detected in the palms of the hands and the soles of the feet, thirst,
a roughness of the tongue, slenderness of the neck, wasting of the
entire body, constipation, wasting and shrinking of the finger-nails
and fingers, hollowness of the eyes, pain in the left scapula
extending to the shoulder, pharyngeal catarrh with abundant and
mucilaginous sputum and a tendency to lachrymation. If the sputum
thrown upon the coals emits a fetid odor, it is a sign of confirmed
ptisis, which is incurable. The disease when it occurs in youths and
young persons rarely lasts longer than a year, often terminates in
less time, and may sometimes, by the aid of medicine, be prolonged for
a greater period. If the sputum received during the night in a vessel
is flushed in the morning with warm water, while some impurities
remain upon the surface, the putrid matter will sink to the bottom
(_sputum fundum petens_), and the indications are fatal. Likewise
sharpness of the nose, hollow eyes, slender nails, falling hair,
flattened temples and diarrhoea are of evil omen. These patients
converse while dying, and die conversing (_moriendo loquentur, sed
loquendo moriuntur_). Gilbert, of course, supplies a formidable array
of remedies for the disease, but tells us that the "very latest" is
cauterization over the clavicles (_Novissimum autem consilium est
cauterium in furcula pectoris_).
The varieties of difficulty of breathing are classified under the
titles of asma, dispnea, orthomia, hanelitus and sansugium. The
last title is given to a condition in which, as Gilbert says, "A
superfluous humor is abundant in the superficies of the lung, which
compresses that organ and renders it unable to dilate in inspiration.
Hence it labors in inspiration like a leech, from which the dyspnea
derives its name."
Under the single title of "_cardiaca passio_" are included all
possible diseases of the heart. The symptoms of this disease are
said to be "palpitation, twitching of the limbs (_saltus membrorum_),
perspiration, weakness of the nerves, facial pallor, weakness of the
body as in hectic fever or phthisis, excessive pain and faintness over
the precordia, a disposition to sleep and often constipation." The
treatment is, of course, entirely symptomatic.
Diseases of the digestive apparatus are discussed under the headings
of difficulties of deglutition, canine appetite, bolismus (boulimia),
disturbances of thirst, eructations, hiccup, nausea and anorexia,
vomiting, anathimiasis (gastric debility), anatropha and catatropha
(varieties of obstinate vomiting), pain in the stomach, abscess of the
stomach, salivation, colic, dysentery and diarrhoea, intestinal worms,
hemorrhoids, rectal tenesmus, prolapsus ani, fistula in ano, diseases
of the liver, dropsy, jaundice and diseases of the spleen.
Abscess of the stomach sometimes manifests a circumscribed tumor,
and accordingly, probably includes cancer of that organ. Approved
remedies are the Al'mirabile, the stomatichon frigidum, calidum or
laxativumvum, etc., stereotyped formulae, of which the composition is
carefully recorded.
Dysentery is a flux of the bowels with a sanguinolent discharge and
excoriation of the intestines. A variety called hepatic dysentery,
however, lacks the intestinal excoriation. Diarrhoea is a simple
flux of the bowels, without either the sanguinolent discharges or
the intestinal excoriation. Lientery is a flux of the bowels with the
discharge of undigested food, occasioned by irritability (_levitas_)
of the stomach or intestines. Colical passion and iliac passion
derive their names from the supposed origin of the pain in the colon
or ileum, a remark which furnishes occasion for the statement that
Gilbert divides the bowels into six sections, viz., the duodenum
jejunum and ileum, and the orobus, colon and longaon (rectum).
Intestinal worms are not generated in the stomach, as Gilbert says,
because of the great heat produced by the process of digestion. In the
intestines they originate chiefly from the varieties of phlegm, e.g.,
saline, sweet, acid, natural, etc. The species mentioned specifically
are lumbrici and ascarides or cucubitini, though the terms long,
round, short and broad are also employed, and probably include the
tape worm or taenia lata. The treatment of these parasites consists
generally in the use of aromatic, bitter or acid mixtures, among which
gentian, serpentaria, tithymal and cucumis agrestis are especially
commended for lumbrici, and enemata of wormwood, lupinus, scammony,
salt, aloes, etc., for ascarides.
The diseases of the liver, though not numerous, are allotted
considerable space most of which is occupied by scholastic
speculations and the usual rich supply of therapeutical suggestions.
Discrasia of the liver has several varieties, warm, cold, moist and
dry, and seems nearly equivalent to our somewhat overworked term of
"biliousness." Gilbert's favorite compounds for the relief of this
condition are the Trifera sarracenica, the Electuarium psilliticum and
above all the Dyantos Besonis.
Obstruction (_oppilatio_) of the liver or enfraxis is defined as a
disease of the canals (_pori_), of which four are enumerated, to-wit,
the meseraic, that of the convexity of the organ (_gibbus--ubi sunt
exitus capillarium venarum_), the duct leading to the gall-bladder
and that leading to the spleen. With an abundance of symptoms, it is
singular that this comprehensive disease does not seem characterized
by any constant or severe pain, as we might reasonably expect.
Abscess of the liver depends upon some vice of the blood, the bile,
the phlegm or the black-bile. The general treatment is poultices and
other maturatives, but, as the author adds rather sadly at the close,
_ultima cura est per incisionem_.
Dropsy is discussed as an independent disease through the exhaustive
speculations of thirty-two pages. Gilbert tells us it depends upon
some fault of the digestive faculty of the liver, and he divides
it into four species, to-wit, leucoflantia, yposarcha, alchitis and
tympanitis, each of which has its special and appropriate treatment.
In the dreary waste of speculative discussion it is cheering, however,
to observe Gilbert's positive recognition of the sphere of percussion
indicated in the passage:
"_Et venter percussus sonat ad modum utris semipleni aqua et venta._"
(f. 250b.)
Ycteritia or jaundice receives equally thorough discussion through
eight weary pages, including the usual polypharmacal treatment.
The spleen, Gilbert says, is sometimes the name of an organ, sometimes
of a disease. As an organ it is spongy and loose in texture, and
attracts and retains the superfluities of the black-bile, expelled
from the liver for its own cleansing. Hence it is a servile and
insensitive organ, and accordingly suffers different diseases, such
as obstruction, tumors, hardening, softening, abscess, and sometimes
flatulence or repletion. The symptoms and treatment of each of these
morbid conditions, arising from either heat or cold, are discussed
with exasperating thoroughness, and the chapter concludes with
the composition and use of various specific remedies of compound
character, bearing the impressive titles of Dyasene, Dyacapparis,
Dyaceraseos (a mixture of cherry juice, honey, cinnamon, mastic and
scammony) and Agrippa.
Scrofulous swellings are carefully considered in a chapter entitled
"_De scrophulis et glandulis._" "Scrophulae and glandulae are hard
swellings developing in the soft parts, as in the emunctory localities
of the veins and arteries, particularly in the neck, armpits
and groins, and sometimes in other places. They spring from the
superfluities of the principal organs, which nature expels, as it
were, to the emunctories and localities designed to receive this
flux." ... "Hence they are often found the cause of scabies, tinea,
malum mortuum, cancer, fistula, etc., and are called glandes.
Sometimes, however, a dryer matter is finely divided and falls into
several minute portions, from which arise many hard and globular
swellings, called scrofulae from the multiplicity of their progeny,
like that of the sow (_scrofa_). The disease is also called _morbus
regius_, because it is cured by kings."
Gilbert advises that these swellings should not be "driven in"
(_repercutienda_), but brought to suppuration generally by emollients
and poultices. When softened they may be opened with a lancet and the
pus allowed to escape gradually, but as this process is tedious, he
prefers the entire removal of the glands with the knife, premissing,
however, that no gland should be cut into which cannot be well grasped
by the hand and pulled from its seat. This surgical manipulation is
fully described, and is undoubtedly taken from the similar chapter
of Roger. It is worthy of notice also that just at the close of this
chapter, Gilbert mentions a swelling called "testudo," a gland-like,
gaseous (_ventosa_) tumor, usually solitary and found in "nervous"
localities, like the joints of the wrist and hand. He says it often
occurs from fracture (_cassatura_?) of the nerves, is cured by
pressure, friction or incision, but is not entirely free from danger.
Possibly this may refer to ganglion. Now, Roger makes no mention
whatever of "testudo," while Roland says:
"_Nota quod quamvis Rogerius non designat inter glandulum et
testudinem, scias igitur quod testudo fit ex majori parte flegmatica,
minori melancholie, glandula vero a contrario_," a statement which
might readily suggest the suspicion that Gilbert had before his
eyes the text of Roland, or that, at least, he had not acquired his
knowledge of testudo from Roger, his usual surgical authority.
Gilbert's sections on goitre (_bocium gulae_)[8] are interesting in
themselves, and characteristic of the method adopted by him in his
discussion of surgical or semi-surgical subjects. An introduction
relative to the pathology of the disease and which seems to be
original, is followed by a treatment, medical and surgical, adopted
almost literally from the Chirurgia of Roger. Thus he says: "Goiter
occurs most commonly among the inhabitants of mountainous regions,
and is due to an amplification and dilatation of the veins, arteries
and nerves, together with the soft tissues, occasioned by the north
wind (_ventum boreale_), or some other confined wind, which during
childhood has accumulated in (_coadunabatur_) and enlarged the part
to the size of the goiter." After suggesting an analogy between the
disease and the redness and turgidity of the neck produced by passion
or in singing, he adds that some cases are due to an accumulation
of spongy tissue between the veins and arteries, or to the use of
flatulent food, and he even tells us that some old women know how to
produce and remove goitrous swellings by means of certain suitable
herbs known to them.
[Footnote 8: Cf. the French _bosse de la gorge_.]
Under medical treatment we find the following: "Dig out of the ground
while chanting a pater noster, a nut which has never borne fruit. The
roots and other parts pound well with two hundred grains of pepper,
and boil down in the best wine until reduced in volume to one-half.
Let the patient take this freely on an empty stomach until cured."
Another more elaborate prescription consists of a long list of
ingredients, including burnt sponge, saponaria, the milk of a sow
raising her first litter, with numerous simple herbs, and the sole
object for which this nonsensical farrago is introduced here is to add
that both these prescriptions are copied from the surgery of Roger. It
is important too to remark here that we owe to Roger the introduction
of iodine, under the form of burnt sponge, into the treatment of
goiter.
In the failure of medical treatment, Gilbert directs the employment
of surgical means, e.g., the use of setons, or, in suitable cases,
extirpation of the goiter with the knife. If, however, the tumor is
very vascular, he prefers to leave the case to nature rather than
expose the patient to the dangers of a bloody operation. The whole
discussion of goiter is manifestly a paraphrase of the similar chapter
of Roger, who also introduced into surgical practice the use of the
seton.
In Gilbert's chapter entitled "_De arthretica passione et ejus
speciebus_," we are introduced to the earliest discussion by an
English physician of that preeminently English disease--gout. We may
infer, too, from the length of the discussion (thirty or more pages)
that this was a disease with which Gilbert was not only familiar, but
upon the knowledge of which he prided himself greatly. Indeed, it is
one of the few diseases of the Compendium in which the author assumes
the position of a clinician and introduces examples of the disease
and its treatment taken from his own clientele. We shall, therefore,
follow our author here rather more carefully and literally than usual,
that we may learn the views of an English physician of the thirteenth
century on, perhaps, the most characteristic disease of his
countrymen.
Gilbert says: "Arthetica is a disease of the joints arising from a
flux of humors descending into their continuity (_concathenationem_).
The name is derived from the Latin _artus_, a joint, and the disease
comprehends three species, viz., _sciatica_, disease of the scia,
or the ligaments uniting the spine with the hip; _cyragra_, disease
of the joints of the hands; and _podagra_, disease of the bones
and joints of the foot, due to the descent of humors into their
continuity. Sometimes, too, the disease affects other organs,
occasioning pain in sensitive members, as, e.g., the head, and then
derives its name from the part affected, as _cephalea_, _emigranea_ or
_monopagia_. Occasionally likewise some humor runs down (_reumatizat_)
into the chest, spreading over the nerves of the breast or those of
the spine between the vertebrae, and sometimes to other places.
Hence the disease derives the general name gout (_gutta_), from its
resemblance to a drop (_gutta_) trickling or falling downward and
flowing over the weaker organs, which receive the humor. For gout
arises particularly from rheumatic causes. Now, as the humors are
rather uncontrollable (_male terminabiles_) fluids, they flow towards
the exterior and softer parts, like the flesh and skin, which receive
their moisture and being soft, dilatable and extensible, there results
some swelling. But if the humors are hard and dry, they are confined
within the interior of the organs, such as bones, nerves and
membranes: and these, being hard in themselves, do not receive the
moisture, nor suffer extension or dilatation, and thus no swelling
results. Since, therefore, the material of this variety of arthetica,
in which no swelling is present, is formed of grosser and harder
substance and is found in the vicinity of hard and cold localities, it
is dissolved slowly and the disease is not cured until this solution
takes place. That form of the disease, however, in which there is
swelling from a subtile and liquid material deposited in the soft
parts is the more quickly cured. Hence swelling is the best sign
of curability. This is most evidently true in podagra, unless the
_materies morbi_, by reason of its scarcity, produces no enlargement
of the affected part."
Quoting the words of Rhazes, Gilbert tells us that the _materies
morbi_ of gout is, for the most part, crude and bloody phlegm. Rarely
is it bilious, and still more rarely, melancholic. If, however, it is
compounded, it consists chiefly of bile mixed with a subtile phlegm,
and more rarely, of phlegm mixed with black bile (_melancholia_),
occasionally of black bile mixed with blood. The mixture of black bile
and blood or bile is very rare, and still rarer a mixture of all the
humors according to their proportion in the body.
If the color of the affected part is red, it indicates that the
_materies morbi_ is sanguineous; if greenish-yellow (_citrinus_), that
it is bilious; if whiter than the general color of the body, that the
materies is a subtile phlegm. If the color shades away into black, it
does not signify necessarily that the materies is simply black bile,
for such a color occurs at the close of acute abscesses, or from
strangulation of the blood. But if, together with the black color, we
find the tissues cold and no increase of heat in the affected part,
this indicates that the _materies_ is black bile.
By touching the diseased part we determine its heat or coldness,
hardness or softness, roughness or smoothness, fullness, distention or
evacuation, all of which signs possess special significance.
The antecedent causes of gout, Gilbert tells us, are a heat too
solvent, cold too constringent (f. 311 c), sometimes a strong bath
or a severe journey in a plethoric person (_in plectorico_), again
excessive coitus after a full meal (_satietatem_), or even habitual
excess, by which the joints are weakened and deprived of their natural
heat and subtile moisture. Hence boys and eunuchs are not commonly
affected by gout--at least boys under the age of puberty. Women, too,
do not usually suffer from this disease, because in coitus they are
passive, unless their menstrual discharge is suspended. Again gout
sometimes arises from infection of the primary semen; for a chronic
disease may be inherited by the offspring and affect the material
causes, i.e., the humors. Flatulence (_ventositas_) is likewise a
cause of gout, as we have already hinted.
In gout of the sanguineous type the favorite remedy of Gilbert was
venesection, pushed to extremes which suggest the bloody theories of
his later confrere Bouillaud. This bloodletting, however, was always
to be practiced on the side opposite to that affected by the disease,
as he tells us, for two reasons: First to solicit the peccant material
to the opposite side; and, second, to retard its course toward the
seat of the swelling. If, therefore, the disease is in the right foot,
he bleeds from the basilic vein, or some of its branches, in the right
hand. No other vein should be taken, but if neither the basilic vein
nor one of its branches can be found, the bleeding may be performed
upon the median vein, for certain branches of the basilic and cephalic
veins unite to form the median. If the disease is in the hand, the
material may be diverted in two ways, either to the other hand or to
the opposite foot. Indeed, blood may be taken from both these parts
in succession. The quantity of blood withdrawn should be in accordance
with the strength of the patient, the character of the swelling, the
pulsation, distention, heat and redness of the affected part. But it
should be repeated frequently, and this bloodletting then frequently
suffices, in itself, to cure the disease.
Gilbert continues: "I will tell you also what I myself saw in a woman
suffering and screaming with pain in her right wrist (_assuere_?),
which was greatly swollen, hot, red and much distended. She was fat,
full-blooded, and before the attack had lived freely on milk and
flesh. Accordingly she was robust, and I bled her from the basilic
vein of the left hand and the saphena of the right foot, both within
an hour. Each hour I withdrew a half-pound of blood, then I fed her
and for three hours I drew half a pound of blood from the saphena. In
the last hour the pain and throbbing (_percussio_) ceased entirely,
and the woman begged me to bleed her again from the hand, for she had
experienced great relief. I wished, however, to divert the material
to the lower extremities for two reasons, one of which I ought not to
mention in this place, while the other is useful, and indeed necessary
in such cases. You should know that this woman was suffering pain in
her left hand also, though this pain was of a less severe character
than in the right. For this reason I desired to divert the peccant
matter downward, a point which the physician should consider and
observe. Once, while treating a man suffering from sanguineous gout,
the pain of which involved the joints between the assuerus and the
racheta (?) of the right hand, I asked him whether any pain was felt
in the other hand or in the feet. He replied that similar pain was
felt in the left hand or its joints, and that hitherto it had been
more severe, but that no pain had ever been experienced in the feet.
Hence I was unwilling to bleed him at all from the left hand, but I
bled him from the right foot. A physician who had treated him before,
and had bled him from the right hand for acute swelling of the joints
of the left, quieted, indeed, the pain in the left hand, but diverted
the disease to the right, where a swelling developed larger than in
the left. And when I asked him about this, he understood that I knew
more about medicine than the other doctor did. And this is one of
the reasons why one ought to divert the material to another part,
especially when the pain is so located that it may be increased at
the beginning. For under such conditions we ought to refrain from
bleeding, frictions and other treatment which may attract the
_materies morbi_ to the part. Indeed we ought to require derivation of
the materies to another part whenever the affected locality contains
one of the nobler organs, towards which the material is directing, or
may direct its course. For instance: A person is suffering pain in
the joints of the right hand, but has also an acute swelling in the
bladder, the kidneys or the womb. Now, I say that in such a case we
ought not to bleed from the hand, because if we do we shall injure the
organ affected by the swelling. Perhaps, however, we may bleed from
the right foot, provided we understand that there is on the right side
a sanguineous tumor, the danger of which is greater than that of the
swelling on the right hand. Again, suppose in the liver or in the
right kidney an acute tumor, and in the joints of the right hand there
is present a moderate pain. I say that we ought first to medicate the
more dangerous lesion, and, possibly, two results may be obtained by
the attraction of the peccant material. Or suppose a woman has gout in
her hand, and with this a suppression of the menstrual flow. I say she
ought to be bled from the foot and not from the hand for two objects,
to solicit the material from the diseased hand, and to provoke a
return of the menstrual discharge.
"But to return to our original patient. I may say that after the third
venesection, with an interval of two hours, I withdrew a half-pound
of blood from the saphena vein, and that night she slept, although
she had not slept for many nights. And I did nothing more, except to
prescribe a light and cool diet. The third day after the bleeding she
was entirely free from any trouble in her hand. Hence I say that we
ought in such cases to begin our treatment by venesection."
After this sanguinary introduction, Gilbert soothes the diseased part
with cooling and astringent ointments, unless these occasion pain,
in which event he omits them entirely and trusts the case to nature,
"_quoniam natura per se curabit_."
The vigorous plan of treatment thus outlined Gilbert seems to regard
as original and peculiar to himself, for the next chapter bears the
title, "The treatment of gout according to the authorities (_secundum
magistros_)." Here he says he quotes the opinions of the modern
teachers and writers, who lay down definite rules for the guidance of
the physicians.
Among these he mentions, as primary and of general application, the
rule that, before all things, the body must be purified, either
by venesection in cases where the material is sanguineous, or by
purgation in other varieties of the disease. If the cause is rheumatic
in its nature, fomentations should never be employed, for fear of
increasing the flux. That the peccant material is to be eliminated
gradually by mild remedies, just as it accumulated by degrees. In all
cases of gout, and in all chronic diseases generally, much attention
must be devoted to the stomach, since if this organ rejects the
medicine, the latter must be at once abandoned, lest the stomach
becomes weakened and even other organs, and thus the humors flow more
readily (_magis reumatizarent_) to the joints, etc.