According to Hippocrates, gout was a painful but non-fatal condition caused by bile and phlegm. It did not affect prepubertal children, eunuchs, and premenopausal women. It typically flared up in spring and autumn and could only be effectively treated during its acute phase. Once it progressed to a chronic state—with tophi and bone erosions—treatment became impossible. During the acute phase, pain relief was achieved using opium poppy and hyoscyamus. Hippocrates attempted to reinforce the body’s natural healing process through fasting, a liquid diet, purges, clysters, and emetics, along with exercise, massages, and baths. Bleeding became necessary in the presence of excess blood. Abstention from wine and sexual activity was mandatory [16].

“In Galen’s view, gout is due to fluid overflow that infiltrates nerves and causes pain. Overflowing fluid may be blood, phlegm, or a mixture of bile, blood, and phlegm. The prevailing humor is crude, mucous, and thick, and by residing in the joint, causes tophi. The nature of infiltrating humor can be diagnosed through the color of the joint, symptoms, effects of heat and cold, effects of drugs, and information related to age, diet, quantity and quality of exercise, and attitude towards baths of the patient. Treatment required immediate bloodletting by venesection at the elbow, which could be repeated. Purges, enemas, and/or emetics were additionally needed to evacuate the humor(s). Poultices played a role in draining the humor(s) as well as for their emollient-softening properties” [14].

We shall bear in mind that according to the “Corpus Hippocraticum”, gout was due to the accumulation of yellow bile, black bile, and phlegm in the blood. The humoral theory, confirmed by Galen centuries later, survived until the seventeenth century.

The section on gout in “Anonymy Medici” consists of a text of 945 words and follows the usual format. A total of 46 words describe the cause, 138 the signs. The remaining 761 words outline the therapy structured over a total of 20 guidelines. Therein, one can appreciate even the stylistic uniqueness underscored by Ivan Garofalo in his introduction concerning the use of the second plural imperative [19]. Therapy is not personalized and ends with suggestions about the start of the restorative phase [22].

Gout, according to the “Ancients” (the 4 authors utilized by “Anonymus Parisinus” to define acute and chronic diseases), “is an inflammation of the tendons of the foot joints and arises sometimes from bilious humors, sometimes from phlegmatic ones.” It manifests with violent pain originating in the big toe or the joint, and may extend to the whole leg. It is called podagra when localized in the foot, cheiragra when localized in the hands, and arthritis when affecting other joints. Pain is less severe when the process is accompanied by swelling. Treatment is based on immediate bloodletting, fasting, abstention from sex, exercise, emptying the intestines by means of enemas, emetics, and purges. Therapy also makes use of embrocations, poultices, and lenitives based on poppy heads or roots of marsh mallow.

“1. Bleed the patients initially, if it is possible; otherwise, evacuate with acid clyster and cure with the light treatment, as in arthritis. 2. In the intervals, let them adopt a long regimen with water alone, and abstain from sex; in many cases, these measures suffice to heal. 3. You must make the regimen gymnastic in the event of fair weather and apply vomiting, both fasting and with radishes. 4. A sufficient length of time is six months, after which you should come back to the previous regimen little by little. 5. If they are not healed with the aforementioned remedies, have them take hellebore and drugs with centaury and scordium, prepared for one year, as they are excellent and digestible.”

“Anonymus Parisinus”, at variance with Hippocrates, also includes patients with chronic gout:

“6. Treat chronic gout at the beginning with reduced food and water drinking and excretion of the belly. If they are accustomed to it, bleed them.”

“Anonymus Parisinus” is very accurate in describing simple poultices that disclose his masterly clinical skills:

“15. […], a simple poultice with fenugreek, or linseed, or iris, or barley meal, or bean, or vetch, or the root of marsh mallow cooked in water with honey, either plain or with linseed, or the root of wild cucumber cooked with water, first douching with such water, then applying the plaster either with vine-leaves with flower of wheat meal, or with marsh lentil, now plain, now with fine meal, and now cold, now gently warmed with < ... > and tendrils of evergreen or leaves of box-thorn with flower of meal or lentil boiled plain or the core of the mallow or of olive sprouts or of lemon or of cucumber or of ripe melon or with fresh oregano or sleepy nightshade or purslane or green pomegranate leaves, pomegranate flowers boiled with diluted vinegar or wild rue, with vinegar, both plain and with meal flower, or in vinegar with celery or figs boiled with water in such a way as to reach the density of honey, or boiled twice.”

However, clinical experience tells him that simple poultice may not reach the goal, and in this eventuality, he provides additional suggestions:

“16. If they are not soothed, add capsules of poppy pounded with their leaves or with the leaves of quinces or sweet pomegranate-peel cooked each apart with white wine and pounded in such a way as to take the density of barley-gruel juice, then boiled together with barley meal or bitumen pounded, with wine, or bulbs with honey or egg whites or rue with honey or root of henbane with storax, or hemlock with oxymel or horehound pounded with salt or tender cheese cut in slices and used as a plaster and frequently changed, or nettle seed and a double quantity of flax seeds cooked with vinegar lees, quicklime, and nitrum with old pig fat or juice [silphium] and storax and bitter almonds or henna oil and vinegar applied as a plaster continuously, or bread with oil and water or with honey. 17. You must soothe their pains with decoction of marsh mallow or bitumen or sulphur, and after this, cover with a simple poultice.”

It must be underlined that guidelines 15–17 include most of the remedies of plant origin used for the treatment of gout in “Anonymus Parisinus”.

Aulus Cornelius Celsus (c. 25 BCE—c. 45 CE) also prescribed bleeding as a means to achieve both immediate and lasting well-being, potentially enduring for up to a year [24]. According to Celsus, abstention from wine and venery was mandatory for an entire year. For intolerable pain, he also recommended using the rind of poppy heads (Papaver somniferum L.), boiled in wine and mixed with a wax-salve infused with rose oil. Alternatively, equal parts of wax and lard can be melted together, and then mixed with the wine. As soon as this application becomes warm, it should immediately be removed and replaced with another. However, if the swellings have hardened and become painful, applying a sponge frequently soaked in oil and vinegar, or cold water, can provide relief. Alternatively, a mixture of equal parts pitch, wax, and alum may also be effective. There are also several emollients suitable alike for the hands and feet. But if the pain was too intense to tolerate anything being applied, when there is no swelling, the joint should be fomented with a sponge which has been dipped in a warm decoction of poppy-head rind, or of wild cucumber root, next the joints are smeared with saffron (Crocus sativus, L), poppy-heads juice (Papaver somniferum L.) and ewe’s milk.

In case of an acute attack, if little time has elapsed, Aretaeus of Cappadocia (mid-first century CE) suggested dietary restriction, and to purge with black hellebore (Helleborum Cyclophyllum R.Br). Hellebore drives down bile and phlegm. He also suggested applying unscoured sheep wool, anointing with rose-oil, and bathing with a cold sea-water sponge soaked with oxycrate. He also deemed it appropriate to prepare cataplasms made of bread, pumpkin (Lagenaria vulgaris Ser.), cucumber (Colocasia antiquorum Schott.), plantain (Plantago L. sp.), and rose leaves. Cataplasms made of bread and sideritis (Sideritis scordioides L.) mitigate pain, as do decoctions of roots of comfrey (Tussilago farfara L.), cinquefoil (Potentilla reptans, L.), and leaves of horehound (Marrobiumvulgare L., Marrobium creticum Miller).

Pedanius Dioscorides of Anazarbus (first century CE) deserves a special mention since De material medica (cited extensively by Galen) can be defined as the book of gout. There are more than 60 passages where therapy of gout is discussed. In addition, in Book IV, 42 he introduces the Five Finger Grass known as Pentatomon or Cinquefoil pentadactylon, hermodactylon (Potentilla reptans L.). “The decoction of its root can …alleviate …toothaches … and those suffering in the joints and from hip ailments when drunk” [25]. He probably knew the virtue of hermodactlylum, (Colchicum autumnale L) but attributed its virtue to another plant.

The four humors were listed as a cause of gout in the 37-chapter treatise of Rufus of Ephesus (98–138 CE). Rufus believed bloodletting was necessary, and that it had to be carried out as soon as possible. Immediacy was particularly beneficial for plethoric individuals by sectioning the vein close to the site of inflammation. Dietary restrictions, abstention from sex, exercise, and baths were part of the armamentaria.

We have attempted to identify the plants used in the treatment of gout by “Anonymus Parisinus” (Table 2), drawing upon the seminal works of John M. Riddle [26] and Lilly Y. Beck [25] on Dioscorides, as well as Nicholas Everett’s monograph on The alphabet of Galen [27]. These works cover scientific literature related to plants, minerals, and animals from the third century BCE to the first century CE. With the understanding that this information is intended for historical purposes rather than therapeutic use, the table may help illustrate the plant remedies for gout detailed in the “Anonymus Parisinus”. Identifying evergreens can be challenging due to their diversity; the category includes cypress, pine, palm, olive, boxwood, holm oak, privet, yew, hornbeam, beech, laurel, myrtle, and rosemary, among others. In general, the vegetable remedies noted in “Anonymi Medici” align well with the medical practices of the period spanning from the fifth—fourth century BCE to the second century CE. Here are a few examples: hellebore (Hippocrates); almonds, centaury, cypress, cucumber, hellebore, poppy capsules (Celsus); purslane (Pliny); barley, figs, fenugreek henbane, marsh lentil, marsh mallow, scordium (Dioscorides). Specifically, Dioscorides used (i). a warm poultice of white willow bark and leaves (Salix alba L.) containing salicine; (ii). a plaster made of asphalt, sodium carbonate and barley meal (Hordeum sp.) as well as (iii) local application of fig pulp (Ficus carica L.), fenugreek flower (Trigonella foenum graecum L.) and vinegar; (iiii). a drachma of the root juice of asphodel (Asphodelus ramosus L., A. albus L.) [26].