Part 6

Ephemeral Hemitertian Double quartan Interpolated Synocha Causon synochides Epilala Quotidian Double tertian Quintan Continued Causon Putrid Lipparia Tertian Quartan Sextan Synochus Synochus causonides Ethica Erratica

Some of these names are still preserved in our nosologies of the present day; others will be recalled by the memories of our older physicians, and a few have totally disappeared from our modern medical nomenclature.

Interpolated fevers are characterized by intermissions and remissions, and thus include our intermittent and remittent fevers; synochus depended theoretically upon putrefaction of the blood in the vessels, and was a continued fever. Synocha, on the other hand, was occasioned by a mere superabundance of hot blood, hence the verse:

"Synocha de multo, sed synochus de putrefacto."

Causon was due to putrefaction of bile in the smaller vessels of the heart, diaphragm, stomach or liver, and was an acute fever characterized by furred tongue, intolerable frontal headache, tinnitus aurium, constant thirst, delirium, an olive-colored face, redness and twitching of the eyes and a full, frequent and rapid pulse. Epiala and lipparia were febrile conditions concerning which there seems to have been much difference of opinion, even in the days of Gilbert. Apparently they were distinguished by variations of external and internal temperature, or by chills combined with fever. Febris ethica is our modern hectic fever. In the discussion of this last variety we are introduced to the "ros" and "cambium" of Avicenna, apparently varieties of hypothetical humors.

All these fevers are regarded from the standpoint of Humoralism, and depend upon variations in the quantity, quality, mixture or location of the four humors, blood, phlegm, bile and black-bile (melancholia).

In the general treatment of febrile diseases, so-called preparatives and digestives are first employed to ripen the humors, after which evacuatives (emetics, cathartics, sudorifics, and occasionally even venesection) are utilized for the discharge of these peccant humors. Much emphasis is laid upon the dietetics of fevers, and this branch of treatment is highly elaborated. Complications are met by more or less appropriate treatment, and the condition of the urine is studied with great diligence. Venesection is recommended rather sparingly, and is never to be employed during the dies caniculares (dog-days) or dies Aegyptiaci, nor during conjunctions of the moon and planets, nor upon the 5th, 15th, 17th, 25th, 26th, or 27th days thereafter, etc.

Among the complications of fevers discussed by Gilbert, two seem sufficiently important to justify special attention. On folio 74b we find a section entitled "De fluxu materie per parotidas venas," in which he remarks that "Sometimes matter flows through the parotid veins behind the ears down to the neck and nares, and obstructs the passages for air, food and drink, so as to threaten suffocation." He cautions us against the use of repressives, "lest the matter may run to the heart," and recommends mollitives and dissolvents, such as butter, dyaltea, hyssop and especially newly shorn wool (lana succida), which, he says, is a strong solvent. Is this a reference to the septic parotitis not unfrequently seen in low fevers?

The following section, "De inflatione vesice et dolore ejus," discusses the retention of urine in fevers, and its treatment. Gilbert says: "Inflation of, and pain in the bladder are sometimes symptoms of acute fevers, since the humors descend into and fill the bladder." If this occurs in an interpolated (remittent) fever, he directs the patient to be placed in a bath of a decoction of pellitory up to the umbilicus, "et effundet urinam." If the complication occurs in one suffering from a continued fever, the bath should be made of wormwood and a poultice should be placed over the bladder and genitals, "et statim minget." The same effect may be produced by poultice mixed with levisticum (lovage) or leaves of parsley. Singularly enough the catheter is not mentioned, though this instrument, under the medieval name of argalia (cf. French algalie), is noticed frequently in the section devoted to vesical calculus.

With the second book of the Compendium the system of the discussion of diseases a capite ad pedes is commenced, and produces some curious associates. To the modern physician the sudden transition from diseases of the scalp to fractures of the cranium seems at least abrupt, if not illogical. It seems, therefore, wiser, in a hasty review like the present, to take up the various pathological conditions described by Gilbert in their modern order and relations, and to thus facilitate the orientation of the reader.

The second book then opens with a consideration of the hair and scalp, and their respective disorders.

The hair is a dry fume (fumus siccus), escaping from the body through the pores of the scalp and condensed by contact with the air into long, round cylinders. It increases rather by accretion than by internal growth, and its color depends upon the humors. Thus red hair arises from unconsumed blood or bile; white hair, from an excess of phlegm; black hair, from the abundance of black-bile (melancholia), etc. The use of the hair is for ornament, for protection and for the distinction of the sexes. Numerous prescriptions for dyeing the hair, for depilatories (psilothra), for the removal of misplaced hair and for the destruction of vermin in the hair are carefully recorded.

Three varieties of soaps for medicinal use are described, and the process of their manufacture indicated. The base of each is a lixivium made from two parts of the ashes of burned bean-stalks and one of unslaked lime, mixed with water and strained. Of this base (capitellum), two parts mixed with one part of olive oil form the sapo saracenicus. In the sapo gallicus the base is made with the ashes of chaff and bean-stalks with lime, and to it is added goat's fat, in place of the oil. The sapo spatareuticus is made in a similar manner, except that oil replaces the goat's fat and the soap is made only during the dog days, since the necessary heat is to be supplied by the sun alone.

Among the diseases of the scalp attention is given to alopecia, dandruff (furfur), tinea caries and various pustular affections, fanus (favus), rima, spidecia, achora, etc. Caries was a pustular disease, in which bristle-like hairs formed a prominent feature. Rima was a name applied by the physicians of Salernum to a superfluity of hair. In addition to these diseases of the scalp, we find also descriptions of gutta rosacea, morphoea and scabies, a fairly extensive dermatology for this early day. In favus, Gilbert tells us that, after the removal of the pustules, there remain foramina, from which exudes a poisonous substance, resembling honey. Of course his system of treatment is rich in variety and comprehensiveness.

We may notice here too a few chapters on Toilet or Decorative Medicine, a branch of art to which modern physicians have devoted perhaps too little attention, with the natural result that it has fallen largely into the hands of charlatans of both sexes. Gilbert's chapter "De ornatu capillorum" offers the following sensible introduction: "The adornment of the hair affords to women the important advantages of beauty and convenience; and as women desire to please their husbands, they devote themselves to adornment and protect themselves from the charge of carelessness. In order, therefore, that our ministry may not be depreciated, and that we may not render ourselves liable to the accusation of ignorance, let us add a few words on the subject of the dressing of the hair and the general care of the person".

Accordingly Gilbert advises ladies who desire to retain or renew the charms of youth to soften the skin and open its pores by the use of steam baths and careful washing in warm water, followed by drying the surface with the finest cloths (panno mundissimo). If necessary, superfluous hair is to be removed by suitable depilatories, color to be restored to the pale cheeks by a lotion of chips of Brazil-wood soaked in rose-water and applied with pads of cotton; or, if the face is too red, it may be blanched by the root of the cyclamen (panis porcinus, sowbread) dried in an oven and powdered. A wealth of remedies for freckles, moles, warts, wrinkles, discolorations and other facial blemishes, with foul breath and fetidity of the armpits, is carefully recorded, and would suffice to establish the fortune of any of our modern specialists in female beauty. Finally a long chapter entitled "De sophisticatione vulvae" introduces us to a phase of decoration and sophistication which I would fain believe little known or studied in the development of modern civilization, in which we are prone at least to follow the advice of Hamlet, to

"Assume a virtue, if you have it not."

At all events, we may congratulate ourselves that the details of these disgusting cess-pools of medical art have disappeared entirely from the pages of our modern text-books. Even Gilbert considers it advisable to preface this gruesome chapter with a sort of "Caveat emptor" apology to the reader:

"Ut tamen secundum ordinem procedamus, in primis cognosactur cognoscere desiderantibus, ne dolus dolo patrocinetur, vel simplex dolose muscipula claudatur."

In the department of neurology Gilbert, after a philosophical discussion of the nature and variety of pain, devotes considerable chapters to the causes, symptoms, diagnosis and treatment of headache, hemicrania, epilepsy, catalepsy, analepsy, cerebral congestion, apoplexy and paralysis, phrenitis, mania and melancholia, incubus or nightmare, lethargy and stupor, lippothomia or syncope, sciatica, spasm, tremor, tetanus, vertigo, wakefulness, and jectigation (jactitation, formication, twitching).

The third book of the Compendium opens with several chapters on the anatomy and physiology of the eye and the phenomena of vision. According to Gilbert, the eye consists of three humors, the albugineous (aqueous), the crystalline lens and the vitreous humor, and seven tunics, apparently

1. The conjunctiva 2. The albuginea or sclerotic 3. The cornea 4. The secundina (choroid) 5. The rethilea (retina) 6. The aranea (iris) 7. The uvea perforata (posterior layer of iris),

though the definitions are not in all cases quite clear and definite. The tela aranea is said to take its origin from the retina, the retina from the optic nerve, and the latter from the rethi (rete, network) involving the substance of the brain. The cornea arises from the sclerotic tunic, the uvea and secundina take their origin from the pia mater, and the conjunctiva from a thin pellicle or membrane which covers the exterior of the cranium and is nourished by a transudation of the blood through the coronal suture. This pellicle is also said to have a connection with the heart, which arrangement furnishes a decidedly curious explanation of the mechanism of sympathetic and maudlin lachrymation. For, as Gilbert tells us, when the heart is compressed this pellicle is also compressed, and if any moisture is found beneath the pellicle it is expressed into the substance of the lachrymal gland by the constriction of the heart, and men in sorrow therefore shed tears. And again, if the heart is much dilated or elevated (by joy), this pellicle is also dilated or elevated, and if any moisture is found beneath it, it is expressed in the form of tears. Accordingly, men who are too joyful shed tears. Still further, drunken men, who are notoriously "moist," and have a superfluity of fluid between the pellicle and the skin of the cranium, are prone to weeping on slight provocation, and their tears are nothing more than an expression of this moisture, which makes its exit, not through the substance of the eye, but through the "lachrymal angle." Q.E.D.

This odd demonstration is followed by a succession of optical questions, which are discussed and answered in true scholastic style, with no little acuteness of observation. Thus: "Utrum visus fiat intus suscipiendo?" Is vision accomplished by something received into the eye? "Utrum color fit de nocte?" Does color exist at night? To the latter question Gilbert replies that in the darkness color exists in posse, but not in esse. Again: "Why do some animals see at night, some in the day only and some only in the twilight?" This phenomenon he ascribes to "the clearness and subtilty of the visual spirits, or to the strength, weakness, grossness or turbidity of the organs of vision." Some animals, he says, have (visual) spirits, subtle and clear as fire, and these animals see perfectly at night because the visual spirits (spiritus visibilis) are sufficient to illuminate the external air. "Why do objects in water seem nearer than those in air?" Gilbert explains this as follows: "Nothing appears distant, except as perceived through an extensive intervening medium. But our judgment is largely guided by the transparency of this medium, since the medium itself is not perceived with much accuracy, except when it is transparent. Accordingly, as the lucidity of air is greater than that of water, an object looks more distant through air than through water."

"Why does not a single object appear double, inasmuch as we have two eyes?" To this he replies: "From the anterior part of the brain two optic nerves pass to the two eyes. But these two nerves unite at a certain point into one. Now, since the two nerves are of equal length, two images proceeding from a single object do not make the object seem double, but single, since the two images are united into one, and accordingly one object is seen as one image."

Other physiological speculations are introduced by the questions: "May one see an object not actually present?" "Why do some animals see best objects at a distance, others those near at hand?" "Why are objects seen in their proper position?" All these questions are answered in accordance with the scholastic formulae, and, not infrequently, with considerable acuteness.

A chapter entitled "De signis oculorum" also introduces us to a curious discussion of ocular physiognomy. Thus:

"When we see a man with large eyes, we argue that he is indolent."