It is not weakness of the parts alone that occasions gouty and arthritic
complaints; for then the paroxysms would be without ceasing, inasmuch as
the debility is always present in the weak parts. Neither is a humour the
sole cause, for then the complaint had not attacked the joints only. But
the disease is occasioned by a preternatural humour and a weakness of the
parts meeting together. For when the nutritive power of the parts becomes
debilitated from repletion with food inducing dyspepsia, the prevailing
humour, fixing in some of the joints which are already in a weak state,
and stretching the nervous ligaments, produces pain. For the inflammation
is not an original affection of the nerves of volition; as then it would
have affected also the parts between the joints, such as the middle of
the legs, thighs, arms, and forearms; but those of volition are affected
sympathetically. When, therefore, the humour is seated in the joints of
the feet only, the complaint is called podagra; but when the cause is
diffused over all the joints of the body, we commonly call it arthritis,
in which the vertebræ, scapulæ, jaws, and every other joint are attacked
with the disease. In certain cases the ears, teeth, and pharynx, and
sometimes even the liver and spleen participate in the arthritic pains,
when, if there is not a speedy translation of the disease to the joints,
the patients will be in urgent danger. The prevailing humour is sometimes
bilious, sometimes sanguineous, sometimes melancholic, but for the most
part it is pituitous and crude, being engendered by excess of food,
indigestion, and want of exercise. When the disease is protracted in
the joints, the humours become thick and viscid, so as to form what are
called tophi or chalk-stones. Sometimes the humour is of a compound
nature, so that the disease is difficult to distinguish, and difficult
to cure, or nearly incurable. The precursory causes of this affection
for the most part are immoderate labour, violent walking, frequent
exercise on horseback, the unseasonable use of venery, cold drink taken
unseasonably, eating of much cold or unwholesome food, and drinking much
wine. And some from accidents, as a blow, a sprain, or the like, have
experienced the first attack of this complaint, the materials of the
disease having previously remained quiet in the system until roused by
the proximate cause. Sorrow, care, watchfulness, and the other passions
of the mind, not only excite an attack of the disorder, but also generate
a cacochymy either primarily or incidentally. Wherefore the causes of
the complaint, as I have said, are various; but the differences of the
noxious humours are in so far easily detected, being discovered by their
colour and other symptoms. A bilious rheum, in addition to paleness and
redness of colour, occasions a sensation of heat and acute pain, and is
speedily determined to the skin, nor is it attended with much swelling.
It is exacerbated by heating applications, and relieved again by cooling,
which, for the most part, is the case with all the others, but more
particularly when the exciting cause is bilious. Fever also frequently
comes on at the height of the paroxysms, and then they are thirsty. Thus
also you will find the skin darker when from a melancholic humour; white
and watery when from a pituitous, in which case the pain is more latent
and more slowly occasions swelling; and the colour is sanguineous when a
bloody humour prevails. In order to form a more decided diagnosis, you
will be assisted by taking into account the previous mode of life, and so
forth.
_The cure of rheums from a bilious humour._ The commencement of the cure,
when from yellow bile, more especially if the quality of it occasion the
disorder, should be the evacuation of the offending humour by purgative
medicines, such as that from rhodomel, that from quinces, the antidote
called picra, and aloetic pills. During the paroxysms, we may apply
externally rose-oil with the yelk of an egg, and some wine, rubbing
the part gently with it; and apply the herbs of a cold nature, such as
nightshade, purslain, henbane, houseleek, marsh-lentil, endive, poppy,
knotgrass, rose-leaves, and the like. These things may be sometimes
rubbed in, and sometimes applied in the form of a cataplasm, with crumbs
of bread soaked in oxycrate, or from barley-meal with rose-oil. When the
inflammation of the joints is of an erysipelatous nature, a decidedly
paregoric application is the peel of a fresh gourd laid on the part, or
the fleshy part of a pompion or cucumber, both alone and with bread; or
the leaves of perdicium (_pellitory of the wall?_), and ivy with bread
and fine polenta. And fleawort boiled in barley-flour mitigates the
inflammatory heat in a wonderful manner; and so also the rose-cerate
cooled with some of the frigorific juices, and that prepared from the
flour of beans. It is prepared thus: Of wax, oz. v; of chamomile-oil, oz.
iiss; of rose-oil, oz. iiss; of the flour of beans, oz. ss; the yelks
of five eggs.—_Another_, a cataplasm: Pound green mallows boiled; and
having made fleawort to the consistence of bird-lime separately, mix
together; then add the red part of eggs and chamomile-oil, and apply as
a cataplasm. When the pain is great and difficult to endure, we must
have recourse to preparations of saffron, of horned poppy, and of opium,
triturating them with oxycrate, and then using them in the form of
liniments, or of cataplasms with crumbs of bread. Galen makes mention of
this one: Of poppy-juice (_opium_), dr. iv; of saffron, dr. j; triturate
with milk of a cow or of a goat; or add the inner part of bread, and
having softened it by touching it with a little rose-oil, use for a
cataplasm. Or triturate the opium and saffron with the milk, and add to
the rose-cerate. And the cerate made from the torpedo and the oil of the
same are possessed of similar properties.—And this one in like manner:
Of crumbs of bread soaked in water or in oxycrate, and of houseleek, or
of nightshade, or of purslain, and of the fleshy parts of dates, and
of poppy-seeds, equal parts; of roasted yelks of eggs and rose-oil, q.
s.; form a cataplasm. The use of narcotics must not be continued, but
until the violence of the pain be abated; for the frequent use of them
occasions impaction and tophi, and makes the difficulty of motion to
be protracted. After the use of anodynes, then, we must have recourse
either to diachylon dissolved in oil of chamomile, or the composition
from marshmallows, or some such application. After we have warmed the
congealed parts, we must strengthen them by a plaster of dates dissolved
in vinegar and rose-oil or wine and rose-oil. Or, if the weight of the
plasters prove troublesome, we may rub in the juice of acacia with
oxycrate, or lycium along with saffron, horned poppy, and the juice of
perdicias in oxycrate. The diet should be cooling and moistening, such as
ptisans, and spoon-meats from chondrus, and of pot-herbs, the mallows,
the lettuce, and the endive; and of birds, more especially the young of
domestic fowls; and of fishes, those caught in rocky places, and the
sea-urchin, shell-fish, and the like. Let them avoid all things that are
heating and form pale and yellow bile, old wines both the yellow and
dark, and repletion. Let them use baths of sweet water, even at the time
of the defluxions, as far as regards the cause of them, unless something
else prohibit. Let them avoid violent passion, abstinence, acrid food,
drinking of wine, immoderate labour, and venery.
_The cure of rheums from a sanguineous humour._ In those cases in
which the prevailing humour is sanguineous, we must have recourse to
venesection without delay, and also in cases where the prevailing humour
is phlegm or black bile; since in them the humour is for the most part
contained in the veins, proving injurious by its quantity rather than
its quality. We must have recourse then to venesection only at the first
attack of the disease; since those who have had already frequent attacks
of rheumatism are injured rather than benefited by the loss of blood,
more especially when the body is naturally cold or weak. After the
evacuation of the blood, if there was more than a plethora of blood, we
must have recourse to purging with hiera after a short interval. And the
Julian oxymel is a purgative suitable to these cases. Those who reject
such purgative medicines may use these pills: Of aloes, of colocynth,
of black hellebore, of scammony, of each, oz. j; of euphorbium, oz. ss;
of nitre, oz. ss; mix with the juice of cabbage, and give according to
the patient’s strength. It will be better, however, if prepared with the
juice of quinces.—Another pill given to gouty persons in the paroxysms,
during the remission, and from whatever humour: Of aloes, oz. vj; of
agaric, oz. ss; of saffron, oz. ss; of costus, oz. j; of spikenard,
oz. j; of schenanth, oz. j; of balsam fruit, oz. j; of cassia, oz. ij;
of scammony, oz. ij; of dodder of thyme, oz. iiiss. A moderate dose is
scr. ij; and a full one, scr. iv. Pills of Armenian stone also purge
in a wonderful manner, being particularly applicable in arthritic
cases, whether given at the commencement, in the decline, or during the
remissions of defluxion. And since some avoid scammony because it is bad
for the stomach, we may give them these things when a pituitous matter
prevails: Of the medullary part of colocynth, of black hellebore, of
bdellium, of gum, of aloes, of each, oz. j; of Alexandrian nitre, of
euphorbium, of each, oz. ss. The dose is scr. iv. Instead of the gum I
have substituted dodder of thyme. Some, in the paroxysms of all arthritic
diseases, have recourse to purging with hermodactylus; but it is to be
remarked that the hermodactylus is bad for the stomach, producing nausea
and anorexia, and ought, therefore, to be used only in the case of those
who are pressed by urgent business; for it removes rheumatism speedily,
and after two days at most, so that they are enabled to resume their
accustomed employment. I knew a person who did not give the substance
of hermodactylus, nor any of the compound medicines containing it; but
boiling the plant itself with some of the common remedies, such as anise
or parsley, he gave the decoction to drink; and it was wonderful how
those who got it, after having evacuations of the bowels, were freed from
the rheumatism. It is necessary, however, as I said, because the medicine
is bad for the stomach, to correct the mouth of the stomach afterwards
by stomachics and tonics, along with things that are moderately heating.
Alexander says that purging by coronopodium is preferable to that by
hermodactylus, as it procures evacuation and relief from pain, and at
the same time is not bad for the stomach. But topical applications are
to be had recourse to in cases of pituitous rheumatism. When the pain
is moderate, a green cabbage-leaf may be applied, and also parsley,
fleabane, and the straight vervain; but when the pain is violent, take
of the flour of fenugreek, p. iij; of the flour of darnel, p. j; of the
flour of chick-peas, p. j; make a cataplasm with honied water, or thin
wine, with a little oil of privet, or of nard, more especially if in
winter. And the ashes of burnt cabbage-roots, or of their stalks, when
formed into a cataplasm with axunge, have proved beneficial to many; but,
in order that it may prove soothing, the axunge must be fresh, whereas,
if we wish it to be discutient, it must be old and salted. And in like
manner the dung of oxen, when boiled in honied water with barley-meal,
or fresh moist dung applied with the leaves of cabbage; and so also
goats’ dung by themselves, or boiled with barley-flour in oxycrate. And
since some have derived relief from seemingly opposite remedies (for a
mixture of various humours confounds the diagnosis), we must state the
materials thereof promiscuously. Wherefore the wild and garden orach in
a cataplasm with bread are beneficial, or the leaves of petty mullein,
triturated with bulbi and bread, or with polenta, or the cataplasm of raw
barley-meal. Upon the whole, when the cause of the complaint is obscure,
we must change sometimes to medicines of the same class, and sometimes to
the opposite, not continuing long with the same application when it does
not afford relief. These things we see every day occur in professional
matters. And often a certain remedy proves beneficial to one joint,
while another joint of the same patient similarly inflamed is not only
not benefited at the same time, but occasionally is even injured by it.
And this is a wonderful circumstance, that one and the same joint, when
treated with the same remedy, is sometimes benefited, and soon afterwards
exasperated. When a viscid and thick matter prevails, it is not perhaps
relieved by calefacients, but the acrid and hot quality of the humour
prevailing is to be soothed by frigorific remedies; nor is it at all
wonderful that a matter naturally cold, in the time of the inflammation,
should become heated and glowing, to say nothing of the admixture perhaps
of bile. The flour of lupines with oxymel or oxycrate, or the root of
laserwort, or of bryony, with bread, prevent the formation of tophi. And
the following composition is safely soothing and moderately discutient:
Of lycium, oz. j; of ammoniac perfume, oz. j; having triturated with very
old wine and oil of unripe olives, boil, and add of the flour of beans,
q. s.; and having boiled moderately, apply as a cataplasm. After the acme
of the complaint, if a swelling be left, apply a cataplasm with the bulbi
by themselves, or with fine polenta, until it produce excoriation; for in
this manner they act. When not relieved by the cataplasms, we may have
recourse to embrocations and affusions on the parts (more particularly
if the extremities be affected), with chamomile, melilot, or centaury
in decoctions. The preparation of capers has entirely relieved some.
The following is the most active of all the applications: Having boiled
thyme, marjoram, savory, and calamint in the most acrid vinegar, bathe
the parts affected with the vinegar, not only once, but often in a day,
with confidence. This has relieved many when suffering not only from
phlegm but also from bile.
Some observe this practice also: The acorns of the ilex being powdered,
are pounded and much boiled, and the joints of the extremities at the
commencement of the rheumatism are fomented for a considerable time with
the decoction, but it is poured from a sponge upon the inner parts;
whereby the violence of the offending matter is repelled. It also is
applicable to bilious cases; and, in like manner, immersion in hot
water without any decoction. For pains occasioned by intense cold, or
infarction of the joints, this is a powerful remedy: Of old oil, lb. iss;
of Alexandrian nitre, lb. j; of turpentine, lb. j; of euphorbium, oz.
j; of iris, oz. ij; of the flour of fenugreek, a sextarius and a half.
In these cases the remedies recommended for ischiatics are excellently
applicable. Many, in the case of those who are thus affected from a cold
cause, apply, after the acme, mustard with dried figs and the other
rubefacients, but some the preparation from cantharides. But these things
prove injurious afterwards, unless one use the emollient applications,
such as that from fuller’s herb, the one called Pyxis, that of Basilius,
that from the fir-tree, that from the poplar, those called Promium and
Lysiponium, and the stronger of the Acopa: in which cases sympathetic
affections of the nerves and impaction of the humours particularly take
place. And the application from the urine of a mule, more particularly
if applied at the acme, is beneficial in the cold rheums: and, in
like manner, the trochisk from the two hellebores is applicable for
the œdematous and spongy swellings; also fomentation with the toasted
salts; or otherwise affusion or embrocation with hot sea water; and the
plasters prepared from salts, those from strained lye and nitre, and the
cataplasms of a like nature after the acme. Food of a drier nature, and
not excrementitious, suits well with these; also abstinence from food,
or a spare diet, and refraining from frequent baths. Having bathed, they
should be rubbed with nitre and the other unguents used for friction.
In the decline, they should have recourse in particular to gymnastic
exercises and friction of the joints, and the natural baths, or the sand
baths, and emetics from radishes and food from grain. Those properly
prepared for it may be vomited or purged with the white hellebore.
_On rheums from a mixture of humours._ Those labouring under a mixture
of humours, after the evacuation of the blood at the commencement of the
disease, should use the topical remedies already mentioned. When the
sanguineous plethora is of a more bilious and acrid nature, recourse
may be had to those things recommended for bile; when it is of a colder
and more pituitous or melancholic nature, those afterwards mentioned,
with the exception of such as are very acrid; and if protracted, these
also may be used. And this cataplasm is applicable at the commencement:
Pomegranate rind, sumach, and polenta triturated with wine, are
applied in the form of a poultice.—_Another_: Having boiled the leaves
of cabbage, and triturated carefully, add the lees of vinegar, two
yelks of raw eggs and a little rose-oil, and having triturated, apply,
changing it frequently. Let them take food that is attenuant and of
little nourishment. Let them, therefore, abstain altogether from flesh
and pulse, from much wine of a dark colour; and, if possible, let them
abstain from drinking wine altogether. For I have known many persons
who have abstained altogether from this article alone, and all of them
derived benefit. Those who did so in the commencement of the complaint
were entirely freed from it; and those who were later in doing so
experienced afterwards fewer paroxysms, and these not of great severity.
If, therefore, no inconvenience occur, or be dreaded from it, they should
abstain from wine all their life. Those who from weakness or coldness
of constitution appear to sink under this regimen, after abstaining
from wine for two years, may gradually accustom themselves to take a
small quantity of diluted wine. Those who refrain from wine should take
instead of it a decoction of anise, or of some such seeds, avoiding
altogether the use of the autumnal fruits, and other things of a cold
nature, and also venery. Of those who attempt to get rid of the complaint
by continuing under a course of medicines for a complete year, many who
suffer from pituitous and redundant humours have been benefited thereby,
whereas such as are of a hot and dry intemperament have brought on sudden
death, the offending matter being translated to the intestines, kidneys,
side, lungs, or some vital part. It is better, therefore, for those who
are bilious and sanguineous, to abstain from wine; as from this course
there is no risk of falling into the dangers just mentioned. Those who
are affected with cold and redundant humours should take the theriac
of vipers more frequently if they have good digestion in winter, but
more rarely in summer; for it either removes the complaint altogether
or renders it more moderate, and proves injurious to none of the
afore-mentioned parts. And since some persons compel us to administer the
medicines called Antidotes, you should be aware that the following are
all of the same kind, namely, that from water plantain, that of Agapetus,
those called Atacton and Octaidon, that of Proclus, that from water
germander, that from coral, and many others. The safest of them all, and
yet of approved efficacy, is the one from coral, which dissolves tophi
that are formed in the joints. The properties of all these things, the
manner of using them, and the precautions to be observed with regard to
them, you will find described in the Pharmaceutical part of this Work;
and also the composition of depilatories for arthritic complaints, and
the mode of applying them to these habits, I mean the pituitous. Some,
for the entire removal of the complaint, boil whole wolves in oil,
wherewith they cure arthritic cases; some throwing them in alive, and
others dead, into a large caldron. And in like manner they boil hyænas,
making a discutient oil from them; and then filling the cistern of the
bath with it, and putting the arthritic patients into it, they direct
them to remain in it for a considerable time. By these means it happens
that not only the swellings about the joints, but the whole body, is
evacuated.
_On tophi, or chalk-stones._ Since tophi are often formed in the
joints, sometimes owing to a thick and terrene humour seating in
the parts, and sometimes owing to the use of applications which are
immoderately discutient and desiccant without being emollient, it is
proper to know that the most suitable remedies are such as are at
the same time emollient and discutient. Wherefore, old suet, marrow,
ammoniac, bdellium, very old oil, and storax, are emollient; and nitre,
salts, strained lye, adarce, euphorbium, and the like, are discutient
and desiccative. This is an excellent application for tophi in the
joints: Very old and acrid cheese pounded and applied with a decoction
of fat swines’ flesh, it also being old. For the chalk-stone breaking
spontaneously, a discharge of it takes place every day. The composition
from ham (which is prepared in two ways) is also an approved remedy, and
those described from strained lixivial ashes (potash?). And this one is
particularly excellent: Of aphronitrum, of turpentine, of protostacton,
of virgin wax (i.e. _bee-glue_), of each, oz. iv; of wax, oz. ix; of
colophonian rosin, lb. j; of oil, oz. xvj; mix together, and use for
chalk-stones and apostemes. The composition from dragon’s blood is of
wonderful efficacy for chalk-stones and many other complaints, but is
difficult to procure. But that from walnuts is not only efficacious but
at the same time easily procured; and is applicable not only to those who
are strong, but also to those who are sensitive, if mixed with honey or
the composition from anemone, in the proportion of two parts to one of
the composition. When these things are not at hand, an equal proportion
of ceruse may often be mixed with it.—_Another for tophi_: Having
triturated red arsenic, mix with mistletoe of the oak, and use.—_Another,
which is applicable also for fistula and ægilops_: Of oil, one sextarius;
of litharge, oz. viiiss; of arsenic, oz. j; boil the litharge and the oil
until they do not stain, then sprinkle the arsenic well levigated, and
before it catch fire, take off and use. The compositions from the flower
of Assian stone, when used during the intervals, are applicable to all
the collections which form in the joints; and some of the ancients attest
that they remove the complaint entirely. The composition from the flower
of salt, when applied in like manner during the remissions, is believed
to dissipate whatever swellings remain.
_On the prophylaxis of gout._ Gout and rheumatism, when formed, are
among the most difficult of diseases to cure, except by the methods we
have described; but, before being fixed, it is easy to prevent their
occurrence by restricting the diet, giving only such food as is of easy
distribution and not excrementitious, with a moderate allowance of
wine, and increasing the exercise as far as proper. As a remedy, salts
triturated with oil and rubbed into the joints, are of great use to all
who are anxious to avoid falling into a gouty affection, unless they
be of a dry intemperament. They ought to use it morning and evening
through life, and the same thing is to be used after the decline of the
inflammation.
* * * * *
COMMENTARY. Consult Hippocrates (Aphor. vi; Prognost. 15); Galen
(Comment. in Aphor. Hippoc., de Med. sec. loc. ix); Celsus (iv, 24);
Serenus Samonicus; Aretæus (Morb. Chron. ii, 12); Scribonius Largus
(41); Cælius Aurelianus (Tard. Pass. v, 2); Alexander (xi); Aëtius
(xii); Oribasius (Synops. ix, 58); Actuarius (Meth. Med. i, 21); Nonnus
(216); Marcellus (de Med. 35); Octavius Horatianus (ii, 21); Demetrius
Pepagomenos (de Podagra); Psellus (Opus Medicum); Macrobius (Saturnal.
vii, 4); Lucianus (Tragodopodagra); Serapion (iv, 25); Avenzoar (ii, 3,
28, ii, 7, 31); Avicenna (iii, 22, 2); Haly Abbas (Theor. ix, 41; Pract.
viii, 32); Alsaharavius (Pract. 38); Rhases (Divis. 102, ad Mansor. ix,
90, Libellus de Morb. Junct., and Contin. xxvi.)
The Prognostics of Hippocrates will be admitted at the present day to
be correct. Those who are old, or who have chalk-stones formed in their
joints, or lead a laborious course of life, or have dried bellies, cannot
be cured by any human means. Young persons not having _tophi_ formed
in their joints, and who live guardedly, and whose bowels will bear
the proper treatment, may be cured. These complaints are best removed
by dysenteries or other evacuations downwards. His principal remedies
are purgatives administered by the mouth or by injection, and local
applications of a cooling nature, and even pouring cold water on the
foot. When the pain of the gout becomes fixed in a joint, he directs us
to burn it with crude flax.
Seneca mentions it as a monstrous example of the depravity of his age,
that the women, by their luxurious habits, had become subject to gout.
(Epist. 95.)
According to Galen, gout and arthritic complaints are occasioned by
a collection of some humour in the affected part. This humour may be
blood, phlegm, or a mixture of phlegm and bile, or of blood along with
these, or simply a crudity. This crude humour, he remarks, sometimes
concretes into _tophi_. The first indication in attempting the cure is to
evacuate the offending humour by bleeding or purging; and then repellent
and discutient applications are to be used. He has given a great many
prescriptions for these. He disapproves of the warm bath in rheumatic
attacks; for, he says, although it appears at first to give relief, it
ultimately aggravates the complaint. (Therap. ad Glauc. ii.)
For an able and full explication of the ancient theory of the humours,
and the manner in which they give rise to arthritic complaints, we refer
the reader to Macrobius (l. c.)
Unfortunately the chapter of Aretæus on the treatment of arthritic
complaints has come down to us in a mutilated state. It appears however,
that he trusted to hellebore as the great remedy in such cases. His local
applications are wool dipped in rose-oil and wine; a sponge soaked in
oxycrate, or such like cataplasms. When the disease is hereditary, he
says it is generally incurable.
Celsus recommends various refrigerant and anodyne applications to the
affected part, such as a sponge soaked in cold water, or in oil and
vinegar, or the same soaked in hot water having poppies boiled in it,
or a mixture of pitch, wax, and alum. The other points of his practice
deserve attention, but we shall not enter upon them, as we wish to afford
room for a fuller abstract of the doctrines of Alexander.
Gout, according to Psellus, is occasioned by an atony of the nutritive
faculty, whereby a thick humour is collected in the system.
Scribonius Largus recommends his favorite remedy for local pains, namely,
the application of a living torpedo to the part affected.
Alexander begins with noticing the common opinion that gout is
irremediable by the art of medicine, which he affirms not to be the case
provided proper attention be paid to the different varieties of it. There
are, he says, many causes of the disease; for sometimes a hot blood flows
into the cavity of the joint and occasions violent pains; and, in like
manner, a defluxion of bile getting between the tendons and ligaments
occasions pain by burning and stretching the parts: phlegm likewise,
by producing cold and compression, becomes the cause of violent pains;
and in like manner the melancholic humour, not only by its coldness and
pressure but also by occasioning a sense of heaviness, brings on no
ordinary paroxysms. Sometimes a simple quality of the humours, such as
heat, cold, dryness, or humidity, will cause a defluxion. The prevalence
of a bilious humour is ascertained by the absence of swelling; from the
pain being rather a fiery heat than distension; and from the colour being
red. The proper remedies in this case are cholagogues, which must not be
of a heating nature nor offensive to the stomach; for when the stomach
is deranged the nerves sympathise and rheumatism is the consequence.
He gives prescriptions for a variety of such compositions containing
scammony, agaric, and the like, mixed with pepper, &c. He particularly
commends pills of scammony and wormwood. He also recommends cooling and
anodyne applications to the affected parts, such as rose-oil with the
yelk of an egg, and the like. He enjoins particular attention to the
diet, in order to avoid such things as have a tendency to form bile.
He recommends moderate exercise rather before than after a meal, but
forbids to carry it to excess. He speaks favorably of baths of common
water. He concludes this part with minute directions about the local
applications: but, as we have already stated his principles, we shall
not enter upon the detail of his practice. When gout is occasioned by
phlegm the part is neither hot nor red; is benefited by calefacients and
injured by refrigerants. For this variety he recommends particularly a
combination of purgative and attenuant medicines, such as the Julian
oxymel, which contained white hellebore, agaric, polypody, thyme, cumin,
&c. After purging he greatly commends hot and attenuant medicines, in
particular the composition from coral, which, among other ingredients,
contained birthwort, spikenard, cloves, myrrh, &c. (Birthwort formed
one of the principal ingredients of the celebrated Portland powder.) He
describes various other antidotes containing bitters, attenuants, and
calefacients. His local applications in this case are pounded cabbage,
parsley-seed, or fleabane, if the pain is moderate; but otherwise he
recommends anodyne cataplasms. Should these, however, rather produce
an increase of the pain, he directs us to substitute instead of them
discutient and repellent applications, such as decoctions of thyme,
mint, &c. with vinegar. He also recommends various cerates with the same
intention. Some, he says, have been benefited by stronger applications,
such as blisters of cantharides, sinapisms, or the like; but he does
not approve of the barbarous practice of burning with the substances
called _iscæ_ (see Aëtius and Paulus), nor of the above-mentioned
rubefacients, but prefers a combination of emollients with discutients.
When it is suspected that the gout proceeds from an overflow of blood
upon the joint, he recommends us to have recourse to bloodletting, unless
otherwise contra-indicated. He proscribes such articles of food as
engender much blood, as all sorts of flesh, especially pork; also sweet
wines and intemperance of every kind. He says he has known some cured by
simply refraining from wine. He then gives directions for the formation
of several topical applications which are of a repellent and discutient
nature. He speaks very favorably of a sponge soaked in an astringent
wine or oxycrate. He then gives ample directions for discussing Tophi or
chalk-stones. He lays it down as a general rule that such applications
should contain ingredients of a moderately calefacient, discutient, and
solvent nature. Among the articles which enter into these compositions we
remark litharge, old oil, sanguis draconis, nitre, turpentine, ammoniac,
&c. He then states, that as some do not choose to submit patiently to
the methodical plan of treatment, but insist upon getting medicines
to allay at once the violence of the pains, he, although he did not in
general approve of this practice, would now give an account of such
remedies. For this purpose, he says, _hermodactylus_ is particularly
trusted to by some; and he admits that it seldom fails to remove a
paroxysm, but affirms that it occasions more frequent returns of it.
Some, he adds, have endeavoured to correct its prejudicial effects by
adding to it cumin, mastich, or ginger, thinking that its action is
narcotic; but this he affirms to be a mistake, for in that case it could
not prove cathartic. He admits, however, that these things may prove
useful by correcting its bad effects upon the stomach. He then gives
various receipts for mixtures containing hermodactylus. As a specimen
of them we may mention the first, which consists of hermodactylus,
myrrh, pepper, and anise, to which scammony may be added. He recommends
it, however, in general, to be given in the form of pills with aloes,
scammony, elaterium, and colocynth. But, as mentioned by our author,
instead of it he prefers the coronopodium. It is the same, we presume,
as the coronopus of Dioscorides, or our buckthorn plantain (_plantago
coronopus_ L.), although the commentators are not agreed upon this point.
(See Matthiolus.) Gesner supposes it a species of _ranunculus_, which he
calls _polyanthemon_. Alexander then gives directions for various local
applications of an anodyne nature, containing opium, strychnos, ceruse,
wax, &c. We regret to say that so admirable a treatise should conclude
with some frivolous directions for curing the disease by means of amulets
of approved efficacy! However, the advocates of the Mesmerian system of
animal magnetism do not hesitate to admit their remedial powers. On the
periapta or amulets of the ancients, see Andreas Laurentius (de Marab.
Strum. Sanat, 85.)
Our limits will not permit us to do justice to the account of the
gout given by Aëtius. Like Aretæus, he maintains that the disease is
hereditary. His general views of the nature of the complaint and his
treatment are very plausible. He says it is occasioned by weakness
of the part and a redundance of humours; that the proper treatment
therefore consists in evacuating the humours by bleeding and purging, and
afterwards in strengthening the part.
Cælius Aurelianus considers arthritis, podagra, and chiragra, as diseases
of the same genus. The usual precursory causes are intemperance,
indigestion, debauchery, cold, too much or too little exercise, and
external injuries. Some, he adds, are of opinion that it is transmitted
from father to son. He gives the symptoms of these complaints with his
wonted accuracy. They are seated for the most part, he says, in the
nerves, by which term he probably means the tendons and membranes. He
remarks the well-known propensity which persons attacked with gout have
to attribute the swelling and pain to a sprain or some such accident.
If the belly be constipated, he advises us to open it by a simple
clyster. He recommends us to abstract blood from the affected part by
scarifications, which, he says, will occasion less irritation than
cupping or leeching. Sponges squeezed out of hot water, or oil and water,
or the decoction of fenugreek, are then to be applied to the part; for he
thinks these preferable to a cataplasm, as it is often too heavy. When
on the decline, he approves of bathing, spare diet, emollient ointments,
and gentle exercise, beginning with gestation, and proceeding to the
stronger kinds of it. When they can be borne, he approves of stimulant
applications, such as dropaces, heated sand, and even sinapisms. He also
speaks favorably of vomiting produced by radishes, hellebore, hip-baths
of oil, fomentations with hot salt water, and swimming in hot water or
even in cold. He particularly commends the naturally-medicated waters, or
spas (as they are now called), such as those of Albula or Cutilia, which,
he says, will either cure or mitigate the complaint. He disapproves of
burning the joints (the reader will have remarked his general aversion
to the cautery), and the indiscriminate application of various narcotics
and other such things. He also condemns the free use of emetics, (which,
he says, prove injurious to the stomach, and occasion a determination
to the head,) of purgatives, acrid clysters, and diuretics. In short,
his practice is not unlike that of our Sydenham. His grand rule is to
keep upon a spare diet, or even to maintain complete abstinence at the
commencement. The formula for his diacentaureo (as Van Swieten remarks)
is the same as that for the Portland powder, namely, Aristoloch. rotundæ;
gentianæ; sum. chamædryos; centaur. min. p. æquales. Cælius Aurelianus,
Galen, Aëtius, Celsus, Aretæus, Oribasius, Scribonius, and Horatianus
make no mention of the hermodactylus. Myrepsus and Actuarius make mention
of a hermodactylus, but Matthiolus and the commentator on the former
think theirs a different plant from the hermodactylus of the other Greek
authors. This may be true, and yet the microscopic eye of critics often
fancies it can see differences which other people are puzzled to remark.
We may mention further regarding the practice of Cælius Aurelianus, that
he speaks of soothing the pains of rheumatism, more especially of the
hip-joint, by music. On this practice see also Aulus Gellius (iv, 13);
Athenæus (Deipnos. xiv, 18); Apollonius (Hist. Marab.); Pliny (H. N.
xxviii, 2.)
There is nothing very important in Nonnus, Octavius Horatianus, or
Oribasius. We shall now give a brief abstract of the curious treatise
on the gout by Demetrius Pepagomenos. The work is dedicated to the
Emperor Michael Paleologus, who flourished about the year 1260; and it
was published by Morel at Paris, A.D. 1558. The author commences by
explaining the nature of that derangement of the animal economy which
occasions this complaint. This he does at considerable length, but in
much the same terms as Macrobius, to whom the reader has been already
referred for an exposition of the humoral pathology. His physiological
opinions appear to us to be highly ingenious and philosophical. He comes
to the conclusion that gout is occasioned by a collection of humours
in the affected joint, these humours being the product of imperfect
digestion and of the retention of excrementitious superfluities, which
ought to have been evacuated from the system. He says the procatarctic or
remote causes of arthritic affections are, long-continued indigestion,
repletion with food, drinking too much wine, venery, unusual exercise,
indolence, and retention of the natural secretions. Venery, in
particular, is said to weaken the tone of the nervous parts. He then
proceeds to explain that when crudities are formed in the system, those
parts which are strong and vigorous cast them off, which those that are
weak cannot effect, and hence collections of such humours take place
in them. The prophylaxis of the complaint, he remarks, is easily laid
down, but is difficult to follow, namely, to observe great moderation in
eating and drinking, and to avoid indigestion. His grand principle of
practice is evacuation, which, according to the general rule laid down
by Hippocrates, is the proper remedy for repletion. He then shows that
vomiting is the mode of evacuation most applicable in this complaint,
because it empties the stomach, which is the fountain whence the
humours are derived. His comparison of the stomach to a fountain which
irrigates all parts of the system is very appropriate, and is beautifully
illustrated by him. He recommends, however, vomiting by simple means; and
for this purpose directs the patient to swallow meat imperfectly chewed,
radishes, leeks, &c. and, having drunk some honied water, to excite
vomiting by tickling the throat with a feather or the finger. He forbids
the use of strong emetics. His second method of evacuation is by purging,
which he recommends to be done by pills containing aloes, hermodactylus,
cinnamon, and scammony. He then proceeds to the cure when an attack has
come on. In this case, he recommends us to begin with letting blood,
unless the stomach be loaded with impurities, when an emetic must be
premised, lest the emptiness of the veins produced by venesection should
cause these crude humours to be conveyed over the body. Venesection,
he remarks, is particularly applicable at the commencement, when there
is simply a plethora of blood, but it is rather prejudicial afterwards
when the fluids become altered in quality. In such cases, as he fully
explains, purging is the proper remedy, especially when performed by
hermodactylus, which, he says, he had found from experience to answer
well, from whatever cause the disease had originated. He directs it to
be combined with various calefacients and aromatics, such as birthwort,
cinnamon, and pellitory. He then makes an ingenious reply to those who
affirmed that the disease is not to be cured by purgatives, but that it
is sometimes exacerbated by them. In such cases, he properly remarks, it
is not the remedy that is in fault but the misapplication of it. Those
who cannot bear cathartics by the mouth may have clysters given them;
or the preparations from elaterium, juice of sow-bread, or the like,
may be applied to the navel. He afterwards gives directions about the
local applications, which are nearly the same as those recommended by
Alexander. We will have occasion, in the Seventh Book, to discuss the
question respecting the nature of the ancient hermodactylus; and we
shall merely state here our own decided persuasion that it was a species
of colchicum or meadow-saffron. It forms one of the ingredients of the
celebrated _Eau médicinale d’Husson_. From the effects produced by the
_Eau médicinale_ we are inclined to think, however, that a certain
proportion of hellebore must have entered into its composition, as we
have never found the colchicum to act so violently as the _eau_ is said
to do. We have stated above that Cælius Aurelianus makes no mention of
the hermodactylus. However, the great modern advocate for Methodism,
Prosper Alpinus, speaks favorably of it, and says decidedly that it is
the colchicum of the Greeks. It appears not to have fallen into disuse in
his time. (De Med. Meth. ix, 4.)
The Arabians follow the Greeks closely in the general principles of
treatment, only substituting certain articles introduced into the Materia
Medica by themselves. Thus Serapion strongly recommends purging with
myrobalans, prunes, and tamarinds. He, Avicenna, and Rhases, join in
praising the virtues of the hermodactylus. Their local applications are
similar to those of the Greeks. When the pain is violent, Serapion even
approves of pouring cold water upon the affected part. Rhases approves
of burning the joint in certain cases. Avicenna directs us to cover the
part with oil and salt, and thus to apply the cautery gradually. Avicenna
speaks more favorably of bathing in thermal waters than any of the other
authorities. According to Haly Abbas, arthritic diseases are collections
of superfluities of the system in some joint which is labouring under
debility. These superfluities are said to be produced by repletion and
indigestion. The debility is generally occasioned by immoderate exercise,
intemperance, debauchery, or some such cause; and a joint having become
weakened, all the impurities of the system are collected into it. He
says that young persons and women who menstruate regularly are scarcely
liable to the gout. He agrees with the authorities already mentioned in
holding it to be hereditary. When the humour in the joints concretes into
chalk-stones, he pronounces the case to be incurable. When the disease
is produced by a sanguineous plethora, he recommends us to begin with
bleeding, and then to use cooling lotions, or even to pour cold water on
the joint. When these do not succeed, anodyne applications, containing
opium, mandragora, lettuce, saffron, and the like, are to be used.
When the pain has abated, any swelling which remains may be discussed
by applying to the part a decoction of marjoram, melilot, chamomile,
and the like. When the defluxion is connected with bile, he recommends
first emetics, and then drastic purgatives, such as aloes, scammony,
colocynth, and hermodactylus. But, if the patient’s stomach be weak,
he recommends milder laxatives. When the defluxion is of a phlegmatic,
that is to say, of a serous nature, he directs us to give the active
cathartics already mentioned, especially hermodactylus; and, if it be
the summer season, he advises us also to give emetics. He cautions us
against using local applications of too stimulant a nature at first,
lest they dispel the more fluid parts of the defluxion and leave the
grosser behind. This is but a meagre sketch of his interesting account of
arthritic diseases. Alsaharavius calls these complaints collections of
phlegm, bile, or blood. He holds that they are often hereditary. Like all
his countrymen, he approves of hermodactylus, which he gives in the form
of pills, with myrobalans, colocynth, turbit, castor, opopanax, &c. When
fulness of blood is present, he recommends bleeding.
The hermodactylus is recommended for the cure of arthritic diseases by
the earlier of the modern writers on medicine. See Lanfrancus (ii, 3.)
Among the ancient treatises on gout, we have mentioned the tragi-comic
poem entitled ‘Tragodopodagra,’ usually ascribed to the famous Lucian.
It ridicules, with much humour and severity, the many pretended nostrums
for this complaint. Among the remedial articles mentioned, we remark
hellebore, nitre (_soda_), henbane, poppy, fenugreek, and galls. The
ridicule thus bestowed upon the use of specifics for the cure of a
complaint so complicated as gout, is no doubt well founded; but we
ought not to be deterred, by the ill success of such a practice, from
attempting to afford relief upon general principles, as ably laid down
by Alexander, Demetrius, and Haly Abbas. We would fain impress upon the
physician and his patient, that more than is usually believed might be
accomplished in all arthritic diseases, by correcting the disorder of the
digestive functions by means of a suitable diet and regimen; and that it
is only when the constitution is radically unsound—when the joints are
deformed by concretions, and the vital powers have been worn out by a
long-continued course of debauchery—that we need adopt the discouraging
opinion of Ovid, as expressed in the following line:
“Tollere nodosam nescit medicina podagram.”
(Pont. i, el. 4.)