SECT. XXXI.—ON SPITTING OF BLOOD.
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.