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.)
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.)