There was at least one, and probably a number of English surgeons who were doing excellent work in the latter part of the Middle Ages, but John of Ardern wrote a book which has come down to us, and from him we may judge the character of his contemporaries. He was educated at Montpellier, and practised surgery for a time in France. About the middle of the fourteenth century, according to Pagel, he went back to his native land and settled for some twenty years at Newark in Nottinghamshire; and for nearly thirty years longer, until near the end of the century, practised in London. Ardern’s speciality was diseases of the rectum, but he made special studies in the treatment of fistulas everywhere in the body. He was an expert operator, and seems to have had excellent success in this field. He made careful statistics of his cases, and was quite as proud as any modern surgeon of the large numbers that he had operated on, which he gives very exactly. He was the inventor of some new instruments and of a clyster apparatus. We know something also about his fees, and there is no doubt that he obtained quite as good fees in proportion to the value of money as even any specialist of the modern time.
Ardern gives many evidences of his power of clinical observation, and incidentally makes it very clear that the eyes of the men of his time were not so held from seeing the things that lay before them as is often assumed. Mr. D’Arcy Power, in the paper on “The Lesser Writings of John Ardern” which he read before the section on the History of Medicine at the Seventeenth International Congress (see Transactions), has quoted a series of paragraphs from Ardern which make it very clear how accurate an observer this fourteenth-century Englishman was. Here, for instance, is his description of epidemic sore throat in his time, probably diphtheria, for the death within five days through strangling would seem to point to this:
“And note diligently that in the sqwynancy [quinsy] and in all the swellynges of the throte and the nekke and in all the lettynges and swolowynge as whanne the pacient thereof is oftetymys dysposyd to the deeth withinne schort time and I have seye manye deyed thereof within v dayes thorough stranglynge. To the weche it is to know that ther is nothynge more profytablere therefore thane to use glysteryes of malowys, mercurye [cheno-podium?] branne and oyle or buttre, hony and Sal gemme or comone salt. This operacione draweth the wykkyd humours to the inner partyes that causeth the syknesse and so it helpeth the sqwynnancye.”
Ardern’s description of rabies, its fatality, and of how a mad dog acts, exemplifies still further his accuracy of clinical observation. Only one who had seen many cases and understood them, and had had many mad dogs under observation, could have given the details he does. A single paragraph confirms the idea that the medieval surgeons had very clearly recognized the disease, and knew as much about it as was known until our own generation added something of more definite knowledge of the affection than could be gained by mere clinical observation. Ardern says:
“The bytynge of a wood [mad] dogge is more venemous and perilous thane it is of a serpente, ffor the venyme of a wood dogge ys hydd often tymes by the hole yere togydere and other whyle by the ii [two] yere and after some auctours it wole endure vii yere or it sle [slay] a man. And note wheyther it be longe tyme hydd or schorte or that it slee ther comene tofore to the pacient thes tokenys medlynge and chaungynge of wytte and resone and abhominacione and lothsomnesse of cold water that is clene and pure. And whane suche sygnys fallen to him that is byten of a wood hound schall unnethe or ellys [seldom or never] escape it.
“The tokenys of a wood dogge ben these; the furste is he knoweth not his lord ne his mayster and he falleth into a voyd goyinge allone with boowynge of his heed and hangynge of the erys [ears] as other wyse than ne he hadde hemin his helthe and the yene [eyes] of him ben rede and the fome cometh out at the mowth and he wole berke at his oune schadowe and he hath ane hos [hoarse] berkynge, and other houndes fleene from hyme and berken towardys hyme. And yf a schyvere [slice] of breed be folden or wette in the bytynge of the sore and yoven a dogge to ete, yf that he ete it, it is a token that the dogge is not wood, for and the dogge be wood tha other dogge that the breed is yoven to wole not ete it, but that he be over moche hungry, and yf he denye to ete the seyde breed, out-take [unless on] the condicione aforeseyd, thane is the dogge wood.”
Ardern’s description of a case of traumatic tetanus is very interesting, because it contains so many elements that are familiar in the history of this affection. The fact that it occurred in a gardener from a hook, so likely to be infected with tetanus bacilli from hay or grass, and that the wound was made where the thumb joins the hand and where, as we know now, the construction of the tissues is so favourable to that burying of the tetanus bacilli away from the free oxygen of the air, giving it a chance to grow anaerobically, all show the disease exactly as in our own time. The other details of the case probably indicate a wound of an important bloodvessel, secondary hæmorrhage after suppuration had been established, and then the development of fatal subacute tetanus.
“A gardinere whyle that he wrowghte in the vynes kytte his owne hande with ane hooke uppone a ffryday after the ffeste of Seynt Thomas of Caunterbury in somere so that the thoombe was altogydere departyd from the hande saff only in the juncture that was joyned to the hande, and he myghte boowe bakward the thoombe to his arme and ther stremyd out therof moche blood.
“And so touchynge to the cure. The thoombe was furst reduced in to his furste ordre and sowyd and the blood was restreyned with the reed pouder of launfrankes [Lanfranc’s red powder] and with the heerys [hairs] of ane hare and it was not remevyd une-to the iiide day when it was remevyd tther apperyd no blood. Thanne was ther putte therto tho medicines that engendren blood, every day ones repeyrynge the wounde, and tho it begane to purge itselffe and to gadere mater. And in the iiiithe nyght after the blood brak out abowte mydnyght in the wheyghte of ii poundes. And whane the blod was restreyned the wounde was repeyred frome day to day as it was furste.
“Also in the xithe nyght abowte the forseyd oure the blood brake owt ayene [again] in more quantyte thane it dyde afore tyme, nevertheless the blood was staunched, and by the morne the pacient was so taken with the crampe in the chekes [cheeks] and in the arme that he myght resseyve no mete in-to his mowth ne neyther opene the mowyth (lockjaw) and so vexynge the pacient in the xv day the blood brake out ayene owt of mesure and alwey the crampe endured forth and in the xx day he dyde.”