Part 9

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.

These general medical rules are succeeded by some twenty pages devoted largely to special formulae for the different forms of gout, with remarks as to their applicability to the different varieties of the disease. Most of the formulae bear special titles, apparently to lend the weight of a famous name to the virtues of the prescription itself, something as in these modern days we speak of "Coxe's Hive Syrup," "Dover's Powder," "Tully's Powder," etc. Thus we read of the "Pilulae artheticae Salernitorum," the "Cathapcie Alexandrine," the "Oxymel Juliani" the "Pilulae Arabice," the "Pulvis Petrocelli," the "Oleum benedictum," the "Pilulae Johannicii," etc. It is important, too, to remark that the active ingredient of very many of these formulae is the root called hermodactyl, believed by the majority of our botanists to be the colchicum autumnale.

Gilbert's discussion of gout closes with a short and characteristic chapter entitled "Emperica," in which he remarks: "Although I perhaps demean myself somewhat in making any reference to empirical remedies, yet it is well to write them in a new book, that the work may not be lacking in what the ancients (antiqui) have said on the subject. Accordingly I quote the words of Torror. If you cut off the foot of a green frog and bind it upon the foot of a gouty patient for three days, he will be cured, provided you place the right foot of the frog upon the right foot of the patient, and vice versa. Funcius, also, who wrote a book on stones, said that if a magnet was bound upon the foot of a gouty patient, he is cured. Another philosopher also declared that if you take the heel-bone of an ass and bind it upon the foot of the patient, he is cured, provided that you take the right bone for the right foot, and conversely, and he swore this was true. Torror also said that if the right foot of a turtle is placed upon the right foot of a patient suffering from the gout, and conversely, he will be cured."

Gilbert's discussion of leprosy (De lepra, f. 336 d) covers twenty pages and, according to Sprengel, is "almost the first correct description of this disease in the Christian West." Freind says this chapter is copied chiefly from Theodorius of Cervia. See page 3 ante. If, however, I am correct in my conjecture that the Compendium was written about the year 1240, the copying must have been done by Theodorius, whose "Chirurgia" did not appear until 1266.

Leprosy is defined as a malignant disease due to the dispersion of black bile throughout the whole body, corrupting both the constitution (complexionem) and the form of its members. Sometimes, too, it occasions a solution of continuity and the loss of members.

The disease is sometimes congenital, arising from conception during the menstrual period. For the corrupt blood within the maternal body, which forms the nourishment of the fetus, leads likewise to the corruption of the latter. Sometimes the disease is the result of a corrupt diet, or of foul air, or of the breath or aspect of another leper. Avicenna tells us that eating fish and milk at the same meal will occasion the same result. Infected pork and similar articles of diet may likewise produce the disease. Cohabitation with a woman who has previously had commerce with a leper may also produce infection.

Among the general symptoms of leprosy Gilbert enumerates a permanent loss of sensation proceeding from within (insensibilitas mansive ad intrinseco veniens) and affecting particularly the fingers and toes, more especially the first and the little finger, and extending to the forearm, the arm or the knees; coldness and formication in the affected parts; transparency (luciditas) of the skin, with the loss of its natural folds (crispitudines), and a look as if tightly stretched or polished; distortion of the joints of the hands and feet, the mouth or the nose, and a kind of tickling sensation as if some living thing were fluttering within the body, the thorax, the arms or the lips. There is felt also a sensation of motion, which is even visible also by inspection. Fetor of the breath, the perspiration and the skin are likewise noticeable. The localities affected lose their natural hair and are re-covered with very fine hairs, invisible except when held between the eye and the sun. The hair of the eyebrows and the eyelashes are lost--one of the worst of symptoms. There are present also hoarseness and an obstruction of the nostrils, without any visible cause. When the patient takes a bath the water runs off the affected localities as if they had been greased--another sign of evil omen. The angles of the eyes are rounded and shining. The skin, even when unaffected by cold, or other similar cause, is raised into very minute pimples, like the skin of a plucked goose. The blood in venesection has an oily appearance, and displays small particles like sand. Small tumors accompany the depilation of the eyebrows. Lepers are unusually and unduly devoted to sexual pleasures, and suffer unusual depression after sexual indulgence. The skin is tormented with a constant itching, and is alternately unduly hot or cold. Small grains are found under the tongue, as in leprous hogs.

Gilbert divides leprosy into four varieties, elephantia, leonina, tyria and allopicia, the pathology, symptoms and treatment of each of which are presented with wearisome minuteness and completeness. A long chapter, entitled "De infectione post coitum leprosi," discusses the transmission of the disease by means of sexual intercourse, and suggests the possible confusion of lepra and syphilis.

The usual catalogue of specific remedies terminates the discussion.

An interesting chapter on small-pox and measles, "De variolis et morbillis," gives us the prevailing ideas relative to these diseases in England during the thirteenth century. Premising his remarks with a classification of diseases as follows:

Diseases universal and infectious--like morphoea, serpigo, lepra, variolae et morbilli.

Diseases universal but not infectious.

Diseases infectious but not universal--like noli me tangere.

Diseases neither infectious nor universal.

Gilbert classifies variolae et morbilli among the universal and infectious diseases, and in the species apostemata. To this latter species belong also ignis Persicus, carbunculus and antrax.

Variolae et morbilli arise from moist matter confined in the body and turbid, like turbid blood. Hence the disease occurs most commonly in boys and in those who are careless about cleanliness and neglect venesection. It is the result of a disposition of the blood resembling putrescence, in which there occurs an external ebullition in the efforts of nature to purify the interior of the body and to expel to the surface the virulent material within. Accordingly the common people declare that persons who have suffered from variolae et morbilli never acquire leprosy. Occasionally, too, the disease arises from excessive corruption of matter in repletion of blood, and hence it is more frequent in sanguineous diseases, like synocha, and during the prevalence of south winds or the shifting of winds to the south, and in infancy--the age characterized particularly by heat and moisture.

The eruptions vary in color in accordance with the mixture of the different humors with the corrupt blood. Hence some are light colored, some the color of saffron, some red, some green, some livid, some black, and the virulence of the disease is the greater, the nearer the color approaches to black. There are, too, four varieties of the eruption, distinguished by special names. When the eruption is light colored and tends to suppuration, it is called scora. When it is very fine and red, it is called morbilli or veterana. The distinction between variolae and morbilli is in the form and matter of the disease, for in variolae the pustules are large and the matter bilious (colerica), while in morbilli the eruption is smaller and does not penetrate the skin (non-pertransit cutem). Variolae, on the contrary, forms a prominent pustule (facit eminentiam). A third form of the disease displays only four or five large, black pustules on the whole body, and this form is the most dangerous, since it is due to an unnatural black bile, or to acute fevers, in which the humors are consumed. This variety bears the name of pustula. A fourth form is called lenticula. This latter form occurs sometimes with fever, like synocha, sometimes without fever, and it arises from pestilential air or corrupt food, or from sitting near a patient suffering from the disease, the exhalations of which are infectious.