bend of the arm, forming in this a loop (_scapham_) into which the
foot of the surgeon is to be placed for counter-extension, while with
the hands extension is to be made upon the forearm until the bones are
drawn into their normal position. Flexion and extension of the joint
are then to be practised three or four times (to assure complete
reduction?), and the forearm flexed and supported by a bandage from
the neck. After a few days, Gilbert tells us, the patient will himself
often try to flex and extend the arm, and the bandage should be so
applied as not to interfere with these movements.
Dislocation of the wrist is reduced by gentle extension from the hand
and counter-extension from the forearm, and dislocation of the fingers
by a similar manipulation.
After so full a consideration of the surgical injuries of the head,
trunk and upper extremities, we are somewhat surprised to find
Gilbert's discussion of the similar injuries of the lower extremities
condensed into a single very moderate chapter entitled "De vulneribus
cruris et tybie" (f. 358a b).
In this, Gilbert, emphasizing the importance of wounds of the patella
and knee-joint and the necessity for their careful treatment, also
declares that wounds of both the leg and thigh within three inches of
the joints, or in the fleshy portion of the thigh _ubi organum est_
(?), involve considerable danger. He then speaks of a blackish, hard
and very painful tumor of the thigh, which, when it ascends the
thigh (_ad superiora ascendit_) is mortal, but if it descends is
less dangerous. Separation of the sacrum (_vertebrum_) from the ilium
(_scia_), either by accident or from the corrosion of humors, leaves
the patient permanently lame, though suitable fomentations and
inunctions may produce some improvement. Sprains of the ankle are to
be treated by placing the joint immediately in very cold water _ad
repercussionem spiritus et sanguinis_, and the joint is to be kept
thus refrigerated until it even becomes numb (_stupefactionem_); after
which stupes of salt water and urine are to be applied, followed by a
plaster of galbanum, opoponax, the apostolicon, etc.
Fractures of the femur are to be treated like those of the humerus,
except that the ends of the fractured bone are to be separated by
the space of an inch, and a bandage six fingers in width carefully
applied. Such fractures within three inches of the hip or knee-joint
are regarded as specially dangerous.
Dislocations of the ankle, after reduction of proper manipulation,
should be bound with suitable splints. If of a less severe character,
the dislocation may be dressed with stupes of canabina (Indian hemp),
urine and salt water, which greatly mitigate the pain and swelling.
Afterwards the joint should be strapped for four or five inches above
the ankle with plaster, _ut prohibeatur fluxus_.
It should be said that the brevity of this chapter of Gilbert is
modeled after the manner of Roger of Parma, who refers the treatment
of injuries of the lower extremities very largely to that of similar
injuries of the upper, merely adding thereto such explanations as may
be demanded by the differences of location and function of the members
involved. Thus in his discussion of dislocation of the femur Roger
says:
_Si crus a coxa sit disjunctum, eadem sit cura quam et in disjuncturam
brachii et cubiti diximus, etc._
The general subject of fistulae is treated at considerable length on
folio 205b, and fistula lachrymalis and fistulae of the jaw receive
special attention in their appropriate places. As a rule, the fistula
is dilated by a tent of alder-pith, mandragora, briony or gentian,
the lining membrane destroyed by an ointment of quick-lime or even the
actual cautery, and the wound then dressed with egg-albumen followed
by the _unguentum viride_. Necrosed bone is to be removed, if
necessary, by deep incisions, and decayed teeth are to be extracted.
The elongated uvula is to be snipped off, and abscesses of the tonsils
opened _tout comme chez nous_.
An elaborate discussion of the subject of hernia is given under the
title "_De relaxatione siphac et ruptura_" (f. 280c)--siphac being
the Arabian name for the peritoneum. Gilbert tells us the siphac is
sometimes relaxed, sometimes ruptured (_crepatur_?) and sometimes
inflated. He had seen a large rupture (_crepatura_) in which it was
impossible to restore the intestines to the cavity of the abdomen
in consequence of the presence in them of large hard masses of fecal
matter, which no treatment proved adequate to remove, and which
finally occasioned the death of the patient. Rupture of the siphac is
most frequently the result of accident, jumping, straining in lifting
or carrying heavy weights, or in efforts at defecation, or of shouting
in boys or persons of advanced age, or even in excessive weeping,
etc. It is distinguished from hernia by the fact that in hernia pain
is felt in the testicle, radiating to the kidneys, while in rupture
of the siphac a swelling on one side of the pubes extends into the
scrotum, where it produces a tumor not involving the testicle. Rupture
of the siphac, he says, is a lesion of the organs of nutrition, hernia
a disease of the organs of generation. Accordingly, in the pathology
of Gilbert, the term hernia is applied to hydrocele, orchitis and
other diseases of the testicle, and not, as with us to protrusions of
the viscera through the walls of their cavities.
In young persons, he tells us, recent ruptures of the siphac may be
cured by appropriate treatment. The patient is to be laid upon his
back, the hips raised, the intestines restored to the abdominal cavity
and the opening of exit dressed with a plaster of exsiccative and
consolidating remedies, of which he furnishes a long and diversified
catalogue. He is also to avoid religiously all exercise or motion, all
anger, clamor, coughing, sneezing, equitation, cohabitation, etc.,
and to lie with his feet elevated for forty days, until the rupture
(_crepatura_) is consolidated. The bowels are to be kept soluble by
enemata or appropriate medicines, and the diet should be selected so
as to avoid constipation and flatulence. A bandage or truss (_bracale
vel colligar_) made of silk and well fitted to the patient is also
highly recommended. If the patient is a boy, cakes (_crispelle_?) of
_consolida major_ mixed with the yolk of eggs should be administered,
one each day for nine days before the wane of the moon. If, however,
the rupture is large in either a boy or an adult, and of long
standing, whether the intestine descends into the scrotum or not,
operation, either by incision or by the cautery offers the only hope
of relief. Singularly enough too, while Roger devotes to the operation
for the cure of hernia nearly half a page of his text, Gilbert
dismisses the whole subject in a single sentence, as follows:
_Scindatur igitur totus exitus super hac cute exteriori cum carne
fissa, et uatur y fac cum file serice et acu quadrata. Deinde
persequere ut in exitu intestini per vulnus superius demonstratum est_
(f. 281d).
Turning now to the title "_De hernia_" (f. 289b), Gilbert tells us
"Swelling (_inflatio_) of the testicles is due sometimes to humors
trickling down upon them (_rheumatizantibus_), sometimes to abscess,
or to gaseous collections (_ventositate_), and sometimes to escape
of the intestines through rupture of the siphac." He adds also: "Some
doubt the propriety of using the term hernia for an inflation. On
this point magister Rn says: There is a certain chronic and inveterate
tumor of the testicles, which is never cured except by means of
surgery, as e.g., hernia. For hernia is an affection common to the
scrotum and the testicles."
The apparent confusion between these two passages is easily relieved
by the explanation that inguinal or other herniae not extending into
the scrotum are called by Gilbert ruptures of the siphac, but scrotal
hernia is classed with other troubles located in the scrotum as
hernia. Accordingly hernia, with Gilbert, includes not only scrotal
hernia, but also hydrocele, orchitis, tumors of the testicles, etc.
This is apparent, too, in his treatment of hernia, which consists
usually in the employment of various poultices and ointments, bleeding
from the saphena, cups over the kidneys, etc., though hydrocele is
tapped and a seton inserted. If the testicle itself is "putrid,"
it should be removed; otherwise it is left. It may be remarked _en
passant_ that the surgeons of medieval times, in their desire for
thoroughness, often displayed very little respect to what Baas calls
"the root of humanity."
We will terminate our hasty review of diseases discussed in the
Compendium by an abstract of Gilbert's views on vesical calculus and
its treatment, which cover more than fifteen pages of his work.
Stone and gravel arise from various viscous superfluities in the
kidneys and bladder, which occasion difficulty in micturition. Stone
is produced by the action of heat upon viscous moisture, sublimating
the volatile elements and condensing the denser portions.
Putrefication of stone in the bladder is the result of three causes,
viz., consuming heat, viscous matter and stricture of the meatus.
For consuming heat acting on viscous material retained by reason
of stricture of the meatus, by long action dries up, coagulates and
hardens the moisture. This is particularly manifest in boys who have a
constricted meatus.
Stones are thus generated not only in the kidneys and bladder,
but also even in the stomach and the intestines, whence they are
ejected by vomiting or in the stools. Indeed they may also be found
occasionally in the lungs, the joints and other places. They are
comparatively rare in women, in consequence of the shortness of the
urethra and the size of their meatus.
Sometimes calculi occur in the bladder, sometimes in one kidney and
occasionally in both kidneys. The symptoms produced by their presence
vary in accordance with the situation of the concretion. If the stone
is in the kidney, the foot of the side affected is numb (_stupidus_),
the spine on the affected side is sore and there is difficulty of
micturition and considerable gravelly sediment in the urine. If the
stone is increasing in size, the quantity of sediment also increases,
but if the stone is fully formed and confirmed, the amount of sediment
decreases daily, and the urine becomes milky both in the kidneys and
the bladder. A stone in the bladder occasions very similar symptoms,
together with pain in the peritoneum and pubes, dysuria and strangury,
and sometimes the appearance of blood and flocculi (_trumbos_?)
in the urine. Patients suffering from vesical calculus are always
constipated, and the dysuria may increase to the degree called furia,
a condition not without some danger.
Three things are necessary in the cure of stone, viz., a spare and
simple diet, the use of diuretics and a moderate amount of exercise.
It should, however, be remarked that confirmed stone is rarely or
never cured, except by a surgical operation.... If a boy has a clear
and watery urine after it has been sandy, if he frequently scratches
his foot, has involuntary erections and finally obstruction in
micturition, I say that he has a stone in the neck of his bladder.
If now he be laid upon his back with his feet well elevated, and his
whole body be well shaken, if there is a stone present it is possible
that it may fall to the fundus of the bladder. Afterwards direct
the boy to bear down (_ut exprimat se_) and try to make water. If
this treatment turns out in accordance with your theory, the urine
necessarily escapes and your idea and treatment are confirmed. If,
however, the urine not escape, let the boy be shaken vigorously
a second time. If this too fails and strangury ensues, it will be
necessary to resort to the use of a sound or catheter (_argaliam_),
so that when the stone is pushed away from the neck of the bladder the
passage may be opened and the urine may flow out. It may be possible
too that no stone exists, but the urethra is obstructed or closed
by pure coagulated blood. Perhaps there may have been a wound of the
bladder, although no external haemorrhage has appeared, but the blood
coagulating gradually in the bladder has occasioned an obstruction or
narrowing of the urinary passage. Or possibly the blood from a renal
haemorrhage has descended into the bladder and obstructs the urethra.
Hence I say that the sound is useful in these cases where the urethra
is obstructed by blood or gross humors. Examination should also be
made as to whether a fleshy body exists in the bladder, as the result
of some wound. This condition is manifest if, on the introduction of
the sound, the urine flows out promptly. I once saw a man suffering
from this condition, who complained of severe pain in the urinary
passage as I was introducing the sound, and I recognized that there
were wounds in the same part, for as soon as these were touched by
the sound the urine began to flow, followed soon after by a little
blood and fleshy particles.... So far as the operation of physicians
is concerned, it is necessary only to be certain of the fact that
obstruction to the passage of urine depends upon no other cause than
stone or the presence of coagulated blood (f. 271).
Gilbert's medical treatment of vesical calculus consists generally
in the administration of diuretics and lithontriptics and the local
application of poultices, plasters and inunctions of various kinds.
Of the lithontriptics, certain combinations, characterized by famous
names or notable historical origin, are evident favorites. Among
this class we read of the _Philoantropos major_ and _minor_, the
_Justinum_, the _Usina_ "approved by many wise men of Babylon and
Constantinople," the _Lithontripon_ and the "_Pulvis Eugenii pape_,"
with numerous others.
Rather curiously and suggestively no mention is made in this immediate
connection of the technique of lithotomy. On a later page, however (f.
309a), we find a chapter entitled "_De cura lapidis per cyrurgiam_,"
in which Gilbert writes:
"Mark here a chapter on the cure of stone in the bladder by means
of surgery, which we have omitted above. Accordingly, to determine
whether a stone exists in the bladder, let the patient take a warm
bath. Then let him be placed with his buttocks elevated, and, having
inserted into the anus two fingers of the right hand, press the fist
of the left hand deeply above the pubes and lift and draw the entire
bladder upward. If you find anything hard and heavy, it is manifest
that there is a stone in the bladder. If the body feels soft and
fleshy, it is a fleshy excrescence (_carnositas_), which impedes the
flow of urine. Now, if the stone is located in the neck of the bladder
and you wish to force it to the fundus: after the use of fomentations
and inunctions, inject through a syringe (_siringa_) some petroleum,
and after a short interval pass the syringe again up to the neck of
the bladder and cautiously and gently push the stone away from the
neck to the fundus. Or, which is safer and better, having used the
preceding fomentations and inunctions, and having assured yourself
that there is a stone in the bladder, introduce your fingers into the
anus and compress the neck of the bladder with the fist of the left
hand above the pubes, and cautiously remove the stone and guide it
to the fundus. But if you wish to extract the stone, let a spare diet
precede the operation, and let the patient lie abed for a couple of
days with very little food. On the third day introduce the fingers
into the anus as before, and draw down the stone into the neck of
the bladder. Then make your incision lengthwise in the fontanel, the
width of two fingers above the anus, and extract the stone. For nine
days after the operation let the patient use, morning and evening,
fomentations of _branca_ (_acanthus mollis_), _paritaria_ (pellitery)
and _malva_ (mallows). A bit of tow (_stupa_) moistened with the yolk
of egg in winter, and with both the yolk and white of egg in summer,
is to be placed over the wound. Proud flesh, which often springs up
near a wound in the neck of the bladder, should be removed by the
knife (_rasorio_), and two or three sutures inserted. The wound is
then to be treated like other wounds. It should be remarked, however,
that if the stone is very large, it should be simply pushed up to the
fundus of the bladder and left there, and no effort should be made to
extract it."
This description of the diagnosis of stone and of the operation of
lithotomy is copied almost literally from Roger of Parma.
Sufficient (perhaps more than enough) has been written to give the
reader a fair idea of the general character of Gilbert's "Compendium
Medicine."
A few words may be added with reference to the proper place of the
work in our medical literature.
It is not difficult, of course, to select from the Compendium a charm
or two, a few impossible etymologies and a few silly statements, to
display these with a witty emphasis and to draw therefrom the easy
conclusion that the book is a mass of crass superstition and absurd
nonsense. This, however, is not criticism. It is mere caricature.
To compare the work with the teachings of modern medicine is not only
to expect of the writer a miraculous prescience, but to minimize the
advances of medical science within the last seven hundred years.
Even Freind and Sprengel, admirable historians, though more thoughtful
and judicious in their criticisms, seem for the moment to have
forgotten or overlooked the true character of the Compendium.
Freind says:
"I believe we may even say with justice that he (Gilbert) has written
as well as any of his contemporaries of other nations, and has merely
followed their example in borrowing very largely from the Arabians,"
and Sprengel writes: "Here and there, though only very rarely, the
author offers some remarks of his own, which merit special attention."
Now, what precisely is Gilbert's Compendium designed to be? In the
words of its author it is
"A book of general and special diseases, selected and extracted
from the writings of all authors and the practice of the professors
(_magistrorum_), edited by Gilbert of England and entitled a
Compendium of Medicine."
and a few pages later he adds:
"It is our habit to select the best sayings of the best authorities,
and where any doubt exists, to insert the different opinions, so that
each reader may choose for himself what he prefers to maintain."
The author does not claim for his work any considerable originality,
but presents it as a compendium proper of the teachings of other
writers. Naturally his own part in the book is not obtruded upon our
notice.
Now the desiderata of such a compendium are:
1. That it shall be based upon the best attainable authorities.
2. That these authorities shall be accurately represented.
3. That the compendium shall be reasonably comprehensive.
In neither of these respects is the compendium of Gilbert liable, I
think, to adverse criticism.
The book is, undoubtedly, the work of a famous and strictly orthodox
physician, possessed of exceptional education in the science of his
day, a man of wide reading, broadened by extensive travel and endowed
with the knowledge acquired by a long experience, honest, truthful and
simple minded, yet not uncritical in regard to novelties, firm in his
own opinions but not arrogant, sympathetic, possessed of a high sense
of professional honor, a firm believer in authority and therefore
credulous, superstitious after the manner of his age, yet harboring,
too, a germ of that healthy skepticism which Roger Bacon, his great
contemporary, developed and illustrated.
I believe, therefore, that we may justly award to the medical pages of
the Compendium not only the rather negative praise of being written
as well as the work of any of Gilbert's contemporaries, but the more
positive credit of being thoroughly abreast of the medical science of
its age and country, an "Abstract and brief chronicle of the time."
The surgical chapters of the work are unique in a compendium of
medicine, and merit even more favorable criticism.
The discouragement of the practice of medicine and surgery on the
part of ecclesiastics by the popes and church councils of the twelfth
century, culminating in the decree of Pope Innocent III in 1215,
which forbade the participation of the higher clergy in any operation
involving the shedding of blood (_Ecclesia abhorret a sanguine_); the
relatively scanty supply of educated lay physicians and surgeons, and
finally the pride and inertia of the lay physicians themselves; all
these combined to relegate surgery in the thirteenth century to the
hands of a class of ignorant and unconscionable empirics, whose rash
activity shed a baleful light upon the art of surgery itself. As a
natural result the practice of this art drifted into an _impasse_,
from which the organization of the barber-surgeons seemed the only
logical means of escape.
The earliest evidence of the public surgical activity of the barbers,
as a class, is found, I believe, in Joinville's Chronicle of the
Crusade of St. Louis (Louis IX) in the year 1250. According to
Malgaigne, no trustworthy evidence of any organization of the
barbers of Paris is available before 1301, and the fraternity was not
chartered until 1427, under Charles VII. The barbers of London are
noticed in 1308, and they received their charter from Edward IV in
1462. The parallel lines upon which the confraternities of the two
cities developed is very noticeable--making due allowance for Gallic
enthusiasm and bitterness.
Lanfranchi, the great surgeon of Paris, about the year 1300 is moved
to write as follows:
"Why, in God's name, in our days is there such a great difference
between the physician and the surgeon? The physicians have abandoned
operative procedures to the laity, either, as some say, because they
disdain to operate with their hands, or rather, as I think, because
they do not know how to perform operations. Indeed, this abuse is
so inveterate that the common people look upon it as impossible for
the same person to understand both surgery and medicine. It ought,
however, to be understood that no one can be a good physician who
has no idea of surgical operations, and that a surgeon is nothing
if ignorant of medicine. In a word, one must be familiar with both
departments of medicine."
Now Gilbert by the incorporation of many chapters on surgery in his
Compendium inculcates practically the same idea more than fifty years
before Lanfranchi, and may claim to be the earliest representative
of surgical teaching in England. Malgaigne, indeed, does not include
his name in the admirable sketch of medieval surgery with which he
introduces his edition of the works of Ambroise Pare, and says Gilbert
was no more a surgeon than Bernard Gordon. This is in a certain sense
true. Gilbert was certainly not an operative surgeon. But it needs
only a very superficial comparison of the Compendium of Gilbert with
the Lilium Medicinae of Gordon to establish the fact that the books
are entirely unlike. Indeed, it may be truthfully said that Gordon's
work does not contain a single chapter on surgery proper. His cases
involving surgical assistance are turned over at once, and with
little or no discussion, to those whom he calls "restauratores" or
"chirurgi," and his own responsibility thereupon ends.
We have no historical facts which demonstrate that Gilbert's
Compendium exercised any considerable influence upon the development
of surgery in England, but when we consider the depressed condition
of both medicine and surgery in his day, we should certainly emphasize
the clearness of vision which led our author to indicate the natural
association of these two departments of the healing art, and the
assistance which each lends to the other.