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Anatomy Acts, a major exhibition exploring the social, cultural and scientific significance of medicine in Scotland over the past 500 years, opens this month in Edinburgh. Our book choice highlights one of the exhibits being lent by Glasgow University Library. It is a heavily illustrated medieval manuscript consisting of several medical works by the renowned fourteenth century surgeon John of Arderne. |
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Born in 1307/08, John of Arderne practised as a surgeon in Nottinghamshire and London. He is traditionally said to have learnt his skills as a military surgeon during the 100 Years War, although there is no real evidence for this. It is perfectly possible, however, that he did travel abroad and his writings certainly indicate that he was man of wide experiences. His fame rests on a number of medical works that he produced towards the end of his life in the 1370s. Drawing on his practical experiences as a doctor, these vividly recount many case histories of patients that he had successfully treated. Although craft trained rather than University educated, Arderne was nonetheless very learned - he wrote in Latin, and had obviously read many of the scholastic authors closely, quoting extensively from authorities such as Galen, Guy of Chauliac, Avicenna, and Dioscorides.
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| Arderne's outstanding achievement was his work on the treatment of anal
fistula, one of the deadliest operations in medieval surgery. His great
advance at the time was to avoid the corrosive after-care treatment used by
other practitioners; a great believer in cleanliness, Arderne counselled
against meddling overly with wounds and dressings, thereby aiding the
healing process. His thorough knowledge of the medical uses of herbs and
plants is obvious, while it is also apparent that he was fully aware of the
effects of the mind on the body in sickness and health. But although pioneering in some ways, Arderne still believed in some of the rather unscientific medical practices of the Middle Ages. His methods are often obscured by his use of nonsensical names for ointments and plaisters, while many of his recipes for prescriptions are vague - appparently deliberate ploys to prevent his competitors from stealing his ideas. He was prepared to include folk charms and popular remedies in his texts, and believed in practising astrology in the diagnosis, treatment and prognostication of ailments, as was the norm. This link between astrology and medicine is typified in the 'zodiac man', a representation of celestial influence on the human body found in hundreds of medieval medical manuscripts. As shown in the illustration here, the zodiacal symbols are painted on the body in the appropriate places, from Aries for the head and face to Pisces for the feet. The signs demonstrate which parts of the body are influenced by which astrological sign, thus indicating the most auspicious times for performing operations. In this respect, Arderne's beliefs and practises were typical of the late medieval English doctor. The Twelfth and Thirteenth Centuries had seen great advances in medicine, the classical teachings of Hippocrates and Galen being given prominence with the growth of universities throughout Europe. But the practical folk medicine of Anglo-Saxon leeches, with their use of plants and willingness to intervene with surgery, was still very influential. |
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| Like many Arderne manuscripts, this book is an anthology of several of his works. Jones (2002) dates it on palaeographical evidence to the last quarter of the fifteenth century, and groups it with two other Arderne manuscripts, British Library Sloane MS 56 and Cambridge, Emmanuel College MS 69: these three all share familial traits in content and layout, although they were not written by the same scribe or decorated by the same artist. |
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| Contained within the book is a copy of the Practica, the text for which Arderne is most well known, commonly referred to as the Practica of fistula in ano. It is actually buried within another work, called by Power the Liber medicinarum sive receptorum liber medicinalium: it has not been established whether this somewhat miscellaneous work of general medicine is actually one text, or an amalgamation of shorter texts. As is the case here, these two (or more) works are often found together in manuscripts, although typically their contents and order vary as a result of the fluid nature of scribal manuscript transmission. To confuse matters still, this copy actually begins with another treatise, a short work on blood letting known by its incipit 'Hoc est speculum phlebotomiae', and often referred to as the Mirror of Phlebotomy. |
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In common with other Arderne manuscripts, this copy is copiously illustrated
with some 143 pictures, coloured in a combination of pen and wash. The
illustrations perform a practical function in showing examples of plants and
herbs to be used in making up curative recipes, qualifying technical points
made in the text, and demonstrating surgical techniques visually.
Not particularly artistic or interpretative, these images are closely co-ordinated with the text. It is thought that Arderne himself had an authorial role in devising the programme, and certainly the text explicitly refers to specific marginal illustrations. Vital in the transmission of the text and invaluable for conveying practical information, they were faithfully copied from manuscript to manuscript. The pictures also help the reader navigate around an often confusing and unstructured work, specific sections being found more easily when marked out by an illustration. According to Jones (2002), this navigational function helps to explain those illustrations that otherwise apparently have no clear correspondence with the text. One instance of this demonstrates Arderne's love of wordplay. A discussion of the symptoms of cancer of the rectum by a swelling known as a 'bubo' is accompanied by an image of an owl, the Latin for which is also 'bubo'. Once a reader was familiar with the text, he would know that he would find a description of this particular disease once he had located the owl. |
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Considering the rather chaotic nature of the textual transmission of
Arderne's works, it is not surprising that occasionally mistakes occurred in
copying the illustrations. There are a few instances where images of plants
and herbs were displaced and ended up being attached to the wrong part of
the text - a potentially dangerous situation which could have lead to the
wrong ingredient being used in making up a prescriptive cure. One
interesting example where two illustrations have been mixed up is described
by Jones (2002) and shown here. The text in this section is discussing the
properties of dragancia (arum dracunculae) and ivy (hedera); the
illustration depicts ivy twined around the distinctive stalk of the
dragancia, resulting in the creation of a hybrid plant. The Latin name for ivy ('Edera') is clearly marked out in the text to the right of the illustration, flagged up by being underlined in red and preceded by a red paraph mark. It is interesting to note that the English name 'yvy' is also cited in the text; it was Arderne's usual policy to provide both names, using the abbreviation 'i' (short for 'id est' (i.e.) or 'that is') between them. |
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| Arderne's style of Latin is rather colloquial; indeed, his texts may almost be described as polyglot as his use of Latin is somewhat inconsistent. As well as providing glosses in English and Anglo Norman, the text occasionally lapses in to sections written in English for no apparent reason. Although it is impossible to say whether this was how Arderne himself originally composed his work, or whether such anomalies crept in as his texts were copied from manuscript to manuscript, it nevertheless demonstrates the multilingual nature of literate medieval English society. |
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The process of distilling Juniper oil is depicted to the right. This involves placing two earthenware pots on top of one another. The lower pot is buried in the ground and small sticks of juniper are placed in the top pot; a fire is made around this top pot and oil is distilled via an iron pipe to the lower receptacle. The resulting oil is said to be good for aching, gout and 'parallesy'. The Practica of fistula in ano is generally acknowledged to be Arderne's most original work. Unlike the Liber, it is devoted to one branch of surgery, the treatment of anal fistula and related diseases of the colon and rectum. Fistula invariably require to be cut open to be cured, and Arderne's fame rested on his skill in performing this particularly lethal operation. Few other medieval surgeons dared to attempt it. The prevalence of this condition in the Middle Ages - usually said to be a problem of the knightly class - has often been attributed abscesses that developed into fistula as a result of long, wet and cold hours in the saddle weighed down with armour. In fact, Arderne's patients came from all strata of society, their problems having been more likely caused by such mundane factors as constipation resulting from a bad diet or complications arising from haemorrhoids. The text draws heavily upon Arderne's personal observations. Always the self publicist, he begins with a long list of successfully treated patients, relating that his first case was that of Lord Adam of Everingham. He tells us that while on campaign in France, Lord Adam consulted many surgeons unsuccessfully, but having returned home expecting to die, Arderne cured him and he lived for some thirty years more. |
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There then follows an interesting section in which the qualities of a successful surgeon are discussed. These include modesty, gravity, sobriety, and courtesy. Arderne also counsels against eagerness in taking cases on, suggesting that patients should always be seen before treatment is offered - at which point, a clear understanding of the fees involved must also be established. The dishonest habit of operating only for the sake of a fee is warned against. Doctors are also advised to learn a good stock of merry tales as they should be able to make their patients laugh. The signs and symptoms of anal abscesses and fistula are then described, along with prescriptions for soothing ointments. Determining the most auspicious days for operating is explained, it being forbidden to make incisions when the moon is in Scorpio, Libra or Sagittarius. Finally, patient counselling is recommended: a surgeon should advise his subject to be brave, patient and obedient, with the encouragement that painful things will soon pass to be followed by glorious health. It is heartening to know that elsewhere in the treatise Arderne also gives several recipes for strong soporifics that can be employed before operations commence. The operation itself is described in graphic detail. It is a variant of a technique known from antiquity, described by Albucasis (d.1013). One of the features of surviving copies of the Fistula are the full page illustrations of the special instruments to be used and the different stages of the operation demonstrating how the instruments were to be deployed.
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The various stages of the operation are shown to the right, starting with the position Arderne recommended that a patient should be secured exposing the fistula (top right). The basic premise of the operation was to cleanly divide the fistula by means of a scalpel inserted along the snouted needle. |
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| Arderne's method of operation certainly worked, but it was probably his simple and clean application of sponge pressure to arrest immediate haemorrhage, followed by conservative care of the wound (avoiding cauterising and powerful purgatives) that ensured his relatively high success rate. |
| The work goes on to discuss various complicated cases that Arderne dealt with, including that of a man from Northampton. Apparently he suffered from three fistula holes in his left buttock and three in his testicle. Arderne says he cured these by cutting through all the holes in the same operation. Since the fistula were deep, the poor man lost so much blood that he swooned; Arderne managed to stem the haemorrhaging with a sponge and made his patient sit in a chair until the blood flow ceased. After taking meat and drink, the man went to bed, slept soundly, and was healed within 14 weeks. In another case, Arderne claims that his patient made such a dramatic recovery that he was able ride some forty days after his operation. |
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A miscellaneous collection of case histories is found at the end of the manuscript. Again, these describe the symptoms and treatment of individual patients in vivid detail. It was intended that this sequence should be accompanied by portraits of each patient. In our copy, however, the work has not been completed: instead, there are fourteen blank spaces where the portraits were supposed to have been inserted. |
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This book is from the collection of the eighteenth century physician
William Hunter. An effaced
inscription on folio 4r records that it belonged to Richard Nix,
Bishop of Norwich (1501-1532) who also owned another Arderne manuscript
now in the Hunterian collection (MS Hunter 112). Both these manuscripts
later belonged to Dr. Richard Mead; Hunter bought many books at the sale
of Mead's library in 1754. |
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Of related interest: The following were useful in compiling this article: |
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Return to main Special Collections
Exhibition Page Julie Gardham May 2006
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