On the Causes and Symptoms of Acute Diseases (2.2)

THERE are two species of the discharge of blood by the mouth. The one that by the mouth from the head and the vessels there; the passage is by the palate and fauces, where are situated the commencement of the œsophagus and trachea; and with hawking, and small and more urgent cough, they eructate the blood into the mouth; whereas, in that from the mouth, neither does hawking accompany, and it is called Emptysis [or spitting of blood]. But when the discharge is more scanty, and by drops, or when it comes more copiously from the head,

or from the mouth, it is no longer called a bringing up, but either the same, or a spitting, or a hemorrhage. But if it ascend from the chest, and the viscera there, the lungs, aspera arteria, the parts about the spine, the discharge from these is not called a spitting, but a bringing up (in Greek, ἀναγωγή, the name being expressive of its coming upwards).[*]

The symptoms of both are partly common, small and few in number, such as the seat of them, in which there is a coincidence between the bringing up and the spitting. But the peculiarities of each are great, many, and of vital importance, by which it is easy to distinguish either of them from the other. If, therefore, it came from the head, with a large discharge of blood, greater and more numerous symptoms will arise, but scanty from a slight and small spitting; in these cases, there is heaviness of the head, pain, noises of the ears, redness of countenance, distension of the veins, vertigo; and these are preceded by some obvious cause, such as a blow, exposure to cold, or heat, or intoxication; for drinking of wine speedily fills the head, and speedily empties it, by the bursting of a vessel; but from a slight intoxication there may be spitting, proceeding from rarefaction. Occasionally an habitual hemorrhage from the nostrils is stopped, and being diverted to the palate, produces the semblance of a bringing up of blood. If, therefore, it be from the head, there is titillation of the palate, frequent hawking, and with it a copious spitting takes place; a desire supervenes, and they readily cough. But if it flow into the aspera

arteria from the palate, they then bring it up by coughing, and this it is which deceives them into the supposition that it comes from the viscera below. It runs, also, from the head into the stomach, when it is vomited up with nausea, and thus proves a source of deception, as appearing to come from the stomach. The blood brought up by spitting is not very thick, but dark in colour, smooth, consistent, unmixed with other substances; for, being hawked up, it comes immediately upon the tongue in a round shape, being readily separated; and if you examine the roof of the palate, you will find it thickened and ulcerated, and, for the most part, bloody; and a slight and simple plan of treatment will suffice, namely, astringents applied to the palate in a cold state; for by hot, relaxing, and dilating applications the flow is increased, and this is an indication that the spitting is from the head, in which case evacuations are to be made from the head by the veins, the nostrils, or by any other channel of discharge. And these things must be done speedily; for if the blood is discharged a considerable time, the flow will become permanent, and the parts there will contract the habit of receiving the blood. The trachea, also, becomes ulcerated, and the patients cough instead of hawking; and this proves the commencement of a consumption.

The flow of blood from the chest and viscera below is called a bringing up (in Greek, ἀναγωγή). It is truly of a fatal nature, if it proceed from any of the vital parts which are ruptured—either the vena cava in the heart, which conveys the blood from the liver, or from the large vein which lies along the spine. For from hemorrhage, as from slaughtering or impeded respiration, death is very speedy. But in those cases in which the blood comes from the lungs, the side, or the trachea, they do not die so speedily; but, nevertheless, they become affected with Empyema and Phthisis. Of these the least formidable is that from the trachea. But if the vomiting come from the stomach or bowels, the cases are not of a very

fatal nature, even though the hemorrhage be large; neither is the recovery slow and changeable. But if it proceed from the liver and spleen, it is neither readily nor constantly discharged upwards, but the defluxion is more easy into the stomach and intestines. Yet neither is the discharge upwards by the lungs impossible or incredible, for in fevers there occur hemorrhages of blood from the liver and spleen by the nostrils, the blood flowing from the nostril on the same side as the viscus from which it comes. These, then, are the places from which the blood comes in the bringing up, and such the differences as to danger or mortality.

But the modes are three; for it is brought up either from rupture of a vessel, or from erosion, or from rarefaction. Rupture, then, takes place suddenly, either from a blow, straining at a load, or lifting a weight upward, or a leap from a height, or from bawling aloud, from violent passion, or some other similar cause, when blood is instantly poured forth from the vessel in great quantity.

But if it proceed from erosion, the patient is to be interrogated if he ever had a cough before, or was affected with dyspnœa, and whether nausea or vomiting ever afflicted him previously. For from such chronic affections the vessels are corroded by a continued, copious, and acrid defluxion. When, therefore, the containing vessels, having been long wasted and attenuated, at length give way, they pour forth blood.

But the mode by rarefaction is, indeed, unattended by rupture, and on that account the discharge is neither copious nor sudden, nor does it consist of thick blood; for by the rarefaction of the vessels, the thin portion is excreted. But if much collect in a cavity, and be again brought up, it becomes thicker than natural, but yet not very thick, neither black, like a clot; but it is quickly brought up in greater quantity, as being from a collection. This mode of bringing up blood is common with women who have not their monthly purgation,

and appears at the periods of the purgation, and stops during the intervals between them; and if the woman is not cured, the discharge upwards of blood will revert for many periods, and also, in certain cases, the vessels burst from fulness.

And there is a difference of the discharge, whether it be brought up from an artery or a vein. For it is black, thick, and readily coagulates, if from a vein; it is less dangerous, and is more speedily stopped; but if from an artery, it is of a bright yellow colour and thin, does not readily coagulate, the danger is more imminent, and to stop it is not so easy; for the pulsations of the artery provoke the hemorrhage, and the lips of the wound do not coalesce from the frequent movements of the vessel.

Recovery, if from erosion, is protracted, difficult, and doubtful; for, owing to loss of substance, the parts of the ulcer do not come together, for it is an ulcer, and not a wound; and adhesion takes place more readily in ruptures, for the lips of the wound touch one another. This, then, is another difference as to danger. The mode attended with least danger is that from rarefaction; and in it the styptic and refrigerant method of treatment is sufficient.

The places are to be indicated from which the blood is brought up; for many of the symptoms are common, deception is easy, and the cure different. Blood, then, from erosion is not readily brought up from the stomach, for the coldness and stypticity of the articles of food and drink bring the parts to a state of condensation. Neither, also, are cases from erosion common, although more so than the former; for acrid defluxions do not adhere for any length of time, but are either brought up or are passed downwards. Rupture is more common in the stomach. If, then, any rupture take place, the hemorrhage is not very great, such as that from the thorax; for the veins there are slender, and the arteries also are small.

But in appearance the blood is not very black, not intensely yellowish, smooth, or mixed with saliva, being brought up with nausea and vomiting, slight cough, sometimes with some discharge, and sometimes alone, without any expectoration; for the trachea sympathises with the gullet, being extended along and connected with it. There is pinching or constriction of the ulcer from the things swallowed, more especially if they are very cold, hot, or austere; and in certain cases pain is produced in the stomach, extending as far as the back; vomitings of phlegm, and sometimes, when the disease is long protracted, and there has been long abstinence from food, they bring up a great quantity of them; fevers, not of a continual type, but of an irregular kind.

But, from the stomach, what is brought up may be black and coagulated, even if it proceed from an artery; but if it proceed from a vein, it is much blacker and much more compact; much nausea and vomiting of pituitous and bilious matter; blood mixed up with the food, provided the man had eaten previously, for both the food and the blood are collected together in the same place; eructations frequent and fœtid, and, if much collect together, there is anxiety of mind and vertigo; but if these be vomited they are relieved. They are prostrate in strength, generally affected with a burning heat, and constant pain of the stomach.

But from the aspera arteria they bring up scanty and very fluid blood, with a cough; or, if they do not bring it up, they cough incessantly. There is a painful feeling in the throat, either a little below or above; voice hoarse and indistinct.

But if it be from the lungs, the discharge is copious, especially if from erosion, with much cough, of an intense yellow colour, frothy, rounded; so that what is brought up from one part may be distinguished from what is brought up from another. But the defluxion, though contained in a common vessel, from the chest, is diversified after mixture, and you

may distinguish parts of them as being portions of the thorax, and parts which have a fleshy appearance as being portions of the lungs. There is heaviness of the chest, freedom from pain, and much redness of the face, particularly in these cases.

But if brought up from the thorax, pain stretching to the anterior part of the breast is indicative of the ruptured part; cough intense, expectoration difficult, the blood not very fluid, moderately thick, without froth. But if, in passing, the lung be affected by consent, a certain amount of froth is imparted to it, for the passage from the chest to the trachea is by the lungs.

But if, indeed, from the side there be discharged with cough blood which is black, smooth, fœtid, stinking, as from putrefaction, with acute pain of the side, many die after the manner of pleuritics with fever.

A season that is humid and hot engenders these affections. Spring is thus humid and hot. Next the summer; autumn less, but winter least of all. They die in summer mostly from hemorrhage, for great inflammations do not readily occur then; secondly, in spring, from inflammation and ardent fevers; but in autumn, attacks of phthisis readily occur.

In a word, every discharge of blood upwards, even if small, and although the ruptured vessels may have already united, is attended with lowness of spirits, dejection, and despair of life. For who is so firm in mind as to see himself enduring a state resembling that of a slaughtered animal, and yet have no fear of death? For the largest and most powerful animals, such as bulls, die very quickly from loss of blood. That, however, is no great wonder. But this is a mighty wonder: in the discharge from the lungs alone, which is particularly dangerous, the patients do not despair of themselves, even although near the last. The insensibility of the lungs to pain appears to me to be the cause of this; for pain, even although slight, makes one to fear death, and yet, in most cases, it is more dreadful than pernicious;

whereas the absence of pain, even in the great illnesses, is attended with absence of the fear of death, and is more dangerous than dreadful.