Chapter 5

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[9] 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_.

[Footnote 9: It is at least interesting to know that small-pox is said to have made its first appearance in England in 1241.]

_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.

The premonitory symptoms of _variolae_ are a high fever, redness of the eyes, pain in the throat and chest, cough, itching of the nose, sneezing and pricking sensations over the surface of the body.

_Morbilli_ is a mild disease, but requires protection from cold, which confines and coagulates the peccant matter.

Attention is directed to the not infrequent ulcers of the eyes, which occur in _variolae_ and may destroy the sight; also to ulcerations of the nose, throat, oesophagus, lungs and intestines, the latter of which often produce a dangerous diarrhoea.

When _variolae_ occurs in boys, it is recommended to tie the hands of the patient to prevent scratching.

Whey is said to be an excellent drink for developing the eruption of _variolae_, and the time-honored saffron (_crocus_) appears in several of Gilbert's prescriptions for this disease. Here, too, we find the earliest mention of the use of red colors in the treatment of _variolae_ (f. 348 c):

"_Vetule provinciales dant purpuram combustam in potu, habet enim occultam naturam curandi variolas. Similiter pannus tinctus de grano._"

Acid and saline articles of food should be avoided, sweets used freely, and the patients should be carefully guarded from cold.

Not the least interesting pages of the Compendium are those (there are about twenty of them) devoted to the discussion of poisons, poisoned wounds and hydrophobia.

An introductory chapter on the general subject of the character of poisonous matters, illustrated by some gruesome and Munchausen-like tales, borrowed mainly from Avicenna and Ruffus, on the wonders of acquired immunity to poisons, the horrors of the basilisk, the _armaria_ (_?_), the deaf adder (_aspis surda_) and the red-hot _regulus_ of Nubia, leads naturally to the consideration of some special poisons derived from the three kingdoms of nature. Very characteristically Gilbert displays his caution in the discussion of a dangerous subject by the following preface:

_Abstineamus a venesis occultis quae non sunt manifesta, ne virus in angues adjiciamus, aut doctrinam perniciosam tradere videamur_ (f. 351 a).

Beginning then with metallic mercury (_argentum vivum_), he considers the poisonous effects of various salts of lead and copper, the vegetable poisons hellebore, anacardium (_anacardis?_), castoreum, opium and cassilago (_semina hyoscyami_), and then proceeds to the bites or rabid men and animals, hydrophobia, and the bites of scorpions, serpents and the _animalia annulosa_, that is, worms, wasps, bees, ants and spiders.

Space does not permit a careful review of this interesting subject, but a novel form of poisoning by the use of quicksilver is startling enough to claim our attention. Gilbert tells us that pouring metallic mercury into the ear produces the most distressing symptoms, severe pain, delirium, convulsions, epilepsy, apoplexy and, if the metal penetrates to the brain, ultimate death. In the treatment of this condition certain physicians had recommended the insertion into the ear of a thin lamina of lead, upon which it was believed that the mercury would fasten itself and might thus be drawn out. Avicenna objected to this that the mercury was liable to speedily pass into the ear so deeply as to be beyond the reach of the lead. Gilbert suggests as an improvement of the treatment that a thin lamina of gold be substituted for the lead, "because mercury thirsts after gold as animals do after water, as it is held in the books on alchemy" (_in libris allzinimicis_). This fact, too, he tells us can be easily demonstrated externally by placing upon a plate a portion of gold, and near, but not in contact with it, a little quicksilver, when the silver, he says, will at once "leap" upon the gold. Avicenna suggests that the patient stand upon the foot of the side affected, lean his head over to the same side, steady it in that position with the hands, and then leap suddenly over upon the other foot--demonstrating thereby his knowledge of both gravity and inertia. Manifestly our "laboratory physicians" of the present day can assume no airs of priority!

The Compendium closes with two very sensible chapters on the hygiene of travel, entitled "_De regimine iter agentium_" and "_De regimine transfretantium_."

In the hygiene of travel by land Gilbert commends a preliminary catharsis, frequent bathing, the avoidance of repletion of all kinds, an abundance of sleep and careful protection from the extremes of both heat and cold. The strange waters may be corrected by a dash of vinegar. Some travelers, he tells us, carry with them a package of their native soil, a few grains of which are added to the foreign waters, as a matter of precaution, before drinking. The breakfast of the traveler should be light, and a short period of rest after a day's travel should precede the hearty evening meal. Leavened bread two or three days old should be preferred. Of meats, the flesh of goats or swine, particularly the feet and neighboring parts, which, Gilbert tells us, the French call _gambones_, the flesh of domestic fowls and of the game fowls whose habitat is in dry places, is to be preferred to that of ducks and geese. Of fish, only those provided with scales should be eaten, and all forms of milk should be avoided, except whey, "which purifies the body of superfluities." Fruits are to be eschewed, except acid pomegranates, whose juice cools the stomach and relieves thirst. Boiled meats, seasoned with herbs like sage, parsley, mint, saffron, etc., are better than roasted meats, and onion and garlic are to be avoided.

The primitive conditions of land travel in the days of Gilbert are emphasized by his minute directions for the care of the feet, which he directs to be rubbed briskly with salt and vinegar and then anointed with an ointment of nettle-juice (_urtica_) and mutton-fat, or with a mixture of garlic, soap and oil. If badly swollen, they should be bathed, before inunction, with a decoction of elder-bark and other emollients.

In travel by sea, Gilbert tells us the four chief indications are to prevent nausea, to allay vomiting, to palliate the foul odor of the ship and to quiet thirst.

For the prevention of nausea he recommends the juice of acid pomegranates, lemons, etc., or a decoction of parsley or sweet cicely (_cerfolium_). The traveler should endeavor to sit with his head erect, should avoid looking around, but maintain his head as immovable as possible, and support himself by a firm grasp upon some beam of the ship. Some sweets may be sucked, or he may chew a few aromatic seeds. If vomiting ensues, acid or sweet pomegranates, figs or barley-sugar (_penides_) may be taken sparingly, but no food should be ingested until the stomach is thoroughly quieted. Then the patient may take a little _stomatichon_ or _dyantos_, and a small portion of digestible food. As the diet must necessarily consist largely of salty food and vegetables, these should be cooked in three or four different waters, and then soaked in fresh water. A little aromatic wine will also benefit the patient, and a few aromatic seeds chewed in the morning are also of service.

The effect of the foul odors of the ship may be combatted by the use of aromatic electuaries, "which comfort the heart, the brain and the stomach." The patient should be removed to some quiet portion of the ship, as distant as possible from the channels for the discharge of the bilge-water, and short walks upon the upper deck will contribute to convalescence. Frequent changes of clothing will palliate the annoyance of fleas and pediculi. Drinking water may be purified by aëration, or by straining, boiling and subsequent sedimentation and removal of the sediment by filtration through fresh and clean sand. For the wealthy, the water may be distilled in an alembic, if such an apparatus is obtainable. Avicenna says that bad water may be corrected by the addition of vinegar. Exposure to the midday sun and to the nocturnal cold, constipation and diarrhoea should be avoided, and prompt attention should be given to all disorders of the health.

To these wise counsels Gilbert courteously adds a medieval _bon voyage_ in these words:

"_Dominus autem omnia dirigat in tranquilitate. Amen._"

It has been already remarked upon a preceding page that Gilbert of England was not a surgeon. Nevertheless it is only fair to say that the surgical chapters of the Compendium present a more scientific and complete view of surgical art, as then known, than any contemporaneous writings of the Christian West, outside of Italy.

It is well known that during the Middle Ages the practice of surgery in western Europe was generally regarded as disreputable, and operative surgery was for the most part relegated to butchers, barbers, bath-keepers, executioners, itinerant herniotomists and oculists, _et id omne genus_, whose pernicious activity continued to make life precarious far down into the modern period.