Gilbertus Anglicus Part 7

Thus far Gilbert has followed Roger almost literally. But he now adds, apparently upon his own responsibility, the following paragraph:

_Quod si placuerit, extrahe canellum: factis punctis in sutura ubi debent fieri antequan stringantur, inter duo puncta canellus extrahatur, et post puncta stringantur. Hoc dico si vulnus intestini sic (sit) ex transverso._

Apparently Gilbert feels some compunctions of conscience relative to the ultimate disposition of the canula of alder-wood, and permits, if he does not advise, its removal from the intestine before the tightening of the last st.i.tches.

Roland adds nothing to the text of Roger. But The Four Masters (_Quatuor Magistri_, about A.D. 1270) suggest that the canula be made of the trachea of some animal, and add:

_Canellus autem per processum temporis putrefit et emittur per egestionem, et iterum per concavitatem canelli transibit egestio._

In his further discussion of wounds of the intestine and their treatment Gilbert also volunteers the information that:

"Mummy (shade of Lord Lister!) is very valuable in the healing of wounds of the intestine, if applied with some astringent powder upon the suture."

In amends for the mummy, however, we are also introduced to the practice of mediaeval anaesthesia by means of what Gilbert calls the _Confectio soporifera_ (f. 234d), composed as follows:

_R._

_Opii, Succi Jusquiami (hyoscyami), Succi papaveris nigri, vel ejus seminis, Sacci mandragorae, vel ejus corticis, vel pomorunt ipsius si succo carueris, Foliorum hederae arborae (ivy), Succi mororum rubi maturorum, Seminis lactucae, Succi cuseutae (dodder)_, aa. ounce I.

Mix together in a brazen vessel and place this in the sun during the dog-days. Put in a sponge to absorb the mixture, and then place the sponge in the sun until all the moisture has evaporated. When an operation is necessary, let the patient hold the sponge over his nose and mouth until he goes to sleep, when the operation may be begun.

To awaken the patient after the operation, fill another sponge with vinegar and rub the teeth and nostrils with the sponge, and put some vinegar in the nostrils. An anaesthetic drink may also be prepared as follows:

_R._

_Seminis papaveris albi et nigri, Seminis lactucae, aa. ounce I.

Opii, Misconis ( , poppy juice?)_, aa. scruples I-II, as required.

The patient is to be aroused as before.

On folio 180d we find a chapter ent.i.tled "_De cathena gulae incisa vel fracta_," and copied almost literally from the chapter "_De catena gulae_" of Roger. In neither writer do I find any precise definition of what the _cathena gulae_ is, though Roger says, _Si es gulae, quod est catena, fractum fuerit_, etc., nor do I find the terms used explained in any dictionary at present available. The description of the treatment of this fracture seems, however, to indicate that the _catena gulae_ of Roger and Gilbert is what we call the clavicle, though the more common Latin names of this bone are _claviculus_, _furcula_, _juglum_ or _os juguli_. Gilbert says: "But if the bone which is the _cathena gulae_ is broken or in any way displaced (_recesserit_), let the physician with one hand raise the forearm (_brachium_) or arm (_humerum_) of the patient, and with the other hand press down upon the projecting portion of the bone. Then apply a pledget moistened with alb.u.men, a pad and a splint in form of a cross, and over all a long bandage embracing both the arm and the neck and suspending the arm. A pad (_cervical_) should also be placed in the axilla to prevent the dropping of the arm, and should not be removed until the fracture is repaired. If the fracture is compound, the wound of the soft parts is to be left open and uncovered by the bandage, so that a tent (_stuellus_) may be inserted, and the wound is then to be dressed in the ordinary manner."

Simple fracture of the humerus, Gilbert tells us, is to be reduced (_ad proprium loc.u.m reducator_) at once by grasping the arm above and below the seat of fracture and exercising gentle and gradual extension and compression. Then four pieces of lint wet in egg-alb.u.men are to be placed around the arm on all sides, a bandage, four fingers wide, also moistened in alb.u.men is to be snugly applied, another dry bandage placed above this, and finally splints fastened in position by cords. This dressing is to remain undisturbed for three days, and then renewed every third day for nine days. After the ninth day a _strictura_ (cast, apparatus immobile?) is to be prepared and firmly applied with splints and a bandage, and the patient is to be cautioned not to bear any weight upon the injured arm (_ne infirmus se super illud appodiet_?). The fracture is then left until it is believed that consolidation has occurred. If, however, it is found that swelling is occasioned by the cast (_ex strictorio_?), the latter should be removed, and the arm well bathed in warm water containing mallowae and other emollients and thoroughly cleansed. If the bone seems to be well consolidated, it should be rubbed with an ointment of _dialthea_ or the _unguentum marciation_, after which the splints and bandage are to be reapplied. If, however, it is found that the bone is not well consolidated, the cast should be replaced in the original manner, until consolidation is accomplished. If erysipelas results from the dressings, it is to be treated in the ordinary manner. During the entire treatment potions of nasturtium seeds, _pes columbini_ (crowfoot) and other "consolidatives" are to be administered diligently. If the fracture is compound, any loose fragments of bone are to be removed, the fracture reduced as before, and similar dressings applied, perforated, however, over the wound in the soft parts.

In fracture of the ribs (_flexura costi_) Gilbert recommends a somewhat novel plan for the replacement of the displaced bone. Having put the patient in a bath, the physician rubs his hands well with honey, turpentine, pitch or bird-lime (_visco_), applies his sticky palms over the displaced ribs, and gradually raises them to their normal position. He also says (f. 183a), the application of a dry cup (_cuffa vero c.u.m igne_?) over the displaced rib is a convenient method for raising it into position.

Of fractures of the forearm Gilbert simply says that they are to be recognized by the touch and a comparison of the injured with the sound arm. They should be diligently fomented, extension made if necessary, and then treated like other fractures.

Dislocation of the atlo-axoid articulation (_os juguli_) he tells us threatens speedy death. The mouth of the patient is to be kept open by a wooden gag, a bandage pa.s.sed beneath the jaw and held by the physician, who places his feet upon the shoulders of the patient and pressing down upon them while he elevates the head by the bandage, endeavors to restore the displaced bone to its normal position.

Inunctions of various mollitives are then useful.

Dislocations of the lower jaw are recognized by the failure of the teeth to fit their fellows of the upper jaw, and by the detection of the condyles of the jaw beneath the ears. The bone is to be grasped by the rami and dragged down until the teeth resume and retain their natural position, and the jaw is then to be kept in place by a suitable bandage.

In dislocation of the humerus the patient is to be bound in the supine position, a wedge-shaped stone wrapped with yarn placed in the axilla, and the surgeon, pressing against the padded stone with his foot and raising the humerus with his hands, reduces the head of the bone to its natural position. If this method fails, a long crutch-like stick is prepared to receive at one end the axillary pad, the patient is placed standing upon a box or bench, the pad and crutch adjusted in the axilla, and while the surgeon stands ready to guide the dislocated bone to its place, his a.s.sistants remove the bench, leaving the patient suspended by his shoulder upon the rude crutch. In boys, Gilbert tells us, no special apparatus is required. The surgeon merely places his doubled fist in the axilla, with the other hand grasps the humerus and lifts the boy off the ground, and the head of the bone slips readily back into place. After we are a.s.sured that the reduction is complete, a strictorium is prepared, consisting of the _pulvis ruber_, egg-alb.u.men and a little wheat flour, with which the shoulder is to be rubbed. Finally, when all seems to be going on well, warm _spata drapum_ (sparadrap) is to be applied upon a bandage, and if necessary the apostolicon ointment.

Dislocation of the elbow is reduced by pa.s.sing a bandage around the bend of the arm, forming in this a loop (_scapham_) into which the foot of the surgeon is to be placed for counter-extension, while with the hands extension is to be made upon the forearm until the bones are drawn into their normal position. Flexion and extension of the joint are then to be practised three or four times (to a.s.sure complete reduction?), and the forearm flexed and supported by a bandage from the neck. After a few days, Gilbert tells us, the patient will himself often try to flex and extend the arm, and the bandage should be so applied as not to interfere with these movements.

Dislocation of the wrist is reduced by gentle extension from the hand and counter-extension from the forearm, and dislocation of the fingers by a similar manipulation.

After so full a consideration of the surgical injuries of the head, trunk and upper extremities, we are somewhat surprised to find Gilbert's discussion of the similar injuries of the lower extremities condensed into a single very moderate chapter ent.i.tled "De vulneribus cruris et tybie" (f. 358a b).

In this, Gilbert, emphasizing the importance of wounds of the patella and knee-joint and the necessity for their careful treatment, also declares that wounds of both the leg and thigh within three inches of the joints, or in the fleshy portion of the thigh _ubi organum est_ (?), involve considerable danger. He then speaks of a blackish, hard and very painful tumor of the thigh, which, when it ascends the thigh (_ad superiora ascendit_) is mortal, but if it descends is less dangerous. Separation of the sacrum (_vertebrum_) from the ilium (_scia_), either by accident or from the corrosion of humors, leaves the patient permanently lame, though suitable fomentations and inunctions may produce some improvement. Sprains of the ankle are to be treated by placing the joint immediately in very cold water _ad repercussionem spiritus et sanguinis_, and the joint is to be kept thus refrigerated until it even becomes numb (_stupefactionem_); after which stupes of salt water and urine are to be applied, followed by a plaster of galbanum, opoponax, the apostolicon, etc.

Fractures of the femur are to be treated like those of the humerus, except that the ends of the fractured bone are to be separated by the s.p.a.ce of an inch, and a bandage six fingers in width carefully applied. Such fractures within three inches of the hip or knee-joint are regarded as specially dangerous.

Dislocations of the ankle, after reduction of proper manipulation, should be bound with suitable splints. If of a less severe character, the dislocation may be dressed with stupes of canabina (Indian hemp), urine and salt water, which greatly mitigate the pain and swelling.

Afterwards the joint should be strapped for four or five inches above the ankle with plaster, _ut prohibeatur fluxus_.

It should be said that the brevity of this chapter of Gilbert is modeled after the manner of Roger of Parma, who refers the treatment of injuries of the lower extremities very largely to that of similar injuries of the upper, merely adding thereto such explanations as may be demanded by the differences of location and function of the members involved. Thus in his discussion of dislocation of the femur Roger says:

_Si crus a c.o.xa sit disjunctum, eadem sit cura quam et in disjuncturam brachii et cubiti diximus, etc._

The general subject of fistulae is treated at considerable length on folio 205b, and fistula lachrymalis and fistulae of the jaw receive special attention in their appropriate places. As a rule, the fistula is dilated by a tent of alder-pith, mandragora, briony or gentian, the lining membrane destroyed by an ointment of quick-lime or even the actual cautery, and the wound then dressed with egg-alb.u.men followed by the _unguentum viride_. Necrosed bone is to be removed, if necessary, by deep incisions, and decayed teeth are to be extracted.

The elongated uvula is to be snipped off, and abscesses of the tonsils opened _tout comme chez nous_.

An elaborate discussion of the subject of hernia is given under the t.i.tle "_De relaxatione siphac et ruptura_" (f. 280c)--siphac being the Arabian name for the peritoneum. Gilbert tells us the siphac is sometimes relaxed, sometimes ruptured (_crepatur_?) and sometimes inflated. He had seen a large rupture (_crepatura_) in which it was impossible to restore the intestines to the cavity of the abdomen in consequence of the presence in them of large hard ma.s.ses of fecal matter, which no treatment proved adequate to remove, and which finally occasioned the death of the patient. Rupture of the siphac is most frequently the result of accident, jumping, straining in lifting or carrying heavy weights, or in efforts at defecation, or of shouting in boys or persons of advanced age, or even in excessive weeping, etc. It is distinguished from hernia by the fact that in hernia pain is felt in the t.e.s.t.i.c.l.e, radiating to the kidneys, while in rupture of the siphac a swelling on one side of the p.u.b.es extends into the s.c.r.o.t.u.m, where it produces a tumor not involving the t.e.s.t.i.c.l.e. Rupture of the siphac, he says, is a lesion of the organs of nutrition, hernia a disease of the organs of generation. Accordingly, in the pathology of Gilbert, the term hernia is applied to hydrocele, orchitis and other diseases of the t.e.s.t.i.c.l.e, and not, as with us to protrusions of the viscera through the walls of their cavities.

In young persons, he tells us, recent ruptures of the siphac may be cured by appropriate treatment. The patient is to be laid upon his back, the hips raised, the intestines restored to the abdominal cavity and the opening of exit dressed with a plaster of exsiccative and consolidating remedies, of which he furnishes a long and diversified catalogue. He is also to avoid religiously all exercise or motion, all anger, clamor, coughing, sneezing, equitation, cohabitation, etc., and to lie with his feet elevated for forty days, until the rupture (_crepatura_) is consolidated. The bowels are to be kept soluble by enemata or appropriate medicines, and the diet should be selected so as to avoid constipation and flatulence. A bandage or truss (_bracale vel colligar_) made of silk and well fitted to the patient is also highly recommended. If the patient is a boy, cakes (_crispelle_?) of _consolida major_ mixed with the yolk of eggs should be administered, one each day for nine days before the wane of the moon. If, however, the rupture is large in either a boy or an adult, and of long standing, whether the intestine descends into the s.c.r.o.t.u.m or not, operation, either by incision or by the cautery offers the only hope of relief. Singularly enough too, while Roger devotes to the operation for the cure of hernia nearly half a page of his text, Gilbert dismisses the whole subject in a single sentence, as follows:

_Scindatur igitur totus exitus super hac cute exteriori c.u.m carne fissa, et uatur y fac c.u.m file serice et acu quadrata. Deinde persequere ut in exitu intestini per vulnus superius demonstratum est_ (f. 281d).

Turning now to the t.i.tle "_De hernia_" (f. 289b), Gilbert tells us "Swelling (_inflatio_) of the t.e.s.t.i.c.l.es is due sometimes to humors trickling down upon them (_rheumatizantibus_), sometimes to abscess, or to gaseous collections (_ventositate_), and sometimes to escape of the intestines through rupture of the siphac." He adds also: "Some doubt the propriety of using the term hernia for an inflation. On this point magister Rn says: There is a certain chronic and inveterate tumor of the t.e.s.t.i.c.l.es, which is never cured except by means of surgery, as e.g., hernia. For hernia is an affection common to the s.c.r.o.t.u.m and the t.e.s.t.i.c.l.es."

The apparent confusion between these two pa.s.sages is easily relieved by the explanation that inguinal or other herniae not extending into the s.c.r.o.t.u.m are called by Gilbert ruptures of the siphac, but scrotal hernia is cla.s.sed with other troubles located in the s.c.r.o.t.u.m as hernia. Accordingly hernia, with Gilbert, includes not only scrotal hernia, but also hydrocele, orchitis, tumors of the t.e.s.t.i.c.l.es, etc.

This is apparent, too, in his treatment of hernia, which consists usually in the employment of various poultices and ointments, bleeding from the saphena, cups over the kidneys, etc., though hydrocele is tapped and a seton inserted. If the t.e.s.t.i.c.l.e itself is "putrid,"

it should be removed; otherwise it is left. It may be remarked _en pa.s.sant_ that the surgeons of medieval times, in their desire for thoroughness, often displayed very little respect to what Baas calls "the root of humanity."

We will terminate our hasty review of diseases discussed in the Compendium by an abstract of Gilbert's views on vesical calculus and its treatment, which cover more than fifteen pages of his work.

Stone and gravel arise from various viscous superfluities in the kidneys and bladder, which occasion difficulty in micturition. Stone is produced by the action of heat upon viscous moisture, sublimating the volatile elements and condensing the denser portions.

Putrefication of stone in the bladder is the result of three causes, viz., consuming heat, viscous matter and stricture of the meatus.

For consuming heat acting on viscous material retained by reason of stricture of the meatus, by long action dries up, coagulates and hardens the moisture. This is particularly manifest in boys who have a constricted meatus.

Stones are thus generated not only in the kidneys and bladder, but also even in the stomach and the intestines, whence they are ejected by vomiting or in the stools. Indeed they may also be found occasionally in the lungs, the joints and other places. They are comparatively rare in women, in consequence of the shortness of the urethra and the size of their meatus.

Sometimes calculi occur in the bladder, sometimes in one kidney and occasionally in both kidneys. The symptoms produced by their presence vary in accordance with the situation of the concretion. If the stone is in the kidney, the foot of the side affected is numb (_stupidus_), the spine on the affected side is sore and there is difficulty of micturition and considerable gravelly sediment in the urine. If the stone is increasing in size, the quant.i.ty of sediment also increases, but if the stone is fully formed and confirmed, the amount of sediment decreases daily, and the urine becomes milky both in the kidneys and the bladder. A stone in the bladder occasions very similar symptoms, together with pain in the peritoneum and p.u.b.es, dysuria and strangury, and sometimes the appearance of blood and flocculi (_trumbos_?) in the urine. Patients suffering from vesical calculus are always constipated, and the dysuria may increase to the degree called furia, a condition not without some danger.

Three things are necessary in the cure of stone, viz., a spare and simple diet, the use of diuretics and a moderate amount of exercise.

It should, however, be remarked that confirmed stone is rarely or never cured, except by a surgical operation.... If a boy has a clear and watery urine after it has been sandy, if he frequently scratches his foot, has involuntary erections and finally obstruction in micturition, I say that he has a stone in the neck of his bladder.

If now he be laid upon his back with his feet well elevated, and his whole body be well shaken, if there is a stone present it is possible that it may fall to the fundus of the bladder. Afterwards direct the boy to bear down (_ut exprimat se_) and try to make water. If this treatment turns out in accordance with your theory, the urine necessarily escapes and your idea and treatment are confirmed. If, however, the urine not escape, let the boy be shaken vigorously a second time. If this too fails and strangury ensues, it will be necessary to resort to the use of a sound or catheter (_argaliam_), so that when the stone is pushed away from the neck of the bladder the pa.s.sage may be opened and the urine may flow out. It may be possible too that no stone exists, but the urethra is obstructed or closed by pure coagulated blood. Perhaps there may have been a wound of the bladder, although no external haemorrhage has appeared, but the blood coagulating gradually in the bladder has occasioned an obstruction or narrowing of the urinary pa.s.sage. Or possibly the blood from a renal haemorrhage has descended into the bladder and obstructs the urethra.

Hence I say that the sound is useful in these cases where the urethra is obstructed by blood or gross humors. Examination should also be made as to whether a fleshy body exists in the bladder, as the result of some wound. This condition is manifest if, on the introduction of the sound, the urine flows out promptly. I once saw a man suffering from this condition, who complained of severe pain in the urinary pa.s.sage as I was introducing the sound, and I recognized that there were wounds in the same part, for as soon as these were touched by the sound the urine began to flow, followed soon after by a little blood and fleshy particles.... So far as the operation of physicians is concerned, it is necessary only to be certain of the fact that obstruction to the pa.s.sage of urine depends upon no other cause than stone or the presence of coagulated blood (f. 271).

Gilbert's medical treatment of vesical calculus consists generally in the administration of diuretics and lithontriptics and the local application of poultices, plasters and inunctions of various kinds.

Of the lithontriptics, certain combinations, characterized by famous names or notable historical origin, are evident favorites. Among this cla.s.s we read of the _Philoantropos major_ and _minor_, the _Justinum_, the _Usina_ "approved by many wise men of Babylon and Constantinople," the _Lithontripon_ and the "_Pulvis Eugenii pape_,"

with numerous others.

Rather curiously and suggestively no mention is made in this immediate connection of the technique of lithotomy. On a later page, however (f.

309a), we find a chapter ent.i.tled "_De cura lapidis per cyrurgiam_,"