Part 51

COMMENTARY. We mentioned, in the 18th Section, that the ancients held quartans to be occasioned by an accumulation of black bile. Hence, says Hippocrates, they prevail most in autumn, and attack persons between the ages of twenty-five and forty-five. (De Nat. Hum. 29.) He recommends principally for them emetics, purgatives, and the warm bath. (De Affect. 19.) By wandering fevers, of which mention is made by our author, is meant fevers, the paroxysms of which return after an interval of many days. See Hippocr. (Epidem.); Rhases (ad Mansor. x, 8.)

Our author’s description is condensed from Galen (Therap. ad Glauc. i), or probably copied direct from Oribasius (Synops. vi, 12.) Galen states that quartans are of a less inflammatory nature than tertians, and hence the pulse is slower and smaller. Ruffus (ap. Aëtium, v, 83) refers the origin of certain quartans to the spleen. Alexander says that quartans arise from yellow bile overheated, or from feculent blood, these humours being lodged either in the vessels or in the spleen. Palladius, Nonnus, Synesius, and, in a word, all the Greek authorities, give a similar account of the nature of quartans. Constantinus Africanus says that a paroxysm lasts for twenty-four hours, and is succeeded by an interval of forty-eight hours. The urine is at first white and watery, but in the decline becomes black. He mentions that it is connected with induration of the spleen. Actuarius gives a similar account of the nature of the disease, and of the characters of the urine. The disease, he says, is generally connected with some affection of the liver or spleen, and passes off by a discharge of black urine. He relates an interesting case to this effect. (De Urinis, ii, 17.) It may be proper to mention that in all other acute diseases, a discharge of black urine was reckoned a very mortal symptom. (De Urinis Comment. ed. Ideler.)

As there is nothing original in the theory and descriptions which the Arabians give of quartans, we shall not enter upon them minutely. Averrhoes states that the fever invades with a great sense of cold, so that the patient’s teeth chatter. The colour of the urine at first inclines to green, or is somewhat white; but afterwards it becomes gross, black, or reddish. The interval between the paroxysms is two days. The most of those affected with quartans have disease of the spleen. Alsaharavius gives exactly the same account of these fevers. Avicenna’s description is most ample and comprehensive, but contains no additional facts to those we have already mentioned. Haly Abbas, Avenzoar, and Rhases, in like manner, adopt the views of the Greeks.

SECT. XXIII.—THE CURE OF QUARTANS.

Those affected with quartans are to be treated gently, without any powerful medicine or evacuation, unless a great fulness of blood prevail, in which case it may be necessary to bleed. The diet should be good and not flatulent, and the belly ought to be loosened by the customary things; and, if these are not sufficient, clysters may be used, at first emollient, and afterwards acrid. They must be prohibited from swine’s flesh, and everything that is viscid and slowly evacuated, and also from all cooling and diluent articles of food. Let them use a thin white wine moderately warm, also pickles and mustard. And after an interval of some days, they should take the composition consisting of three peppers, or that called Diospoliticus. And if they take every day of pepper alone in water, they will do well. But if the patient is at the acme of the complaint, his diet ought to be very light, he should be enjoined to take protracted rest, and to take care of his bowels by using emollient and laxative things. Next, let him use diuretics; and if the symptoms of concoction appear manifest, then he may boldly have recourse to such as evacuate black humours, and that not once only, but frequently. After a powerful evacuation give also the medicine from vipers, and such others as are recommended for these fevers, among which is the well-known and most celebrated of all containing the Cyrenaic juice.

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COMMENTARY. This Section is copied from Oribasius (Synops. vi, 13.) Galen, however, is the great authority upon this subject. With respect to venesection, he directs us to have recourse to it only when there is a plethora of blood; but recommends, when a vein has been opened, and the blood found to be black and thick, especially in the case of diseased spleen, to abstract blood until it change its colour. He approves of laxatives, and clysters, at first emollient and afterwards acrid. He forbids those things which were supposed to engender black bile, and recommends a thin white wine. He speaks favorably of pepper. When the disease is come to its acme, he recommends the state of the viscera to be rectified by fomentations and cataplasms, and by administering melanogogues, especially hellebore, in such quantity as to operate powerfully upwards and downwards. He speaks favorably of vipers, and also of assafœtida. (Therap. ad Glauc. i.) The Commentary of Stephanus on this work, lately published by Dietz, contains very sensible remarks on the practice here recommended.

Alexander delivers his opinions regarding the treatment of quartans at so great a length that it is impossible to do justice to them in an abridgment. As usual, he animadverts freely upon the doctrines of Galen, whom he finds fault with for recommending desiccants and calefacients in every species of quartan fever; whereas he maintains that when it arises from adust bile, refrigerants are indicated. He strongly commends emetics at the beginning of a paroxysm. He approves of peppers combined with opium, henbane, and other articles. Synesius and Constantinus Africanus admit the distinction made by Alexander, and nearly follow his principles of treatment. Synesius makes mention of wormwood, which, however, had been recommended by Ruffus. (Ap. Aëtium.) Serenus Samonicus also recommends wormwood: “Mira est absinthi cum simplice potio lympha.”

Celsus gives minute directions for conducting the treatment in all the stages of the complaint. He thus sums up the remedies which he recommends: “In ejusmodi valetudine medicamenta sunt, oleum, frictio, exercitatio, cibus, vinum.”

Serapion mentions black hellebore, agaric, and the lapis lazuli, as medicines which purge black bile. (De Antid. vi, 15.) Averrhoes, however, cautions against using black hellebore for the cure of quartans; expresses himself in dubious terms respecting venesection; and, upon the whole, seems to place his principal reliance in things of a diffusible, attenuant, and penetrating nature. Haly Abbas, Avicenna, and Rhases speak of venesection in much the same terms as Galen, that is to say, they recommend it when symptoms of plethora are present, but say that it may prove prejudicial in any other circumstances. They approve of emetics at the commencement, and of wormwood in the decline of the fever. Avicenna appeals to Galen in favour of the black and white hellebore. Several of Rhases’ authorities in his ‘Continens’ recommend bleeding. They in general approve of the early use of the bath, and of diuretics and sudorifics; and recommend, in the decline of the fever, things of a heating nature, such as pepper, anise, spikenard, ginger, &c.

It remains to be mentioned that amulets were very much used in ancient times for the cure of quartans. Alexander Trallian had great confidence in them. Galen supposed that they owed their virtues to the physical properties of the substances which were appended. Ælius Spartianus, one of the writers of the Augustan History, says, that the emperor Caracalla wished to punish those who made use of amulets. On the περίαπτα, περίαμματα, vel amuleta of the ancients, see Andreas Laurentius (de Mirab. Strum. sanat. p. 83); Rendtorfius (Notæ in Anatolii Fragment. ap. Fabricii Biblioth. Græc. iv, 305); and Wolfius (ap. Act. Lips. 1690.) The practice of using amulets for the cure of diseases must have been very ancient, for it is alluded to by Pindar (Pyth. iii), and Theophrastus (H. P. ix, 10.) The facts recently stated in support of the system of Animal Magnetism have been supposed to give some countenance to the ancient belief in the efficacy of amulets.

SECT. XXIV.—THE DIAGNOSIS OF THE QUOTIDIAN.

The quotidian does not make its attack with a rigor on the first day, but in progress of time, a chill rather than rigor takes place, which is, with difficulty, succeeded by heat, and it has a protracted increase. Yet, it does not make those affected hot, nor their respiration frequent and thick, nor does it make them pant or drink cold water. But they have vomitings of phlegm, and whatever is voided by the belly is cold, crude, and watery, in these fevers. And they have no sweats during the first days, neither have they an interval of freedom from fever. Their colour is white and pale; their urine thin and white, or thick, turbid, and red.

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COMMENTARY. We have stated, in the 18th Section, that the ancients were of opinion that quotidians derive their origin from phlegm, that is to say, serum.

Our author’s description is abridged from Galen (Therap. ad Glauc. i.) The other authorities treat of it in much the same terms. Even Alexander, who aims at originality, agrees with Galen and Hippocrates, in referring the origin of quotidians to phlegm. Palladius, in his valuable little treatise on Fever, is at great pains to explain the manner in which putrid extravasated phlegm gives rise to quotidian. He represents the heat as being smothered and concealed like that of moist fuel. Celsus describes all the varieties of the disease very minutely. Constantinus Africanus gives an accurate description of this intermittent. He says that the paroxysm lasts for twenty-four (eighteen?) hours, and is followed by an interval of six hours. First, old persons, and then boys, are said to be peculiarly subject to the disease, which is apt to make its attack in cold countries and at cold seasons of the year. It is attended with a great degree of cold, especially of the extremities; the face is swelled, the colour pale, and no thirst is present.

As the Arabians give the same account of the origin and symptoms of quotidians, we need not enter upon a detail of their descriptions. All agree that they are connected with phlegm as an exciting cause, and that the fever is less ardent and well-marked than in the case of tertians.

SECT. XXV.—THE CURE OF QUOTIDIANS.

In curing the quotidian, we use oxymel during the first days, and those things which properly promote the discharge of urine. And, upon the whole, the diet ought to be incisive; but, at its acme, we must look to the stomach, particularly its orifice. We must also prescribe an emetic from radishes taken with food, and phlegmagogue cathartics in abundance, until it subside.

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COMMENTARY. This Section is taken from Oribasius (Synops. vi, 14.)

Celsus enjoins abstinence for three days; after which food is to be taken every alternate day. After the fever has subsided, he recommends the bath and wine.

Galen’s treatment is exactly the same as our author’s. Alexander, as usual, makes nice distinctions as to the circumstances under which each of the remedies ought to be applied. In general, he approves of incisive and attenuant medicines, but blames Galen for recommending the latter too indiscriminately. He forbids cataplasms and embrocations at the commencement, lest they should occasion a determination of the humours to the affected part.

Synesius appears to have proceeded upon much the same principles as our author, but he makes mention of some additional medicines, such as camphor, wormwood, and the like.

Nonnus recommends, at first, things of an incisive and attenuant nature, and then emetics, after which the phlegm is to be purged by means of colocynth and agaric, and cataplasms and fomentations are to be applied to the pit of the stomach.

Avicenna lays down the rules of treatment with so great minuteness, that we cannot venture upon an abridgment of them. His principles, however, seem to be the same as those of Galen. Averrhoes recommends, for the first seven days, medicines of an incisive, attenuant, and deobstruent nature. He then gives cathartics which evacuate phlegm, such as turbith, agaric, and hiera picra, but forbids the use of colocynth. He approves very much of friction, the mode of applying which is minutely described by him. Rhases recommends much the same treatment. He, in particular, recommends turbith and agaric along with wormwood and mastich. Haly’s remedies are mostly diluents and attenuants. Alsaharavius recommends the same remedies as Rhases.

SECT. XXVI.—ON THE FEVER HEPIALUS, AND THE RIGOR WITHOUT HEAT.

The vitreous phlegm being the coldest of all, if it accumulate in the body, and remain free from putrefaction, it occasions the rigor without heat, which is not attended with fever. In those fevers which are kindled by the humours, it is putrefaction for the most part which kindles febrile heat. If it become putrid, and that through its whole substance, which is rarely the case, owing to its great coldness, it occasions quotidian fever. But when it is half putrid, and not equally through its whole substance, but some parts of it being putrid, and others not, it gives rise to the fever called hepialus, in which those affected have rigors and fever at the same time; for the parts of the humour which are not putrid being scattered through the veins all over the body, occasion rigor; but the putrid parts kindle fever. The word hepialus is either derived from ἡπίας ἁλος, i. e. the sea, which is mild in appearance, although formidable in reality; or from ἡπίως ἁλεάζειν, i. e. warming gently. And, as this fever is of the quotidian kind, being formed by phlegm, it is to be treated in the same manner; only that it requires remedies as much hotter and more incisive than the quotidian, as its phlegm is colder than that of the other. The rigor without heat stands in need of heating things still more than the hepialus. Wherefore, the composition of three peppers, that from calamint, and still more that from Cyrenaic juice are particularly suitable to this complaint, as also the remedies prepared from castor and the like. You will find a fuller account of these matters in the 46th section, “on immoderate rigor and cold.” The fevers called lipyriæ, and the typhoid or smoky, and whatever others are mentioned besides those described, being all of the same kind as the above mentioned, will require the same methods of cure as those which have been mentioned, or will soon be described.