Part 55

As a tertian paroxysm commences with a rigor, and a quotidian without one, the fever composed of both brings on a degree of shivering, which is less than a rigor, and greater than chillness, as being a mixture of these two extremes. Whence, this fever has not improperly got the name of semi-tertian. These fevers are formed in two ways, either the two paroxysms uniting into one, or being mixed together from the commencement. When, therefore, the tertian prevails, the fever is attended with a strong shivering, and has even a certain degree of rigor at the attack. Such a fever also soon becomes hotter and more ardent, and brings on some vomiting of bile, or a discharge of it downwards, or by a sweat. When the other, the pituitous, prevails, there is coldness of the extremities, but little shivering; neither are they accompanied with thirst, nor are they ardent. But when the tertian intermittent and continual quotidian are equal in magnitude, the commencement of the paroxysm is with shivering; and when that from phlegm prevails, there are contractions and shiverings; but if the hotter species prevail, they soon acquire heat. This is the true semi-tertian, being a fever formed from an equal combination of both, a tertian intermittent, and a continual quotidian. But that which is not the true semi-tertian has either more of the bilious, or of the pituitous character; which species is of easiest cure, the smaller humour being readily overcome by the prevalence of the greater, or by the aid of art. When the pituitous state prevails, we must use especially the remedies mentioned for the quotidian; or, if yellow bile, those for the tertian, always bestowing most attention upon that which is most urgent, but not neglecting the other entirely.

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COMMENTARY. The reader may find histories of the semi-tertian in the Epidemics of Hippocrates, where see the Commentary of Galen. Our author’s account is condensed from Galen (de Diff. Febr. ii, 2, and de Typis, 4.) See Aëtius (v, 81); Actuarius (Morb. Dig. ii, 1); Nonnus (142); Celsus (iii, 8); Palladius (21.) Celsus describes it as the second species of tertian in the following terms: “Alterum longe perniciosius, quod tertio quidem die revertitur, ex octo autem et quadraginta horis fere sex et triginta per accessionem occupat, interdum etiam vel minus, vel plus; neque ex toto in remissione desistit, sed tantum levius est. Id genus plerique medici ἠμιτριτᾶιον appellant.” He approves of bleeding at the commencement, and of a diet that is nutritive without being heating.

Palladius says that the semi-tertian is compounded of a tertian intermittent, and a continual quotidian, the quotidian paroxysm taking place every day, and the tertian every alternate day. He ascribes their origin to a mixture of putrid bile and phlegm. (21.) Haly Abbas gives a similar account of it. He calls it a fever compounded of a tertian and quotidian, and remarks that it has a tendency to pass into hectic. He treats it with diluents and refrigerants. (Pract. iii, 17.) Avicenna gives a very detailed account of the symptoms and cure of the semi-tertians. He remarks that the fever is apt to be protracted and to pass into the hectic. (iv, 1, 4.) See Rhases (Cont. xxxi.) All his authorities agree in describing it as a compound of the tertian and quotidian, having a severe paroxysm the one day and a slighter the following. It is said to be generally protracted to the fortieth day.

Platearius, and the other earlier modern writers, describe the semi-tertian in nearly the same terms as the ancients. It is a species of fever still occasionally met with in warm climates. (See Littré’s Hippocrates, t. ii, 569.)

SECT. XXXV.—ON EPIDEMIC DISEASES.

We call those diseases epidemic and common, that attack many persons together; which, having a common origin, have also a common cause. Common diseases are produced by common food of a bad quality, drinking of bad water, inordinate fatigue, the want of the customary exercise, deprivation or repletion from the prevalence either of a famine or of great abundance. The nature of the country will also often occasion common diseases, either from its lying adjacent to marshes, or to some deep pit, which emits a deleterious and pernicious exhalation. These things are constantly occurring. But the atmosphere which surrounds us may alter the temperaments, by being hotter, colder, or more humid than ordinary. For to other causes we are not all exposed together, nor do we come in contact with them for the whole day; but the ambient air is diffused around all, and is inhaled by respiration. Now, the bodies of animals must undergo a change along with these changes as to temperature. He, therefore, who is acquainted with these matters, will not only be able to predict the diseases which are to arise from every state of the atmosphere, but will be able also to prevent them by substituting a counteracting regimen to the intemperament of the air. Wherefore, those bodies which are disposed to a certain disease, from a peculiar intemperament, will be affected by a similar temperature of the surrounding air. But those of an opposite temperament to the atmosphere will not only not be hurt but will be improved; the excess of their intemperament being overcome by the opposite excess. He that is acquainted with these things will preserve the health, by superinducing the contraries to the constitution of the body; sometimes perhaps using refrigerants, and sometimes heating things, cooling with water, using restricted exercise and food, and plenty of dilution; and warming, by means of increased clothing, exercise, more food and less drink. And, by kindling a great pile, one may change the air from a humid state to that which is dry and hot, as they say was done by Acron of Agrigentum.

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COMMENTARY. This Section is mostly taken from Oribasius (Synops. vi, 24, and Euporist. 1.)

The works of Hippocrates contain many interesting remarks on the origin and nature of epidemics. He states that diseases in general may be said to arise either from the food we eat or the air we breathe. When, therefore, a disease seizes on a multitude of persons of different ages, sexes, and habits, he justly infers that it must arise from the latter cause. (See de Flatibus, Epidem. cum Commentariis Galeni.) The fevers described by Hippocrates, in his ‘Books of Epidemics,’ are in general intermittent and remittent fevers. In his first and third books he describes forty-two cases of fever, twenty-five of which had a fatal termination. They had evidently been selected from a larger number. The descriptions are rigidly confined to a detail of the characters of the season and the symptoms of the epidemic. In general, scarcely any remedial means are mentioned. In some of the cases slight exanthemata speedily disappearing are mentioned among the symptoms. These are more likely to have been petechiæ than the typhous eruption. It is reported of Hippocrates, that, like Acron of Agrigentum, he changed the morbific state of the atmosphere at Athens by kindling fires. (Galen, Therap. ad Pison; Aëtius, v, 94.) Acron’s method of purifying the atmosphere is mentioned by Plutarch (de Iside et Osiride.) For an account of Acron, see Fabricii (Biblioth. Græc. xiii, 32); Conringii (Introduct.) and Mangeti (Bibl. Med.) Pliny says of fire as a corrective of the state of the atmosphere, “Est et ipsis ignibus medica vis. Pestilentiæ, quæ solis obscuratione contrahitur, ignis suffitu multiformiter auxiliari, certum est. Empedocles et Hippocrates id demonstravere diversis locis.” (H. N. xxxvi, 69.) With the same intention Simeon Seth proposes fumigations with frankincense. The historian Herodian relates that fumigations with aromatics were recommended as a preventive of the plague. (i.)

Galen, in like manner, attributes the origin of epidemics to the state of the atmosphere in a great measure, but also holds that the nature of the country may contribute; as, for example, its vicinity to a gulf like the Charonian, from which miasmata are exhaled that taint the air and occasion diseases. In many passages of his ‘Commentary on the Epidemics’ of Hippocrates, he states that epidemical diseases arise from the condition of the country in which they prevail. Lucretius accounts for the prevalence of epidemical diseases upon similar principles:

“Atque ea vis omnis morborum, pestilitasque, Aut extrinsicus, ut nubes nebulæque superne Per cœlum veniunt, aut ipsâ sæpe coorta De terrâ surgunt, ubi putrorem humida nacta est, Intempestivis pluviisque, et solibus icta.”

(De Rerum Nat. vi, 1100.)

Silius Italicus appears to refer an epidemical fever to the same cause. (xiv.)

In his work, on the ‘Varieties of Fever,’ Galen expresses his opinion on this subject very fully. He remarks that an atmosphere of a hot constitution, such as generally prevails at the time of the rising of the dog-star, having been inhaled by the heart, increases the heat in it, from which it is diffused all over the system, and enkindles a febrile affection. In pestilential constitutions, he adds, it is principally by the respiration that the disease is contracted, although sometimes it may arise from the fluids of the body being disposed to putrescency, which is increased by the condition of the atmosphere; but for the most part epidemical complaints derive their origin from the atmosphere being tainted with putrid exhalations. The putridity of the atmosphere may be occasioned either by a multitude of dead bodies which have not been burnt, as is apt to happen in wars, or it may arise from the exhalations of certain marshes or lakes in the summer season, or sometimes the inordinate heat of the atmosphere may give rise to them, as happened in the case of the Athenian plague, according to the testimony of Thucydides. And here we must digress to remark, that Homer evidently ascribes the plague which attacked the Grecian army to the great heat of the sun. See the Commentary of Eustathius on the beginning of the Iliad; Ammianus Marcellinus (xix); Heraclides Ponticus (Allegor); and Macrobius (Saturn. vii, 5.) Galen, however, inculcates that the constitution of the atmosphere alone is not sufficient to produce disease without a peculiar disposition of the body to admit it; for that, otherwise, all without exception would be seized with the prevailing epidemic. This leads him to give directions to correct the intemperament of the body when it is such as disposes it to be readily affected by the constitution of the atmosphere. His directions are similar to those of our author. Besides the causes of epidemical diseases which we have mentioned, he states that unwholesome food and drink may sometimes, though rarely, give rise to them. Of this he relates a striking instance. (De Rebus boni et mali Succi, c. i.) He remarks that the most common epidemical diseases are pestilential fevers. We shall have occasion to state his opinion of them in the next Section.

Of the Greek authors posterior to Galen, Oribasius and Aëtius give the same account of epidemical diseases as our author; and the others either do not treat of them at all, or class them with the subject of our next Section.

Avenzoar has given us an elaborate treatise on epidemical complaints. (iii.) The first cause of them which he mentions is a humid and warm state of the atmosphere, such as that to which Hippocrates ascribed the pestilence which afflicted Thasus in his time. (Epid. iii.) The other causes enumerated by him are the effluvia from dead bodies, stagnant air, the miasmata from stagnant and corrupted waters, and unwholesome food. (iii, 3, 1.)

On the origin of epidemical diseases, especially the pestilence, see, in particular, Haly Abbas (Theor. v, 11.) The principal causes of the change of the atmosphere to a pestilential state, according to Haly, are the nature of the country and the season of the year. The former cause operates owing to the putrid effluvia arising from corrupted fruit, pot-herbs, &c., or the miasmata from marshes, cloacæ, or dead bodies, whether of men or cattle. It was from such causes, he remarks, that the plague of Athens derived its origin. The nature of the season, as it produces diseases in the vegetable, so does it also in the animal creation. As epidemical complaints, he mentions ephemerals, cynanche, smallpox, acute fevers, and other fatal diseases.

Avicenna’s account of the origin of pestilential and epidemic diseases is taken almost entirely from Galen; he therefore enumerates as causes of them, a humid and warm state of the atmosphere, the stagnant air of caverns, the miasmata of lakes and marshes, and the effluvia from dead bodies. (iv, i, 4.) Alsaharavius enumerates exactly the same causes. (32.) Rhases’ account is mostly taken from Hippocrates and Galen. (Contin. xxx.)

The historian Ammianus Marcellinus gives an ingenious disquisition on the origin of these diseases; but the distinction which he endeavours to establish in the following passage is not acknowledged by the medical authors in general: “Prima species luis Pandemus appellatur, quæ efficit in aridioribus locis agentes caloribus crebris interpellari; secunda, Epidemus quæ tempore ingruens acies hebetat luminum, et concitat periculosos humores; tertia, Lœmodes, quæ itidem temporaria est, sed volucri velocitate letabilis.” (xix, 4.) The causes of these complaints, as enumerated by him, are excessive heat, cold, drought, or moisture, effluvia from putrid bodies, and exhalations from the earth.

According to Diodorus Siculus, the causes which gave rise to the pestilential epidemic which attacked the Carthaginian army in Sicily were the marshy nature of the country in which they were encamped, the bodies of the dead lying unburied, and the excessive heat of the season. (xiv.) He ascribes the plague of Athens to similar causes. (xii. 58.)

SECT. XXXVI.—ON THE PLAGUE, FROM THE WORKS OF RUFFUS.

In the plague there is everything which is dreadful, and nothing of this kind is wanting as in other diseases. For there are delirium, vomitings of bile, distension of the hypochondrium, pains, much sweatings, cold of the extremities, bilious diarrhœas, which are thin and flatulent; the urine watery, thin, bilious, black, having bad sediments, and the substances floating on it most unfavorable; trickling of blood from the nose, heat in the chest, tongue parched, thirst, restlessness, insomnolency, strong convulsions, and many other things which are unfavorable. Should a person foresee that the plague is coming, by attending to the badness of the season, and the unhealthy occupations of the inhabitants, and from observing other animals perishing; when one observes these things, let him also observe this—what is the character of the present season, and what that of the whole year, for you will be able thereby to find out the best regimen; such, for example, as if the temperature of the season ought to have been dry, but has become humid; in that case, it will be necessary, by a drying diet, to consume the superabundant moisture. Care also must be had of the belly, and when there is phlegm in the stomach it must be evacuated by emetics. And when a fulness of blood prevails, a vein should be opened. Purgings also by urine, and otherwise by the whole body, are proper. But, if the patient is affected with ardent fever, and has a fiery heat about the breast, it will not be improper to apply cold things to the breast, and to give cold drink, not in small quantities, for it only makes the flame burn more; but in full draughts, so as to extinguish it. But if an ardent fever prevails within, and the extremities are cold, and the skin cold, the hypochondrium distended, and the stomach sends the matters which have been melted, some upwards, and others downwards; if watchfulness, delirium, and roughness of the tongue, are present; in these cases, calefacient remedies are wanted to diffuse the heat all over the body, and every other means ought to be tried, in order to determine the heat from the internal to the external parts. The following propoma may be used: of aloes, two parts; of ammoniac perfume, two parts; of myrrh, one part; pound these in fragrant wine, and give every day to the quantity of half a cyathus (ʒv.) I never knew a person, says Ruffus, who did not recover from the plague after this draught. So says Ruffus: but Galen says, concerning pestilential putrefactions, that to drink Armenian bole, and, in like manner, the theriac from vipers, is of great service; and that, in the plague which prevailed in Rome, all died who were not benefited by either of these things.

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COMMENTARY. By the plague, as Galen explains in his ‘Commentary on Hippocrates,’ is to be understood an epidemical fever of a fatal nature. Hippocrates has related several histories of diseases which came under this description in his ‘Epidemics,’ but they present such variety of symptoms, that we cannot undertake to give their general characters. It is deserving of remark, however, that he several times makes mention of fevers accompanied with buboes. (Aphor. iv. 54, Epidem. &c.) According to M. Littré, buboes are noticed among the symptoms of plague by Ruffus, and also by Dioscorides and Posidonius in an extract given in the following publication: ‘Classicorum auctorum e Vaticanis codicibus editorum,’ tomus iv, curante Angelo Maio, p. 11, Romæ, 1834. See Littré’s Hippocrates (ii, p. 585.) Aretæus mentions incidentally that pestilential buboes are connected with the liver. (Morb. acut. ii, 3.) Under Sect. XVI will be found several passages from ancient authors, in which pestilential buboes are incidentally mentioned. It must be admitted they are very insufficient materials for illustrating the ancient history of the glandular plague, and it may justly excite surprise that the historian Procopius, in the sixth century, P. C., should be the first writer who has given a complete description of this disease. At the same time we cannot agree with M. Nauman, M. Pariset, and other late writers on the plague, who maintain that the epidemic which devastated the world in the reign of Justinian was a new disease. The frequent mention of pestilential buboes by previous authors, although vague, is sufficient to mark the existence of the disease. In this light, at all events, they are viewed by the commentators on Hippocrates, who lived after the glandular plague was properly described. (See Pallad. Comment. in Hippoc. Ep. t. ii, p. 47, ed. Dietz.)

We shall now begin our exposition of the ancient opinions regarding the plague, with a brief notice of the celebrated description of it given by Thucydides, the Greek historian. The more prominent symptoms mentioned by him are the following: Strong heat of the head; redness and inflammation of the eyes; the mouth and internal fauces turgid with blood; breath fetid; sneezing, hoarseness, and afterwards violent cough; vomiting of bile, retching, and convulsions; the heat of skin not much increased, but the internal parts glowing with heat; the skin reddish, or livid, and covered with minute phyletænæ and ulcers; despondency, restlessness, and intense thirst; and, towards the conclusion, diarrhœa, ulceration of the bowels, and various symptoms of putrefaction. Those who survived the febrile attack were subject to blindness, fatuity, and mortification of the testicles and extremities. The disease generally proved fatal on the ninth or seventh day. The historian affirms that the plague never attacked the same person more than once. This opinion, by the way, has been advocated in modern times by Massarius, Diomedes Amicus, Heurnius, and Sir William Pym, but general experience seems to be against it. Evagrius relates of the plague which prevailed in the reign of Justinian, that many persons who recovered from the first attack sunk under a second. Ficinus, Montisianus, Joubertus, and many late authorities, hold this opinion. He mentions that the disease was supposed to originate in Ethiopia, and from thence to spread to Egypt, Lybia, and the Persian empire; that in Athens it made its first appearance in the Piræus, where it was at first suspected that the Peloponnesians had poisoned the wells. He says the previous summer was remarkably healthy. Thucydides’ celebrated description of the plague is given in a poetical form by Lucretius (de Rerum Natura, apud finem), and by Ovid (Metamorphoseon, vii, 528.) Sophocles, the tragedian, appears also to have had the same plague in view. (Œdip. Tyran. ap. initium.) The Latin poet Silius Italicus evidently copies his images from it. (xiv.) See also Lucanus (Pharsal. vi), and Manilius (Astronom. i.)

Our next great authority on this subject is Celsus. In his account of the plague, we have to regret, however, that, although he dwells rather minutely on the prophylaxis and treatment, he has omitted to give us a description of the disease; and it is not easy to perceive the principles upon which some of his directions as to the prophylaxis and treatment are given. He recommends a journey to a distant place, or a sea voyage; when this cannot be accomplished, gestation and gentle exercise in the open air, but he forbids all excess. He also forbids early rising, exercise with naked feet after a meal or the bath, also emetics, laxatives, and sudorifics. He directs people to drink, by turns, first water and then wine. (i, 10.) With regard to the treatment, he disapproves, in general, of abstinence and purgative medicines, recommends bleeding, if the strength permit, more especially if the fever be attended with pain; but, if venesection cannot be practised, he directs emetics to be given. At an earlier period than in ordinary fevers the patient is to be put into the bath, and is afterwards to get hot undiluted wine, and everything of a glutinous nature, and flesh of this description. In the case of young persons, he directs these remedies to be administered with great caution. (iii, 7.)

The historian Appian, Lucian, Pliny, and Plutarch, mention wine as an antidote to the plague. Livy and other ancient writers say that the plague is sometimes occasioned by excessive cold. (Histor. v.)