For inflammation of the tonsils and of the uvula. Since, as Galen remarks, the same treatment applies to inflammation of the tonsils and uvula, we shall treat of both together.
Aretæus has described inflammation of these parts with great accuracy and minuteness. He has also given a very circumstantial account of the ulcers which occur there. Some, he says, are common, mild, and not dangerous; others are uncommon, pestilential, and fatal. The latter are described as being covered with a livid or black crust. The ulcer, he says, is apt to spread to the tongue, or it passes down the trachea and proves fatal by occasioning suffocation. The disease, he says, is brought on by cold acrid substances, and sympathy with disease of the stomach or lungs. Children are most subject to it. It is endemial in Syria and Egypt. He gives a striking description of death occasioned by suffocation. With regard to the treatment, when the parts are inflamed, swelled, and threaten suffocation, he advises copious bleeding from the arm, acrid clysters, purgatives, ligatures to the extremities, astringent and emollient applications to the parts, cupping the hind-head or breast, and other such means. Respecting the pestilential ulcers, when attended with inflammation and sense of suffocation, he approves of clysters, venesection, gargles, fomentations, ligatures to the extremities, cupping, and so forth. When the disease is spreading, he directs us to burn the sore with powerful caustics, such as alum with honey, chalcitis and the like. Sometimes, as he remarks, the uvula and parts there are eaten down to the bone.
Galen gives a long and very interesting account of these complaints intermixed with curious extracts from Archigenes. The general treatment consists of venesection, acrid clysters, and purgatives. The local applications are mostly of an acrid and austere nature.
When the tonsils suppurate, Aëtius directs us to open the abscess. He gives an interesting description of pestilential ulcers, which, however, is not very different from that of Aretæus. He approves of bleeding at the arm, suppositories, clysters, ligatures to the extremities, and so forth. The subsequent Greek authors follow him and Galen in their descriptions.
Marcellus, the Empiric, recommends for swelled uvula various escharotic applications containing chalcitis, flos æris, alum, &c.
Celsus delivers a brief account of ulcers of the internal fauces. He speaks in rather equivocal terms of warm cataplasms, fomentations and fumigations; but is, upon the whole, inclined to permit the use of them if there be no danger of cold afterwards. He very properly forbids such things as will irritate the parts. He does not approve much of gargles of vinegar, although recommended by Archigenes, whom he calls, “multarum rerum auctor bonus.” He prefers emollient gargles at first, and afterwards repellent ones.
The Arabians treat inflammation of these parts like the Greeks. Avicenna follows closely our author’s plan of treatment. Mesue approves of bleeding, clysters, and so forth. Rhases mentions bleeding and gargles with vinegar, the water of roses, and other astringents. In inflammation of the uvula, Haly Abbas recommends general bleeding, gentle purgatives, and astringent gargles containing alum, pomegranate flowers, sal ammoniac, and the like; and when these do not succeed, he advises us to have recourse to the operation. (See Book Sixth.) Alsaharavius recommends a plan of treatment perfectly similar, and, like Haly, directs us to have recourse to excision when other remedies fail. Alexander Aphrodisiensis says, however, that those who have had the uvula cut off die of consumption; and attempts to account for the operation having this effect. (Probl. ii, 3.)
Avicenna and the other Arabians make mention of the amulet recommended by Galen.
When the parts within the throat are inflamed, the disease is called synanche; when those without it, parasynanche. In like manner, when the parts within the windpipe are inflamed, the disease is called cynanche; and when those without it, paracynanche. All these complaints are attended with orthopnœa and pain, with difficulty of breathing, and in some cases with fever. There is redness of the face and neck, and swelling in some cases, and sometimes the mouth is kept constantly open, and they cannot swallow drink. Cases of cynanche are sometimes attended with a sense of suffocation. This disease attacks children but rarely, and then only from injuries of the spinal vertebræ occasioned by a fall, which case, being incurable, is not to be meddled with. In the others, we must immediately bleed from the arm, and take away not a great quantity at once, but in divided quantities; for from a rapid evacuation there is danger of suffocation, owing to the matters rushing to the affected part, if the patient should faint. Should they not be immediately relieved by it, we must open the veins below the tongue; or make incisions into the tongue itself, if it be swelled and protrude out of the mouth. The bowels are to be evacuated by acrid clysters; hot water is to be poured upon the feet, and the extremities firmly bound with ligatures. The neck is to be wrapped in unwashed wool, or in wool smeared with oil, and a cataplasm of raw barley-meal applied. At the commencement we may use the gargles described for inflammation of the tonsils, or the simple medicine from mulberry, with the decoction of sumach; but the best remedy is that from wild mulberry, and after that the compound application from mulberry, or the parts are to be anointed with the composition from walnuts. When the disease is at its height, we may add a little nitre or sulphur vivum, unless the acrimony prohibit their use. And dog’s dung, dried and powdered, and rubbed in with honey, is a most excellent application, more especially the white kind; also the dung of wild swallows, in like manner. When the complaint is of long standing, we may use the liniment from besasa, or wild rue, sometimes increasing and sometimes diminishing its strength, by the mixture of other medicines. Cupping-instruments or leeches are to be applied to the chin and neck, and the patients must use the stronger gargles from iris, hyssop, gith, southernwood, liquorice, dried figs boiled in honied water, or in the juice of rue with milk, or mustard with oxymel. If irritation arise from the use of them, we must give warm oil of the finest kind, or rose-oil by itself, or with the juice of ptisan or of fenugreek, to gargle with. The food should be honied water until the third day, after which the juice of ptisan, with some of the sweet drinks, and then the yelks of eggs in a liquid state. They may use spoon-meats made from chondrus, when deglutition is unobstructed, and take food suitable to their strength. When the disease is on the decline, we may get them to take exercise and the bath. The parts are to be enveloped in a cerate of the oil of rue; and we must have recourse to the other means of an analeptic nature.
In suspended animation, such as have the foam already at their mouth we must do nothing to, agreeably to the precept of Hippocrates (Aph. ii, 43); but the others may be resuscitated by pouring into their mouths vinegar and pepper, or the fruit of the nettle pounded in the strongest vinegar. It is with difficulty that they swallow it, but they must be compelled; and when the redness about the neck is dispelled, they immediately look up and recover. The same means are to be used towards those who have been wrecked in the sea; and, in fine, towards all those whose respiration has been suspended; for their heat is thereby resuscitated.
Commentary. See Hippocrates (de Victu Acutorum, 39; de Prognos.; de Morbis, ii, iii); Galen (de Med. sec. loc. vi; de loc. Affect. iv); Aretæus (de Morb. Acut. i, 7); Alexander (iv, 1); Aëtius (viii, 48); Oribasius (Morb. Curat. iv, 71); Leo (iv, 10); Actuarius (Meth. Med. iv, 14); Celsus (iv, 4); Nonnus (123); Scribonius Largus (16); Cælius Aurelianus (Morb. Acut. iii, 1); Octavius Horatianus (ii, 6); Marcellus (de Med. 15); Serapion (ii, 18); Avicenna (iii, 9); Mesue (de Ægr. Gutturis); Avenzoar (i, 10); Haly Abbas (Pract. i, 26, and vi, 2); Alsaharavius (xi, 2); Rhases (ad Mansor. ix, 54, and iv, 25; and Contin. vii).
The plan of treatment recommended by Hippocrates can scarcely be improved upon: general bleeding, opening the veins below the tongue, giving warm gargles and linctuses, shaving the head, wrapping the neck in soft wool, or applying fomentations to it, giving honey and water, or ptisan not cold, and administering clysters or purgative medicines. According to Le Clerc, he performed bronchotomy in extreme cases. He refers, we suppose, to lib. iii, 11, ‘de Morbis,’ but the language is not so precise as to make it quite certain that bronchotomy was there meant to be described. Sprengel supposes that he only introduced a tube by the nostrils into the trachea. He describes a species of cynanche in which there is no external swelling, and which proves fatal in the course of a day, or at least of a very short time. (Prog.) Cynanche, he says elsewhere, is apt to be determined to the lungs. (Aph.) Fever, again he says, attending ulcerated sore throat is bad. (Prog.) When the tonsils are swelled and red, he says it is dangerous to scarify them. (Ibid.) His commentator Stephanus remarks that when the disease becomes indolent the part may be burned or cut.
Aretæus states that the parts affected with synanche are the tonsils, epiglottis, fauces, uvula, the upper part of the trachea, and, if the inflammation spread, the tongue and jaws. He makes a distinction between cynanche and synanche. The former is attended with swelling of the parts and other well-known symptoms, of which he has given a striking description. In synanche (which he attributes to the pneuma being over-heated and over-dried), the parts, on the contrary, are contracted, and there is a strong sense of suffocation. This disease, he says, generally proves soon fatal, unless swelling and inflammation of the parts supervene, or erysipelas of the breast occur; in imitation of which, he states that a good physician will apply a sinapism or cupping-instrument to the chest to produce revulsion. In treating of the former variety of the disease, he begins with administering two clysters to evacuate the bowels and produce revulsion; he bleeds in the arm from a large orifice so as nearly to bring on deliquium animi, and he approves also of bleeding by opening the veins below the tongue: he recommends applications at first of an astringent nature, but, if suppuration be expected, he directs hot ones from fenugreek, hot fomentations, sponges squeezed out of the decoction of bay or hyssop, and the like, to be used. In the other variety, he recommends us to determine outwardly by all possible means, such as by applications containing nitre, mustard, &c. He says the application of fire would be most suitable in such cases, but as it cannot be applied from the situation of the disease, he recommends medicines which resemble fire (caustics), so as to stop the ulceration from spreading. The caustics and astringents mentioned by him are alum, galls, pomegranate rind, and in particular calcined chalcitis. The last was a vitriol resembling sulphate of copper. (See the preceding Section.) He mentions that in this variety some were said to have opened the windpipe, in other words to have performed laryngotomy. He does not believe, however, that the operation had ever actually been performed, and dissuades from attempting it, as it would only increase the evil; and he apprehended that the wound in the cartilages would never heal. From his account of synanche, Le Clerc concludes that Aretæus belonged to the Pneumatic sect; and although Ackerman is doubtful upon this point, we could point out many passages in his works which have quite satisfied us on this point. By pneuma was probably meant the vital heat in the body, acted upon by a spiritual substance within us, the same being a portion of that principle which the ancient philosophers called nature. It was truly a vis medicatrix. (See Morb. Chron. cur. i, 7.)
Celsus, like Aretæus, describes the two varieties of the disease, and recommends nearly the same treatment.
Galen, and after him Aëtius, give a similar account with great minuteness and precision. We cannot pretend to do justice to their treatment, and shall merely mention that, in the second variety, they praise mustard for a gargle, and elaterium as a purgative. It is worthy of notice that Galen describes a rare species of this disease, in which the tongue is so swelled that the mouth cannot contain it. (Meth. Med. i.)
Alexander’s directions are most minute and judicious, but we must be content with stating that he approves of opening the ranal and jugular veins, and that his treatment is otherwise similar to that of Galen. This is the first mention of opening the jugulars that occurs in a medical author.
Octavius Horatianus we shall merely mention, in order to state that he has described the two varieties of the disease like the others.
Cælius Aurelianus gives a singularly accurate and circumstantial account of this disease, but it is so long that we can merely afford room to point out a few of his leading opinions. He approves of a fomentation made with a bladder half filled with hot sweet oil. He directs the patient to inhale the steam of hot water, and to have sponges squeezed out of it applied to the neck and throat. He approves of cupping the neck or of leeching it, and also of scarifying the tongue and fauces if they are much swelled. With respect to the treatment of the other sects, he blames Hippocrates for making too rapid a detraction of blood, and also for opening the veins below the tongue, which, he says, will only aggravate the evil, and may be productive of inconvenience, owing to the difficulty of stopping the bleeding. But, in particular, he finds fault with Archigenes for mentioning laryngotomy, and treats the operation as entirely fabulous and the fiction of that physician. His aversion to it is so strong that he pronounces it a crime. Before having done with this author, we may remark that Prosper Alpinus, the modern advocate for ancient Methodism, does not agree with Cælius in condemning the Hippocratic practice of opening the veins below the tongue. In his own case he had experienced the good effects of this practice. (Meth. Med. vii, 10.)
The Arabians, like their Grecian masters, describe the two varieties of the disease, and treat them accordingly. For the variety called synanche by the Greeks, they approve of hot gargles consisting of mustard, pepper, and the like. This resembles the modern practice of using gargles of Cayenne pepper. In the following passage, Rhases evidently points at the contagious synanche: “It happens on certain years in spring that a bad and destructive species of synanche attacks a great many persons. Wherefore at such a time it will be proper to anticipate the disease by venesection, abstracting blood from the legs with cupping-instruments, opening the belly, and gargling with rose-water, or infusions of sumach, mulberries, and nuts.” Haly Abbas likewise states that the disease is sometimes epidemical. Rhases approves of general bleeding, of opening the sublingual veins, and of using astringent gargles at first, and afterwards maturative ones consisting of figs, sweet almonds, and the like. In his ‘Continens’ he seems to allude to bronchotomy. Alsaharavius describes the two varieties of the disease with great minuteness. He agrees with the others as to the danger of that variety in which there is no swelling nor inflammation outwardly. Avicenna and other of the Arabians follow Alexander in recommending bleeding by opening the jugulars. The two kinds of angina, mentioned by the ancients, are described in similar terms by Sydenham, Boerhaave, and Van Swieten. The first variety, or common quinsey, is well known. The second is of less frequent occurrence. The modern authorities have found it as fatal as the ancients gave them reason to expect. The reader will find a very interesting commentary on Aretæus’ description of malignant sore throat in a tract, ‘de Recondita Abscessum Natura.’ (Mangeti Bibl. Chirurg. i, 48.) It is the disease now called laryngitis acuta.
Haly approves of the treatment recommended by our author in cases of suspended animation. In treating those who have been in water, he directs, very improperly we are convinced, the patient to be hung by the heels, to favour the escape of the water by the mouth. It would appear, however, from the late experiments of Professor Meyer, that the ancients were correct in supposing that water is generally found in the lungs of drowned persons. When a person has hung by the neck for a time, and there is any prospect of recovery, Haly directs us, as soon as he can swallow, to make him gargle with oil of violets and tepid water, and to drink barley-gruel and the like.
All these complaints have this in common, that they are occasioned by the defluxion of a redundant humour from the head to the parts below. When, therefore, it seats in the nostrils, the disease is called coryza; when in the pharynx and roof of the mouth, simply catarrh; but when it attacks the larynx and arteria trachea, so as to occasion a roughness of the membrane which lines them, the voice becomes hoarse, and the disease is called branchus, or morbus arteriacus: these terms being applicable not only to the inflammatory roughness occasioned by a defluxion from the head, but also to that arising from vociferation and inhaling cold air. When the complaint is protracted, and the defluxion is carried down to the chest and lungs, it gives rise to bad coughs. And a cough often arises from an intemperament; sometimes a hot one, as in fevers, and sometimes a cold, as in northerly states of the weather, which is rather a dry one. Cough is also sometimes symptomatic of some other disease, such as pleurisy, hepatitis, phthisis, or peripneumonia. Wherefore Galen relates that, in certain chronic cases of cough, chalazia (hail-stones) have been brought up from the chest. But Alexander relates that a certain heavy stone, like that which forms in the urinary organs, was brought up in a chronic cough, upon which the cough ceased. We ourselves have seen a discharge of stones with vomiting of blood, as we will describe more accurately when we come to that part. Those who have coryza and catarrh from exposure to heat have a sensation of heat about the parts, and a running of acrid and thin humours from the nostrils and mouth, and there is redness about the face and nose. When they are occasioned by cold, there is distension about the head and forehead, and obstruction of the ethmoid pores, so that the voice does not resound through the nose; and when they are protracted, cough supervenes, and expectoration of phlegm, which is sometimes unconcocted and fluid, and sometimes green. In some cases fever comes on, which does not alleviate the complaint when it proceeds from heat, but when from cold it promotes concoction.
The cure of catarrh and of coryza. When a hot intemperament prevails, those remedies will apply which suit with headachs from the same cause. They must have recourse to baths, and have a large quantity of hot water poured upon the head. The food most befitting are spoon-meats and eggs in a state to be supped, starch, sweet cake, sesame, rice, almonds, the fruit of the cones of pine, and all confections from milk. The wines which are drunk should be sweet and not old. The lohoch from poppy-heads, called diacodium, and other compound medicines for these complaints, are to be taken. When a cold intemperament prevails, and the disease is difficult to remove, a restricted diet is to be observed, and the head anointed with some heating and attenuating ointment, such as that of nard or rue. But the ointment of iris is not only to be rubbed in, but is also to be injected into the nostrils; and, internally, they are to be rubbed with frankincense and myrrh, with oil; and this more especially when the coryza arises from cold. But these are remedied by odoriferous substances with burnt linen, or by gith and cumin burnt and bound up in a linen rag. Let them also smell to the cyphi seleniacum, and let it be rubbed into the forehead; and to it let there be added one of the antiphlogistic plasters, such as the Icesian, the Oxera, the Barbarum, and the Athena. For catarrh from cold it will be expedient to drink of cyphi, and to rub into the chest the juice of balsam by means of unwashed wool; or to apply calefacients to it, along with storax, the ointment of iris, or that of dill. Let them also use hot and concocting food. But when the matter is already concocted, a masticatory will answer well with them, and detergent ointments (smegmata) to the head, such as the soap of Constantine, and the like.
The cure of affections of the trachea, or hoarseness. For the complaint called arteriacus and branchus, those things already mentioned will apply; but, in particular, when an inflammatory affection of the trachea and larynx prevails, we must, at the commencement, use the emplastic remedies, until the inflammation become more moderate; such as those from Cretan sweet wine, tragacanth, gum, and starch, and a decoction of the fatty dates and that of liquorice, with rob, until it become of the consistency of honey. And we must use that class of electuaries called hypoglottides. But, above all things, the patient at this period must abstain from drinking wine; but when the inflammation becomes moderate, he may take some sweet wine. And let him use those spoon-meats which are made from honey and milk, with starch, and bread of fine flour, and almond emulsions; and let him take butter. When a humour remains fixed in the parts, he must have recourse to detergent remedies, such as the porridge of beans, and those things which are prepared from honey, cabbage, and well-boiled leeks. He may also take the hotter medicines, and those used for the cough, in the rob of dried figs, of frankincense, iris, turpentine, storax, galbanum, pepper, cinnamon, cassia, and the like.
On cough. Coughs are to be cured by the same method, attending only to this, whether they be occasioned by sympathy with other parts, such as a defluxion from the uvula or head, and whether they be symptomatic of other diseases; in which case, they are to be disposed of in the manner already mentioned, or as will be described afterwards. An exposition of the compound remedies follows.
Pills for catarrh and cough. Of storax, of myrrh, of opium, of galbanum, equal parts; mix with must, or pound by themselves in a mortar, and make into pills the size of a tare. Give three, four, or five at bedtime, and swallow with some must. These things are for an acrid and thin rheum.—Another: Of the seed of henbane, dr. xij; of pine-nuts, dr. vj; of saffron, dr. ij. Mix with rob or with must, and use.
An electuary. Of honey, oz. j; of butter, oz. ss. Boil together and give; and let the decoction of hyssop, of figs, of pine-nuts, and of iris, be swallowed.
Pills for more inveterate coughs. Of storax, dr. vj; of myrrh, dr. iiss; of turpentine, of galbanum, of opopanax, and of iris, of each, dr. ij; of white pepper, of nitre, of henbane-seeds, of the juice of poppy, of each, dr. j. Beat in a mortar without any liquid, form into pills, and use as formerly directed.
For roughness of the windpipe, cough, and bloody expectoration. Of bitter almonds whitened, xxv in number; of toasted linseed, dr. iv; of tragacanth, dr. ij; of pine nuts, xxx grains; the yelk of an egg roasted in dough. The tragacanth is macerated with water, and the whole mixed with must. If the sound of the voice be broken, mix honey instead of the must, more particularly when there is anything to expectorate.
An arteriac to be kept below the tongue for those who have lost the voice, for hoarseness, and bloody expectoration. Of tragacanth, dr. vj; of gum, dr. vj; of myrrh, dr. iss; of white pepper, xx grains; of saffron, dr. j; of liquorice-juice, dr. vj; the flesh of three dates; of Cretan sweet wine, q. s. The juice of the tragacanth alone placed under the tongue answers very well. Instead of the juice of liquorice, its decoction boiled down to the proper consistence may be substituted in quadruple quantity.
An arteriac for loss of voice, suiting also for strengthening the voice. Boil six leeks to a third part; throw them away, but with the decoction mix the juice of alica and honey; boil with them the yelks of three eggs previously boiled, stirring with a branch of dill.
For coughs. Of pennyroyal, oz. ij; of pine-nuts, of bastard saffron, of linseed, of each, oz. j; of white pepper, oz. iv; mix with boiled honey.—Another: Of hyssop, of pennyroyal, of pepper, of each, oz. j; of Macedonian parsley, oz. ss; of honey, a hemina.
For concocting an inveterate cough. Of honey, dr. xvj; of turpentine, dr. ij; of galbanum, dr. xiv. Having boiled them together, and having formed to the size of beans or of walnuts, let them be sucked.—Another: A dry cough is cured by the arteriacs, and also by the drinking of hot water; for, not being able to expectorate, owing to the thickness of the phlegm, they are assisted in so far by diluents. A decoction from hyssop, and iris, and pine-nuts, also answers with them.
A trochisk to be inhaled for a continued cough. Of storax, of pepper, of mastich, of Macedonian parsley, of each, oz. j; of sandarach, scr. vj; two bay-berries; mix with honey; and fumigate by throwing them upon coals, so that the person affected with the cough may inhale the vapour through a funnel. It answers also with those affected by cold in anywise.
Commentary. All the writers referred to in the preceding Section (with the exception of Aretæus) may be consulted here.
Galen, in the seventh book of his work, ‘de Med. sec. loc.’ has treated of these diseases so fully that he may be said to have exhausted the subject. We can only afford room for a few of his general remarks. He states that the arteriacs, or compositions for affections of the arteria trachea, consist of three different kinds of medicines. First, those called by him obstruents, and answering to those now called demulcents, such as Cretan sweet wine, tragacanth, liquorice, and the like, which act by smoothing the asperities of the parts. Second, the acrid, containing cinnamon, turpentine-rosin, and the like. Third, the intermediate, consisting of the juice of ptisan, almonds, and the like. He gives a great number of compositions from Andromachus, Criton, and others, which might deserve attention. Of their ingredients some are expectorants, such as squills, myrrh, &c.; some demulcents, such as liquorice, tragacanth, &c.; and some narcotic, such as opium, mandragora, hyoscyamus, and hemlock. With the medicinal properties of the last-mentioned article (we mean the conium maculatum), which Dr. Paris commends so highly in diseases of the chest, the ancients were sufficiently well acquainted. For humid coughs Galen recommends a composition of alum, opium, galbanum, and storax. He mentions lumbrici in the stomach as a cause of coughs. (Com. in Epid. iii.) Among the remedies mentioned by our author, by Galen, and by most of the ancient authorities, we may remark the inhaling the fumes of certain acrid medicines, such as yellow orpiment and sandarach, or realgar, i. e. red orpiment. Whether the practice be safe or not we shall not pretend to determine; but, unquestionably, it is recommended upon high authority; and therefore it is not true, as has been often stated, that this practice arose from the mistake of confounding the gum juniper, or vernix of the Arabians, also often called sandarach, with the sandarach of the ancients, or realgar. (See Bree on Asthma, p. 231.) We refer to Aëtius (viii, 61); Pseudo-Dioscorides (Euporist. ii, 33); Pliny (H. N. xxxiv, 55); Alexander (v, 4); Myrepsus (xli, 76); Serapion (ii, 19, and 24); and Rhases (Cont. viii.) The ancient veterinary surgeons used arsenic in fumigations for the coughs of cattle. See Vegetius (Mulom. iii, 67.) Platearius, a modern writer of the thirteenth century, recommends arsenic for chronic coughs, both in fumigations and taken into the stomach, and yet he distinguishes quite correctly the sandarach, or red arsenic, from the gum vernix. (De Simplici Medicina.) Some of the earlier writers on the venereal disease recommend fumigations with arsenic for syphilitic ulcers of the throat. (V. Aphrodisiacus, and Sect. XXIX of this Book.)
At the commencement of a common catarrh, Celsus advises to abstain “a sole, balneo, vino, venere;” but to use “unctione et assueto cibo.” When the lungs become affected he recommends much friction and exercise on foot. He gives the following account of the origin of these complaints: “Destillat autem humor de capite interdum in nares, quod leve est; interdum in fauces, quod pejus est; interdum etiam in pulmonem, quod pessimum est.” The idea of the disease originating in the head and spreading downwards prevails in all the ancient descriptions of the disease, and, we may mention, is now sanctioned by the authority of the illustrious Laennec. See, in particular, Aëtius, who copies, however, in part from Galen.
Alexander devotes a whole chapter to the consideration of these complaints. He forbids diuretics, because they carry off the thin part of the humours and leave the thick behind. Respecting the chalazia mentioned by Galen, and “the smooth, hard, and firm stone” said to have been expectorated by Alexander’s patient, we have a few remarks to make. The passage in Galen’s work where they are described is at ‘de Loc. Affect.’ iv, near the end. These sputa have been described by recent pathologists. Thus Andral calls them small clots, of a dull white, or inclining a little to yellow, from a small pin’s head to a pea in size. (Clinical Medicine, 464, Engl. ed.) The modern authorities agree that they are indicative of phthisis. Aretæus describes by the name of pneumodes, and as a species of asthma, a diseased state resembling that which we are treating of. The symptoms are dyspnœa, cough, and wasting; pulse small, frequent, and feeble; the sputa, if any, small, white, round, and like hail. The disease proves fatal in the course of a year, and often ends in dropsy and anasarca.
The treatment recommended by the great Methodist Cælius Aurelianus is not much different from the practice of the other sects, only he enjoins a more rigid abstinence from wine and food of a heating nature. He also condemns the practice of inhaling the vapours of red arsenic (sandaracha), and the like. In protracted cases he recommends a change of place.
There is nothing original in the practice of the Arabians. Avicenna prudently forbids preparations of poppies after expectoration has commenced. For coryza Haly Abbas recommends, if the patient’s age and temperament permit, bleeding, a spare diet, abstinence from wine, fumigations with the vapours of camphor, lignum aloes, vinegar, &c.; avoiding to lie on the back, and so forth. He treats at great length of coughs, distinguishing them according as they are seated in the throat, gullet, or lungs, and whether they be sympathetic or not. For hoarseness, he directs gargles from the seed of anise or fennel, or a decoction containing radishes, parsley, fennel, mastich, spikenard, iris, figs, &c. Alsaharavius treats fully of these complaints in much the same terms.
Those who breathe thick without fever, like those who have run fast, are said to be asthmatic, that is to say, to pant for breath; and from their being obliged to keep the chest erect for fear of being suffocated, they are called orthopnoic. The affection arises from thick and viscid humours becoming infarcted in the bronchial cells of the lungs. Dyspnœa is a common symptom which accompanies these and many other complaints. The indication of cure in asthmatic complaints is to consume the viscid and thick humour by attenuant and detergent medicines. Wherefore the vinegar of squills will answer well with them, and the oxymel prepared from it; the baked squill itself when triturated with honey; the antidote called hiera, continued purging with drastic medicines, and vomiting from radishes. And, in like manner, the round birthwort may be drunk, the root of the great centaury, the fruit and root of cow-parsnip, the fruit of calamint, hyssop, iris, and gith. Put a sextarius of slaters, into an earthen vessel, roast upon the coals; when whitened, pulverize, and, mixing with boiled honey, give a mystrum thereof before and after food. If there be any urgent necessity, before doing all these things, open a vein and evacuate proportionably to the patient’s strength; and stimulate the belly by clysters. Externally to the chest we may apply cataplasms from figs, the flour of iris, and of barley, containing rosin, wax, and honey; and iris and manna may be sprinkled upon them. Some benefit may also be derived from raw barley-flour, with rosin, wax, iris, and manna. We may use the more heating ointments, such as those of iris, dill, and rue. But the following application is particularly proper: Of pumice-stone, p. j; of burnt lees of wine, p. iv; of arsenic, p. j; of the schenanth, p. ij; of alcyonium, p. j; of aphronitrum, p. ij; pound, sift, mix with the ointment, and with it rub the parts about the chest, and use emollient ointments for attracting the humours.
A draught for asthmatics. Of poley, of southernwood, of castor, of ground pine, of ammoniac perfume, equal parts; mix with honey, and give.—Otherwise: Some give a spoonful of aphronitrum in three cyathi (cupfuls) of honied water.—Another: Of aphronitrum, dr. ix; of pepper, dr. j; of laserwort, dr. ss; give a spoonful in water.—Another: Of castor, of ammoniac perfume, of each, dr. vj; of pepper, xl grains; mix with must, and give to the size of a bean in honied water.—Another: Of mustard, dr. j; of the spuma nitri, three oboli; of elaterium, a diachylon (i. e. half an obolus): form the whole into eight trochisks, and give two every two days; for they will evacuate upwards gently. To those who are choked for want of breath, give, of aphronitrum, dr. iij, with three cyathi of hydromel, and sometimes with cardamom, and it will relieve them immediately. It is also useful in ischiatic disease.
Commentary. The following ancient works may be consulted: Hippocrates (Aphoris.); Galen (de Comp. Med. sec. loc. vii); Celsus (iv, 4); Aretæus (Morb. i, 11); Cælius Aurelianus (Morb. Tard. iii, 1); Aëtius (viii, 63); Oribasius (Loc. Affect. iv, 79); Actuarius (Meth. Med. iv, 4); Marcellus (de Med. 17); Nonnus (127); Octavius Horatianus (ii, 2, 12); Serapion (ii, 24); Avicenna (iii, 10, 1, 38); Mesue (de Ægrit. Pect.); Haly Abbas (Pract. vi, 8; Theor. ix, 20); Alsaharavius (Pract. viii, 5); Rhases (ad Mansor. ix, 56; Contin. viii.)
Our author’s theory of the disease is borrowed from Galen, and seems very plausible. It being admitted by our best modern pathologists, that there is no organic alteration of structure in ordinary cases of convulsive asthma, it seems likely that the paroxysm is occasioned by thick and viscid humours infarcted in the lungs; or, most probably, in many cases from the system being loaded with such humours which nature casts off by the lungs. We need scarcely add, that it is now well ascertained that asthma is frequently produced by engorgement of the lining membrane of the bronchi, thus forming what is called the dry catarrh. Galen, like our author, maintains that the use of attenuant and detergent medicines is indicated. His internal remedies are squills, pepper, wormwood, opopanax, storax, sulphur, oxymel, millepedes, &c. He forbids all things which are either of a very hot or cold nature, as in either case they tend to thicken the humours.
Aëtius gives nearly the same account as our author, both having evidently borrowed from Galen. He strongly praises vinegar of squills, myrrh, pepper, and the like. In certain cases he advises the application of the actual cautery to the head (see Book Sixth, Sect. I) under the impression that the disease is occasioned by a defluxion from it. He also speaks of burning the chest in several places for the purpose of making issues; and further recommends strong rubefacients.
Among the articles recommended by Marcellus, the Empiric, for difficulty of breathing, we remark vinegar of squills, natron (soda), opium, horehound, &c. The first article, it will be perceived, among his remedies for asthma is vinegar of squills. Almost all the ancient authorities praise the virtues of squills in this disease.
Aretæus gives a good description of the symptoms of the disease, which he attributes to a humid, thick, and glutinous matériel in the lungs. He says, the lungs are primarily affected, and through them sympathetically the diaphragm, and parts about the chest which assist in respiration. But if the heart be affected, he adds, the issue is speedily fatal. Among the incipient symptoms he mentions flatulence of the bowels, restlessness, and latent heat by night. As the paroxysm proceeds, the cheeks become red, the nose sharp, the eyes prominent as if from strangulation, there is a râle even when awake, and still more so when asleep; the voice is humid and devoid of resonance, with an insatiable desire of cold air, panting, and orthopnœa. To these symptoms are added, paleness of the countenance, with the exception of the cheeks; profuse sweats about the face and chest; constant and difficult coughing, with little expectoration. His chapter on the treatment is lost.
As Oribasius, Actuarius, and Nonnus follow the principles laid down by Galen, we need not give any account of their opinions.
Octavius Horatianus adopts Galen’s theory, which he thus explains: “Pingui autem et frigido phlegmate pulmonibus adhærente, cavernæ, vel meatus, quibus naturaliter spiritus redditur et accipitur, concluduntur; et ex hoc impedimento suspirium, vel anhelitus molestissimus, nascitur, ut sedendo magis quam jacendo respiret.” He recommends bleeding, if not contra-indicated; but, if that is the case, frequent abstinence. Among his internal remedies we remark oxymel, gum ammoniac, castor, and vinegar of squills. He approves also of emetics. He recommends stimulant applications to the chest, also fomentations and sinapisms. A long journey, he says, is beneficial.
Cælius Aurelianus disapproves of burning the head and of strong purging. He approves of bleeding, if the patient’s strength permit, of clysters, cupping the breast, gestation, friction, vociferation, emetics from radishes, or even from hellebore, and of giving the vinegar of squills. He speaks favorably of the cold bath. His description of humid asthma is very striking, and has been commended by late authorities on the subject. The sounds within the chest are thus described: “stridor, atque sibilatio pectoris, cum vocis debilitate.”
Cassius discusses the question why there is a sibilant murmur in cases of orthopnœa, and decides that it is because the affection is a contraction and falling-in of the cells of the lungs, and the breath rushing through a narrow passage produces this murmur. (Prob. 82.)
Serapion recommends friction, exercise, squills, fumigations with arsenic, &c. Mesue also recommends arsenic in various forms. Avicenna’s account is particularly full and judicious. He properly remarks that asthma is sometimes connected with derangement of the heart, liver, and stomach. Like the others, he approves of arsenic, both in pills and in solution.
Haly Abbas, like Galen, refers asthma to a collection of gross phlegm about the cells of the lungs. His remedies are of an attenuant and incisive nature, and he particularises the vinegar of squills. He cautions asthmatics to beware of indigestion, and, therefore, forbids exercise after food, but recommends it before a meal. After exercise he enjoins hard friction, no doubt with the intention of favouring the cutaneous perspiration. Rhases commends squills and the tepid bath. Like the others, he approves of inhaling the vapours of arsenic.
Vegetius, the veterinary surgeon, recommends squills with wine, assafœtida, and oil, for these complaints in cattle.
Respecting the use of arsenic in asthma, Prosper Alpinus remarks: “Præterea audent aliqui arsenicum summè exitiale venenum illis exhibere. Narrant quidam nepotem patris fratri decrepito orthopnoico, ut cum interimeret, clam in ferculo ex cucurbitâ parato porrexisse arsenicum, coque non modo non interimisse decrepitum, verum et ab asthmate prorsus sanasse.” (De Meth. Med. x, 13.) He states further, by the way, both in that work and in the one “de Medicina Ægyptiorum,” that the Egyptians were in the practice, for the cure of asthma, of applying cones of cotton to the breast, and setting them on fire. Fracastorius, who recommends this practice of imbibing the fumes of arsenic, for contagious phthisis, speaks of it in the following terms: “Nonnulli antiquorum jubent Sandaracæ nidorem per anhelitum in pulmones trahi: quum autem Sandaracam dico non eam intelligi volo quæ vernix vulgo vocatur, sed quæ auripigmentum a nobis dicitur: porro nec per auripigmentum velim a te accipi priorem illam speciem quæ citrina est sed alteram, quæ est ruffa, et propriè Sandaraca vocatur.” (Morb. Contag. iii.)
Dr. Hill, however, properly remarks that the arsenic of the ancients, or orpiment was a much more innocent substance than the factitious arsenic of the moderns. See also Cleaveland (Mineralogy p. 680.) The arsenic of the ancients, in fact (as will be shown in the proper place), was the mineral substance called yellow orpiment, consisting of sixty-two parts of arsenic and thirty-eight of sulphur, according to the analysis of Klaproth. The sandarach was realgar, which consists of seventy-five parts of arsenic and twenty-five of sulphur.
Peripneumonia is an inflammation of the lungs, supervening, for the most part, upon violent catarrhs, cynanche, asthma, pleurisies, or other complaints, but being sometimes the original affection. It is accompanied with difficulty of breathing, an acute fever of the ardent type, weight and tightness of the chest, a râle, a seizure of the face with great fulness, the morbific matter being determined upwards like fire. Wherefore the cheeks appear red, the eyes swelled, with falling down of the eyebrows, and the cornea appears somewhat glossy. When the symptoms incline to a more ardent type, it is to be apprehended that the inflammation is of an erysipelatous nature. When the disease originates from the conversion of other diseases into this, we must not have recourse to venesection, more especially if the diseases be of a chronic nature, and if blood had been previously let. But, in the remissions, clysters are to be injected into the bowels, which are moved with difficulty; or, when nothing contra-indicates, large cupping-instruments with scarifications may be frequently applied to the breast and sides. But if the peripneumonia was the original affection, and the strength permit, we must open a vein; or if not, we may cup, proportioning the evacuation of blood to the powers of the patient. Let draughts of the juice of ptisan, or of chondrus with honey, be taken, or from bitter almonds with semilago, or chondrus having some sweet potion mixed with it, such as hydromel, apomel, or hydrorosatum. Fresh butter to the extent of three spoonfuls is also proper. The patient must also drink the propoma of the decoction of figs with hyssop, or of iris boiled in honied water, or of powdered iris, to the amount of two spoonfuls sprinkled upon honied water. This also evacuates downwards. To keep up the strength, he should be made to drink frequently of honied water alone, and with pine-nuts, and the seed of cucumbers. And cupping-instruments and the cerate of privet, having some iris sprinkled upon it; or the cerate of the oil of rue and dried iris; or that made of wax, and rosin, marrow, butter, hyssop, dried iris, and nard ointment, may be applied to the whole chest and sides.
Commentary. The reader is referred to the authorities on pleurisy, as most of them treat of both diseases together.
Hippocrates recommends bleeding, purging, and attenuant drinks as his general plan of treatment. If the appendix to his treatise on the Regimen in Acute Diseases be genuine he approved of carrying venesection the length of inducing deliquium.
Aretæus gives a minute and faithful account of the disease, but his description is too long for our limits. He remarks that as the lungs have but small nerves, there is little pain unless the investing membrane be affected. He states that when the suppuration takes place, a metastasis of the matter to the bladder or belly sometimes occurs and relieves the patient, whereas, if it be determined to the lungs, it is apt to terminate in phthisis. He gives excellent directions for the application of his remedies, which are the same as those now in use, namely, copious bleeding (but so as to avoid deliquium), purging, attenuant and diluent drinks, rubefacients, containing mustard, to the chest, alkaline substances, such as soda, given in the decoction of hyssop; and when the fever has subsided he allows wine devoid of astringency.
Aëtius makes the same remark as Aretæus respecting the metastasis of the matter. His account of the disease is excellent, but like our author’s.
Celsus properly states that the danger is greater than the pain. His account of the treatment is too long for our limits, but is well deserving of attention.
According to Actuarius, in hot affections of the lungs the urine is first a bright yellow, but if the disease gain ground, and dyspnœa and thirst supervene, the urine becomes red and of a dark wine colour. (De Urinis, vii, 5.)
As the Arabians treat the disease like the Greeks, it is unnecessary to say much of their practice. Haly Abbas describes the disease as a hot inflammation of the lungs, for which he recommends bleeding, cooling and diluent draughts, containing linseed, fenugreek, barley, oil of almonds, liquorice, &c.
Rhases describes a species of pneumonia, requiring the use of tonics, analeptics, and wine. He relates the case of a patient who, he affirms, would infallibly have sunk under this disease, if he had not resisted the advice of the other medical attendants, who prescribed the anti-inflammatory treatment and laxatives.
Although our business be with facts and opinions, and not with words, we are confident we shall be excused in giving here a short verbal disquisition on one of the terms which occur in this Section, we mean ῥωγμὸς, translated by us rále. It occurs again at Book Sixth, Sect. XXXIII, in the description of laryngotomy, and in Aretæus’s description of asthma (Morb. Chron. i, 11.) Cælius Aurelianus thus defines the term: “gutturis stridor quem Græci rhogmon vocant.” (Morb. Acut. ii, 10.) In the Latin translations of the Arabians it is made oregmon. See Rhases (Div. i, 5.) About the terms used by Hippocrates in describing ráles there is some difficulty, owing to the differences of the readings. Thus in the appendix to the work on Regimen in Acute Diseases we read ῥωγμὴ in some MSS., and ῥωχμὴ in others. See Littré (Hipp. t. ii, 464.) In other places he uses ῥέγξις. (Ibid. 262.) In Psellus we read ῥεγμός. (Op. Med. l. 230.) These, as far as we know, are the only terms used by the ancients for the noisy sounds of the respiration in the throat and chest. Ῥόγχος, in Latin rhonchus, we believe, always signifies snoring.
When the spitting of blood arises from rupture, a great quantity will be evacuated, and sometimes from an obvious cause, such as a fall, straining of the voice, and the like; and sometimes from an obscure cause, such as plethora, or immoderate cold; for cold, as Hippocrates says, occasions rupture of the veins. If it proceed from erosion, the discharge of blood will not be rapid, but in small quantity, and will have been preceded by acrid and unwholesome food, or abstinence, or an acrid defluxion. When it arises from exhalation, none of the afore-mentioned circumstances, unless, perhaps, the plethora precedes; but a more moistening and heating diet, the use of immoderate baths, and living in very hot places, may appear to occasion it: and it will neither supervene upon inflammations, nor fevers, nor pains, as in the case of erosion; but, on the contrary, the patients will appear in all probability to be relieved by the evacuation. If the hemorrhoidal or the menstrual discharge in women be suppressed, the renewal of these will remove the danger; and the like good effects will result from discharges of blood by rupture, when the disease is connected with plethora, unless the ulcer, or the greatness of the loss of blood prove injurious. When the discharge of blood is from erosion, it is never productive of good. If it is brought up by vomiting, it is clear that it comes from the stomach or bowels, from which parts it is sometimes evacuated by the anus; but, if by coughing, it comes from the respiratory organs; but if it is frothy and whitish, and is brought up at intervals, without pain and oppression, it is clear that it is brought up from the lungs, upon which, in process of time, a continual fever will supervene, more especially if occasioned by erosion; and part of the substance of the lungs, bronchia, or veins, will be brought up. I knew a certain person affected with spitting of blood from the lungs, who, after a time, with much coughing, and full evacuation of blood, spit up four or five stones, rough as caltrops, and of the weight of three or four siliquæ; and he was immediately relieved, but soon after fell into a consumption and died. If the discharge consist of phlegm, with a slight cough or hawking, and the expectoration be frothy and light, you may know that it comes from the trachea. But if it consist of black and grumous blood, and there is pain in the part, it indicates that the discharge is from the thorax, being transmitted by the lungs or bronchia. If it be brought up with hawking, it is by the palate from the parts about the pharynx. But if it flow from the head, it is evacuated with some tickling and cough, for it runs down into the windpipe, and is again brought up. Such discharges are commonly preceded by an acrid defluxion, headach, or heaviness. Sometimes the evacuation of blood is from the palate, owing to a leech having been swallowed, and fixing on some of the parts there. But of this case we will treat on the subject of Poisons.
The cure. Those who have a spitting of blood from catarrh are to be immediately bled (unless the defluxion be very acrid), and a quantity of blood taken away proportionate to the strength. Ligatures are to be applied around the extremities, and the whole body, excepting the head, is to be rubbed with hot old oil, or with Sicyonian. Farinaceous food, containing the juice of some austere fruit, such as that of pomegranate, of apples, or of pears, is to be taken; or let these be boiled with it. When going to sleep, give them the trochisk from amber; and on the third day give some boiled honey to lick. If these do not succeed, and the disease is protracted, shave the head, and use the application from wild-pigeon’s dung; and after three hours remove this application, and put the patient into a bath, taking care not to anoint the head. Then, having given him spoon-meats for food, administer to him the theriac antidote at bedtime, and repeat this next day; and rub in like manner the whole body, except the head, but to it apply the cerate from thapsia, or the like, and again use the spoon-meats. When the complaint is protracted, apply a cupping-instrument to the back part of the head. But if the defluxion be of a very acrid nature, we must abstain from venesection, and have recourse to the food and remedies formerly described when treating of Catarrh, and such as are now to be mentioned. When the spitting of blood proceeds from cold, the chest should be warmed, along with remedies which are of a desiccative nature; and we must give the medicine from two peppers, with the trochisk of amber. Those who bring up blood from the respiratory organs, owing to rupture or anastomosis of the vessels, are to be bled from a vein, unless the discharge of blood be great. In every case, the patient is to be laid in a well-ventilated place, upon a steady couch, in an erect position; and he ought to abstain from strong respiration and talking. To the affected parts we may apply sponges soaked in tepid oxycrate; but after the seventh day, unwashed wool, with the oil of roses, of myrtle, or of lentisk, sometimes with vinegar, and sometimes with austere wine; or, if the discharge be great, we may apply fine flour and manna, with vinegar, or alum and acacia, or pomegranate rind, or galls with vinegar, or dates with polenta and quinces boiled in austere wine. Afterwards we may put on the plaster from willows, more particularly if the discharge be moderate. But the following things are to be taken by the mouth: Purslain when eaten is of use (but its juice when drunk is more powerful), the flowers also of the wild pomegranate, the fruit of the bramble and its flowers, the fibrous part of the common oak, and the membrane under the shell of the acorn (but these are used more especially in decoction); and yet those of the fagus and ilex are more powerful remedies. The Samian aster applies to every spitting of blood, and also the Lemnian earth, and bloodstone finely triturated with the juice of pomegranate or knot-grass. The dose of the stone should be one scruple. The following compound remedies are useful; namely, the trochisk from amber, that from coral, and that from Egyptian thorn, also the powder composed of the earth called Samian aster, Lemnian earth, coral, comfrey, and starch, of each, equal parts. When the disease is occasioned by erosion, more especially if a catarrh precede, we may mix half a part of opium. And the composition admitting of equal parts of Samian aster, agerat stone, and Lemnian earth, is an excellent remedy when drunk to the amount of two spoonfuls (cochlearia) in two cupfuls (cyathi) of plantain-juice.—Another: Of Lemnian sealed earth, dr. xvj; of Samian aster, dr. xviij; of starch, dr. viij; of sarcocolla, dr. iv; of gum, dr. ij. Of this in powder let one spoonful be taken with two cyathi of the decoction of dates. Let them also take cold oxycrate, or the decoction of dates, of apples, of pears, of vine tendrils, or the like. They may take food, if the strength urgently requires it, about the second or third hour, but if otherwise, about the fourth. Let it consist of bread that has been soaked in cold water, or halica, or chondrus, with some of the refrigerant juices, such as those of pomegranate, or myrtles, or with honey and unripe grapes mixed together, or eggs softly boiled, or cakes prepared from milk with some astringent. Of pot-herbs they may take endive, succory, plantain, boiled with the oil of unripe olives and vinegar. Of autumnal fruits they may use apples, pears, medlars, pomegranates, and the fruit of the cornel-tree. When they have no fever, their drink may consist of a small quantity of diluted wine; but, when they have fever, of some of the afore-mentioned draughts, or Cibyratic hydromel. Those who vomit blood may be treated on the same plan, only they must abstain from taking food often. They are easily cured, because the remedies taken by the mouth are applied directly to the parts from which the blood flows. When blood is coagulated in the stomach, let the patient drink of rennet, more especially that of a hare, or the lixivial ashes of figs with water, or thyme, or savory with vinegar; or evacuations may be produced by means of milk divided into parts (lac scissum), or of aloes. Those who hawk blood from the palate must use astringent gargles, and apply to the forehead and the rest of the head the remedies for bleeding from the nose. Such is the treatment of spitting of blood, which must be carefully attended to, on account of the danger from an immoderate discharge of it; for if a great quantity be evacuated, it will bring instant death, as in the case of a slaughtered animal; but a continuance of the complaint threatens a conversion into phthisis. Wherefore, when everything is properly attended to, and the discharge of blood ceases, their strength must be recruited by getting fish and the feet and brains of young swine. We must also direct them to get their bodies rubbed, to abstain from the frequent use of baths, from drinking wine, and from mental emotions and venery.
Commentary. See Hippocrates (de Morbis, et alibi); Galen (Meth. Med. v, and sec. loc. iv and vii); Aretæus (de Morb. Acut. ii, 2); Aëtius (viii, 65); Celsus (iv, 5); Alexander (vii, 1); Oribasius (Synops. ix, 2); Leo (iv, 30); Actuarius (Meth. Med. i, 17); Octavius Horatianus (ii, 2, 9); Nonnus (128); Scribonius Largus (83); Marcellus (de Med. 17); Serapion (ii, 25); Averrhoes (Collig. vi, 34); Mesue (de Ægr. Pect. 6); Avicenna (iii, 10, 3, 4); Avenzoar (i, 16, 5); Haly Abbas (Theor. ix, 26; Pract. vi, 10); Alsaharavius (xii, 6); Rhases (ad Mansor. ix, 59; Contin. ix.)
The father of medicine has mentioned this disease casually, but has not given a full account of it. We may mention, however, that he refers one species to disease of the liver. (Coac. 450.) Aristotle states that vomiting of blood is not dangerous when connected with obstructed menstruation. (H. N. vii, 10.)
The description given by Aretæus is exceedingly accurate. Blood that is discharged by the mouth, he remarks, may come from the fauces, nose, and palate, in which cases it is seldom attended with danger; or from the lungs and arteria trachea, which is exceedingly dangerous, and may prove fatal either suddenly, or by terminating in consumption; or from the stomach, which is less dangerous, as the remedies can be applied direct to the part affected; or from the liver and spleen, which is a more dangerous case, as the remedies cannot be so readily applied to them. They all arise, he says, from rupture, erosion, or rarefaction. By rarefaction (ἀραιῶσις) he means the same as exhalation (ἀναστόμωσις). If the blood be black and thick, it comes from a vein; and if florid and thin, from an artery. Of these cases that in which it proceeds from rarefaction is said to be the least dangerous, as it may readily be cured by astringents. The circumstances and characters of all the other cases are stated with great accuracy and at some length. He concludes with the remark, that in hemoptysis the patient despairs from the first, whereas in consumption he flatters himself with the hopes of recovery to the last. With regard to the treatment he directs that the patient be laid on a firm couch (as all motion increases the complaint), in a cool place, and that he abstain from speaking and all mental emotions. In every case, if the patient’s strength will permit, he recommends venesection at the elbow. Ligatures, not so tight as to occasion pain, are to be applied to the extremities. Over the place from which the blood flows he directs us to apply wool or sponges soaked in austere wine and rose-oil, or in vinegar. In certain cases he directs us to put an astringent plaster upon the chest. With regard to the medicines taken by the mouth, he recommends astringents, especially coral, when the disease is occasioned by dilatation. These, however, are only to be given when no fever is present. The diet is the same as that recommended by our author.
The account given by Celsus is very similar, and highly interesting. He approves of bleeding, the internal and external use of vinegar, and cold water to drink. Part of his treatment deserves to be given in his own inimitable language: “Præter hæc necessaria sunt quies, securitas, silentium. Caput cujus quoque cubantis sublime esse debet, rectèque tondetur. Facies sæpe aquâ frigidâ fovenda est. At inimica sunt vinum, balneum, venus, in cibo oleum, acria omnia, item calida fomenta, conclave calidum et inclusum, multa vestimenta corpori injecta, etiam frictiones. In hoc casu per hiemem, locis maritimis; per æstatem, mediterraneis opus est.”
Scribonius Largus, among other remedies, mentions sponging the chest with vinegar.
Pliny the elder recommends the juice of henbane in hemoptysis. (H. N. xxvi, 15.) See also Marcel. Empir. (17); Plin. Valerian. (iv, 69.)
The account given by Aëtius is full and judicious, but mostly borrowed from Galen. He approves of the internal use of vinegar, and of applying to the chest wool soaked in the same.
Oribasius, Actuarius, and Nonnus recommend internal remedies like those of our author.
Alexander’s observations are exceedingly judicious; but we can only afford room to state his opinion of external applications. He approves of embrocations by means of wool soaked in rose-oil, or the like, with some vinegar or austere wine not very old; but recommends us to change the application frequently, as by allowing it to remain it will only irritate and provoke the flow of blood. With such precautions Octavius Horatianus, in like manner, approves of sponging the chest with sour wine and water, or vinegar. Alexander properly forbids us to give anything warm, and cautions against violent exercise, anger, venery, and saltish food.
Galen expounds the pathology and principles of treatment so fully, that we cannot even venture to give an abridgment of his account, but will venture to recommend it to the serious attention of the medical reader. We must not omit, however, what he says respecting the use of cold and astringent applications to the chest: “I do not, like most physicians, approve of applying externally astringents, or things which are of a cooling nature without astringency, in cases of hemorrhage; for it appears to me that they have sometimes a contrary effect from what they are intended to produce, as they occasion a determination inwardly, and congestion in the deep-seated veins. I have therefore known cases of persons affected with spitting of blood who were evidently hurt by the application of cold to the chest. Wherefore, in cases of hemorrhage, I do not approve of the indiscriminate use of cold applications.” (Meth. Med. v, 6.) See also de Const. Artis Med. (16.) Galen mentions that blood may run down from the fauces into the windpipe, and thereby occasion groundless apprehensions of hemoptysis.
It deserves to be remarked that Dioscorides, Pliny, Galen, Alexander, and Paulus agree in recommending the hæmatite, or bloodstone for hemoptysis. It is a native oxyde of iron.
To the long and accurate account given by Cælius Aurelianus it is impossible to do justice in a short abstract. Passing over entirely his description of the symptoms, and explanation of the sources from which the blood is discharged, we shall merely dwell upon a few points of his practice. He insists with proper earnestness on the necessity of complete rest, coolness, and abstinence from everything of a stimulant nature; and recommends the practice already often mentioned of applying to the part affected sponges or compresses soaked in cold water, or in water and vinegar, or in some astringent decoction. He also approves of the application of ointments or plasters composed of galls, alum, the rind of the pomegranate, and the like. From among his many internal medicines we would point out the composition consisting of gum acacia, alum, and the decoction of poppies. When the discharge does not stop before the third day, he recommends venesection. But if pain, difficulty of breathing, or a dry cough should come on, he approves of bleeding at an earlier period of the disease. He then directs us to give emollient epithemes, electuaries containing frankincense and opium, and the like. When the pain is protracted, he recommends us to apply cupping-instruments or leeches to the part affected. Food of a middle quality, milk, and the like are to be given. From his strictures upon the practice of the others, it appears that some of the medical sects had condemned venesection, but it is satisfactory to know that most of the authorities were agreed about the propriety of it. The Methodist forbids it when there are no symptoms of inflammation present. It seems there were disputes also about the propriety of ligatures to the extremities, but Cælius pronounces in favour of this practice. He informs us further that some questioned the propriety of giving vinegar, but he decidedly approves of it. When there is any inflammation, he disapproves entirely of astringents. He also condemns sudorifics and diuretics. He allows exercise only when the complaint has abated.
Marcellus condemns ligatures to the extremities, but approves of applying to the chest a sponge soaked in cold water or acrid vinegar.
We have not room for many extracts from the Arabians, who, however, supply little additional information, although they treat fully of the disease. We would refer to Avicenna’s account as being particularly full and excellent. He approves of the internal use of vinegar, and when there is a tickling cough, of anodynes, such as mandragora, henbane, and poppy. Rhases and Serapion approve of sponging the chest with vinegar. Averrhoes, who is fond of contradicting preceding authorities, condemns the practice of giving vinegar in hemoptysis. Mesue recommends the use of chalybeate water for drink. He approves in general of astringents. Haly Abbas gives a very full and interesting account of the causes and varieties of the disease, and modifies his treatment accordingly. He recommends bleeding from the basilic vein, to be repeated if circumstances require, purging with gentle laxatives, such as myrobalans and rhubarb, giving demulcents, such as gum arabic and starch, to which poppy is sometimes to be added, for allaying irritation. He directs the bath, strong exercise, and vociferation to be avoided. When the disease arises from a cold cause (he means in cases of passive hemorrhage), he forbids venesection, and recommends stimulants, such as frankincense and myrrh. In certain cases he allows astringents, such as alum, balaustine, galls, sumach, &c. He also directs us to apply to the breast an astringent cerate containing roses, plantain, purslain, &c. Alsaharavius recommends bleeding, cold applications to the chest, opiates, and astringents, according to circumstances. Rhases states that opium, by thickening or congealing the blood, proves useful in hemoptysis. He approves very much of a milk-diet. In general he recommends venesection. He directs the physician to be at pains to ascertain from what part the blood proceeds.
Cold applications to the chest are not now generally resorted to in this disease, although it will be seen that the ancient authorities generally approve of this practice. It will be remarked, however, that Galen condemns the indiscriminate use of this remedy; and Rhases also states that he had seen mischief produced by the unseasonable application of cold to the chest. In short, like every other mode of practice, it ought, no doubt, to be applied with proper caution and discrimination.
Empyema is formed either in the cavities of the chest, or in the pleura, sometimes arising from vomiting of blood, when the ulcer has not healed (in which case phthisis soon comes on, provided the discharge came from the lungs), and sometimes from a precursory inflammation, which has formed into an abscess and burst (as is sometimes the case in pleurisy), or from a defluxion from the head. The symptoms of a confirmed empyema are weight in the chest, an intense dry cough, with pain, and sometimes with a fluid, in which case they seem to experience an alleviation. At the commencement the attacks of fever are weak, irregular, and difficult to perceive; but when the abscess is about to burst, they have more violent fever, attended with rigor, and in speaking their breathing is obstructed. When the abscess bursts, matter is brought up, sometimes pure and sometimes feculent: sometimes it is discharged upwards, when it is attended with more danger; and sometimes downwards, in which case the matter is partly translated to the stomach and bowels; and partly to the bladder, the metastasis taking place by certain vessels. All along they have hectic fever until the ulcer becomes clean; and if this do not speedily take place, the empyema is converted into phthisis from the lungs undergoing ulceration. When this takes place, the cheeks are livid; there are copious sweats about the forehead and neck; the flesh is melted, the nails bent, and they appear glossy, white, or pale. When the disease gains ground, the bowels become loose, the hypochondria are retracted; for the most part thirst and a loathing of food oppress them; and the expectoration is very fetid.
The cure. Our first object, therefore, ought to be to assist the concoction of the abscess, which may be attempted by fomenting with sponges, and applying cataplasms made of barley-flour, with dried figs boiled, some rosin, pigeon’s dung, nitre, and mallows. The rupture of the abscess is promoted by lying upon the side which is not affected. Let them drink at intervals honied water, and the juice of ptisan with honey. Those who are stronger may likewise drink the decoction of hyssop and thyme with honey. Eating pickles also forwards the breaking of the abscess, and likewise the pills from the colocynth hiera, taken at bedtime. When the pus begins to be discharged, give again the decoction of hyssop, iris, and liquorice boiled in honied water, or liquorice triturated with sesame; and apply a cataplasm of fine flour, boiled in honied water and oil. When the ulceration is difficult to cleanse, we must use the compound remedies, such as that from horehound, either the simple or the compound one; that from tares; and those called dodecatheon, and the medicine named from Philoxenus. When it is converted into phthisis, we may give the headed leek, dissolved in draughts of chondrus or ptisan, and let them be twice boiled, and given by themselves. Let the water which is drunk be rain, and honied water made from it. At the beginning of the remissions apply cataplasms of linseed and fine flour, with the decoction of fenugreek, or mallows, oil, honey, and the leaves of marshmallows. In process of time we may have recourse to cerates, such as those from butter, oil of privet, oil of bays, and iris. The plaster of Mnasæus is also to be used. When there is a defluxion upon the chest, that made of willows may be applied to it. They may also take the simple propoma, mentioned already for empyema, and some of the compound ones. When a violent cough prevails, mix thyme and hyssop along with the juice of liquorice, in well boiled honey; and, having formed them properly, give to be retained under the tongue. The antidote of Mithridates, at intervals, will likewise suit with them, as also that from vipers. But the best remedy is the Armenian bole taken in a draught, and the antidote esdra is not at all inferior to those aforesaid.
Commentary. See Hippocrates (de Morbis, ii, 45; Coacæ Prænot. et alibi); Galen (Meth. Med. v); Aretæus (Morb. Chron. i, 8); Aëtius (viii, 75); Oribasius (Synops. ix); Alexander (vii, 2, 3, 4); Leo (iv, 10); Actuarius (Meth. Med. iv, 4, and i, 17); Nonnus (123); Cælius Aurelianus (Morb. Tard. ii, 14, and v, 8); Celsus (iii, 22); Octavius Horatianus (ii, 8); Marcellus (17); Avicenna (iii, 10, 5); Mesue (de Ægrit. Pect. ii, 12); Serapion (ii, 27); Alsaharavius (Pract. xiii, 3); Haly Abbas (Pract. vi, 12, Theor. ix, 20); Avenzoar (i, 16, 4); Rhases (ad Mansor. ix, 69; Contin. x.)
Hippocrates states, as tests of the nature of the sputa, that, if they possess a fetid smell, or sink to the bottom of salt water, they indicate great danger. When a collection of pus is suspected, he directs us to shake the patient, when a peculiar sound will be heard if there be fluid in the chest. And here, by the way, we may mention that Laennec gives Hippocrates great credit for his diagnostic talent in this case. It is in pneumothorax that succussion is applicable as a test of fluid being confined in the chest. In that case, he directs us to make an incision into the chest; in other words, he recommends paracentesis thoracis, an operation revived of late years, but with very equivocal results. Hippocrates, however, restricted the operation to those cases in which there is protrusion of the collected fluid. (Aff. Int. xxv.) It would appear, from one of his Aphorisms, that the pus was let out either by a cutting instrument or the cautery. (vii, 43.) In his Prognostics, he pronounces a falling out of the hairs and a diarrhœa to be fatal symptoms in phthisis. He gives a very striking description of confirmed empyema. (Prognost. 17.) His account of the formation of hydrothorax (Affect. Int. xxv.) has also been highly commended by the great master of auscultation. According to Hippocrates, phthisis is most common between the ages of eighteen and thirty-six. (Aphor. v, 9.)