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.

Roger Frugard's Chirurgia

Roger Frugard (pre-1140 - c.1195) was also known as Rogerius, and sometimes called Roger of Salerno because he taught and worked at the hospital there (but not to be confused with the Roger of Salerno who was a regent of Antioch during the Crusading period). We don't know much about his life, but c.1180 he produced Practica Chirurgia ("The Practice of Surgery") with a no-nonsense approach to the subject.

Rather than write long pre-ambles, quoting Hippocrates or Galen or other surgeons and doctors on which much of 12th-century surgical knowledge was based, he gives clear and brief explanations for how to treat different illnesses and injuries. His writing provided the first Western European practical manual for teaching surgery. It was duplicated and used in universities at Bologna and Montpelier. Besides describing surgical techniques, he also described how medicines were prepared and applied, and how to diagnose illnesses. He was the first to use the word "lupus" to describe a rash that appeared on the cheeks.

In the 13th century, an Anglo-Norman translation was made and illustrated (above you see the dispensary and a doctor instructing his students). Though written in French, it was likely written in England because English terms are used throughout the text. This manuscript is now in the Trinity College Library collection. One of the delights of the illustrations is the facial expressions given to the patients, indicating the level of (dis)comfort they are going through. Also, surgical instruments are drawn with admirable accuracy.

(There are errors, however, due to sloppy reading of the text. One illustration is supposed to depict a condition that causes a blackened tongue, but the illustrator painted the tongue red. In another section on nasal polyps, the copyist did an "eye skip" where, while looking from original to copy, his eye skipped to a later occurrence of a word he just wrote, omitting the section in between. These errors can be determined by comparison to other manuscripts, and show that the copyist was not paying close attention to textual comprehension.)

Medieval surgeons were always looking for new ways to treat injury:

For example, it is believed that Roger of Salerno may have originated a technique for detecting a tear in the dura or cerebral membrane in skull fractures. Now known as the Valsalva maneuver, the doctor would have his patient hold their breath, introducing pressure into the skull, and the doctor would watch for air bubbles or cerebrospinal fluid leaking from the skull. Additionally, Roger was a pioneer in the treatment of nerve damage, advocating reanastomosis – the realignment of damaged tissue by surgical means – to repair severed nerves. [source]

The illustration of the dispensary above is in the section about treating fistula. This brings us to one of the most painful and "icky" treatments, but also to one of my favorite figures in medieval medicine, John Arderne, whom I'll tell you about tomorrow. 

Medieval Surgical Procedures

Yesterday's post took a turn toward a particular surgical procedure, so I thought we'd talk a little more about that topic. What procedures were known and practiced with evidence of patient survival, back when doctors believed in the Four Humors of Hippocrates? I have talked about medicine numerous times, so here I want to focus on actual invasive practices with instruments.

Purging was one of the most common forms of surgery, piercing a vein to let out blood because a person's fever or angry nature indicated an excess of blood.

Amputation was another fairly common practice when a limb was so damaged by accident or warfare that there was no chance of it healing. Unfortunately, surviving an amputation was not always assured. An interesting article by the National Library of Medicine points out early art of people with crutches that supports their educated medical opinion that a leg amputation was only likely to survive if it were below the knee. Above the knee amputation led to too much bleeding. [link] Presumably amputations of smaller parts—toes, fingers, arms up to elbows—were less of a problem.

Related to amputation was cautery/cauterization, sealing off blood vessels by heating iron and pressing it to the wound. In an ideal situation, the wound was sealed, bleeding was stopped, infection did not occur, and the patient would survive. Even in this situation, however, the process caused intense pain, especially if you accepted the treatment for hemorrhoids that involved inserting a hot poker. This did not work, nor did the non-surgical suggestion of going to sit on the rock where St. Fiacre was cured of hemorrhoids. [link] (Maimonides finally wrote a seven-chapter treatise on the subject ultimately suggesting a good soak in a bath.)

Dental surgery was not unknown. Toothache was a major problem in the Middle Ages, and extractions were common. Situations arose, however, whose descriptions suggested the client had oral cancer. Roger Frugard (pre-1140 - c.1195), a surgeon in Salerno, wrote a Practica Chirurgia ("Practice of Surgery") in which he describes cancer in the jaw:

"if the flesh is hard, perforated and blackened' ('Si la char est dure, perse e anercie') cancer ('cancre') of the mouth was difficult to cure."

He describes cutting into the healthy flesh around the hard cancer, cauterizing the wound, and sealing it with muel de oef ("egg yolk"!).

Trepanning—boring a hole in the head to relieve pressure—is the oldest surgical procedure for which we find evidence: Skulls—many hundreds of them—that were trepanned have been found dating back 7000 years ago and more, with evidence of healed bone around the edges showing that the patient lived. The circumstances under which it was decided to drill a hole in the cranium are unknown.

Cataracts were originally dealt with by using a thick needle to push the cornea back. Islamic medicine came up with a better solution: a thin hypodermic needle inserted through the white part of the eye to extract the obstructing cataract material.

The illustration above is from a later manuscript copy in the Trinity College Library of Roger Frugard's Practica Chirugia that has many illustrations that help explain his techniques. Let's learn a little more about him and them tomorrow.