Introduction

Gout is the oldest non-communicable disease known in humans, with origins dating back to around 2760 BC in Egypt. It is regarded as the earliest documented form of chronic inflammatory arthritis in human history. Historically, gout has been known as podagra (meaning “foot-grabber”) from Greek stems. According to Webster’s Dictionary, it literally means foot-trap from “pous” (foot) and “agra” (catching, seizure). The term “gout” was introduced by Randolphus of Bocking (1197–1258), who connected it to the Latin word “gutta” (drop). Gout is a systemic disease caused by hyperuricemia – at or above 6.8 mg/dL – leading to the deposition of sodium monurate crystals in peripheral joints and periarticular tissues. Crystal deposition activates the NOD-like receptor protein 3 inflammasome causing – via caspase-1 – the release of the cytokine IL-1β, also known as an endogenous pyrogen, a highly inflammatory cytokine and a key mediator of the acute attack [4].

Hyperuricemia may result from renal overload, renal underexcretion, or a combination of both [1, 2]. Urate deposition causes the release of cytokine IL-1β [2], mediator of the acute attack. Gout typically begins by affecting a single joint, often the first metatarsophalangeal joint of the great toe, and is usually self-limited, resolving within two weeks. Flare-ups affect two or more joints, becoming a chronic disease characterized by tophi and joint erosion. Diagnosis is based on clinical history, symptoms, signs, polarized microscopy, or fine-needle aspiration of tophi [3].

An effective cure was introduced in the fifth century CE [4] by Theodosius, Severus Iatrosophista and Jacobus Psychrestos, who applied a plaster made from Hermodactylus, a root rich in colchicine – a compound previously used as a cathartic. It was the main drug of choice for gout until the advent of allopurinol.

We have been drawn to this disease by the history of popes [5–7], which provides all the details necessary for a comprehensive understanding of gout as the oldest lifestyle disease, a disease of distinction [8], and a man-made condition. It is explainable by the theory of epidemiological transition but also a disease amenable to prevention in individuals with a high degree of education [9, 10].

Recently, we have initiated a study dedicated to illuminating the timeline of “Gout from the Corpus Hippocraticum to the Renaissance”. Our focus has been on Hippocrates and Galen [11, 12], and we have also provided preliminary data on Alexander of Tralles [13] and Rufus of Ephesus [14, 15]. The latter is studied extensively in this context.

 

Aims

A multipurpose study has been devised to: 1) translate into English and Italian the medieval Latin of De podagra the treatise of the VII-VIII century AD,  2) define Rufus’s role within the historical timeline of gout from the Corpus Hippocraticum to the Renaissance; 3) analyze the causes, clinical presentations, and therapies of both acute attacks and chronic gout; and 4) identify the vegetable remedies described therein. Neither an English nor an Italian translation of “De Podagra”, nor the identification of the plants mentioned, has been attempted before.

 

Rufus’ short biography

Rufus of Ephesus, one of the most celebrated physicians of antiquity, probably lived in the second half of the first century and the early second century, with dates assigned by Suida between 98 and 117 CE, during the reign of Trajan [16, 17].

Details about his life are scanty and often imprecise. Rufus was born at Ephesus (Asia Minor, near modern Selçuk, Turkey) and it is believed that he studied in Ephesus and Alexandria where he learned anatomy by dissecting apes, pigs and other animals, while also acquiring medical knowledge from Hippocratic texts. Rufus practiced medicine in Egypt and various parts of Asia Minor, including Ephesus, Magnesia, and Miletus, travelling extensively. However, reliable evidence of his having been in Sicily and Rome has yet to be found.

Rufus authored numerous works, but most of his writings have been lost and the surviving material is incomplete and contains errors. Among the surviving manuscripts a special mention is due to The Naming of Parts of the Human Body, a manual of anatomy based more on animal dissection than on human; a treatise on Diseases of the kidneys and bladder and to a treatise on Purgatives. Also preserved is the already mentioned Latin manuscript from the VII-VIII Century CE on “De podagra” translated into French as Traitè de la goutte by Littré and published in Review Philologique. The list additionally includes a work on Pulses, preserved in Greek and translated into French by A. Daremberg in 1810, as well as fragments transmitted in the works of Oribase and Aetius of Amida. Rufus’ Opera omnia was published by C.H. Daremberg and É. Rouelle in 1879 [18].

He adopted the theory of the four humors and practiced a medicine based on identifying their imbalance and restoration. Rufus was more interested in clinical practice than in theoretical questions. A prolific writer, many of his works survive only in Arabic translations. His clinical method, well described in “On the Interrogation of the Patient”, was based on questions. Questions were indispensable to trace the origin of the disease, identifying the critical days, understanding the time-course, determining antecedents and assessing the humours involved thereby facilitating the decision about treatment.

He covered many topics, including anatomy and pathology, and mastered both medical and surgical illnesses. He also devoted particular effort to the study of Melancholia. In the treatise on gout – he was gouty – he reports on tophi and his experience pointing to the fact that on many occasions he saw them dissolving during treatment; however, he indicated that many physicians decided to leave them in situ after an attempt with poultices and heat. He realized that it is not a humour as cause, but a toxic substance in the organism, which can target the internal parts.

Rufus was quoted thrice with appreciation by Galen [19, 20]. The first time for his studies on melancholy and later for preservation and interpretation of Hippocrates’ manuscripts. His studies have been reported in the works of Oribasius, Aetius of Amida (De re medica libri XVI, transcribed chapter XXX and XXXI of the treatise on gout), Paul of Aegina and Rhazes. No less than 36 Arab scholars have quoted him [21]. Rufus was defined by Oribasius as “The Great” [20] and by Haller “illustris medicus et insignis scriptor” [22].

His surviving writings have been edited over the centuries.

 

Methods

We have translated into English and Italian the 37 paragraphs of “De Podagra” using the same Latin text employed by Littré for his French translation (Traité de la goutte). Their contents are summarized in Table 1 and provide the most immediate way to grasp the vast knowledge Rufus had on gout. Subsequently, we have distilled a synopsis bearing all essential elements of the disease (see Enclosure, Rufus text).

Plants used by Rufus for therapies were identified using three criteria derived from the works of Lily Y. Beck and John M. Riddle on Pedanius Dioscorides, and Nicholas Everett for The Alphabet of Galen [22–24].

ON PODAGRA

1. Prologue

2. Signs to diagnose the disease

3. On exercises

4. On frictions

5. On baths

6. On the properties of natural and mineral waters

7. On herbs useful to add to sweet waters

8. On fomentations

9. Legumes

10. On fish

11. On birds

12. On meats

12a.On bread

13. On wine

14. Nutrition of the gouty persons during the attacks of the disease

15. On salting

16. On walking after waking

17. On cathartics

18. Drugs that should not be administered to gout sufferers as purgatives

19. Purgings useful to gouty persons

20. Remedies used to induce vomiting

21. On vomiting

22. On acrid aliments, other aliments

23. Why podagra descends from colon to feet

24. On remedies removing flatulence

25. On clysters

26. On potions

27. On antidotes

28. Potions should not be removed immediately

29. Methods of treatment

30. A different cure for podagra

31. On the application of cauteries and on the production of eschars on joints

32. An additional modality to cure with liniments and poultices

33. Treatments to be followed when there are complications in the pains of rheumatic diseases

34. On cooling the joints

35. On poultices producing heat

36. Remedies for treating very humid podagra

37. Fomentations

Table 1. Contents of the Treatise on podagra by Rufus of Ephesus. In Oeuvres de Rufus d’Éphèse, Paris 1845, pp. 307-348.

 

Rufus of Ephesus on Gout (De podagra)

1. PROLOGUE

Joint diseases can be cured, provided they are caused by congestion and excess humidity, which lead to loss of heat and dryness. Initially, even when the disease is mild, the onset of congestion warrants concern. Thus, at the beginning of attacks, the pain is not severe and causes little harm; however, if the attacks become intermittent, there is an increasing influx of humors into the joints, making healing progressively more difficult. Those who overeat, especially unhealthy foods, are prone to worsening of their condition. So, the patient begins to feel very mild pain in the joints, then very acute suffering begins. The most serious condition occurs when the congestion in the patient’s joint ceases; this is followed by another danger that threatens, then soon prevails and overwhelms the patient, such as pleuropneumonia, apoplexy, or some other acute disease. Therefore, it is important to explain everything to the patient, so that detailed remedies can be explored to determine which ones are appropriate for treating the disease.

2. DIAGNOSIS OF THE DISEASE

If a joint is painful, the patient should be asked if he has bumped the affected area. If he denies this, he must immediately be placed on a diet, given an enema and made to undergo bloodletting (preferably near the site of the pain). Abstaining from eating reduces blood production and prevents the joints from becoming sluggish. We prescribe enemas because they help evacuate the bowel. Bloodletting is useful, but less so in the lower parts. There is a need to relax the abdomen; if there is bleeding, this will be of great help, because the disease progression will be halted. Even when the disease has completely resolved in patients, they should not be considered cured, as relapses return over time, given that this disease, like many others has its periods. Those who, by not observing their state, do not take into account what we say, expose themselves to very serious diseases. Therefore, we strongly advise them, before the second and third recurrence, not to ignore the prescribed treatments typical for such cases. Immediately after bloodletting, it is beneficial to perform a massage, dehydrate the body with strenuous exercise, consume easily digestible foods, and above all, make efforts to dry the body.

3. ON EXERCISES

Indeed, if the joints in the hands and upper limbs are in poor condition due to nodules, the feet must be exercised by walking, running, horseback riding, massaging the thighs and lower limbs. Conversely, if the joints of the feet are affected, attention should be given to the hands by encouraging different movements and performing different tasks, as this helps dehydrate the body. When a certain area has been sufficiently exercised, it is time to start very vigorous general exercises with a desiccant effect. Gout sufferers experience the most intense nerve pain when their upper and lower joints are affected simultaneously, and therefore, require very careful treatment.

4. ON MASSAGE

I praise massages, first dry, then with oil. They should not be very prolonged, but should last until the hands become soft to the touch without being greasy under the rubbing. Do not use new oil, but rather the oldest possible, to which drying and warming ingredients will be added, such as iris (Iris florentina, L.) or St John’s wort (Hypericum crispum, L.), or plenty of salt, or even a small amount of honey. All this is beneficial to gouty patients. An equally effective remedy is pork fat, or wild boar fat, which is even more drying. I think it is important to rub the joints with suet (because there is always some on hand), oil should be used more often than not, as well as other remedies (medicines), when available. The best is to massage the area where the pain is most intense. Furthermore, for gout and all diseases of the joints and hepatic colic as well, it is good to treat the parts (limbs) with very old pork fat. Melt it over burning coals, add equal amounts of larch (Larix decidua, Mill.) and butter, then grease the sore parts.

5. ON BATHS

I will not mention baths, in absolute terms, as effective treatment for this disease, except in cases of fatigue, sluggish digestion, plethora, or finally, excessive dryness of the joints; in these instances, baths are very often effective. Again resort to baths when the body suffers (insistent) pain, if there are nocturnal emissions or after a venereal act. In all other circumstances, baths should be avoided by gouty sufferers.

6. ON PROPERTIES OF NATURAL OR MEDICINAL WATERS

If you put medicinal plants in the water, and if you use natural warm waters, such as waters full of asphalt, sulfur or alum, as long as you take frequent baths, they will do no harm; and, if you take sea water baths, you will be happy. Swimming will also be good for you, as this exercise is healthy for your joints.

7. HERBS THAT ARE GOOD TO PUT IN FRESH WATER

If the waters are not natural, the types of ingredients to put in the fresh water are the following: sage (Salvia officinalis, L.), laurel (Laurus nobilis, L.), chaste tree (Vitex agnus-castus, L.), myrtle (Myrtus communis, L.), tender willow leaves (Salix, L.), salt for making brine, especially non-sea salt. All this provides the baths with drying properties, and provides a benefit when there is an excess of humors. But baths are not helpful when they are cold, because, when the patients get accustomed to the baths that we have prescribed, cold baths taken at other times will do even more harm.

8. ON FOMENTATION – Differences in warm applications to ease pain

I recommend the perspiration caused by a sand bath, the baths that are taken by wrapping oneself in leather or fabric, and the Laconia baths. The use of dry steam baths is effective. It is what the Greeks call the tub. As for us, with a pine cone placed in a tub, closed at its end and heated with a branch, after having removed the fire, we let patients perspire inside, taking care that the water does not spill. There is still a method of perspiration which consists of rubbing the entire body with cleansing lotions, ointments and moderate anointing with iris (Iris florentina L.) or privet (Ligustrum L.) oil. We now need to get to the foods that can be beneficial for these ailing individuals.

9. VEGETABLES

In my opinion, vegetables do not provide any real benefit; however, we must eat some of them in order to soften the belly, others, because they are cold and moist (refreshing and humectant), some are caustic, others are acrid; and some even have diuretic properties.

10. FISH

Suitable fish are very dry ones, such as mullet, sea scorpion, or scorpion fish, odilcon (untranslatable); as well as soft-fleshed fish: for example, brown wrasse, cichlids, parrotfish, and another species of Labrus merula. This is all good as dehydrating and easy to digest; but the best meats (in this disease) are still those of anchovies, hermit crabs, and sea prawns, which are more drying. I do not recommend young tuna, any of the meaty fish, which are fatty, indigestible, give stomach problems, cause mucus and are humectant, such as sea eels. Cartilaginous fish, and generally all freshwater fish, are equally mediocre.

11. BIRDS

As for birds, all should be recommended, except those living in water or marshes; in fact, these do not represent a healthy nourishment (for our patients), but a humectant and aqueous one; moreover, they are difficult to digest. I recommend those which live in dry places and feed on wheat, they are at the same time digestible and nutritious.

12. SLAUGHTER MEAT

Pork is recommended in any type of diet when it comes to strengthening; for this reason, this is the only meat given to athletes. At least, this is the case now, but not in the past. It is nutritious for everyone, provided, however, that attention is given to the condition of the abdomen; because, when this tends towards humidity, it is controlled by desiccants; if it causes inflammation, it is controlled by refreshers. However, in my opinion, pork is not effective for gouty or arthritic persons; and, more generally, for people who have nerve disease who should not eat a heavy diet, especially if it is humectant, because it soon causes some other disease. Why am I against pork? It’s because it’s humectant and bad for your gut. Kid, lamb and veal are digested much better; and, in fact, these animals digest all species of vegetables, and are not harmful (to the abdomen) like pork.

12a. BREAD

You must eat bread baked in an oven heated on all sides, so that the cooking is even, and that it is well leavened, made with a flour that is not too refined, made with three-month-old wheat.

13. WINE

Drink red wine that is neither well aged nor too fresh. For ordinary people, I do not recommend either red wine or young wine; both are indigestible for everyone, especially for the sick we are taking care of. These are the usual foods and drinks suitable for gout sufferers.

14. NUTRITION DURING ATTACKS OF THE DISEASE

In the presence of inflammation, I recommend water rather than wine, and eggs rather than slaughtered meat. Do not administer fomentations immediately after the meal; they carry the risk of tissue contraction when the food is still raw (undigested). Does cold provide relief? So first of all we suggest drinking a cup of wine with honey, 1 cotyle, rather than just wine. This compound is both a drink and a medicine. Then possibly eat the foods mentioned before every day, taking into account the good condition of the abdomen. In fact, if it is not relaxed, it will be necessary to use all types of boiled food: and among vegetable chard (Beta vulgaris L.), mallow (Malva sylvestris, L.), dock plant (Rumex obtusifolius), male mercurial herb (Mercurialis sp. L), the soft part of the thistle (Cirsium vulgare (Savi), Ten.); drink chicken broth with sea shells. If, on the contrary, the abdomen is relaxed, these foods are not necessary; but, once the pain has calmed, bread and meat will be allowed. The best foods, in this diet as in all others, are a small quantity of bread and a moderate diet, if the aim is to regulate the status of the belly, choose among the above-mentioned things.

15. SALTING

As for salting, adopt those of Pont or those of Cadiz. Otherwise, just salt the food in any other way.

16. WALKS AND WAKEFULNESS AFTER A MEAL

You have to walk or rest; in fact, when it comes to sleeping (immediately) after taking a meal, as for humidity, I am not in favor. After eating one has to walk or rest; after all, if one wants to take a nap, do it before the meal. This is the rule to follow for gout sufferers. We are not obliged to provide a complete detail, we should not at all blame ourselves for not having described everything about the diet and treatment. It was enough for us to remember the medical advice set out above.

17. CATHARTICS

As for cathartics, those that should be administered to gout sufferers will be identified as follows. I consider it excellent for the gouty patient to be purged twice a year. First he will purge himself at the beginning of spring, before the humors boil and pour into the joints, and the second time in autumn, at the time of the Pleiades, before the first cold temperatures cause blood to freeze. Purge with remedies that eliminate mucus and bile. These humors must therefore be eliminated with cathartics that are beneficial to gout sufferers. As for the medicines that eliminate the liquid humors in gout sufferers, immediately after use they seem to calm the patients well, but afterwards they do them more harm (than good) since they cause extreme emaciation or wasting.

18. DRUGS THAT SHOULD NOT BE ADMINISTERED TO GOUT SUFFERERS AS PURGATIVES

Scamony (Convolvulus scammonia L.), tithymallus (Euphorbia amygdaloides L.), wild vine (Vitis sylvestris Gmel.), euphorbia (Euphorbia helioscopia L.), Cnidus berry (Chrozophora tinctoria L., A. Juss.), and similar medicines.

19. USEFUL PURGATIVES FOR GOUT SUFFERERS

You will give gout sufferers especially up to two drachmas of black hellebore (Helleborus cyclophyllus R.Br.), to which you will add a light dose of salt and berries of spurge flax (Daphne gnidium L.). This medicine moderately eliminates phlegm and bile. You will also give some polypody  (Polypodium vulgare L.), a plant that moderately eliminates phlegm and bile; you will have to take a dose of 2 drachmas, because it purges very gently. If you want to make a decoction of black hellebore (Helleborus cyclophyllus R.Br.) and administer it, it will be fine, likewise the polypodium. An excellent laxative for gout sufferers is still the internal part of coliquintide (Citrullus colocynthis Schrad.), at a dosage of 4 drachmas, sprinkled with honey wine or water. This medicine eliminates acidic humors, even after their resolution. Moreover, in nervous disorders none of these remedies will be harmful.  For my part, I know an excellent recipe for gout sufferers; it is made up of internal part of the coliquintide, 20 drachmas; oyster mushroom (Pleurotus ostreatus, Jacq.) 10 drachmas; wall gemander (Teucrium chamaedrys, L.), 10 drachmas; panax (Opopanax, L.) juice, 8 drachmas; silphium (extinguished plant), 8 drachmas; asafoetida (Ferula assa-foetida, L.), 8 drachmas; wild parsley (Anthriscus sylvestris, L.) 5 drachmas; round aristolochia (Aristolochia, rotunda, L.), 5 drachmas; white pepper (Piper nigrum L.), 5 drachmas; cinnamon (Cinnamomum, sp.), 4 drachmas; spikenard (Nardostachys jatamansi DC.), 4 drachmas; myrrh (Commiphora Myrrha Engl.), 4 drachmas; saffron (Crocus sativus L.), 4 drachmas. Add enough honey, mix everything together. You must take this drug frequently. It is therefore not necessary to administer these medicines at once, but first of all take care to give them at intervals, at a maximum dose of 4 drachmas, in honey wine or water. You will add a spoonful of salt, which helps to purge better, more quickly and more easily. These are the laxatives for both gout sufferers and arthritic people.

20. REMEDIES THAT PURIFY WITH VOMITING

The best purifier for inducing vomiting is white hellebore, but I do not think it is necessary (to use it). It must be avoided as it is extremely harmful; and, if it is necessary to take it, let it be done before the disease has fully developed. At the slightest sign of small danger, try a gentler medicine to induce vomiting, such as narcissus bulb (Narcissus poeticus L), which is completely harmless and is taken in the form of a decoction; or even staphysagria (Delphinium staphisagria L.) triturated in honey wine, in a potion at a dosage of 15 grains. Another excellent medicine is garden cucumber (Cucumis sativus L.), mixed with staphisagria (Delphinium staphysagria L.), as it slightly impedes breathing. When there is pain in the feet, and (usually) if gout mainly affects the lower limbs, purging the humors by vomiting is more effective; if it affects the upper limbs, it is better to eliminate the humors through the gut.

21. VOMITING

As with other diseases, I recommend vomiting for gouty patients, and I also recommend that they provoke it often. But in this case it must be after the meal. Give a decoction in the water in which you cook oregano (Origanum vulgare L.) at the dosage of 3 cups, mixed with oxymel. Let them drink hyssop (Satureja graeca, L.), or thyme (Euphorbia chamaesyce, L., thymus Sibthorpii (LSJ.) or horseradish (Armoracia rusticana L.), taken separately, and soaked in salted oxymel. Should one decide to vomit after a meal, when pain has almost subsided, it requires appropriate attenuation, and everything that the patient wants must be given to him before the meal, so that he can take additional foods afterwards: these are the conditions under which vomiting shall be used.

22. ON ACRID FOODS AND OTHER FOODS

One shall eat horseradish, onions, pickles, mustard and vegetables, fatty butchered meat, fatty fish, pastries made with cheese, honey and oil. Finally, poultices will be given on an empty stomach, then vomiting will be caused, so that the belly returns what it has absorbed. Whether the patient is walking or resting, one should invite him to drink a bit [a broad bean amount] of absinthe (Artemisia absinthium L.) juice in 3 cyathi of water (1 cyathus 35 ml). Why do I prescribe drinking absinthe? Because I find that this plant (wormwood) aids digestion and is a good diuretic, a double result to aim for when treating gout, because there is a close relationship between the colon and the joints.

23. GOUT MAY ORIGINATE IN THE COLON

Many people with a deep, long-lasting articular ulcer die of diarrhea. A large number of them, who complain of pain in the intestine, experience severe pain in the joints. Therefore, do not neglect digestion, or the gas that can continually arise in this type of patient; their persistence is a danger.

24. REMEDIES SUPPRESSING FLATULENCE

It is useful, in this case, to take those (medicines) that help pass gas. These are rue (Ruta graveolens, L.), cumin (Cuminum cyminum L.), anise (Pimpinella anisum L.) and dill (Anethum graveolens, L.). These plants are taken in the form of a decoction. It is also advisable to apply oil-based lotions to the belly or to perform dry rubs with a lambskin.

25. ON CLYSTERS

I also recommend enemas for gouty people, especially those whose stools are hard. For what purpose? In order to release substances that damage the joints. We must therefore prepare enemas that have the purpose of evacuating, or some other (similar) remedy. Common enemas are simple, others are pharmacological; I especially indicate those that are related to the disease (which is in question); and in fact they are the ones that will only evacuate the feces; because other diseases require other drugs (via clysters). I think hot enemas used by ancient doctors had scarce effect. Here then are medicated enemas: water, in which a decoction of coloquintis (Citrullus colocynthis, Aschrader), black hellebore (Hellebore niger L), absinthe (Artemisia absinthium, L.), southernwood (Artemesia abrotanum, L.), centaurea (Centaurea, L.), rue (Ruta graveolens, L.), hyssop (Satureja graeca, L.), iris (Iris florentina, L.), common corn-cockle (Agrostemma githago, L.), garden cress (Lepidium sativum, L.); add more saltpeter than salt and more salt than in the other enemas and also greater amounts of honey, but smaller amounts of oil, and it should be old. However, when you deem it appropriate to use this clyster, it is necessary to precede it with a mild enema. Then you’ll have this done, which is acid. In fact, it is necessary, first of all, to take into account the strength of the patient, and an evacuation that is too abrupt is always bloody. After this the patient shall drink milk to soften the intestines affected by corrosion. Attention must be paid to the diet. These clysters always greatly relieve people whose upper joints are diseased, or who have prolonged pain in the loins, and who suffer from sciatica; but those whose gout affects the lower joints experience less relief.

26. MEDICINES ADMINISTERED ORALLY

There is also another treatment method that involves medicines taken in potions. I know, in fact, that people suffering from sciatica and gout have been relieved from gout by these potions, and that some of them have helped dissolve viscous concretions. However, one should not expect prompt or immediate relief from this treatment: these remedies act slowly because the condition is not acute and does not progress rapidly. Therefore, drunkards receive a decoction of chamomile (Matricaria chamomilla, L.), cinquefoil root (Potentilla reptans L.) or helichrysum (Helichrysum orientale L.) heads; a decoction of alpine fennel (Foeniculum vulgare Gaertn.), taken in a potion, is also effective; the same goes for St. John’s wort (Hypericum crispum, L.), nutmeg (Nigristica fragrans Houtt), and camedrio (Teucrium chamaedris, L.); the amanita (Amanita caesarea Pers.) is the most effective; drink it in the oxymel at a dose of two obols. Wild spikenard (Nardostachys jatamansi DC.), decoction offers the same benefit and increases urine output; its effect is very immediate; it consists of facilitating the disposal of dense humors that stagnate, dissolving concretions and eliminating viscous humors.

27. COMPOSITE MEDICINES AGAINST GOUT

We find yet other composite potions. First of all is the centaury potion, which includes: centaury (Centaurea centaurium, L.), gentian (Gentiana lutea, L.), round aristolochia (Aristolochia rotunda, L.), 4 pounds of each; leek (Allium porrum, L.), wild parsley (Petroselinum hortense, Hoffm.), cumin (Cuminum cyminum, L.), scordio (Teucrium scordium, L.) or wall germander (Teucrium chamaedrys, L.), 3 pounds of each; honey, 6 pounds; prepare and use. 

Here is another one, rue, which includes: gentian, round aristolochia (Aristolochia rotunda, L.), 4 drachmas of each; centaurea (Centaurea centaurion, L.), wall germander (Teucrium chamaedrys, L.), 14 drachmas of each; wild rue (Ruta graveolens, L.) seeds, 2 ounces; honey, 5 pounds; prepare and use. 

There are still other potions recommeneded by the author of Aucistae (unknown author) who in his Medicinal Preparations writes: wall germander (Teucrium chamaedrys, L.), 10 obols; round aristolochia (Aristolochia rotunda, L.), 9 obols; gentian (Gentiana lutea, L.), 8 obols; absinthe (Artemisia absinthium, L.), 7 obols; centaury (Centaurea centaurion, L.), 1 pound; St. John’s wort (Hypericum crispum, L.), 5 obols; valerian (Valeriana celtica, L), 4 obols; alpine fennel (Foeniculum vulgare, Gaertn.), 3 obols; wild parsley (Petroselinum hortense, Hoffm.), 2 obols; agaric (Polyporus, sp.); a sufficient amount of honey. 

Other potion: germander, gentian, centaury, aristolochia, wild parsley, wild lavender (Santolina chamaecyparissus, L.), agaric (Polyporus, sp.), cyclamen (Cyclamen graecum, Link), 3 [pounds of each], cyperus (Cyperus papyrus, L.), 1 pound; flaxseed (Linum usitatissimum, L.), 5 ½ pounds; aloe, 5 ½ pounds; a sufficient amount of honey. 

Other: germander, gentian, aristolochia, centaury, rue, of equal weight; a sufficient amount of honey; to be taken at a dose of 2 drachmas. 

Other: Agaric given once a day has an excellent effect. The sacred medicine, taken once a month, purges well; or even thyme (Thymus sibthorpii) and rhubarb (Rheum ribes, L.) flower powder; give two scruples once a day in wine with honey, or in anointings, and in all the ways in which it may be suitable. 

Other: spikenard (Nardostachys jatamansi, DC), 9 scruples; rhubarb, 1 ½ servings; round aristolochia, 6 obols; gentian, 3 obols; myrrh, 6 oboles; refined bay berry (Myrica rubra, Lour.) 1 pound; dose, 2 scruples. 

Avoid anything that is not useful. Above all, it is necessary to fully understand which foods are to be prescribed. One should not abruptly give up a potion after having taken it only once; I’m not convinced that we should stop taking the diuretics we are used to take, but we must eliminate them gradually, otherwise we expose ourselves to apoplexy or some other incurable disease, as I learned what happened to a certain Clemmagniti (as in the original text and untranslatable), stricken by gout, he took the centaury potion; then, feeling relieved, he interrupted the treatment: he soon felt spasmodic pain, and ultimately succumbed to cerebral apoplexy, resulting in his passing. I also know another patient who fell victim to the same misfortune; only that, since he was moody, he purged himself often and recovered; then, having suddenly stopped the enemas, he died. It is therefore necessary to gradually eliminate the sedimented humors, for fear that these very harmful substances, remaining in the body, as a result of their accumulation, could suddenly cause the patient’s demise.

28. ONE SHOULD NOT SUDDENLY STOP TAKING POTIONS

The best thing therefore, I repeat, is not to suddenly forego the composite potions of the aforementioned medicines. But if it is believed that the patient has taken enough, assuming that it is not yet convenient to have his usual drink, it is necessary, in this case, to no longer take the same amount of potion, or to take it every day, but it is necessary to reduce the dosage systematically and not eliminate it all at once.

29. TREATMENT METHODS

Is it good to change purgatives? Should the patient be purged with stronger remedies? If there really is an excess of blood, it is necessary to bleed and induce vomiting, even when these methods do not relieve the pain; and in fact one cannot do without resorting to anointings and other treatments. Therefore, treatment methods are always harmful if the interruption of their use is too abrupt. Having made this recommendation, it is following the advice of the experts that I have indicated the treatment and diet, and, if you ask me for my opinion, (I will answer) I do not attribute the same effectiveness to all the prescriptions I have provided.

30. ANOTHER WAY TO TREAT GOUT

There are various commendable ways to cure this serious disease; we recommend them for gout in the joints of the feet; I also recommend making an incision in the vein under the sole, as when varicose veins affect the thighs or tibia. In fact, these parts can be seen to swell slightly at the beginning of the disease, then more seriously. If the vein receives a deeper incision, the blood within can no longer be renewed, because there is inflammation, especially when the gout originates from the plethora, in this case diagnosis is based on redness around the foot, formation of nodules on the same part, enlargement of the veins, inflammation of the entire foot accompanied by pain and relieved by cold compresses. When the disease affects other joints, the vein is not visible. Otherwise it must be incised.

31. ON CAUTERS AND ULCERS TO BE CREATED BY AFFIXING THEM ON JOINTS

It is also necessary to create ulcers on the joints, especially those caused by cauteries, or, in the absence of these, by medications. It is better to use cauteries, because they burn more penetratingly and more dryly. We must ensure that the joint thus burned does not heal too quickly. In some cases, it is best not to let the sores heal.

32. ANOTHER WAY OF HEALING WITH ANOINTINGS AND POULTICES

There is another way to cure. For gouty people, a choice must be made among drying remedies; if they are very effective, causing excessive dehydration, after having dried up the fluid humor, they give rigidity to the dense humor and produce calluses. Erasistratus prescribed bringing the activity of the humors to the joints, in order to repress the plethora. So, here are the remedies to use: there are liniments, especially those that are spread on linen and applied in this way; then all the desiccants. There is also a soothing preparation composed of sulfur and vinegar, alum, heather leaves crushed with gall, myrrh (Commiphora myrrha Engl.) and vinegar. Apply this preparation on the affected parts, i.e. the elbows, arms, knees, thighs, feet, shins and other similar parts where the pain occurs. These substances prevent congestion from affecting the joints. We also mention drying poultices, hicésium, diaitéas, and all those composed of bitumen, tar and calamine. This is sufficient on anointings and liniments. In the absence of soothing, you can resort to dry rubs and sprinkle with mustard or watercress flour; in fact these remedies are of great help, provided they are not used differently than before the depletion.This is the cure I have to prescribe for all joint affections, and I believe I can guarantee recovery to anyone who will tolerate it, and will not be stopped by weakness or negligence.

33. TREATMENT TO BE FOLLOWED WHEN THERE ARE COMPLICATIONS OF RHEUMATIC PAIN

Now we have to talk about remedies against rheumatic pain and against inflammation of the joints. It is necessary to calm them down immediately with proper methods; indeed, for some diseases, it is enough to administer low-dose emollients. It is therefore a question of applying them to pain; but, first, an emollient enema must be carried out to empty the abdomen, then, in the first days (of treatment), abstinence from drinking and eating is prescribed. If the patient has a full stomach when the pain begins, make him vomit; if there is an observable excess of body fluid, bloodletting [is indicated]. Extreme methods decrease foot inflammation.

34. COOLING OF THE JOINTS

If the joints need to be refreshed, make a poultice of either crushed celery (Apium graveolens L.) with bread or euphorbia peplis (Euphorbia peplis L.). For this, you can also use knotweed (Polygonum aviculare, L.), poppy (Papaver somniferum L.) leaves, black-fruited nightshade (Solanum nigrum, L.), parietaria (Parietaria officinalis L) or poison nut (Strychnos nux vomica L.), cupwort or Venus navel (Omphaloides linifolia L.), henbane (Hyoscyamus, L.), plantain (Plantago, L. sp.), verbena (Verbena L.) leaves and the head of hemlock (Conium maculatum L.). All these plants must be mixed with bread, as aforementioned. However, it is better to mix the old poultices with fine flour. If you use this flour alone in vinegar, apply this mixture as a poultice. Grinding the flour with the juice of the aforementioned plants, to render it soothing is also a good prescription. We also mention the juice of saffron (Crocus sativus, L.), celery (Apium graveolens, L.), sea buckthorn (Hippophae rhamnoides L.), fleawort (Plantago psyllium L.) and other similar plants. It is not a bad idea to apply gauze soaked in rose oil and water. Do not exaggerate in cooling, because intense cooling transfers the inflammation inside, resulting in relaxation of the swollen joints, a resurgence of pain and inflammation that is localized inside. 

35. HEATING POULTICES

When the patient finds comfort in warmth, a poultice made of bread and wine with cooked honey, cooked barley (Hordeum vulgare, L.), or linseed (Linum usitatissimum L.) and fenugreek (Trigonella foenum-graecum, L.) should be applied. Even better is a fig decoction prepared with these plants. Additionally, a poultice of crushed figs (Ficus carica, L.) with wine can be used. Always prepare a good poultice using cleaned and stripped vetch in wine with cooked honey, and the same applies when using tares flour.

36. [REMEDIES] AGAINST VERY MOIST GOUT

For those who have moist joints, use drying medicines, such as Nile grass (Cyperus L.) cooked in honey, garlic in vinegar, and bitumen cooked in barley flour. These are the most active remedies. Now here are the ones that are sweetest. Dehydration is moderated with a poultice of pan-fried lentils and flour mixed with honey; or leek (Allium porrum, L.) mixed with goat fat, applied as an emollient poultice. Make a mixture of two parts of marine heliotrope (Heliotropium curassavicum L.) and one part goat fat, and apply the poultice. If the medicine is too dry, add egg yolks. There is also a poultice composed of goat or sheep fat mixed with goat and crocodile dung.

37. FOMENTATIONS [hot moist substances to ease pain]

When the joints are relaxed and the humors are diffused, turn to astringent fomentations, such as a decoction of leaves or willow bark (Salix, L. Sp.), rush (Juncus, L.), myrtle (Mirtus communis L), cypress (Cupressus sempervirens, L.), live sulfur mixed with a quantity of mildly hot vinegar using these medications, avoid joint stiffness. For this reason I find it useful, after using fomentations, to slowly cool and apply very fatty liniments. Patients must remain completely at rest during the period of inflammation. This is the treatment for gout when there is inflammation.

 

Summing up the De podagra

Gout is a disease caused by excess humidity that can be cured. However, when it becomes chronic, healing is impossible, and the patient’s condition worsens, potentially leading to death from pleuropneumonia or apoplexy. Therefore, it is important to be aware of the clinical course of the disease so that the appropriate remedies can be identified and applied from the very beginning.

During the acute attack, when the disease affects feet and hands, individuals with gout experience the most severe nerve pain. The disease is caused by bile and phlegm, an excess of blood, and plethora.

Treatment must be immediate. Fasting is appropriate to reduce blood production. “Bleeding may be of great help”. “Strong generic exercises of desiccant nature to dehydrate the body”. “Easily digestible food” should be allowed. Massages using aged oil infused with iris or hypericum are the most appropriate. They should be applied directly to the areas where the pain is most intense. Baths do not cure the disease but may help fight fatigue. The addition of salts increases dehydration. Swimming in sea water is recommended since this exercise improves the joints. Immersion in warm water or in hot sands, the use of steam baths and rubbing the entire body with ointments containing iris or privet are beneficial since they increase perspiration.

Eating vegetables does not help except for those that soften the belly. Very dry fish as well as soft-fleshed fish are recommended. Additionally, birds are recommended, except for those that live in water or marshes. Red wine is also allowed but not indispensable. During the acute attack, water should be preferred to wine, eggs rather than meat. When cold provides relief, wine mixed with honey should be allowed.

The condition of the bowel must be checked and if not loosened, some vegetables such as card, mallow, dock plant, male mercurial herb may be used. The best nutrition is based on small quantities of bread and a moderate diet. Once pain subsides bread and meat will be allowed. Foods should be salted: any salt, but preferably, that from the Pontus or Cadiz. No sleep should be taken immediately after eating, as it increases humidity. If a nap is needed, it can be allowed before eating.

Purges are important remedies for the gouty sufferers, who should be purged in spring and autumn. Purges eliminate bile and phlegm. However, during an acute attack, their use must be limited in time since they may cause wasting. Some purgatives can harm individuals with gout, including scammony, tithymal, wild vine, euphorbia, and Cnidus berries. However, the list of useful purgatives is long and includes hellebore, polypodium, and coloquintide. Drugs causing vomiting are helpful and should preferably be used, especially those based on harmless substances like Staphysagria or Narcissus. Inducing vomiting gives excellent results in gouty patients and should be practiced frequently, preferably after meals. So, patients may eat “horseradish, onions, pickles, mustard, vegetables, fatty butchered meat, fatty fish, pastries made of cheese, or honey” and immediately afterward, induce vomiting.

In gouty persons, intestinal pain is frequent. Thus, flatulence must be suppressed by means of rue, cumin, anise and dill. Enemas are also recommended since they evacuate substances that damage the joints. Enemas may be simple or pharmacological like those containing coloquintis, hellebore, hyssop and centaurea.

Potions may be used successfully; some of them can even dissolve tophi. They generally act slowly but effectively. Many composite medicines are available for treating gout; however, one should be cautious about stopping those potions suddenly. When an excess of blood is diagnosed, bleeding and vomiting are necessary manoeuvres, even if ineffective on pain.

In some patients, cautery should be applied to the joints to create deep, dry ulcers that must persist for a long time to be effective. Anointing poultices may help in the acute attack. In case of complications, the abdomen should be emptied, no water or food should be allowed, and if the stomach is full, the patient should vomit.

The armamentarium of plant-based drugs to refresh (cool) the joints is vast, but one should not exaggerate. Heating poultices are also advisable if warming the joints relieves pain.

Very important are the remedies for very moist gout (edematous). For this purpose, astringent fomentations should be used.

 

Discussion

On humors

Rufus adopted the theory of humors and based his explanations on blood, bile, phlegm (white, thick, and salty). Bile was described as yellow, greenish-yellow, green, or black. Bile originates from the gall bladder, and phlegm from the nose.

Rufus classified bile and phlegm as “perissoma”, like mucus, saliva, urine, gas, menstrual blood, earwax, milk, and semen. It should be noted that Aristotle also classified bile and phlegm as “perissoma”, but he did not include saliva and earwax in this category; instead, he included feces and blood [20].

Humors originate from food. When humors are in good balance, health is maintained, when they are out of balance disease results. Black bile, associated with autumn, may originate from blood due to long-standing imbalance. Everything can be explained by deficiency or excess, satiety or fasting, and working in hot environments. Some foods generate specific humors. Generally speaking, an excess of food produces an excess of blood; excess cheese increases phlegm; milk contributes to phlegm and bile; and wine and pomegranate increase blood.

Black bile is a permanent presence in the liver and is drawn into the spleen. When the spleen is unable to attract it, jaundice supervenes, which is different from jaundice associated with yellow bile. Cooling the blood and overheating can generate black bile and yellow bile.

There are four qualities, namely hot, cold, dry, and moist. An excess of humidity or a lack of dryness causes an excess of bile and can lead to pain, as in the case of gout. Some fish, such as tuna and eels, cause mucus (phlegm) production. Thyme discharges bile, which, after collecting in the gallbladder, travels to the kidney and intestines, thereby coloring urine and feces.

Excess humidity and lack of dryness cause pain in gout. Therefore, exercises were recommended to dissolve the humidity, which can even result from abandoning exercise or reducing it.

Exercise has a great role in the treatment of gout. I would like to focus on the role of exercise in the therapy of gout. Arthralgia is driven by excess humidity. Thus, it is important to exercise to dissolve it and even to prevent its formation by avoiding late-night meals when fluids are attracted to the body. Rufus removes the excess of blood by venesection, combined with abstinence from food to reduce blood formation, and uses clysters to remove any additional excess fluid.

Rufus’ therapy of gout

The therapy of gout is based on bleeding, fasting, foods, exercise, baths, reducing humoral production, and removal of their excess.

To this end, Rufus makes full use of plant-based remedies (see Table 2). Nutrition during an acute attack centers on the use of chard, mallow, dock, mercurial herbs, and thistle. He uses purgatives to soften the belly, emetics before and after meals (with the latter preferred), laxatives, and enemas that may be prepared from many useful plants such as hellebore, abrotan, absinthe (which is diuretic and aids digestion), centaurea, hyssop, iris, rue, thyme, and watercress. Massages are necessary to reduce the excess humidity, complemented by walking, running, riding, exercises. Napping after a meal is discouraged since it promotes the retention of humidity. During an attack, water should be preferred to wine and fish to meat. An extensive list of plants useful for cooling joints is provided (Table 3). Rufus also suggests being careful to avoid stopping treatment too early, as the disease may recur. Venesection should be practiced near the point of pain. However, it is less effective when the foot is affected.

Concerning bleeding after the initial venesection, it should be immediate if there is an excess of blood. The procedure may be repeated annually in spring and autumn. Suggestions regarding nutrition are more qualitative than quantitative; specific recommendations are provided, but no exact quantities are given.

For the therapy of gout, Rufus also made full use of compound preparations of major use, which are described in Table 4. The list highlights the importance of their knowledge, which had passed the scrutiny of Rufus’s clinical skills.

Common Name	Scientific name	Use
Chard	Beta vulgaris L.	nutrition during attack
Mallow	Malva sylvestris L.	nutrition during attack
Dock plant	Rumex patientia, L.	nutrition during attack
Male mercurial herb	Mercurialis ssp.	nutrition during attack
Thistle (soft part)	Cirsium vulgare (Savi), Ten.	nutrition during attack
Spurge flax (berries)	Daphne cnidium L.	Purgative
Black Hellebore	Helleborus niger L.	Purgative
Polypoly	Polypodium vulgare L.	Purgative
Coloquintide	Citrullus colocynthis Schrad	Purgative
Common corn-cockle	Agrostemma githago L.	Purgative
Garden cress	Lepidium sativum L.	Purgative
Narcissus (bulb)	Narcissus poeticus L.	emetic
Staphysagria	Delphinium staphysagria L.	emetic
Cucumber	Cucumis sativus L.	emetic
Oregano1	Origanum vulgare L	after meal emetic
Hyssop	Satureja graeca, L	after meal emetic
Thyme2	Thymus sibthorpii (LSJ).	after meal emetic
Horseradish2	Armoracia rusticana L.	after meal emetic
Absinthe	Artemisia absinthium L.	digestive, diuretic
Rue	Ruta graveolens L.	suppressing flatulence
Cumin	Cuminum cyminum L.	suppressing flatulence
Anise	Pimpinella anisum L.	suppressing flatulence
Dill	Anethum graveolens L.	suppressing flatulence
Chamomille	Matricaria Chamomilla L.	Laxative
Cinquefoil (root)	Potentilla reptans L.	Laxative
Helichrysum (heads)	Helichrisum orientale L.	Laxative
Alpine fennel	Foeniculum vulgare Gaertn.	Laxative
St. John’s wort	Hypericum crispum  L.	Laxative
Nutmeg	Myristica fragrans Houtt	Laxative
Camedrio	Teucrium chamaedrys L.	Laxative
Amanita	Amanita caesarea  Pers.	Laxative
Spikenard (Wild)	Nardostachys jatamansi DC	Laxative
Myrrh	Commiphora myrrha Engl.	Laxative
Hellebore (black)	Hellebore niger L.	for enemas
Abrotane	Artemisia abrotanum L.	for enemas
Absynth	Artemisia absinthium L	for enemas
Centaurea	Centaurea L.	for enemas
Hyssop	Satureja graeca L.	for enemas
Iris	Iris florentina L.	for enemas
Rue	Ruta graveolens, L.	for enemas
Throw	Agrostemma githago L	for enemas
Watercress	Lepidium sativum sp.	for enemas

Table 2. Plants used by Rufus of Ephesus for therapy of gout (foods, purgatives, emetics, laxatives, drugs against flatulence and for enemas). ¹cooked in water associated with oxymel; ²taken separately and mixed with oxymel

Common name	Scientific name	Use
Iris	Iris florentina L.	massage
St. John’s worth	Hypericum crispum L.	massage
Larch (added to pork fat)	Larix decidua Mill.	massage
Privet	Ligustrum L.	massage
Chaste tree	Vitex agnus-castus L.	to medicate water for baths
Laurel	Laurus nobilis L.	to medicate water for baths
Myrtle	Myrtus communis L.	to medicate water for baths
Sage	Salvia officinalis L.	to medicate water for baths
Willow (tender leaves)	Salix L.	to medicate water for baths
Celery3	Apiumgraveolens L.	cooling the joints
Euphorbia peplis3	Euphorbia peplis L.	cooling the joints
Fleawort4	Plantago psyllium, L.	cooling the joints
Nightshade(black)	Solanum nigrum L.	cooling the joints
Nux vomica	Strychnos nux vomica L.	cooling the joints
Pellitory (erect)	Parietaria officinalis L.	cooling the joints
Poppy (leaves)	Papaver somniferum L.	cooling the joints
Saffron	Crocus sativus L.	cooling the joints
Venus navel	Omphaloides linifolia L.	cooling the joints
Cperus	Cyperus L.	edematous gout
Garlic	Allium sativum L.	edematous gout
Green Heliotrope	Heliotropum arborrescens L.	edematous gout
Leek	Allium porrum L.	edematous gout
Lentil	Vicia lens L.	edematous gout
Cypress	Cupressus sempervirens L.	inflammation
Myrtle	Mirtus communis L.	inflammation
Willow (leaves, bark)	Salix, L.	inflammation
Barley (cooked)	Hordeum vulgare L.	heating poultice
Fig (crushed)	Ficus carica L.	heating poultice
Fenugreek	Trigonella foenum-graecum L.	heating poultice
Linseed	Linum usitatissimum L.	heating poultice
Myrrh	Commiphora myrrha Engl.	soothing poultice

Table 3. Plants used by Rufus of Ephesus for therapy of gout (for massage, to medicate water for baths, to cool and to heat joints, edematous joints, inflammation). ³used in association; ⁴mixed with fine flour.

Common name	Scientific name
Absynth	Artemisia absinthium L.
Agaric	Polyporus sp.
Aristolochia (round)	Aristolochia rotunda L.
Bayberry	Myrica rubra Lour.
Centaury	Centaurea centaurium L.
Cyclamen	Cyclamen graecum Link
Ciper	Cyperus papyrus L.
Cumin	Cuminum cyminum L.
Fennel (alpine)	Foeniculum vulgare L.
Flaxseed	Linum usitasissimum L.
Gentian (lutea)	Gentiana lutea L.
Gentian (purpurea)	Gentiana purpurea L.
Germander	Teucrium chamaedrys L.
Lavender (wild)	Santolina chamaecyparissus
Leek	Allium porrum L.
Parsley (wild)	Petroselinum hortense Hoffm.
Rhubarb	Rheum ribes L.
Rue	Ruta graveolens L.
Scordio	Teucrium scordium L.
Spikenard	Nardostachys iatamansi DC
St. John’s wort	Hypericum crispum L.
Thyme	Thymus sibthorpii LSD

Table 4. Plants used by Rufus of Ephesus for compound medicines for gout.

On Hiera Rufi

In Chapter 19 of the Oeuvres de Rufus d’Éphèse,  lines 10-12 on page 325, and lines 1-9 on page 326, read:

“Maximum autem ego scio et manifestum adjuntorium ad artriticos esse quod recipit colocynthidis interiores, agarico, chamaedrys, opopanacos, opu cyrenaicu, sagapenu, petroselinu, aristolochiae rotundae, piperis alba, cinnamomu…”

“For my part, I know an excellent remedy for gout sufferers; it is made from the internal part of the coliquintide (Citrullus colocynthis L.), 20 drachmas; oyster mushroom (Pleurotus ostreatus Jacq.) 10 drachmas; wall gemander (Teucrium chamaedrys L.), 10 drachmas; panax (Opopanax L.) juice, 8 drachmas; silphium (extinguished plant), 8 drachmas; asafoetida (Ferula assa-foetida L.), 8 drachmas; wild parsley (Anthriscus sylvestris L,) 5 drachmas; round aristolochia (Aristolochia rotunda L.) 5 drachmas; white pepper (Piper Nigrum, L), 5 drachmas; cinnamon (Cinnamomum sp.), 4 drachmas; spikenard (Nardostachys jatamansi DC.), 4 drachmas; myrrh (Commiphora myrrha Engl.), 4 drachmas; saffron (Crocus sativus L.), 4 drachmas. Add enough honey, mix everything together. You must take this drug frequently. Therefore, it is not necessary to administer these medicines all at once, but primarily, ensure they are given at intervals, with a maximum dose of 4 drachmas, in honey wine or water. You will also add a spoonful of salt, which helps to purge more quickly, and easily”.

In the passage, Rufus provides remedies for treating individuals with gout and describes a complex preparation. He says “scio” that means “I know,” and describes an excellent preparation to treat gouty sufferers. He knows that it is effective but does not claim priority. However, Oribase, Aetius of Amida and Paul of Aegina refer to it as Hiera Rufi, the cathartic of Rufus of Ephesus. In particular Oribasius speaks of “Hiera of syconia taken from De podagra” (Hiera Rufi) [21].

As discussed extensively by Abou-Aly on pages 275-291 of his thesis [21] many Arab scholars including Avicenna and Al-Jazzar support the authority of Rufus and call the remedy “Hiera Rufi”. All of the discussions support the authority of Rufus. It is not surprising that as time passed this preparation was converted to pills (Pillulae Rufii) by Arabs.

On tophi

Tophi are formed in the joints by the flow of humors to the joints. The chronicity of the disease causes their thickening and transformation into concretions that may evolve from viscous to stony deposits. Tophi may also develop from the repeated use of desiccants, which over time can transform viscous material into tophi. The real concern is the formation of tophi by humors, which may be due to the desiccating properties of medicines used in the therapy of gout. The major risk resides in the use of drugs to counteract plethora.

As reported in Chapter 26, skilled physicians can assist their patients by prescribing medicines taken in potions, which, however, act slowly. “I know, in fact, that people suffering from sciatica and gout have been freed from gout by these potions, and that some of them have caused the resolution of viscous concretions. However, one should not expect prompt or immediate relief from this treatment: these remedies act slowly”.

 

Conclusion

The study shows that Rufus of Ephesus, the third most famous figure in medicine after Hippocrates and Galen, is celebrated for his contributions to obstetrics, gynecology, pediatrics, and neurology. As a gouty physician, he left a personal mark on the history of gout by making full use of his clinical skills, which were honed through a rigorous apprenticeship in anatomy and the study of the Corpus Hippocraticum.

 

Acknowledgements

We are grateful to Professor Joseph Sepe, University of Maryland Global Campus, for his editing support.

A special thanks is due to Dr. Rosaria Di Martino, Head of Centro Servizio del Sistema Bibliotecario di Ateneo Università degli Studi della Campania Luigi Vanvitelli for nurturing our interest in Rufus of Ephesus.

 

Bibliography

1. Igel TF, Krasnokutsky S, Pillinger MH (2017) Recent advances in understanding and managing gout. F1000Res 6:247. https://doi.org/10.12688/f1000research.9402.1
2. Dalbeth N, Choi HK, Joosten LAB, Khanna PP, Matsuo H, Fernando Perez- Ruiz F and Stamp LK (2019). Gout. Nature Reviews Disease Primers 5:69. https://doi.org/10.1038/s41572-019-0115-y
3. Dalbeth N, Choi HK, et al. (2019) Gout. Nat Rev Dis Primers 5:69. https://doi.org/10.1038/s41572-019-0115-y
4. Martinon F, Petrilli V, Mayor A, Tardivel A, Tschopp J. (2006) Gout-associated uric acid crystals activate the NALP3 inflammasome. Nature 440:237–241. https://doi.org/10.1038/nature04516
5. Tsoucalas G, Sgantzos M. (2017) Severus Iatrosophista, Theodosius the Philosopher and Jacobus Psychrestos, introducing Colchicumas an innovative treatment for podagra in the early Byzantine period. Mediterr J Rheumatol 28(2):106–109. https://doi.org/10.31138/mjr.28.2.106
6. De Santo NG, Bisaccia C, De Santo LS. Gout: a papal disease-a historical review of 25 gouty popes (34-2005 AD). J Nephrol. 2021 Oct;34(5):1565-1567. https://doi.org/10.1007/s40620-021-01117-8
7. De Santo NG, Bisaccia C, De Santo LS. High Prevalence of Kidney Stone Disease of Gouty Origin in Roman Pontiffs Reigning in the Years 537-2005. Experimental and Clinical Transplantation 2023 Jun;21(Suppl 2):91-94. https://doi.org/10.6002/ect.iahncongress.21
8. De Santo NG, Bisaccia C, De Santo LS. Pius X (1835-1914): the last gouty pope. G Ital Nefrol. 2022 Feb 16;39(1):2022-vol1. PMID: 3519163
9. Schwartz SA. Disease of distinction. Explore (NY). 2006 Nov-Dec;2(6):515-9. https://doi.org/10.1016/j.explore.2006.08.007
10. Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Q. 2005;83(4):731-57. https://doi.org/10.1111/j.1468-0009.2005.00398.x
11. McKeown R. The epidemiologic transition: changing patterns of mortality and population dynamics. Am J Lifestyle Med 2009;3(1 Suppl):19S-26S. https://doi.org/10.1177/1559827609335350
12. De Santo NG, Bisaccia C, De Santo LS. Gout From the Corpus Hippocraticum to the Renaissance: The Role ofGalen. G Ital Nefrol. 2025 Apr 29;42(2):2025-vol2. Italian. https://doi.org/10.69097/42-02-2025-14. PMID: 40332982
13. De Santo NG, Bisaccia C, De Santo LS. Gout in the Corpus Hippocraticum. G Ital Nefrol. 2025 Aug 29;42(4):2025-vol4. Italian. https://doi.org/10.69097/42-04-2025-10. PMID: 40923585
14. De Santo NG, Bisaccia C, and De Santo LS. Alexander of Tralles, On Gout. In Manuscripts, Plants, Remedies inthe Mediterranean Traditions: Studies across Disciplines for Alain Towaide. Berlin, Walter De Gruyter,2025, https://doi.org/10.1515/9783110780062-010
15. Bisaccia C, De Santo LS, De Santo NG. Timelines of the history of gout from the fifth Century BCE toRenaissance: the contributions of Rufus of Ephesus. Presented in part at the XIII Congress of the International Association for the History of Nephrology
16. Littrè É. Traité de la goutte. In Daremberg CH et Ruelle É. Oeuvres de Rufus d’Éphèse texte collationé sur les manuscrits, traduits pour la première fois en français, avec une introduction. Paris: Imprimerie National 1879
17. Suidae Lexicon, ed. Adler, pars IV, Leipzig, 1935, p. 301
18. De Chambre. Rufus. Dictionnaire Encyclopedique des Sciences Medicales. Tome cinquiême, p. 587-588
19. Daremberg CH. Ruelle É. Oevres de Rufus d’Ephèse. Paris Imprimerie Nationale 1879
20. Claudii Galeni Opera Omnia, Kuhn CG, Ed, Hildesheim, Georg Holms, 1964-1965; V: 105, XVI, p.636, XVII p.93
21. Abou-Aly. The medical writings of Rufus of Ephesus. Ph.D. Thesis, University Medical College, University of London 1992. http://discovery.ucl.ac.uk (pdf)
22. Albrecht von Hailer, Bibliotheca chirurgica qua scrita ad artem chiruraiam facientia a rerum initiis recensentur, I, p. 78
23. Beck L:Y (2020). Pedanius Dioscorides of Anazarbus. Georg Olms Verlag: Hildesheim
24. Riddle JM. (1985). Dioscorides on pharmacy and medicine. University of Texas Press: Austin
25. Everett N. The Alphabet of Galen. Pharmacy from antiquity to Middle Ages. University of Toronto Press, 2012