Gilbertus Anglicus: Medicine of the Thirteenth Century

by Henry E. Handerson

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).