Chapter 4

In the departments of general medicine not as yet entirely appropriated by specialists it will suffice to mention scrofula, pleurisy and pneumonia, hemoptysis, empyema, phthisis, cardiac affections, diseases of the stomach, liver and spleen, diarrhoea and dysentery, intestinal worms, dropsy, jaundice, cancer, rheumatism and gout, small-pox, measles, leprosy and hydrophobia, all of which claim more or less attention.

Peripneumonia and pleurisy are both inflammations of the chest, the former affecting the lungs, the latter the diaphragm and the pellicle which lines the ribs. The prominent symptoms of both diseases are pain in the chest or side, cough and fever and dyspnoea. Accidents or sequelae are hemoptysis, empyema and phthisis.

Empima (empyema) is the hawking-up of sanies, with infection of the lung and a sanious habit. Hence persons laboring under pneumonia or pleurisy are not necessarily empyemics, but when these diseases progress to such a point that blood and sanies are expectorated and the lung is infected, that is when the ulceration of the lungs fails to heal and corruption and infection occur, the disease becomes empima, and is with difficulty, or never cured.

Ptisis is a substantial consumption of the humidity of the body, due to ulceration of the lungs. For when a solution of continuity occurs in the lungs, the inspiratory and expiratory forces fail. Hence the lungs do not inspire sufficient air to mitigate the innate heat of the heart, and the heart fails to purify itself of the fumosity or fumous vapors generated in itself. Accordingly, deprived of the means of mitigating its heat or ventilating its fumosities, the spirits within it become unduly heated, and a consuming fire is generated in the entire body.

The symptoms of ptisis are a continued fever, greater or less, detected in the palms of the hands and the soles of the feet, thirst, a roughness of the tongue, slenderness of the neck, wasting of the entire body, constipation, wasting and shrinking of the finger-nails and fingers, hollowness of the eyes, pain in the left scapula extending to the shoulder, pharyngeal catarrh with abundant and mucilaginous sputum and a tendency to lachrymation. If the sputum thrown upon the coals emits a fetid odor, it is a sign of confirmed ptisis, which is incurable. The disease when it occurs in youths and young persons rarely lasts longer than a year, often terminates in less time, and may sometimes, by the aid of medicine, be prolonged for a greater period. If the sputum received during the night in a vessel is flushed in the morning with warm water, while some impurities remain upon the surface, the putrid matter will sink to the bottom (_sputum fundum petens_), and the indications are fatal. Likewise sharpness of the nose, hollow eyes, slender nails, falling hair, flattened temples and diarrhoea are of evil omen. These patients converse while dying, and die conversing (_moriendo loquentur, sed loquendo moriuntur_). Gilbert, of course, supplies a formidable array of remedies for the disease, but tells us that the "very latest" is cauterization over the clavicles (_Novissimum autem consilium est cauterium in furcula pectoris_).

The varieties of difficulty of breathing are classified under the titles of asma, dispnea, orthomia, hanelitus and sansugium. The last title is given to a condition in which, as Gilbert says, "A superfluous humor is abundant in the superficies of the lung, which compresses that organ and renders it unable to dilate in inspiration. Hence it labors in inspiration like a leech, from which the dyspnea derives its name."

Under the single title of "_cardiaca passio_" are included all possible diseases of the heart. The symptoms of this disease are said to be "palpitation, twitching of the limbs (_saltus membrorum_), perspiration, weakness of the nerves, facial pallor, weakness of the body as in hectic fever or phthisis, excessive pain and faintness over the precordia, a disposition to sleep and often constipation." The treatment is, of course, entirely symptomatic.

Diseases of the digestive apparatus are discussed under the headings of difficulties of deglutition, canine appetite, bolismus (boulimia), disturbances of thirst, eructations, hiccup, nausea and anorexia, vomiting, anathimiasis (gastric debility), anatropha and catatropha (varieties of obstinate vomiting), pain in the stomach, abscess of the stomach, salivation, colic, dysentery and diarrhoea, intestinal worms, hemorrhoids, rectal tenesmus, prolapsus ani, fistula in ano, diseases of the liver, dropsy, jaundice and diseases of the spleen.

Abscess of the stomach sometimes manifests a circumscribed tumor, and accordingly, probably includes cancer of that organ. Approved remedies are the Al'mirabile, the stomatichon frigidum, calidum or laxativumvum, etc., stereotyped formulae, of which the composition is carefully recorded.

Dysentery is a flux of the bowels with a sanguinolent discharge and excoriation of the intestines. A variety called hepatic dysentery, however, lacks the intestinal excoriation. Diarrhoea is a simple flux of the bowels, without either the sanguinolent discharges or the intestinal excoriation. Lientery is a flux of the bowels with the discharge of undigested food, occasioned by irritability (_levitas_) of the stomach or intestines. Colical passion and iliac passion derive their names from the supposed origin of the pain in the colon or ileum, a remark which furnishes occasion for the statement that Gilbert divides the bowels into six sections, viz., the duodenum jejunum and ileum, and the orobus, colon and longaon (rectum).

Intestinal worms are not generated in the stomach, as Gilbert says, because of the great heat produced by the process of digestion. In the intestines they originate chiefly from the varieties of phlegm, e.g., saline, sweet, acid, natural, etc. The species mentioned specifically are lumbrici and ascarides or cucubitini, though the terms long, round, short and broad are also employed, and probably include the tape worm or taenia lata. The treatment of these parasites consists generally in the use of aromatic, bitter or acid mixtures, among which gentian, serpentaria, tithymal and cucumis agrestis are especially commended for lumbrici, and enemata of wormwood, lupinus, scammony, salt, aloes, etc., for ascarides.

The diseases of the liver, though not numerous, are allotted considerable space most of which is occupied by scholastic speculations and the usual rich supply of therapeutical suggestions.

Discrasia of the liver has several varieties, warm, cold, moist and dry, and seems nearly equivalent to our somewhat overworked term of "biliousness." Gilbert's favorite compounds for the relief of this condition are the Trifera sarracenica, the Electuarium psilliticum and above all the Dyantos Besonis.

Obstruction (_oppilatio_) of the liver or enfraxis is defined as a disease of the canals (_pori_), of which four are enumerated, to-wit, the meseraic, that of the convexity of the organ (_gibbus--ubi sunt exitus capillarium venarum_), the duct leading to the gall-bladder and that leading to the spleen. With an abundance of symptoms, it is singular that this comprehensive disease does not seem characterized by any constant or severe pain, as we might reasonably expect.

Abscess of the liver depends upon some vice of the blood, the bile, the phlegm or the black-bile. The general treatment is poultices and other maturatives, but, as the author adds rather sadly at the close, _ultima cura est per incisionem_.

Dropsy is discussed as an independent disease through the exhaustive speculations of thirty-two pages. Gilbert tells us it depends upon some fault of the digestive faculty of the liver, and he divides it into four species, to-wit, leucoflantia, yposarcha, alchitis and tympanitis, each of which has its special and appropriate treatment. In the dreary waste of speculative discussion it is cheering, however, to observe Gilbert's positive recognition of the sphere of percussion indicated in the passage:

"_Et venter percussus sonat ad modum utris semipleni aqua et venta._" (f. 250b.)

Ycteritia or jaundice receives equally thorough discussion through eight weary pages, including the usual polypharmacal treatment.

The spleen, Gilbert says, is sometimes the name of an organ, sometimes of a disease. As an organ it is spongy and loose in texture, and attracts and retains the superfluities of the black-bile, expelled from the liver for its own cleansing. Hence it is a servile and insensitive organ, and accordingly suffers different diseases, such as obstruction, tumors, hardening, softening, abscess, and sometimes flatulence or repletion. The symptoms and treatment of each of these morbid conditions, arising from either heat or cold, are discussed with exasperating thoroughness, and the chapter concludes with the composition and use of various specific remedies of compound character, bearing the impressive titles of Dyasene, Dyacapparis, Dyaceraseos (a mixture of cherry juice, honey, cinnamon, mastic and scammony) and Agrippa.

Scrofulous swellings are carefully considered in a chapter entitled "_De scrophulis et glandulis._" "Scrophulae and glandulae are hard swellings developing in the soft parts, as in the emunctory localities of the veins and arteries, particularly in the neck, armpits and groins, and sometimes in other places. They spring from the superfluities of the principal organs, which nature expels, as it were, to the emunctories and localities designed to receive this flux." ... "Hence they are often found the cause of scabies, tinea, malum mortuum, cancer, fistula, etc., and are called glandes. Sometimes, however, a dryer matter is finely divided and falls into several minute portions, from which arise many hard and globular swellings, called scrofulae from the multiplicity of their progeny, like that of the sow (_scrofa_). The disease is also called _morbus regius_, because it is cured by kings."

Gilbert advises that these swellings should not be "driven in" (_repercutienda_), but brought to suppuration generally by emollients and poultices. When softened they may be opened with a lancet and the pus allowed to escape gradually, but as this process is tedious, he prefers the entire removal of the glands with the knife, premissing, however, that no gland should be cut into which cannot be well grasped by the hand and pulled from its seat. This surgical manipulation is fully described, and is undoubtedly taken from the similar chapter of Roger. It is worthy of notice also that just at the close of this chapter, Gilbert mentions a swelling called "testudo," a gland-like, gaseous (_ventosa_) tumor, usually solitary and found in "nervous" localities, like the joints of the wrist and hand. He says it often occurs from fracture (_cassatura_?) of the nerves, is cured by pressure, friction or incision, but is not entirely free from danger. Possibly this may refer to ganglion. Now, Roger makes no mention whatever of "testudo," while Roland says:

"_Nota quod quamvis Rogerius non designat inter glandulum et testudinem, scias igitur quod testudo fit ex majori parte flegmatica, minori melancholie, glandula vero a contrario_," a statement which might readily suggest the suspicion that Gilbert had before his eyes the text of Roland, or that, at least, he had not acquired his knowledge of testudo from Roger, his usual surgical authority.

Gilbert's sections on goitre (_bocium gulae_)[8] are interesting in themselves, and characteristic of the method adopted by him in his discussion of surgical or semi-surgical subjects. An introduction relative to the pathology of the disease and which seems to be original, is followed by a treatment, medical and surgical, adopted almost literally from the Chirurgia of Roger. Thus he says: "Goiter occurs most commonly among the inhabitants of mountainous regions, and is due to an amplification and dilatation of the veins, arteries and nerves, together with the soft tissues, occasioned by the north wind (_ventum boreale_), or some other confined wind, which during childhood has accumulated in (_coadunabatur_) and enlarged the part to the size of the goiter." After suggesting an analogy between the disease and the redness and turgidity of the neck produced by passion or in singing, he adds that some cases are due to an accumulation of spongy tissue between the veins and arteries, or to the use of flatulent food, and he even tells us that some old women know how to produce and remove goitrous swellings by means of certain suitable herbs known to them.

[Footnote 8: Cf. the French _bosse de la gorge_.]

Under medical treatment we find the following: "Dig out of the ground while chanting a pater noster, a nut which has never borne fruit. The roots and other parts pound well with two hundred grains of pepper, and boil down in the best wine until reduced in volume to one-half. Let the patient take this freely on an empty stomach until cured."

Another more elaborate prescription consists of a long list of ingredients, including burnt sponge, saponaria, the milk of a sow raising her first litter, with numerous simple herbs, and the sole object for which this nonsensical farrago is introduced here is to add that both these prescriptions are copied from the surgery of Roger. It is important too to remark here that we owe to Roger the introduction of iodine, under the form of burnt sponge, into the treatment of goiter.

In the failure of medical treatment, Gilbert directs the employment of surgical means, e.g., the use of setons, or, in suitable cases, extirpation of the goiter with the knife. If, however, the tumor is very vascular, he prefers to leave the case to nature rather than expose the patient to the dangers of a bloody operation. The whole discussion of goiter is manifestly a paraphrase of the similar chapter of Roger, who also introduced into surgical practice the use of the seton.

In Gilbert's chapter entitled "_De arthretica passione et ejus speciebus_," we are introduced to the earliest discussion by an English physician of that preeminently English disease--gout. We may infer, too, from the length of the discussion (thirty or more pages) that this was a disease with which Gilbert was not only familiar, but upon the knowledge of which he prided himself greatly. Indeed, it is one of the few diseases of the Compendium in which the author assumes the position of a clinician and introduces examples of the disease and its treatment taken from his own clientele. We shall, therefore, follow our author here rather more carefully and literally than usual, that we may learn the views of an English physician of the thirteenth century on, perhaps, the most characteristic disease of his countrymen.

Gilbert says: "Arthetica is a disease of the joints arising from a flux of humors descending into their continuity (_concathenationem_). The name is derived from the Latin _artus_, a joint, and the disease comprehends three species, viz., _sciatica_, disease of the scia, or the ligaments uniting the spine with the hip; _cyragra_, disease of the joints of the hands; and _podagra_, disease of the bones and joints of the foot, due to the descent of humors into their continuity. Sometimes, too, the disease affects other organs, occasioning pain in sensitive members, as, e.g., the head, and then derives its name from the part affected, as _cephalea_, _emigranea_ or _monopagia_. Occasionally likewise some humor runs down (_reumatizat_) into the chest, spreading over the nerves of the breast or those of the spine between the vertebrae, and sometimes to other places. Hence the disease derives the general name gout (_gutta_), from its resemblance to a drop (_gutta_) trickling or falling downward and flowing over the weaker organs, which receive the humor. For gout arises particularly from rheumatic causes. Now, as the humors are rather uncontrollable (_male terminabiles_) fluids, they flow towards the exterior and softer parts, like the flesh and skin, which receive their moisture and being soft, dilatable and extensible, there results some swelling. But if the humors are hard and dry, they are confined within the interior of the organs, such as bones, nerves and membranes: and these, being hard in themselves, do not receive the moisture, nor suffer extension or dilatation, and thus no swelling results. Since, therefore, the material of this variety of arthetica, in which no swelling is present, is formed of grosser and harder substance and is found in the vicinity of hard and cold localities, it is dissolved slowly and the disease is not cured until this solution takes place. That form of the disease, however, in which there is swelling from a subtile and liquid material deposited in the soft parts is the more quickly cured. Hence swelling is the best sign of curability. This is most evidently true in podagra, unless the _materies morbi_, by reason of its scarcity, produces no enlargement of the affected part."

Quoting the words of Rhazes, Gilbert tells us that the _materies morbi_ of gout is, for the most part, crude and bloody phlegm. Rarely is it bilious, and still more rarely, melancholic. If, however, it is compounded, it consists chiefly of bile mixed with a subtile phlegm, and more rarely, of phlegm mixed with black bile (_melancholia_), occasionally of black bile mixed with blood. The mixture of black bile and blood or bile is very rare, and still rarer a mixture of all the humors according to their proportion in the body.

If the color of the affected part is red, it indicates that the _materies morbi_ is sanguineous; if greenish-yellow (_citrinus_), that it is bilious; if whiter than the general color of the body, that the materies is a subtile phlegm. If the color shades away into black, it does not signify necessarily that the materies is simply black bile, for such a color occurs at the close of acute abscesses, or from strangulation of the blood. But if, together with the black color, we find the tissues cold and no increase of heat in the affected part, this indicates that the _materies_ is black bile.

By touching the diseased part we determine its heat or coldness, hardness or softness, roughness or smoothness, fullness, distention or evacuation, all of which signs possess special significance.

The antecedent causes of gout, Gilbert tells us, are a heat too solvent, cold too constringent (f. 311 c), sometimes a strong bath or a severe journey in a plethoric person (_in plectorico_), again excessive coitus after a full meal (_satietatem_), or even habitual excess, by which the joints are weakened and deprived of their natural heat and subtile moisture. Hence boys and eunuchs are not commonly affected by gout--at least boys under the age of puberty. Women, too, do not usually suffer from this disease, because in coitus they are passive, unless their menstrual discharge is suspended. Again gout sometimes arises from infection of the primary semen; for a chronic disease may be inherited by the offspring and affect the material causes, i.e., the humors. Flatulence (_ventositas_) is likewise a cause of gout, as we have already hinted.

In gout of the sanguineous type the favorite remedy of Gilbert was venesection, pushed to extremes which suggest the bloody theories of his later confrere Bouillaud. This bloodletting, however, was always to be practiced on the side opposite to that affected by the disease, as he tells us, for two reasons: First to solicit the peccant material to the opposite side; and, second, to retard its course toward the seat of the swelling. If, therefore, the disease is in the right foot, he bleeds from the basilic vein, or some of its branches, in the right hand. No other vein should be taken, but if neither the basilic vein nor one of its branches can be found, the bleeding may be performed upon the median vein, for certain branches of the basilic and cephalic veins unite to form the median. If the disease is in the hand, the material may be diverted in two ways, either to the other hand or to the opposite foot. Indeed, blood may be taken from both these parts in succession. The quantity of blood withdrawn should be in accordance with the strength of the patient, the character of the swelling, the pulsation, distention, heat and redness of the affected part. But it should be repeated frequently, and this bloodletting then frequently suffices, in itself, to cure the disease.