The Owl Hidden in the Dark: Medieval Surgeon John of Arderne and the Birth of Palliative Care

In medieval Europe, surgery was a painful and often fatal craft, usually practiced on battlefields without anesthesia or antisepsis. Surgeons generally cut away any mass brutally or cauterized it with hot iron. But in England in the 14th century, a figure emerged who changed this dark picture and entered history as much through his pen—and compassion—as through his scalpel: John of Arderne (1307–1392).

Regarded as the father of English surgery, Arderne was known for his skill in treating anal fistulas caused by the long hours knights spent on horseback. Yet in his masterpiece written in the 1370s, “Practica of fistula in ano” , he included an entirely different detail that would be written in golden letters in the history of oncology: Cancer of the rectum (the final part of the large intestine).

The power of metaphor: "Bubo" (owl)

In his work, Arderne named rectal cancer "Bubo" (Latin for owl), using a surprising and poetic metaphor in medical literature. Why? He explained it in his own words:

The original manuscripts contained small owl figures he had drawn beside the lines describing this disease.

Diagnosis: the truth seen by the fingers

The diagnostic method he described was the digital examination (digital rectal examination) that forms the basis of modern proctology: "The physician should insert a finger into the patient's anus. If something as hard as stone is found inside, and this hardness prevents the patient from passing stool, it is certainly a bubo."

"Primum non nocere": knowing where to stop

But what made John of Arderne a true medical legend was not just his accurate diagnosis; it was knowing "where he should stop" as a physician. While charlatans of the time promised desperate patients they would cut out every kind of tumor, leaving them to die in terrible pain, Arderne openly wrote that advanced rectal cancer was inoperable under the conditions of that era. He warned his colleagues:

"Do not intervene excessively in this disease. No treatment performed by human hands can cure it; do not cut the mass with your scalpel and cause the patient more pain."

A palliative care protocol in the Middle Ages

Instead, he offered one of the oldest known "Palliative Care" protocols (relieving and supportive treatment) for cancer patients in human history. His aim was not to eliminate the disease, but to relieve the patient's suffering and allow their final days to be spent with human dignity.