Volume 1 / Book 2 — BOOK SECOND. (continued 2)

Prosper Alpinus has stated correctly the doctrines of Hippocrates and Galen, but is entirely silent respecting those of Theophilus and Actuarius. (u. a.)

Besides the ancient authors referred to by us in this chapter, the works of the following writers de Urinis exist in manuscript, but have never been published: 1, Athenæus, quoted by DuCange (ex Cod. Colbert, 3614); 2, Constantinus Africanus (in Bibl. Cæsarea); 3, Joannes Episcopus (Cod. Reg. 3497); 4, Maximus Planudes and Meletius Monachus (Cod. Reg. 3175); 5, Nicephorus Blemmydes (in Bibl. Cæsarea); 6, Anonymus, &c. (Cod. Colb. 3614 and 4230, et in Bibl. Cæsar.); 7, Piropulus (in Bibl. Corsliniana, 448.) See Fabricii (Bibl. Grac. xiii, 779.) The treatise of Abicianus, noticed by Fabricius, has been published by Ideler. It proves to be a mere compilation from the works of Avicenna.

SECT. XV.—ON THE INDICATIONS FROM THE SPUTA.

Such as are somewhat yellow, golden, frothy, and thin, indicate only want of concoction, but nothing positively bad. But such as are intensely yellow, golden, frothy, green, viscid, round, and still more the black, are bad. For, with the exception of the blood, whatever of the other humours is unmixed, indicates a bad diathesis, having its origin in an inflammatory heat. The bloody sputa are of an intermediate character, but those of yellow and black bile are unfavorable. The manner in which they are brought up ought also to be considered; for, if they are readily spit up, it is clear that such are good, whereas the contrary are bad. It is an indication of complete concoction that the expectoration is unctuous, white, and equable, and in consistence, neither fluid nor very thick; as it is of a complete failure of concoction that it is not spit up at all. If it is indeed spit up, but thin, it is a mark of feeble concoction. If it is of an unmixed yellow or golden colour, it is not good. But if it is livid, of a verdigris-green, or black, it is a most fatal symptom.

Commentary. Galen has treated fully of this subject in his work (de Crisibus, ii, 10.) See also Hippocrates (Prognost. and Coacæ), and Celsus (ii, 9.) Aëtius is somewhat fuller than our author (v, 52.) See Avicenna (iv, 2); Averrhoes (Cantic. i, 2); Haly Abbas (Theor. vii and x, 10); Rhases (ad Mansor. x, 24.)

We shall be content with giving a few of the observations of the Arabians, of whom Haly is the most full and accurate upon this head. The lungs and the other parts within the chest being the organs of life, when affected, they occasion inflammation of the heart. Expectoration indicates some affection of those parts. When the expectoration is thin and small in quantity, the disease is not concocted; when the sputa are of moderate consistence and equable, the disease is at its acme; when thick, it is certainly on the decline. Thinness indicates that the humour which occasions the complaint is of a subtle nature; thickness, the contrary. Blackness indicates vehement heat. Green sputa are indicative of the presence of green bile, white of phlegm, and redness of blood. When fetid, they proceed from putrefaction. Black sputa indicate great danger.

Prosper Alpinus makes many ingenious remarks on the characters of the sputa. (De Vita et Morte ægrot. vii, 19.)

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.

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.

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.

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.)

All the ancient authorities disapprove of the bath, except in the decline of the fever. See Ugulinus (de Balneis.) Rabbi Moyses says that the use of it is to be regulated by three circumstances: 1st. That no rigor be present. 2d. That no important member be affected. 3d. That there be no crudities in the veins. These appear to be very judicious regulations.

SECT. XIX.—THE DIAGNOSIS OF TERTIAN FEVERS.

The tertian fever being occasioned by yellow bile set in agitation, has a considerable rigor in the beginning, which differs, however, from the rigor of a quartan in this, that the skin feels as if it were pierced and wounded; but, in quartans, the attack is accompanied with a strong chill; and quotidians have no preceding rigor, they are only accompanied with a chill. But in tertians, the order of the pulse is regular, and the fever is attended with strong thirst towards the acme, and burns up the man; but shortly afterwards the acme takes place, and the heat is equally diffused everywhere. If you apply your hand, at first it is met by a strong and pungent heat, which seems as if carried upwards in the form of vapour, but it is soon extinguished under the hand, if it is allowed to remain. And when the person drinks, a hot vapour in great quantity immediately issues from the skin, announcing sweat. But vomiting of bile supervenes, or the belly is purged, and bilious urine is passed. With these the fever goes off, having comprehended not more than twelve hours in one paroxysm. When, therefore, it abates within twelve hours, we call it true tertian; when the paroxysm is more protracted, we name it simply tertian; and when the paroxysm is prolonged to the utmost, so as to have but a small interval, we call it prolonged tertian.

Commentary. Hippocrates relates many interesting cases of tertian fevers in his ‘Epidemics.’ He attributes their origin to bile. (De Nat. Hum. 29.)

Celsus describes two kinds of the tertian, the one beginning with shivering, and being succeeded by heat, the paroxysm returning every alternate day; and the other constituting the semi-tertian, of which we will have to treat afterwards.

Galen treats of these fevers in different parts of his works. (In Hippocrat. Epidem. Comment., Therap. ad Glauc., de Different. Feb. ii, 3, de Typis, 3.) The symptoms of the tertian are thus described by him: It is attended with intense thirst, heat, acrid and bilious vomitings, loss of appetite, and restlessness. For the most part these symptoms are preceded by rigors, or sometimes by extreme coldness. The pulse in tertians is small and dense. At first, the night preceding an attack is passed in a restless state, but after the disease is prolonged this is not the case. The urine is yellow. In many parts of his works he announces it as his decided opinion that the quotidian intermittent is produced by phlegm; the tertian by yellow bile; and the quartan by black bile. This theory of intermittents was adopted, in a word, by all his successors. See Oribasius (Synops. vi, 9); Aëtius (v, 80); Nonnus (de Febr. 6); Palladius (de Febr. 6); Alexander (xii, 6); Synesius (iii); Avicenna (iv, 1, 2); Haly Abbas (Theor. viii); Serapion (vi, 13); Avenzoar (iii, 1, 2); Averrhoes (Collig. iv, 28.)

SECT. XX.—ON THE CURE OF TERTIAN FEVER.

In the true tertian, as arising from yellow bile, we must dilute and cool, evacuate the defluxions upon the stomach by emetics, and downwards by the belly, and carry them off by urine and perspiration. The bowels, therefore, are to be moved by emollient clysters, and the secretion of mine promoted by infusions of parsley and dill in the drinks. And if symptoms of concoction appear, you may confidently give wormwood. Apply also baths of warm common water, and let neither nitre, nor salts, nor mustard be sprinkled upon the body in the bath; but let the patient enter it after having had warm oil poured over his body. There will be no mistake if those who are fond of baths be bathed twice; and, if symptoms of the diseases being concocted appear, there will be no harm even if they be bathed oftener. Until the disease is concocted, wine is to be entirely prohibited; but when concoction commences, first some thin and watery wine may be given, and food of a diluent and cooling nature will be proper; but honey, mustard, pickles, and everything heating must be abstained from. Such was the practice of the ancients; nor is it to be wondered at, as these men were more habituated to exercises and a restricted diet; but now, when order is perverted, the bile is, for the most part, found mixed with phlegm. Wherefore, now-a-days, most tertians are either without a rigor, or it is very slight. And the mode of cure is also changed; for, neither does the bath suit with tertians now before concoction, nor yet a full diet, except crumbs of bread, eggs, or the like.

Commentary. Hippocrates recommends generally purgatives at the commencement, and afterwards the hot bath, and trefoil, assafœtida, and wine, to promote perspiration. (De Morbis, ii, 39.) He lays it down as a general rule applicable to all intermittent and remittent fevers, that the administration of food should be restricted during the paroxyms. (Aphor.) See the Comment of Theophilus (ed. Dietz, t. ii, 268.)

Celsus informs us that Cleophantus treated tertians by pouring warm water upon the patient’s head, and giving him wine before the accession of a paroxysm. This, however, he considers to be precarious practice. Upon the whole, his great dependence is upon these three remedies: vomits, purgatives, and wine; of which the first is to be tried on the third day, the second on the fifth, the third on the seventh.

Galen’s practice is exactly detailed by our author. He evacuates the bile upwards and downwards at the commencement, and also, with the same intention, administers diuretics and sudorifics. After these he reposes great confidence in wormwood, which, indeed, all the ancients held to be a powerful cholagogue. He also approves much of the tepid bath of common water. He directs the physician not to neglect venesection, if it be indicated; upon which his commentator Stephanus remarks, that the circumstances commonly indicating bloodletting are the condition of the patient, if he be young and plethoric, and the season of the year, if it be spring. (Ed. Dietz.) He forbids wine until the fever is concocted, but afterwards allows a small quantity of thin watery wine. The food is to be refrigerant, and diluent. Everything of a heating and acrid nature is to be abstained from.

Aëtius, Oribasius, and Nonnus conduct the treatment upon the principles laid down by Galen. Actuarius directs bleeding at the commencement.

Alexander discusses the established principles of treatment freely and fully. He disapproves of Galen’s practice of giving the decoction of wormwood in the genuine or true tertian, after the seventh day, and confines the administration of it to spurious tertians, when he mixes it with oxymel. His own remedies are of a diluent and refrigerant nature. He approves very much of the bath. He speaks highly of the good effects of grapes and peaches, and still more of water-melons given with cold water before the fit. He approves of gentle, but not of strong purgatives. He praises very especially a rhodomel prepared from the juice of roses, honey, and scammony; and another, consisting of the same ingredients, along with agaric and pepper.

Synesius recommends cooling articles, such as damascenes, gourds, &c. but says nothing of wormwood. Constantinus Africanus also omits to make mention either of wormwood or the tepid bath. He, however, pours water on the head and puts the feet into hot water.

Serapion directs emetics, if the matters are determined to the stomach, and clysters, or gentle purgatives, if to the bowels. He recommends myrobalans afterwards, and then wormwood, but not until the morbific matter is concocted. (Tr. vii, 13.)

Rhases recommends gentle and cooling purgatives, with refrigerant and diluent drinks, containing sorrel, cucumber, camphor, &c. (Ad Mansor. x, 4.)

Avicenna’s directions are exceedingly minute, and seemingly very judicious. He cautions against using drastic purgatives, and expresses himself doubtfully of the effect of venesection. His practice consists principally in the administration of gentle purgatives, diluent and refrigerant medicines. He approves of pomegranates, plums, and water-melons. Averrhoes lays down the same principles of practice. (Collig. vii, 11.) Haly Abbas states that, as it is the nature of these fevers to occasion heat and dryness of the body, they are to be treated with diluents and refrigerants. Agreeably to these principles, he directs us to give clysters and gentle laxatives, to use the tepid affusion, and the like. (Pract. iii, 12.) Alsaharavius recommends similar treatment. Rhases, like Haly, recommends refrigerants and diluents. He approves of cooling purgatives, such as a combination of myrobalans and scammony, or a draught made from prunes and manna. He speaks favorably of emetics. Several of his authorities recommend the bath, and others approve of wormwood. (Contin. xxx.)

It will be remarked that many of the ancient authorities recommend the tepid bath for the cure of tertian intermittents. Prosper Alpinus informs us that he had seen this practice successfully pursued by the Egyptian physicians. (De Med. Ægypt.)

SECT. XXI.—THE CURE OF SPURIOUS TERTIANS.

It does not suit with spurious tertians to bathe at the commencement, nor until symptoms of concoction have made their appearance. Neither does it answer to give food every day, but every alternate day will be sufficient. Rest and warm applications to the hypochondriac region agree with them, also broths of easy digestion, and clysters not very emollient. And if detraction of blood be expedient, it ought by no means to be omitted. The nature of the diet ought not upon the whole to be cooling and diluent, but things of a more incisive nature ought to be added. They are particularly benefited by the juice of ptisan, to which have been added pepper, hyssop, sweet marjoram, and spikenard. Also, add pepper to honied water, boil, and give it to drink, and likewise everything which will promote the secretion of urine, except those things which are of a very heating and desiccant nature. In particular, after the seventh day, give wormwood; and many have been benefited by drinking oxymel, and taking gentle laxatives. A vomit taken with food is very beneficial to those in whom the affection is of long continuance.

Commentary. Galen explains that tertians are called spurious or bastard, when the symptoms assume an anomalous character. He states correctly that they are generally connected with disease of the spleen. His practice, which is consistent with his views of the nature of the attack, is similar to our author’s, that is to say, he recommends venesection and fomentations at the commencement, and afterwards things of a hot penetrating nature, such as wormwood and pepper, which he, no doubt, gave with the intention that they should act as deobstruents. Here, again, Alexander cautions against the indiscriminate adoption of Galen’s practice, affirming that these calefacient medicines sometimes prove dangerous, by increasing the inflammatory action. Almost all the other authorities, however, adopt the views of Galen. See, in particular, Oribasius (Synops. vi, 11); Aëtius (v, 81); Nonnus (de Febribus, c. v.) From the characters of the urine Actuarius infers that the spurious tertians are still more intensely bilious than the true, and consequently require longer time to reach their acme. (De Urinis, v, 15.) Avicenna recommends at first venesection and clysters; and afterwards deobstruent medicines, such as wormwood and pepper. Haly Abbas treats spurious tertians like true, at the commencement. After their acme, he strongly recommends wormwood, but forbids it earlier. It acts, he says, by increasing the strength of the stomach, opening the pores, increasing the urine, and promoting the secretion of bile. He approves of wine in the decline of the fever, with the view of supporting the strength, and of promoting the urinary and cutaneous secretions. He therefore directs that the wine be white, and not too old. (Pract. iii, 13.)

From the account of the ancient practice in cases of tertians, as given in this and the preceding chapter, it will be seen that the use of bitters in these diseases was well understood formerly. The administration of pepper in such cases, it will also be remarked, was an ancient practice.

SECT. XXII.—THE DIAGNOSIS OF QUARTANS.

The quartan makes its attack with much coldness, as having its origin from a cold humour, namely, the black bile; but it is not attended with ardour and febrile heat like the tertian, neither does a vomiting of bile accompany. If, in addition to these, the urine be thin, white, and watery, the fever certainly is a quartan; but the characteristic of a true quartan is a small and rare pulse. They have their beginning most frequently in autumn, supervening upon wandering fevers. At that season, intermittents generally assume the quartan type, although sometimes the paroxysm observes a longer interval of days.

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.

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.

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.

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.

Commentary. Hippocrates applies the term hepialus to a fever occasioned by amenorrhœa. He briefly notices the lipyria in several parts of his works, (as Coac, 32, 27.) Galen enters minutely into the consideration of the nature and causes of the hepialus, which appears to be a variety of the quotidian intermittent. He says the fever derives its origin from the putrefaction of a thick phlegm resembling melted glass. Its distinguishing characteristic is, that the patient experiences a sensation of heat and rigor at the same time.

Aëtius, and the other subsequent authorities, treat of the fever in the same terms. They recommend, principally, sudorifics and calefacients.

Rhases, Avicenna, Serapion, and Haly treat of the epiala, and the “frigus quod non calefit,” as varieties of the quotidian. Alsaharavius gives a very distinct account of the epiala. He says it arises from a gross vitreous phlegm, and is attended with internal heat, and cold of the extremities. The pulse is small and weak, the urine white and unconcocted, and the perspiration suppressed, owing to the constriction of the pores and thickness of the humours. He approves of giving emetics, attenuants, and calefacients. The lipyriæ are treated of by Serapion, Avicenna, Rhases, and Alsaharavius. They are said to be the counterpart of the epialæ, being distinguished by internal cold and external heat. Rhases describes the hepialus as consisting of internal heat and external cold. He says it arises from vitreous phlegm. The lipyria, he states, is one of the worst varieties of ardent fevers.

The rigor without heat, or “frigus quod non calefit,” is a febrile affection still met with in warm climates.

The term typhus, now generally applied to the common fever of this country, is used by Hippocrates, in his work on ‘Internal Affections,’ where he describes five varieties of the disease. They are cases of ardent fever, attended with stupor and insensibility. The term typhodes occurs in Galen’s ‘Commentaries on Hippocrates;’ in his work, ‘De Diff. Feb.’ (i, 9); and ‘De Prognost. Puls.’ (ii, 9.) Leo defines a typhous fever to be one in which the heat is weak and concealed. (14.) It would appear that the fevers to which the ancients applied the term typhoid were either intermittents or remittents. Isidorus thus defines typhous fevers: “Typhi sunt frigidæ febres, quæ abusivè typhi appellantur ab herbâ quæ nascitur in aquis quæ Latinè forma atque status dicitur: est enim accessionum revolutio per statuta temporum intervalla.” (Orig. iv, 7.) The word τύφος occurs in Marcus Antoninus (ii, 17), where Gataker remarks, “Est enim τύφος κυρίως idem quod κάπνος, fumus.” Salmasius gives the derivation of the term as follows: “τύφος proprie est fomes, τύφεσθαι enim ἠσυχῆ κάιεσθαι Græci exponunt.” (In Tertulliani Librum de Pallio Annot. 318.)

Prosper Alpinus thus explains the nature of typhoid fevers: “Has febres exterius mites seu obscuras intus turbantes Græci typhodes appellant, quippe quæ naturam multitudine humorum gravatam, ac fere suffocatam, incendium foras transmittere nequeuntem, significent. Hasque vulgus medicorum appellat, foris mites, intus conturbantes; suntque eæ omnes, admodum perniciosæ.” (De Præsag. Vita et Morte Ægrot. i, 10.)

SECT. XXVII.—ON THE CONTINUAL FEVERS.

The continual fevers are allied to each of the intermittents; thus, to the true tertian is allied the causus or ardent fever; to the quotidian, that fever which has a paroxysm every day, but does not terminate in a complete freedom from fever; and, in like manner, to the quartan, that which has an exacerbation every fourth day. For the true causus has all the other characteristics of the tertian, and differs from it only in not commencing with a rigor, nor ending in a complete remission of the fever. The continual fever which has an exacerbation every day, possesses all the other characteristics of a quotidian, except that it does not terminate in a perfect apyrexy. In like manner, the continual fever which has an exacerbation every fourth day, but does not terminate in a complete apyrexy, is allied to the quartan. A continual fever, therefore, is one which does not terminate in any interval from fever until it is altogether resolved. But when it evinces no remission, it is, indeed, of the same class as the ardent fevers, but differs from them in acuteness.

Commentary. Hippocrates has stated the alliance between the intermittent and continual fevers. (Epidem., Op. Galeni, ed. Basil, v, p. 362.) In his report of the epidemical diseases of a certain season, he mentions that the continual fevers (συνεχεῖς) were distinguished by an exacerbation every alternate day, after the manner of tertians, and that they were attended with ardent symptoms. He also remarks their tendency to terminate in dysenteries, lienteries, and tenesmus.

Galen marks a distinction between the continual fever (συνεχῆς) and the synochus, which it is necessary that the reader should particularly attend to. He remarks that there are three varieties of intermittents: the quotidian, which arises from putrid phlegm; the tertian, from yellow bile; and the quartan, from black bile. Of continual fevers, arising from yellow bile, there are two species; the one being called synochi, and consisting of one paroxysm from beginning to end; and the other, to which the generic appellation continual (συνεχεῖς) is particularly applied, and which consists of a number of particular paroxyms. Of the continual fevers, some assume the tertian type, having a remission of the fever every alternate day; some the quotidian, and have a remission every day; and others, of rare occurrence, resemble the quartans, in having remissions after an interval of three days. (De Diff. Feb. ii, 2.) In another place he says of synochous fevers that they consist of two varieties, the one arising from an ebullition of the blood, and being produced by the conversion of ephemerals; and the other arising from putrefaction of the blood in persons who are gross and plethoric. (Meth. Med. ix.)

Aëtius treats of continual fevers (συνεχεῖς) in nearly the same terms as our author, and distinguishes them from the synochi.

Alexander states that the continual fevers (συνεχεῖς) differ from the intermittents, solely from the humours which occasion the former being of a thicker nature.

Our author’s account is nearly copied word for word from Oribasius.

Actuarius remarks that the synochus proceeds from an ebullition of the blood, and the continual fever (συνεχὴς) from putrefaction of the different humours.

Nonnus states very distinctly the difference between the synochus and continual fever. In the latter, he says, there is an incomplete remission of the febrile symptoms, but in the former there is no remission at all.

Synesius and Constantinus Africanus adopt the distinction between the synochus and continual fever, as stated by Galen.

Leo says, a continual fever has no intermission, but merely a remission and abatement of the fever in the decline of the paroxyms.

Celsus, although he does not describe the febres continuæ particularly, seems to allude to them in the following account of the quotidians: “Rursus aliæ sic desinunt, ut ex toto sequatur integritas; aliæ sic, ut aliquantum quidem minuatur ex febre, nihilominus tamen quædam reliquiæ remaneant, donec altera accessio accedat; ac sæpe aliæ vix quidquam aut nihil remittant, sed ita ut continuent.”

In the works of Rhases, the distinction between the continual and synochous fevers is clearly pointed out. He states that the synochus, or continens, is a fever which consists of one paroxysm from beginning to end; whereas the continual, called συνεχὴς by the Greeks, and f. continua by the Romans, is allied to the intermittents.

In the barbarous translation of Alsaharavius, there is some difficulty in recognizing this distinction. He first describes a fever, which he denominates synocha, which arises, he says, from inflammation of the blood, and is marked by redness of the face, headach, and difficulty of breathing. Second, nearly allied to it is the synochus or februs continua (it ought to be f. continens), which arises from putrefaction of the blood. Third, the febris quotidiana, the febris tertiana continua, and the febris quartana continua, which are distinguished from their corresponding intermittents by being attended with a partial remission and not a complete intermission of the febrile symptoms.

Avicenna describes the tertian intermittent by the name of febris tertiana periodica, and the continual tertian by that of tertiana continua; the quotidian intermittent by the name of febris phlegmatica periodica, and the continual quotidian by that of febris phlegmatica inseparabilis, or latica; the quartan intermittent by the name of quartana periodica, and the continual quartan by that of quartana continua. The synochus he calls by the name of febris sanguinis; and, in treating of it, remarks that Galen is guilty of inconsistency in stating the proximate cause of it; for that in one place he says it arises from the blood, and in another from bile. Averrhoes states the same objections to Galen’s account of the origin of synochous fevers.

Avenzoar marks the distinction between the intermittent and the continual quotidians, tertians, and quartans.

We have been more than usually minute in explaining the opinions of the ancients with regard to the Continual fevers, because much confusion has arisen in modern nosological treatises and works on medicine, from the distinction between them and the synochi not being properly understood. After what has been said, the medical reader will readily perceive that the Continual fevers (συνεχεῖς) of the Greeks are the same as the Remittent fevers described by Pringle, Monro, and other English authors of that age who have treated of fevers.

SECT. XXVIII.—THE DIAGNOSIS AND CURE OF SYNOCHOUS FEVERS.

Synochous fevers are produced sometimes by effervescence of the blood alone, and sometimes by putrefaction of the same, arising from obstruction, and have, therefore, but one paroxysm from beginning to end. The symptoms are, pulse very great, strong, quick, dense, equable; but they are not pungent; and the urine is little different from the natural. The cure of them consists in bloodletting ad deliquium. And those who are affected with these fevers, and are not bled, run the most imminent danger. But if anything should prevent us from having recourse to phlebotomy, we must use such other remedies as are calculated to remove obstructions, those which evacuate, and such as will allay the effervescence of the blood. But when in these cases you remark symptoms of concoction of the humours, and there is neither inflammation, œdematous swelling, nor scirrhus in any important part, nor any part cold, so as that the evil may be determined to it, you may boldly give cold water, more especially if the patient has been accustomed to cold drink.

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.

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.

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.

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.

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.

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.

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.