Classic Articles in Colonic and Rectal Surgery MARVIN I.. CORMAN, M.D., Editor John Arderne

1307-1380 (?) In this third installment of Arderne's Treatise on fistula-in-ano, the author d e s c r i b e s other m e t h o d s o f treating the condition, e.g., the use o f a seton and the various m e d i c a m e n t s . H i s approach to the treatment of c o m p l i c a t e d fistulas has o n l y recently,been revised in that u n r o o f i n g of all external o p e n i n g s is n o longer c o n s i d e r e d a requisite.* A r d e r n e J. Treatises of fistula in ano, h e m o r r h o i d s , and clysters. Dis Colon R e c t u m 1 9 8 3 ; 2 6 : 1 3 4 - 1 3 8 .

Treatises of

Fistula in Ano Haemorrhoids, and Clysters BY

J O H N ARI)ERNE, FROM

AN EARLY F I F T E E N I ' t t - C E N T U R Y MANUSCRIPT TRANSLATION.

EDITED, Wl'l'tt INTRODUCTION,

NOTES, E'rc.,

BY

I)'ARCY POWER, F.R.C.S. FNO. SURGEON TO, AND LECTURER ON SURGERY A t , ST. BARTHOLOMEW'S IIOSPI'IAL.

I.ONI)ON: PUBI.ISHED FOR T I l E EARLY ENGLISH T E X T SOCIETY BY K E G A N

PAUL, TRENCIi,.'FRI~BNER

DRYDEN IIOUSE,

A N D BY I I E N R Y

43

GERRARD STREET,

FROWDE,

AMEN CORNER,

OXFORD

E.C.,

AND IN

& CO., LTD., SOHO,

W.

UNIVERSITY

PRESS,

NEW YORK.

1910.

T h e Council of Early English Text Society grants permission to reprint the following: Arderne, .John. Treaties of Fistula-in-Ano, Hemorrhoids, and Clysters, from early Fifteenth Century M a n u ~ r i p t Translation (Original Series 139, 1910). Power, D'arcy, FRCS, Ed. Treatises of Fistula-in-Ano, Hemorrhoids, and Clysters by J o h n Arderne, from an early Fifteenth Century Manuscript Translation. Kegan Paul, T r e n c h , T r u b n e r & Co., Ltd., London. And by Henry Frowde, Oxford University Press, New York, 1910. * Editor's suggestions: Read aloud. 3 = the letter "Y" or the silent "GH": the letter "S" at the end of" a word. ,b = the sound, "th." 0012-3706/83/0200/0134/$01.05 9 American ,Society of Colon and Rectal Surgeons

134

Volume 26 Number 2

CLASSIC

ARTICLES

135

O f a-nober m a n e r wirchyng in be same fistule a n d Joe cure wib diuerse exemple 3 . Reasons fbr preterring to cure by lig a-

1 Prosecuta ergo tall cura et innexlone debito modo |acta/ 2 C u r e nodo currente Anglice "large knot" vel "slippyng knot."

Set CUll] nastare ligneo infundatur in a n u m de vitello o~i c r u d o cure oleo ros. nlisturll.

T h e leech to keep a stock o f ligature material, and to be very careful to keep his methods secret.

A prescription for a g ~ o d clyster,

and another tbr a plaster.

lcunl spatulk

If it Joy falle forsob bat be fistule be depe and haue grete distance atuix .be hole of be f i s t u l e and be lure. Or ifJ0e pacient be ferdful for to suffer kuttyng. Or for ober notable cause 3 b e i n g ber, ban may be lech with kuttyng of.be brede ydrawen thur 3 .be midde 3 of Joe hole of.be fistule and Joe lure kutte Joe flesch, and bat availeb even to kuttyng with iron, outtake bat it askeb a longer tyme of curyng. For why; Joof'al be b o u n d e n ri3t streitly at be first tyme 3itte vnnebe schal.be fretygn be complete in som men by a monejo or thre weke 3. 82Sich cure berfor ysewed and Joe festnyng ydo on dewe maner, 1 bat is after bat be pacient may resonaJoly suffre, puruey.be leche if be pacient be delicate or feble, or waike o f hert, bat b e brede by which Joe fistule is knytte, be so b o n d e n bat if it be nede bat it may be loused without kuttyng, bat is with a lache knotte or slyppyng knotte, z 82Which ydo, lye .be pacient o n a bedde; or stande he or go he by'bre oure 3 or 5, or 6, vnto b a t h e payne ycaused of be b y n d y n g cese somwhat. A n d wheber Joe akyng cese at be forseid tyme or no3t, putte ,be pacient on a bedde and with a naister of tree putte into .be lure o f be 3olk of a raw ey, medled with oile of rose leuke, 3 and be .be lure wele enoyntid 4 of.be same withouteforJoe. And so wiboute puttyng atuix o f any-.bing late it aloon by a ni3t; At morne, forsobe, bifore bat Joe pacient go to priu~, be 3ettid into be lure by a nastre som oyle, what-so pl~sejo to be, Joat Joe pacient may so moche more li3t ese hym. Witte b o u bat bus owjoou to chaufe Joe 3olk o f an ey with oyle. Tape be nastare wib be forseid medicyue putte in Joe bledder, and be bledder putte in some vessell wijo hote water, Joatbe medicyne may be chauffed by be hete of be watre; ffor why; hote bing eseb better Joe akyng, b a n afore be pacient go to Joe priu6, take Joe leche Joe forseid Jorede in Joe lure, and be Joe vtter knotte loused, and aftir be Joe Jorede more strongly constreyned if it may wibout anguissh of Joe pacient. Elle 3, forsojoe, be it b o u n d e n wib tuo knott/s or bre vnlouseable, and be Joe h e u e d e 3 o f be Jorede 3 kutte away so nero be knotte bat bai may no3t be perceyued of Joe pacient or o f ojoer men. A n d witte b o u Joat be leche shuld haue e u e r m o r e Jorede of white silke, small and strong; if he haue no3t, forsobe, Joan take he strong Jorede o f lyne or of tuyne. A n d in no maner after his mi3t shewe he n o 3 t his wirkyng, nouber in kuttyng ne wib brede byndyng, bat his werke Joe perceyued o f strange men, bat his cure be no3t litle sette by, or Joat any ojoer witty man perceyuyng his werk mow vsurpe it to hymself; for Jous did I, berfore wake 3 e, for he bat is warned aforne is no3t bigiled. It byhouejo a leche vse many cautele 3 , 'bat he adourne 1 his faculte, whiche I may no3t note to Joe laste. It seemeb, forsobe, vnwor'bi for to vse wele bingis y-giffe Joat kan no3t gette hym mo bingis, berfore when Joe pacient has clensed his wombe, be he putte vpon a bedde, and be his lure wele clensed and wyped wijo hote watre and wiJo a sponge. Aftirward be it e n o y n t e d wib bi fynger atuix Joe buttoke 3 and on ich aside about Joe lure wib Salus p0puli hette in an ostree shell. Aftirward be her 3etted in by a nastare Joe 3olk o f an ey as aboue wib oile. Aftirward be her putte aboue siche ane Emplastre: Recipe--be Iuyse of smalache or merch, wormode, Molayne, walworte, Sparge, waybrede, Mugworte, auance, petite consoude, wodbynd. O f alle Joise herbes, if Joou may haue Joam, take e u e n porcion, outtake o f wodebynde, o f whiche if it may be hadde, be taken be triple or quadriple. If al, forsobe, may not be hadde, take Joe tober Joat b o u may haue, and namely be ])re first named wib wodejoynd i f b o u may haue it. T h e confeccion) is b u s : - - T a k e be Iuse o f be herbes, and Joe it medled wib als mich of wele clarified hony, al-wise m o u y n g on an esy fire, and boile tham so long vnto bat be watrynes o f Joe Iuyse be somewhat bikned; whiche, y-take o f Joe fire and keled, kepe it in a gode potte? It may laste al one 3ere or tuo; berfore w h e n b o u wilt vse berof, take of it als mich as it is nede, and putte berto als miche of whites of eiren, wele y-bette and seomed, s and m o n e barn togider. Aftir be,ber put to Joam o f subtile mele of whete als moche as sufficeb, and medle ham wele to-gidre;,bam putte to a litle oyle o f olyue, or o f fressli buttre scomed at .be fire, wib als miche virgino wax togidre dissolued at Joe fire by it self; Joan first putte abune Joe iuse to be fire wijo h o n y and white o f eyren, and m o u e ham all wayse wib a sklyse 1 bat Joai cleue not to Joe panne. W h e n forsobe it is wele hote but

t..... ther cislon.

than by in-

T h e details o f treatment by ligature.

A method of giving a clyster by Means o t a bladder softened in hot water and attached to the e n d o f the nastar or glyster pipe.

lut facu1. tatdecoret. .......

'ab i~e aepo~itaet infrigerata, ~ . . . . tur. 'priu~ad ignem despunati.

1 36

Treatment of compficated fistulae. Lay all the openings into one.

A successful case.

Qui vero, ut dixit, viginti medicorum c u r a m subegit.

CLASSIC ARTICLES

Dis. Col. & Rect.

February 1983

not wele y-soben, be be wax molten wib oile or buttre, as it is seyde aboue; whiche y - m o h e n and be forseid ,bingis b e y n g hote--J~at is to seye,be hony, J~e iuse, and Jbe white o f e y r e n - - b e 'bai 3etted togidre, and so e u e r m o r e m o u y n g strongly wib a spatour, se,be ,bam on a softe fyre vnto,bey be made o o n body: whiche y-do, sette it of,be fire, and it beyng hote, putte to o f t e r e b e n t y n e als moche as suffice,b and m o u e it Strongly wi b a spature vnto bat ,be terebentyne be d r o n k e n in. And if it be n e d e for to chaufe it m o r e for~be t e r e b e n t y n e , loke .bat it suffre n o 3 t mych hete, for in se,bing lose.b t e r e b e n t y n e his my3tes. Jbise y-do, be it yputte in a .box a n d y-kepte to vse. Take o f his and wib a s p a t o u r or with b i , b o m b e strech it vpon clene lyn stupe 3 and softe, and put it v p o n b e lure, and aboue put a lyn cloute and b y n d e it, as it is seyde, in ,be cure o f cuttyng, his emplastre, forso,be, is called 'diaflosmus,' for molayne .bat is called flosmus. And not oonly it availe,b in ,bis forseid cure but also in cuttyng of.be fistule; ffor why; it hele,b wele alle woundes, J~of-al ,bai be horrible, & also bolnyngis in w o u n d e 3 and in brissures; and it seseb wele b e akyng/s o f woundes and o f brusours. And it eseb wele ,be akyng/s and.be bolyng~s o f ioyntures; Jais, forsobe, haue I ful ofte proued. I sey, forso,be, bat .Ibis emplastre i-had, it is no3t n e d e in,be forseid case 3 to r e n n e to ober medicynes. And witto b o u bat ,ber is a naturel vertu in walwort bat moste wele r e s t r e y n e b blode o f woundes, and akyng and bolnyng o f w o u n d e s and o f a l m e m b r e 5 it do,b best away. Witte b o u ,bat.bat confeccion aboue ,bat receyue,b Smalache, w o r m o d e , moleyne, sparge, &e, wib clarified hony so,ben togidre at.be fire and kept by itself in a vessell is called 'Tapsimel.' When, forsobe, her is a d d e d ,berto white o f eiren a n d oyle, wiJ~ wax and whete floure and terebentyne, and ar so.ben togidre, b a n is is called 'diaflosmus.' And ,bus ow,bam to b e proporcioned:--Recipe, tapsimel, white o f e i r e n - - a n a ~ iiij; whete floure 3 iij; oyle, w a x - - a n a ~ iij; terbentyne ~ ij. A n d witte b o u .bat if in ,be tyme o f be m a k y n g o f Tapsimel may be f o u n d e n a litel pety morel 1 whiche bere'b white f o u r s a n d b l a k grapes o r berie 3, it shuld for certayn make ri3t noble ,be emplastre diaflosmus. A n d petite morel is called in fflaundres 'Naghtstach. '2 And witte b o u bat 'be iuse o f it do,be best awey J~e pustules in childres 3 mouJ~es, If, f0rso,be, ,ber be many holes persed to-gidre, J~an owe be leche als sone as he may for anguissh of be pacient, after.be reperacion of.be first wounde, as it is seid afore, for to knytte wib a,brede, as it is seyde afore, be to,bet holes strongly. Or, if he may, bat is better.bat bay be kutte al fro oon hole to an-ober, acu rostrata, b o snowted nedle y-putte in'be hole, or sem lynne tent, kutte .bam to be g r o u n d e wib a rasour or wib a launcete. Whiche holes, fbrsobe, y-brou3t into oon, be .be wounde als soon y-filled o f puluer sine pari; Aboue the p o u d r e , forsobe, I putte stupes kutte small, o r coton), or carpe o f lynnen clobe. Aftir p u t t e aboue,be forseid emplastre diaflosmus, and be it b o u n d e n as it is seid, and ich day oone 3 reparailed. I sawe a man o f N o r t h a m p t o u n 4 ,bat had ,bre holes in ,be lefte buttok, and .bre in ,be testicle 3 codde, and al persed fro oon to ano,ber by,be m i d d e 3 o f longaon; whom I c u r e d wit~ cuttyng o f al be holes at oon tyme, of longaon as wele as o f o,ber. Of,be kuttyng, forso,be, o f longaon, blode went strongly out, for ,be fistule was ri3t depe; w h e r e f o r e ,be pacient swowned; perfore I putte to a sponge wette in cold watir and r e c e y u e d Jae blode. Aftirward I put in be kuttyng o f longaon restrictyues o f blode, o f whiche it is seid aboue, and a gode sponge y-wette in cold watre. I made ,be pacient for to sitte in a chayer, and als soon b e blod was cesed. And aftir reietyng o f mete and drink, he went into his b e d d e and sleped wele all be ni3t, wil~oute goyng out o f blode. In,be m o r n e , forsobe, he had hym wele; ,be seconde day, forsobe, after be k u t t y n g I filled all b e w o u n d e s o f puluer sine pari, and as it is seid afore in all Jaingis, with oile and an ey and salus p0puli and diaflosmus I helid h y m finaly wib in 14 wekes. Whiche, forso,be, 1 as he seid, he v n d e r 3 e d e ,be cure of m e n y leches, A n d suffred it ten 3ere. A n d witte'bou bat I saw neuer man v n d e r my h a n d suffre swounyng, outake hym ,bis; he was forso,be c o r p u l e n t and waike o f hert, ,but neherlesse aboute be f o u r t y day after be kuttyng he rode. I heled anoher man bat had a fistule in,be same m a n e r in all,b{ngis, outake bat longaon was no3t persed; w h o m I cure wi.b kuttyng in be same maner as it is seid of.be first. I haue sene som men hayng oon hole aloon ni 3 ,be lure bat persed no3t be longaon w h o m I heled wi'b puluer sine pari finaly; but for,be m o u b e of.be vlcere was ouer streit, first I put aboue o f v n g u e n t o r u p t o r i o o f calce vine & sape for to large,be m o u h e o f the fistule; o f whiche it shal be treted afterward a m o n g ob/r confeccions. I haue sene som m e n haue

B..... ful in heating

preparations

which contain turpenheattine beaissi. ..... pates its strength. T h e preparation o f "diaflosmus."

it......

"Tapsimel, its prepara-

ti. . . . d ..... 1~ol p a r v. u.m. . possit haberi. ~Naghtsarth. 3childre3

4Vidiet

alium homi-

......

lohan: Colyn de ton.N~

Another ....

Volume 26 Number 2

Treatment by tents.

Blind internal fistuhe.

Arderne's operation good,

bene alleviatur.

CLASSIC

13 7

ARTICLES

tuo holes bysde,be lure, of whiche oon persed be longaon and.be tober persed in no place, .but it was oonly symple by itself in be flesshe, h a u y n g no passyng to .be tother hole. O f whiche was such a c u r e : - - T h e hole nerre .be lure was cured wi`b kuttyng or byndyng; `be to ber, forsobe, wi.b poudre sine pare y-put in and diaflosmo, and oon emplastre.bat is called Neyrbone putaboue, whos confeccion) shal be shewed aftirwarde. I saw also, and, oure lord beyng mene, I heled perfitely a man.bat had ffistula in ano on .be ri3t side and on .be lefte side; whiche, forso`be, had on-be lefte buttok 8 hole 3, and `bre in .be ri3t buttok; and wibin was longaon persed toward`be ri3t side oonly. But ne`berless all`be holes of ai`ber party of`be lure answered togidre in `be g r o u n d e `bat was p r o u e d .bus. I toke a siryng of siluer and a bleddre y-bounden boute ful of sanguis veneris, and .be siryng y-putte in bur 3 oon hole and .be bleddre compressed wi-b,be fyngers, be oile in3etted went out by al be holes togidre on bo`be sides, nad ne`berlesse `be hole of longaon answared no3t but to oon hole oonly, and .bat in`be ri3t buttok; ,be soJgefastnes of whiche .bing was p r o u e d wi`b,be instrument `bat is callid sequere me, and wi`b acu rostrata, wiJ9 ful gret hardness an bisynes; .be cure of whiche was suche: ffirst euery day in`be lefte buttok.bur 3 oon of.be holes I 3etted in sanguis veneris wiJ9 .be forseid siring and bledder; whiche y-do, I putte in tuo tentes or,bre, or lard of pork or swyne in .be larger holes; after.bat be depnes of.be fistules asked, .be heuedes, forso-be, of`be tentes was tokned with `bredes drawen`bur 3 `be middes wi.b a nedell, `bat]be tentes shuld no3t be d r o w n e d in`be g r o u n d e of-be fistules when .be tentes war put in. A n d I putte aboue -be emplastre.bat is called Neyrbon strecchid vpon lynne clouts, and dewly y-bounden about.be lendes wi.b a girdill and cloutes y-shapen as it is seid afore. I lefte it in pece vnto,be morne. At morne, forso`be, .be emplastre remoued, `ber appered a,boue 3 e emplastre ful putrid quitour in superflue quantite. Eftsones in,be secounde day I reparailed it in al.bing/s as in.be first day, and it bifell as in .be firste day; and so it continued almost by a mone.b. W h e n .be quitour, ,berfore, bigynne to lessen somwhat, and the bolnyng somwhat to cese, and ,be colour and.be substaunce of.be skynne for to turne to his ovne naturel habitude, ,ban at.be first t u r n e d I to ,be pr/ncipale cure of.be fistule with persyng of longaon, whiche I cured fina ly wi-b b y n d y n g of a,brede in,be hole of longaon..be to-ber hole 3, form-be, beyng bisyde it I cured wi-b cuttyng and with puluer sine pare. Euermore continuyng.be cure wi.b`be siryng in .be lefte side, and wi.b tentes als long as .bay wolde entre in, a n d .be emplastre Neyrbon y-putte aboue, and salus populi and vnguento arabico, vnto a loueable ende wi`b goddes help aboute half a 3ere I cured hym, and lefte hym in pece. Also `ber bene som men ,bat ha`b fistules no3t a p p e r y n g outward, but bay putte o u t miche putred & watrye humour, and som-tyme clere blode, and somtyme blode y-medled wib quitour. A n d .bai disese myche,be pacientes and feble.b,bam. And oft-tymes suche m a n e r sikenes bene toward`be rigbone of,be bak ni 3 .be lure, ,bat ,bay may be feled wi.b a fynger. But whe-ber,bay may be feled or no3t be .ber done suche a cure wi.b whiche I haue cured many men. Be -be pacient putte vpon a bedde wyde opne agaynes a wyndowe, li3t shynyng, and.be legges y-raised vp and wi`b a towel y-hungen or wib a corde o r d e y n e d to `bis werk; whiche y-do, be .be lure y-opned wi.b tonges so y-shape.bat when.be vtward endes bene streyned togidre,be inner endes be opned & agaynward. O r if.be leche kanne ymagyne more couena`ble instrumentis to b e forseid werk to `be done, for so mocbe loued be god`bat streyngbes mannes witte in godes..be lure, forso.be, y-opened, and`be sikenes,bisily y-sene, be,be hole of-be sikenes y-filled wi`b puluer sine pare, and coton y-putte aboue; be .be tonges warly drawen out .bat -bai spill no3t ,be poudre, or .bat ,bei h u r t no3t .be pacient. Whiche y-drawen out, and .be legges laten doun, late -be pacient long reste or`bat he go, ,bat.be poudre be no3t letted for to go; and abide it so stille vnto -bat `be pacient clense his wombe; and if.be pacient may abstene hymself fro,be pryu~ by two dayes, it war full necessary to hym. When ,be pacient, form.be, ow to be reparaled,.ban be.be lure wasshen and dried; whiche y-wasshen, be`ber 3ette in of a 3olk of an ey wi`b sanguis veneris to esyng of `be ake ,bat come]) of puluer sine pare, and to .be clensyng of`be vlcer of flessh mortified by,be forseid poudre. And ,Ibiscure continue`be leche .by fife dayes or mo, `bat is to sey of`be 3olk and of sanguis venaris, vnto,bat he se ,be pacient wele alegedde 1 of.be first akyng. Whiche y-do, `ban owe ,be leche in ,be best maner`bat he may for to opne .be lure and bisily biholde wi-bin, and considere if`be sikenes be mortified; whiche is knowen if.bat `be vlcer seine d e p p e r b a n it was sene afore .be p u t t y n g in of .be

cfistulae ..... f with ..... yopenings.

a methodto realfistula when there ...... y external openings. discover the

hut he is not wedded to it.

After-treatment.

Examine for gangrene.

138

2et prosequatur.

Diminished discharge a good sign.

T h e treatment of ulceration o f the rectum.

T h e applications are not to be too irritating.

Soothing clysters are best.

Hoc superposito post mortificationem putrid~e carnis.

Dis. Col. & Rect.

CLASSIC ARTICLES

February 1983

p o u d r e , and also by o,ber tokenes,bat a g o d e leche fynde,b m o r e experte o f long exercise. In J~is J0erfore to ,be y k n o w e n be n o 3 t be leche slowe; f o r why; ,ber shal folow n o 3 t litle louyng )~erof. ,berfore if it,be no3t mortified be it eftsones filled o f puluer sine pare, a n d be it sewed ~ in all ,bingis as it is seld afore, wib b e 3olk o f an ey, & wib sanguis veneris, v n t o .bat he se efte-sones .be pacient wele alegged, as it is seid afore. W h e n , forso,be, he trowe.b 'bat it is mortified, b a n it is to t u r n e agayne to ano,ber cure, ,bat is to sey,bat he take ,be 3olke o f an ey to whiche be a d d e d ,be h a l f p a r t e o f tapsimell, a n d als miche as suffice,b o f p o u d r e o f a l u m m e 3 u e a r y n e y-brent. And.be it so m a d o , b a t it may,be 3etted in by a N a s t a r o f tree; a n d ,bis cure ,be c o n t i n u e d al-oonly by J~re or f o u r e dayes: ,be fourJ~e, forso,be, o r , b e fifthe d a y aftir J~is m e d i c y n e d o n e to, be b e vlcer r e p a r a l e d wib,be 3olk o f an ey a n d sanguis veneris J~re or f o u r e dayes continued. A n d so owe,be leche for to c h a u n g e his h a n d e f r o o o n m e d y c y n e to ano.ber, vnto.bat he se ,be superflue moistene 3 firste g o y n g o u t for to cesse; .bat is t o k n e o f cure or helJ~ b e y n g ni3e. Joan, forsoJ~e, may he with v n g u e n t o arabico a n d salus populi finaly spede ,be forseid cure a b o u t e f o u r & tuenty wekes, or m o r e or lesse, aftir J~at,be pacient be o b e d i e n t and bisy; ffor why; gret s p e d e o f werk standeth in J~e paciens a n d bisynes o f J~e pacient. 1 A n d it is to witte .bat in all vlcerie 3 J~eyng wi,bin 'be lure, or moiste ragadiis p u t t y n g out q u i t o u r o r blode, ,bis I sey.bat.be vlcerez be no3t buboncs, i.e. owles, o f whiche it shal be seid aftirward, for,bai be al vncurable~: ,bat if a leche may n o 3 t wi,boute grete anguissh, als wele o f h y m s e l f as ofJ~e pacient, o p n e ,be lure of,be pacient wib tonges, as it is seide afore, 'ban owe .be leche oonly putte in o f tapsimell a n d puluer sine pare m e d l e d togidre in suche biknes.bat it may be 3etted in by a nastare o f tree. For why; ,bis medicyne mortifieJ~ wele a n d clenseJ~ p u t r e d flessh in an vlcere. But witte,bou .bat e u e r m o r e aftir,be 3ettyng in o f tapsimel wi.b,be forscid p o u d r e , ,bou ow in J~e nexte r e p a r a l y n g for to 3ette in wi,b a nastare o f tre of ,be 3olk o f an ey wib sanguis veneris o r oyle rosette, or wiJ~ comon) oile if'be forsaid wante. A n d 'bis cure be c o n t i n u e d wiJ~oute leffyng by ,bre or f o u r e dayes. It s p e d e b no3t, forsoJ~e, J~at medicynes b r y n g y n g in a k y n g be to m o c h e vsed or h a u n t e d , as is tapsimel wib puluer sine pare. Ne'berlesse tapsimel wiJ~out puluer sine pare, wib,be 3olk o f an ey a n d wiJ~ p o u d r e o f bole a r m o n i c ful smal y-broke and m e d l e d wi~ oile o f lynsed togidre, olye o f rose a d d e d to, o r of violett/s, or o f sanguis veneris if it be had redy. A n d 3etted in wi~ Nastare of tre, heleb wele vlceres, ragadyes, and excoriacions or fleyngis wipin .be lure; his s u p p o s e d after be sleyng of flessh p u t r e d , 1 wiJ~ e n o y n t y n g o f salus p0puli, .bat availeth beste for certeyn in e u e r y cause wiJ~in ,be lure a n d wiJ~oute.

Treatment for gangrenous inflammation o f rectum.

1 Nam magna operis expeditio in patienti~t et sedulitate patientis consistit.

2 Nota de ulceribus infra anum existentibus. Et notandnm quod in omnibus ulceribus infra anum existentibus, vel rhagadiis humidis saniem emittentibus vel sanguinem, hoc dico, quod ulcera non snnt bubones, de quibus inferius suo loco dicetur; Bubones namque sunt omnes incurabiles.

The continuation of this material will appear in subsequent issues of'Diseases of the Colon and Rectum.

Acknowledgments The editor is most grateful for the assistance of Miss Elizabeth McChristie, research associate, Reeves Medical Library, Santa Barbara Cottage Hospital, Santa Barbara, California. The editor thanks Frank C. Gardner, Ph.D., Associate Professor of English at the University of California at Santa Barbara, for his help in the preparation of the article and J. Peerman Nesselrod, M.D., Sansum Medical Clinic, Santa Barbara, California, for

suggesting the Arderne book and making it available from his personal collection.

Bibliography Power D, Ed. Arderne J. Treatises of fistula in ano, hemorrhoids, and clysters, from an early fifteenth century manuscript translation. London, Kegan Paul, Trench, Trtibner and Co:, Ltd., 1910.