Part 54

SECT. XXXI.—DIAGNOSIS AND CURE OF FEVERS WITH AN ERYSIPELATOUS AFFECTION.

Fevers accompanied with an erysipelatous affection about the viscera, may be known by the vehement effervescence and violent pain in the part, also, by the thirst and inordinate burning; in a word, by the symptoms of very acrid bile putrefied along with a deficient blood. They are to be treated in this manner: the patient must abstain altogether from the bath, and at the acme of the complaint, use very cold water in the most decided manner. Yet it must not be used at the commencement, but cold things are to be applied externally; and if this is not sufficient, they must be taken internally. Lettuces and such like things are particularly befitting. The juice of the lettuce is likewise a seasonable application externally, also, that of the house-leek (semper-vivum), and such like cooling things. We may use the following application, which is an excellent one: Squeezing out the juice of some cooling thing, we put it into a mortar with purslain, then pound and strain it; at the time of using, we mix a little polenta with it, and place it in cold water to cool it. A piece of cloth folded double is to be put into it, and afterwards applied to the hypochondrium, and not suffered to remain, but another cold one must be substituted. We sometimes mix the oil of unripe olives.

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COMMENTARY. This section is mostly taken from Oribasius, (Synops. vi, 20.) On erysipelas of the lungs consult Hippocrates, (De Morbis, i, 13, and ii, 53.) Hippocrates says in one of his aphorisms (vi, 25), that it is dangerous when an external erysipelas is determined internally, but favorable when an internal erysipelas is determined externally. He describes an epidemical erysipelas which was attended with extensive gangrene of the limbs, but did not often prove fatal. (Epid. i.)

The following are the symptoms of fever connected with erysipelatous inflammation, as detailed by Alexander: The patient experiences thirst more strikingly than in any other case, throws the clothes off his body, has exacerbations every third day, with bilious and ichorous discharges from the bowels; those in whom the erysipelatous inflammation is seated in the lungs have not so intense thirst, but breathe thick and large, their cheeks are red, tongue rough, they are delirious, and long rather for cool air, and are more benefited by it than by cool drink, which ought rather to be given to those who have erysipelatous inflammation in any other part, whereas those in whom the lungs are affected ought to be supplied with cool air. In ordinary cases he approves of giving cold water to extinguish the fever, but says that he has seen patients brought to imminent danger by the unseasonable application of cold cataplasms and clysters.

Aëtius states that fevers are kindled by the parts about the bowels, liver, and lungs, being attacked with erysipelas. Like our author, he approves of cold drink, cool air, and cold applications to the part affected. (v, 88.)

The acute affection of the vena cava, which is minutely described by Aretæus, ought probably to be ranked with the diseases which we are now treating of. He himself is in doubt whether to consider it as a species of causus. Like the latter, he says, it has a tendency to pass into syncope. (De Sign. Morb. Acut. iii, 8.) He recommends for it venesection and the refrigerant plan of treatment. (Cur. Morb. Acut. ii, 7.) We have stated in the xxixth section that Palladius refers one variety of ardent fever to erysipelas of the lungs.

A similar account of these affections is given by Avicenna, (iv, i, 4, c. 13, 14, and 15); and by Rhases (ad Mansor. x, 15, alibique.)

We can draw no information from modern works to illustrate the opinions of the ancients respecting the febrile affections treated of in this section. It does not seem to be suspected now that erysipelas ever attacks the lungs or bowels; and yet, as this disease when it occurs externally is known to be seated principally in the epidermis, and as the epithelium, or membrane which lines the internal cavities, is admitted to be a prolongation of it, (see Kaau Boerhaave, Perspiratio Dicta Hippocrati,) it would seem probable a priori, that the diseases of both portions of it should be alike. That fevers are often complicated with ardent affections of the lungs and bowels, and bilious symptoms, we all admit; and it was, no doubt, to such febrile affections that the ancients gave the name of fevers from erysipelas—erysipelas, as we shall see afterwards, being referred by them to the state of the bile. One cannot but admire the sagacity of Hippocrates in tracing the connexion and resemblance between the diseases of the epidermis and those of the epithelium. (See Littré’s Hippocrat. t. iv, 419.)

SECT. XXXII.—DIAGNOSIS OF HECTIC FEVERS.

The hectic fever is not only seated in the fluids and spirits, but also in the solid parts. It is unaccompanied with pain, and those affected with this fever imagine that they have no fever at all, for they are sensible of no heat, all the parts being heated equally. There are two kinds of hectic fevers, the one for the most part supervening upon ardent fevers which have been protracted so long as to consume in time all the juices in the body of the heart; the other may come on while it remains plentiful. The former constitute not only hectic but marasmus. Those that come on while the juices of the heart remain, seize upon the body of the heart, and hence the febrile flame is kindled, like the flame of a lamp from its wick. This is one of the modes of formation. The other mode is, when they make their attack originally, commencing like ephemeral fevers, from grief, anger, or much fatigue attended with heat. These may be cured without difficulty; but those of them which have terminated in marasmus, it is impossible to cure. A hectic fever which is running into marasmus may be easily recognized. You may see the patients’ eyes immeasurably hollow, dry rheums determined to them, and they have a certain squalid appearance. The vital bloom of their colour is gone; their forehead is parched and stretched; they constantly wink as if asleep, and yet the affection is not sleep, but an inability to keep awake; their temples are collapsed; and what remains, but the bones and skin alone? If you lay bare, and examine the parts about the abdomen, you will fancy that none of the entrails and intestines remain, and that the hypochondrium is forcibly drawn upwards. The skin is parched in the last extreme, the pulse slender, dense, and hard. The heat on the first application of the hand seems faint, but soon afterwards feels acrid and pungent. While, therefore, any of the natural moisture remains, the fever is only hectic; but when the humidity runs the risk of being altogether consumed, a true marasmus is formed.

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COMMENTARY. Our author has copied from Oribasius (Synops. vi, 21), who in his turn is indebted to Galen (de Diff. Feb. i, 11.) A similar account is given in somewhat fuller terms by Aëtius (v, 92.) See also Alexander (xii, 4.) We shall merely give his explanation of the characters of the pulse. It is hard and small, because the vessels have become dry and contracted; it is dense (frequent?) because the necessities of the system require it to be so, (namely, in order to make up for the reduced expansion of the artery); it is feeble, owing to the weakness of the vital powers; and slender, because the vessel does not admit of being stretched in breadth. Nonnus and Actuarius derive their views from Galen. According to the latter, hectic fever is a very dangerous disease when it arises from the conversion of any other fever, but when connected with inflammation or scirrhus of any vital organ it is almost incurable. Palladius says that the hectic is an unceasing fever, wasting and consuming the natural humidity of all the members, and supervening for the most part upon acute and ardent fevers, but sometimes arising from sympathy with some vital organ. He states it as a characteristic of the hectic fever, that food increases the febrile heat, in like manner as water poured upon unslacked lime enkindles heat. This comparison is borrowed from Galen, and is repeated also by Alexander and Nonnus. Palladius, like our author, represents marasmus as the termination of the hectic fever. It is distinguished, he says, by prostration of the natural faculties, aridity, and wasting of the body, which becomes dried and parched like a tree deprived of its juices by exposure to excessive heat.

According to Haly Abbas, hectic fevers commonly arise either from the conversion of semi-tertians, or from abscesses of the lungs, whence heat is sent to the heart, and from it is diffused over the system. (Theor. viii, 7.) Alsaharavius states that hectic fevers arise from protracted ephemeral or putrid fevers, or from sympathy of the system with ulceration of the lungs, bladder, or liver, or from any chronic and prolonged disease. (Pract. xxxii.) Averrhoes represents the hectic as supervening upon ephemeral and putrid fevers. He ridicules the comparison of the effects of food on the febrile heat to those of water poured upon lime. (Collig. iv, 33.) Avenzoar gives the same account of hectic as our author. (iii. 3, c. 13.) Serapion’s account, although borrowed from the Greeks, is distinct and curious (vi, 11.) See also Rhases (ad Mansor. x, 3, alibique.) He and Haly Abbas repeat the graphic delineation of a person in the last stage of hectic fever, borrowed by our author from Galen, who seems to have had in view a similar description of a person sinking of consumption, given by Aretæus. (De Morb. Chron. i, 8.) Avicenna’s account of the nature and causes of hectic fevers is so ample, that we regret our limits will not permit us to do justice to it. The principal causes of them which he enumerates are ephemeral and putrid fevers, and abscesses of the lungs and liver. The pulse, he says, is hard, small, frequent, and weak, and may become myurus, if the fever pass into the state of marasmus. He gives, principally from Galen (de Marasmo), an interesting description of what he calls the hectic of old age, but which Galen calls old age from disease. Its symptoms, as described by these authors, are coldness and aridity of the body; the pulse slow, small, and rare, unless very weak; the urine white, thin, and watery. (iv, 1, 3.) Franciscus de Pedemontio, a writer of the fourteenth century, in like manner pronounces the hectic of old age to be a dry intemperament of the system, and recommends for it a calefacient and moistening regimen.

SECT. XXXIII.—THE CURE OF HECTIC FEVERS.

Those affected with hectic fevers should be well supplied with food from the commencement, on account of the pungency of the humours. The best cure is a moistening diet. You ought therefore to give for nourishment the juice of ptisan, and broths of chondrus, with a little bread in addition; and to treat the patient with a draught, of moderately cold water, when neither inflammation nor putrefaction of the humours is present. But if you conclude that the lesion is great, you must proscribe the cold water, and have recourse to the cooling applications externally. To those affected in this manner, baths are at all times proper.

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COMMENTARY. This section is taken from Oribasius (Synops. vi, 22.) It will be remarked that our author’s treatment consists of diluents and refrigerants internally, with cold applications and baths. It is entirely derived from Galen. Galen defends, in very strong terms, the use of the cold bath, which had been condemned by a celebrated physician of the name of Philip. (Meth. Med. x.) He admits, indeed, that an inflammatory or erysipelatous affection of a vital organ, and a redundance of crude and putrid humours in the body, may compel us to abstain from the bath; but, in all other circumstances of hectic fever, he insists that it is the remedium unicum. He also recommends cold drink and cold applications to the part primarily affected. He speaks favorably also of the internal administration of refrigerants, such as lettuces, which may also be applied externally. (De Marasmo.) For diet, he recommends articles of a diluent and cooling nature, such as ptisan, bread steeped in cold water, and the milk of asses. (Meth. Med. l. c.)

Aëtius, in like manner, recommends the bath, unless the use of it be contraindicated by the inflammation of some vital organ, or a fever enkindled by the putrescency of the humours. He gives minute directions for the application of the bath, the amount of which is this, that, under certain circumstances, it will be most prudent to use the tepid bath before the cold. In all cases he directs the body to be rubbed with oil before going into the bath, and to be gently rubbed with towels after coming out of it. He greatly praises the milk of asses, which he recommends to be drunk warm.

Alexander also forbids the use of the bath, when inflammation of any vital part is present. He approves greatly of the milk of asses for food. He allows wine only when the patient is of a cold and dry intemperament. He inculcates the necessity of ascertaining whether the hectic fever and marasmus be connected with chronic inflammation of any internal organ, such as the stomach, mesentery, colon, liver, kidneys, womb, lungs, or diaphragm, in order that the remedies may be applied to the seat of the disease. We need not go over the practice of the subsequent Greek authors, as they follow servilely the doctrines of Galen.

According to Avicenna, the great indications of cure are dilution and refrigeration. To the class of refrigerant remedies he refers barley-water, the milk of asses, and trochisks of camphor, with cooling epithemes and ointments. To the class of diluents he refers the bath, about the administration of which he is very particular. He directs us to use the tepid bath at first, and gradually bring the patient to bear the cold. When it can be borne, he says, the cold bath should be taken immediately after the hot. He also speaks favorably of the affusion of tepid water.

Haly Abbas directs us, when the symptoms of consumption are fairly set in, to administer before sunrise trochisks containing camphor, poppies, &c. to mitigate the cough. Like most of the other authorities, he speaks favorably of the milk of asses and of women for food. But, upon the whole, his greatest dependence seems to have been upon camphor. (Pr. iii, 26.)

Alsaharavius directs us first to make the patient go into the warm bath, and immediately afterwards to plunge him into the cold. (Pract. xxxii.)

What Avenzoar most particularly recommends is the tepid bath of fresh water, which he directs to be taken several times in the day. He speaks favorably of goat’s milk. (iii, 1, 13.)

Averrhoes recommends nearly the same practice; but he says that the bath ought to be gradually applied. He approves of the milk of women, asses, and goats, and also of refrigerant herbs. (Colliget. vii, 15.)

Serapion is very minute in his directions about the asses’ milk. He says the animals should be fed upon juicy and cooling herbs, such as grow by the side of rivers. He also directs us to medicate the bath, by previously boiling in it refrigerant herbs, such as gourds, barley, and violets. (vi, 11.)

Rhases’ directions, although they possess, perhaps, little originality, are in the highest degree interesting. He recommends for food fishes, cooling herbs, such as mallows, lettuces, citrons, cucumbers, &c. and the milk of asses or of goats. He especially commends the tepid bath, and rubbing with oil afterwards. He also speaks of applying to the chest cloths soaked in rose-water, which has been cooled in snow. When these cold applications bring on shivering, he directs them to be somewhat warmed. He forbids copious draughts of cold water. He recommends cool and humid air, and cautions to avoid smoke. When the belly is constipated, he gives opening medicines, such as prunes and manna. When, on the other hand, the belly is loose, he recommends astringents. He particularly commends trochisks of camphor, which, he says, will cool the heat of the heart, liver, or chest. (Ad Mansor. x, 3; see also Contin. xxxi.) In the latter work he informs us that physicians were divided in opinion regarding the use of the bath in hectic fever. He forbids the cold bath and cold drink when the patient is much wasted, because the cold penetrates to the vital organs and impairs them.

SECT. XXXIV.—ON SEMI-TERTIANS.