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 acc.u.mulated in (_coadunabatur_) and enlarged the part to the size of the goiter." After suggesting an a.n.a.logy between the disease and the redness and turgidity of the neck produced by pa.s.sion or in singing, he adds that some cases are due to an acc.u.mulation 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 b.l.o.o.d.y 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 ent.i.tled "_De arthretica pa.s.sione 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 a.s.sumes 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 b.l.o.o.d.y 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 p.u.b.erty. Women, too, do not usually suffer from this disease, because in coitus they are pa.s.sive, unless their menstrual discharge is suspended. Again gout sometimes arises from infection of the primary s.e.m.e.n; 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 b.l.o.o.d.y 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 r.e.t.a.r.d 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 quant.i.ty 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 (_a.s.suere_?), 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 a.s.suerus 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 n.o.bler 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 t.i.tle, "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 acc.u.mulated 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 t.i.tles, 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 "c.o.xe'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 _colchic.u.m autumnale_.

Gilbert's discussion of gout closes with a short and characteristic chapter ent.i.tled "_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 a.s.s 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 const.i.tution (_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 hoa.r.s.eness 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 s.e.xual pleasures, and suffer unusual depression after s.e.xual 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, ent.i.tled "_De infectione post coitum leprosi_,"

discusses the transmission of the disease by means of s.e.xual 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 cla.s.sification 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 cla.s.sifies _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 p.r.i.c.king 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, ill.u.s.trated 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 h.e.l.lebore, anacardium (_anacardis?_), castoreum, opium and ca.s.silago (_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.