JOHN ARDERNE, SURGEON OF EARLY

By ALFRED BROWN, M.D.

OMAHA

T has been stated often and truly that through his religious zeal made an error man is moulded principally by two which was to cost him much of his domina- factors, heredity and environment. tion. The pilgrims, in their journey across Which of these plays the greater role is Europe and the Mediterranean to the Holy still, and probably always will be, a matter Land had been mistreated by the Moslem Ifor argument. In whatever way one until finally these men, searching for con- decides the question, of one thing there secration at Christ’s Sepulchre, began to can be no doubt that in order to evaluate travel in bands under arms. This was taken properly the accomplishments of any man as an opportunity by the cleric to foster an and place him, as best we may in his offensive spirit on the part of Chivalry. fitting niche in history, these two elements, Chivalry had already taught the laity that when possible, should be taken into con- it was proper to defend by force what was sideration. In the case of the first of these, right but as time went on, the idea urged heredity, the feat is at times difficult of by the monk grew, to take the offensive accomplishment, especially when the study and capture from the Moslem the Sepulchre is of a man of the middle ages such as John of Christ and restore it to its proper guard- Arderne who lived during the major part of ian the Christian Church. So this Pilgrim’s the fourteenth century. Of his heredity and Progress turned into a Holy War and the immediate family we know nothing. So knight in his glittering armour came to we must confine ourselves to the study of take his stand beside the monk, both intent his environment and here the problem is on a common purpose. In the attempted different for of this we do know something carrying out of this purpose during the and can partially at least reconstruct it by crusades however the people did not know a review of the general conditions of the whether to follow the monk or the knight, time in which he lived. for the close contact of the warrior and his In the case of John Arderne this study followers with the culture and knowledge carries us back to one of the most interesting of the Saracen resulted in the building of a times in the world’s history, the latter part new Europe through the influx of new ideas. of the medieval period when that flickering While the crusades were in the making, spark of the waning science and art of the Constantine, the African, had come to early Greeks, kept alive by the Arabians and then to Monte and through many centuries, was breaking into had translated the works of the early a feeble flame, fanned by the efforts of Greeks, and late Arabians, into Latin and such as Arderne, and destined later to thus taught the continental Europeans the blaze anew and again furnish light for an then advanced surgery. In part through era of progress ushered in by the Renais- his efforts and in part because Salerno sance and continued to the present day. It became the great military hospital for carries us back to the time when two figures, the crusaders the teaching and practice the monk and the knight, held the center of surgery and medicine took firm root in of the stage of the world. The monk, theo- Southern Europe. From there it spread, in retically having little or no interest in part directly and in part through the mundane affairs but practically their guid- Western Caliphate situated in Toledo and ing hand, had, in the eleventh century Cordova, until it reached Paris and Mont- pellier where the great schools were founded, ville had given to surgery at Montpellier and finally surgery reached Oxford, it is possible that this had held over to the England. time of John. Such would have had to be With this revival of medical and surgical the case for de Mondeville died when learning on the continent a veritable suc- Arderne was but eight years of age. As was cession of famous surgeons began. Con- commonly the case with many men of his stantine, the African, was followed at period he did not spend his entire profes- Salerno by Roger, Roland, and the Four sional life in one place. Though generally Masters. Arnold of Villanova and Henri known as John Arderne of Ncwarkc he did de Mondeville worked and taught at Mont- not settle there until he was forty-two years pellier. In opposition to the Paris Faculty old. In 1346 he served as Sergeant Surgeon where clerics only could teach, Jean Pitard in the army of Edward in which fought the founded the College de St. Come to which French at Crecy. After his return he Lanfrancus of Milan came in 1295 and practiced in Wiltshire and was there when after becoming a member began to teach the Black Death swept England in 1348. surgery by lectures and demonstrations. The following year found him moving to Finally in the early part of the fourteenth Newarke where he remained until 1370. century the father of modern surgery arose, There he gained a great reputation as a the great Frenchman, Guy de Chauliac. Surgeon and built up a large practice. In So the stage was set and the pathway spite of this he moved again, this time to made for an Englishman to carry the London, where so far as is known, he surgery of the continent to England and remained until his death, the exact date ol there carve for himself a niche in the Hall of which is uncertain. Fame. and John of As one reads the surgery of these years ol Gaddesden had practiced in England and the Middle Ages the constant repetition the latter had become the Professor of of the stone, fistula and hemorrhoids gradu- Medicine at Oxford but there was little new ally forces on the consciousness the great or original in their surgical work. John prevalence of these diseases. Stone in the Arderne grasped the opportunity and bladder, if the diagnosis was not confused became the first great English surgeon. with that of enlarged prostate, was much Born in England in 1307, and practicing more common in those days than it is now. in England most of his life he has left little It offered a good field for a young and autobiographical data. He does not tell us ambitious surgeon save for the fact that where he received his preliminary education its treatment was mostly in the hands of and later studied medicine. That he received the itinerant and ignorant barber surgeons. a fairly good education is self evident for But the treatment of the diseases of the anal he wrote his work in passable Latin, and canal held no such stigma and this young that he studied medicine and received as surgeon, with both preparatory and surgical much instruction as the times could give training and in addition the knowledge of appears reasonable for he describes himself wound treatment he had acquired during his as “Chirurgicus inter Medicos,” Surgeon experience as a war surgeon, evidently among Medical men. Can this mean other decided to devote himself largely, though than that he was educated as a physician not exclusively, to the specialty of fistulae, and attained all the eminence and self not only of that in ano, but also to fistulae constituted authority that the physician in any part of the body. It is, however, as of those days assumed and then took up and the originator of the operation for fistula practiced surgery? Baas1 says that he “had in ano that he is best known. probably studied at Montpellier” and con- Arderne’s original works arc in manu- sidering the impetus that Henri de Monde- script. Certain of them however, have been translated and printed. In 1883 Gore2 1645.” ^^0 manuscript consists of 440 pages described a manuscript entitled “The Works with numerous illustrations. Preceding this, of Master John Arderne, Chirurgeon, of Arderne’s work on fistula had appeared in

Ncwarke, in Nottinghamshire, written by the works of Franciscus Arcaeus translated his own hand, in the year of our Lord 1349, by John Read3 in 1588. The latter part of with some Observations collected in blank the title reads “With a treatise on the paper by Walter Hammond, Chirurgeon, Fistulac in the fundament, and other places of the body, translated out of Johannes In this last connection after having told Ardern etc. London 1588.” A still more of a large number of persons that he had recent translation of Arderne’s manu- cured of the fistula John says “Neverthc- scripts is that by Sir D’Arcy Power4 pub- lished in 1922, as the first of the Wellcome Historical Medical Museum Research Studies in Medical History. This manu- script which is entitled “The practice of Master John Arderne of Newarkc in the art of Medicine and Surgery, 1412,” was written after his death but gives consider- able of his work concerning fistula and also gives much of the absurdities of his medical ideas for, though advanced in Surgery, Arderne, bound by the traditions and super- stitions of his time, used the then prevalent ridiculous medical treatment for internal disease. It is interesting to note that Arderne’s manuscripts are illustrated. This was an innovation in surgery. Anatomy had been illustrated as had also obstetrics and some illustrations of instruments had appeared in the manuscripts of the Arabians but here we find a man who was illustrating the lesion itself and endeavoring to convey to the reader his ideas of living pathology by means of visual impressions, a method which has gradually developed until today it is the foundation rock upon which all pedagogic ideas in medicine rest. Sec the lesion and then file it away in the visual memory. If he had done nothing more John Arderne would deserve a high place in medical history for this service alone. lesse 1 affermc not that 1 mist hole al Being one of the few well educated men fistulae in ano for some ben incurable as it to enter the domain of surgery and knowing shal be said within when I shal trete of the low type of the usual surgeon of the tham.” His operation for fistula consisted in short robe of the day, John was naturally first passing a metal sound through the anxious to put his standards before his fistula until the internal orifice was found, audience so he writes: this instrument was called “Sequere me” (Follow me). The structures between the A description of ye qualities and conditions tract and the bowel were divided either by which ought to be in ye surgeon that performeth this or any other operations in Chirurgery: passing a thread through the fistula and First, that he be devout. Secondlie, charitable out of the anus and tightening it until to ye poor. Thirdly, to use few words. Fourthly, it cut through or by incision with a to avoid drunkenness. Fifthly, to be chaste both knife. In either event the entire tract was to in words and gesture as well as to fear ye not. be laid open. This, in its ultimate aim, is Sixthly, not to undertake an incurable disease. practically the modern operation. In addi- tion to the “Sequere me” John used the it, appeared at the end of the wound and “Acus rostrata,” “a snouted nedle,” a became more and more moveable. And when I wooden “Tendicula,” a thread called the saw this I put the point of a scalpel under the “frenum cesaris,” and a “syringa” which he edge of the bone and raised it little by little. describes as “an holow instrument by the But that piece of bone was four thumbs in midcz, and it ow to be made of the shappc length and two thumbs in breadth and in thickness it extended nearly to the marrow of the bone and it was in front of the tibial bone i.e. schyn bone. After the separation of the bone I finally closed the wound with a Iycium dressing of honey &c. and the yolk of raw eggs.

The work of John Arderne as exemplified in the Stockholm manuscript seems to me to be connected with one of the most famous books in English literature; the book of which the great physician of our generation Sir William Osler thought so much, the “Religio Medici.” As the title shows, the book deals with the religion of a physician. It first appeared in 1642 but in as it is peynted here nouther greter ne this edition there was no hint given as to longer but even fater the shappe as it is the identity of the author, only the name peynted here, ne have it no 3 + but oon of the publisher, Andrew Crooke, was men- hole in the nether ende or smaller endc tioned, and he took no responsibility for the as it is peynted here.” This is evidently for opinions expressed in the text. Immediately irrigation of the wound. the book attained a great popularity and John Arderne recognized also ischio- the first edition was sold out so rapidly that rectal abscess and its etiological relation to a second edition was required the same fistula in ano. He advised that they be year (1642). This second edition also lacked treated by plasters and then laid open and the name of the author and it was not until dressed. His treatment of fistulae in other the following year (1643), when the book was parts of the body was also incision and again published that Thomas Browne dressing. His treatment of wounds con- acknowledged the work as his. In Browne’s sisted of ointments and various medica- introduction to the third edition he says tions but it is interesting to note that a that he had shown and loaned the original good deal of washing with hot and cold manuscript to some friends and that they water was also done.4 I quote one case: had surreptitiously had it published in an An injury to the leg which I cured in a noble- imperfect state and that he in the edition of man when he had suffered from it for eighteen 1643 was publishing it correctly for the years. I first removed the flesh down to the bone first time. The book therefore is distin- with an ointment of roses and I scraped it guished as having both a first and second every day. And one day when I was scraping surreptitious edition and a first authorized the bare bone with an instrument it moved edition. Whether the two editions of 1642 upwards and downwards. I watched this remarkable node but for the rest I gave up any were really printed without Browne’s knowl- further operation and put nothing over the edge has been questioned by good authority. wound except Iycium mingled with new honey One of the most striking points about and the yolk of a raw egg applied on carded linen the book is its title page which appeared in stupes and I did this from day to day until the first five editions, including in this the aforesaid bone with the flesh receding from number the two surreptitious publications. This represents a figure falling head down cases of cramp by many who have used it both from a high rock; a hand reaches out from in foreign countries and at home. Take a sheet the clouds and grasps the wrist of the of parchment and write on it the first sign 0 falling figure. From the mouth of the Thebal 0 Suthe 0 Gnthenay 0. In the name figure come the words a coelo salus, from of the Father 0 and of the Son 0 and of the Heaven, deliverance. The plate was en- Holy Ghost 0 Amen 0. Jesus of Nazareth 0 Mary 0 John 0 Micheal 0 Gabriel 0 Raphael graved by one Will Marshall and appeared 0 The Word was made Flesh 0. The sheet is as the title page of both the first and second afterward closed like a letter so that it cannot be unauthorized editions which were published readily opened. And he who carries that charm by Andrew Crooke but when Sir Thomas upon him in good faith and in the name of the Browne published the authorized edition Omnipotent God and firmly believes in it will the next year the title page, with a few without doubt never be troubled with the changes, was retained, and Crooke remained cramp. the publisher. Of this title page Geoflry Keynes5 says, “The source of the design Power adds a footnote to amplify the is not known, but it presumably arose from subject; he writes: Marshall’s fancy. Clearly it met with The section on the treatment of cramps by a Browne’s approval for it was used in all the charm is much abridged. The writer has editions, except one, that were published omitted the fact that Arderne obtained it “from during his life time.” The idea that the a certain knight, the son of Lord Reginald de title page was a figment of an engraver’s Grey de Schirloud near Chesterfield, who was fancy, though a bit far fetched, might at Milan with the Lord Lionel, at the time when hold, provided no better reason could be the Lord Lionel, son of the King of England, found. The figure represents man falling— married the daughter of the Lord of Milan. The English there were troubled with spasms due here physically but by inference morally, to their potations of the strong and hot wines of while Heaven or God, in the shape of a the country and of too many carouses. The hand, religion, is affording him safety. The knight had with him the following charm and story of the book, The Religion of a Physi- saw a certain gentleman so troubled with the cian, is told in the title page. spasm that his head was drawn backward When we turn to the Stockholm manu- nearly to his neck, just like a crossbow, and he script of John Arderne’s work written in was almost dead from pain and starvation. And 1412; in the right hand column of the when the said knight saw this he brought the fourth plate of the Power reproduction the charm written on parchment and placed it in a second figure from the top illustrates a purse and put it on the neck of the patient figure falling which very closely resembles whilst those who stood by said the Lord’s Prayer, the figure of the title page of the “Religio and one to our Lady Mary, and as he swore Medici.” It is undraped and the legs are faithfully to me, within four hours or five he was restored to health.” transposed but the characteristic dorsi- flexion of the head appears in both and the Here is the element of heavenly interces- facial expression is very similar. It is the sion for the saving of the figure. The addition first illustration of opisthotonus in medical of the rock, the sea, and the heavenly hand literature. But the similarity of the two readily suggest themselves. figures means very little unless there is If this hypothesis be accepted it seems something further that will apply to the rather unlikely that an engraver would be comparison. The words of John Arderne acquainted with the work of John Arderne. which accompany his figure seem to supply That Browne would know his work is not this lack. He says: at all unlikely as he was considered to be one Against spasm i.e. cramp. The following of the best read men in medicine of the charm has been found most satisfactory in early seventeenth century, and this makes it appear very likely that Browne himself more than five centuries, we can visualize suggested the subject of the title page. If standing with the poets Geoffrey Chaucer this be so it follows that Browne knew of and John Gower, the figure of this surgeon the first and second unauthorized editions of Early England, John Arderne, who did and in fact consented to their publication. great things for his science. He was the first Wilkin6 calls attention to the fact that to teach surgery by illustration of the living Dr. Samuel Johnson7 in his life of Browne pathology as he saw it. He was the first suspects him “of having contrived the educated operating surgeon in England and anonymous publication of the work in devised an operation for fistula in ano, the order to try its success with the public.” principles of which hold good today, and Keynes rejects this by saying “but our he may have furnished the inspiration for knowledge of Browne’s character is suffi- the title page of one of the most famous cient disproof of his having been guilty of books in medical literature, the “Religio any such sharp practice.” But would it have Medici.” been sharp practice? It was commonly done in those days. Not only to try out the Refer ences success of a book with the public but also 1. Baas , J. H. Outlines of the History of Medicine to ascertain the feelings of royalty and its and the Medical Profession. Tr. by H. E. reaction to the publication. Royal dis- Handerson. J. H. Vail & Co., N. Y., 1889. pleasure when aroused showed itself in no 2. Gore , A. A. Maister John Arderne. Some account uncertain ways and religion was a ticklish of an old Ms. presented to the Royal College of Surgeons in Ireland by Sir John Lentaignc, subject to write about. As it was, the c .b . Dub. J. M. S., 1883, lxxv i, 269-297. appearance of the work raised a storm of 3. Rea d , J. Franciscus Arcaeus, A most excellent criticism but this blew over and the follow- and compendious method of curing woundes ing year Browne published the work under in the head, and in other partes of the body . . . his own name, of course disowning the and translated into English by John Read, previous editions, but he kept the title Chirurgion. Whereunto is added the exact cure of the Caruncle, neuer before set foorth in the page and employed the same publisher who English toung. With a treatise of the Fistulae in had printed the previous editions though the fundament, and other places of the body, he describes this book as “A true and full translated out of Johannes Ardern etc. Lond., coppy of that which was most imperfectly 1588, iv, 119. and Surreptitiously printed before under 4. Powe r , Sir D’A. D’ Arte Phisicale et de Cirurgia the name of: Religio Medici.” A further of Master John Arderne, Surgeon of Newark, dated 1412. Translated by Sir D’Arcy Power, fact which would make one think that k .b .e ., M.B., Oxon., f .r .c .s ., from a transcript Browne knew of the previous editions is made by Eric Millar, m.a . Oxon., from the that in the 1643 edition he prints “A letter replica of the Stockholm manuscript in the sent upon the Information of Animadver- Wellcome Historical Medical Museum. With sions to come forth, upon the imperfect and coloured Frontispiece and 13 plates. New York, William Wood & Co., 1922. surreptitious Copy of Religio Medici; whilst 5. Keynes , G. A Bibliography of Sir Thomas this true one was going to the Presse, Browne, Kt., m.d . Cambridge, University signed Your Servant, T. B. Norwich, Press, 1924. March 3, 1642.” This statement would make 6. Sir Thomas Browne’s Works including his life and it appear that Crooke had charge of the correspondence edited by Simon Wilkin f .l .s . true manuscript and was arranging for the Wm. Pickering, Josiah Fletcher, Lond., iv, 1836. printing of it and at the same time was 7. Brow ne , Sir T. Christian Morals. With a life of getting out the surreptitious editions, for the author, by Samuel Johnson; and explana- Browne’s letter is dated in March 1642. tory notes. Ed. 2, Lond., Richard Hett, 1756. When we look back over a period of Quoted from reprint.