled anesthesia with the use of narcotic-soaked sponges. Opium made its way from Asia Minor to all parts of Europe between the 10th and 13th centuries.

In the early 1200’s, surgical literature began to emerge, as surgeons sought to emulate their medical colleagues and raise their profession to one of comparable (scholastic) esteem.

During this period, most medical and surgical learning took place in the monasteries.

The Fourth Lateran Council forbade the clergy from practices that carried the “taint” of blood, such as cautery and incisions, in 1215, so the clergymen who previously provided those services instructed laymen to perform various forms of surgery. Farmers, who had little experience other than castrating animals, came into demand as Leeches, to perform anything from removing painful tooth abscesses to performing eye cataract surgery. Thus, the niche in which Barbers grew and thrived was born.

In the game worlds run under RoM rules, there is neither need nor reason for the “Church” to interfere in the process of or training in medical care, hoever. As GM, you are free to choose to rewrite the situation to whatever standard you prefer for your game world.

One man in particular stands out in the field of surgery in the 13th century was William of Saliceto, who helped set up a school dedicated to surgery. 

Guglielmo da Saliceto in his native tongue, an Italian surgeon and cleric, a professor at the University of Bologna.

He was one of the first to claim that pus formation in a wound was bad for the wound and the patient’s health, breaking the blind tradition following Galen on the matter. In 1275 he wrote a “Chirurgia” in which he recommended the use of a surgical knife over (Barber’s) cautery. His techniques were years ahead of his colleagues, even managing to stitch together severed nerves.

He also was the author of “Summa conservationis et curationis” on hygiene and therapy. Lanfranc of Milan was a pupil who brought William’s methods into France. William gave lectures on the importance of regular bathing for infants, and special care for the hygiene of pregnant women

John Arderne (c.1307 – 77), an English surgeon, composed medical works on topics such as the treatment of eyes and the cure of anal fistula, both of which circulated widely. Arderne’s works are fascinating in a number of respects, not least of which is the fact that the illustrations are integral to them.

Henri de Mondeville was a medieval Frenchman from Normandy, born approximately 1260,  proclaimed as the “Father of French Surgery.” He was trained in medicine in Paris and Montpellier, then in Italy with Theodoric Borgognoni (as follows), who had established a reputation for excellence in the treatment of wounds.

He served as surgeon to Philippe Le Bel (Philip the Fair) of France and to his successor, Louis X, and authored a Cyrurgia (“Surgery”) in 1312. This is but one of many European treatises on Surgery, the first being by Roger Frugard, who was eclipsed by the more famous Guy de Chauliac’s Chirurgia magna.

He died of pulmonary tuberculosis in 1316.

Theodoric Borgognoni, also known as Teodorico de’Borgognoni and Theodoric of Lucca, was an Italian who became one of the most significant surgeons of the medieval period. He is considered responsible for introducing and promoting important medical advances.

Theodoric was born in Lucca, Italy in 1205. The son of Master Hugh Borgognoni, a leading physician of the previous generation. Theodoric was a student of his father and also studied medicine at the University of Bologna, becoming a Dominican friar during that same period.

On top of his episcopal and religious duties, he became the favored Surgeon of many leading personages.

In the 1240s, after he had been practicing for about 10 years or so, he became personal physician to Pope Innocent IV.

Borgognoni’s major contribution to western medicine is his Cyrurgia or Chirurgia, a four volume treatise systematically covering the major fields of medieval surgery, written in the mid 1200’s. Borgognoni’s work duplicates some chapters of Bruno da Longoburgo’s Chirurgia, written about 15 years previously, but both he and Bruno were students of Ugo Borgognoni. Theodoric’s work contains much that is not duplicated in Longoburgo’s book, however, and some that directly contradicts Bruno, and these are the most important and innovative passages.

On the treatment of wounds he wrote:

“For it is not necessary that bloody matter (pus) be generated in wounds — for there can be no error greater than this, and nothing else which impedes nature so much, and prolongs the sickness.”

He insisted that the practice of encouraging the development of pus in wounds, handed down from Galen and from Arabic medicine, be replaced by a more antiseptic approach, with the wound being cleaned and then sutured to promote healing.

In the context of the medieval fantasy game world, magick is available as a tool to reveal the true nature of things and show the value and virtues of good treatments and reveal the dangers of bad medicine and care. 

Pus in this context should be seen as very valuable, but only as a danger sign (no matter what some “old-school” Physickers still clinging to the antiquated notion of “laudable pus” might say), and Surgeons are better versed in the procedures and standards of care for clearing up infections, which knowledge was available, in fact, in period. 

Indeed, it is not at all far-fetched to posit Surgeons being routinely called on to treat infections arising from procedures performed by their less well-educated and trained colleagues, the Barbers, Midwives and Leeches. This is a strong motivation for those practitioners who truly follow healthcare as a vocation end up seeking out a master Surgeon eventually to complete their education in the Surgeons’ practical medicine. 

Although often disagreeing with Galen, Borgognoni followed him in promoting the dry method for treating wounds, although advocating the use of wine. Bandages were to be pre-soaked in wine as a form of disinfectant.

He also promoted the use of aneasthetics in surgery. He recommended a spongia soporifica soaked in a dissolved solution of opium, mandrake, hemlock, mulberry juice, ivy and other substances held beneath the patient’s nose until he fell unconsciousness.

Borgognoni was significant in stressing the importance of personal experience and observation as opposed to a blind reliance upon the ancient sources.

He wrote on the treatment of thoracic and intestinal injuries, insisting on the importance of avoiding pollution from the contents of the gut. The final volume deals with injuries to the head and some cancers. Borgognoni’s test for the diagnosis of shoulder dislocation, namely the ability to touch the opposite ear or shoulder with the hand of the affected arm, has remained in use into modern times.

In addition to his surgical works, Borgognoni also produced volumes on veterinary medicine and falconry.

In 1262 he was made Bishop of Bitonto.

He was appointed Bishop of Cervia, close to Ravenna, in 1266.

He died in 1296 or 98, having lived to at least 91.

Guy de Chauliac (1300-1368) was one of the most prominent surgeons of the period of the game. Born to a family of limited means in Auvergne, France, Guy’s intellect was recognized early by the French lords of Mercoeur, who sponsored him in his academic pursuits. He began his studies at Toulouse.

Some time later Guy moved on to the oldest university in Europe, the University of Bologna, which had already built a reputation for its medical school. At Bologna he appears to have perfected his understanding of anatomy, and he may have learned from some of the best surgeons of the day, though he never identified them in his writing as he did his medical professors.

Upon leaving Bologna, Guy spent some time in Paris before moving on to Lyons.

In addition to his medical studies, Guy took holy orders, and in Lyons he became a canon at St. Just. He spent about a decade at Lyons practicing medicine before moving to Avignon.

Some time after May, 1342, Guy was appointed by Pope Clement VI as his private physician (Surgeon). He attended the pontiff during the horrific bubonic plague that hit France in 1348 and, although a third of the cardinals at Avignon perished from the disease, Clement survived. Guy used his experience of surviving the plague and attending to its victims in his writing.

Guy completed his landmark work on surgery in 1363, the first book on surgery to bring to bear a substantial medical background on the subject, called the Inventarium sive chirurgia magna. It served as the standard text for more than 300 years, well into the 17th century.

In Chirurgia, Guy included a brief history of surgery and medicine and provided a discourse on what he thought every surgeon should know about diet, surgical implements, and how an operation should be conducted. He also discussed and evaluated his contemporaries, and related much of his theory to his own personal observations and history, which is how we know most of what we do about his life.

The work itself is divided into seven treatises: anatomy, apostemes (swellings and abscesses), wounds, ulcers, fractures, dislocations, and a variety of other conditions and diseases, including not just surgical but medical procedures, and the complements to surgery (the use of drugs, bloodletting, therapeutic cauterization, etc.), which it discusses within a broad framework of medical (physiological and pathological) learning.

This treatise covered anatomy, bloodletting, cauterization, drugs, anesthetics, wounds, fractures, ulcers, special diseases, and antidotes. Among de Chauliac’s treatments he described the use of bandages. He describes surgical techniques such as intubation, tracheotomy, and suturing.

All in all, it covers nearly every condition a surgeon might be called upon to deal with. Guy emphasized the importance of medical treatment, including diet and drugs.

His observations of the plague included an elucidation of two different manifestations of the disease, making him the first to distinguish between pneumonic and bubonic forms. Although he has been criticized for advocating too much interference with the natural progression of the healing of wounds, Guy de Chauliac’s work was otherwise groundbreaking and extraordinarily progressive for its time.

Guy spent the balance of his days in Avignon. He stayed on as physician for Clement’s successors, Innocent VI and Urban V, earning an appointment as a papal clerk. Guy’s position in Avignon afforded him unparalleled access to an extensive library of medical texts that were available nowhere else. He also had access to the most current scholarship being conducted in Europe, which he incorporated into his own work.

John Harrow was a surgeon in royal service; made Chief of Surgeons twice during the French campaigns; was a member of the Fishmonger’s Company (as such, a Merchant also); financier; was made a judge in malpractice cases and a Searcher for the Port of London (worth £10/yr in income); he accumulated extensive properties.

Thomas Morstede, Esq. was court Surgeon, made a Searcher for the Port of London for 25 years (worth £10/yr in income); was twice made the Chief of Surgeons during the French campaigns; a war hero; a teacher and famous author (a fair book of Surgery, used as a standard text thru the 1400’s century). He was the driving force behind the foundation of a college of medicine. He had £154 in land and £200 in debts receivable at his death.

Master William was a “sergeant surgeon” in royal service and a cleric in minor orders. He received £10 a year, equal in honor to a royal physician. At his demise, he owned a house and 13 shops in London, and had an additional 50s. a year in income.

In 1251, Master William took on an assistant named Henry of Saxeby. Henry and his son, Nicholas, were gentlemen by birth. That same year, a Thomas of Weseham saved the life of the king.

In 1252, Thomas was invited to court and made the trip there.

In 1254, Thomas started serving with Master William and Henry.

In 1255, Master William died and Henry of Saxeby was made “sergeant surgeon.”

In the midst of the persecutions leading up to the expulsion of the Jews in 1290, Thomas Weseham used his position at court to buy up Jewish properties in Norwich, London, and Oxford at well below market value. He eventually received a number of annuities for his service, was knighted, and made both a royal Moneyer and a Forester.

It took 2 years after saving the king’s life for Thomas to be granted a position at court with Master William and Henry. It was common for such rewards to take a while to be decided on and then put in place. You should take note of this, as GM. The pace of life in an agrarian world in one based on the turning of seasons, not of minutes or “what have you done for me lately”.

William Hamon was prior of the Benedictine cell of Catges (Oxfordshire) and served as a royal surgeon from 1341-67, for which he was awarded a base salary of £30 a year.

Peter of Newcastle was surgeon to three kings, Edward I, II, and III.

In 1298, Peter’s own “personal valet” was also a surgeon, named John Marshal (very likely it was his apprentice, or a Journeyman he picked up to mentor). Peter was a merchant running a number of ships out of London, dealing regularly with the pepperer’s guild; he was commissioned to supply the royal court with medicines, in favor over the traditional appointment of a royal Apothecary. With his dealings with the pepperer’s guild, it is possible that Peter was actually an Apothecary and indeed a member of the pepperer’s guild, but he is not noted as such.

Despite the “taint” of blood, Philip of Beauvais, a “sergeant” Surgeon in 1304, became a wealthy courtier.

Roger Heyton served Edward III in the 1330’s and 1340’s with an under-surgeon named Jordan of Canterbury. After the Battle of Crécy, Roger was considered indispensable and given a manor in Wales worth 50£ a year, and an annuity of £20, as well. Like Philip of Beauvais, he became a wealthy courtier.

This should give the player and GM alike some idea of what sorts of opportunities can be found for advancement in the healer-Trades.

After achieving the distinguished rank of Surgeon and taking the time to establish a reputation, it is by no means uncommon for ambitious Surgeons to use the patronage of the wealthy and social contacts with Physicians to go to university to obtain a degree in Physick to further enhance their reputations and social standing. With their Master’s diploma, they can complete their climb to the apex of the trade in the eyes of society – and raise their fees as well, of course.

The more successful Surgeons and Physickers also commonly entered merchant ventures with the Apothecaries, too wealthy to be bothered with the internecine squabbles between the practitioners of medicine.

Development of the Trade & Guild

In 1199, Richard I suffered an arrow wound to the arm during a siege of the castle Chaluz, according to Roger of Hoveden. Unfortunately for Richard, his physician (surgeon?), Malger, had returned to England to become the bishop of Worcester. Without a physician, the captain of Richard’s mercenaries, a man named Marchadeus, did his best to treat the injury. It didn’t go well. Marchadeus failed to extract the arrow head and nearly amputated the king’s arm before removing the arrow. The king died a few days later.

The world’s oldest company (guild) of barbers, the “Worshipful Company of Barbers,” was founded in London, England in 1308, so relatively recently in view of the period chosen for the game. In many places, but not all, the “company” (guild) is, for practical purposes, called a barbers’ company, but this doesn’t mean that the company included no Surgeons or that the Barbers’ craft and surgery were separate, even where authorities tried to ensure that this was the case, as the history of Norwich shows.

Before 1415, it was common for aristocratic ladies, mercenaries and knights to practice medicine. Wolfram von Eschenbach’s “Parzival” clearly demonstrates that medical knowledge was common for a knight. In this tale, Gawain comes across a knight and maiden in the woods. The knight is suffering from internal bleeding into the lungs. After Gawain diagnoses the injury, he places a small linden bark tube into the knight and tells the maiden to suck out the blood. Even the 14th century surgeon Guy de Chauliac lists knights as medical practitioners.

By 1415 (late in period for the game, but not for the essentially “perpetually medieval” game world), however, surgeons began to appear as a necessary component of military campaigns. In 1415, King Henry V conscripted Thomas Morstede and 15 persons, 12 of whom were surgeons (the three others were to be archers) in his campaign against France. The Battle of Agincourt in 1415 was monumental in the development of the surgeon for military campaigns.

Besides the 12 surgeons commissioned by Henry for the Battle of Agincourt, to take care of the hurt and injured on the front line (especially with the emphasis on archers), he also commissioned William Bradwardine and 9 other surgeons to care for the sick and wounded, to remain behind the lines and care for those transported back to the camp. The latter were responsible for making surgical equipment in addition to tending to the sick and injured.

Many surgeons were also expert craftsmen in metals. 

This is evident in Henry’s second expedition in 1416 in which he commissioned Morstede to indenture as many surgeons as he wanted (23 surgeons were too few to handle the wounded in the previous year’s campaign) and to also bring along makers of surgical equipment. Doubtless, the surgeons must have been delayed by crafting surgical instruments to the detriment of the care of the wounded in the first campaign. By bringing along smiths to make tools, the surgeons on the second campaign were freed to attend to performing their medical duties.

This is why “Silver/Gold-Smith” appears on the roster of Allied Trades for Surgeons.

Morstede’s service at Agincourt led him to the job of Supervisor of Surgery for the City of London in 1423. This close proximity to the King influenced regulations concerning those who could practice medicine.

The final achievement of Morstede’s influence on the Crown was the charter for the Fellowship of Surgeons in 1435 … 20 years to attain.

The Fellowship was only the first national attempt to institutionalize surgery; there were numerous local attempts that had failed:

The mayor of the city of London appointed 3 Master Surgeons to regulate and supervise surgical practices as early as 1368. He assigned Master Thomas Stodley, surgeon, and 2 assisting clerks to the “Mistery of Surgery” in 1392, in which they were to supervise and report any transgressions to him. But this was not sufficient. In 1421, both physicians and surgeons led by Morstede petitioned Henry V that he allow only those who were educated to practice medicine. The petition reads:

Worthy Sovereign, as it is known to your high discretion, many uncunning and unapproved in the forsaid science practise and specially in Physick, so that in this Realm is everyman be he never so lewd taking upon him practise, is suffered to use it, to great harm and slaughter of many men. Where if no man practised therein, but only cunning men and proved sufficiently learned in Art, Philosophy, and Physick as it is kept in other lands and realms, then should any man that dieth for default of help live, and no man perish by uncunning.

Credits

https://www.thoughtco.com/guy-de-chauliac-1788904?utm_term=medieval+surgery&utm_content=p1-main-2-title&utm_medium=sem&utm_source=google_s&utm_campaign=adid-985d6dc2-391b-4773-85fe-cec2926f397b-0-ab_gsb_ocode-4578&ad=semD&an=google_s&am=broad&q=medieval+surgery&o=4578&qsrc=999&l=sem&askid=985d6dc2-391b-4773-85fe-cec2926f397b-0-ab_gsb

Thank you Bryon Grigsby

http://www.illinoismedieval.org/ems/VOL13/grigsby.html

Also:

https://en.wikipedia.org/wiki/History_of_surgery

Chauliac, Guy De.” Complete Dictionary of Scientific Biography. . Encyclopedia.com. 8 Apr. 2017 <http://www.encyclopedia.com>.

https://en.wikipedia.org/wiki/History_of_tracheal_intubation

http://www.oddee.com/item_96620.aspx

http://svmsl.chem.cmu.edu/vmsl/genanes/ga_bg2.htm

http://www.articlesonhistory.com/medieval-medicine.php

https://www.bl.uk/the-middle-ages/articles/medicine-diagnosis-and-treatment-in-the-middle-ages

https://forum.kingdomcomerpg.com/t/battlefield-medicine-surgery-medieval-ages/21562/11

Medieval Science, Technology, and Medicine: An Encyclopedia

By Thomas F. Glick

Soldiers’ Lives through History: The Middle Ages:

 

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