Imagine today walking into your local barber shop, sitting in a comfy swivel chair, having a nice clean sheet draped over your chest to protect your clothes and hearing the following words.

“What’ll it be today then, sir? A wet cut and shave or is it teeth pulling or leg amputation?

No. Alright, how about a bit of blood letting? The moon is in Gemini and I’ve got some lovely fresh leeches in the back!”

• Rome
• A Backwards Step?
• The Crusades
• War and Medical Advancement
• Wound Types
• Why Barbers?
• The Right Tools
• The Father of Modern Surgery: Ambrose Pare
• The Role of the Surgeon
• The Winds of Change
• The End of the Barber

Okay, it may not have gone down quite like that. They didn’t have those comfy swivel chairs in the Middle Ages for starters!
Throughout the period, if you required any surgical intervention, it would likely be performed by none other than your local barber or barber-surgeon. Perhaps it is no wonder that the period earned the name the Dark Ages.

Rome

In this context, the term ‘Dark Ages’ relates not to the increased barbarism of the early medieval period but rather that Europe saw a dramatic regression when the Roman Empire fell. It is generally accepted that the Romans were gradually forced to abandon their outposts as they faced invasion at home.

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When the Romans did occupy large areas of Britain, they had brought with them good public health systems and some reasonably logical medical knowledge influenced by the ancient Greeks. This had been developed further through practical application and experience treating the men of their extensive military.

However, as with any country that is at once occupied, influenced and then abandoned, when the invading force left, there followed a period of decline in many aspects of daily life.

The aqueduct systems put in place to provide a reliable water supply began to fail without the organised workforce and knowledgeable Roman engineers. Plumbing and drainage systems fell into disrepair and disease soon followed.

A Backwards Step?

The country, no longer under Roman control and now lacking a central government, had fragmented into multiple small kingdoms and in-fighting was rampant. Not to mention the fact that the Anglo-Saxon wars were also underway at this point!
All of this change and the constant power struggle left little time for worrying about public health and medical advancement or lack thereof.

There was no organised national English army. Rather, small groups of retainers belonging to various warlords who led far smaller groups of men (often just farmers) were compelled to fight in their master’s name by the feudal system.

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Nothing existed like the mass organisation of the Roman legions which had required their own medical staff. It is more likely that an injured man-at-arms would be cared for by camp followers and other soldiers.

Everyday people would have relied heavily on herbal remedies from their local wise woman or healer. Therefore, if you survived childhood and (by some miracle) avoided war and ill health, you could reasonably expect to live until you were 30 – 35.

As the Middle Ages progressed, organisation slowly began to improve. Central leadership had been established with a king at the head.
Through knights swearing oaths of fealty, larger armies numbering 10,000 to 15,000 men could now be raised. Larger numbers of manpower meant a greater capacity to wage war which in turn led to weaponry developments and more injured soldiers requiring treatment.

The Crusades

In November 1095, Pope Urban II incited the First Crusade at The Council of Clermont in Southern France. He urged all Christians in the Western world to join together in fighting their shared enemy, the Muslims, for the control of the city of Jerusalem in the Holy Land.

Thousands of Europeans answered the call and began to make their way East.
The Muslim grasp of medicine at this time was superior to that practiced in the Christian world. The main cause of this disparity in knowledge and practice was arguably down to the Church.

According to church doctrine at this time, the spilling of blood in any way was considered a violation of the sanctity of the human body. Therefore, the practice of surgery was generally discouraged and certainly held back any would-be surgeons from developing their knowledge of anatomy.

However, it was also in the name of God that in 1080, a hospital had been created in Jerusalem. Working under Brother Gerard, a group of monks had established this charitable endeavour.

This sought to offer care to the many pilgrims on their journey to and within the Holy Land should they fall ill. Known as Hospitallers, the men and women who offered this service were officially recognised by the Church in 1113.

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The Crusades caused the Hospitallers to develop a militarised arm which became known as the Order of the Knights of St John of Jerusalem (the forerunner of today’s St John’s ambulance). Its members took a vow to care for all sick and wounded regardless of their status, race or faith.

War and Medical Advancement

The fighting at this time was brutal on both sides! Islamic forces exploited the weaknesses of the European knights.
Their superior agility, knowledge of the landscape and use of arrow volleys were all evidenced in some of these early battles. The use of archery was extremely effective in overcoming heavy cavalry.

They targeted horses and their riders. An unhorsed and heavily armoured knight made for easy pickings. Still wearing the cumbersome metal armour popular in the West, they now suffered for it in the extreme heat.

The weapons available at the time of the Crusades included the lance, sword, and dagger. The crusaders used heavy broad swords which, held in two hands, commonly caused amputations and wide penetrating wounds.

By contrast, the agile Muslim forces used lighter weight, thinner and longer curved swords with very sharp blades. Held in one hand, these could inflict deep wounds with ease.

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Knights, thrown from their horses, sustained broken bones which took time to heal. Indeed, the practice of treating fractures had progressed significantly by the later Crusades.

Wound Types

Infected wounds caused by embedded projectiles such as arrows led to the invention of new tools. These tools were designed by barbers for the purpose of extracting arrowheads safely.

Wounded soldiers in the earlier crusades were cared for by non-combatants (camp followers). As the crusader wars progressed, medical organisation on the battlefield improved.

Fighting men were evacuated from the battlefield and conveyed to a nearby castle or hospital by organised groups such as the Knights of St John. There, they may be assessed by a physician but any operations would be performed by a barber surgeon.

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Unfortunately, any records regarding specific medical treatments or the process of diagnosing ailments at this time have largely been lost. Historians have recognised a Byzantine influence in some European treatment methods indicating the sharing of medical knowledge.

The ancient practice of studying the stars, for example, was translated from Arabic to Latin and soon became a key part of European medical practice.

However, the development of Italian medical schools in the 1200s saw the beginnings of expertise in treating fractures, knowledge of the wound healing process and the development of some understanding regarding prevention of infection and methods of anaesthesia.

Skulls and bones from this period show signs of breaks which have healed suggesting that the treatment of injury was successful in some cases. Even traumatic head wounds were now not always fatal.

However, as with the Romans the well documented practices of the Ancient Greeks continued to prevail. The advances picked up by the crusaders were gradually forgotten.

Why Barbers?

Over the course of the later Middle Ages the longbow emerged as a favoured weapon in Europe and dominated the scene for a good 200 years. Later, developments in gunpowder weapons led to a wider variety of military units.

A late medieval ruler would now have at his disposal everything from archers and pikemen to artillerists and musketeers. However, once again, medical advancement was slow to catch up.

There were now allocated groups of men whose job it was to evacuate the wounded. But much of the healing and nursing would still have been conducted by camp followers.

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Only the lord or wealthy knights would have their own personal physician. But a physician would not have conducted any surgery. Any surgical requirements would have been conducted exclusively by a barber surgeon.

Though the connection between being a barber and conducting operations is hard for us to reconcile, it made sense to those alive in 1000 AD when the first recorded barber surgeons were practising their craft. So, how does the guy who cuts your hair and trims your beard qualify to conduct a minor operation?

The Right Tools

In medieval times, a barber was a man who could be trusted not only with your appearance but also with holding a knife to your throat! He was skilled and carried a range of sharpened scissors and blades in his toolkit.

He had a steady hand and an eye for precision and detail so of course, these qualifications made him the perfect candidate to conduct surgical procedures.

The earliest concrete evidence of barber surgeons shows that they originally plied their trade in monasteries. Barbers were either trained or hired in order to help monks maintain their required ‘tonsure’. The distinctive clipped hair cut which so openly demonstrated their religious devotion.

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While working with monks they were also believed to be performing bloodletting and other minor surgical procedures such as pulling teeth.

During wartime, monasteries often established themselves as charitable hospitals. When France passed a law in the 13th century requiring all trainee physicians to swear not to perform surgery it left an opening which barber-surgeons (not considered medical professionals) could fill.

Unfortunately, for fighting men and the general public, these surgeons often learned on the job which must have made for a worrying prognosis!

As a physician also considered himself above getting his hands dirty, the sphere of the surgeon grew to cover a range of treatments. From dealing with basic wounds, burns and cuts to setting bone fractures and dislocations.

They could also treat venereal diseases, lance boils, perform cupping and apply leeches for blood-letting. Once their apprenticeship was complete, they would also be performing more skilled surgical procedures such as trepanation, cauterising wounds, amputation and even delivering babies!

The Father of Modern Surgery: Ambrose Pare

No writing on the existence of barber surgeons would be complete without considering the early practitioner of evidence based medicine himself, Ambrose Pare. In his own words, Pare explained,

“There are five duties of surgery: to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided, and to redress the defects of nature.” 

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Pare was a barber surgeon from humble beginnings. The physicians of his day considered themselves above getting their hands dirty by performing crude medical procedures such as amputation or eye operations.

Rather ironically, in today’s world, becoming a surgeon is one of the highest paid and most revered medical positions attainable. Not so in the medieval and Renaissance world.

A physician was a man of learning. Having attended a university, he would have spent his time pouring over his books, diagnosing ailments by consulting urine charts and prescribing various medicines and treatments. He most definitely would not perform surgery!

The Role of the Surgeon

A surgeon, however, would have learned his trade via a practical apprenticeship concurrently with learning barbering so that he could fund his training. It was perceived as a manual occupation.

Pare bridged the gap between surgery as a solely practical occupation and as a practice which required learned experimentation and careful observation of the patient. He also began to challenge the broadly accepted doctrines of Galen, held as the gold standard in medical practice throughout the Middle Ages.

Pare gained invaluable experience through his wartime service. He was present at many battles of his day providing his services, along with many others, as a barber surgeon.

The increased use of firearms in the 16th century led to greater instances of soft tissue damage. The resulting infections meant a significant increase in the need for amputations.

Before Pare, it was generally accepted that severe pain would likely accompany any surgical procedure. Pare realised that taking care and being gentle would reduce the risk to the wounded soldiers.

The trouble was, pain relief in 16th century France had not moved much further forward from early medieval methods. The use of plant-based drugs such as opium, mandrake root and henbane often combined with alcohol was commonplace.

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Completing a procedure quickly was also the best way to prevent risk of infection at a time where there were no antibiotics.

The Winds of Change

Pare discovered a new method of treatment by accident in the year 1537 while treating a soldier suffering from a bullet wound. The accepted form of treatment was to remove the bullet and cauterise the wound with boiling oil. Yikes!
However, Pare had run out of the oil solution and set about producing his own alternative consisting of egg yolk, rose oil and turpentine.

On observing his patients the following day he was surprised to notice that those treated with the soothing new balm were restful and fever free. By contrast, those men who had their wounds cauterised with boiling oil were feverish and remained in great pain.

After this, Pare determined to only treat his patients with methods which he had personally observed to be successful. He also abandoned writing in the traditionally accepted Latin and instead wrote in French. This made his books accessible to his fellow barber surgeon practitioners.

Over the course of Pare’s career, training opportunities for barber surgeons had improved. They were allowed into university lectures on anatomy and surgery and could take a special examination to receive a professional qualification.

The End of the Barber

Interestingly, despite the new educational opportunities, the fields of medicine and surgery grew further apart. In England, the Company of Barber Surgeons was created in 1540.
It was not until much later that the two professions of barber and surgeon began to divide, eventually separating in the 1800s.

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There are few signs of the link between today’s barbers and surgeons. One vestige of the past is the way a surgeon is titled today.
When they complete their qualification within the UK, they are normally referred to as Mr / Mrs / Miss etc as opposed to Dr.

This perhaps originating from the days when they did not require a university education to practice.

And finally, one lasting symbol is the traditional red and white pole often displayed outside a barber shop. This is said to represent the blood and bandages that would have once been a part of their professional lives.