Journal of Archaeological Science (1995) 22, 369–384

Evidence for Remedial Medical Treatment of a Severe Knee Injury from the Gilbertine in the City of

Christopher J. Knüsel

Calvin Wells Laboratory, Department of Archaeological Sciences, University of Bradford, Bradford, West Yorkshire BD7 1DP, U.K.

Richard L. Kemp

York Archaeological Trust for Research and Excavation Ltd., 55 Piccadilly, York YO1 1PL, U.K.

Paul Budd

Ancient Metallurgy Research Group, Department of Archaeological Sciences, University of Bradford, Bradford, West Yorkshire BD7 1DP, U.K.

(Received 8 September 1993, revised manuscript accepted 10 March 1994)

During the analysis of a skeletal population from the Fishergate site in the City of York, an individual from the eastern part of the cemetery associated with the Gilbertine monastic foundation of St. Andrew revealed evidence of a chronic septic arthritis, secondary to a severe right knee twist-fracture, and bone adaptation in response to altered biomechanical loading. This disability had been the subject of remedial medical treatment with copper-alloy plates. Their presence, only the fourth such treatment thus far recorded from the mediaeval period, and the sole example applied to a lower limb, suggests that monastic houses, or those buried at these establishments, and specifically those associated with the , had preferential access to medical specialists.

Keywords: MEDIAEVAL, INJURY, TREATMENT, SPLINT, BRONZE.

The Archaeological Context of Burial Sk 251 south with a rectangular nave, central crossing, north and south transepts with attendant eastern chapels, t. Andrew’s Priory of the Gilbertine order lay on and a presbytery. The eastern range comprised a the south-eastern side of the City of York, chapter house, dormitory and latrines, and to the north S beyond the section of the mediaeval was a refectory. The western range had been destroyed defences, and directly east of the confluence of the in the early 20th century. The three ranges enclosed a Rivers Foss and Ouse (SE 60655115). The Priory’s small cloister garth, and were linked by a cloister alley. church, cemetery and claustral complex were subjected Uniformity in the size of the rooms and of the con- to archaeological excavation between February 1985 struction techniques reveal that, although built in and September 1986, and the majority of the complex stages, the entire Priory was probably conceived as a was fully examined under the direction of one of us single entity and built over a period of about 30 years (R.L.K.), for York Archaeological Trust, in advance of from the last decade of the 12th century to the second redevelopment for housing and a hotel. The full results decade of the 13th century. The Priory was dedicated of this work are being prepared with a grant from to St. Andrew in 1202. HBMC (Historic Buildings and Monuments Commis- Associated with the church and chapter house in its sion) as a series of publications that will appear in the original form were numerous burials in a series of Archaeology of York. The Priory structures will appear concentrations, including the presbytery, the north as volume AY11/2, whilst the human remains have transept chapel, the east cloister alley, the central appeared as volume AY12/2. crossing, the nave, the area south of the nave and the The Priory in its original guise (Period 6a, c.  area east of the presbytery/chapter house. This last 1195–1300) comprised a long cruciform church to the group comprised 49 individuals of which the vast

369 0305-4403/95/030369+16 $08.00/0  1995 Academic Press Limited 370 C. J. Knu¨sel, R. L. Kemp and P. Budd

Figure 1. Anterior view of the injured right knee. The tibial plateau crush fracture can be seen laterally. majority were adult males, and included burial Sk 251 dentition, and dental caries of the root of the left (Context 10266) on the northernmost fringes. This maxillary second molar which has produced abscessing group of burials were undoubtedly associated with the of the alveolar process. This disorder has also probably first phase of the church as they were carefully aligned produced a localized infection indicated by reactive with its walls. bone in the floor of the hard palate. The teeth are worn The Priory church, chapter house, dormitory and to an extent that they score in the 35–45 (5) range of latrines were evidently rebuilt in the 14th century Brothwell’s (1981) dental wear method of age assess- (Period 6c), and historical evidence indicates that this ment, which for the population as a whole is not may have taken place in the second quarter of the 14th abnormal (Stroud & Kemp, 1993). The basic pattern is century. The new church was rebuilt to the west and one of a generalized crown destruction and a consid- occupied the area of the former nave, a reduction of erable exposure of secondary dentine. This individual 60% from the original. The eastern end of the first also presents with cribra orbitalia, which Stuart- church, including the central crossing, and north and MacAdam (1992) has recently suggested to be a lesion south transepts were never replaced; the walls were associated with anaemia and is perhaps an adaptive robbed of their stone and the area flattened. The response of the body to a high parasitic load. In burials to the east of the presbytery were, therefore, addition to these pathological conditions this indi- unlikely to have been added to after this demolition, vidual also possesses several discreta or non-metric and can hence be dated to between the start of the 13th traits, including mandibular tori, and a shovel-shaped century and the mid-14th century when the rebuilding left maxillary central incisor, as well as agenesis of all took place. third molars.

Analysis of the Corporeal Remains Pathological Description of the Burial The right knee-joint of this individual appears abnor- Burial Sk 251 is that of an older adult male who was mal on both naked-eye and radiographic examination. probably at least 45 years of age at death, if not The right tibia articulates with the corresponding fe- somewhat older. Application of Lovejoy et al.’s (1985) mur in a laterally rotated and posteriorly displaced auricular surface method and Katz & Suchey’s (1986) fashion and is about 30) out of its normal anatomical pubic symphysis method suggest an age at death in the alignment (Figure 1). A large osteophyte protrudes early seventh decade of life. Apart from a major anteriorly from the tibial plateau and the entire surface traumatic disorder treated below, this individual also of the femoral condyles and tibial plateau have a presents signs of periodontal disease, heavy dental porous, lytic appearance, especially prominent on the calculus build-up on and crowding of the anterior medial epicondyle of the femur (Figure 2). A marked Mediaeval Knee Injury Treatment 371

Figure 2. Inferior view of the right femur and superior view of the right tibia demonstrating the extent of subchondral bone affectation. patch of disorganized and highly trabecular bone on Osteophytes appear within the area of the enthesis the posterior surface of the tibial plateau immediately for the medial head of M. gastrocnemius and M. posterior to the tibial spines extends to the margin of adductor magnus on the posterior aspect of the distal the tibial plateau and corresponds with a similar patch femur. It is no longer possible to discern the markings of rarefied bone on the posterior surface of the lateral left by the anterior and posterior cruciate ligaments condyle of the femur. A flange expansion (exostosis) within the intercondylar region of the distal right is present along the lateral condylar portion of the femur, although the lateral epicondylar area retains the right femur. Periosteal new bone has formed in the markings of the entheses for the lateral collateral knee area of the soleal line of the right proximal tibia ligament, M. popliteus, and the lateral head of M. and encompasses the entire distal femur including gastrocnemius. There is, however, a pit-like depression the popliteal space and proximal fibula. The distal on the lateral posterior margin of the associated tibia third of the right femoral shaft has a swollen appear- which may represent part of the tibial attachment of ance and the nutrient foramen is expanded. Two the posterior cruciate ligament. osteophyte-free, thumbprint-shaped depressions are present on the lateral aspects of the femur and tibia Discussion of the Primary Injury amidst this periosteally deposited new bone. The dimensions of the articular surfaces of both From the examination of radiographs of this the right femur and tibia are asymmetric when com- individual’s right tibia, it is apparent that he had pared with homologous elements of the left side. suffered a comminuted fracture of the lateral condyle Although the biepicondylar breadth of the distal right of the tibial plateau with dislocation and twisting of the femur has been only minimally affected, the bicondy- tibia posteriorly and laterally (i.e. a rotary fracture- lar breadth is noticeably altered by the presence of dislocation). This type of injury results from forced reactive bone. The right-side bicondylar breadth abduction of the flexed knee and simultaneous rotation measures 7·35 cm, whereas that dimension of the left of the tibia. Often in this type of injury a fragment of member measures only 7·0 cm. The maximum proxi- bone from the tibial rim is displaced, and it is likely mal breadth, a transverse measurement across the that it is this fragment which has formed a nearthrosis condylar surfaces of the tibia medio-laterally, is from the previously identified anteriorly placed osteo- 8·0 cm in the right member and 7·4 cm in the left, phyte of the tibia. The nearthrosis and the faintness of which suggests joint space modification. The maxi- the fracture line are indicative of a well-healed and mum anterior–posterior measurement of the medial long-standing injury. From the radiograph it does not condyle of the femur measures 5·15 cm on the left appear that there was an accompanying fracture of the side and 5·0 cm on the right. It seems, then, that the proximal fibula, so the plateau fracture seems to equate joint space has expanded more in a medio–lateral to a central depressed variety (Hohl, 1967; Moore, direction than in an antero–posterior one. 1981; Waddell, Johnston & Neidre, 1981). 372 C. J. Knu¨sel, R. L. Kemp and P. Budd

In experimental trials on cadavers, Kennedy (1963) noted on the lateral aspect of the femur and tibia found that up to eight times the amount of force was (Figure 1). required to cause this type of posterolateral injury in The disorganized and highly trabecular bone on comparison to that required to produce a posterior the posterior surface of the tibial plateau and on the displacement of the tibia. In both types of injury the posterior surface of the lateral condyle of the femur patellar tendon ruptured. The right patella was not appear to be remnants of a soft tissue arthrodesis recovered, so no assessment of the integrity of this (osseous fusion), following ligamentous and cartilage- element was possible. The injury must have occurred, nous deterioration of the knee-joint. This interpreta- however, after an insult to the knee involving tion would argue for a substantial loss of mechanical considerable force. function in the limb, although its arterial and neural Modern prognosis for this type of injury is compli- supply was apparently unimpaired. This scenario is in cated not only by damage to the tibial condyle as the general agreement with that of the clinical literature. femoral condyle is pressed into it, but also by severe Reckling & Peltier (1969) report that there is often little soft tissue damage in the form of medial collateral and or no lasting injury to the blood vessels and nerves in cruciate ligamentous tears (Hohl, 1967; Aston, 1976) such an injury, although Hill & Rana (1981) report the and neurovascular and arterial disruption (Kennedy, occurrence of nerve injury in their experience with this 1963; Taylor, Arden & Rainey, 1972; Moore, 1981; disorder. Resnick & Niwayama, 1988). It is thus rendered irre- One consequence of this injury is necrosis of the skin ducible except by surgical intervention; currently, open overlying the medial condyle due to cutaneous nerve reduction is performed with internal screw fixation damage, often to such an extent that a skin-graft is (Moore, 1981; Reckling & Peltier, 1969). Such a pro- required to repair the damage (Reckling & Peltier, cedure would have been unavailable to mediaeval 1969; Hill & Rana, 1981). It is likely that this indi- practitioners, leaving the patient with a chronic knee vidual carried the outward signs of his injury in the injury. Alteration to the right knee joint space and the form of a deadened area of skin and a chronic ulcer- presence of joint surface destruction, eburnation and ation. That the entire surface of the femoral condyles osteophyte formation are commensurate with a diag- and tibial plateau have a porous, lytic appearance, nosis of secondary osteoarthritis. This feature is also especially prominent on the medial epicondyle, appears the modern clinical result of such a fracture in ageing to provide support for this interpretation. The medial sufferers. epicondyle provides attachment for the medial collat- Due to the severity and rarity of this particular eral ligament which often becomes trapped in the joint injury, it is relatively easy to diagnose from the dry space after penetrating the medial membrane of the bones. It is more difficult, however, to reconstruct the synovial capsule in such an injury (Reckling & Peltier, prognosis of such an injury as it involves considerable 1969; Hill & Rana, 1981). It is this part of the injury soft tissue damage. One must infer such trauma from which excludes closed reduction today (Kennedy, 1963; assessments of the altered osseous tissue. A posterolat- Reckling & Peltier, 1969). This type of impingement eral rotary injury such as that observed often involves may also explain in part the greater affectation of the the common peroneal nerve, which passes around the medial epicondyle in the present individual. The pres- neck of the fibula (Hill & Rana, 1981; MacKinnon ence of periosteal new bone affecting the right proximal & Morris, 1986) and the popliteal artery, which tibia in the area of the soleal line, the entire distal passes posteriorly behind the knee joint (Taylor, Arden femur including the popliteal space, and proximal & Rainey, 1972; Romanes, 1986). Injury to the fibula, as well as expansion of the nutrient foramen of popliteal artery can cause gangrene and often precipi- the femur, suggests infection of the surrounding tissues tates above knee amputation (Kennedy, 1963; Taylor, and medullary canal (a septic arthritis). The swollen Arden & Rainey, 1972). The proximal fibula, just appearance of the distal third of the right femoral inferior to the head, of the present individual demon- shaft attests to osteitis, or inflammation of the bone strates osteophytes which testify to interosseous liga- matrix itself, possibly in response to a chronic, infected ment insult and potential damage to the peroneal ulceration. nerve. Elements of the right foot which are supplied by The lateral condylar portion of the right femur this nerve show no sign of atrophy or of the dorsal presents with a flange expansion (a Martin’s facet) that tarsal bars which accompany foot-drop deformity and Kostick (1963) and Martin (1932) identify with a are often the sequelae of insults to the nerve (Taylor, proclivity to squatting. In this instance it may better Arden & Rainey, 1972; Andersen & Manchester, 1988). relate to an altered means of stress transmission Therefore, it seems that the peroneal nerve was unim- through the condyles and cartilagenous degeneration paired by the injury. In this case the lateral superior (cf. Trinkaus, 1975). There are osteophytes within the genicular and the medial inferior genicular arteries, area of the enthesis for the medial head of M. gastroc- which make up part of the anastomoses of the knee, nemius and M. adductor magnus, suggesting that these appear to have been traumatized by the injury. The muscles were traumatized by the injury or through course of these arteries is likely to be responsible for over-exertion subsequent to the injury. These muscles the osteophyte-free, thumbprint-shaped depressions are responsible for plantar flexion of the foot and Mediaeval Knee Injury Treatment 373

flexion of the leg and powerful adduction and medial experienced in the second or third decade of life, rotation and extension of the thigh at the hip joint, although the other degenerative changes may be age- respectively; all movements required in normal walk- related and activity- or posture-related phenomena. ing. These changes suggest that the tendinous attach- These vertebrae also demonstrate scoliosis to the left ments of these muscles were stressed beyond their side, which is an alteration previously noted in skel- normal capacity through exposure to abnormal forces etonized individuals with right lower limb pathologies (Niepel & Sit’aj, 1979). Since it is no longer possible to affecting gait (Knüsel, Chundun & Cardwell, 1992; discern the markings left by the anterior and posterior Knüsel & Göggel, 1993). The lumbar vertebrae are cruciate ligaments within the intercondylar region of similarly affected by degenerative changes, notably the distal right femur, it is likely that they were anterior osteophytic lipping of L3 and L4 and lytic completely disrupted in the course of the injury. Fur- pitting of the superior surface of the body of L5, which ther support for this assessment comes in the degraded is accompanied by scoliosis to the right side (Knüsel, state of the area around the tibial spines where the Chundun & Cardwell, 1992; Knüsel & Göggel, 1993). cruciate ligaments attach. The pit-like depression on The sacrum also demonstrates osseous alteration. The the lateral posterior margin of the tibia may represent left lamina of the first sacral vertebra is considerably the attachment of the posterior cruciate ligament, more robust than that of the right lamina and the which is spared in some cases of this injury: this may spinous processes as a whole are deviated to the left have been so in the present case (Watson-Jones, 1944). side, which attests to hypertrophy of the ligamentous The lateral epicondylar area retains the markings of entheses on the left, unaffected side. The left lamina of the entheses for the lateral collateral ligament, M. the first sacral vertebra has the appearance of develop- popliteus, and the lateral head of M. gastrocnemius, ing a spondylolytic separation, a condition commen- suggesting that these attachments were not severely surate with abnormal lower back mechanical stresses traumatized by the injury and the muscles were active (Farfan, Osteria & Lamy, 1976). afterward, an observation which is in keeping with the The left lower limb demonstrates osseous response skeletally healthy foot noted previously. resulting from muscular hypertrophy. Conversely, the right lower limb has suffered from partial disuse atro- phy. Both the diaphysis and articulations of the tibia Osseous Alteration in Response to the Injury are affected to a variable extent. The maximum distal breadth, measured from the medial malleolus of the Osseous alterations are responses of the skeleton to tibia to the fibular notch, is 4·3 cm in the right limb as stress in relation to its load (force transmission) his- opposed to 4·15 cm in the left limb. The anterior– tory. One can expect the skeleton to reflect osseous posterior diameter (measured at the nutrient foramen) responses (osteological indicators) to changes in the of the tibial diaphysis has not been affected, but the load history over time in order to maintain functional medio–lateral diameter is 2·55 cm in the left, unaffected integrity (Rubin, McLeod & Bain, 1990). The infra- limb, while that of the affected right side measures only cranial skeleton of Sk 251 demonstrates considerable 2·35 cm. Thus the right tibia is platycnemic, while the evidence of asymmetrical development of the limbs left is mesocnemic, as defined by Brothwell (1981). The suggestive of a long-standing alteration in the manner left tibia is somewhat longer in maximum length in which body weight was transmitted through these (37·2 cm to 36·0 cm and 36·0 cm to 35·0 cm), although elements during movements. The most noticeable of this difference in length is entirely attributable to the these adaptive alterations, subsequent to the injury, are fracture and subsequent subchondral destruction of the found in the lower limbs, vertebral column, arm and proximal tibia. forearm. The dimensions of the femora have also been altered The vertebral column of Sk 251 reflects changes in by the injury, especially those of the diaphyses. Ruff et response to incapacity of the right lower limb, which al. (1993) have demonstrated that increased diaphyseal act ultimately from and upon this axial series of -sectional area of the femur relates to increased elements. All three areas of the vertebral column are mechanical loadings. The alterations noted in this affected by degenerative osteoarthritic changes. These individual include a flattened proximal right femur include anterior lipping of the 4th and 6th cervical (platymeric) when compared to the same dimension of vertebrae, with the inferior surfaces of the bodies of C5 the left side, which is perhaps an alteration to increased and C6 and the superior surface of the body of C7 medio–lateral bending in the affected femur, which affected by cyst formation and lytic pitting. The tho- further supports the assertion that this individual pos- racic vertebrae T6 and T12 possess anterior osteo- sessed an altered gait. The right mid-shaft circumfer- phytic lipping with T9 being most severely affected, ence measures some 4 mm less than that of the left side osteophytes in the entheses of ligamentum flava and the (9·3 cm as opposed to 9·7 cm). This discrepancy is supraspinous ligament, and osteochondrosis of the produced by an increase in medio–lateral dimension of inferior surface of the body of T11 and the superior the left, unaffected femur (3·45 cm as compared to surface of the body of T12. Kelley (1982) has argued 3·3 cm). Ruff (1987) has argued that an increase in this that osteochondrosis results from physical stresses diameter is associated with greater bending in the 374 C. J. Knu¨sel, R. L. Kemp and P. Budd

Figure 3. The paired humeri of Sk 251 which shows the right member to be substantially more robust in the region of the deltoid tuberosity and epicondylar region. medio–lateral plane. This type of bending would bearing (Hoyte & Enlow, 1966). The linea aspera of the result from increased pelvic tilt caused by reduced right member is not as distinctive as that noted in weight-bearing in the incapacitated right limb. The the unaffected left member. Again, this alteration scoliosis previously discussed provides further sup- may relate to hypertrophy of the extensor muscles port for this hypothesis. Although the robusticity of the anterior compartment of the left thigh and of indices of the femora are identical, comparative the adductor muscles of the medial compartment, radiographs demonstrate that this apparent similarity which insert onto the linea aspera. One of the conse- derives from two separate osteogenic processes. The quences of the type of injury described above is dimensions of the left side are attributable to increased wasting or atrophy of the anterior compartment mus- cross-sectional area of the femur due to bio- culature (Watson-Jones, 1944; Resnick & Niwayama, mechanically altered function (cf. Lazenby & 1988), which appears to have occurred in the right Pfeiffer, 1993), whereas, those of the right side reflect thigh. the altered diaphyseal dimensions associated with In addition to these lower extremity and axial alter- osteitis. This observation adds further support to the ations, there are several asymmetries of the upper notion that considerable remodelling had occur- extremities as well, which argue for what may have red subsequent to the injury, perhaps over several been crutch-aided locomotion. The most notable of years. these occurs in the humeri where the right member is The origin of the medial head of M. gastrocnemius, substantially more robust in its diameter across the which forms a mound of bone in the popliteal surface deltoid tuberosity than the left member (2·65 cm to of the posterior–medial portion of the distal femur, is 2·3 cm) (Figure 3), although the lengths and distal somewhat more pronounced in its usual position on articulations of these elements are unaffected by asym- the left side, suggesting hypertrophy of the M. gastroc- metrical development (cf. Ruff, 1987). A deltoid robus- nemius in the left leg. This mound of bone appears less ticity index (calculated by substituting diameter at the distinctly in the right side and is located somewhat deltoid tuberosity for least circumference in the hu- more proximally within the area of reactive bone, meral robusticity index, i.e. standardized to the maxi- which may suggest disruption in the functioning of the mum length) produces an index of 7·57 for the right corresponding right-side muscle. There are also two member and only 6·67 for the left. These external crease-like sulci in the vicinity of the insertion for M. alterations result from hypertrophied musculature vastus medialis and the short head of M. biceps femoris in the right arm. Osseous alterations such as this on the left side, just superior to the popliteal area. have been noted previously in a crippled leper from These alterations may have increased the surface area Chichester, West Sussex, U.K. (Knüsel & Göggel, for the attachment of these leg muscles as they hyper- 1993). Similar subperiosteal alterations have been as- trophied in response to a greater proportion of weight- sociated with differential hand preference and activity Mediaeval Knee Injury Treatment 375

Figure 4. The radii of Sk 251 showing the right member to be more robust in its distal third. in various human groups dating back to the Middle the right radius is considerably more robust and the Palaeolithic (Jones et al., 1977; Pfeiffer, 1980; Ruff & maximum breadth at the interosseous crest occurs Jones, 1981; Bridges, 1989; Churchill, 1993; Stirland, along the distal third of the radial diaphysis, whereas, 1993). in other individuals from the Fishergate assemblage There is some experimental work which suggests that and in the left member of Sk 251, the same measure- the alterations seen in the present individual could ment occurs along the proximal third of the shaft relate to differential use of the arms in response to a (Figure 4). This may suggest that the interosseous crippled and unstable right lower limb. In an EMG ligaments in this area and M. pronator quadratus, study of crutch-using patients, Peacock (1966) demon- which inserts over a large area of the distal radius, strated the extent of demands made on all three groups were hypertrophied due to greater demands being of fibres of M. deltoideus in crutch-aided walking. In made upon them during the lifetime of the individual addition, the right humeral head demonstrates 25) of and possibly after his lower limb injury. In support of torsion while the left side provides only 15) of torsion. this assessment, Wing & Tredwell (1983) found A similar, though more severe amount of torsion was greater bone density, which corresponds to greater identified in the Chichester individual and was argued external robusticity, in the radii of modern crutch- in that case to result from the limb being repeatedly using patients. placed in external rotation. The right humeral head is A more medial orientation of the radial tuberosity in also somewhat bigger in both its vertical and transverse the right member, rather than the more common diameters, measuring 4·8 cm and 4·45 cm as opposed anteromedial orientation, also suggests that the power- to 4·55 cm and 4·3 cm on the left side. The right ful supination and flexion provided by M. biceps humeral caput also presents with a nodal deposit, and brachii when the elbow is partially flexed were en- there is porosity in the area of the insertion for M. hanced in this individual’s right forearm (cf. Trinkaus supraspinatus of the greater tubercule, which would & Churchill, 1988) (Figure 4). Partial flexion of the suggest trauma to the rotator cuff musculature, the elbow is required during crutch-aided locomotion in stabilizers of the shoulder joint, and secondary osteoar- order to pull the body forward and to elevate the thritis. Additionally, a radiograph of the distal humeri crutch above the substrate (Peacock, 1966). Supination demonstrates the right member to be more radio-dense is required using crutches without transverse handrests than the left member, especially in the epicondylar (see depictions from Bosch in Jakobsen, 1985/6) as the area, a likely osseous response to hypertrophied flexor hand is held in a supinated position in order to move musculature in the right arm (cf. Chichester crippled the instrument forward along the substrate. Thus the leper). pronator and supinator muscles which provide antag- The more distal brachial members are characterized onistic movements were both hypertrophied in this by a single noticeable asymmetry. The diaphysis of individual, providing for controlled movement. The 376 C. J. Knu¨sel, R. L. Kemp and P. Budd

Figure 5. The metal plate ‘‘in situ’’ with the right fibula still in place and the outline of the tibia apparent in the soil. alteration of the right radial tuberosity appears to have Metallographic Investigation of the facilitated these motions and may account for the Copper Plates asymmetry noted. The condition of the plates after excavation shows them to have suffered considerable corrosion, which The Associated Find has left them in a friable and incomplete condition. Within the corrosion product there remain fragments It is clear from the archive in situ photograph of of metal. Two small samples of this metal from the the knee area that, originally, two metal plates were centre of one of the plates were examined metallo- located in the vicinity of the knee, although the recon- graphically to demonstrate the manufacturing history struction employed pieces of both to make a single of the plate. Scanning electron microscopy and energy plate (Figure 5). In places there is leather adhering to dispersive X-ray fluorescence analysis (EDX) were the corrosion product of the underlying metal, pre- undertaken as part of the study in order to determine served by the anti-microbial properties of the copper the composition of the metal and associated corrosion. (R. C. Janaway, pers. comm.). These plates were found in direct association with the right knee area, leaving a verdigris stain on the proximal lateral tibia and medial Sampling and Compositional Analysis proximal fibula. The staining of the tibia, more exten- The plate was in a highly corroded condition and sive than that on the fibula, is somewhat circular in extensive areas were largely devoid of metal. This shape and covers a 7 cm area in a proximal–distal posed difficulties in locating an uncorroded area for direction and about 4 cm in an antero–posterior direc- metallographic sampling. In order to maximize the tion on the lateral tibia, stretching from the tibial probability of locating a sufficiently large metallic area, tuberosity across the medial side of the bone, but does two samples of 3–4 mm2 were removed for examina- not extend onto the posterior portion of the bone. The tion. These were mounted by standard techniques and distal femur does not have any identifiable staining. very carefully polished using fine grit and then 1 ìm One of the two plates was probably originally beneath diamond paste to reveal a cross-section with the great- the tibia, lying on the bottom of the grave cut with the est possible quantity of uncorroded metal. The samples second above the knee and covering it. This latter plate were examined, using a metallographic microscope, was perhaps responsible for the staining noted. The in the as-polished condition and after etching in objects measure about 10 cm across and are of horse- ammonia/hydrogen peroxide solution. The samples shoe shape (Figure 5). Lines of holes across them were also examined in the Scanning Electron Micro- merge with a series found along the borders and scope (SEM) operating in both secondary emission and may have transmitted some sort of binding material, backscattered electron modes. EDX analysis was used although no trace of this material survives. to aid the identification of micro-constituents. Mediaeval Knee Injury Treatment 377

Table 1. Energy dispersive X-ray fluorescence results. All figures are normalized weight percentages

Description of analysed area Cu Sn Pb Zn As Sb Ag Fe Ni P

Solid solution 95·57 3·34 1·01 n.d. n.d. n.d. n.d. n.d. n.d. n.d. Solid solution 93·47 4·71 1·83 n.d. n.d. n.d. n.d. n.d. n.d. n.d. Solid solution 93·22 4·73 2·06 n.d. n.d. n.d. n.d. n.d. n.d. n.d. Solid solution 93·37 4·27 2·35 n.d. n.d. n.d. n.d. n.d. n.d. n.d. Solid solution 95·11 4·33 0·57 n.d. n.d. n.d. n.d. n.d. n.d. n.d. Solid solution 91·39 5·06 3·54 n.d. n.d. n.d. n.d. n.d. n.d. n.d. Mean composition for solid solution 93·69 4·42 1·89 n.d. n.d. n.d. n.d. n.d. n.d. n.d.

Corrosion phase 65·32 23·30 4·80 n.d. n.d. 1·01 0·60 n.d. n.d. 1·02 Corrosion phase 76·76 12·25 6·16 0·67 n.d. 0·69 n.d. n.d. n.d. n.d.

Approximate sensitivity 0·20 0·20 0·40 0·40 0·20 0·20 0·33 0·25 0·20 0·20

EDX analyses of solid solution areas were under- presumably being derived from the burial as no traces taken using a Jeol 6800 scanning electron microanaly- were detected in uncorroded areas of the metal). ser operating at 25 kV accelerating voltage. Analyses of corrosion phases were undertaken using a Cambridge Instruments Stereoscan 150 instrument operating at Description of the Microstructure 20 kV. The mean composition of the solid solution (Table 1) indicates that the alloy is essentially a low tin Examination of both of the samples in the unetched bronze with a substantial (almost 2%) lead content. condition revealed very substantial corrosion. One EDX results indicate that the uncorroded parts of the sample was so completely corroded that only small alloy contain about 4–5% tin; however, elevated tin isolated pockets of metal remained. The other, al- levels in the corrosion products indicate post- though also substantially corroded, contained metallic depositional destannification of the solid solution, areas up to about 0·5 mm2 in size. Two principle suggesting that the original tin content may have been corrosion phases could be distinguished under reflected higher, perhaps in the 5–7% range. The corrosion also light (Figure 6): a dark grey phase forming the bulk of contained considerable lead, as well as significant the corrosion and distributed primarily in large zones levels of antimony, silver and phosphorus (the latter and deep penetrative fissures within the metal; and a

Figure 6. Part of the sample in the unetched condition showing uncorroded metal (white) and the two corrosion phases (dark and pale grey). Note the long fissure caused by penetrative corrosion and the grain boundary distribution of the pale grey corrosion phase. Magnification #300. 378 C. J. Knu¨sel, R. L. Kemp and P. Budd

Figure 7. The sample after etching in ammonia/hydrogen peroxide solution. A pattern of fine equiaxed grains with annealing twins is revealed showing a pattern of intersecting slip traces. Note the penetration corrosion along grain boundaries. Magnification #300. paler, blue-grey phase seen as an extensive network the lack of substantial distortion to annealing twins extending along grain boundaries within the metal. The and the grains themselves suggests that this working dark grey phase appeared predominantly blue-green in must have been limited, perhaps achieving an overall colour under cross-polar illumination and is likely to reduction in thickness of the order of 20%. contain principally malachite (Cu2CO3(OH)2). The blue-grey phase is more varied under cross-polar illu- mination, but contains numerous orange/red crystals Discussion of the Metallographic of cuprite (Cu O). Detailed optical microscope exam- 2 Investigation ination of the uncorroded areas showed that the struc- ture was largely free from resolvable inclusions. A 5–7% tin bronze, with or without the addition of Numerous very small (<5 ìm), pale grey inclusions, lead, is potentially a well-suited material for the manu- which could be seen predominantly at grain bound- facture of a load-bearing device. Although not offering aries, were identified as lead during the SEM examin- the hardness and wear resistance of higher tin alloys, ation. The uncorroded metallic areas appeared to the material is easily workhardened to a considerably consist entirely of single phase solid solution with no greater hardness than unalloyed copper. The most evidence of additional intermetallic phases. important property for a supportive component is Examination of the samples after etching showed the probably toughness, which can be considered as a uncorroded metal to have a recrystallized structure combination of strength and ductility characterized by containing fairly fine (c.40ìm diameter) equiaxed resistance to failure under dynamic loading conditions. grains (Figure 7) with annealing twins. No microsegre- A tin bronze of this composition offers considerable gation was apparent, suggesting that the surviving toughness, comparable with that of higher tin alloys, metallic areas are substantially homogeneous. Analy- whilst having the additional benefit of solidification as ses of uncorroded solid solution areas (see Table 1) a single phase solid solution during casting. Although, indicate that there has been some destannification of in theory, Cu–Sn alloys containing up to 13·5% Sn will the solid solution as a whole, with tin levels in the solidify as a single phase, under the non-equilibrium range 3·4–5·1%, compared with up to 23% in the grain cooling conditions, which normally pertain in casting, boundary corrosion phase. Lead levels are also en- alloys of about 8% Sn or above will solidify as two- hanced in the corrosion, but this is unsurprising given phase structures containing islands of hard, brittle, áä the inevitable grain boundary distribution of the lead eutectoid (27% Sn). The eutectoid will hamper working (which is virtually insoluble in copper) in the original unless removed first by prolonged heat treatment. structure. Many of the grains feature patterns of Many mediaeval copper alloys contain lead (cf. intersecting slip traces indicating that the plate has Hallbäck, 1976–7), which may be present either as a been subject to a final phase of cold working, although deliberate addition or as a result of recycling scrap Mediaeval Knee Injury Treatment 379

Figure 8. The ‘‘in situ’’ photograph of Sk 251, Context 10266, showing the unusual orientation of the elements of the right pectoral girdle and of the right lower limb. Photograph by the York Archaeological Trust. material. Finely distributed throughout the structure, cycles of both cold working and heat treatment (both and at the levels indicated here, lead may have had a to homogenize the as-cast structure and to anneal the slight beneficial effect, increasing the fluidity of the metal during working). The result was a homogeneous, metal during the original casting operation. Traces of single phase, 5–7% tin bronze with considerable tough- antimony and silver concentrated in the corrosion ness, consistent with the function of the artefact as a products might suggest that the copper was produced support structure. These properties are unlikely to have from the smelting charge which included the sulphide been particularly seriously affected by the other major mineral of the tetrahedrite series ((Cu,Fe)12(Sb,As)4S13) elements present, which seem more likely to reflect or one of its secondary products. The minor traces of the (probably undetectable) contamination of stock zinc detected in one of the analyses are unlikely to be material than the deliberate modification of the intentional and may result from the presence of brass in composition. copper-alloy scrap which may have contributed to the stock metal from which the artefact was made. The properties of the material appear to have been The in situ Burial Photograph fully utilized. The lack of evidence for microsegrega- tion (in the form of residual coring) shows that the The in situ photograph of this individual, one which alloy was thoroughly homogenized by heat treatment records the burial orientation of Sk 251, reveals following casting; probably during the course of complementary evidence to support the interpretations fabrication of the plates. made above (Figure 8). Burial orientation, apart from Further evidence for the thermal history of the being dictated by cultural funerary norms, often also artefact is provided by the recrystallized grain struc- records aspects of the actual posture of the individual ture. This shows that the metal was heated above its prior to death. The in situ photographs of this indi- recrystallization temperature, probably in periodic an- vidual reveal that his legs are not aligned as are the legs nealing phases during working. The slip traces suggest of the other members of the burial population at the that the final manufacturing operation was a lower east end of the monastic church, nor are they similar to temperature, or cold working, operation, producing other burials at the site (Stroud & Kemp, 1993). something of the order of a 20% overall reduction in Usually, the legs are found either side-by-side or thickness. This would have had the effect of workhard- crossed. As can be seen in this photograph, the right ening the plate after the softening heat treatment, leg is deviated laterally and abducted somewhat and considerably increasing its hardness and stiffness, but has a rounded, bow-legged appearance (compare this without undue embrittlement. alignment with that of the neighbouring skeleton, In summary, the plates appear to have had a fairly Sk 253, for example). As noted above, forced abduc- complex manufacturing history involving one or more tion of the knee and leg leads to the type of injury 380 C. J. Knu¨sel, R. L. Kemp and P. Budd described. It is very likely, then, that this posture was positive statement is warranted based on the nature the habitual one assumed by this individual in life. of the evidence. The metal plates affixed to this Additionally, although the left arm obeys the same individual’s knee would have compensated for a cer- pattern and alignment as observed in other burials at tain amount of laxity and the condition of the lower the east end of the site—that is, hand pronated and limb elements suggests that the right limb remained placed at the pelvis—the right arm is in full extension weight-bearing, although not to the same extent as the with the lower arm elements in a supine position. The left limb. right shoulder is elevated, while the left is in a normal A review of the literature shows that there have been anatomical position (note position of the left scapula). three previous examples of individuals treated with If both shoulders were in an elevated position, one copper-alloy plates. The earliest discovery of such an would ascribe this positioning to burial in a shroud, a association comes from the eastern outskirts of situation which appears to characterize most individ- Reading, Berkshire, U.K., where two unprovenanced uals at the east end of the monastic church. In this case, copper-alloy plates, lined with dock leaves (Rumex however, the shoulders are in two different positions, obtusifolius), were found wrapped around a badly which suggests that this individual received a different necrosed and osteomyelytic right humerus in 1890 sort of mortuary treatment and is unique among those (Reading Museum archive number A635013, accession at the east end of the site. Between the right upper limb number 5299/1936). These plates were found in assoc- and the trunk is a well-defined space, which looks very iation with the skeletal remains of a female from a much as if it contained an object that no longer cemetery judged to be Romano-British, but probably survives. The unique positioning of the pectoral and Saxon, and dating from between  500 and  1000, brachial elements of this side of the body with its although Wells (1964), who restudied the specimens, injured right knee might suggest that this individual contends that they date from the 11th to 13th centuries was accompanied in his burial by a crutch or support and derive from a cemetery known as Jack of Both of some type. Sides. The plates were apparently bound round the arm with thread or other material through holes punched in the metal. Discussion Two other examples have been published previously. The most unusual of these comes from the Cistercian The individual in question would have been left with a Abbey of Varnhem, Västergötland, Sweden, and was noticeable limp and general knee laxity by his injury found about 1928 (Hallbäck, 1976–7). These twin since the anterior cruciate ligament, the major stabil- copper-alloy plates were internally fixed through holes izer of the knee (Hastings, 1986), had been disrupted. around a now disassociated left humerus that had been In addition, the knee would have been chronically fractured through the deltoid tuberosity (a blade in- infected. How could this individual have sustained this jury?) sometime during the period 1150 to 1527. The injury? patient thus treated appears to have survived the Most modern cases of dislocated knees and tibial surgery and the treatment for some time afterwards plateau fractures occur as the result of traffic accidents based upon the presence of remodelled bone around either as a passenger of an automobile involved in a the plate. Janssens (1987) reports on the previous two head-on collision or as a pedestrian hit by an auto- examples and a third dated to the period 1579–1650. mobile, though many are sport-related, for instance This latter instance accompanies the left humerus of a football injuries, and occur as a result of simple falls roughly 30-year-old male buried in Vrasene, Flanders, (Hill & Rana, 1981; Moore, 1981). Falls from a height Belgium. The plates in this case were joined by leather are the most common predisposing factor in fractures strings and hooks to each other. This individual is of the tibial plateau, although automobile accidents are suggested to have been of high status as his corporeal implicated so often that this injury bears the name remains were interred and excavated from within the ‘‘bumper’’ fracture (Aston, 1976; Waddell, Johnston & Church dedicated to the Holy Cross. Janssens argues Neidre, 1981). In the case reported by Hill & Rana that these plates were therapeutic in their application (1981), the patient had simply slipped off a curb and and were intended as a treatment for suppurating, twisted the knee. This particular man’s knee was non-specific infections of the soft tissues. locked in permanent flexion before reduction. In the The function of these copper-alloy plates may have present case it seems that closed reduction must have been as a talisman of sorts with curative properties. been performed as the previously discussed nearthrosis The ability of copper to perform as a disinfectant may would seem to indicate that the leg was normally have dictated this form of treatment. The example extended after the injury. It is most probable that the from Reading, lined with dock leaves, a plant with present injury was sustained after some sort of violent medicinal qualities as a blood purifier, mild laxative, trauma, perhaps after a fall. An early reference to and as a tonic, would seem to support a similar football playing amongst the Gilbertines in Graham’s interpretation. Interestingly, this plant is most com- (1901: 158) monograph on the Order might suggest a monly used in the treatment of eczema and psoriasis possible cause of the injury noted, although no more (Potterton, 1983). A deadened patch of skin would Mediaeval Knee Injury Treatment 381 have the appearance of these disorders and may thus thing more akin to armour scale, which would consist have contributed to the treatment in the present in- of a series of small copper plates fastened together. The stance, although no evidence for plant remains was placement of the holes in the reconstructed plate might recovered. suggest, in fact, that this literal translation is more apt. With the economic, social and cultural revival of the If this translation is more accurate, then the affected 12th century Renaissance came a renewed interest in knee would have had support with mobility. the translation and interpretation of medical treatises Siraisi (1990), citing several researchers’ works, notes from the Antique and Late Antique periods, many of that although Celsus was known to the mediaevals, his which were in the Greek and Arabic languages, and work did not have the impact of similar and older most notably included the works of Hippocrates. works, such as those of Hippocrates, due to their Chaucer (1979 edition) in his Canterbury Tales men- extreme length and great complexity. This assessment tions the latter as being among those authors known to gains credence by noting that among the medical his archetypal Doctor of Physic. With these texts also personages known to Chaucer’s Doctor, one finds both came renewed interest in Latin medical authorities Galen and Hippocrates, as well as the early mediaeval such as Celsus and Galen. As with most intellectual doctor and philosopher, Avicenna, but not Celsus. pursuits, cloistered monks played a considerable role in However, we are dealing with individuals—canons— the dissemination, interpretation and practice of medi- who were highly literate and may not only have had cine (Siraisi, 1990). The two best known examples of access to, but may also have employed less well-known the use of metal plates are associated with the and complex texts, including that of Celsus. We can, Cistercian Order. Perhaps, then, it is to the Cistercians however, look to other ancient medical writers for the that we might look for prescriptions and practices inspiration for this copper plate treatment. which may have inspired such remedies. There are at least two passages from Hippocrates The Gilbertines, although a uniquely English Order, that bear upon the treatment received by this indi- were linked to the Cistercian Order from their incep- vidual (Hippocrates, 1952, 1959). In Instruments of tion in the 12th century, having based a portion of their Reduction (Chapter XXIV), Hippocrates comments own Rule on that of the Cistercians, as well as portions that dislocations of the knee are of a milder character borrowed from the Augustinian and Premonstraten- than those of the elbow and describes posterior dis- sian canons (Graham, 1901). These Rules were chosen location and methods of reduction. In On Fractures because of their greater strictness when compared with (Chapter XXX), Hippocrates prescribes the following the older and more relaxed Rules of the Benedictines treatment for a fracture of the lower limb: and Cluniacs. The great ecclesiastic, mystic, and Abbot of Clairvaux, St. Bernard of Clairvaux, records his Now, there are some who in all cases of leg fractures, Order’s view of medical learning in the form of a whether they are bandaged or not, fasten the foot to the rebuke, which provides insight into the most fre- bed, or to some post which they fix in the ground by the quent forms of medical practice, both tolerated and bed. They do all sorts of harm and no good; for extension is not ensured by fastening the foot, since the rest of the untolerated. He writes (quoted in Siraisi, 1990): body will none the less move towards the foot, and thus extension will not be kept up. Nor is it of any use for I fully realize that you live in an unhealthy region and that preserving the normal line, but even harmful. . . If it were many of you are sick . . . It is not at all in keeping with not tied up, there would be less distortion, for it would not your profession to seek for bodily medicines, and they are be left behind so much in the movement of the rest of the not really conducive to health. The use of common herbs, body. Instead of this, one should get two rounded circlets such as are used by the poor, can sometimes be tolerated, sewn in Egyptian leather such as are worn by those who and such is our custom. But to buy special kinds of are kept a long time shackled in the large fetters. The medicines, to seek out doctors and swallow their nostrums, circlets should have coverings on both sides deeper on this does not become religious (Siraisi: 14). the side facing the injury and shallower on that facing the joints. . . They should have on each side two attachments of leather thongs, single or double, short like loops, one set It seems likely, then, that folk remedies were at the ankle on either side, the other on either side of the amongst those remedial treatments allowed and en- knee. . . (LI. 10–36). couraged in Cistercian houses. One of the earliest of these remedies which is still prevalent in folk remedies It may have been this method which was adopted in is that which purports that metal placed near a wound the present case. The metal plate, covered in leather, or sore will precipitate healing. Celsus, a 1st century then, may have been employed as a support structure authority (auctor), and possibly a practising medical using copper for its prescribed curative effects. The doctor (medicus) describes among those substances plates may have acted as a permanent splint. A similar having a cleansing effect the following: verdigris [cop- treatment, ‘‘a padded splint’’, was initially applied in at per acetate (CH3.COO)2 Cu.H2O)], orpiment [arsenic least one modern case of an anteriorly dislocated knee sulphide (As2S3)], and squama aeris (copper oxide?) (Kennedy, 1963). (Book V .3 .5). This latter reference may have a literal Who within the mediaeval urban community of meaning, namely a plate or scale of copper or some- York might have been most likely to be responsible for 382 C. J. Knu¨sel, R. L. Kemp and P. Budd this kind of treatment? In his survey of English medical metallurgist to make the required plates as a member practitioners, Gottfried (1984) notes that although the of a high-status monastic community. estimates of the numbers of medically-trained clerics might have been exaggerated in the past, most large monastic houses would have retained the services of a Conclusion monk trained in the rudiments of medicine. In the 14th Evidence for remedial treatment of injuries is a unique century there seem to have been more medically- occurrence in the archaeological record, most likely trained clerics, in fact, than in the succeeding centuries. because such treatments relied, in most instances, upon Among them, one finds priests (58, the largest num- materials that do not survive the rigours of burial. In ber), followed by deacons (45) and then members of the late 13th century a member or an associate of the the Franciscans (3), Dominicans (3), Benedictines (2), religious community of the Gilbertines was treated for Austins (2), Carthusians (1), Carmelites (1) and Cister- a dislocation–twist fracture of the knee, an irreducible cians (1). A fourth of all medical practitioners in type of fracture before the advent of surgery, with a Gottfried’s sample came from the ranks of the clergy, pair of metal plates, the form and orientation of which all being physicians rather than surgeons, the latter recall those described by the 6th century  medicus, often being less well-educated, if not as equally skilled, Hippocrates. This treatment was very probably aided as the physicians. It is possible that the practitioner by the addition of a crutch which was held in the hand involved attended one of the great medical institutions of the injured side and allowed the individual to remain that sprang up on the Continent in Salerno, Bologna, ambulatory in that manner for a considerable period Parma, Paris or Montpellier in the course of the afterwards, as suggested by bone alteration of the 11th–13th centuries. Here, the practitioner would have appendages. Severe soft tissue damage, produced by had access to the various guides created for dissemi- the injury, however, would have left this individual nating the basic tenets of Galenic and Hippocratic with a visible and chronic knee ulceration. The treat- medicine, which served as a part of the basic curriculum ment prescribed may have involved the ministrations (Siraisi, 1990). Gottfried’s assertion that English medi- and specialist knowledge of a Gilbertine brother, per- aeval medici were often drawn to the urban centres haps in residence at St. Andrew’s, Fishergate, or a might argue for the practitioner to have been resident specialist consultant trained in practical remedies. This in the City of York itself, perhaps associated with the is the only example of this type of treatment for a lower metropolitan see, who may have come into contact limb injury thus far reported in the literature and with the injured individual on a consultancy basis. known to the authors, although three other similar Equally, the person in question may have been a treatments applied to the arm have previously been surgeon who had learned the trade through association documented in mediaeval or immediately post- with a skilled surgeon, who may have been trained in mediaeval contexts. These applications seem to be Galenic and Hippocratic treatises. associated with monastic establishments, often of In a review of the biographies of mediaeval English Cistercian inspiration. practitioners, Talbot & Hammond (1965) list 16 indi- viduals who were active in the York area during the period from the 13th–15th centuries, the period of time Acknowledgements in which the monastic cemetery of St. Andrew’s was in use. During the whole of the mediaeval period, these We thank Professor A. M. Pollard and Dr Gerry authors list 16 additional individuals who were active McDonnall of the Department of Archaeological in the City of York and some 31 who were active in Sciences, University of Bradford, for their help with Yorkshire during the same period, most in some deciphering Celsus’ chemical and metal terminology relation to the powerful Yorkshire of and to Rob Janaway, who aided in the identification of Fountains; St. Mary’s, York; Rievaulx and Jervaulx, the leather. Steve Mitchell, Experimental Officer in the all but St. Mary’s being a Cistercian house. Among Department of Mechanical Engineering, University their listing one finds reference to monks being medici, of Bradford, provided SEM facilities and advice. medical men acting on a consultancy basis to or in the Nicky Rogers of the Finds Department of the York employ of royal personages and ecclesiastical officials, Archaeological Trust brought the metal artefact to the as well as ministering to prominent members of the attention of the investigators and encouraged the City. analysis of it and Sk 251. Drs Charlotte Roberts and Surgeons appear, then, to have been much like other Keith Manchester of the Calvin Wells Laboratory, craftsmen and often specialized in a particular treat- Department of Archaeological Sciences, University of ment and travelled widely to apply it. It seems likely, Bradford, offered diagnostic opinions on the injuries though, based on the method of treatment exhibited sustained by Sk 251. Dr Dominic Tweddle of the York by this individual, that the practitioner was familiar Archaeological Trust provided permission for the with Hippocratic works and those of Celsus as well, analysis of the metal artefact. This work was made and that he would have been more likely to come possible through the efforts of Dr Peter Addyman and across both this knowledge and the aid of a skilled Ms Christine McDonnell of the York Archaeological Mediaeval Knee Injury Treatment 383

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