Arderne's Medical Manual

John Arderne (1307 - 1392), of whom I first wrote many years ago, has been called the father of English surgery. He earned this by producing a manual in Latin that was copied into English and widely used.

Although we know little of his personal life except that he practices in Nottinghamshire and London, his broad knowledge suggests someone who traveled and had a variety of experiences. Since he lived through the Black Death and the Hundred Years' War (during which he saw action in France), he had plenty of opportunities to learn about and deal with a wide variety of illnesses and injuries.

In 1370 he wrote the Practica Chirurgiae ("Practice of Surgery"), in which he detailed many of his techniques and boasted a for-his-time astonishing survival rate of 50%. There are not only detailed instructions, but detailed illustrations of the parts of the body being operated on, as well as illustrations of the instruments (many of which he designed) used.

More than the practical side of things, however, he gave advice to the surgeon open dress and behavior. He urged the university-trained doctor to dress the part, rather than wear the limited short (above the knee) robe of the typical "barber surgeon" (educated in a guild), to appear more important. Barber surgeons were looked down upon, and he advises his readers not to share techniques with them, lest they usurp the position of the university-educated surgeon. In a later century, in Paris, a distinction was made with the titles "Surgeons of the Short Robe" (who could offer their services never having taken an exam or proved their knowledge) and "Surgeons of the Long Robe."

Arderne's advice went beyond haughty classism, however. He also advised a pleasant bedside manner: the doctor should be able to tell tales "that may make þe pacients to laugh" and tales from the Bible to "make or induce a liȝt hert[light heart] to þe pacient or þe sike [sick] man." He should also, when speaking to a patient, not confuse him with complicated terms or harsh language:

“be the wordeȝ short, and, als mich as he may, faire and resonable and withoute sweryng”

make the words short, and, as much as he may, faire and reasonable and without swearing.

He felt that wealthy patients should be charged as much as possible, but poor patients treated for free.

More than 50 copies of his Practica exist today; 36 of them are copies with the original 250 illustrations. The expense of reproducing so many illustrations was significant, but it is a testimony to how valuable the work was considered to be. The illustrations were not only important to show how the body was being treated, but to understand the use of the instruments. These tools of the trade were not readily available, and had to be custom-made. I feel not enough has been said about the relationship of people with specific requests to the metal-workers of the age, so tomorrow let's talk a little about the blacksmith trade.

The Father of English Surgery

John of Arderne (1307 - 1392) was an innovative English surgeon who devised a number of cures and procedures and is considered the first English surgeon.

He grew up in Newark-on-Trent, which in his lifetime was a fairly large town. It is believed he attended the University of Montpellier; if so, then he may have been exposed to the Practica Chirurgia of Roger Frugard. He was in London in 1370, and was active in the Hundred Years' War in the regiment of Henry Grosmont, Duke of Lancaster, and John of Gaunt (King Edward III's son and Henry's son-in-law). (Incidentally, this would put him in the orbit of a young Geoffrey Chaucer.) He remained an employee of Gaunt.

War creates injuries, and this is where surgeons are most needed and are given opportunities to come up with new ideas for treating people. Long stretches bouncing on horseback can be damaging and lead to an issue now called a pilonidal cyst, but described by Arderne as a fistula in ano ("fistula in anus"). A fistula is a connection between two parts of the body that don't normally connect. You can learn more about this and Arderne's painful-but-successful treatment in this post.

But perhaps not so painful. Arderne knew of the soporific and nerve-deadening effects of opium, and prescribed it so that the patient "shal sleep so that he shal feel no cutting." To the opium he would add hemlock and henbane. He would apply this topically via an enema, and also use it on arrow wounds to deaden the pain while they were extracted.

His innovations were not just in what he was able to do for patients, but also in the profession itself. He believed, for instance, that wealthy patients should be charged what the market would bear, but poor patients should be treated for free. He also suggested ways to con duct oneself as a surgeon, and what to wear. The frontispiece for one of his manuscripts (shown above) shows him dressed in the robes of a university doctor, elevating the status above that of the more mundane "barber surgeon" who (because they possessed razors) were used to quickly treat war-related amputations, blood-letting, and (of course) hair-cutting. Because of the messiness involved, barber surgeons wore short robes. Arderne advised against this, urging his followers to distinguish themselves from the less-educated barbers.

More than 50 medieval manuscripts exist today with his texts, most with multiple illustrations as well. I'll share more of his guide for successful surgeons tomorrow.

A Pain in the Ass

(I apologize if the title—or the topic—is too crude for some.)

The poor fellow to the right (the one half showing) is suffering from an anal fistula, described thusly:

... a small channel that can develop between the end of the bowel and the skin near the anus.
... can cause bleeding and discharge when passing stools - and can be painful. ...
In some cases, an anal fistula causes persistent drainage. In other cases, where the outside of the channel opening closes, the result may be recurrent anal abscesses. The only cure for an anal fistula is surgery. [WebMD]

Nowadays it is called a "pilonidal cyst." At the very least, inconvenient; in many cases, extremely painful, especially when sitting down.

At a time when many men spent long stretches of time bouncing on horseback, these fistula-in-ano (to give it the Latin phrase) were debilitating. Fortunately, soldiers of Edward III's time had a solution in the skill of John of Gaunt's favorite physician and surgeon.

John Arderne (1307-1392) left us very little information about his early life. It seems he was a surgeon in Nottinghamshire. During the Hundred Years War, he probably traveled with the army; his writing suggests a well-traveled man with wide experience of the world as well as medical practices.

He produced the definitive work on treating this particular medical problem. His writing describes the cause and the treatment, and describes the surgical instruments needed for his procedures. He also shows knowledge of Galen & Guy de Chauliac, Avicenna, and Dioscorides.

Arderne was ahead of his time in some ways. He advised opium to dull pain during surgery, and the code of conduct proper for a physician. In the matter of fees, he was fine with charging a rich patient whatever the traffic would bear, but felt that the poor should be treated for free. He was also a great believer in cleanliness, and in not fussing with a wound once treated, but allowing the healing process to proceed untampered with.

That is not to say that he was "modern." He also subscribed to the belief that parts of the body were aligned with astrological signs, and that the time of the year could influence the efficacy of surgery on parts of the body.