This account is so full and judicious that we think it unnecessary to give extracts from any more of the Greek and Latin authorities.
From the Arabians little or no additional information is to be derived. Haly Abbas recommends bleeding by opening the basilic vein, and then cataplasms of barley-flour, &c. He then gives a cooling draught containing the seeds of cucumbers, gourds, melons with purslain, mallows, and the syrup of violets. This part of his practice deserves consideration. When the abscess forms he directs us to apply cataplasms containing chamomile, fenugreek, melilot, &c. Alsaharavius, in like manner, recommends bleeding, cooling and demulcent draughts, the tepid bath, and discutient cataplasms. The same plan of treatment is fully laid down by Rhases. When pus is discharged from the bladder, owing to ulceration of it, he directs us to give astringent injections prepared from galls, sumach, purslain, pomegranate leaves, &c.
On hemorrhage of the kidneys. Our author’s treatment is so fully stated that it will be unnecessary to multiply extracts from the others. It is mostly condensed from Aëtius. (xi, 27.) The latter makes mention of injecting into the bladder some astringent infusion by means of an instrument like a catheter, having a bladder attached to one extremity. When the coagulated blood (and the urine generally does coagulate it) cannot be got otherwise discharged, he recommends, like our author, an incision to be made in the perinæum.
Cælius Aurelianus also recommends injecting into the bladder some astringent infusion, such as that of hypocistis, knot-grass, &c. In the case of women astringent pessaries may be used.
Avicenna recommends us to inject the rennet of a hare. Haly Abbas directs us to bleed by opening the basilic vein, and then to give draughts containing various vegetable astringents, such as wild pomegranate flowers, cucumbers, and purslain, with alum, Cyprian earth, &c. According to Rhases, the discharge of blood by urine is often connected with disease of the liver.
The veterinary surgeon Vegetius ascribes the bloody water of cattle to general plethora. This is a very plausible hypothesis.
On hardness of the kidneys. Nearly the same account is given by Aëtius, and also by Avicenna, Rhases, Serapion, and all the medical authorities who have treated of this subject. Haly Abbas and Alsaharavius particularly commend the diachylon plaster. Ruffus, as quoted by Rhases, recommends rest, emollient clysters, the application of cupping-instruments to the back, tepid baths, refrigerant and sedative medicines internally.
On diabetes. Aretæus remarks that diabetes is a wonderful affection, being a melting down of the flesh into urine, occasioned by a cold and humid cause like dropsy. The disease, he says, is of slow formation, but when completely formed speedily proves fatal. His description of the symptoms is very striking: a fiery thirst, a never-ending desire to make water, a parched skin, a dry mouth, and so forth. Diabetes, he justly remarks, is a species of dropsy, the water in the one case being determined to the peritoneum, and in the other to the urinary organs. We have, in fact, known these diseases reciprocate. He recommends by all means attention to the thirst, endeavouring to allay it by means of the medicines called Adipsa; rectifying the stomach by purging with hiera; and applying epithemes of spikenard, mastich, and the like. For drink he directs us to give water in which the autumnal fruits have been boiled; and for food recommends starch, milk, and cold astringent wines. He concludes by saying that the general remedies and regimen proper in dropsical cases will answer in diabetes, and particularly mentions the theriac and mithridate. Among the causes of diabetes he mentions poisoning by the sting of the African viper, called the dipsas. This subject will be found treated of in the Fifth Book.
Celsus recommends exercise, friction, purging, astringent food, and austere wine. Galen states that he only recollected having met with two cases of diabetes. He maintains that it is such an affection of the urinary organs as lientery is of the bowels. He is decidedly of opinion that the kidneys are primarily affected, and not the stomach, as some had supposed. He explains his views of the nature of the disease with great precision. (De Locis Affectis, vi, 3.)
Aëtius has given the fullest account of diabetes. Upon the authority of Archigenes, he recommends at the commencement bleeding and diuretics, the latter being given to clear away the vitiated urine from the kidneys; but if the disease be of long standing, he proscribes both those measures. He recommends also a cooling diet, ruddy wine diluted, cooling applications to the pubes and loins, and, in certain cases, narcotics, such as opium and mandragora.
Alexander’s theory respecting the nature of the disease is the same as our author’s, both having borrowed it from Galen. He recommends food of difficult digestion, such as the feet of oxen, the flesh of pompions, chesnuts, &c. He forbids all saltish, acrid, and diuretic articles. He says nothing of venesection.
Actuarius recommends purgatives, in order to determine to the intestines, and astringent and refrigerant remedies in general.
Avenzoar explains fully his views respecting the nature and treatment of diabetes, in which he follows Galen closely. But the fullest and most accurate of the Arabian authorities on this subject is Avicenna. In certain cases, he admits of venesection at the commencement. The remedies, however, in which he seems to place the greatest reliance, are emetics and sudorifics, which he gives until the intention of altering the determination of the fluids to the kidneys. He particularly directs the patient to avoid taking all diuretic articles, to use exercise on horseback, moderate friction, and, in the decline of the disease, the tepid bath with fragrant wine.
Serapion gives nearly the same account as Aëtius, only he says nothing of venesection. Haly Abbas states, with his usual precision, the theory of Galen and the other Greek authorities, namely, that the disease is occasioned by a preternatural increase of the attractive faculty of the kidneys, arising from heat of the viscus. Agreeably to this theory of the disease, his remedies are refrigerants and astringents. Alsaharavius advocates similar views of the nature and treatment of the disease. When the urine is thick, with some appearances of blood, he recommends venesection. According to Rhases, the affection is connected with preternatural heat of the kidneys and debility of their retentive faculty. He says it resembles lientery of the intestines.
To those who are conversant with the principles of ancient physiology, the theory advanced by Galen, and advocated by all subsequent authorities, will appear very plausible and ingenious. The ancients appear not to have known that the urine some times possesses saccharine properties.
Rogerius, like the ancient authorities, refers diabetes to a hot intemperament of the kidneys, whereby their attractive faculty is increased. (Tr. i, 54.) All the earlier writers on medicine appear to have held the same hypothesis.
On strangury and dysuria. As these diseases arise from a variety of causes, our author has properly treated of them accordingly. We do not find that the other authorities supply much additional information.
Hippocrates mentions that there are many varieties of strangury. His remedies are the tepid bath, diluent drinks, diuretics, and anodynes.
Aëtius states that the disease is called dysuria when the patient has a desire and passes his urine with difficulty, and strangury when it is passed in drops. It is occasioned, he says, by acrimony of the urine, ulceration, or debility of the bladder. It may also arise from affections of the kidneys and liver, or from an intemperament. The treatment is to be varied accordingly.
When dysuria is connected with weakness of the bladder Leo recommends that pressure should be made with the hands on the hypogastric region.
Avicenna is particularly full upon these affections. For ardor urinæ Haly Abbas recommends various emollient and cooling articles, such as mallows, the seeds of cucumbers, pompions, and the hot bath, &c. When it proceeds from an inflammatory cause, he recommends the treatment directed in the beginning of this Section. When these remedies prove ineffectual, the catheter is to be used. He says that one of the most common causes of the complaint is debility of the expulsive faculty of the bladder. Alsaharavius treats fully of these complaints in much the same terms. When dysuria is connected with inflammation, he recommends bleeding, diluent drinks, and the warm bath. When it proceeds from a clot of blood he directs us to inject into the bladder the water of ashes. (Aqua cinerum, perhaps it should be aqua cicerum.) Rhases states that the complaint generally arises in old men from heat or ulceration at the neck of the bladder. He justly remarks that when retention arises from inflammation, no urine at all is passed, and the pain is constant; and that, when connected with obstruction, the bladder gets distended.
For inflammation, pain, and ulceration of the bladder, Scribonius Largus recommends water into which a heated iron had been plunged. He adds that he had known the chalybeate waters of Tuscany do much good in diseases of the bladder. This may be said to be an anticipation of the modern practice, introduced, we believe, by the late Mr. Cline, of giving the tincture of muriated iron in such cases.
On incontinence of urine. Galen properly remarks that incontinence of urine is often occasioned by injury of the spinal marrow either through violence, or the application of cold. (De Loc. Affect. iv, 7.)
According to Avicenna it is occasioned by excessive cold, by relaxation of the muscles (sphincter vesicæ?) or weakness of the bladder, as happens at the end of certain diseases, or by the immoderate use of diuretics. Rhases says briefly, that the complaint is occasioned by excessive heat or coldness. When it proceeds from the former cause, he recommends a composition of coriander, vinegar, Armenian bole, acorns, &c. When from cold, he prescribes the following: Of dried acorns, of frankincense, q. s. to be rubbed into the pubes with oil of ben, or oil of rue. Haly Abbas attributes the complaint to enervation of the sphincter vesicæ and loss of the retentive faculty of the bladder. He also mentions its connexion with disease of the spine. Alsaharavius recommends various stimulant liniments externally, and galls, vinegar, and the like internally.
Ruffus briefly describes a disease of the urinary organs, by the name of scabies vesicæ, attended with furfuraceous sediments and pains in the hypogastric regions, and ending, for the most part, in ulcerations of the bladder. The disease is said to be of a very intractable nature. It is alluded to by Hippocrates. (Aph. iv, 77; where see the Comment. of Theophilus, ed. Dietz.) It is further stated in one of the aphorisms that blood, pus, and scales in the urine, accompanied with deep pain, indicate ulceration of the bladder. (Ed. Dietz., t. ii, 437.) Theophilus says, blood, pus, and scales in the urine, with a heavy smell, indicate ulceration of the kidneys or bladder. (De Urinis, 15.)
SECT. XLVI.—ON THE AFFECTIONS OF THE LIVER.
The affections of the liver being various (for it is subject to atony, inflammation, erysipelas, scirrhus, apostemes, ulcers, and obstructions), we shall treat first of atony of it, in which case, particularly those affected with it, are usually called hepatics. If, therefore, it evacuate the excrements in a state of chyle, but more liquid than natural, the distribution of the food to the liver being either diminished or altogether stopped, while the stomach is unaffected, it is to be inferred that the attractive power of the liver is in a weak state. But if they resemble the washings of newly-killed flesh, it is the alterative, and, as it has been called, the sanguificative power that is affected. But if the atony arise from a hot intemperament, in process of time it appears more feculent and very fetid, the bile being high-coloured and thick. Wherefore, the substance of the liver being already melted, the whole body also is melted down; and there is fever, anorexia, and vomiting of bile. When the intemperament is cold, the discharges are neither constant nor many, for the affection is a chronic one; and for several days the discharges from the belly will be more abundant, but less fetid, like the lees of thick blood, approaching to black bile. And many and various colours indicate a cold intemperament; for the fever is obscure, the face not collapsed, and there is rather a desire of food. Whichever of these intemperaments prevails, if complicated with the dry, the excrements appear drier and fewer in number, and there is more thirst; but, if the humid, they are more liquid and abundant, and the patients have less thirst. When the liver is inflamed, there is, in all cases, pain in the right hypochondrium, extending upwards as far as the clavicle, but downwards as far as the false ribs; an acute fever, dry cough, thirst, loathing of food, and difficulty of breathing; the tongue at first appears red, but afterwards black; there is vomiting of bile, and the belly is constipated. These symptoms being like to those of pleurisy, we have stated the difference under the head of pleurisy. When erysipelas is seated in the liver, the inflammatory heat is intense, there is ardent fever, and marasmus supervenes. In particular, when the concave parts of the liver are inflamed, there is nausea and vomitings, anorexia, intense inflammatory heat, deliquium animi; and the parts often become congealed, so that dropsical effusions derive their origin from hence. When the convex parts are inflamed, the other symptoms just now enumerated are present, with a visible swelling along its circumference, which swelling is manifest both to the sight and the touch. These are the symptoms of a strong and great inflammation; but if it is weak, we must order the patient to take in a large inspiration, and, if he says that he has pain in the right hypochondrium, we may conclude that there is moderate inflammation of the liver. But if an oblong tumour of a phlegmonous nature appear in the position of the muscles which lie over it, and none of the aforesaid symptoms be present, we know that the muscles themselves are inflamed. Weight with distension, and a sensation of pain in the right hypochondrium, without swelling or fever, indicate an obstruction of the veins, at the place where those of the porta and concave parts of the liver join those of its convex parts. When the inflammation is converted into an abscess, the pain and distension increase, inordinate rigors come on, and they cannot lie on the left side without increasing the pain in the liver. When the abscess bursts, the matter is discharged freely by the urine or bowels. If the tumour pass into a scirrhous state, the pain is diminished, but there is a manifest swelling, attended with hardness, and the surrounding parts become emaciated. But, in process of time, the diagnosis becomes difficult; for dropsy supervenes, and the whole hypochondrium is concealed by the water. For a hot intemperament of the Liver, we must use those things which have the properties of moderately cooling and strengthening the viscus, such as endive and succory, sometimes eaten raw and sometimes boiled with coriander; and the decoction and juice of them may be drunk; and not only thus, but the plant, when sprinkled dry upon honied water, relieves hot and cold intemperaments of the liver. And the species of those herbs called intybus, and troximus, and the sow-thistle, are possessed of similar properties. And a cupful of the juice of citron added to honied water has the same effect, and that of the brake in like manner. But if the intemperament is moderate and complicated with obstruction, these things may be given in some light wine, or some of the diuretics. And the following pill may be taken: Of succory, dr. iv; of the root of ground-pine, dr. iv; give in boiled honey to the size of a Pontic nut, and let the patient take some warm water, and then let him be made to drink the propomata from opium and the seed of hyoscyamus, and the antidote of Philo. In those cases in which the heat is intense, it may be very proper to give of the oil of roses, or of apples, in a draught. For food, let them take of the juice of ptisan, or chondrus, with hydrorosatum, and bread in like manner out of water, with some of the sweet potions; and, in a word, let them take such food as is moderately cooling without being obstruent; abstaining altogether from wine, unless they require it for some other cause, such as atony of the stomach, and in that case the kind which is given should be thin, weak, and watery. And erysipelas of the liver must be cured in like manner. When the intemperament is cold, we must proceed on the opposite mode; we must give them bread with wine, and cabbage which has been twice or three times boiled. Let them taste lightly of chesnuts, take what is sufficient of grapes, and of the flesh of fowls, and drink wine. Let them get a propoma from eupatorium, asarabacca, or the medicine from pepper; and a selection must be made for them from among the remedies formerly mentioned for colic and dysentery. The medicines called cyphoid do not suit entirely with the hot intemperaments, unless the heat be small and joined to much humidity; but they are excellent remedies for the cold, and more especially if complicated with humidity or obstruction of the liver. When the obstruction is occasioned by thick and viscid humours, we may give the myacantha (wild asparagus?), more especially the fruit of it, and the rind of the root of bay, agrimony in oxymel, or in the decoction of bitter lupines, with rue and pepper. And the flour of lupines in a draught; and of roots of cappers, p. ij; of costus, p. j, with wine; and the medicine from cacanus, are of use for obstructions occasioned by thick and viscid humours; also the iris, the fruit and rind of pistaches, horehound, and bitter almonds, and the trochisks from them, the root of dracunculus, and wakerobin, agaric, vinegar of squills, and oxymel. And the dried liver of a wolf, powdered and given with sweet wine to the amount of a spoonful, is applicable for all affections of the liver. And the antidote Theodoretus is one of the best remedies for obstructions of the liver, scirrhus, chronic inflammation, colics, and jaundice; and in like manner the picra with oxymel. The food which is given should be of a heating and deobstruent nature, such as leeks in oxymel, marsh asparagus, and capers in like manner; and the other articles of food should be boiled with some of the calefacient and deobstruent condiments. They should drink light old wine, avoiding such as are thicker, and also frequent baths, more especially after food. If the affection be protracted, we may have recourse to venesection and purging, if nothing prevent. When the liver is inflamed, we must bleed from the right arm without delay, and take away a great quantity, if the strength permit. And over the viscus we must apply externally a cataplasm made of the flour of barley, of fenugreek, and of linseed, with dates, or quinces and the flower of melilot, wormwood, and oil of chamomile; in a word, we must mix astringents with emollients. The epithemes to be applied are that of Nileus, the fragrant, the Philagrianum, that of Apollophanes, that made of melilots, and the one called Copton. For great inflammations, the following one is of tried efficacy: Of the flowers of wormwood, of Celtic nard, of asarabacca, of saffron, of each, oz. j; of iris, of myrrh, of storax, of bdellium, of ammoniac perfume, of each, oz. ij; of a calf’s marrow, oz. iv; of cerate of lentisk, lb. iv. Oxymel is also to be given to them, and the simple remedies, such as asarabacca, Celtic or Indian nard, bog-rush, and Macedonian parsley. We must stimulate the bowels by nettle, or the herb mercury eaten boiled; and during the decline of the complaint we must give of dodder of thyme (epithymum), and of polypody in honied water; and evacuate the bowels with a clyster, in the beginning by means of honied water with salts or nitre, but in the decline mix with hyssop, marjoram, or bastard saffron, or centaury and colocynth. In a word, the concave parts of the liver are to be purged by the belly, and the convex by the urine. For food, give them the juice of ptisan in which parsley has been boiled. We have already stated the cure of erysipelatous inflammation. When an aposteme is formed, we must promote its rupture, by applying a cataplasm of the composition called trispermus, with rosin, manna, pitch, the roots of marshmallows, pigeon’s dung, and goat’s dung. But let them take the propoma from the decoction of poley, that of the fumitory which grows in hedges, reduced to a third part, the decoction of treacle-mustard or of succory, and of the root of wall-germander. When the rupture takes place, honied water and the other things mentioned for ulcerated kidneys may be given; and externally the plaster of Mnasæus, and the other emollient plasters, and the Icesian, or that from willows may be applied. When the liver is in a scirrhous state, there is little hope of recovery, as the affection will pass into dropsy; and yet it may be attempted by mixing ammoniac, bdellium, marrow, grease, and things of similar properties, with emollients. The patients may take draughts of such things as will act as deobstruents and detergents of the viscus, such as diuretics and lithontriptics, along with those just now mentioned for obstruction of the liver; the diet being regulated accordingly.
Commentary. Consult Hippocrates (de Intern. Affect. 30); Galen (Meth. Med. xiii; Sec. Loc. vii); Aretæus (Morb. Acut. ii, 7; Morb. Chron. i, 13); Celsus (iv. 8); Alexander (vii, 19); Aëtius (x, i); Oribasius (Loc. Affec. iv, 96); Nonnus (182); Cælius Aurelianus (Pass. Tard. iii, 4); Octavius Horatianus (ii, 13); Marcellus (de Med. 22); Scribonius Largus (30); Avicenna (iii, 14, 1); Avenzoar (i, 13); Haly Abbas (Theor. ix, 30; Pract. vii, 31); Alsaharavius (Pract. xviii); Serapion (iv); Rhases (Divis. 62; ad Mansor. ix, 67; Contin. xvi.)
Hippocrates describes three varieties of hepatic disease, which appear to have been bilious fevers. It is not easy to define the principles upon which his practice is directed. He mentions, however, emollient applications, bleeding, purging, and vomiting; and, when the disease is protracted, recommends the side to be burned with spindles of box-wood smeared with oil. He directs abscesses of the liver to be opened by the cautery. (Coac. 457.) He states that abscesses of the liver are least dangerous when they open externally; more so when they open internally; and most of all when they open both internally and externally. (Prognost. 7.) He makes mention of hydatids, and says of them that when they burst into the cavity of the peritoneum, the case proves fatal. (vii, 54; where see the Comment. of Theophilus and Damascius, ed. Dietz, p. 540.)
Galen has laid down the principles upon which inflammation of the liver should be treated in the 13th book of his ‘Methodus Medendi.’ We can only afford room for his conclusions. He approves of venesection with the intention of producing revulsion. Such articles of food and medicine are to be given as will emulge the biliary ducts without occasioning irritation, and everything of the opposite kind is to be abstained from. Wherefore such things as are sweet and viscid are to be avoided, and only such as are detergent without pungency are to be allowed. Of this class are ptisan and oxymel much diluted. Astringents, such as pomegranates, are improper, because they occasion contraction of the vessels; and they are more especially to be avoided when the concave side of the liver is affected. When the convex is affected, these articles, being altered by the action of the liver before they reach the seat of the disease, prove less prejudicial. When the concave side is the seat of the disease, he directs us to evacuate by the bowels, which may be accomplished by mixing with the food cnicus (carthamus tinctorius?) the herb mercury, &c.; but, if stronger medicines are required, black hellebore, colocynth, the small centaury, and the like, may be given. When the convex side is affected, he directs us to give diuretics; at first parsley, but, after the inflammation has subsided, the stronger ones, such as Celtic nard, valerian, spignel, &c. He animadverts in strong terms upon the practice of the Thessalian Asses, so he calls the Methodists.
We regret that our limits prevent us from doing justice to the views of Aretæus. The liver, he states, is the grand seat of sanguification, being itself but a concretion of blood. Hence, he says, diseases of it prove speedily fatal. He accounts for the pain which is felt at the top of the shoulder or clavicle in this way: the liver, being enlarged and becoming heavier than natural, drags down the diaphragm to which it is attached, and thus stretches also the pleura from its upper adhesions, whereby pain in the part is produced. A crisis, he says, may take place by a hemorrhage, a copious discharge of bile, or of urine; or the disease may terminate in suppuration, or in dropsy. When pus is formed, it may be discharged by urine, by the bowels, or it may point outwardly. In this last case, he recommends us to open it with an instrument red hot. When it does not suppurate it is apt to end in scirrhus, which is marked by a dull pain in the part. His treatment of acute hepatitis consists of venesection, refrigerant and discutient applications externally, cupping or leeching the side affected, then applying cerates and emollient ointments, consisting of attenuants and diuretics, such as wormwood, cider, &c. The food is to be light, of easy distribution, and diuretic. His treatment of chronic disease is varied, according as the matter passes by the urine or the bowels; but the chapter on it is incomplete.
Celsus at the commencement recommends bleeding, purging even with black hellebore, cataplasms at first repellent and then calefacient. Diuretics are to be given, such as thyme, hyssop, &c.; and all cold things are to be avoided. When a vomica forms, it is to be opened and burnt.
Alexander’s account is full and judicious. He says that, in cases of obstruction of the liver, when deobstruents are given before the swelling is softened, the juices being overheated become like stones and cannot be discussed. He alludes, of course, to hepatic calculi, or gall-stones. He gives copious directions for emollient ointments to be rubbed into the side to dispel the enlargement of the liver.
In treating of scirrhus, Aëtius recommends the emollient ointments, cupping, leeching, calefacient plasters, sinapisms, burning by medicines or by the actual cautery.
The account given by Actuarius is in so far important, as it shows that the views of practice had not changed in his days. In inflammation, he recommends to bleed two or three times, and to unite emollients with deobstruents in the external applications.
For a full exposition of the doctrines of the Methodists, we must refer to Cælius Aurelianus, of whose opinions we can afford room only for a very brief outline. The symptoms of scirrhus of the liver, as stated by him, are a round circumscribed tumour felt below the ribs, the colour jaundiced, the urine muddy, pain extending to the throat of the affected side, difficulty of lying on the left side, as this posture suspends the enlarged viscus. (By the way, Cassius assigns the same reason why persons labouring under disease of the liver or spleen lie easiest on the affected side. Probl. vi.) At the commencement he recommends fomentations, cataplasms, laxative food, and then cupping, scarifications, and leeching. When the attack is violent, venesection is to be premised. Frequent changes, acrid food, and emetics with vinegar of squills or hellebore are also mentioned. He recommends a sea-voyage, vapour-baths, hot springs, the sand-bath, and various stimulant and rubefacient applications to the side. He delivers his strictures very freely upon the practice of the other sects. Thus he justly condemns as too bold and dangerous a measure the proposal of Erasistratus to lay bare the liver, and apply the remedies direct to the part affected. He thinks Asclepiades improperly rejected gestation, baths, cataplasms, and emollient ointments. He also condemns the free use of cauteries to the affected side.
Serapion, like Alexander, states strongly the danger of using discutients before emollients, lest the juices become indurated. No ancient author has treated of the diseases of the liver so fully as Avicenna. He is most minute in his distinctions of disease, and particular in his application of remedies. Among other diseased states of the viscus, he mentions diminution of bulk. Had not inspectiones cadaverum been common in ancient times, the existence of this state of diseased structure could not have been ascertained. In abscess, he and Serapion make mention of taraxacum or the dandelion, which was recommended by the late Dr. Pemberton in cases of diseased liver, and is still used occasionally. Haly Abbas directs us, when suppuration takes place, to determine to the kidneys by diuretics; and, when the abscess bursts into the cavity of the peritoneum, he advises us to open it. When it makes its way to the stomach or bowels, he recommends us to promote its discharge by purging. He remarks that sometimes an abscess will form externally to the liver and put on the appearance of hepatic abscess. He directs it to be opened with aperient medicines or the lancet. He takes notice of the pain at the top of the shoulder, which, like Aretæus, he attributes to the dragging down of the parts by the heavy liver. In the cold aposteme (chronic inflammation?) he recommends wormwood, fenugreek, hyssop, spikenard, fennel, and the like. One of his favourite remedies for hepatic disease is rhubarb. Alsaharavius gives a long account of these diseases. Inflammation he treats by bleeding, various laxative and cooling medicines, emollient plasters, &c. In obstruction he gives rhubarb, wormwood, fennel, endive, &c.; and bleeds, if there be a sanguineous plethora. He treats fully of a discharge of blood from the liver. When it arises from the bursting of a vein after excessive fatigue, he directs us to bleed; but when it proceeds from relaxation and debility, he recommends astringents externally and internally. The account of hepatic diseases given by Rhases in his ‘Continens’ is particularly excellent, but it is too lengthy for our limits. He explains the pain at the top of the shoulder in the same way as Aretæus. He mentions that gross food produces enlargement of the liver, and hence animals fed on figs have large livers. For inflammation he recommends at first depletion and afterwards refrigerants, such as camphor, fleawort, and even snow-water. He recommends aloes with wormwood as a deobstruent cathartic.
SECT. XLVII.—ON CACHEXIA.
We are accustomed to call the commencement of dropsical affections cachexia. Wherefore we must cure it by bleeding, if nothing prevent, at intervals, and continuing the abstraction until the third or fourth day. But, in an especial manner, we must evacuate those who have fallen into this affection from retention of the hemorrhoidal or menstrual discharge; as in those cases which arise from a copious evacuation, we must abstain from venesection, and by all means purge with the hiera from colocynth. The diet should be light and desiccative; and recourse must be had to natural baths, namely the aluminous, and more especially the nitrous, and then the sulphureous; but the other kind of baths may be taken at greater intervals. Let them be exercised in every way, more especially by those who are called jatraliptæ. At last they must be put under a course of hellebore. They are wonderfully remedied by a propoma of wormwood, and by sinapisms and dropaces. If the affection is converted into dropsy, we must have recourse to the treatment applicable for dropsical cases in the manner about to be explained.
Commentary. Almost all the authors referred to in the preceding Section may be consulted on cachexia and dropsy.
Aretæus gives an accurate account of this affection, which, he says, usually terminates in dropsy, phthisis, or wasting. He mentions many symptoms of it, such as œdema, difficulty of breathing, and so forth; and he correctly remarks that the alvine discharges are dry, white, crude, and without bile. His chapter on the treatment unfortunately is lost.
Cælius Aurelianus says that Themison was the first who explained the treatment of cachexia. He mentions as causes of the disease intemperance, the improper use of medicines, hardness of the liver or spleen, long-continued hemorrhoidal discharge, vomiting, protracted fevers, &c. His treatment is judiciously varied according to the cause of the disease, and is given at great length.
Aëtius gives a very interesting account of the views and practice of Archigenes. He says the disease is generally occasioned by scirrhus of the liver or spleen. Like our author, he recommends bleeding if not contra-indicated, and purging with drastic cathartics, such as the hiera from colocynth, friction, rubefacients, exercise, the bath, and thin white wines. Celsus admits of bleeding, but not until after purging, friction, unction, and exercise have failed to restore the health.
Serapion expresses himself in much the same terms as our author and Aëtius respecting venesection; but Avicenna recommends not to have recourse to it unless there be a sanguineous plethora. He also forbids baths of sweet water, but otherwise he adopts the treatment recommended by the Greeks.
SECT. XLVIII.—ON DROPSY.
When the liver is greatly congealed, sometimes primarily, as when it has been inflamed, indurated, or otherwise affected, or when from sympathy with other parts, the process of sanguification ceases, and the affection is called dropsy. When a great quantity of air is collected with a small quantity of fluid between the peritoneum and intestines, so that the abdomen when struck sounds like a drum, the dropsy in this case gets the name of tympanites, being formed by flatulence about the stomach, belly, and colon, and by chronic fevers. But sometimes from hardness of the peritoneum and of the uterus in women, or from scirrhus, on the contrary, a great collection of fluid with a very small proportion of air is formed in the same parts, being confined as it were in a bladder, when the dropsy is named ascites, and is occasioned by the afore-mentioned causes; but, for the most part, it arises from hardness and scirrhus about the spleen and liver, and from chronic defluxions about the intestines; whereby it happens that the belly is swelled, while the rest of the body is melted owing to its not being nourished. Sometimes throughout the whole body a colder and more pituitous blood is collected, either coming from the liver, or deriving its origin from a melting down of the flesh of the whole body, which is as it were converted into water, so that the whole body appears white and pituitous like a corpse, and then the affection is called leucophlegmatia, dropsy of the flesh, or anasarca, being occasioned by protracted fevers, cachexia of the stomach, suppression of long-continued hemorrhoidal discharges, the female flux, dyspnœa, inordinate insomnolency, and similar causes. In treating these complaints, we commence generally with evacuation; but in ascites and tympanites it is by administering hydrogogue medicines; and in anasarca by bloodletting, more especially when the affection is formed by retention of the hemorrhoidal or menstrual discharges, unless the patients had been previously bled for cachexia; and in this case, as in cachexia, the evacuation must be made at intervals. Then, having carefully triturated the dried dung of an ox of the herd, boil it in oxycrate or oxymel, and sprinkling on it a fourth part of sulphur, apply it over the whole belly; or, apply a cataplasm of goat’s dung with the urine of a child, made of the thickness of bath-sordes. These things purge strongly by the belly; and we may use cataplasms made of leaven, dried figs, calcined lime, nitre, iris, cardamom, native sulphur, ammoniac, bay-berries, stavesacre, the dung of wild pigeons, all or some of these may be used with oxymel. After which the epitheme, called spongium, made of goat’s dung, evacuates the fluids in a wonderful manner, both by the insensible pores and by the belly. Afterwards we must apply desiccative plasters, that from willows, the Icesian, the barber’s, that from bay-berries, the Polyarchium, and that from seeds. And the following one is wonderfully efficacious, for it fetches, as it were, the fluids from the deep-seated parts: Of the stone pyrites, dr. xij; of native sulphur, dr. xij; of ammoniac perfume, dr. xij; of cumin, dr. xvj; of nitre, dr. xij; add to a little wax and turpentine, and spreading it upon a piece of skin, apply to the whole belly. Let them take the propoma (liqueur) made by boiling the root of vervain-mallow in wine, or macerate the wild cucumber in austere wine, and give every three days, adding a cupful every day, until the dose amount to three cupfuls. The following is a very compound mixture: Of balsam, of nard, of cassia, of cumin, of liquorice, of St. John’s-wort, of bog-rush, of asarabacca, of carrot, of amomum, of myrrh, of Macedonian parsley, of sweet hay, of pepper, of hartwort, of cow-parsnip, equal parts. Each of these produces a good effect by itself, and in like manner all the diuretics. Squill baked and triturated with honey, and given as a linctus, provokes urine without trouble; or it may be boiled in the water which is drunk. And the following is an excellent remedy: Boil lb. ij of the inner part of squills in iij sextarii of austere wine until it be reduced to one third; give every day of this wine, beginning with a mystrum, until the dose amount to an ounce. The following is an excellent diuretic: Of moist alum, the size of a bean; dissolve in water; strain through a linen cloth; and give to drink every third day, or every alternate day. Picra given in oxymel, the theodoret, and the trochisk from bitter almonds also suit with them. There are many hydragogues, but the following are of approved efficacy: The seeds of the thymelæa (grana cnidia), xl or l; or lathyrides, xx or xxx; or of euphorbium, v or vj siliquæ; or of flakes of copper, dr. ij or iij; being mixed with crumbs of bread and formed into pills; or the juice of the rind of elder-root, drunk with prepared wine; or of the leaves of mezeron, of burnt copper, and of anise, equal parts; give in water at first to the amount of dr. j; and afterwards of dr. ij, or more. And the following are admirable pills: Of aloes, of euphorbium, of grana cnidia, of each, oz. j; of rhubarb, oz. ss; mix together with the juice of cabbage, and form into pills, and give to the amount of viij or ix siliquæ. And the antidote from cloves evacuates water in a wonderful manner. And we must try the effect of a hydragogue wine. The following makes an excellent one: Of squills, oz. iij; of parsley-seed, of the rind of the root of capers, of pepper, of each, dr. iv; of peeled grana cnidia, dr. j; of the Indian leaf, two balls; of best wine, xij heminæ; of raw honey, dr. xvj; beat together, sift, and macerate in the wine, but triturate the squill. The dose is three cyathi. After the evacuation of the water, we must use the theriac. And ox-dung dried and drunk to the amount of a spoonful every day is of mighty use. We must use the most stimulant clysters, unless the belly be spontaneously very loose, in which case we must rather use things for drying it up. When women are affected with dropsy we must use this pessary: Of anise, of cardamom, of cumin, of nitre, of birthwort, of fenugreek, of pennyroyal, of the inner part of figs, equal parts; mix together in the oil called Susinum, and apply per vaginam. Afterwards we may use the natural baths perseveringly, and the sand-bath, but we must abstain from the others; but if they do ever go into a bath, let them sprinkle the body with powders from nitre, salts, mustard, lime, and the like. These things even without bathing are useful, when rubbed into the belly in a dry state, or with oil. In anasarca they must exercise the other parts as much as possible, and use dry friction in the sun. And a desiccative diet should be taken. Let them, therefore, eat pickle, mustard, garlic, wild and dry fowls, asparagus, picktooth fennel, leeks, wild carrot, and the other wild pot-herbs; and the theriac salts, or those of Iamblichus may be mixed with condiments; and old light diuretic wine may be used, or if it is at hand, the wine prepared with salt water. But the patients must abstain from much drink of any kind, and from water altogether.
When the dropsy is attended with fever, the patient must abstain from the more heating and acrid food or remedies; but we may give them intermixed with other things in case of urgent necessity. In tympanites, purgatives and every medicine which wastes the body must be rejected, and also the more drastic diuretics; and we must use both externally and internally such things as can attenuate and dissipate the flatus; and dry-cupping may be frequently applied over the whole belly. When those who have ascites are not benefited by any of the remedies already described, we must have recourse to paracentesis, which does not apply to any of the other varieties of dropsy.
Commentary. See Hippocrates (de Intern. Affect. 25; de Ratione Victus in Morb. Acut.), and Galen’s Commentary on the same (Prognost.), with the Commentary of Stephanus (ed. Dietz), and almost all the authors who treat of hepatic diseases may be consulted.
Hippocrates gives a tolerably correct account of the causes and treatment of dropsy. The varieties of the disease described by him are dropsy from the drinking of cold water, from disease of the liver, and from disease of the spleen. He further states that it is frequently the consequence of protracted fevers, diarrhœa, dysentery, and quartan fevers (de Aer. &c.) He mentions a species of dropsy which he calls the dry (Aph. iv, 11), which has been generally referred to tympanitis. See Littré (t. iv, 416.) In certain cases attended with dyspnœa he recommends venesection; and Galen in his Commentary states that these cases are, when the disease is preceded by suppression of the hemorrhoidal or menstrual discharges, or is connected with plethora. But no one, he says, ventures to bleed in tympanites or ascites. Hence Avicenna and most of the ancient authorities forbid venesection in dropsy, except under the circumstances mentioned by Galen. Galen says, indeed, in his work (de Venesect. ad Erasistrat.) that he had sometimes cured dropsy by bleeding; but it is not to be understood that he approved of it as a common practice. In short, he was no Sangrado, but had anticipated Blackall. One of his hydragogue potions is composed of cantharides. (De Reg. in Morb. Acut.) Hippocrates recommends us to perform paracentesis thoracis in the side at the third rib from the last. He also approves of paracentesis abdominis in cases of ascites; and directs us to burn the region of the liver, when that viscus is affected. He further approves of free scarifications of the testicles and thighs. He has described hydrops uteri, or hydrometra, a case which, although of rare occurrence, is occasionally met with. See Van Swieten (Comment. 1224); Vesalius (de Fabrica Hum. v, 9); Monro (Works), and Dr. A. T. Thomson (Paper in the Med. Chir. Trans. xiii, 1.)
Galen gives a long list of external and internal remedies for dropsical complaints. (Sec. Loc. ix.) Ox-dung mentioned by our author was a common remedy in ancient times, according to Galen. Diogenes Laertius relates that the celebrated Heraclitus died lying in a bed of it. Upon the authority of Antonius Musa, Galen recommends a cataplasm containing elaterium, stavesacre, and hyssop. He recommends a vinous preparation of elder. Pliny particularly commends this medicine in dropsy, and most of the ancient authorities make mention of its diuretic properties. Galen says that the liver is affected in all cases of dropsy. (De Locis, v, 6.) In like manner Stephanus, the commentator on Hippocrates, states that in all cases of dropsy the liver is affected, either primarily or sympathetically. Hippocrates refers one species of dropsy to disease of the parts situated in the loins, by which Galen and Stephanus agree that he means the jejunum, mesaraic veins and kidneys. (Ed. Dietz. 139.)
Celsus describes three varieties of dropsy, namely, ascites, anasarca, and tympanites. He enjoins restriction as to food and drink, and recommends walking, friction, and sudorifics, such as heated sand and warm baths. He gives a long list of diuretics, as iris, valerian, saffron, cinnamon, &c. In tympanites he recommends emetics, cupping the belly, rubbing it with rubefacients, and applying sinapisms to it, or burning eschars on it with heated irons. In anasarca he recommends scarifications at the inner part of the leg, squills in a linctus, and the like. He approves of tapping in ascites.
Aretæus describes the symptoms of dropsy with great accuracy and elegance. He says it is a most unseemly disease, from which few recover, and those more by the aid of the gods than of art. He treats of the three varieties already mentioned, and also makes mention of hydatids. Hydatids, by the way, are described also by Galen (Comm. ad Aphor. vii, 55), and Rhases (Cont. vii). He remarks that it is wonderful how much the patient in dropsy flatters himself with hopes of recovery, more than in many other diseases far less dangerous. He states that there are partial dropsies, such as of the head, lungs, liver, spleen, and uterus. He mentions among the exciting causes of the disease the drinking of cold water, flatulent food, and the insect buprestis (meloe vesicatoria L.)
From a passage in Plutarch, it would appear that certain forms of dropsy had at one time been thought infectious. (De Serâ Num. Vind.)
Dioscorides and Ruffus praise elaterium as a hydragogue in dropsy. In the ‘Euporista,’ baked squills and oxymel are particularly commended, with various cataplasms externally.
Cælius Aurelianus states fully the causes of dropsy, such as cachexia, protracted fevers, hardness of the liver, spleen, peritoneum, or uterus; dyspnœa, cæliac affection, dysentery, retention of the hemorrhoidal or menstrual discharges, abstinence, an unseasonable draught of water, especially of salt water, the abuse of medicines, and so forth. He maintains, however, that the disease is the same, from whatever cause it arises. The common symptoms of all its varieties are said by him to be swelling, torpor, difficult breathing, disturbed sleep, thirst, diminished urine, and sometimes latent fever. He informs us that Erasistratus in his dissections generally found the liver indurated. His external applications are very similar to those of our author. He particularly commends a vinous tincture of squills as a hydragogue. He approves highly of paracentesis, and has answered all the objections which had been made to the operation. He mentions that Asclepiades practised scarifications at the ankles.
The ordinary cases of dropsy are well stated by Serenus Samonicus in the following lines: