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

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

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

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

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

Gilbert continues: "I will tell you also what I myself saw in a woman suffering and screaming with pain in her right wrist (assuere?), which was greatly swollen, hot, red and much distended. She was fat, full-blooded, and before the attack had lived freely on milk and flesh. Accordingly she was robust, and I bled her from the basilic vein of the left hand and the saphena of the right foot, both within an hour. Each hour I withdrew a half-pound of blood, then I fed her and for three hours I drew half a pound of blood from the saphena. In the last hour the pain and throbbing (percussio) ceased entirely, and the woman begged me to bleed her again from the hand, for she had experienced great relief. I wished, however, to divert the material to the lower extremities for two reasons, one of which I ought not to mention in this place, while the other is useful, and indeed necessary in such cases. You should know that this woman was suffering pain in her left hand also, though this pain was of a less severe character than in the right. For this reason I desired to divert the peccant matter downward, a point which the physician should consider and observe. Once, while treating a man suffering from sanguineous gout, the pain of which involved the joints between the assuerus and the racheta (?) of the right hand, I asked him whether any pain was felt in the other hand or in the feet. He replied that similar pain was felt in the left hand or its joints, and that hitherto it had been more severe, but that no pain had ever been experienced in the feet. Hence I was unwilling to bleed him at all from the left hand, but I bled him from the right foot. A physician who had treated him before, and had bled him from the right hand for acute swelling of the joints of the left, quieted, indeed, the pain in the left hand, but diverted the disease to the right, where a swelling developed larger than in the left. And when I asked him about this, he understood that I knew more about medicine than the other doctor did. And this is one of the reasons why one ought to divert the material to another part, especially when the pain is so located that it may be increased at the beginning. For under such conditions we ought to refrain from bleeding, frictions and other treatment which may attract the materies morbi to the part. Indeed we ought to require derivation of the materies to another part whenever the affected locality contains one of the nobler organs, towards which the material is directing, or may direct its course. For instance: A person is suffering pain in the joints of the right hand, but has also an acute swelling in the bladder, the kidneys or the womb. Now, I say that in such a case we ought not to bleed from the hand, because if we do we shall injure the organ affected by the swelling. Perhaps, however, we may bleed from the right foot, provided we understand that there is on the right side a sanguineous tumor, the danger of which is greater than that of the swelling on the right hand. Again, suppose in the liver or in the right kidney an acute tumor, and in the joints of the right hand there is present a moderate pain. I say that we ought first to medicate the more dangerous lesion, and, possibly, two results may be obtained by the attraction of the peccant material. Or suppose a woman has gout in her hand, and with this a suppression of the menstrual flow. I say she ought to be bled from the foot and not from the hand for two objects, to solicit the material from the diseased hand, and to provoke a return of the menstrual discharge.

"But to return to our original patient. I may say that after the third venesection, with an interval of two hours, I withdrew a half-pound of blood from the saphena vein, and that night she slept, although she had not slept for many nights. And I did nothing more, except to prescribe a light and cool diet. The third day after the bleeding she was entirely free from any trouble in her hand. Hence I say that we ought in such cases to begin our treatment by venesection."

After this sanguinary introduction, Gilbert soothes the diseased part with cooling and astringent ointments, unless these occasion pain, in which event he omits them entirely and trusts the case to nature, "quoniam natura per se curabit."

The vigorous plan of treatment thus outlined Gilbert seems to regard as original and peculiar to himself, for the next chapter bears the title, "The treatment of gout according to the authorities (secundum magistros)." Here he says he quotes the opinions of the modern teachers and writers, who lay down definite rules for the guidance of the physicians.

Among these he mentions, as primary and of general application, the rule that, before all things, the body must be purified, either by venesection in cases where the material is sanguineous, or by purgation in other varieties of the disease. If the cause is rheumatic in its nature, fomentations should never be employed, for fear of increasing the flux. That the peccant material is to be eliminated gradually by mild remedies, just as it accumulated by degrees. In all cases of gout, and in all chronic diseases generally, much attention must be devoted to the stomach, since if this organ rejects the medicine, the latter must be at once abandoned, lest the stomach becomes weakened and even other organs, and thus the humors flow more readily (magis reumatizarent) to the joints, etc.

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

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

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

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

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

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

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

The usual catalogue of specific remedies terminates the discussion.

An interesting chapter on small-pox[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 aeration, 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.

In Italy alone did surgery vindicate for itself an equality with medicine, and the pioneer of this advance was Roger of Parma, who, as we have seen, flourished early in the thirteenth century. Roger and his pupil Roland, with the somewhat mythical "Four Masters" (Quatuor Magistri), were the surgical representatives of the School of Salernum, while Hugo (Borgognoni) di Lucca and his more famous son Theodorius represented the rival school of Bologna. Equally famous Italian surgeons of this century were Bruno of Logoburgo (in Calabria) and Gulielmus of Saliceto (1275), the master of Lanfranchi (1296). Gilbert of England, as a pupil of Salernum, naturally followed the surgical teachings of that school, and we have already noticed that his chapters on surgery are taken chiefly from the writings of Roger of Parma, though the name of neither Roger, nor indeed of any other distinctly surgical writer, is mentioned in the Compendium. How closely in some cases Gilbert followed his masters may best be seen by a comparison of their respective chapters upon the same subject. I accordingly introduce here for such comparison Roger's chapter on wounds of the neck, and the corresponding chapter of Gilbert. Roger says:

"De vulnere quod fit in cervice.

"Si vero cum ense vel alio simili in cervice vulnus fiat, ita quod vena organica incidatur, sic est subveniendum. Vena tota sumatur (suatur) cum acu, ita quod vena non perforetur, et ex alia parte acus cum filo ei inhaerente ducatur, et cum ipso filo nectatur atque stringatur, quod sanguinem non emittat: et ita facias ex superiori parte et inferiori. In vulnere autem pannus infusus mittatur, non tamen de ipso vulnus multum impleatur. Embrocha, si fuerit in myeme, superponatur quosque (quousque) vulnus faciat saniem. Si vero fuerit in aestate vitellus avi semper superponatur. Quum autem saniem fecerit, cum panno sicco, unguento fusco et caeteris bonam carnem generantibus, adhibeatur cura, ut in caeteris vulneribus. Quum vero extremitatem venae superioris partis putruisse cognoveris, fila praedicta dissolvas, et a loco illo removeas: et deinde procedas ut dictum est superius. A. Si vero nervus incidatur in longum aut ex obliquo, sed non ex toto, hac cura potest consolidari. Terrestres enim vermes, idest qui sub terra nascuntur, qui in longitudine et rotunditate lumbricis assimilantur, et apud quondam terrestres lumbrici dicuntur, accipiantur et aliquantulum conterantur et in oleo infusi ad ignem calefiant: et nullo alio mediante, ter vel quater, vel etiam pluries, si opportunum videbis, plagae impone. Si vero incidatur ex obliquo totus, minime consolidatur: praedicto tamen remedio non coadjuvante saepe conglutinatur. Potest etiam cuticula, quae supra nervum est, sui, pulvisque rubens, qui jam dictus est, superaspergi, quae cura non est inutilis, aliquos enim non solum conglutinatas, sed etiam consolidatas, nostra cura prospeximus. Si vero locus tumet, embrocham illam, quam in prima particula ad tumorem removendum, qui ex percussura contigit, praediximus, ponatur, quousque talis tumor recesserit."

Gilbert, after premising two short chapters entitled "De vulneribus colli" and "De perforatione colli ex utraque parte," continues as follows:

"De vena organica incisa.

"Si vena organica in cervice incidatur: tota vena suatur cum acu, ita quod vena non perforetur, et ux alia parte acus cum filo ei adherente ita nectatur atque stringatur quod (non) emittat sanguinem, et ita fiat ex superiori parte et inferiore vene. In vulnere autem pannus infusus in albumine ovi mittatur, nec tamen de ipso panno vulnus multum impleatur. Embroca vero superius dicta, si in hyeme fuerit, superponatur, donec vulnus saniem emittat. Si vere in estate, vitellum ovi tum super ponatur, et cum saniem fecerit, panno sicco, et unguento fusco et ceteris regenerantibus carnem, curetur. Cum vero extremitatem vene superioris et inferioris putruisse cognoveris, fila dissolvantur et a loco removeantur, et deinde ut dictum est procedatur.

"De incisione nervi secundum longum aut secundum obliquum.

"Si vero secundum longum aut obliquum vervi incidantur, et non ex toto, ita consolidamus. Terrestres vermes, qui sub terra nascuntur, similes in longitudine et rotunditate lumbricis, qui etaim lumbrici terre appellantur: hi aliquantulum conterantur et in oleo infusi ad ignem calefiant, et nullo aliomediante, ter vel quater vel pluries, si opportunum fuerit, plagelle impone. Si vero ex oblique nervus incidatur, eodem remedio curatur, et natura cooperante saepe conglutinatur. Potest quoque cuticula quae supra nervum est sui, et pulvis ruber superaspergatur. Nervos enim conglutinari et consolidari hoc modo sepius videmus. Si vero locus tumeat, embroca, praedicta in vulnere capitis quae prima est ad tumorem removendum, superponatur, quousque tumor recesserit. Si vena organica non inciditur, pannus albumine ovi infusus in vulnere ponatur. Embroca vero post desuperponatur" (f. 179 c).

The selection and collection of words and phrases in these two passages leaves little doubt that one was copied from the other. Indeed, so close is their resemblance that it is quite possible from the one text to secure the emendation of the other. Numerous similar passages, with others in which the text of Gilbert is rather a paraphrase than a copy of the text of Roger, serve to confirm the conclusion that the surgical writings of the English physician are borrowed mainly from the "Chirurgia" of the Italian surgeon. Some few surgical chapters of the Compendium appear to be either original or borrowed from some other authority, but their number is not sufficient to disturb the conclusion at which we have already arrived. Now, as Roger's "Chirurgia" was probably committed to writing in the year 1230, when the surgeon was an old man, these facts lead us to the conclusion that Gilbert must have written his Compendium at least after the date mentioned.

Another criticism of these chapters suggests certain interesting chronological data. It will be observed that Roger, in the passage quoted above, recommends a dressing of egg-albumen for wounds of the neck, and expresses considerable doubt whether nerves, when totally divided, can be regenerated (consolidari), though they may undoubtedly be reunited (conglutinari).

Now Roland, in his edition of Roger's "Chirurgia," criticises both of these statements of his master, as follows:

Nota quod quamvis Rogerius dicat quod apponatur albumen ovi, non approbo, quia frigidum est naturaliter, et vena et nervus et arteria frigida sunt naturaliter, et propter frigiditatem utrorumque non potest perfecte fieri consolidatio.

And again:

Nota quod secundum Rogerium nervus omnino incisus non potest consolidari, vel conjungi nec sui. Nos autem dicimus quod potest consolidari et iterum ad motum reddi habillis, cum hac cautela: Cauterizetur utrumque caput nervi incisi peroptime cum ferro candenti, sed cave vulneris lobia cum ferro calido tangantur. Deinde apponantur vermes contusi et pulveres consolidativi, etc.

It will be observed that Gilbert, in spite of the rejection by Roland of the egg-albumen dressing of Roger, still recommends its use in wounds of the neck, and although he professes to have seen many nerves regenerated (consolidari) under the simple angle-worm treatment of his master, he still makes no mention of the painful treatment of divided nerves by the actual cautery, so highly praised by Roland. It would seem, therefore, that Gilbert was not familiar with the writings of Roland when his Compendium was written, or he would, doubtless, not have omitted so peculiar a plan of treatment in an injury of such gravity. As Roland's edition of Roger's "Chirurgia" is said to have been written in 1264, the comparison of these passages would seem to indicate that Gilbert must have written the Compendium after 1230 and prior to the year 1264.

Gilbert's surgical chapters discuss the general treatment of wounds and their complications, and more specifically that of wounds of the head, neck, throat, wounds of nerves, of the oesophagus, scapula, clavicle, of the arm, the stomach, intestines and the spleen; fractures of the clavicle, arm, forearm and ribs; compound fractures; dislocations of the atlas, jaw, shoulder and elbows; fistulae in various localities, and the operations on the tonsils and uvula, on goitre, hernia and stone in the bladder, etc.—certainly a surgical compendium of no despicable comprehensiveness for a physician of his age and country.

In the general treatment of wounds (f. 86 c) Gilbert tells us the surgeon must consider the time, the age of the patient, his temperament (complexio) and the locality, and be prepared to temper the hot with the cold and the dry with the moist. Measures for healing, cleansing and consolidation are required in all wounds, and these objects may, not infrequently, be accomplished by a single agent. The general dressing of most wounds is a piece of linen moistened with the white of egg (pecia panni in albumine ovi infusa), and, as a rule, the primary dressing should not be changed for two days in summer, and for three days in the winter. In moist wounds vitreolum reduces the flesh; in dry wounds it repairs and consolidates. Flos aeris, in dry wounds, reduces but does not consolidate, but rather corrodes the tissues. Excessive suppuration is sometimes the result of too stimulating applications, sometimes of those which are too weak. In the former case the wound enlarges, assumes a concave form, is red, hot, hard and painful, and the pus is thin and watery (subtilis). If the application is too weak, the pus is thick and viscous, and the other signs mentioned are wanting. In either case the dressings are to be reversed. If any dyscrasia, such as excessive heat, coldness, dryness or moisture appears in the wound and delays its healing, it is to be met by its contrary. If fistula or cancer develops, this complication is to be first cured and then the primary wound. The signs of a hot dyscrasia are heat, burning and pain in the wound; of a cold dyscrasia, lividity of the wound; the moist dyscrasia occasions flabbiness (mollicies) and profuse suppuration, and the dry produces dryness and induration.

Wounds of the head (f. 84 c) occur with or without fracture of the cranium, but always require careful examination and exact diagnosis. The wound is to be carefully explored with the finger, and, if necessary, should be enlarged for this purpose. Large, but simple, wounds of the scalp should be stitched with silk in three or four places, leaving the most dependent angle open for escape of the discharges, and in this opening should be inserted a tent (tuellus), to facilitate drainage. The wound is then sprinkled with the pulvis rubeus and covered with a plantain or other leaf. On the ninth to the eleventh day, if the wound seems practically healed, the stitches are to be removed and the cure completed with simple dressings.

The signs and symptoms of fracture of the cranium are: Loss of appetite and failure of digestion, insomnia, difficulty in micturition, constipation, a febrile dyscrasia, difficulty in cracking nuts or crusts of bread with the jaws, or severe pain when a string is attached to the teeth and pulled sharply. If the meninges are injured we have further: headache, a slow and irregular but increasing fever, alternating with chills, distortion of the angles of the eyes, redness of the cheeks, mental disturbances, dimness of vision, a weak voice and bleeding from the ears or the nose. In the presence of such symptoms the death of the patient may be expected within at most a hundred days.

If the fracture of the cranium is accompanied by a large scalp wound, any fragments of bone or other foreign body are to be extracted at once, unless haemorrhage or the weakness of the patient are feared, and then a piece of linen is to be cautiously worked in with a feather between the cranium and the dura mater. In the fracture itself a piece of linen, or better of silk, is inserted, the apparent purpose of this double dressing being to protect the dura mater from the discharges and to solicit their flow to the exterior. A piece of sponge, carefully washed, dried and placed in the wound, Gilbert tells us, absorbs the discharges satisfactorily and prevents their penetration internally. Over the wound is placed a bit of linen moistened with egg-albumen, then a dressing of lint, and the whole is maintained in place by a suitable bandage. Finally the patient is to be laid in bed and maintained in such a position that the wound will be dependent, so as to favor the ready escape of the discharges. This dressing is to be renewed three times a day in summer, and twice in winter. Proud flesh upon the dura mater is to be repressed by the application of a sponge, well-washed and dried, and if it appears upon the surface of the wound after the healing of the fracture, it is to be destroyed by the use of the hermodactyl. When the external wound is healed, the cicatrix is to be dressed with the apostolicon cyrurgicum, an ointment very valuable for the consolidation of bones, the leveling (adaequatio?) of wounds, etc.

When the wound of the scalp is small, so as to render difficult the determination of the extent of the fracture by exploration with the finger, it should be enlarged by crucial incisions, the flaps loosened from the cranium by a suitable scraper (rugine) and folded back out of the way, and any fragments of bone removed by the forceps (pinceolis). If, however, haemorrhage prevents the immediate removal of the fragments, this interference may be deferred for a day or two, until the bleeding has stopped or has been checked by suitable remedies. Then, after their removal, the piece of linen described above is to be inserted between the cranium and dura mater. Upon the cranium and over the flaps of the scalp, as well as in their angles, the ordinary dressing of albumen is to be applied, covered by a pledget of lint and a suitable bandage. No ointment, nor anything greasy, should be applied until after the healing of the wound, lest some of it may accidentally run down into the fracture and irritate the dura matter. Some surgeons, Gilbert tells us, insert in the place of the fragments of the cranium removed a piece of a cup (ciphi) or bowl (mazer), or a plate of gold, but this plan, he says, has been generally abandoned (dimittitur.)

Sometimes the cranium is simply cracked without any depression of the bone, and such fractures are not easily detected. Gilbert tells us, however, that if the patient will close firmly his mouth and nose and blow hard, the escape of air through the fissured bone will reveal the presence of the fracture (f. 88a). In the treatment of such fissures he directs that the scalp wound be enlarged, the cranium perforated very cautiously with a trepan (trepano) at each extremity of the fissure and the two openings then connected by a chisel (spata?), in order to enable the surgeon to remove the discharges by a delicate bit of silk or linen introduced with a feather. If a portion of the cranium is depressed so that it cannot be easily raised into position, suitable openings are to be made through the depressed bone in order to facilitate the free escape of the discharges.

Gunshot wounds were, of course, unknown in Gilbert's day. In a chapter entitled "De craneo perforato" he gives us, however, the treatment of wounds of the head produced by the transfixion of that member by an arrow. If the arrow passes entirely through the head, and the results are not immediately fatal, he directs the surgeon to enlarge the wound of exit with a trephine, remove the arrowhead through this opening, and withdraw the shaft of the arrow through the wound of entrance. The wounds of the cranium are then to be treated like ordinary fractures of that organ (f. 88c).

In wounds of the neck involving the jugular vein (vena organica), Gilbert directs ligation of both extremities of the wounded vessel, after which the wound is to be dressed (but not packed) with the ordinary dressing of egg-albumen.

Wounds of nerves are treated with a novel dressing of earthworms lightly beaten in a mortar and mixed with warm oil, and he professes to have seen nerves not only healed (conglutinari), but even the divided nerve fibres regenerated (consolidari) under this treatment. In puncture of a nerve Gilbert surprises us (f. 179d) by the advice to divide completely the wounded nerve, in order to relieve pain and prevent tetanus (spasmus).

Goitre, not too vascular in character, is removed by a longitudinal incision over the tumor, after which the gland is to be dragged out, with its entire capsule, by means of a blunt hook. A large goitre in a feeble patient, however, is better left alone, as it is difficult to remove all the intricate roots of the tumor, and if any portion is left it is prone to return. In such cases Gilbert says we shrink from the application of the actual cautery, for fear of injury to the surrounding vessels and nerves. Whatever method of operation is selected, the patient is to be tied to a table and firmly held in position.

Wounds of the trachea and oesophagus, according to Gilbert, are invariably mortal.

In wounds of the thorax the ordinary dressing of albumen is to be applied, but if blood or pus enters the cavity of the thorax, the patient is directed to bend his body over a dish, twisting himself from one side to another (supra discum[10] flectat se modo hac modo ilac vergendo) until he expels the sanies through the wound, and to always lie with the wound dependent until it is completely healed (f. 182d).

[Footnote 10: It is interesting to observe how the Latin discus developed dichotomously into the English "dish" and the German "Tisch." The former is doubtless the meaning of the word in this place.]

In case an arrow is lodged within the cavity of the thorax, the surgeon is directed to trepan the sternum (os pectoris), remove the head of the arrow gently from the shaft, and withdraw the shaft itself through the original wound of entrance. If the head is lodged beneath or between the ribs, an opening is to be made into the nearest intercostal space, the ribs forced apart by a suitable wedge and the head thus extracted. The wound through the soft parts is to be kept open by a tent greased with lard and provided with a suitable prolongation (cauda aliqua) to facilitate its extraction and prevent its falling into the cavity of the chest.

Wounds of the heart, lungs, liver, stomach and diaphragm are regarded as hopelessly mortal (f. 233d), and the physician is advised to have nothing to do with them. Wounds of the heart are recognized by the profuse haemorrhage and the black color of the blood; those of the lung by the foamy character of the blood and the dyspnoea; wounds of the diaphragm occasion similar dyspnoea and are speedily fatal; those of the liver are known by the disturbance of the hepatic functions, and wounds of the stomach by the escape of its contents. Wounds of the intestine are either incurable, or at least are cured only with the utmost difficulty. Longitudinal wounds of the spine which do not penetrate the cord may be repaired, but transverse wounds involving the cord, so that the latter escapes from the wound, are rarely, if ever, cured by surgery. Wounds of the kidneys are also beyond the art of the surgeon. Wounds of the penis are curable, and if the wound is transverse and divides the nerve, they are likewise painless.

Si vene titillares in coxis abscidantur homo moritur ridendo. A passage which I can refer only to the erudition and risibility of our modern surgeons and anatomists. The ticklish vene titillares are to me entirely unknown.

Modern abdominal surgeons will probably be interested in reading Gilbert's chapter on the treatment of wounds of the intestines in the thirteenth century. He says (f. 234c):

If some portion of the intestine has escaped from a wound of the abdomen and is cut either longitudinally or transversely, while the major portion remains uninjured; if the wound has existed for some time and the exposed intestine is cold, some living animal, like a puppy (catulus), is to be killed, split longitudinally and placed over the intestine, until the latter is warmed, vivified by the natural heat and softened. Then a small tube of alder is prepared, an inch longer than the wound of the intestine, carefully thinned down (subtilietur) and introduced into the gut through the wound and stitched in position with a very fine square-pointed needle, threaded with silk. This tube or canula should be so placed as to readily transmit the contents of the intestine, and yet form no impediment to the stitches of the wound. When this has been done, a sponge moistened in warm water and well washed should be employed to gently cleanse the intestines from all foreign matters, and the gut, thus cleansed, is to be returned to the abdominal cavity through the wound of the abdominal wall. The patient is then to be laid upon a table and gently shaken, in order that the intestines may resume their normal position in the abdomen. If necessary the primary wound should be enlarged for this purpose. When the intestines have been thus replaced, the wound in the abdominal wall is to be kept open until the wound of the intestine seems healed. Over the intestinal suture a little pulvis ruber should be sprinkled every day, and when the wound of the intestine is entirely healed (consolidatur), the wound of the abdominal wall is to be sewed up and treated in the manner of ordinary flesh wounds.

If, however, the wound is large, a pledget (pecia) of lint, long enough to extend from one end to the other and project a little, is placed in the wound, and over this the exterior portion of the wound is to be carefully sewed, and sprinkled daily with the pulvis ruber. Every day the pledget which remains in the wound is to be drawn towards the most dependent part, so that the dressing in the wound may be daily renewed. When the intestinal wound is found to be healed, the entire pledget is to be removed and the unhealed openings dressed as in other simple wounds. The diet of the patient should be also of the most digestible sort.

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 stitches.

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 entitled "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 albumen, 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 locum 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-albumen are to be placed around the arm on all sides, a bandage, four fingers wide, also moistened in albumen 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 cum 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 passed 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 assistants 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 assured that the reduction is complete, a strictorium is prepared, consisting of the pulvis ruber, egg-albumen 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 passing 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 assure 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 entitled "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 space 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 coxa 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-albumen 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 title "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 masses 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 testicle, radiating to the kidneys, while in rupture of the siphac a swelling on one side of the pubes extends into the scrotum, where it produces a tumor not involving the testicle. 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 testicle, 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 scrotum 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 cum carne fissa, et uatur y fac cum file serice et acu quadrata. Deinde persequere ut in exitu intestini per vulnus superius demonstratum est (f. 281d).

Turning now to the title "De hernia" (f. 289b), Gilbert tells us "Swelling (inflatio) of the testicles 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 testicles, which is never cured except by means of surgery, as e.g., hernia. For hernia is an affection common to the scrotum and the testicles."

The apparent confusion between these two passages is easily relieved by the explanation that inguinal or other herniae not extending into the scrotum are called by Gilbert ruptures of the siphac, but scrotal hernia is classed with other troubles located in the scrotum as hernia. Accordingly hernia, with Gilbert, includes not only scrotal hernia, but also hydrocele, orchitis, tumors of the testicles, 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 testicle itself is "putrid," it should be removed; otherwise it is left. It may be remarked en passant 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 quantity 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 pubes, 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 passage 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 passage. 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 passage 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 passage 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 class 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 entitled "De cura lapidis per cyrurgiam," in which Gilbert writes:

"Mark here a chapter on the cure of stone in the bladder by means of surgery, which we have omitted above. Accordingly, to determine whether a stone exists in the bladder, let the patient take a warm bath. Then let him be placed with his buttocks elevated, and, having inserted into the anus two fingers of the right hand, press the fist of the left hand deeply above the pubes and lift and draw the entire bladder upward. If you find anything hard and heavy, it is manifest that there is a stone in the bladder. If the body feels soft and fleshy, it is a fleshy excrescence (carnositas), which impedes the flow of urine. Now, if the stone is located in the neck of the bladder and you wish to force it to the fundus: after the use of fomentations and inunctions, inject through a syringe (siringa) some petroleum, and after a short interval pass the syringe again up to the neck of the bladder and cautiously and gently push the stone away from the neck to the fundus. Or, which is safer and better, having used the preceding fomentations and inunctions, and having assured yourself that there is a stone in the bladder, introduce your fingers into the anus and compress the neck of the bladder with the fist of the left hand above the pubes, and cautiously remove the stone and guide it to the fundus. But if you wish to extract the stone, let a spare diet precede the operation, and let the patient lie abed for a couple of days with very little food. On the third day introduce the fingers into the anus as before, and draw down the stone into the neck of the bladder. Then make your incision lengthwise in the fontanel, the width of two fingers above the anus, and extract the stone. For nine days after the operation let the patient use, morning and evening, fomentations of branca (acanthus mollis), paritaria (pellitery) and malva (mallows). A bit of tow (stupa) moistened with the yolk of egg in winter, and with both the yolk and white of egg in summer, is to be placed over the wound. Proud flesh, which often springs up near a wound in the neck of the bladder, should be removed by the knife (rasorio), and two or three sutures inserted. The wound is then to be treated like other wounds. It should be remarked, however, that if the stone is very large, it should be simply pushed up to the fundus of the bladder and left there, and no effort should be made to extract it."

This description of the diagnosis of stone and of the operation of lithotomy is copied almost literally from Roger of Parma.

Sufficient (perhaps more than enough) has been written to give the reader a fair idea of the general character of Gilbert's "Compendium Medicine."

A few words may be added with reference to the proper place of the work in our medical literature.

It is not difficult, of course, to select from the Compendium a charm or two, a few impossible etymologies and a few silly statements, to display these with a witty emphasis and to draw therefrom the easy conclusion that the book is a mass of crass superstition and absurd nonsense. This, however, is not criticism. It is mere caricature.

To compare the work with the teachings of modern medicine is not only to expect of the writer a miraculous prescience, but to minimize the advances of medical science within the last seven hundred years.

Even Freind and Sprengel, admirable historians, though more thoughtful and judicious in their criticisms, seem for the moment to have forgotten or overlooked the true character of the Compendium.

Freind says:

"I believe we may even say with justice that he (Gilbert) has written as well as any of his contemporaries of other nations, and has merely followed their example in borrowing very largely from the Arabians," and Sprengel writes: "Here and there, though only very rarely, the author offers some remarks of his own, which merit special attention."

Now, what precisely is Gilbert's Compendium designed to be? In the words of its author it is

"A book of general and special diseases, selected and extracted from the writings of all authors and the practice of the professors (magistrorum), edited by Gilbert of England and entitled a Compendium of Medicine."

and a few pages later he adds:

"It is our habit to select the best sayings of the best authorities, and where any doubt exists, to insert the different opinions, so that each reader may choose for himself what he prefers to maintain."

The author does not claim for his work any considerable originality, but presents it as a compendium proper of the teachings of other writers. Naturally his own part in the book is not obtruded upon our notice.

Now the desiderata of such a compendium are:

1. That it shall be based upon the best attainable authorities.

2. That these authorities shall be accurately represented.

3. That the compendium shall be reasonably comprehensive.

In neither of these respects is the compendium of Gilbert liable, I think, to adverse criticism.

The book is, undoubtedly, the work of a famous and strictly orthodox physician, possessed of exceptional education in the science of his day, a man of wide reading, broadened by extensive travel and endowed with the knowledge acquired by a long experience, honest, truthful and simple minded, yet not uncritical in regard to novelties, firm in his own opinions but not arrogant, sympathetic, possessed of a high sense of professional honor, a firm believer in authority and therefore credulous, superstitious after the manner of his age, yet harboring, too, a germ of that healthy skepticism which Roger Bacon, his great contemporary, developed and illustrated.

I believe, therefore, that we may justly award to the medical pages of the Compendium not only the rather negative praise of being written as well as the work of any of Gilbert's contemporaries, but the more positive credit of being thoroughly abreast of the medical science of its age and country, an "Abstract and brief chronicle of the time."

The surgical chapters of the work are unique in a compendium of medicine, and merit even more favorable criticism.

The discouragement of the practice of medicine and surgery on the part of ecclesiastics by the popes and church councils of the twelfth century, culminating in the decree of Pope Innocent III in 1215, which forbade the participation of the higher clergy in any operation involving the shedding of blood (Ecclesia abhorret a sanguine); the relatively scanty supply of educated lay physicians and surgeons, and finally the pride and inertia of the lay physicians themselves; all these combined to relegate surgery in the thirteenth century to the hands of a class of ignorant and unconscionable empirics, whose rash activity shed a baleful light upon the art of surgery itself. As a natural result the practice of this art drifted into an impasse, from which the organization of the barber-surgeons seemed the only logical means of escape.

The earliest evidence of the public surgical activity of the barbers, as a class, is found, I believe, in Joinville's Chronicle of the Crusade of St. Louis (Louis IX) in the year 1250. According to Malgaigne, no trustworthy evidence of any organization of the barbers of Paris is available before 1301, and the fraternity was not chartered until 1427, under Charles VII. The barbers of London are noticed in 1308, and they received their charter from Edward IV in 1462. The parallel lines upon which the confraternities of the two cities developed is very noticeable—making due allowance for Gallic enthusiasm and bitterness.

Lanfranchi, the great surgeon of Paris, about the year 1300 is moved to write as follows:

"Why, in God's name, in our days is there such a great difference between the physician and the surgeon? The physicians have abandoned operative procedures to the laity, either, as some say, because they disdain to operate with their hands, or rather, as I think, because they do not know how to perform operations. Indeed, this abuse is so inveterate that the common people look upon it as impossible for the same person to understand both surgery and medicine. It ought, however, to be understood that no one can be a good physician who has no idea of surgical operations, and that a surgeon is nothing if ignorant of medicine. In a word, one must be familiar with both departments of medicine."

Now Gilbert by the incorporation of many chapters on surgery in his Compendium inculcates practically the same idea more than fifty years before Lanfranchi, and may claim to be the earliest representative of surgical teaching in England. Malgaigne, indeed, does not include his name in the admirable sketch of medieval surgery with which he introduces his edition of the works of Ambroise Pare, and says Gilbert was no more a surgeon than Bernard Gordon. This is in a certain sense true. Gilbert was certainly not an operative surgeon. But it needs only a very superficial comparison of the Compendium of Gilbert with the Lilium Medicinae of Gordon to establish the fact that the books are entirely unlike. Indeed, it may be truthfully said that Gordon's work does not contain a single chapter on surgery proper. His cases involving surgical assistance are turned over at once, and with little or no discussion, to those whom he calls "restauratores" or "chirurgi," and his own responsibility thereupon ends.

We have no historical facts which demonstrate that Gilbert's Compendium exercised any considerable influence upon the development of surgery in England, but when we consider the depressed condition of both medicine and surgery in his day, we should certainly emphasize the clearness of vision which led our author to indicate the natural association of these two departments of the healing art, and the assistance which each lends to the other.

THE END