SECT. LXXVIII.—ON GOUT AND ARTHRITIS.
It is not weakness of the parts alone that occasions gouty and arthritic complaints; for then the paroxysms would be without ceasing, inasmuch as the debility is always present in the weak parts. Neither is a humour the sole cause, for then the complaint had not attacked the joints only. But the disease is occasioned by a preternatural humour and a weakness of the parts meeting together. For when the nutritive power of the parts becomes debilitated from repletion with food inducing dyspepsia, the prevailing humour, fixing in some of the joints which are already in a weak state, and stretching the nervous ligaments, produces pain. For the inflammation is not an original affection of the nerves of volition; as then it would have affected also the parts between the joints, such as the middle of the legs, thighs, arms, and forearms; but those of volition are affected sympathetically. When, therefore, the humour is seated in the joints of the feet only, the complaint is called podagra; but when the cause is diffused over all the joints of the body, we commonly call it arthritis, in which the vertebræ, scapulæ, jaws, and every other joint are attacked with the disease. In certain cases the ears, teeth, and pharynx, and sometimes even the liver and spleen participate in the arthritic pains, when, if there is not a speedy translation of the disease to the joints, the patients will be in urgent danger. The prevailing humour is sometimes bilious, sometimes sanguineous, sometimes melancholic, but for the most part it is pituitous and crude, being engendered by excess of food, indigestion, and want of exercise. When the disease is protracted in the joints, the humours become thick and viscid, so as to form what are called tophi or chalk-stones. Sometimes the humour is of a compound nature, so that the disease is difficult to distinguish, and difficult to cure, or nearly incurable. The precursory causes of this affection for the most part are immoderate labour, violent walking, frequent exercise on horseback, the unseasonable use of venery, cold drink taken unseasonably, eating of much cold or unwholesome food, and drinking much wine. And some from accidents, as a blow, a sprain, or the like, have experienced the first attack of this complaint, the materials of the disease having previously remained quiet in the system until roused by the proximate cause. Sorrow, care, watchfulness, and the other passions of the mind, not only excite an attack of the disorder, but also generate a cacochymy either primarily or incidentally. Wherefore the causes of the complaint, as I have said, are various; but the differences of the noxious humours are in so far easily detected, being discovered by their colour and other symptoms. A bilious rheum, in addition to paleness and redness of colour, occasions a sensation of heat and acute pain, and is speedily determined to the skin, nor is it attended with much swelling. It is exacerbated by heating applications, and relieved again by cooling, which, for the most part, is the case with all the others, but more particularly when the exciting cause is bilious. Fever also frequently comes on at the height of the paroxysms, and then they are thirsty. Thus also you will find the skin darker when from a melancholic humour; white and watery when from a pituitous, in which case the pain is more latent and more slowly occasions swelling; and the colour is sanguineous when a bloody humour prevails. In order to form a more decided diagnosis, you will be assisted by taking into account the previous mode of life, and so forth.
The cure of rheums from a bilious humour. The commencement of the cure, when from yellow bile, more especially if the quality of it occasion the disorder, should be the evacuation of the offending humour by purgative medicines, such as that from rhodomel, that from quinces, the antidote called picra, and aloetic pills. During the paroxysms, we may apply externally rose-oil with the yelk of an egg, and some wine, rubbing the part gently with it; and apply the herbs of a cold nature, such as nightshade, purslain, henbane, houseleek, marsh-lentil, endive, poppy, knotgrass, rose-leaves, and the like. These things may be sometimes rubbed in, and sometimes applied in the form of a cataplasm, with crumbs of bread soaked in oxycrate, or from barley-meal with rose-oil. When the inflammation of the joints is of an erysipelatous nature, a decidedly paregoric application is the peel of a fresh gourd laid on the part, or the fleshy part of a pompion or cucumber, both alone and with bread; or the leaves of perdicium (pellitory of the wall?), and ivy with bread and fine polenta. And fleawort boiled in barley-flour mitigates the inflammatory heat in a wonderful manner; and so also the rose-cerate cooled with some of the frigorific juices, and that prepared from the flour of beans. It is prepared thus: Of wax, oz. v; of chamomile-oil, oz. iiss; of rose-oil, oz. iiss; of the flour of beans, oz. ss; the yelks of five eggs.—Another, a cataplasm: Pound green mallows boiled; and having made fleawort to the consistence of bird-lime separately, mix together; then add the red part of eggs and chamomile-oil, and apply as a cataplasm. When the pain is great and difficult to endure, we must have recourse to preparations of saffron, of horned poppy, and of opium, triturating them with oxycrate, and then using them in the form of liniments, or of cataplasms with crumbs of bread. Galen makes mention of this one: Of poppy-juice (opium), dr. iv; of saffron, dr. j; triturate with milk of a cow or of a goat; or add the inner part of bread, and having softened it by touching it with a little rose-oil, use for a cataplasm. Or triturate the opium and saffron with the milk, and add to the rose-cerate. And the cerate made from the torpedo and the oil of the same are possessed of similar properties.—And this one in like manner: Of crumbs of bread soaked in water or in oxycrate, and of houseleek, or of nightshade, or of purslain, and of the fleshy parts of dates, and of poppy-seeds, equal parts; of roasted yelks of eggs and rose-oil, q. s.; form a cataplasm. The use of narcotics must not be continued, but until the violence of the pain be abated; for the frequent use of them occasions impaction and tophi, and makes the difficulty of motion to be protracted. After the use of anodynes, then, we must have recourse either to diachylon dissolved in oil of chamomile, or the composition from marshmallows, or some such application. After we have warmed the congealed parts, we must strengthen them by a plaster of dates dissolved in vinegar and rose-oil or wine and rose-oil. Or, if the weight of the plasters prove troublesome, we may rub in the juice of acacia with oxycrate, or lycium along with saffron, horned poppy, and the juice of perdicias in oxycrate. The diet should be cooling and moistening, such as ptisans, and spoon-meats from chondrus, and of pot-herbs, the mallows, the lettuce, and the endive; and of birds, more especially the young of domestic fowls; and of fishes, those caught in rocky places, and the sea-urchin, shell-fish, and the like. Let them avoid all things that are heating and form pale and yellow bile, old wines both the yellow and dark, and repletion. Let them use baths of sweet water, even at the time of the defluxions, as far as regards the cause of them, unless something else prohibit. Let them avoid violent passion, abstinence, acrid food, drinking of wine, immoderate labour, and venery.
The cure of rheums from a sanguineous humour. In those cases in which the prevailing humour is sanguineous, we must have recourse to venesection without delay, and also in cases where the prevailing humour is phlegm or black bile; since in them the humour is for the most part contained in the veins, proving injurious by its quantity rather than its quality. We must have recourse then to venesection only at the first attack of the disease; since those who have had already frequent attacks of rheumatism are injured rather than benefited by the loss of blood, more especially when the body is naturally cold or weak. After the evacuation of the blood, if there was more than a plethora of blood, we must have recourse to purging with hiera after a short interval. And the Julian oxymel is a purgative suitable to these cases. Those who reject such purgative medicines may use these pills: Of aloes, of colocynth, of black hellebore, of scammony, of each, oz. j; of euphorbium, oz. ss; of nitre, oz. ss; mix with the juice of cabbage, and give according to the patient’s strength. It will be better, however, if prepared with the juice of quinces.—Another pill given to gouty persons in the paroxysms, during the remission, and from whatever humour: Of aloes, oz. vj; of agaric, oz. ss; of saffron, oz. ss; of costus, oz. j; of spikenard, oz. j; of schenanth, oz. j; of balsam fruit, oz. j; of cassia, oz. ij; of scammony, oz. ij; of dodder of thyme, oz. iiiss. A moderate dose is scr. ij; and a full one, scr. iv. Pills of Armenian stone also purge in a wonderful manner, being particularly applicable in arthritic cases, whether given at the commencement, in the decline, or during the remissions of defluxion. And since some avoid scammony because it is bad for the stomach, we may give them these things when a pituitous matter prevails: Of the medullary part of colocynth, of black hellebore, of bdellium, of gum, of aloes, of each, oz. j; of Alexandrian nitre, of euphorbium, of each, oz. ss. The dose is scr. iv. Instead of the gum I have substituted dodder of thyme. Some, in the paroxysms of all arthritic diseases, have recourse to purging with hermodactylus; but it is to be remarked that the hermodactylus is bad for the stomach, producing nausea and anorexia, and ought, therefore, to be used only in the case of those who are pressed by urgent business; for it removes rheumatism speedily, and after two days at most, so that they are enabled to resume their accustomed employment. I knew a person who did not give the substance of hermodactylus, nor any of the compound medicines containing it; but boiling the plant itself with some of the common remedies, such as anise or parsley, he gave the decoction to drink; and it was wonderful how those who got it, after having evacuations of the bowels, were freed from the rheumatism. It is necessary, however, as I said, because the medicine is bad for the stomach, to correct the mouth of the stomach afterwards by stomachics and tonics, along with things that are moderately heating. Alexander says that purging by coronopodium is preferable to that by hermodactylus, as it procures evacuation and relief from pain, and at the same time is not bad for the stomach. But topical applications are to be had recourse to in cases of pituitous rheumatism. When the pain is moderate, a green cabbage-leaf may be applied, and also parsley, fleabane, and the straight vervain; but when the pain is violent, take of the flour of fenugreek, p. iij; of the flour of darnel, p. j; of the flour of chick-peas, p. j; make a cataplasm with honied water, or thin wine, with a little oil of privet, or of nard, more especially if in winter. And the ashes of burnt cabbage-roots, or of their stalks, when formed into a cataplasm with axunge, have proved beneficial to many; but, in order that it may prove soothing, the axunge must be fresh, whereas, if we wish it to be discutient, it must be old and salted. And in like manner the dung of oxen, when boiled in honied water with barley-meal, or fresh moist dung applied with the leaves of cabbage; and so also goats’ dung by themselves, or boiled with barley-flour in oxycrate. And since some have derived relief from seemingly opposite remedies (for a mixture of various humours confounds the diagnosis), we must state the materials thereof promiscuously. Wherefore the wild and garden orach in a cataplasm with bread are beneficial, or the leaves of petty mullein, triturated with bulbi and bread, or with polenta, or the cataplasm of raw barley-meal. Upon the whole, when the cause of the complaint is obscure, we must change sometimes to medicines of the same class, and sometimes to the opposite, not continuing long with the same application when it does not afford relief. These things we see every day occur in professional matters. And often a certain remedy proves beneficial to one joint, while another joint of the same patient similarly inflamed is not only not benefited at the same time, but occasionally is even injured by it. And this is a wonderful circumstance, that one and the same joint, when treated with the same remedy, is sometimes benefited, and soon afterwards exasperated. When a viscid and thick matter prevails, it is not perhaps relieved by calefacients, but the acrid and hot quality of the humour prevailing is to be soothed by frigorific remedies; nor is it at all wonderful that a matter naturally cold, in the time of the inflammation, should become heated and glowing, to say nothing of the admixture perhaps of bile. The flour of lupines with oxymel or oxycrate, or the root of laserwort, or of bryony, with bread, prevent the formation of tophi. And the following composition is safely soothing and moderately discutient: Of lycium, oz. j; of ammoniac perfume, oz. j; having triturated with very old wine and oil of unripe olives, boil, and add of the flour of beans, q. s.; and having boiled moderately, apply as a cataplasm. After the acme of the complaint, if a swelling be left, apply a cataplasm with the bulbi by themselves, or with fine polenta, until it produce excoriation; for in this manner they act. When not relieved by the cataplasms, we may have recourse to embrocations and affusions on the parts (more particularly if the extremities be affected), with chamomile, melilot, or centaury in decoctions. The preparation of capers has entirely relieved some. The following is the most active of all the applications: Having boiled thyme, marjoram, savory, and calamint in the most acrid vinegar, bathe the parts affected with the vinegar, not only once, but often in a day, with confidence. This has relieved many when suffering not only from phlegm but also from bile.
Some observe this practice also: The acorns of the ilex being powdered, are pounded and much boiled, and the joints of the extremities at the commencement of the rheumatism are fomented for a considerable time with the decoction, but it is poured from a sponge upon the inner parts; whereby the violence of the offending matter is repelled. It also is applicable to bilious cases; and, in like manner, immersion in hot water without any decoction. For pains occasioned by intense cold, or infarction of the joints, this is a powerful remedy: Of old oil, lb. iss; of Alexandrian nitre, lb. j; of turpentine, lb. j; of euphorbium, oz. j; of iris, oz. ij; of the flour of fenugreek, a sextarius and a half. In these cases the remedies recommended for ischiatics are excellently applicable. Many, in the case of those who are thus affected from a cold cause, apply, after the acme, mustard with dried figs and the other rubefacients, but some the preparation from cantharides. But these things prove injurious afterwards, unless one use the emollient applications, such as that from fuller’s herb, the one called Pyxis, that of Basilius, that from the fir-tree, that from the poplar, those called Promium and Lysiponium, and the stronger of the Acopa: in which cases sympathetic affections of the nerves and impaction of the humours particularly take place. And the application from the urine of a mule, more particularly if applied at the acme, is beneficial in the cold rheums: and, in like manner, the trochisk from the two hellebores is applicable for the œdematous and spongy swellings; also fomentation with the toasted salts; or otherwise affusion or embrocation with hot sea water; and the plasters prepared from salts, those from strained lye and nitre, and the cataplasms of a like nature after the acme. Food of a drier nature, and not excrementitious, suits well with these; also abstinence from food, or a spare diet, and refraining from frequent baths. Having bathed, they should be rubbed with nitre and the other unguents used for friction. In the decline, they should have recourse in particular to gymnastic exercises and friction of the joints, and the natural baths, or the sand baths, and emetics from radishes and food from grain. Those properly prepared for it may be vomited or purged with the white hellebore.
On rheums from a mixture of humours. Those labouring under a mixture of humours, after the evacuation of the blood at the commencement of the disease, should use the topical remedies already mentioned. When the sanguineous plethora is of a more bilious and acrid nature, recourse may be had to those things recommended for bile; when it is of a colder and more pituitous or melancholic nature, those afterwards mentioned, with the exception of such as are very acrid; and if protracted, these also may be used. And this cataplasm is applicable at the commencement: Pomegranate rind, sumach, and polenta triturated with wine, are applied in the form of a poultice.—Another: Having boiled the leaves of cabbage, and triturated carefully, add the lees of vinegar, two yelks of raw eggs and a little rose-oil, and having triturated, apply, changing it frequently. Let them take food that is attenuant and of little nourishment. Let them, therefore, abstain altogether from flesh and pulse, from much wine of a dark colour; and, if possible, let them abstain from drinking wine altogether. For I have known many persons who have abstained altogether from this article alone, and all of them derived benefit. Those who did so in the commencement of the complaint were entirely freed from it; and those who were later in doing so experienced afterwards fewer paroxysms, and these not of great severity. If, therefore, no inconvenience occur, or be dreaded from it, they should abstain from wine all their life. Those who from weakness or coldness of constitution appear to sink under this regimen, after abstaining from wine for two years, may gradually accustom themselves to take a small quantity of diluted wine. Those who refrain from wine should take instead of it a decoction of anise, or of some such seeds, avoiding altogether the use of the autumnal fruits, and other things of a cold nature, and also venery. Of those who attempt to get rid of the complaint by continuing under a course of medicines for a complete year, many who suffer from pituitous and redundant humours have been benefited thereby, whereas such as are of a hot and dry intemperament have brought on sudden death, the offending matter being translated to the intestines, kidneys, side, lungs, or some vital part. It is better, therefore, for those who are bilious and sanguineous, to abstain from wine; as from this course there is no risk of falling into the dangers just mentioned. Those who are affected with cold and redundant humours should take the theriac of vipers more frequently if they have good digestion in winter, but more rarely in summer; for it either removes the complaint altogether or renders it more moderate, and proves injurious to none of the afore-mentioned parts. And since some persons compel us to administer the medicines called Antidotes, you should be aware that the following are all of the same kind, namely, that from water plantain, that of Agapetus, those called Atacton and Octaidon, that of Proclus, that from water germander, that from coral, and many others. The safest of them all, and yet of approved efficacy, is the one from coral, which dissolves tophi that are formed in the joints. The properties of all these things, the manner of using them, and the precautions to be observed with regard to them, you will find described in the Pharmaceutical part of this Work; and also the composition of depilatories for arthritic complaints, and the mode of applying them to these habits, I mean the pituitous. Some, for the entire removal of the complaint, boil whole wolves in oil, wherewith they cure arthritic cases; some throwing them in alive, and others dead, into a large caldron. And in like manner they boil hyænas, making a discutient oil from them; and then filling the cistern of the bath with it, and putting the arthritic patients into it, they direct them to remain in it for a considerable time. By these means it happens that not only the swellings about the joints, but the whole body, is evacuated.
On tophi, or chalk-stones. Since tophi are often formed in the joints, sometimes owing to a thick and terrene humour seating in the parts, and sometimes owing to the use of applications which are immoderately discutient and desiccant without being emollient, it is proper to know that the most suitable remedies are such as are at the same time emollient and discutient. Wherefore, old suet, marrow, ammoniac, bdellium, very old oil, and storax, are emollient; and nitre, salts, strained lye, adarce, euphorbium, and the like, are discutient and desiccative. This is an excellent application for tophi in the joints: Very old and acrid cheese pounded and applied with a decoction of fat swines’ flesh, it also being old. For the chalk-stone breaking spontaneously, a discharge of it takes place every day. The composition from ham (which is prepared in two ways) is also an approved remedy, and those described from strained lixivial ashes (potash?). And this one is particularly excellent: Of aphronitrum, of turpentine, of protostacton, of virgin wax (i.e. bee-glue), of each, oz. iv; of wax, oz. ix; of colophonian rosin, lb. j; of oil, oz. xvj; mix together, and use for chalk-stones and apostemes. The composition from dragon’s blood is of wonderful efficacy for chalk-stones and many other complaints, but is difficult to procure. But that from walnuts is not only efficacious but at the same time easily procured; and is applicable not only to those who are strong, but also to those who are sensitive, if mixed with honey or the composition from anemone, in the proportion of two parts to one of the composition. When these things are not at hand, an equal proportion of ceruse may often be mixed with it.—Another for tophi: Having triturated red arsenic, mix with mistletoe of the oak, and use.—Another, which is applicable also for fistula and ægilops: Of oil, one sextarius; of litharge, oz. viiiss; of arsenic, oz. j; boil the litharge and the oil until they do not stain, then sprinkle the arsenic well levigated, and before it catch fire, take off and use. The compositions from the flower of Assian stone, when used during the intervals, are applicable to all the collections which form in the joints; and some of the ancients attest that they remove the complaint entirely. The composition from the flower of salt, when applied in like manner during the remissions, is believed to dissipate whatever swellings remain.
On the prophylaxis of gout. Gout and rheumatism, when formed, are among the most difficult of diseases to cure, except by the methods we have described; but, before being fixed, it is easy to prevent their occurrence by restricting the diet, giving only such food as is of easy distribution and not excrementitious, with a moderate allowance of wine, and increasing the exercise as far as proper. As a remedy, salts triturated with oil and rubbed into the joints, are of great use to all who are anxious to avoid falling into a gouty affection, unless they be of a dry intemperament. They ought to use it morning and evening through life, and the same thing is to be used after the decline of the inflammation.
Commentary. Consult Hippocrates (Aphor. vi; Prognost. 15); Galen (Comment. in Aphor. Hippoc., de Med. sec. loc. ix); Celsus (iv, 24); Serenus Samonicus; Aretæus (Morb. Chron. ii, 12); Scribonius Largus (41); Cælius Aurelianus (Tard. Pass. v, 2); Alexander (xi); Aëtius (xii); Oribasius (Synops. ix, 58); Actuarius (Meth. Med. i, 21); Nonnus (216); Marcellus (de Med. 35); Octavius Horatianus (ii, 21); Demetrius Pepagomenos (de Podagra); Psellus (Opus Medicum); Macrobius (Saturnal. vii, 4); Lucianus (Tragodopodagra); Serapion (iv, 25); Avenzoar (ii, 3, 28, ii, 7, 31); Avicenna (iii, 22, 2); Haly Abbas (Theor. ix, 41; Pract. viii, 32); Alsaharavius (Pract. 38); Rhases (Divis. 102, ad Mansor. ix, 90, Libellus de Morb. Junct., and Contin. xxvi.)
The Prognostics of Hippocrates will be admitted at the present day to be correct. Those who are old, or who have chalk-stones formed in their joints, or lead a laborious course of life, or have dried bellies, cannot be cured by any human means. Young persons not having tophi formed in their joints, and who live guardedly, and whose bowels will bear the proper treatment, may be cured. These complaints are best removed by dysenteries or other evacuations downwards. His principal remedies are purgatives administered by the mouth or by injection, and local applications of a cooling nature, and even pouring cold water on the foot. When the pain of the gout becomes fixed in a joint, he directs us to burn it with crude flax.
Seneca mentions it as a monstrous example of the depravity of his age, that the women, by their luxurious habits, had become subject to gout. (Epist. 95.)
According to Galen, gout and arthritic complaints are occasioned by a collection of some humour in the affected part. This humour may be blood, phlegm, or a mixture of phlegm and bile, or of blood along with these, or simply a crudity. This crude humour, he remarks, sometimes concretes into tophi. The first indication in attempting the cure is to evacuate the offending humour by bleeding or purging; and then repellent and discutient applications are to be used. He has given a great many prescriptions for these. He disapproves of the warm bath in rheumatic attacks; for, he says, although it appears at first to give relief, it ultimately aggravates the complaint. (Therap. ad Glauc. ii.)
For an able and full explication of the ancient theory of the humours, and the manner in which they give rise to arthritic complaints, we refer the reader to Macrobius (l. c.)
Unfortunately the chapter of Aretæus on the treatment of arthritic complaints has come down to us in a mutilated state. It appears however, that he trusted to hellebore as the great remedy in such cases. His local applications are wool dipped in rose-oil and wine; a sponge soaked in oxycrate, or such like cataplasms. When the disease is hereditary, he says it is generally incurable.
Celsus recommends various refrigerant and anodyne applications to the affected part, such as a sponge soaked in cold water, or in oil and vinegar, or the same soaked in hot water having poppies boiled in it, or a mixture of pitch, wax, and alum. The other points of his practice deserve attention, but we shall not enter upon them, as we wish to afford room for a fuller abstract of the doctrines of Alexander.
Gout, according to Psellus, is occasioned by an atony of the nutritive faculty, whereby a thick humour is collected in the system.
Scribonius Largus recommends his favorite remedy for local pains, namely, the application of a living torpedo to the part affected.
Alexander begins with noticing the common opinion that gout is irremediable by the art of medicine, which he affirms not to be the case provided proper attention be paid to the different varieties of it. There are, he says, many causes of the disease; for sometimes a hot blood flows into the cavity of the joint and occasions violent pains; and, in like manner, a defluxion of bile getting between the tendons and ligaments occasions pain by burning and stretching the parts: phlegm likewise, by producing cold and compression, becomes the cause of violent pains; and in like manner the melancholic humour, not only by its coldness and pressure but also by occasioning a sense of heaviness, brings on no ordinary paroxysms. Sometimes a simple quality of the humours, such as heat, cold, dryness, or humidity, will cause a defluxion. The prevalence of a bilious humour is ascertained by the absence of swelling; from the pain being rather a fiery heat than distension; and from the colour being red. The proper remedies in this case are cholagogues, which must not be of a heating nature nor offensive to the stomach; for when the stomach is deranged the nerves sympathise and rheumatism is the consequence. He gives prescriptions for a variety of such compositions containing scammony, agaric, and the like, mixed with pepper, &c. He particularly commends pills of scammony and wormwood. He also recommends cooling and anodyne applications to the affected parts, such as rose-oil with the yelk of an egg, and the like. He enjoins particular attention to the diet, in order to avoid such things as have a tendency to form bile. He recommends moderate exercise rather before than after a meal, but forbids to carry it to excess. He speaks favorably of baths of common water. He concludes this part with minute directions about the local applications: but, as we have already stated his principles, we shall not enter upon the detail of his practice. When gout is occasioned by phlegm the part is neither hot nor red; is benefited by calefacients and injured by refrigerants. For this variety he recommends particularly a combination of purgative and attenuant medicines, such as the Julian oxymel, which contained white hellebore, agaric, polypody, thyme, cumin, &c. After purging he greatly commends hot and attenuant medicines, in particular the composition from coral, which, among other ingredients, contained birthwort, spikenard, cloves, myrrh, &c. (Birthwort formed one of the principal ingredients of the celebrated Portland powder.) He describes various other antidotes containing bitters, attenuants, and calefacients. His local applications in this case are pounded cabbage, parsley-seed, or fleabane, if the pain is moderate; but otherwise he recommends anodyne cataplasms. Should these, however, rather produce an increase of the pain, he directs us to substitute instead of them discutient and repellent applications, such as decoctions of thyme, mint, &c. with vinegar. He also recommends various cerates with the same intention. Some, he says, have been benefited by stronger applications, such as blisters of cantharides, sinapisms, or the like; but he does not approve of the barbarous practice of burning with the substances called iscæ (see Aëtius and Paulus), nor of the above-mentioned rubefacients, but prefers a combination of emollients with discutients. When it is suspected that the gout proceeds from an overflow of blood upon the joint, he recommends us to have recourse to bloodletting, unless otherwise contra-indicated. He proscribes such articles of food as engender much blood, as all sorts of flesh, especially pork; also sweet wines and intemperance of every kind. He says he has known some cured by simply refraining from wine. He then gives directions for the formation of several topical applications which are of a repellent and discutient nature. He speaks very favorably of a sponge soaked in an astringent wine or oxycrate. He then gives ample directions for discussing Tophi or chalk-stones. He lays it down as a general rule that such applications should contain ingredients of a moderately calefacient, discutient, and solvent nature. Among the articles which enter into these compositions we remark litharge, old oil, sanguis draconis, nitre, turpentine, ammoniac, &c. He then states, that as some do not choose to submit patiently to the methodical plan of treatment, but insist upon getting medicines to allay at once the violence of the pains, he, although he did not in general approve of this practice, would now give an account of such remedies. For this purpose, he says, hermodactylus is particularly trusted to by some; and he admits that it seldom fails to remove a paroxysm, but affirms that it occasions more frequent returns of it. Some, he adds, have endeavoured to correct its prejudicial effects by adding to it cumin, mastich, or ginger, thinking that its action is narcotic; but this he affirms to be a mistake, for in that case it could not prove cathartic. He admits, however, that these things may prove useful by correcting its bad effects upon the stomach. He then gives various receipts for mixtures containing hermodactylus. As a specimen of them we may mention the first, which consists of hermodactylus, myrrh, pepper, and anise, to which scammony may be added. He recommends it, however, in general, to be given in the form of pills with aloes, scammony, elaterium, and colocynth. But, as mentioned by our author, instead of it he prefers the coronopodium. It is the same, we presume, as the coronopus of Dioscorides, or our buckthorn plantain (plantago coronopus L.), although the commentators are not agreed upon this point. (See Matthiolus.) Gesner supposes it a species of ranunculus, which he calls polyanthemon. Alexander then gives directions for various local applications of an anodyne nature, containing opium, strychnos, ceruse, wax, &c. We regret to say that so admirable a treatise should conclude with some frivolous directions for curing the disease by means of amulets of approved efficacy! However, the advocates of the Mesmerian system of animal magnetism do not hesitate to admit their remedial powers. On the periapta or amulets of the ancients, see Andreas Laurentius (de Marab. Strum. Sanat, 85.)
Our limits will not permit us to do justice to the account of the gout given by Aëtius. Like Aretæus, he maintains that the disease is hereditary. His general views of the nature of the complaint and his treatment are very plausible. He says it is occasioned by weakness of the part and a redundance of humours; that the proper treatment therefore consists in evacuating the humours by bleeding and purging, and afterwards in strengthening the part.
Cælius Aurelianus considers arthritis, podagra, and chiragra, as diseases of the same genus. The usual precursory causes are intemperance, indigestion, debauchery, cold, too much or too little exercise, and external injuries. Some, he adds, are of opinion that it is transmitted from father to son. He gives the symptoms of these complaints with his wonted accuracy. They are seated for the most part, he says, in the nerves, by which term he probably means the tendons and membranes. He remarks the well-known propensity which persons attacked with gout have to attribute the swelling and pain to a sprain or some such accident. If the belly be constipated, he advises us to open it by a simple clyster. He recommends us to abstract blood from the affected part by scarifications, which, he says, will occasion less irritation than cupping or leeching. Sponges squeezed out of hot water, or oil and water, or the decoction of fenugreek, are then to be applied to the part; for he thinks these preferable to a cataplasm, as it is often too heavy. When on the decline, he approves of bathing, spare diet, emollient ointments, and gentle exercise, beginning with gestation, and proceeding to the stronger kinds of it. When they can be borne, he approves of stimulant applications, such as dropaces, heated sand, and even sinapisms. He also speaks favorably of vomiting produced by radishes, hellebore, hip-baths of oil, fomentations with hot salt water, and swimming in hot water or even in cold. He particularly commends the naturally-medicated waters, or spas (as they are now called), such as those of Albula or Cutilia, which, he says, will either cure or mitigate the complaint. He disapproves of burning the joints (the reader will have remarked his general aversion to the cautery), and the indiscriminate application of various narcotics and other such things. He also condemns the free use of emetics, (which, he says, prove injurious to the stomach, and occasion a determination to the head,) of purgatives, acrid clysters, and diuretics. In short, his practice is not unlike that of our Sydenham. His grand rule is to keep upon a spare diet, or even to maintain complete abstinence at the commencement. The formula for his diacentaureo (as Van Swieten remarks) is the same as that for the Portland powder, namely, Aristoloch. rotundæ; gentianæ; sum. chamædryos; centaur. min. p. æquales. Cælius Aurelianus, Galen, Aëtius, Celsus, Aretæus, Oribasius, Scribonius, and Horatianus make no mention of the hermodactylus. Myrepsus and Actuarius make mention of a hermodactylus, but Matthiolus and the commentator on the former think theirs a different plant from the hermodactylus of the other Greek authors. This may be true, and yet the microscopic eye of critics often fancies it can see differences which other people are puzzled to remark. We may mention further regarding the practice of Cælius Aurelianus, that he speaks of soothing the pains of rheumatism, more especially of the hip-joint, by music. On this practice see also Aulus Gellius (iv, 13); Athenæus (Deipnos. xiv, 18); Apollonius (Hist. Marab.); Pliny (H. N. xxviii, 2.)
There is nothing very important in Nonnus, Octavius Horatianus, or Oribasius. We shall now give a brief abstract of the curious treatise on the gout by Demetrius Pepagomenos. The work is dedicated to the Emperor Michael Paleologus, who flourished about the year 1260; and it was published by Morel at Paris, A.D. 1558. The author commences by explaining the nature of that derangement of the animal economy which occasions this complaint. This he does at considerable length, but in much the same terms as Macrobius, to whom the reader has been already referred for an exposition of the humoral pathology. His physiological opinions appear to us to be highly ingenious and philosophical. He comes to the conclusion that gout is occasioned by a collection of humours in the affected joint, these humours being the product of imperfect digestion and of the retention of excrementitious superfluities, which ought to have been evacuated from the system. He says the procatarctic or remote causes of arthritic affections are, long-continued indigestion, repletion with food, drinking too much wine, venery, unusual exercise, indolence, and retention of the natural secretions. Venery, in particular, is said to weaken the tone of the nervous parts. He then proceeds to explain that when crudities are formed in the system, those parts which are strong and vigorous cast them off, which those that are weak cannot effect, and hence collections of such humours take place in them. The prophylaxis of the complaint, he remarks, is easily laid down, but is difficult to follow, namely, to observe great moderation in eating and drinking, and to avoid indigestion. His grand principle of practice is evacuation, which, according to the general rule laid down by Hippocrates, is the proper remedy for repletion. He then shows that vomiting is the mode of evacuation most applicable in this complaint, because it empties the stomach, which is the fountain whence the humours are derived. His comparison of the stomach to a fountain which irrigates all parts of the system is very appropriate, and is beautifully illustrated by him. He recommends, however, vomiting by simple means; and for this purpose directs the patient to swallow meat imperfectly chewed, radishes, leeks, &c. and, having drunk some honied water, to excite vomiting by tickling the throat with a feather or the finger. He forbids the use of strong emetics. His second method of evacuation is by purging, which he recommends to be done by pills containing aloes, hermodactylus, cinnamon, and scammony. He then proceeds to the cure when an attack has come on. In this case, he recommends us to begin with letting blood, unless the stomach be loaded with impurities, when an emetic must be premised, lest the emptiness of the veins produced by venesection should cause these crude humours to be conveyed over the body. Venesection, he remarks, is particularly applicable at the commencement, when there is simply a plethora of blood, but it is rather prejudicial afterwards when the fluids become altered in quality. In such cases, as he fully explains, purging is the proper remedy, especially when performed by hermodactylus, which, he says, he had found from experience to answer well, from whatever cause the disease had originated. He directs it to be combined with various calefacients and aromatics, such as birthwort, cinnamon, and pellitory. He then makes an ingenious reply to those who affirmed that the disease is not to be cured by purgatives, but that it is sometimes exacerbated by them. In such cases, he properly remarks, it is not the remedy that is in fault but the misapplication of it. Those who cannot bear cathartics by the mouth may have clysters given them; or the preparations from elaterium, juice of sow-bread, or the like, may be applied to the navel. He afterwards gives directions about the local applications, which are nearly the same as those recommended by Alexander. We will have occasion, in the [Seventh Book], to discuss the question respecting the nature of the ancient hermodactylus; and we shall merely state here our own decided persuasion that it was a species of colchicum or meadow-saffron. It forms one of the ingredients of the celebrated Eau médicinale d’Husson. From the effects produced by the Eau médicinale we are inclined to think, however, that a certain proportion of hellebore must have entered into its composition, as we have never found the colchicum to act so violently as the eau is said to do. We have stated above that Cælius Aurelianus makes no mention of the hermodactylus. However, the great modern advocate for Methodism, Prosper Alpinus, speaks favorably of it, and says decidedly that it is the colchicum of the Greeks. It appears not to have fallen into disuse in his time. (De Med. Meth. ix, 4.)
The Arabians follow the Greeks closely in the general principles of treatment, only substituting certain articles introduced into the Materia Medica by themselves. Thus Serapion strongly recommends purging with myrobalans, prunes, and tamarinds. He, Avicenna, and Rhases, join in praising the virtues of the hermodactylus. Their local applications are similar to those of the Greeks. When the pain is violent, Serapion even approves of pouring cold water upon the affected part. Rhases approves of burning the joint in certain cases. Avicenna directs us to cover the part with oil and salt, and thus to apply the cautery gradually. Avicenna speaks more favorably of bathing in thermal waters than any of the other authorities. According to Haly Abbas, arthritic diseases are collections of superfluities of the system in some joint which is labouring under debility. These superfluities are said to be produced by repletion and indigestion. The debility is generally occasioned by immoderate exercise, intemperance, debauchery, or some such cause; and a joint having become weakened, all the impurities of the system are collected into it. He says that young persons and women who menstruate regularly are scarcely liable to the gout. He agrees with the authorities already mentioned in holding it to be hereditary. When the humour in the joints concretes into chalk-stones, he pronounces the case to be incurable. When the disease is produced by a sanguineous plethora, he recommends us to begin with bleeding, and then to use cooling lotions, or even to pour cold water on the joint. When these do not succeed, anodyne applications, containing opium, mandragora, lettuce, saffron, and the like, are to be used. When the pain has abated, any swelling which remains may be discussed by applying to the part a decoction of marjoram, melilot, chamomile, and the like. When the defluxion is connected with bile, he recommends first emetics, and then drastic purgatives, such as aloes, scammony, colocynth, and hermodactylus. But, if the patient’s stomach be weak, he recommends milder laxatives. When the defluxion is of a phlegmatic, that is to say, of a serous nature, he directs us to give the active cathartics already mentioned, especially hermodactylus; and, if it be the summer season, he advises us also to give emetics. He cautions us against using local applications of too stimulant a nature at first, lest they dispel the more fluid parts of the defluxion and leave the grosser behind. This is but a meagre sketch of his interesting account of arthritic diseases. Alsaharavius calls these complaints collections of phlegm, bile, or blood. He holds that they are often hereditary. Like all his countrymen, he approves of hermodactylus, which he gives in the form of pills, with myrobalans, colocynth, turbit, castor, opopanax, &c. When fulness of blood is present, he recommends bleeding.
The hermodactylus is recommended for the cure of arthritic diseases by the earlier of the modern writers on medicine. See Lanfrancus (ii, 3.)
Among the ancient treatises on gout, we have mentioned the tragi-comic poem entitled ‘Tragodopodagra,’ usually ascribed to the famous Lucian. It ridicules, with much humour and severity, the many pretended nostrums for this complaint. Among the remedial articles mentioned, we remark hellebore, nitre (soda), henbane, poppy, fenugreek, and galls. The ridicule thus bestowed upon the use of specifics for the cure of a complaint so complicated as gout, is no doubt well founded; but we ought not to be deterred, by the ill success of such a practice, from attempting to afford relief upon general principles, as ably laid down by Alexander, Demetrius, and Haly Abbas. We would fain impress upon the physician and his patient, that more than is usually believed might be accomplished in all arthritic diseases, by correcting the disorder of the digestive functions by means of a suitable diet and regimen; and that it is only when the constitution is radically unsound—when the joints are deformed by concretions, and the vital powers have been worn out by a long-continued course of debauchery—that we need adopt the discouraging opinion of Ovid, as expressed in the following line:
“Tollere nodosam nescit medicina podagram.”
(Pont. i, el. 4.)