Part 53

COMMENTARY. After what we have said in the preceding section, and in the section on Ephemerals, it will be unnecessary to enter into any detailed account of the ancient opinions with regard to the nature of synochus. It is to be distinctly recollected, however, that all the authorities from Hippocrates to Actuarius held, with Galen, that the synochi are produced either by an ebullition of the blood, as in the case of neglected ephemerals, or from putrefaction of this fluid. (See Meth. Med. ix.)

In other parts of his works Galen seems, indeed, to hold that these fevers are connected with corruptions of the bile, and we shall not attempt to defend him from the charges of inconsistence and contradiction with which he is assailed by Avicenna and Averrhoes. His treatment is well deserving of our attention. He inculcates with becoming earnestness that the great remedies for synochous fevers are bleeding and cold drink. He approves of bleeding ad deliquium animi, and relates an interesting case of its good effects. (Meth. Med. ix.) When the pulse is large and firm, he insists that no considerations of age, strength, or any other circumstance, ought to deter the physician from abstracting blood freely. He directs the apartments of the sick to be kept cool and well ventilated, and to have the floors sprinkled and rendered fragrant by means of suitable flowers. The diet is to be of a light and diluent nature, especially at the acme of the fever. (Therap. ad Glauc. i.) He forbids the bath when inflammation is present. (Hyg.)

Aëtius conducts the treatment upon the same principles as Galen, and the directions which he gives for the application of the different remedies are most important. He states most decidedly, that unless venesection is had recourse to, the patient will be in the utmost danger, and can only be saved by the strength of his constitution, or some critical evacuation. When the stomach is loaded, however, he forbids depletion, because, by emptying the veins, the distribution of the crudities in the primæ viæ will be accelerated. When the menstrual or hemorrhodial discharge is expected, he directs us to bleed less profusely than otherwise. Persons of a hard, sanguine, and compact habit of body are said to bear bleeding best. In practising venesection, he directs the physician to pay more attention to the strength of the patient than to the period of the fever. He is particularly earnest in recommending the use of cold drink: he directs it to be given at the acme of the disease, but not at the commencement. He forbids us to administer it freely when there is obstruction or inflammation of an internal viscus; and states many serious evils which may arise from the unseasonable administration of cold water, although it be an excellent remedy when given at the proper time. With regard to diet, he directs nothing but ptisan to be given for the first three days. On the fourth he recommends the bath. Through the whole course of the fever the food is to be light, unless the powers of the patient be very feeble.

As the other Greek authorities differ in no material respect from the principles of treatment laid down by Galen and Aëtius, we need not enter upon any minute exposition of their views of practice. As a specimen, however, of the practice of the later authors, we shall briefly mention that of Synesius and Constantinus Africanus. They approve of bleeding, unless the stomach be loaded with crudities; in which case they forbid the operation until these are concocted or discharged. They recommend diluents; and, if the belly is constipated, clysters, with decoctions, containing tamarinds, damascenes, manna, and the like. To remove the remains of the febrile excitement in the decline of the fever, they direct medicines of a refrigerant nature to be given, such as camphor, the seeds of melons, cucumbers, gourds, and the like.

Palladius gives the following directions for the treatment of fevers in general. In all these diseases the skilful physician ought to know and understand accurately the constitution and temperament of the sick; and the peculiar form of the fever, and the formation, movement, onset, increase, and acme of every disease, and the analogies of the paroxysms, and the returns of the periods. And the first and general object in all these diseases is to clear the body of impurities, and render it perspirable; and the second in order is to contend with the prevailing cause; for the work of the physician in all cases is to rectify whatever is amiss about the body. (De Febribus, 29.)

Celsus recommends venesection in all fevers at the commencement, provided the patient is not very young, weak, or has crudities in his stomach; but after the fourth day he does not approve of it. He also makes some ingenious remarks on the contrary methods of giving water and wine in cases of fever. He recommends the latter when there is cold, torpor, and restlessness. He likewise mentions the affusion of cold water and oil, with the intention of changing the morbid state of action.

In the Epistle of Vindicianus, physician to the Emperor Valentinian, there is an interesting history of a fever, arising from indigestion and obstruction of the bowels, brought on by excess in eating and drinking. In this case Vindicianus, in opposition to the advice of the other professional attendants, would not administer a clyster, and gave his patient nothing but salt and water, which procured first copious perspirations, and afterwards free evacuations of the bowels. He then directed him to use the bath, and completed the cure by giving wormwood to remove obstructions. This is a well-marked case of intestinal fever. (Fabricii Bibl. Græc. t. xiii.)

We may state the general characters of the urine as given in an interesting little treatise, ‘On the Urine,’ lately published by Ideler. In synochous fevers, as being connected with fulness of blood, the urine is red, thick, and indicating by its colour and consistence the want of concoction. (De Urinis Commentatio.)

Haly Abbas, during the first three days, strongly recommends venesection, which, he says, will either have the effect of cutting short the fever at once, or of rendering it milder. His other remedies are altogether refrigerant, consisting of acidulated drinks, and gentle purgatives, such as prunes, tamarinds, and the like. Alsaharavius, in like manner, recommends depletion, and the refrigerant plan of treatment.

Serapion strongly recommends bleeding, ad deliquium animi, which, he says, will probably have the effect of procuring discharges from the bowels, and of promoting perspiration. He admits of venesection even after the sixth or seventh day, when other circumstances indicate it. He further prescribes refrigerant remedies, such as tamarinds, cassia-fistula, and the like.

Averrhoes, although he approves of venesection, condemns Galen’s direction to carry it the length of bringing on deliquium animi. He also cautions against carrying the administration of cold drink too far.

Avenzoar strongly recommends bleeding ad deliquium. Avicenna likewise approves of this practice. When the strength does not permit to carry depletion so far, he directs us to open the temporal veins, or to abstract blood by cupping. In such cases he also recommends purgatives and refrigerant medicines. Towards the conclusion of the fever he directs the trochisks of camphor to be given.

Rhases gives an excellent account of synochus. His remedies are bleeding, gentle purgatives, acidulated drinks, restricted diet, and complete abstinence from wine. He particularly recommends aloes as a purgative. (See, in particular, Contin. xxx, v, 2.) He approves of the bath, but prefers delaying the use of it until the decline of the fever. He is very decided in recommending bleeding, unless the patient be of a weak constitution, or his system loaded with crudities. After the fever is concocted, he approves of giving cold water freely for drink.

SECT. XXIX.—ON THE DIAGNOSIS OF ARDENT FEVERS.

The following symptoms accompany ardent fevers: tongue dry, rough, and black, griping of the stomach, excrements pale, strong thirst, watchfulness, and sometimes delirium.

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COMMENTARY. Our author’s description of the causus, or ardent fever, is taken from Hippocrates (de Rat. Vic. Acut.), where the commentary of Galen is worth consulting. According to Hippocrates, the causus is generally produced in the summer season, owing to the veins becoming dry and attracting bilious humours. In other parts of his works he gives an account of several varieties of the disease, differing considerably in character from that described in the above-mentioned work. For example, one variety mentioned in his ‘Epidemics’ was distinguished by the absence of thirst and delirium, and by the paroxyms occurring on the even days. (See Galen’s Commentary, Opera, ed. Basil. t. v, 424; also, de Morbis, i, 27; and Coacæ, 130.) He further describes, under the head of causus, various cases of febrile complaints after childbirth and abortion, which would now be called puerperal fevers. (Epidem. iii.)

Aretæus delivers a most striking description of ardent fevers, which we regret that our limits prevent us from giving at full length. The following are some of the most important symptoms: the heat acrid and subtile, especially in the internal parts, desire of cold air and of cold things, the extremities cold, the pulse dense and small, the eyes clear, bright, and reddish; and, if the fever go on increasing, delirium, oblivion of every thing, lividity of the nails, frequent respiration, profuse perspiration about the forehead and neck, coldness of the body, and at last a complete collapse marked by a return of the powers of reason and certain indications of a prophetic spirit. This is but a meagre outline of his matchless delineation of the phenomena of causus.

As all the Greek, Latin, and Arabian writers treat of causus in nearly the same terms as Hippocrates, we shall be very brief in noticing their descriptions. According to Alexander, there are two varieties of causus, the true and the spurious, the former being marked by intense thirst, bilious stools, tongue rough and black; and the latter by the thirst being moderate, the tongue not black, and the stools consisting not of bilious matters, but rather of corrupted food. The former kind is said to be occasioned by a bilious, and the latter by a pituitous humour. Aëtius describes the disease in the same terms as our author. He says that it is produced by putrefaction of yellow bile. Palladius says that ardent fevers are occasioned by an erysipelatous inflammation of the lungs, or by the putrefaction of bilious humours which have become immoderately heated. The Arabians describe it exactly as the Greeks. According to Avicenna, there are two varieties of the disease, the bilious and the pituitous. The inseparable symptoms of the disease are, he says, concealed heat, roughness, and, at last, blackness of the tongue. There is no perspiration until after the crisis. For the most part the heat is not strong in the external parts, but is particularly so in the internal. Rhases states that the ardent fever called καῦσος by the Greeks belongs to the class of tertians, only that in the former the heat is more intense, and the paroxysms do not terminate in a complete intermission of the febrile symptoms. The symptoms, he adds, bear a considerable resemblance to those of the tertian intermittent, but are more strongly marked. According to Alsaharavius, the causus, or ardent fever, is occasioned by heated bile collected in the veins adjoining to the heart, stomach, or liver, and its symptoms resemble those of tertians, but are more intense.

From the above exposition of the opinions of the ancients regarding the causus, or ardent fever, the medical reader will readily recognize its identity with the bilious remittent fever of Sir John Pringle and other English authors. If there were any doubt on this head, it would be set aside by the description of the symptoms of ardent fever which is given by the late Dr. Robert Jackson, as they were manifested in his own person during a severe attack of it. (On Fever, 403.)

Some late writers have confounded the causus of the ancients with synocha, or inflammatory fever. But, as we have said, and as was correctly stated by Baccius, the causus was decidedly of the continual or remittent type, and nearly allied to the tertian intermittent. (De Thermis.) Hoffman remarks that it seldom appears in the more temperate parts of Europe, but is very common in Asia, Greece, and Italy; and hence the frequent mention of it in the works of Hippocrates, Galen, and Aretæus. (Oper. t. ii, § 2, c. 2.)

Homer says that the dog-star brings many fevers upon unhappy mortals (Iliad, xxi, 31); and his commentator Eustathius remarks that the poet correctly refers the origin of ardent fevers to the heat of the dog-days.

SECT. XXX.—THE CURE OF ARDENT FEVERS.

Either of the following things must take place, that this fever may terminate completely; the bilious humours must either be evacuated or extinguished. They are evacuated then by sweating, vomiting, or purging downwards; but they are extinguished by cold drink, with which we have entirely cured ardent fevers. For diet, those in causus should not take water alone, nor mead alone, but boiled mead much diluted with water; for the food of such persons ought to consist entirely of drinks. The bath will suit with those only affected with causus who are free from all inflammatory and erysipelatous swelling. And if they exhibit signs of concoction, it will suit still better with them; but not so if the fever be occasioned by a saltish humour. These should be supported with the juice of ptisan.

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COMMENTARY. Our author’s directions respecting the treatment are mostly taken from Hippocrates (de Rat. Vict. Acut.) Hippocrates allows venesection only when the attack is violent. He approves of the application of cold water to the surface. Archigenes, as Aëtius informs us, sponged the head and chest with cold water during the acme of ardent fevers. (iii. 159.) His own treatment, which is borrowed from Philumenus and Galen, consisted of cooling remedies internally and externally, such as drinking cold water and other things of a refrigerant nature, using cold applications, and the cold bath, (v, 28.) Alexander, Oribasius, Synesius, and Constantinus Africanus treat the causus upon the same plan as our author. They say nothing of bleeding. Celsus likewise omits to make mention of venesection, but recommends refrigerants, and especially cold water to be given, even to satiety. He forbids it, however, when there is any affection of the internal viscera, and when there is a cough. He informs us that Asclepiades, of Bithynia, strongly recommended gestation for the cure of this fever.

Averrhoes abstracts blood when there are symptoms of plethora, gives gentle purgatives, such as tamarinds, and allows the patient cool drink and cool air. Haly Abbas treats the causus entirely upon the refrigerant plan, with cold drink, cooling fruits, fresh air, gentle laxatives, such as prunes, and by cold applications to the skin. Alsaharavius conducts the treatment upon much the same principles. When the patient is troubled with protracted watchfulness, he directs us to rub the temples with the juice of poppies, lettuces, and coriander. Avicenna also speaks favorably of these soporifics, but does not in general approve of bleeding. The treatment recommended by Rhases is altogether refrigerant. He directs us to clear away the asperities of the tongue, and then to give cooling and acid drinks. When there is no inflammation of any internal viscus, he permits water cooled with snow. He says nothing of venesection. However, some of his authorities, as quoted in his ‘Continens,’ recommend bleeding. They seem in general to have approved of keeping the patient in a cool room perfumed with aromatic and fragrant herbs. One of them approves of applying over the stomach a robe moistened with a fluid prepared from camphor, rose oil, &c.

We omitted to mention that Hippocrates states that children at the breast are subject to attacks of causus, by which of course he meant the infantile remittent fever, first well described some years ago by Dr. Butter.