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.

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.

About Preventing Children

Folk in Classical and Medieval times developed many methods for avoiding getting pregnant, but sometimes the inevitable happened. The Bible's statement to "be fruitful and multiply" made the Church's stance on aborting a pregnancy clear, but the rest of the culture did not always see it that way.

Avicenna (c.980 - 1037) offered this reasoning:

At times it may be necessary to induce abortion; that is, when the pregnant woman is young and small and it is feared that childbirth would cause her death, or when she suffers from a disease of the uterus or when a fleshy growth in the uterus makes it very difficult for the fetus to emerge. Also when the fetus dies in the womb of the woman. Know that when labour continues for four days it means that the fetus is already dead.

Methods of abortion could be dangerous to the women as well. Hippocrates had refused to use abortifacients because of the danger they posed to the mother. The early Church stated that women who abort a child should be exiled from the church. A synod in 314 modified that to 10 years of exile. The Church Father Basil the Great later softened that, saying it should be less if the woman shows repentance.

In another case, a woman was sentenced to death for aborting her child precisely because she did it with malicious intent to prevent her husband (whom she had come to hate) from having an heir. Roman law allowed that, if a woman were to do the same thing for the same reason but it post-divorce, then she should only be exiled.

The Church Father St. John Chrysostom criticized abortions, but gave the example of a sex worker who needed to abort a pregnancy or else she would lose her livelihood. He goes so far as to blame her male client, who was responsible for getting her pregnant, as the real murderer.

A 9th century Byzantine author of a biography of a Greek Patriarch Ignatios tells the story of a woman with a breech birth who is in intense pain. The doctors prepare for an embryotomy (removing the baby by cutting it into parts and removing them). The 6th-century Bishop Paul of Mérida, who trained as a doctor in his youth, doesn't scruple to perform an embryotomy to save a woman's life.

That late-term abortions can find their way into accounts of religious lives and can be justified by Christian saints suggests a very different attitude toward the health and safety of the mother than is sometimes taken these days.

Embrotomies would have been difficult for the surgeon and the patient. Let's talk next about some of the other surgical practices that were employed in the Middle Ages. 

Medieval Germ Theory?

It was Ignaz Semmelweis in the 1840s in Vienna who noticed a link between illness (and death) and unsanitary conditions, specifically a link between women dying during childbirth who were aided by people who also were performing autopsies. He spent years trying to implement a universal handwashing policy. He did not know what was causing the deaths, but he saw a link to something.

Figuring out the cause of disease was a goal for anyone practicing medicine from the beginning of the discipline. Long before germ theory was developed, the miasma theory was proposed by Hippocrates (c. 460 – c. 370 BC): that some form of "bad air" or even "bad water" arising from rotting matter caused diseases like the Black Death, cholera, and other infections. This was an important move away from the theory of supernatural causes of illness. (There was also the idea of an imbalance in the body's natural humors.) The miasma theory allowed infection to pass through a population because of the environment, not from personal contact.

To counter bad air, you would naturally want "good air."  medical faculty of the University of Paris, writing in 1348 to explain the causes of the Black Death, said "The present epidemic or pest comes directly from air corrupted in its substance" and recommends incense which "hampers putrefaction of the air, and removes the stench of the air and the corruption [caused by] the stench."

Earlier, however, there were counters to the miasma theory.

The Classical Era and Middle Ages did have theories of person-to-person contact. Thucydides (c.460BCE - c.400CE) believed that the plague of Athens was being spread by personal contact. Galen (129 - c.200CE) referred to "seeds of plague" in the air. Isidore of Seville also mentioned "plague-bearing seeds." Avicenna (c.980-1037) was widely studied, and he linked the miasma theory with personal contact, believing an ill person could infect others by transmitting the "bad air" through breathing. His example was tuberculosis, and he believed that disease could also be transmitted through dirt and water, anticipating Semmelweis by 800 years.

Recent posts have mentioned Bologna as an important center for medical study, so it is not surprising that it was a professor of Bologna, Tommaso del Garbo (c. 1305–1370), who in 1345 promoted Galen's "seeds of plague" idea in his works

It took Girolamo Fracastoro in 1546, however, to publish De Contagione et Contagiosis Morbis ("On Contagion and Contagious Diseases"), three volumes on different diseases and their avoidance and treatment. He believed that there were particles that could travel through the air or by direct contact.

The idea that these "seeds of disease" were living things (what we call "germs") and traveling from one person to another was not being entertained, simply because there was a long-standing theory that living matter could arise spontaneously from putrefaction, and no one believed in invisible living things floating in the air. The belief that life could spring from rotting organic matter hindered understanding of bacteria already existing in the air around us. As it turns out, there were plenty of examples of Spontaneous Generation; let's talk about those tomorrow.

Theodoric Borgognoni

Speaking of surgery recently, we need to take a look at Theodoric Borgognoni, who pioneered some practices that were ahead of their time. Born in Lucca in 1205 to a physician and teacher, Hugo Borgognoni, he was destined for a medical career. He studied medicine at the University of Bologna. He also became a Dominican, then the personal physician to Pope Innocent IV, was made Bishop of Bitonto, and eventually became Bishop of Cervia.

Although he had ecclesiastical duties, he still practiced medicine and taught. One of his students was later the "father of French surgery," Henri de Mondeville. Borgognoni wrote the Chirurgia ("Surgery") in the mid-13th century, four volumes that cover what was known about surgery at the time, with his own additions. (A copy of the work created c.1300 on vellum was auctioned at Christie's a few years ago; a sample page is illustrated above.)

In the Chirurgia, he advocates many interesting techniques. Broken bones were a serious problem, and Borgognoni explained how to re-align the bones and tie them together with gold or silver wire. He also advocated post-operative massage of the area to aid proper healing.

Much of Chirurgia is similar to a work written 15 years earlier by Bruno da Longoburgo, but since both of them were students of Hugo Borgognoni, that can be expected. Borgognoni the younger, however, has plenty of ideas not found in the other work.

He departed from standard medical beliefs about pus. For centuries, pus bonum et laudabile ("good and laudable pus") in a wound was considered a sign of proper healing. There was some sense to this, because severe infection led to necrotizing tissue, which and looked very different was much worse. Pus was a different symptom, and looked to early doctors much better than the other option. Wounds that showed pus, therefore, would be left open to suppurate to support the healing process.

Borgognoni did not believe that pus in the wound was proper: he advocated cleaning and drying the wound, then suturing it:

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

He also (which was not a unique idea) used wine to treat a wound. Now we know, of course, that alcohol in wine would help to kill harmful bacteria. Of course, wine for treating wounds did not automatically lead to the idea that a substance in wine was "killing" something in the wound. Wine was a good thing, and its goodness had healing properties—that was the thinking. It would take centuries to develop germ theory. There were, however, small steps in that direction, and I'll explain those tomorrow.

Medicine Men

In the middle of the 14th century, the centers of medical knowledge were the universities at Bologna, Montpellier, and Paris. One of the professors linked to Bologna who trained several future doctors was Taddeo Alderotti.

Alderotti was born in Florence but moved to Bologna where he taught several men like Gentile da Cingoli, the emperor's doctor Bartolomeo da Varignana, and the anatomist Mondino de Luzzi.

Alderotti was a highly reputed doctor in his own right, and patients came from all over Italy to see him, making him a very wealthy man.

Another student at Bologna was Henri de Mondeville. Mondeville (c.1260 - 1320) was French, and studied at Montpellier and Paris before moving to Bologna to study under the prominent surgeon Theodoric Borgognoni, who had some new ideas about treating wounds. After studying under Borgognoni, he went back to the University of Montpellier as a professor of anatomy and surgery. He became royal surgeon to King Philip IV and his son King Louis X.

Mondeville wrote the first French surgical treatise, La Chirurgie ("Surgery"). Intending to write it in five sections, he only completed two from 1306, when he started, to his death in 1320. Some of his statements were opposed to current "wisdom," and it wasn't until centuries later that it was rediscovered in 1892 and Mondeville's ideas were justified.

What was so controversial? His approach to treating wounds, which he learned from Borgognoni. I'll explain the radical ideas of Theodore Borgognoni next time.

Mondino de Luzzi, Anatomist

Successful surgery benefits from knowledge of the body's interior, and the study of anatomy was not always easy to come by. Dissecting human bodies fell out of favor after the Classical Era. One Italian physician did extensive research in anatomy and restored the study of it. His name was Mondino de Luzzi, and he lived and worked in Bologna from c.1270 - 1326.

His father and grandfather were pharmacists, and his uncle taught medicine. Mondino himself taught medicine and surgery at the University of Bologna from 1306 to 1324. In 1316 he published an illustrated manual of details of the inside of the human body (sample to the left). The Anathomia corporis humani ("Anatomy of the human body") was the first of its kind.

He theorized a hierarchy of body parts based on what he considered most important. The abdomen was the "least noble" part of the body, and so should be dissected first. The thorax came next, and last was the head with its "higher and better organized" structures (the organs of the senses: eyes, ears, mouth). He also discussed different methods of dissection between simple versus complex structures, like muscles and arteries versus eyes. When dissecting muscles, he suggested letting the cadaver desiccate, rather than mess with a decaying cadaver. The Anathomia was a manual to explain Mondino's proper methods for dissection.

That doesn't mean he was right about everything. He claims the liver has five lobes, the stomach is round and its internal lining is where sensation happens and the external layer is where digestion takes place. He apparently never found an appendix in a cavern, even though he examined many intestines. He says the heart has three chambers, not four. Still, the text became a standard in medical knowledge for 300 years.

Mondino wasn't much interested in pathology of disease, which is just as important to medicine as understanding how the physical; body works, if not more so. Fortunately, there were others—contemporaries of Mondino's, in fact—of whom we shall speak...tomorrow.

Surgery in the Middle Ages

The Middle Ages saw illness as an imbalance in the humors of the body. Sometimes that could be treated by changing the diet. In the case of some illnesses, it might be determined that the body had too much of the "hot, wet" humor, blood, for which the treatment was to drain some of it.

Blood-letting was the simplest surgical procedure, but medieval surgeons were eager to accomplish more. Part of the history of surgery in Western Europe was tied to the needs of warfare. Consider John Bradmore's efforts to remove an arrow from Henry V. Another surgeon connected to royalty was John Arderne, the expert on a very particular and painful physical problem that he treated with surgery.

Monasteries and other religious organizations were more educated than the general population, and their access to books meant knowing more about medicine. There was one branch of medicine they avoided, however, even though the Egyptian and Greeks practiced it: dissection and surgery. The church was squeamish about surgery because it shed blood (and could lead to infection and death). The Fourth Lateran Council of 1215 prohibited clerics from surgery or any practice that shed blood. Dissection of corpses was also frowned on.

Lay people, however, continued to expand knowledge of anatomy. The Italian Cronica of Salimbene di Adam (1221 - c.1290) tells the story of an epidemic that was killing men and chickens. A physician of Cremona discovered through dissection that the chickens had abcesses in their hearts. The corpse of a human victim was dissected; the same abcesses were found. The physician put out a pamphlet warning people against eating chicken or eggs, assuming that they were causing the spread of the disease.

Italy was where great strides in anatomy and surgery took place. The Anatomical Theatre of Padua, begun in 1595, was the first permanent anatomical theater in the world, where students watched their teachers dissect bodies to learn human anatomy. Anatomical dissection in Italy had begun long before that, however. For that story, we have to look at Italian physician Mondino de Luzzi (c.1270 - 1326), and the Anathomia corporis humani of 1316. We'll look into him next time.