Treatises of fistula in ano : haemorrhoids, and clysters / by John Arderne

FOREWORDS

THE history of mediæval medicine, says Prof. E. Nicaise, ["La grande chirurgie de Guy de Chauliac." Paris, 1890, pp. x-xv.] has been divided into four great epochs. The first, lasting from the fifth to the eleventh century, was remarkable for the Arabian school of medicine. The second period embraced the eleventh and twelfth centuries, and witnessed the rise of the schola Salernitana: it was the time of the Crusades and of that intermingling of the East and West from which sprang the marvellous work of the twelfth and thirteenth centuries. The work of the third period was all too short, and was brought to a sudden close by the Black Death which ravaged the world in 1348-9. It is properly described as the beginning of the modern era, the pre-Renaissance. A mere list of the Universities established will give some idea of the intellectual activity of the time. Montpellier (1137); Paris (1176); Oxford (1200); Cambridge (1209); Padua (1222); Naples (1224); Salamanca (1230); Toulouse (1230); Orléans (1231); Valladolid (1250); Seville (1254); Coimbra-Lisbon (1290); Lerida (1300); Avignon (1303); Rome (1303); Grenoble (1332); Angers (1337); Pisa (1343); Prague (1347); Florence (1349); Perpignan (1349); Huesca (1359); Cracovia (1364); Pavia (1365); Orange (1365); Vienna (1365); Erfurt (1379); Heidelberg (1385); Cologne (1388); Buda (1389). [The dates appended to the Universities are merely intended to show when each was known to be actually in existence—a few were created, the majority developed from small beginnings.] The fourth period was retrograde. Wars abroad and economic troubles at home seemed to have crushed the spirit of the few survivors from the previous generation.

John Arderne belongs to the thirteenth century in spirit and in thought, although the accident of birth placed him in the next generation. He was well educated, and he reflects the current ideas of his time just as every well-educated surgeon at the present day is an epitome of his surroundings. Nothing is known of his history except for the autobiographical details given in the various manuscripts of his works and a small body of floating tradition which has been handed down through the centuries.

BIOGRAPHICAL FACTS.

There seems to be little doubt that he was a member of the family of Arderne, or Arden, who claimed descent from Saxon times. The best known representative of the family was Turchill or Turketil, styled de Warwic in Domesday, and De Eardene in the Register of Abingdon Abbey, "being one of the first here in England that, in imitation of the Normans, assumed a surname. [Dugdale, 675.] The Ardernes were Lords of Watford in Northamptonshire from 1140, and spread thence to Cheshire and Staffordshire. In the Aldford, Cheshire, branch the name of John was borne hereditarily by John de Arderne (fl. 1220); Sir John de Arderne (1266-1308?); Sir John de Arderne (1307-1349); and John de Arderne (fl. 1332). ["Parentalia," Genealogical Memoirs, compiled by George Ormerod, D.C.L. F.R.S., privately printed 1851.] It was possibly the lastnamed John Arderne [Perhaps it was this John Arderne who is mentioned in Rymer's "Fœdera" (vol. ii, part 2, p. 119, col. 2). He was commanded to attend the King in war to Guienne in the year 1324.] who received a grant of land in Connaught from Edward the Black Prince (Appendix, p. 105), and who is mentioned in John of Gaunt's Register [I, 337, leaf 64, back. I am indebted to the kindness of Mr. Sydney Armitage-Smith for this reference.] as having been appointed Seneschal of the manor of Passenham in Northamptonshire on October 7th, 1374. The name of John Arderne, or John de Arderne, therefore, was well known in London, [In London John Arderne was a Fishmonger in 1361, and Richard Arderne was a prominent Skinner in 1376. John Arderne, esquire, was living in the parish of St. Mary Aldermariachurch in 1425. (Dr. Reginald Sharpe's "Calendar of Wills—Court of Husting." London, part 2, pp. 63 and 439.)] in the midlands and in the counties of Cheshire and Lancaster during the fourteenth century, but there is no evidence forthcoming at present to show to which branch of the family the surgeon belonged.

The date of Arderne's birth is fixed by his own statement that he was seventy in the first year of the reign of Richard II. Edward III died at Sheen on June 21, 1377, and was immediately succeeded by Richard II. Arderne, therefore, was born in 1307. [Sloane MS. 75, leaf 146. De Curâ Oculi. "Et sciant presentes et futuri quoad Ego Magister Johannes de Ardern, cirurgorum minimus, hunc libellum propriâ manu meâ exaravi apud London; anno, videlicet regis Ricardi 2di primo et etatis me lxx. ("And be it known to present and future generations that I, Master John of Ardern, the least of the surgeons, scribbled this book with my own hand in London in the year, viz. the first year of the reign of King Richard the Second and in the seventieth year of my age.")] It is clear too that he practised abroad, for he says that he tried a remedy "in foreign

parts upon one King and two Bishops." [MS. bought at the Towneley Sale. It is now in the Surgeon General's Library at Washington, U.S.A. The extract on leaf 54 is, "Hoc probavi in uno rege et duobus episcopis in transmarinis partibus." It is quoted in the "Johns Hopkins Bulletin," vol. v, 1894, pp. 21 and 67, but I am indebted to the courtesy of Lient.-Col. Walter D. McCaw, Librarian S. G. O., for a complete transcription of the passage.] I have no doubt in my own mind that the king was John of Gaunt, "Roy de Castell et de Leon, Duc de Lancastre," who was always addressed as "Monseigneur d'Espaigne." ["John of Gaunt," by Sydney Armitage-Smith, p. 258.] In 1376 John of Gaunt was the best hated man in England, says Mr. Sydney Armitage-Smith in his valuable study of his life. It was undesirable, therefore, John Arderne would think, to draw too close attention to the fact that he had once been attached to his person, for the book was written in this very year 1376. The precaution was wise in view of the events which happened when a London mob burnt the Duke's palace at the Savoy in 1381 and killed his physician, merely because he was a trusted and valued friend. [Johannes de ordine Minorum in armis bellicis strenuus, in physica peritissimus, domino Johanni duci Lancastriae familiarissimus."—Knighton's Chronicle-Rolls Series, ii, 133.] Mr. Sydney Armitage-Smith [Op. cit. p. 248, note.] says that the name of the physician was William de Appleton, and that he was retained by the Duke of Lancaster at 40 marcs per annum for life. An interesting example of the caution which was habitual to Ardern in this matter is to be found in two of the manuscripts in the British Museum. The one [Sloane MS. 3548.] tells of a certain noble knight in the service of the Duke of Lancaster at Algeĉiras, in Spain, who had a sudden attack of facial paralysis, which so twisted his mouth that it was drawn back nearly to his ear and prevented him from speaking. The manuscript continues, "I, the aforesaid John Ardern, made a cure of him." The second manuscript [Sloane 29301.] gives an account of the same case, but, instead of giving any name to the leech who cured him, it merely says "for whom the King of Spain's doctor made a cure in this way." ["Quidam miles nobilis Ducis Lancastriae apud Agezir in Hispania passus est subito torturam oris ita quod os ejus distractum fuit fere retro aurem nec loqui poterat. Ego Predictus Joh. Ardern talem feci sibi curam" (MS. 3548). "Cui medicus regis hyspaniae talem curam fecit," says MS. 29301.] The latter MS. is a magnificently written copy on vellum, with such carefully executed illustrations that it is usually exhibited in the British Museum as an example of fourteenth-century work. It was possibly a presentation copy to John of Gaunt himself; the first one is a poorly written paper manuscript, such as would have an ordinary

circulation. It was copied at a much later date, for the scribe, by mistake, has written Henrici de Arderne, and it belonged to Robert May.

Haeser ["Lehrbuch d. geschichte der Med.," ed. 3, Jena, 1875, i, 784.] says that perhaps Arderne was educated at Montpellier and practised in France as a military surgeon on the English side during the earlier and most brilliant years of the One Hundred Years' War. E. H., who translated his "Latin practises and consailes concerning the helping of all diseases," [Sloane MS. 2271.] in the early part of the seventeenth century, is responsible for the statement that he practised at Antwerp, and he certainly knew a few words of Flemish, for, in speaking of the Nightshade, he says that in Flanders it is called "Naghtstach" (p. 32).

Dr. Milward [A circular invitatory letter . . . concerning . . . British Physical and Chirurgical Authors, by Edward Milward, M.D., Lond. 1740, p. 23.] believed that he was present at the battle of Creĉy, but this I take leave to doubt. He practised, or at any rate he treated patients, in Wiltshire, ["Hoc probavi in vicecomite Wilteshure," says the MS. in the Surgeon-General's Library at Washington, U.S.A., quoted in the "Johns Hopkins Hospital Bulletin," vol. v, 1894, pp. 21 and 67, and I am again indebted to Lieut.-Col. McCaw for verifying the reference.] and from 1349 until 1370 he lived at Newark in Nottinghamshire. [Teste all the MSS.] He came to London in 1370, but I have found no record of where he lived. It was the year of his grand climacteric, in an age when men lived a much shorter time than now, yet he practised with vigour and success for five or six years. By this time he had secured a competence and he set himself to write. In 1376 he issued his treatise on the cure of Fistula in ano which is here printed, "written," as he says, "with my own hand, in the year when the strong and warlike Lord" (Edward the Black Prince) "was taken to God." ["Et eodem anno quo Dominus strenuus et bellicosus Princeps migravit ad Dominum, scripsi libellum istum manu propria, viz. Millesimo ccclxxvi. . . . quem Deus absolvat, quia fuit flos Miliciæ Mundi sine pare."] It is possible that the treatise on Clysters [See postea, p. 74 et seqq.] was already written; it is certain that the treatise "De cura oculorum" was written in 1377, [P. x, note 6, of these Forewords.] but we know nothing more than this about John Arderne. There is nothing to show that he was living in the reign of Henry IV, who came to the throne in 1399. The reference to Henry IV (p. 74), "With this medicine was kyng Henry of ynglond cured of the going out of the lure," is a side-note written in a different hand in some of the MSS. and has only crept into the English text in

process of time. The Hunterian copy of the Commentary in English on "Aegidii Corboliensis tractatus metricus de Urinis," which mentions the leech of "our Lord King the most illustrious prince Henry the Fourth, on whose soul may God have Mercy, Amen," was clearly written after 20 March, 1413, and the scribe has forgotten Arderne's right name, for he says that it is written by Master John Arderon. ["Ego Magister Johannes Arderonn hoc opusculum composui de judiciis urinarum per colores et contenta secundum indicium Egidii et Ypocratis, Walterii, Gilis, Gilberti, Gordoni, Johannis de Sancto Amando, Ysaac, Auicenne, theophili, Galyeni, Galterii et tholomei in medicinam et medicum domini regis illustrissimi principis henrici quarti cujus anime propicietur deus. Amen." The MS. is in the Hunterian Library at Glasgow, No. 328, U. 7, 22 (cf. Notes, 59/32).]

It seems to me that the easiest way to correlate the various facts recorded about John Arderne is to assume that he was attached at first to Henry Plantagenet, the first Duke of Lancaster, and afterwards to John of Gaunt, who married his younger daughter Blanche as his first wife—the White Lady of Chaucer's "Book of the Duchess." Henry, as Earl of Derby, was at Antwerp in 1338, and John Arderne is said to have practised there. Henry, in company with the Earl of Salisbury, fought against the Moors at the siege of Algeĉiras in 1343, when much use was made of Greek fire, and gunpowder is said to have been employed for the first time. John Arderne had been to Algeĉiras because he treated a knight there who was suffering from a trivial complaint from which he would have recovered during the long journey, if he had visited Arderne in England. Arderne was interested both in Greek fire and in gunpowder, for he gives a receipt for making Ignis Græcus and for an artificial fire to burn ships. Henry of Lancaster was Lieutenant and Captain of Aquitaine in 1345, and was granted the town of Bergerac with the right of coinage in 1347. John Arderne nowhere says specifically that he served with the Earl of Derby, Duke of Lancaster, but he betrays an intimate knowledge of this campaign, for he gives the names of the towns in the order in which they were reached by the invading army and not in their geographical succession; his knowledge is even remarkable, for he gives the towns in the order in which they were reached by a single column of the army, and he was writing more than thirty years after the events. ["The forsaid sir Adam (p. 1, line 12 et seqq.) forsooth suffering from fistula in ano asked counsel of all the leeches and surgeons that he could find in Gascony, at Bordeaux, at Bergerac, Toulouse, Narbonne and Poitiers." Arderne seems to have had a soft place in his heart for Narbonne. He calls one of his favourite plaisters Emplastron de Nerbon, and says, "Istud emplastron dicitur Norbon quia quamvis sit nigrum tamen bonum." ("This emplastre is called Noirbon, for although it be black nevertheless it is good." P. 91, l. 31.)]

The campaign ended and the Duke of Lancaster returned to London, 13th January, 1347-8, and died of the plague at Leicester in 1361. John Arderne may then have attached himself to John of Gaunt, the son-in-law of the Duke, who called himself King of Castile and Leon from his marriage with Constance, daughter of Don Pedro I of Castile, in September 1371, until his own daughter Katherine married Enrique III in 1388, and became Queen of Castile and Leon in 1390. If Arderne was really surgeon to the King of Castile it must have been after the year 1370, and this perhaps gives the reason why John Arderne left Newark after he had practised there for so many years. Mr. Armitage-Smith tells me, however, that there is no record of such an appointment in the Duke's roll which he has lately published.

ARDERNE AS A SURGEON.

John Arderne is a good example of a type of surgeon who has happily never been absent from England. He is the earliest example that we know at present, but he was followed in direct succession by Thomas Morstede, who was present at Agincourt in 1415, and was buried in St. Olave, Upwell, in the Jewry, in 1450; by Richard Ferris, who wrote nothing, but was revered as their master by many succeeding generations of surgeons in London. He died, an old man, in 1566, and had seen much service in the wars of Henry VIII. William Clowes (1540-1604), my great predecessor at St. Bartholomew's Hospital, learnt much of him. Clowes handed on the tradition to John Woodall (1556-1643), and Woodall to Richard Wiseman (1622-1676), the surgeon of the Commonwealth. Wiseman was succeeded by Samuel Sharp (1700 (?)-1778) of Guy's Hospital, and by Percivall Pott (1714-1788) at St. Bartholomew's. The distinguishing mark of each was the possession of the qualities which make an English gentleman as well as a fine surgeon. They were all men of good education, wide experience, and sound judgment. John Arderne possessed these qualities in abundance. He preferred personal experience to the teaching of the schools. He would rather learn by experiment than by authority, and with characteristic frankness he related his failures as well as his successes (p. 83). He was not in advance of his time, for he believed, like every one else, in Astrology (p. 16). He kept his methods as secret as he could by giving fancy names to his ointments and plaisters (p. 89), and by writing his charm in Greek letters "ne a laicis perspicietur" (p. 103).

John Arderne wrote on Fistula, on diseases of the Eye, on Clysters, on Bleeding; on Plants and their Uses, and he also published a common-place book containing various receipts and notes of cases arranged without any method. There exists also his Commentary on Giles de Corbeil's metrical treatise "de Urinis" (p. xiii, note 1), and he is the author of a "Scala Sanitatis contra plagas." By some means he had access to a large medical library, for he quotes the very words of the manuscripts to which he refers in his treatise on Hæmorrhoids (p. 55, line 3), and it is evident that they were lying before him as he wrote. It is clear from the number of manuscripts which still remain in the various libraries (Bibliography, pp. xxxiv and xxxv) that Arderne's works were read and valued by his contemporaries and immediate successors. They were written originally in Latin, and, as he is careful to explain, with his own hand, but English translations were soon produced. The Latin is of the colloquial type like that in which the "Epistolae Obscurorum Virorum" was written in the early years of the sixteenth century, neither better nor worse, and when Arderne was at fault for a Latin word he never scrupled to use its English or French equivalent. His handwriting was as crabbed as his style, if, as there is some reason for believing, the Sloane MS., No. 75, is a holograph in so far as it deals with diseases of the eyes. The treatise on Fistula in Ano is certainly the most interesting and practical of Arderne's works. John Read published an abstract of a part of this treatise in the reign of Queen Elizabeth, but it has never been printed in full until now, and for this purpose an early fifteenth-century translation has been selected.

THE TREATMENT OF FISTULA IN ANO.

Arderne's attention was no doubt called to the subject of Fistula by the actual cases which came to him for relief. The hardship of the Hundred Years' War must have produced many cases of ischio-rectal abscess which ended in fistula. Wet, cold, long hours in the saddle weighted down by the heavy armour of the time, would readily lead to this condition in the knightly class; whilst the sedentary habits and gross feeding causing chronic constipation would account for it in the religious and civic population. Tubercle, too, was rife in the fourteenth century, but it would be interesting to learn whether the Black Death left an aftermath of boils and abscesses. The work is full of detail, and shows the author to be original, thoughtful, observant, and a master of his art both in theory and practice. He

says, very rightly, that the treatment of fistula in ano had fallen into disrepute because it was a troublesome condition which brought very little credit to surgeons, whilst it required long and patient treatment for which the majority of the sufferers were not prepared to pay. An examination of the writings of the immediate predecessors and contemporaries of John Arderne shows that these statements are literally correct. To go back no farther than Albucasis, who died in 1013, ["Methodus Medendi certa, clara et brevis," Lib. ii, cap. 810. Basil, 1541, p. 132.] it was taught that complete fistulæ were incurable, and that all operations and the application of ointments was but labour in vain. Some believed that a cure could be obtained occasionally, and Albucasis advised, therefore, that a small copper or iron probe should be introduced into the bowel through the fistula which should then be laid open in its whole extent until the probe fell out. But if the bleeding were so severe as to stop the operation, or the surgeon was afraid of the hæmorrhage, the actual cautery might be used. In other cases, Albucasis taught, a probe armed with a ligature of five strands might be passed from the external orifice of the fistula through its track into the rectum. The end of the probe was then caught by the finger and drawn out through the anus bringing with it one end of the ligature. The two ends of the ligature, the one hanging out of the fistula and the other from the anus, were then tied tightly together, care being taken to include as much tissue as possible. The knot was tightened on the second or third day, and as often afterwards as was necessary. The fistula was thus cured by the ligature cutting its way out, the track behind it healing by granulation.

William de Salicet (fl. 1245), who taught surgery at Bologna, and was considered the most skilful surgeon of his age, had so great a dread of fistula that he wrote: ["Chirurgie de Guillaume de Salicet." Paul Pifteau. Toulouse, 1898, p. 139.] "When the fistula is complete it is assuredly so difficult to cure that it is better and more honourable for the surgeon to give up the case at once. But if he decide to undertake it the orifice should be dilated with a sponge tent and the whole track burnt with the actual cautery. If this fails the fistula may be laid open into the bowel by a seton of silk, horsehair or cow's hair pulled to and fro daily like a saw until it cuts its way out; but," he adds, as a warning, "I have seen bad results from this method of cure."

Lanfrank, the most distinguished pupil of William de Salicet, who

died in 1306, the year before John Arderne was born, contents himself with saying that fistulæ are incurable, and he utters a lamentable cry against those who would attempt to operate even if it were only by applying a corrosive. [Lanfrank's "Science of Cirurgie," Early English Text Society, No. 102, pp. 292-3.]

Henri de Mondeville (1260(?)-1320(?)) merely enlarged the orifice of the fistula with a tent, and utterly condemns the teaching of the school of Salernum, as represented by Roger and Roland, who would operate and afterwards apply a painful corrosive, ["Chirurgie de Maître Henri de Mondeville." E. Nicaise. Paris, 1893, p. 465.] —and de Mondeville was in Paris what Arderne was in London, a first-rate surgeon.

Guy de Chauliac (d. 1368), prince of the mediæval writers of surgical text-books, published his "Great Surgery" thirteen years before Arderne wrote his treatise on Fistula. After the manner of text-books various operations are described for the cure of fistula, each with insufficient details, and the reader is left in doubt as to which, if any, is to be employed. ["La Grande Chirurgie de Guy de Chauliac, composée en l'an 1363." E. Nicaise. Paris, 1890, p. 134.]

ARDERNE'S OPERATION FOR FISTULA.

John Arderne's operation is clearly a modification of the method recommended by Albucasis, and, like a good surgeon, he preferred a clean incision to fretting the fistula through with a ligature tied tightly. He recommends that the patient should be secured in the lithotomy position. A probe—called appropriately enough, sequere me—is passed through the fistula until it is felt in the rectum. The eye of the probe is then threaded with a ligature of four strands—the frænum Cæsaris—which is drawn through the fistula as the probe is pulled out of the rectum until one end hangs out of the anus and the other from the opening of the fistula. These two ends are knotted together and the whole ligature is tightened by means of a peg—the wrayste—fixed into the widest part of a gorget—the tendiculum—in the same way that a violin peg tightens the strings passing round it. The use of the ligature is partly to control the bleeding and partly to maintain a correct line while the fistula is being divided. The gorget or tendiculum is pushed well up into the fistula and a grooved director with a curved end—the acus rostrata, or snowted needle—is passed along it until the end projects into the rectum where the probe had

been previously inserted. A shield—the cochlearia, or spoon—with a depression in its centre is then passed through the anus until the grooved director engages in the depressed notch. The object of this shield is partly to prevent the surgeon cutting down upon his own finger and partly to protect the opposite wall of the rectum should the patient struggle or make a sudden movement at the moment the fistula is divided. A scalpel—the razor or lance—is passed along the groove in the acus rostrata, and the fistula is cleanly divided along its whole length by drawing the knife, the acus rostrata, and the spoon out of the rectum with a single movement, the ligature or frænum Cæsaris coming away at the same time. Each branch of the fistula may be laid open in turn if the patient can bear it, or any farther operation can be postponed, as Arderne had found by experience that when the main track was laid open the other channels often healed of themselves.

The operation was a good one, except that his instruments were needlessly cumbersome, and would cure a fistula equally well at the present day, but the great advance which Arderne made was in avoiding the corrosive and irritating after-treatment used by every one else. It is difficult now to put ourselves in his position and to realize what an amount of originality it meant for a surgeon in the fourteenth century to leave a wound alone and not to try and kill it with the actual cautery or with caustics. Such a method was contrary to all teaching, and would seem to be undertaken with the very greatest risk. Yet John Arderne only applied a little oil of roses with the white or yolk of an egg, and he washed the wound with tepid water and a sponge. He never changed the dressings oftener than he could help (p. 87), but he was careful to see that they were not soiled, whilst his experience with simple enemata led him to prefer a clyster of salt and water to the powerful purgatives in ordinary use. Some of his patients recovered, therefore, and he was not slow to advertise the fact; but the weight of authority was against him, and in spite of his success, surgeons preferred to mundify their wounds and use incarnatives for nearly five hundred years after his death.

THE MASTER SURGEONS.

The position which Arderne occupied was perfectly well recognized both in England and France, and was identical with that which we occupy at the present time as consulting and operating surgeons. In France such surgeons were known in Arderne's time as surgeons of the

long robe, to distinguish them from the barbers practising surgery, who were surgeons of the short robe. In England the prefix of Master indicated the difference, and John Arderne is careful therefore always to style himself Magister Johannes de Arderne, Magister being his title as Master of Surgery, which distinguished him, on the one hand, from the Doctor of Physic who was his superior, and, on the other, from the Barber and the Apothecary who ranked below him. The Master Surgeons formed a small guild in London from very early times, and records of persons entrusted with its supervision are known as early as 1369. [South's "Craft of Surgery," p. 17. Messrs. Cassell & Co., London, 1886.] Arderne calls himself "cirurgorum minimus" (p. x, note 6), and he was probably admitted a member of this guild when he came to London in 1370, in which case Master John Dunheued, Master John Hyndstoke and Master Nicholas Kildesby would be three of his colleagues. The guild never contained many members, but what it lacked in numbers it made up in influence, and, in spite of many struggles with the more numerous Guild of Barbers, it was able to hold its own for many years. The Guild of Surgeons united for a short time with the Physicians about 1423, and finally became merged into the United Company of Barbers and Surgeons in 1540. But it is unnecessary to trace the growth and development of the Guild of Surgeons, and those who are interested in it will find a fuller account in "The Medical Magazine" for 1899. The present treatise contains slight references to the struggle which was going on between the Surgeons and the Barbers at the time it was written. There is the case, for instance (p. 100), of the rich fishmonger who had a lacerated wound of the arm which was made worse by the incompetent treatment of a barber who had stuffed it with corrosive dressings. Arderne tore off the dressings and replaced them by a soothing fomentation which allowed the patient to have a good night's rest.

But the human interest of the treatises here published is concentrated in Arderne's description of the qualities required in a good surgeon (p. 4). It sets forth his ideal of the morals and etiquette of the highest class of surgeons—the Masters of Surgery—during the thirteenth and fourteenth centuries, and shows that it was at least as high as it is amongst the best men of the present day. Pity, charity, continence in all things, the patient first but the fee not unimportant, because then as now the labourer was worthy of his hire, were the distinguishing characteristics of the educated surgeon.

Henri de Mondeville gives similar rules in somewhat greater detail.

I quote partly from Prof. E. Nicaise's splendid edition of his works, ["Chirurgie de Maître Henri de Mondeville, composée de 1306 à 1320," parEd. Nicaise. Paris, 1893, pp. 91 et seqq.] and partly from the contemporary translation into French, published by Dr. A. Bos: ["Soc. des Anciens Textes Franĉais." Paris, 1897, tome i, p. 140.] "A Surgeon ought to be fairly bold. He ought not to quarrel before the laity, and although he should operate wisely and prudently, he should never undertake any dangerous operation unless he is sure that it is the only way to avoid a greater danger. His limbs, and especially his hands, should be well-shaped with long, delicate and supple fingers which must not be tremulous. He ought to promise a cure to every patient, but he should tell the parents or the friends if there is any danger. He should refuse as far as possible all difficult cases, and he should never mix himself up with desperate ones. He may give advice to the poor for the love of God only, but the wealthy should be made to pay well. He should neither praise himself nor blame others, and he should not hate any of his colleagues. He ought to sympathise with his patients in their distress and fall in with their lawful requests so far as they do not interfere with the treatment. Patients, on the other hand, should obey their surgeons implicitly in everything appertaining to their cure. The surgeon's assistants must be loyal to their surgeon and friendly to his patients. They should not tell the patient what the surgeon said unless the news is pleasant, and they should always appear cheerful. They must agree amongst themselves as well as with the patients, and they must not be always grumbling, because this inspires fear and doubt in the patient."

De Mondeville then shows how an honest surgeon may be replaced and damaged by one who is less conscientious, for he says: "A rich man has the beginning of an inflammation. He calls in an upright surgeon, who says after examining him, 'Seigneur, there is no need for any operation here, because nature will relieve herself, etc.; but if the inflammation gets worse, send for me.' It then happens that the patient calls in another man who is a quack, and he is told, 'Seigneur, you have a great deal of inflammation, I can feel it inside, and if you are not treated at once you will certainly regret it.' This surgeon then sets to work and makes an inflammation, which he afterwards cures, so that the whole proceeding redounds to his credit and profit, for he discovered an inflammation which did not exist, whilst the first surgeon is damaged both in his reputation and his pocket because he did not find out what was not there."

"Then again, one of these second-rate surgeons will come to a sick man who is wealthy, and will say to him, with the voice of an archangel—taking care that no witnesses are present—'Seigneur, you must remember that you are the one who is ill and in pain. It is not your son or your nephew. It is you who are kept awake by the pain whilst your friends and servants sleep. Others won't take care of you if you don't take care of yourself. You are rich enough to get advice and to buy health and whatever else you want if you choose to do so. Riches are not more than health, nor is poverty worse than sickness. Have you not made the greater part of your money yourself and for yourself, so that if you are not a miser you can apply it to relieve your wants? Would to God that those who look after you so badly had your complaint. But all this is between ourselves, and what I tell you is only out of pity for you and for your good.' Then, in the absence of the patient, he speaks to the relatives and says, 'Seigneurs, this man has the greatest confidence in you, and, truly, if you lose him, you will lose an excellent friend. It is not to your credit either to let him go without advice, for if he died without advice you would be blamed everlastingly, even if it made him as poor as Job. He is really in great danger, and it is a serious case, but nature sometimes does better than we have any right to expect. He is sure to die if no one treats him, but if he is properly treated it is just possible that he will escape and not die. If he dies it won't be the result of the treatment, because he is nearly dead already, his only chance is to have a consultation, etc. I am speaking to you as a friend and not as a doctor.'

"But it is quite another matter when this same surgeon has to treat a poor man, for he says, 'I am really sorry for you, and I would gladly help you for the love of God only. But I am very busy just now with a lot of difficult cases, and, besides, the season is not a very favourable one for an operation. You can't afford to buy what is necessary for your case, such as drugs and dressings, so I would put it off until the summer. You will then be able to get the herbs and whatever else is wanted and so save expense. The summer, too, is the best time for the poor.' When the same pauper comes back in the summer the surgeon says to him, 'I am very sorry that I put you off in the winter and told you to wait until the summer, because the winter is really the best time. Summer is too hot and there is a fear of stirring up the disease. I should advise you to wait until the hot weather is over.' And this goes on everlastingly, for this kind of surgeon never finds time to operate upon a pauper."

De Mondeville classifies his patients according to their ability to pay fees. "The first class are paupers who must be treated for nothing; the second class are a little better off, and may send presents of fowls and ducks; they pay in kind. The third class are friends and relations who pay no fixed fee, but send victuals or presents in token of gratitude, but no money. Our assistants ought to suggest the presents to this class, saying behind our backs, and as if we knew nothing about it, when anything is said about money, 'No, indeed, the Master would not like it, and you would do much better to make him a little present, though I am sure that he does not expect anything.' Indeed, a sharp assistant sometimes makes more by such suggestions than the Master does by his operation, and it is just like doubling the fee on account of the horse when the Master makes his visits on horseback. Then there is a class embracing those who are notoriously bad payers, such as our nobility and their households, government officials, judges, baillies and lawyers, whom we are obliged to treat because we dare not offend them. In fact, the longer we treat these people the more we lose. It is best to cure them as quickly as possible, and to give them the best medicines. Lastly, there is a class who pay in full and in advance, and they should be prevented from getting ill at all, because we are paid a salary to keep them in health."

The difficulty of obtaining payment for operations in the fourteenth century must have been very great, for De Mondeville still further emphasizes it and says, "The chief object of the patient, and the one idea which dominates all his actions, is to get cured, and when once he is cured he forgets his own obligation and omits to pay; the object of the surgeon, on the other hand, is to obtain his money, and he should never be satisfied with a promise or a pledge, but he should either have the money in advance or take a bond for it. As the poet says, 'Sæpe fides data fallit, plegius plaidit, vadium valet—The promise is often broken, the security is worthless, the bond alone holds good.'" De Mondeville also thinks that it is better on the whole for the surgeon to be paid for what he does rather than by a retaining fee, because a salary is apt to make him so hopeful that he will think the blind can certainly see and the lame can walk or even run. The surgeon too must beware of those who will make infamous proposals to him, because from time immemorial it has been an article of faith with the common people that every surgeon is a thief, a murderer or a swindler. He should also be careful to estimate the strength of a patient before he operates. If a patient dies of the operation and not of mere weakness the surgeon is held excused so long as the friends

think the wound looks healthy, but if the wound looks badly the surgeon is credited with the death even though the patient has simply died of weakness. The surgeon must not put too much faith in appearances. The rich have a nasty habit of coming to him in old clothes, or, if they are properly dressed as befits their station they invent all kinds of excuses for beating down his fees. They say Charity is a flower when they find a man who helps the poor, and think that a surgeon ought to assist the unfortunate, but they never consider that a like rule is binding upon them. "I often say to such folk," De Mondeville adds, "Well, then, pay me for yourself and for three paupers and I will cure them as well as you. But they never make any answer, and I have never yet found any one in any position, whether he was a cleric or a layman, who was rich enough, or rather honest enough, to pay what he had promised until he was made to do so." Lesser surgeons must have fared very badly if this was the experience of the surgeon to the King of France.

De Mondeville returns to the question of fees in another part of his book (Nicaise, op. cit. p. 199). "The surgeon ought to consider three things when a patient comes to see him and arrange about the fee for an operation. First, his own position; secondly, the condition of the patient; thirdly, the state of the disease. As regards himself the surgeon should think whether he is celebrated or at least better known than his colleagues, whether he is the only surgeon in the country, whether he is rich and not obliged to practise, whether he has enough cases to fill up his time, and whether he is on the point of undertaking more important cases. On the second point, viz. the condition of the patient. He either knows or he does not know him; if he knows him he is aware whether he is rich or poor, whether, for example, he is the nephew of a bishop or of an abbé. But if he does not know him he ought to make careful inquiries, or rather he ought to get his assistants to make them, because sometimes, indeed often, it happens that the rich come to the leech dressed like paupers. If the surgeon suspects this he should say to his patient, 'Seigneur, I have examined your case but I must think it over, and I should like to see you again when I have done so, because he who judges in haste repents at leisure,' and in the interval the surgeon should make inquiries. As to the third point, the surgeon should think of the disease whether it is serious, if it is difficult to cure, and if long attendance will be required, whether few people know how to treat it, if it is chronic, and if it presents any unusual characters.

"When the surgeon has considered all the points under these three

headings he ought to charge the patient boldly a very large fee, though he may moderate it according to circumstances. To a rich man he should say, 'The fee a surgeon ought to receive is a hundred pounds for this operation,' and if the patient is staggered by the sum he would continue, 'but I did not say that I was going to charge you that amount,' and thus little by little he lowers his fee. But he should always have a minimum for each operation and never go below it. In such cases it is more graceful for him to say, 'I am ready to do this operation as you and your friends wish, but I would rather do it for nothing to please you than for so small a fee.' And the surgeon should pretend that he has no living (prebende) nor capital except his profession, and that everything is as dear as possible, especially drugs, and ointment; that the fee is as nothing compared with his services; and the wages of all other artisans, masons, for example, have doubled of late. I repeat that the surgeon ought to charge the rich as much as possible and to get all he can out of them, provided that he does all he can to cure the poor. You then, Surgeons, if you operate conscientiously upon the rich for a sufficient fee and upon the poor for charity, you ought not to fear the ravages of fire, nor of rain nor of wind; you need not take orders or make pilgrimages nor undertake any work of that kind, because by your science you can save your souls alive, live without poverty and die in your houses. Live in peace and joy and rejoice because your recompense is so great in heaven, as necessarily follows from the words of the Saviour, spoken in the psalm by the mouth of His prophet, 'Beatus qui intelligit super egeneum et pauperem...' For this reason surgeons enjoy such immunities and are free from all personal service and from all common burdens, such as the repair of walls, moats and roads, from the night watch in towns, and from all kinds of things. The Surgeons are classed as Surgeon-major and as Surgeons of the palace or Examiners, who are generally called Archiatres by the common people."

William of Salicet, another surgeon, experienced in war and of the same high standard as Arderne and De Mondeville, had written in 1275 ("Chirurgie de Guillaume de Salicet Achevée en 1275, Traduction et Commentaire, par Paul Pifteau." Toulouse, 1898, p. 3) in somewhat similar terms. He says a surgeon should grant the wishes of his patient so long as they do not interfere with the operation. He ought also to comfort his patient as far as possible by kind actions and by soothing words. He should hold out hope even in the most desperate cases, because the patient's courage reacts to these words and promises,

and they may have a more powerful influence on his recovery than any of the surgeon's remedies. But the matter should be discussed with the friends whenever there is danger, partly to save them the shock of an unexpected death, and partly to protect the surgeon from any suspicion of having caused it. Neither a surgeon nor a physician should talk to the women of the house with closed doors, whether she be mistress or servant. He should never speak improperly to her, nor make eyes at her, especially in the presence of the patient. Such actions may cause a patient to lose confidence in his surgeon, and thus the operation may prove unsuccessful because the patient has lost the good opinion he had of the operator. A wise surgeon too will do well to refrain from stealing anything whilst he is in attendance; he will not stir up strife amongst the patient's friends or quarrel with the people of the house; he will be careful, too, not to employ notoriously bad characters as his assistants, for all these things may spoil a good operation and thus detract from the dignity of medicine. Above all things, he must refrain from becoming too familiar with the laity. They are always ready to speak ill of doctors, and too great familiarity merely means that one cannot demand the proper fees for an operation with any assurance and safety. It is well known that a large fee increases the authority of the doctor as well as the confidence the patient puts in him, even though the doctor is very ignorant, because it is thought that a large fee secures better attention. The surgeon ought to observe the rules of those with whom he is living or amongst whom he finds himself. He should visit the poor because it is a good thing to have a reputation for Charity, partly because it increases his estimation in the eyes of the people, and partly because it enables the Divine Power to extend its influence over his spirit. The surgeon ought not to allow himself to be swayed by the entreaties of the patient, because if he yields the patient will lose faith in the operator, and the operator may himself become timid and hesitating. The assistants ought to be amiable and helpful to the patient, and they should never repeat to him what the surgeon has said unless it is pleasant and encouraging. Leeches should be especially careful not to discuss matters with the patient or in his presence, and above all things, they must avoid whispering or talking together in corners, for such actions rouse all kinds of suspicion in the mind of the patient and his friends.

Lanfrank, who was in Paris in 1295, and is looked upon as the founder of French surgery, says in the English version transcribed in

1380 (Early English Text Society, No. 102, 1894, p. 8): "Needful it is that a surgeon be of a complexion well proportioned. . . He must have hands well shaped, long small fingers, and his body not quaking. Also he must be of subtle wit, for all things that (be)longeth to surgery may not with letters be written. . . Be he no glutton, nor not envious nor a niggard; be he true; humble and pleasingly bear himself to his patients; speak he no ribaldry in the sick man's house; give he no counsel but if he be asked; nor speak he with no woman in folly in the man's house; nor chide he not with the sick man nor none of his household, but courteously speak to the sick man, and in all manner of sickness promise him health although you despair of him, but nevertheless tell his friends the truth. Love no hard cures and undertake no desperate cases. Help poor men as far as possible and ask good reward of the rich. Praise he not himself with his own mouth, nor blame he over sharply other leeches. Love he all leeches and clerics, and, as far as possible, make he no leech his enemy. So clothe he himself with virtue that he may obtain a good name and a fair reputation. This is the ethical teaching."

It is clear from these extracts that Arderne had read Lanfrank's rules for a surgeon, and that he amplified them from his own experience, which corresponded very much with that of the French surgeons who were his contemporaries. But Arderne's teaching of the duties of a surgeon compares very favourably with that of William Salicet or Henri de Mondeville. He had a higher moral tone, or, at any rate, he based his warnings on morality rather than upon self-interest, and there is nowhere any reference to a surgeon as a common thief. His fees are high, but, as a contemporary writer explains, this is to make up for the long periods when he had nothing to do, and it is clear that it was extremely difficult to obtain money from patients.

Every surgeon was taught never to treat cases which appeared incurable or were unlikely to run a straightforward course. This was due to ignorance, to the weakness of the law, and to the arbitrary treatment to which individuals might be exposed. Throughout the Middle Ages, and long afterwards, there was no science of toxicology and very little knowledge of morbid anatomy. Persons who died suddenly, therefore, were usually thought to have been killed by poison, and the histories of the present day are full of accounts of the deaths of great men who are said to have been poisoned, when it is clear to every medical reader that they died a natural death from some acute disease. A perforated gastric ulcer, a perforated duodenal ulcer, an acute gangrenous

inflammation of the vermiform appendix would present all the characters of poisoning to the lay mind. Failure after an operation was liable to be followed by the most undesirable consequences to the leech. King John of Bohemia, from whose body Edward the Black Prince took an ostrich feather for his crest, sewed up his French leech in a sack and threw him into the Oder because he had not cured his cataract as he had promised.

Arderne must have led an interesting and adventurous life, and his treatises contain many sidelights on contemporary events. He appears to be the only contemporary authority for the story of the means by which Edward the Black Prince obtained the ostrich feather which has since become the cognisance of the heir apparent to the English throne. The passage runs as follows, "We are not able to cure rhagades unless the remedy can be put through the anus either as a clyster or by means of a suppository, since remedies applied outside are either useless or do very little good. We ought, therefore, to work with stimulating applications until the wound is clean, and afterwards with applications which both heal and dry, as has been said already in the chapter on internal piles, to wit, where Nastar is painted—and Nastar is a kind of clyster or enema known as a glisterpipe.—The feather of the Prince of Wales is also shown there, viz. on the preceding page. And note that Edward the eldest son of Edward King of England bore a similar feather above his crest, and he obtained the feather from the King of Bohemia, whom he killed at Cressy in France. And so he took the feather which is called an 'ostrich feather,' which that most noble Lord King had used hitherto to bear above his crest. And in that year when our Lord the strenuous and warlike Prince departed to God, I wrote this little book of mine with my own hand, viz. in the year one thousand three hundred and seventy-six. And our Lord Edward the Prince died on the sixth June on Trinity Sunday at Westminster during the great Parliament, and may God assoil him, for he was the very flower of chivalry, without peer in the world." ["Rhagades curare non possumus nisi medicinis infra anum inferamus aut in clystere aut modo suppositorii quia medicinæ exterius appositæ parum vel nihil prosunt, unde primo oportet cum corrosivis operare ad mundificationem et postea cum consolidantibus et desiccantibus ut prædictum est capitulo de hæmorrhoid. infra anum latentibus ubi nastare depingitur et penna Principis Walliæ, viz. folio præcedente. Et nota quod talem pennam albam portabat Edwardus primogenitus filius Edwardi Regis Angliæ, super crestam suam. Et illam pennam conquisivit de rege Boëmo, quem interfecit apud Cresse in Francia. Et sic assumpsit sibi illam pennam quæ dicitur 'Ostrich fether,' quam prius Dominus Rex nobillissimus portebat super crestam suam et eodem anno quo Dominus strenuus et bellicosus Princeps migravit at Dominum, scripsi libellum istum manu propriâ, viz. anno Millesimo ccclxxvi. Et Dominus Edwardus princeps obiit vi Idus Junii, viz. die Sanctæ Trinitatis, apud Westmonasterium in magno parliamento, quem Deus absolvat, quia fuit flos Miliciæ Mundi sine pare. Nastare species est clysteris sive enematis 'a glister pipe.'"]

This passage is omitted from the English translation which is here printed (Sloane 6), as well as from the later and different English translation (Sloane 76), which are often merely abstracts of what Arderne wrote. But it is present in the Latin texts (Sloane MSS. 56, leaf 74; 335, leaf 68; 2002, leaf 333; 176, back; 29301, leaf 42, col. 157; in MS. 1153, leaf 41, in Trin. Coll. Camb.; and in the MS. No. 339 in the Hunterian Library at Glasgow, leaf 77).

It was from the last MS., which was then called Sloane 2, that Thomas Hearn copied it in the "Chronici Walteri Hemingford." [Vol. 2, pp. 444, 446, in note.] In each case it is a part of the text, and is written by the same hand as the rest of the manuscript. The scribes have not copied from each other, and there is very little doubt in my own mind that Arderne wrote it originally, and that it contains the story current in his day about the source of the feather, and Arderne was in a position to obtain the story at first hand. Incidentally it bears out an interesting point, for it says that both the King of Bohemia and the Prince of Wales bore the feather above his crest, not as his crest, so that it was used in exactly the same manner as was the Garter at first, viz. as an ornament to be worn at jousts or tournaments. ["Observations on the Institution of the Most Noble Order of the Garter, by Sir Nicholas Harris Nicolas." "Archæologia," vol. 31, p. 130.] It only became a crest in later years, and so long as it was a mere ornament or distinguishing badge there was no need for it to be associated with a motto; indeed, in each of Arderne's figures the scroll placed upon the quill of the feather, which is single, is left blank instead of being charged. This use of the ostrich feather as an ornament at jousts further explains the passage in the Black Prince's will, in which he desired that his corpse should be taken through the City of Canterbury as far as the Priory, and that "two war horses, covered with our Arms and two men armed in our Arms and in our crests," should precede his corpse; that is to say, "the one for War, with our entire Arms quarterly, and the other for Peace, with our Badge of Ostrich Feathers," with four banners of the same suite. [

"On the Badge and Mottoes of the Prince of Wales," vol. 3. "Archæologia," vol. 31, p. 356.

"Et volons qe a quele heure qe notre corps soit amenez parmy la ville de Cantirbirie tantq'a la priorie, q'deux destreȝ covertȝ de nos armeȝ, et deuȝ homeȝ armeȝ en nos armeȝ et en nos heaumes voisent devant dit n're corps, c'est assavoir l'un pur la guerre de noȝ armeȝ entiers quartelleȝ, at l'autre pur la paix de noz bages des plumes d'ostrace, ove quarter baneres de mesme la sute, et qe chacun de ceaux q'porteront les diteȝ baneres ait sur sa teste un chapeau de noȝ armes." "Nichols's Royal Wills," p. 68. See also "Notes and Queries," Series ii, 1861, vol. xi, pp. 224 and 294.

]

The directions for making Nerbone plaister (p. 91) show the difficulties in reckoning small subdivisions of time. Arderne directs that the melted diachylon should be allowed to stand without moving by the space of a "pater noster" and an "ave maria." I asked a patient recently, the Mother Superior of a Convent, how long it would take to repeat these prayers, and she replied about three quarters of a minute. When I next saw her, after she had spent a sleepless night with a clock in front of her, she said that the question had interested her, and she found that a pater and an ave took exactly half a minute. Dr. Norman Moore draws attention ("The Progress of Medicine at St. Bartholomew's Hospital," 1888, p. 13) to a similar method employed by John Mirfeld, a Canon of the priory of St. Bartholomew, who wrote a general treatise on medicine—Breviarium Bartholomei—about the year 1380. He says, "Mirfeld treated chronie rheumatism by rubbing the part with olive oil. This was to be prepared with ceremony. It was to be put into a clean vessel while the preparer made the sign of the cross and said the Lord's Prayer and an Ave Maria, and when the vessel was put to the fire the Psalm, 'Why do the heathen rage,' was to be said as far as the verse 'Desire of me, and I shall give thee the heathen for thine inheritance.' The Gloria, Pater Noster, and Ave Maria are to be said, and the whole gone through seven times. 'Which done let that oil be kept.'" . . . "The time occupied I have tried," says Dr. Norman Moore, "and found to be a quarter of an hour."

The charm against Cramp (p. 102) was obtained from one who was at Milan when Lionel, Duke of Clarence, married Violante, the daughter of Galeazzo Visconti, at the door of the Cathedral, on June 5th, 1368. Five months of continuous jousts, feasts and revels were followed by the inevitable consequences of delirium tremens and epileptiform convulsions.

The sober testimony to the profligacy of the times given in the receipt for making confection of Sanguis Veneris (p. 89) is the natural outcome of the conditions described in Dr. Furnivall's "Early English Meals and Manners" (Early English Text Society, Original Series, No. 32). The boys and girls of the upper classes were transferred

from their own homes to be educated in the houses of the nobility as pages and maids of honour. They were well fed, spent their lives in a round of pleasure, and were often badly looked after.

The account of juniper shows that Arderne knew London and its neighbourhood and talked with the countryfolk as he went amongst them. He says, "Juniper grows in Kent upon Shooter's Hill on the road to Canterbury, at Dorking also in Surrey as well as in many other places in that County, at Bedington too near Croydon, and the inhabitants of that country call it gorst because they do not know its proper name." ["Et crescat in cancia super Scheteres hylde in viâ versus cantuariam, apud Dorkyng, eciam in Soþeray et eciam in aliis pluribus illius provincie, crescit eciam apud Bedyngton iuxta Croyden quam incole patrie illius vocant gorst, quia proprium nomen illius ignorant." (MS. Digby 161, leaf 23, in the Bodleian Library, Oxford.)] The Black Death does not seem to have left much impression upon Arderne's mind, because, like most contemporary medical writers, he only mentions it incidentally, and what we look upon as an appalling visitation had already faded from his mind, and its impression had been replaced by more recent epidemics.

Arderne lived through the most chivalrous period of English history, and in all probability he knew personally many of the peerless knights and splendid champions who survive for ever in the pages of Froissart. To have known such men was in itself an education, and to have lived in the household of Henry, Duke of Lancaster, and of John of Gaunt was sufficient to make Arderne the best type of an English surgeon—a scholar and a gentleman. The chivalry of the age is well brought out in the extant manuscripts of Arderne's treatises. In some cases he mentions the names of the patients, but in many instances he tricks their coat-armour instead of giving names, and thus some early shields are preserved, amongst others that of the great Douglas.

Arderne left a few traces on the sands of time, but very few. Johannis Argentin, a physician at Cambridge, wrote a treatise, which still remains in the Bodleian Library as Ashmol. MS. No. 1437. Tanner ["Bibliotheca," p. 48.] thinks that it was written about 1476. He mentions Arderne no less than eleven times, and copies his style, especially his manner of quoting cases in illustration of his various subjects.

Arderne's fame as a pharmacist long outlasted his reputation as a surgeon. Tapsimel (p. 31), Pulvis sine pari (pp. 26 and 86), Tapsivalencia(p. 69), and the valences of Scabious and Wormwood (p. 97),

remained until the time of the first Pharmacopœia, 1618. Dr. Alleyne ["A New English Dispensatory," 1733, p. 336.] speaks thus of them:—

"Powers of Scabious, Valentia Scabiosœ.—Take of the juice of green Scabious, pressed out and strained through a cloth, and of Hog's lard cleared of its membranes, each as much as you please. Let the Lard be beat in a stone mortar, and the juice poured in by little at a time, for the conveniency of mixture, and giving its tincture; and then put them together into a proper vessel, to be exposed to the sun, and so that the juice may cover the lard; after nine days put them again into the mortar as before, and throw away that thin and discoloured humidity, which separates upon beating, without rubbing them together; and again put into its vessel for five days. And afterwards beat it again and by little at a time, mix with it fresh juice of scabious, and after a fresh insolation of fifteen days in its proper vessel in the Sun, let it be cleared as before of its watery humidity. Let it then stand again in the same manner for fifteen days longer with fresh juice, and after a little beating let it be kept for use in a glass or earthen vessel. This, we are told by the first compilers of the College Dispensatory, was the contrivance of John Arden, an experienced surgeon at Newark in Nottinghamshire, who lived in the reign of Edward III. After insertion of this, which they had from an ancient manuscript, they particularly direct to repeat the processes with fresh juice till the Lard looks of a deep green; and that is made the measure of the repetition necessary. The powers and honey of Mullein were from the same author, and almost three hundred years ago were in great esteem amongst the surgeons of our own country, though they have now been long in disuse."

"The Powers of Mullein; Tapsi Valentia.—Take of the juice of Mullen and of Hog's lard, each as much as you please; let the Lard be cleansed of its membranes and fibres, and broke into small parcels; then beat it with the expressed juice, press out and strain as directed in the preceding process. Let it afterwards be put into a proper vessel for nine or ten days, and then be twice more impregnated with fresh juice until it is quite green. Lastly, after all the humidity that will separate is poured off, beat it again briskly, and put it by in a proper manner for use."

The first contriver of these processes, as appears from the first edition of the College Dispensatory, directs the medicines thus made to be fresh beat once in a month.

"Honey of Mullen; Tapsimel.—Take of the juice of Celandine and one part Mullen, of despumated Honey two parts; boil gradually till the juices are evaporated, adding thereto, if the Operator pleases, calcined Vitriol and Alum with Copperas, and again boil secundum artem."

The first College Dispensatory adds from the Author, that "if occasion requires this should be at last boiled up to a pretty thick consistence; and says that it will certainly cure itchings in any part of the body, and is a most noble ointment. But it seems the present Practice hath not faith enough to rely upon it for anything, for neither this nor the foregoing are ever prescribed or made. However, it hath been thought fit to continue such extraordinary discoveries still upon record for the sake of any that may think proper to make trial with them."

It is my pleasant duty, in conclusion, to thank those who have given me much help in the preparation of this volume. First, to Dr. Warner, the Keeper of Manuscripts, who allowed me to study the Sloane MSS. at the British Museum in comfort in the room which is doing duty as the large room; secondly, to Mr. L. Galbraith, who afforded me similar facilities in the University Library at Glasgow; and, lastly, to Mr. Falconer Madan, who made me feel at home in the Bodleian. Lieut.-Col. Walter D. McCaw, Surgeon of the United States Army, responded kindly, promptly and fully to my questions about the only manuscript of Arderne which Dr. Harvey Cushing of Baltimore has been able to obtain tidings of in America. Miss Evaline G. Parker at Oxford, and Miss Margaret E. Thompson in London, have helped me by transcribing obscure passages which I was quite unable to decipher; whilst my friend, Mr. J. H. Noble, has assisted me with the heraldry of the various MSS., a subject of much interest, which I hope some day to consider in greater detail. My obligations to Mr. S. Armitage-Smith are great; and I have endeavoured to show my appreciation of the interest which Dr. Frank Payne has always taken in Arderne, and the help I have received by dedicating to him this edition of his treatises. I have tried to make the text literally accurate, and to elucidate it by such notes as were needed to explain to myself the various difficulties which occurred in reading it. No one can be more conscious of the defects in the notes than myself, but the work has been a labour of love, and if they

seem extremely bad it must be remembered that, after all, I am but a surgeon, whose business in life is to act and not to write.

BIBLIOGRAPHY.

The following table shows the manuscripts which I have examined personally at the British Museum, and in Oxford, Cambridge and Glasgow. There is said to be a French version in Paris and a Latin one at Stockholm, but I have not yet been able to obtain any information about them: there is a manuscript in Washington and another in Dublin.

Arderne issued his writings in the form of treatises, written in Latin, and with his own hand. These treatises were afterwards collected and were sometimes translated. The manuscripts therefore contain different combinations. The collection here printed is one of the more usual groups, but the translator has not rendered the whole of the last part on the preparation of various remedies. It is given in greater detail in the Ashmole MS. 1434 in the Bodleian Library.

MANUSCRIPTS OF JOHN OF ARDERNE IN THE VARIOUS LIBRARIES.

• I. PRACTICA DE FISTULA IN ANO, &C.
  
  • Sœc. xiv. Brit. Museum, Sloane MSS. No. 341, ff. 41-69 b.
  • Sœc. xiv. Brit. Museum, Sloane MSS. No. 3844, ff. 2-16 b.
  • Sœc. xiv. Brit. Museum, Sloane MSS. No. 3548, ff. 65-88.
  • Sœc. xiv. University Library, Glasgow, No. 339.
  • Sœc. xiv-xv. University Library, Glasgow, No. 112, ff. 38-98.
  • Sœc. xiv-xv. Surgeon-General's Lib., Washington, U.S.A., ff.41-138.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 6, ff. 141-154 b. [English].
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 76, ff. 143 and 144. [English].
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 238, ff. 99-214.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 277, ff. 60 b.-75 b. [English].
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 347, ff. 122-240.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 563, ff. 63-121 b. [English].
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 795, ff. 96 b.-163 b.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 2002, ff. 1-180.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 2122, ff. 10-32.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 29301, ff. 22-32 b.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 8093, ff. 140-174 [English].
  • Sœc. xv. Brit. Museum, Harleian MSS. No. 3371, ff. 13-39 b.
  • Sœc. xv. Brit. Museum, Harleian MSS. No. 5401, ff. 34 b.-52.
  • Sœc. xv. University Library, Glasgow, No. 251, formerly Sloane 2.
  • Sœc. xv. Bodley's Library, Oxford, Ash. 1434, ff. 11-107.
  • Sœc. xv. St. John's College, Oxford, No. 132, ff. 68.
  • Sœc. xv. Emmanuel Coll., Cambridge, No. 69.
  • Sœc. xv. Royal College of Surgeons, Ireland.
  • Sœc. xvi. Bodley's Library, Oxford, Ash. 829, ff. 76-80 and 81-115.
  • Sœc. xvi. University Library, Glasgow, No. 135.
  • Sœc. xvi. University Library, Glasgow, No. 403.
  • Sœc. xvii. Brit. Museum, Sloane MSS. No. 1991, ff. 142-159.
  • Sœc. xvii. Bodley's Library, Oxford, Rawl. No. 355 c.
• II. LIBER MEDICINARUM SIVE RECEPTORUM LIBER MEDICINALIUM.
  
  • Sœc. xiv. Brit. Museum, Sloane MSS. No. 56, ff. 1-100.
  • Sœc. xiv. Brit. Museum, Sloane MSS. No. 335, ff. 1-78 b.
  • Sœc. xiv. Brit. Museum, Sloane MSS. No. 341, ff. 1-40 b.
  • Sœc. xiv. Brit. Museum, Sloane MSS. No. 3548, ff. 26-99.
  • Sœc. xiv. Bodley's Library, Oxford, Digby 161, ff. 16-23 b.
  • Sœc. xiv. St. John's College, Oxford, No. 86, ff. 53.
  • Sœc. xiv. University Library, Glasgow, No. 339, ff. 232.
  • Sœc. xiv. Royal College of Surgeons, Ireland. ? date.

• ...
  • Sœc. xiv-xv. University Library, Glasgow, No. 112.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 76, ff. 1-143.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 238, ff. 8-96 b.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 347, ff. 2-75.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 795, ff. 20 b.-96 b.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 962, ff. 123 b.-248 b.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 2122, ff. 32-74.
  • Sœc. xv. Brit. Museum, Sloane MSS. No. 29301, ff. 3-22, and 32 b.-47 b.
  • Sœc. xv. Bodley's Library, Oxford, Ash. 1434, ff. 117-131.
  • Sœc. xv. University Library, Glasgow, No. 251.
  • Sœc. xv. Caius Coll., Cambridge, No. 219.
  • Sœc. xv. University Library, Cambridge, No. 292.
  • Sœc. xv. Trinity Coll., Cambridge, No. 1153, ff. 99 + 3.
  • Sœc. xv. Emmanuel Coll., Cambridge, No. 69 [English].
  • Sœc. xvi. Brit. Museum, Sloane MSS. No. 563, ff. 122-129 b.
  • Sœc. xvi. University Library, Glasgow, No. 403.
  • Sœc. xvii. Brit. Museum, Sloane MSS. No. 1991, ff. 168-224.
  • Sœc. xvii. Brit. Museum, Sloane MSS. No. 2271 [English].
  • Sœc. xvii. Bodley's Library, Oxford, Rawl. 355 c.
  • Sœc. xix. Royal College of Surgeons, England. Transcript of E. H.'s [Sloane 2271] abstract.
• III. COMMENTARY "DE JUDICIIS URINARUM."
  
  • Sœc. xiv. University Library, Glasgow, No. 328 [English].
• IV. HOC EST SPECULUM PHLEBOTOMIÆ.
  
  • Sœc. xiv. Brit. Museum, Sloane 56, ff. 1-2.
  • Sœc. xiv-xv. University Library, Glasgow, No. 112.
  • Sœc. xv. University Library, Glasgow, No. 251.
  • Sœc. xv. Emmanuel College, Cambridge No. 69 [English].
• V. SCALA SANITATIS.
  
  • Sœc. xv. Brit. Museum, 1080 A, ff. 31 b.-36 b.