Hippocrates describes three varieties of hepatic disease, which appear to have been bilious fevers. It is not easy to define the principles upon which his practice is directed. He mentions, however, emollient applications, bleeding, purging, and vomiting; and, when the disease is protracted, recommends the side to be burned with spindles of box-wood smeared with oil. He directs abscesses of the liver to be opened by the cautery. (Coac. 457.) He states that abscesses of the liver are least dangerous when they open externally; more so when they open internally; and most of all when they open both internally and externally. (Prognost. 7.) He makes mention of hydatids, and says of them that when they burst into the cavity of the peritoneum, the case proves fatal. (vii, 54; where see the Comment. of Theophilus and Damascius, ed. Dietz, p. 540.)
Galen has laid down the principles upon which inflammation of the liver should be treated in the 13th book of his ‘Methodus Medendi.’ We can only afford room for his conclusions. He approves of venesection with the intention of producing revulsion. Such articles of food and medicine are to be given as will emulge the biliary ducts without occasioning irritation, and everything of the opposite kind is to be abstained from. Wherefore such things as are sweet and viscid are to be avoided, and only such as are detergent without pungency are to be allowed. Of this class are ptisan and oxymel much diluted. Astringents, such as pomegranates, are improper, because they occasion contraction of the vessels; and they are more especially to be avoided when the concave side of the liver is affected. When the convex is affected, these articles, being altered by the action of the liver before they reach the seat of the disease, prove less prejudicial. When the concave side is the seat of the disease, he directs us to evacuate by the bowels, which may be accomplished by mixing with the food cnicus (carthamus tinctorius?) the herb mercury, &c.; but, if stronger medicines are required, black hellebore, colocynth, the small centaury, and the like, may be given. When the convex side is affected, he directs us to give diuretics; at first parsley, but, after the inflammation has subsided, the stronger ones, such as Celtic nard, valerian, spignel, &c. He animadverts in strong terms upon the practice of the Thessalian Asses, so he calls the Methodists.
We regret that our limits prevent us from doing justice to the views of Aretæus. The liver, he states, is the grand seat of sanguification, being itself but a concretion of blood. Hence, he says, diseases of it prove speedily fatal. He accounts for the pain which is felt at the top of the shoulder or clavicle in this way: the liver, being enlarged and becoming heavier than natural, drags down the diaphragm to which it is attached, and thus stretches also the pleura from its upper adhesions, whereby pain in the part is produced. A crisis, he says, may take place by a hemorrhage, a copious discharge of bile, or of urine; or the disease may terminate in suppuration, or in dropsy. When pus is formed, it may be discharged by urine, by the bowels, or it may point outwardly. In this last case, he recommends us to open it with an instrument red hot. When it does not suppurate it is apt to end in scirrhus, which is marked by a dull pain in the part. His treatment of acute hepatitis consists of venesection, refrigerant and discutient applications externally, cupping or leeching the side affected, then applying cerates and emollient ointments, consisting of attenuants and diuretics, such as wormwood, cider, &c. The food is to be light, of easy distribution, and diuretic. His treatment of chronic disease is varied, according as the matter passes by the urine or the bowels; but the chapter on it is incomplete.
Celsus at the commencement recommends bleeding, purging even with black hellebore, cataplasms at first repellent and then calefacient. Diuretics are to be given, such as thyme, hyssop, &c.; and all cold things are to be avoided. When a vomica forms, it is to be opened and burnt.
Alexander’s account is full and judicious. He says that, in cases of obstruction of the liver, when deobstruents are given before the swelling is softened, the juices being overheated become like stones and cannot be discussed. He alludes, of course, to hepatic calculi, or gall-stones. He gives copious directions for emollient ointments to be rubbed into the side to dispel the enlargement of the liver.
In treating of scirrhus, Aëtius recommends the emollient ointments, cupping, leeching, calefacient plasters, sinapisms, burning by medicines or by the actual cautery.
The account given by Actuarius is in so far important, as it shows that the views of practice had not changed in his days. In inflammation, he recommends to bleed two or three times, and to unite emollients with deobstruents in the external applications.
For a full exposition of the doctrines of the Methodists, we must refer to Cælius Aurelianus, of whose opinions we can afford room only for a very brief outline. The symptoms of scirrhus of the liver, as stated by him, are a round circumscribed tumour felt below the ribs, the colour jaundiced, the urine muddy, pain extending to the throat of the affected side, difficulty of lying on the left side, as this posture suspends the enlarged viscus. (By the way, Cassius assigns the same reason why persons labouring under disease of the liver or spleen lie easiest on the affected side. Probl. vi.) At the commencement he recommends fomentations, cataplasms, laxative food, and then cupping, scarifications, and leeching. When the attack is violent, venesection is to be premised. Frequent changes, acrid food, and emetics with vinegar of squills or hellebore are also mentioned. He recommends a sea-voyage, vapour-baths, hot springs, the sand-bath, and various stimulant and rubefacient applications to the side. He delivers his strictures very freely upon the practice of the other sects. Thus he justly condemns as too bold and dangerous a measure the proposal of Erasistratus to lay bare the liver, and apply the remedies direct to the part affected. He thinks Asclepiades improperly rejected gestation, baths, cataplasms, and emollient ointments. He also condemns the free use of cauteries to the affected side.
Serapion, like Alexander, states strongly the danger of using discutients before emollients, lest the juices become indurated. No ancient author has treated of the diseases of the liver so fully as Avicenna. He is most minute in his distinctions of disease, and particular in his application of remedies. Among other diseased states of the viscus, he mentions diminution of bulk. Had not inspectiones cadaverum been common in ancient times, the existence of this state of diseased structure could not have been ascertained. In abscess, he and Serapion make mention of taraxacum or the dandelion, which was recommended by the late Dr. Pemberton in cases of diseased liver, and is still used occasionally. Haly Abbas directs us, when suppuration takes place, to determine to the kidneys by diuretics; and, when the abscess bursts into the cavity of the peritoneum, he advises us to open it. When it makes its way to the stomach or bowels, he recommends us to promote its discharge by purging. He remarks that sometimes an abscess will form externally to the liver and put on the appearance of hepatic abscess. He directs it to be opened with aperient medicines or the lancet. He takes notice of the pain at the top of the shoulder, which, like Aretæus, he attributes to the dragging down of the parts by the heavy liver. In the cold aposteme (chronic inflammation?) he recommends wormwood, fenugreek, hyssop, spikenard, fennel, and the like. One of his favourite remedies for hepatic disease is rhubarb. Alsaharavius gives a long account of these diseases. Inflammation he treats by bleeding, various laxative and cooling medicines, emollient plasters, &c. In obstruction he gives rhubarb, wormwood, fennel, endive, &c.; and bleeds, if there be a sanguineous plethora. He treats fully of a discharge of blood from the liver. When it arises from the bursting of a vein after excessive fatigue, he directs us to bleed; but when it proceeds from relaxation and debility, he recommends astringents externally and internally. The account of hepatic diseases given by Rhases in his ‘Continens’ is particularly excellent, but it is too lengthy for our limits. He explains the pain at the top of the shoulder in the same way as Aretæus. He mentions that gross food produces enlargement of the liver, and hence animals fed on figs have large livers. For inflammation he recommends at first depletion and afterwards refrigerants, such as camphor, fleawort, and even snow-water. He recommends aloes with wormwood as a deobstruent cathartic.