Part 83

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.

SECT. XXXII.—ON EMPYEMA AND PHTHISIS.

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.

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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.)

Aretæus gives a good description of the phenomena attending empyema thoracis. He says that when the abscess points outwardly, it separates the ribs from one another to make room for itself. It is occasioned, he says, by inflammation with a collection of blood. But the most graphic delineation of the phenomena of disease to be found in the whole records of medicine is that which he draws of a patient in the last stage of consumption. We will not mar it by attempting a copy which would fall so short of the original. He does not approve of the common tests, as recommended by Hippocrates; and, instead of forming an opinion of the case by throwing the sputa upon fire or water, he prudently directs us to judge of the case from the general symptoms. Unfortunately only a fragment of the chapter on the treatment has come down to us. It appears from it that he approved of a milk-diet and a sea-voyage. In cases of empyema he states that the matter sometimes forms a communication with the windpipe, and is evacuated in that way, and sometimes it is carried off by the urinary passages.

Celsus recommends in particular a sea-voyage, change of air, gestation in a couch, and a milk-diet. He cautions against the bath and exposure to the sun or cold. When other means do not effect a cure, he directs us to burn the chest in different places with the actual cautery, so as to form issues. See a strong recommendation of this practice in Caillot (Elemens de Physiologie, p. 6.)

Galen has detailed the principles upon which phthisis ought to be treated in the fifth book of the ‘Meth. Med.’ He commends strongly a diet of milk, especially that of goats, which is, he says, of an intermediate consistence between the milk of cows and of asses. The ancients, he says, made consumptive patients suck a woman. Whatever kind be used, he recommends it to be drunk as soon as it is milked from the animal; and he further directs sometimes honey or a little salt to be added to it. According to Galen, portions of the lungs are sometimes brought up in the sputa. (Loc. Affec. iv.) Cælius Aurelianus also confirms this statement. (Tard. Pass. ii, 14.) Aretæus, Alexander, and Leo further say that portions of the bronchia have been brought up with the expectoration.

Alexander gives very judicious directions for the choice of milk, and treats of empyema otherwise very fully. He says, when pus is collected in the chest, the sound of it may be heard in succussions of the body.

Aëtius states, upon the authority of Archigenes, that in certain cases empyema is formed without fever. This is now well ascertained to be the case. He approves of the cautery, like Celsus. His account of phthisis is taken from Galen.

Cælius gives many important observations on the proper treatment of consumption, and strictures on the practice of the other sects. He remarks that in old coughs attended with fever, although the expectoration be at first transparent and not purulent, the complaint often terminates in phthisis. His description of the disease is singularly accurate. The pectoral râle he notices in these words: “Quosdam etiam sibilatio vel stridor thoracis sequitur.” The pulse is said to be “debilis, densus ac deinde formicalis.” He mentions that it usually terminates by a colliquative diarrhœa. His treatment is judiciously suited to the circumstances of the case. He condemns the early use of the bath, hellebore, and the formation of issues on the part affected. Of the varieties of empyema he has treated elsewhere at great length. He appears to consider the operation of paracentesis as dangerous.

Many of the remedies recommended by Marcellus contain a combination of stimulant with narcotic substances, that is to say, of myrrh, storax, and the like, with opium and hyoscyamus.

Pliny speaks of navigation, that is to say, a sea-voyage, as a popular remedy for phthisis in his time. (H. N. xxxi, 33.)

Vegetius, the veterinary surgeon, remarks that tubercles like boils form in the lungs of cattle. (Mulom. ii, 45.)

Avicenna’s treatment is in general like that of Galen and his followers. He speaks of inhaling the vapours of arsenic, pine-fruit, &c. He and his countryman Avenzoar approve of paracentesis and the cautery. Mesue recommends the tepid bath in the decline of phthisis. Serapion approves of opening the abscess in cases of empyema by means of a red-hot iron. In the treatment of empyema Haly Abbas appears to have put great confidence in absorbent earths, such as burnt crabs, gum Arabic, Cyprian earth, &c. He gives the milk of asses in the morning, and at night the syrup of poppies. He also praises goats’ milk. He approves of a milk-diet and demulcents likewise in phthisis. He makes frequent mention of poppies, doubtless with the view of alleviating the cough. In certain cases he prescribes the tepid bath; and, under proper regulations, we are convinced that it might often be of service. Haly approves of the tests of purulent expectoration, which we have stated above that Aretæus condemned. Alsaharavius says that the bath may prove useful in phthisis, but that it ought not to be tried except under the direction of a skilful physician. He seems to direct the patient first to use the tepid bath in a warm place, and afterwards to go for a short time into a cold bath. He does not explain the principles of his practice. He approves in general of a milk-diet, but directs us to change it if a diarrhœa come on. The milk of asses or of goats is what he prefers. He approves of the Hippocratic tests of pus. Rhases describes several species of consumption. One of them he represents as being seated in the trachea. His account of the various modes of treatment is most ample. He strongly commends the milk of asses.

Galen, Rhases, and most of the ancient authorities held that consumption is contagious. See, further, Aristotle (Prob. 7), and Isocrates (Æginet.) Alexander Aphrodisiensis accounts for the propagation of the disease by supposing that putrid matter is conveyed from the lungs of the affected person to others. (Prob. ii, 42.)

The historian Sallust uses the word tabes as synonymous with contagium, in the following sentence: “Tanta vis morbi, uti tabes, plerosque civium animos invaserat.” (Catalin. 36.) Livy does the same in several places. (See ii, 23.)

SECT. XXXIII.—ON PLEURISY.

Pleurisy, properly so called, is an inflammation of the membrane which lines the ribs, and is attended with difficulty of breathing, cough, continual fever, and pain shooting to the clavicle and hypochondrium. You may distinguish pleurisy from inflammation of the liver (for in it there are all these symptoms), by the pain in pleurisy being pungent, and the cough being sometimes without expectoration (when it indicates that the disease is not yet concocted), and sometimes with expectoration, the appearance of which indicates the nature of the humour that occasions the complaint; for it is red and tinged with blood when a fulness of blood is the cause; yellow and palish when caused by yellow bile; white and frothy when from phlegm; and blackish when from the melancholic humour. And the pulse is hard and serrated. But, in inflammation of the liver, the pain is not pungent, nor is the pulse so hard; and the cough throughout is dry and without expectoration, and the face appears paler. Pleurisies from inflammation of the external muscles (which are not, properly speaking, pleurisies) are not accompanied with cough and expectoration, nor is the pulse hard; and if one touch the part affected with his hand, the patients feel pain; and if not resolved, the swelling is converted into pus, which may be evacuated externally by an incision; whereas pleurisy from inflammation of the membrane which lines the chest has not this termination; for if it do not discharge the empyema either internally or externally, it terminates in peripneumonia.

The cure. If the pain shoot to the clavicle, we must straightway open a vein; or if to the hypochondrium, we must purge downwards. Physicians of late, in all cases, have recourse to venesection, apprehending, I suppose, the disturbance occasioned by purging. When the strength prevents us from having recourse to either of these remedies, we must use stimulant clysters; and if the pain is moderate, after the clyster we may give honied water, and the juice of ptisan and of chondrus. When the affection is on the decline, we may add to the juices leeks or calamint, and the patient may get the seeds of pennyroyal and nettle, with honey, as a linctus. When the pains are violent after the evacuation, they must be soothed by the application of hot wool, or of sulphurated wool; or by fomentations of millet and flour in a bag, or by means of hot water or oil in a bladder. Unwashed wool may be applied with oil; and wine, containing an admixture of sea-water, or salt, may be added to it. Or we may apply a cataplasm, formed of the medicine from seeds, with the decoction of chamomile and marshmallows, or of dried figs, iris, wormwood, and some honey, with oil of nard. About the fourth day give spoon-meats for food, with some honey; but after the seventh day we are to give a linctus of almonds and nettle-seeds, triturated in honey, or the linctus of butter and honey pounded together. And we are to use the hypoglottis (electuary) of boiled honey. And we must apply to the affected parts the fetid epitheme—that from sweet marjoram, and the rue-plaster. The bulbi, applied with axunge, are often an effectual remedy, and they may also be administered in a clyster with butter and turpentine. Among the most powerful remedies is the linctus from pine-nuts and bitter almonds, linseed, pitch-fruit, and starch, in equal parts, with honey. When they are troubled with insomnolency, it will be proper to give a linctus of poppy-heads; and we may use the antidote called athanasia, and those prepared for this purpose. When the disease remains after the fourteenth day, we must cup them, and keep them upon a spare diet; and then, when the disease is on the decline, we may make them take the bath (but avoiding the cold), and allow them to use a more nutritious diet. If the inflammation of the pleura be not resolved, but appear to be converted into pus, we must have recourse to the remedies formerly mentioned.

For pains of the sides without fever. Pains of the sides without fever are cured by bdellium and costus, mixed with the ashes of burnt cabbage-leaves and tallow: for this remedy is powerfully discutient.

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COMMENTARY. See Hippocrates (de Morbis, ii; de Rat. Vict. in Acut.); Galen (de Med. sec. loc. vii, et alibi); Celsus (iv, 6); Aretæus (Morb. Acut. i, 10; Curat. Morb. Acut. i, 10); Aëtius (viii, 76); Psellus (Op. Medicum); Alexander (vi, 1); Oribasius (Synops. ix, 7, 8); Actuarius (Meth. Med. iv, 4); Nonnus (129); Cælius Aurelianus (Morb. Acut. ii, 13); Octavius Horatianus (ii, 4); Marcellus (de Medicam. 24); Serapion (ii, 21); Mesue (de Ægrit. Pect. 7); Avicenna (iii, 10, 4); Alsaharavius (Pract. xii, 8); Avenzoar (i, 16, 4); Haly Abbas (Theor. ix, 21; Pract. vi, 13); Rhases (Divis. 54; Contin. x.)

Hippocrates gives brief descriptions of pleurisy, and recommends nearly the same treatment that is now practised, namely, bleeding ad deliquium animi, purging, diluent drinks, and fomentations to the side by means of sponges squeezed out of hot water, or of bags filled with salts and millet, or the like. He says, those who have neither been bled nor purged die on the seventh day, either with delirium, or with orthopnœa and a râle. One of his aphorisms is, that pneumonia supervening upon pleurisy is dangerous. (vii, 11.) He was acquainted with pulmonary adhesions, as is remarked by his devoted admirer Laennec.

Aretæus, with his usual accuracy, gives a most complete description of all the symptoms of pleurisy, but, as it is not much different from our author’s, we shall not enter far upon a detail of it. He states distinctly that the disease is an inflammation of the membrane which lines the chest. The sputa are pituitous, bilious, or deeply saturated with blood, or yellowish. He remarks, by the way, that pleurisy is sometimes a sporadic disease, and sometimes epidemical. His directions about the application of the common remedies are dictated by his usual excellent judgment. On the necessity of early and repeated venesection he insists strongly, but recommends it not to be carried the length of producing deliquium animi, as the fluids will thereby be determined inwardly. Archigenes (ap. Aëtium) and other ancient authorities joined him in this rule of practice, although in opposition to Hippocrates. He approves of cupping the side, but not until after the seventh day, and directs us to apply to the scarifications salts or nitre. His internal remedies consist of demulcents, diluents, and narcotics, varied according to circumstances. He forbids the use of cold drink and cold air. Celsus also cautions against cold, and directs sinapisms to the chest. His general treatment is nothing different from that of Hippocrates.

Galen treats of pleurisy cursorily in many parts of his works, but, as he follows entirely the views of Hippocrates, we need not enter into a detail of his practice. We may mention, however, that the worst character of the pulse, according to him, is when it is hard, small, and very frequent. (Diff. Puls. iv, 5.)