Part 49

SECT. XVI.—THE DIAGNOSIS AND CURE OF EPHEMERAL FEVERS.

It is a peculiar and inseparable symptom of ephemeral fevers, that concoction of the urine takes place on the first day; and a pleasant state of the heat is likewise peculiar and inseparable from such fevers. After the first resolution of the fever, you will have a still more confident diagnosis; for the motion of the arteries then becomes similar to that of persons in health, whereas no other fever returns so soon to the natural state. And it is also a very great mark of this fever that the patient bears it well. Those persons are readily seized with this complaint in whom the perspirations are not vaporous, but very acrid, as if containing something fuliginous. Such are they who are of a hot and dry temperament, and, in fine, those who are troubled with bitter bile. Those who are seized with this fever from fatigue should be rubbed softly with oil and bathed; but those from dryness, are to be rubbed less and bathed more. Those from cares, grief, watchfulness, or anger, are not to be bathed often, but slightly rubbed with plenty of tepid oil possessed of little stypticity; and bathed according to habit. Those who have been seized with the fever from inordinate heat are to be treated from the commencement with cooling things and more baths, but by no means with much oil and friction. The cooling things should be rose oil, or cold oil of unripe olives, prepared without salts. The same are to be poured upon the open of the head, and the bath used when the fever has passed its acme. If a person has a fever from congelation, he is to be bathed in the decline; but if the fever be attended with catarrh, he is not to be bathed until concoction takes place; but those who have fever from exposure to heat are to be bathed while these symptoms are present. Those from exposure to cold are to be warmed moderately, and have the head bathed with such applications as the oil of iris and of nard. To those in whom the fever is occasioned by constriction of the skin, the proper remedies are, tepid baths of sweet waters, friction to open the pores, exercises, and an exhilarating diet. Those in whom the fever is occasioned by want of food are to be led to the bath after the decline of the first paroxysm, and to have plenty of tepid oil poured upon them; are to be rubbed most gently, and to remain for the greater part of the time in the cistern of the warm bath. After coming out and recovering their strength, they are to be led again to the bath, and afterwards get warm water to drink, the juice of ptisan, and sometimes of lettuce; and are to partake of fishes having tender flesh, in white broth. The common diet in all these cases ought to consist of things which contain good juices, of easy digestion, and which will not be restrained within the pores of the skin. Wine should be given which is watery in appearance and strength. It will sometimes be proper, on the first attack of the fever, to give some nourishing food, when the fever has been enkindled by an intemperament inclining to the hot and dry. Those who have this fever from inflammation of the glands of the groin, do not require a physician to instruct them what ought to be done; for, attending to the ulcer from the time that the bubo is formed, they take the bath in the decline of the paroxysm. But they ought to be restricted as to wine, until the inflammation of the groin is resolved, and use a spare diet.

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COMMENTARY. Among all the remains of ancient medicine which have come down to us, there is not, perhaps, anything more valuable than the reports of febrile diseases, contained in the ‘Epidemics’ of Hippocrates, illustrated, as they fortunately are, by the learned ‘Commentaries’ of Galen. Many of them are histories of ephemeral fevers, brought on by certain exciting causes, and terminating in synochus. The procatarctic causes generally assigned are fatigue, excessive debauchery, grief, exposure to extreme heat or cold, and the like.

Hippocrates thus defines the duty of the physician in conducting the treatment of febrile diseases: To be able to tell what had preceded them; to know the present state and foretel the future; to have two objects in view, either to do good, or at least to do no harm. (Epidem. i, 7.) His general rule with regard to regimen in fevers is most important, namely, that a diluent or moistening diet is proper in all febrile affections. (Aphoris. i, 16.) See his Comment. (t. ii, p. 283, ed. Dietz.)

Of no disease has Galen treated so frequently and fully as of fever. (See de Diff. Febrium, Meth. Med. viii and ix; Therap. ad Glauc., de Crisibus ii, 13, et alibi.) He everywhere inculcates that ephemeral fevers are affections of the spirits, by which he seems to have understood the heat and gases contained in the blood. The exciting or remote causes of them, according to him, are want of sleep, indigestion, sorrow, fear, anger, anxiety, the application of heat and cold, excessive fatigue, tumour of the groin, and the like. He remarks, that the heat in these fevers is not offensive on the first application of the fingers, but conveys an acrid sensation after a short time. He has particularly stated constriction as a proximate cause of fever; and this, by the way, is agreeable to what is stated by Cælius Aurelianus: “quidam vero conclusioni viarum causam febrium ascribentes.” (Acut. Morb. ii, 33.) In this variety, he approves of venesection, unless the patient be a child or a very old man. In the other cases, his most approved remedy is the bath; but his treatment is judiciously varied, according to circumstances. For example, when the fever arises from the depressing passions, he forbids hard friction and frequent baths, and merely directs us to pour tepid oil over the patient’s body. When it is produced by exposure to heat, he forbids us to use much oil, or to have recourse to hard friction, and directs us to pour upon the head water which has been cooled by means of ice, and to put the patient into a cold bath. Alexander, however, finds fault with him for giving heating medicines, such as pepper, and using hot applications over the stomach in such cases. Alexander’s account of the nature and treatment of these fevers cannot be perused with too much attention. He mentions as characteristics of ephemerals, that the urine is properly concocted from the first; and that the pulses have a quick and elevated diastole, with a shorter systole; the vessels, he adds, requiring refrigeration, rather than purification. They arise, he says, from many and various causes, such as repletion, want, watchfulness, fatigue, disorder of the belly, apostemes; and, in a word, from all the procatarctic causes. When the fever is occasioned by excessive fatigue, the indication, he states, is to supply moisture to the body, rather than to take from it. Hence, all friction with discutient oils ought to be avoided; and what is used for rubbing the body should be mixed with much water. But the principal dependence is to be put upon the tepid bath. Here, again, he thinks that Galen erred, in not directing that the oil used for rubbing the body should be diluted with water. He adds, that it will often have an excellent effect after the patient has come out of the tepid bath, and been anointed as directed, to make him take a warm bath and remain in it for a considerable time. When ephemerals arise from indigestion, he gives very minute directions for the treatment, according to the nature of the exciting cause. When connected with constriction, he approves of bleeding, if, as generally happens, it be attended with fulness.

Oribasius and Aëtius treat of ephemeral fevers in much the same terms as our author.

Palladius says that ephemerals are affections of the spirits, arising from some external exciting cause, such as fatigue, intoxication, anxiety, watchfulness, or from a tumour of the groin. Celsus gives a similar enumeration of the causes, but in briefer terms: “Febris ex inguine, vel ex lassitudine, vel ex æstu, aliâve simili re est.” Almost all the authorities, from Hippocrates downwards, mention enlargement of the glands, especially those of the groin, among the causes of fever. Agathias, the historian, remarks, that pestilential fever is attended with enlargement of the inguinal glands, but does not terminate favorably in one day, like the ephemerals. (Hist. v.) Stephanus, the commentator, accounts for the enlargement of the glands in fever, as being a collection of the impurities of the system in its weakest points. (Ed. Dietz, p. 244 and 256.)

Nonnius enumerates nearly the same causes of these fevers as our author, whom he appears to have followed closely. He remarks, that ephemerals are sometimes protracted to the third or fourth day, from which it appears that the term is not to be taken in too strict a sense. Leo, also, expresses himself in like terms.

Synesius treats of ephemeral fevers with great accuracy, so that we have reason to regret that the text of this author should be so corrupt. Like preceding authors, he enumerates, among the exciting causes, abscess of the glands of the groin, neck, and armpits, the heat of which, he says, being determined to the heart, kindles a fever. In this case he recommends discutient and emollient applications, such as mallows, linseed, and the like. The account given by Constantinus Africanus is exactly similar to his.

Actuarius mentions the same causes, and briefly recommends the same treatment as our author.

Alexander Aphrodisiensis says expressly, that the ephemeral fever may pass into the putrid and the putrid into the hectic. (De Febribus, 28.)

Haly Abbas gives a most distinct and accurate account of the phenomena of ephemeral fevers, according to the nature of their remote causes. The first class are produced by external causes, such as exposure to the heat of the sun, hot baths, or astringents which occasion constriction of the pores of the skin. He also inculcates that these causes may likewise give rise to synochous or putrid fevers. The second class are produced by calefacient food and medicines. The third class are occasioned by immoderate exercise, or violent passions, such as anger, fear, and the like. The fourth are sympathetic affections proceeding from inflammatory swellings of the glands. He remarks, that in certain kinds of fever the increase of heat is not felt upon the first application of the hand, owing to constriction of the pores. (Theor. viii, 3.) His treatment merits attention. When the fever arises from a hot cause, he directs us to pour refrigerant liquids, such as vinegar, rose oil, and the like, upon the head, and to apply to the forehead a cloth moistened with the same. When the fever is produced by cold, he recommends the warm bath, with friction, in order to promote perspiration; after which calefacients may be given; but he forbids wine, if the exciting cause be great, lest it should occasion a conversion of the complaint into a putrid fever, which, as he remarks, Galen states not to be an uncommon occurrence. To prevent this he recommends venesection and the liberal administration of diluents. The next class of ephemerals of which he treats are intestinal fevers originating in errors of food and drink. For these he recommends cooling drink, cooling articles of food, clysters, eccoprotics, and the like. When the fever is brought on by violent labour, he prescribes the tepid bath, gentle friction with emollient oils, light food, and a spare allowance of wine, provided the patient has been habituated to it. When the fever is produced by violent emotions of the mind, he recommends the tepid bath, refrigerant food, camphor, and the like. When it arises from sorrow, he directs us to have recourse to treatment of an exhilarating nature, the bath, wine, and so forth. For fever brought on by want of sleep, he recommends soothing treatment, the affusion of tepid water and wine, if the patient has been accustomed to it. In fevers arising from glandular swellings, he approves of venesection, and forbids the use of the bath and of wine. This is somewhat different from our author’s treatment. The account of the causes and treatment of ephemerals given by Alsaharavius is so like that of Haly Abbas, that we shall not enter particularly upon it. Serapion, Averrhoes, and Avenzoar give sensible expositions of the causes and cure of these fevers; but there is little in them worthy of attention that is not derived from the Greeks. Avenzoar states distinctly, that, if neglected or mismanaged, they are apt to be converted into putrid, or synochous fevers. For ephemerals occasioned by labour, he recommends the tepid bath, and friction with the pulp of melons. Avicenna remarks, that if, in ephemerals, the blood become inflamed, the fever is apt to be converted into synochous, or, if it become putrid, into putrid fever. This, he says, is particularly the case, when the ephemeral fever is connected with obstruction of the pores of the skin. For the cure of this species, he approves of venesection. He recommends the same remedy when the disease arises from drinking too much wine, or from aposteme of the groin, armpits, or neck. His expositor Syrasis particularly commends the tepid affusion in ephemerals. Rhases joins in enforcing the same practice as Avicenna. He gives a most comprehensive account of the causes of these fevers. Like all the other authorities, he decidedly inculcates this important fact, that, although ephemeral fever be in itself neither serious nor fatal, it may be converted into a vehement and acute fever, when any error is committed in the regimen or method of cure. Constriction, he says, may take place, either in the pores of the skin, or in the internal parts, and is generally occasioned by cold or astringents. This is one of the causes of fever. The others are, immoderate exercise, the application of heat, food of a heating nature, and putridity.

According to Prosper Alpinus, the Methodists held that the proximate cause of fever is constriction. Galen, as we have stated, held this to be one of the causes, but not the sole one. The Methodists, like our Cullen and Hoffman, seem to have generalized too much. Their most approved remedies were the warm bath and friction with emollient oils. (De Med. Method. v.)

The earlier modern writers on medicine give the same account of ephemerals as their ancient masters, whose views in all cases they servilely adopt. See Rogerius (Tract. iii), and Platearius (de Febribus.) Rogerius correctly remarks, that ephemeral fever, from enlargement of the glands, is merely symptomatic. The causes of ephemerals, as enumerated by him, are exposure to extremes of heat and cold, food and drink of a heating nature, strong exercise, violent passions of the mind, and the like. Platearius remarks that if an ephemeral be prolonged beyond the third or fourth day, it is apt to be converted into a putrid fever.

SECT. XVII.—ON DIAGNOSIS OF FEVERS FROM PUTREFACTION.

The diagnosis of fevers from putrefaction is formed from observing that none of the procatarctic or exciting causes had preceded; and it is peculiar to fevers from putrefaction, that they do not commence with rigors, and have not been preceded neither by strong heat or cold; and compression of the pulse is also peculiar to them. This is the name given to the pulse, when in the commencement of the paroxysm it is very small and irregular. This is a well-marked peculiarity of such fevers. But the strongest characteristic of putrid fevers is, the quality of the heat; for it is fuliginous so as to prove pungent to the touch. Want of concoction in the urine and feeble digestion are also peculiar to them; for, in such fevers, a strong and distinguished appearance of concoction in the urine is never to be seen at first.

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COMMENTARY. This Section is mostly taken from Oribasius (Synops. vi, 7.) Many of the histories in the Epidemics of Hippocrates are synochous fevers, accompanied with putrefaction of the fluids. Galen remarks that they occur principally in persons of a plethoric and gross habit of body. (Meth. Med. viii.) According to him, putrid fevers may either arise from the conversion of ephemerals, or originally from putrefaction of the fluids within the vessels. (De Diff. Feb. i, 9.) Aëtius states that they arise from constriction of the skin, or viscidity of the humours, whereby the perspiration is stopped, and the quality of the vital heat so altered as to give rise to putrefaction, first of the fluids, and afterwards of the fat and solid parts. When these corrupted fluids are contained within the vessels, they occasion synochous fevers; but, when distributed over the body, they give rise to intermittents. (v, 74.) Synesius and Constantinus Africanus give a similar account. Alexander gives an interesting and ingenious disquisition on the origin and nature of putrid fevers, one of the most common causes of which he holds to be the conversion of ephemeral fevers, and the inseparable symptoms being want of concoction in the urine and quickness of the pulse with systole. This is the account of them given by most of the other authorities, both Greek and Arabian, so that we need not enter into any very circumstantial exposition of their views. We shall merely give the brief account of them furnished by Palladius. There are, he says, two kinds of synochous fevers, the one being occasioned by effervescence, and the other by putrefaction of the blood; of these, the latter are the more protracted and dangerous. In them the pulse is contracted, the heat pungent, and the urine white and putrid. Among the Arabians, see, in particular, Alsaharavius (xxxii, 6); Haly Abbas (Theor. viii, 5); and Rhases (Cont. xxx.) Rhases states that putrid fevers are often engendered by eating too much fruit, such as peaches. He says they generally begin with depression of the pulse, horripilation, torpor, and somnolency.

SECT. XVIII.—THE CURE OF PUTRID FEVERS.

When the powers of the constitution are strong, a person affected with a putrid fever ought to be bled in the commencement, provided there be no crudities in the stomach. But when the powers are weak, or the age of the patient is an objection, you must not bleed. After the evacuation by bleeding, it will be proper to clear away the putrid matters by urine, the belly, and sweating. And, if they have spontaneously been determined towards the mouth of the stomach, they may be evacuated by emetics, but otherwise you must not produce an unnatural irritation. Such things ought also to be selected as will effect the afore-mentioned evacuations without heating or drying, such as the juice of ptisan, honied water, oxymel, apomel, and the root of parsley. When the belly is not opened, an injection of mulse, with oil, may be given. The body is not to be rarefied before evacuations; but, after evacuations, it may be rarefied by means of an oil possessing a gentle heat, such as that of chamomile. At this season, all the secretions are promoted by drinking of some watery wine, and using a tepid bath of sweet water. When the strength of the fever is an objection, you must neither use wine, the bath, nor rarefying unctions; but, in such cases, drinking of cold water is the most suitable remedy, if nothing prevent the use of it likewise. But if all the powers are strong, the fever of a very hot nature, with clear symptoms of concoction, cold water may be given boldly. But if he is muscular, and the constitution of the air hot and dry, he will not be hurt by being thrown into a cold bath. And if the fever is moderate, and the strength good, with symptoms of concoction, baths, the drinking of wine, and unctions of a rarefying nature will be beneficial to such persons.

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COMMENTARY. All subsequent writers on this subject are indebted to Galen for laying down, in the most satisfactory terms, the principles upon which the treatment of putrid fevers ought to be conducted. He particularly recommends bleeding ad deliquium. When this evacuation is neglected, the patient’s only chance of safety is from a spontaneous hemorrhage or profuse perspiration. He is so confident in the remedial powers of venesection, that he directs it to be performed as late as the seventh day, and even later, if the strength of the patient permit. He particularly directs us likewise to allow the patient to drink as much as he chooses of the coldest water, which, he says, when seasonably administered, is most efficacious in extinguishing the febrile heat. This remedy, however, he says, is to be used with becoming caution. But, upon the whole, he strenuously inculcates that the safety of the patient depends upon the free use of phlebotomy and cold drink. When the fever abates, he allows wine. Alexander, although sufficiently disposed to differ from Galen, entirely concurs with him in opinion respecting the treatment of putrid fevers, for which he particularly commends bleeding and cold drink. When venesection is contraindicated by the weakness of the patient, he is to be treated by a refrigerant and diluent regimen.

Aëtius and Oribasius follow Galen, and their treatment, therefore, agrees perfectly with our author’s. Synesius and Constantinus Africanus agree in recommending bleeding and cold drink. But when the patient is very weak, they forbid us to have recourse to the former, and, in that case, direct us to use gentle aperients, and medicines of a refrigerant and diluent nature, such as prunes, jujubes, purslain, and the like.

Although Avicenna lays little claim to originality, his plan of treatment in this case is deserving of attention, as being directed by the soundest judgment. He begins with venesection, if the patient’s strength permit, and then opens the belly gently, but cautions against violent purging. He then gives first diuretics, and afterwards sudorifics. Unless when the stomach is loaded with crudities, he approves very much of cold drink. Though favorable to the seasonable practice of venesection, he forbids it except at the commencement; and directs to proportion the loss of blood to the strength of the patient. He also forbids interference with the crisis by bleeding, purging, or giving gross food at that season. Further, with regard to venesection, he does not approve of abstracting much blood at once, which may occasion a dangerous prostration of strength; but prefers taking a moderate quantity, and repeating the operation, if necessary. The purgatives which he most commends are tamarinds and myrobalans; but when these are not sufficiently strong, he permits scammony, aloes, and colocynth to be given. He also directs us to give camphor as a refrigerant. It is to be kept in mind that the Arabians held the action of camphor to be frigorific, that is to say, narcotic. He is most minute in his directions about the diet. For drink, he gives barley-water, with a small proportion of wine or vinegar.

Haly Abbas lays down the rules of treatment with great precision. He recommends venesection at the commencement, provided the fever be of a sanguineous type; but, if the patient be debilitated, he is to be treated with refrigerants.

Averrhoes treats of putrid fevers at great length, and with more than his usual judgment; but, as he differs but little from Avicenna, we shall not attempt to give an abstract of his practice. (Collig. vii, 9.) Rhases gives a full account of the practice of the Greeks. When the extremities are cold, and the pulse weak, he directs them to be rubbed, in order to draw off the blood from the internal parts.

Alexander Aphrodisiensis inquires how it happens that wine, which is of a hot nature, proves useful in fever. The amount of his speculations upon this matter is this, that the wine acts by strengthening the powers of the system. (Probl.)