The intermittent and intercurrent pulses are opposed to one another, there being a complete failure of a pulsation in the one case, and an accessory or superfluous one in the other. There cannot be a better proof of the imperfection in our modern systems of the pulse, than that there should be no mention in them of the intercurrent pulse.
The hectic pulse, it is well known, is small and dense. Alexander Trallian says, small and feeble. (xii, 4.)
The serrated is hard, quick, and unequal in its feel. Rhases says that it is principally observed in inflammations of the pleura and diaphragm. According to Actuarius, the pulse characteristic of inflammation is serrated and hard, more especially if seated in a tendinous part. (Meth. Med. i, 25.) Le Clerc renders it le pouls en manière de scie. (Hist. de la Méd. p. iii, l. iii, c. 3.) It appears to correspond with the pulse called harsh in the works of English writers on medicine.
Borden speaks of the terms formicans, myurus, and caprizans as having been justly banished from our modern nomenclatures. But it may be doubted whether it be from superior information or from ignorance that we have rejected these nice distinctions. Some of these terms were in use long before the time of Galen, (he mentions that Herophilus used the term dorcadissans,) and for more than a thousand years afterwards the characters of the pulse to which they were applied were acknowledged as real; and, on a matter depending solely upon experience and observation, the concurring suffrages of so many ages must be admitted to be entitled to some consideration. That many of the Greek and Arabian physicians were men of great learning and of much practical skill in medicine cannot admit of a doubt; and therefore their opinions ought not to be hastily rejected as visionary and unfounded. Galen, indeed, expresses in strong terms the difficulty which he found in defining accurately the states of the artery to which the terms we are treating of are applied, and warns the reader that such characters are to be detected only by a person well experienced in the art of feeling pulses, which he pronounces to be one not easily attained. (Synops. viii.) Alsaharavius insists strongly on the necessity of having a nice sense of touch, and that it be well cultivated in order to attain the tact of feeling pulses properly. Haly Abbas and Actuarius in like manner state the difficulty and importance of the art of feeling pulses. It is to be borne in mind that the ancients performed the operation of feeling the pulse more methodically than is now generally done, which may in part account for our having lost sight of some of the nicer shades of distinction which they recognized. It is worthy of remark, further, that the truly learned and experienced Prosper Alpinus recognized and described these characters of the pulse which we have been treating of. (De pr. Vit. et Morte ægrot.)
Whoever will consult Galen’s treatises on the pulse will find discussed in them many subtle questions which are now seldom thought of. For example, he enters into a disquisition whether or not we can perceive the systole of the artery. He informs us that Agathinus had denied and Herophilus affirmed the possibility of this. He, after having, as he says, examined the matter fully, agrees with the latter. (De Dignosc. Puls. i, 3.)
Psellus gives the characters of the pulses in not inelegant politic verses. A very clear and satisfactory description of them is given in the short treatise of Theophilus Protospatharius.
The causes which produce all these varieties of pulse, and the changes of the system which they indicate, are, upon the whole, pretty clearly explained by our author; and the reader who wishes to consult other abridgments of the doctrines of Galen, may find them in the works of Rhases, Haly Abbas, and Actuarius. We shall merely make a few more remarks upon some of the more obscure and least understood parts of the system.
Respecting the myuri, Galen states that they all indicate a prostration of the vital powers, but differing in degree, according to circumstances. When the pulse gradually becomes smaller, and in like manner recovers its magnitude gradually, and so on alternately, so as to form the recurrent myuri, it indicates an inferior degree of prostration; and, when the diminished state of pulsation continues permanent, a greater degree of oppression is indicated. In the former case the powers of the system seem able to struggle against the load, but in the latter they are completely overcome. This state is next in danger to that of complete asphyxia. These three are the worst kinds of pulse. The intermitting is said by him to be allied to these, being indicative of great danger, though inferior to that of those we have mentioned. Next to the intermitting is the intercurrent, which indicates that the powers of the system are strong, but oppressed, and contending against some great load. Galen was particularly apprehensive of the intermitting pulse, which he held to indicate that the system is struggling against some urgent cause. He remarks, however, that, when the pulse is otherwise strong and frequent, it indicates less danger than when it is weak and slow. But, upon the whole, he considered this kind of pulse so full of danger, that he affirms he had never known a person recover whose pulse intermitted during the interval of two pulsations. When the pulse intermits during the space of only one pulsation or a little more, he says he had often seen the patient recover. He also states that an intermitting pulse is less dangerous in old persons than in adults or children. Some, he says, affirm that they have seen cases of intermission which did not prove dangerous, but he believes that they had confounded rarity with intermission. The intermitting is to be distinguished from the rare by the length of the time of rest, and by the latter being often equable, whereas the former is always unequable. He says it is generally occasioned by frigidity of the heart. These doctrines may be traced through all the subsequent authorities, both Greek and Arabian, down to Actuarius.
Galen, Rhases, and Haly Abbas repeatedly inculcate that the undulatory pulse indicates an approaching crisis by a sweat. They describe it as being strong, full, soft, bounding, and unequable. According to Galen it is most commonly met with in lethargic affections, quotidian, marsh, and typhoid fevers. (De Præs. ii, 9.) It is also said to be common in sudden attacks of dropsy. (Ib.) In some instances, however, it is the precursor of some critical evacuation, such as that by the hemorrhoids, or by the bowels. (Synops. 22.) Actuarius particularly states that critical sweats are indicated by the undulatory pulse. (Meth. Med. ii, 2.)
The dicrotos is distinguished by a smaller pulsation suddenly succeeding to a larger one. Galen compares it to a hammer, which, when forcibly struck against the anvil, rebounds, and strikes it again. The artery in such cases is always strong and vibratory. Philaretus describes the pulsation as being hard, vehement, and rebounding. Galen says it can only occur when the powers of the system are strong, the artery hard, and the body oppressed with a redundance of humours. He repeatedly inculcates that it indicates an approaching crisis.
The singular pulse called dorcadissans, which we have translated goat-leap, is said by Galen to occur most frequently in affections of the heart and inflammations of the parts within the chest. (De Prognos. ii, 8.) It is the same as the pulse now called jerking, which the best authorities agree to be characteristic of pericarditis. In such cases, Hope says, the pulse is “full, hard, jerking, and often with a thrill.” (Diseases of the Heart, p. 99.) We suspect the modern term jerking, although perfectly intelligible to one experienced in the art of feeling pulses with discrimination, will be found fully as difficult to define as the dorcadissans of the ancients.
The vermicular appears to have been the same as that which is now sometimes denominated creeping. In fact, Galen derives its name from its resemblance to the motion of a creature creeping. (Synops. 22.) It is said by the ancient authorities to occur in cases of sudden prostration of the vital powers, produced by inordinate evacuations, such as hemorrhage, cholera, diarrhœa, and the like. (De Prognos. Puls. ii.)
The pulse called innuens et circumnuens, is said to occur only in cases of extreme debility and danger, more especially when attended with a great chill. It is connected, says Galen, with idiosyncrasy. (De Præs. ii, 11.) Is it the same as the pulse now named flickering?
Galen gives the following ingenious explanation why the pulse is contracted and frequent, in cases of acute inflammations. He remarks that, if a person have an inflammation in a limb, he will experience most ease in a state of complete rest; but if obliged, by some urgent necessity, to perform a journey, he will find that he can accomplish this most easily by taking short and frequent steps. In like manner, when any part is inflamed, it would afford most relief if the motion of the arteries could be altogether suspended for a time; but, as this cannot be, nature renders the dilatation as confined as possible, and makes up for its smallness by frequency. (De Usu Respirationis.)
Of the alvine discharges, the best is that which is soft and compact, and is evacuated at the hour which is customary in health. Such excrement is yellowish, of the proper consistence, and not very fetid; for whatever is different from these is not good. That which resembles in colour the food which has been taken, or is thin, wants the natural juices, and is passed quickly, is indigested. But that which is intensely yellow, if evacuated in the beginning of a disease, indicates that the complaint is of a very bilious nature; but if after the acme, that the body is properly purged. The green is the sign of verdigris-green bile, but the black of black bile, or of adust blood mixed with it. The livid marks a coldness and considerable mortification of the internal parts. The oily is the mark of a melting of the fat in the body; as the glutinous, which is worse than the oily, is a mark of a melting of the parts of the animal. That which is very fetid is a mark of no small degree of putridity. With regard to them all, if the quality of the excrements does not correspond with the food which had been taken, you may thus judge of the affection. Of all kinds, the worst and most fatal is black, livid, oily, and what is hastily passed.
Commentary. See, in particular, Hippocrates (Prognost.); and Galen (de Crisibus, xi.) Galen remarks that the stomach may do its office properly, but that, owing to the heat of the neighbouring parts, the moisture may be dissipated, and the contents of the bowels rendered too dry; or that, owing to an imperfect distribution of the chyle, they may be too liquid. When the alvine discharges are soft and consistent, we are certain that both the digestive and distributive functions are properly performed, and likewise, that no part within the belly is in a state of inflammation. He afterwards makes many other ingenious observations on this subject, the importance of which, towards the restoration of health, is now generally admitted. He remarks, that, agreeably to the description of Hippocrates (Prognost.) the proper alvine evacuation ought to be yellowish; for, if very yellow, it indicates the presence of too much bile, or, if it do not partake of that colour at all, it indicates that the passage of the bile to the intestines is stopped. Rhases and Avicenna concur in this remark. Galen describes the frothy evacuation, which appears to be the same as the one resembling yeast, described by modern authorities. Hippocrates (Progn.) and Galen makes mention of a discharge, which consists of small, hard, and convoluted portions. Galen is of opinion that it is occasioned by constipation and heat of the bowels. According to Hippocrates, a discharge of black bile indicates that death is at hand. (Aphor.) Theophilus treats of this subject at such length that we cannot afford room for a proper outline of what is contained in his treatise. Bloody evacuations, he says, proceed either from disorder of the liver, ulceration of the intestines, or rupture of a vessel. Discharges of pus may come either from the liver, or from the stomach, or from the intestines. A viscid and fatty evacuation indicates melting of the body, and if attended with a fetid smell, putrefaction. Flatus in the bowels may either arise from flatulent humours forming in the bowels, or food dissolved into gases by the heat of the parts. (De Excrementis.)
The account of this subject given by Haly Abbas (Theor. vii, 16, and x, 10) is excellent, but principally collected from the Greek writers. An unctuous discharge, he remarks, is occasioned by a melting of the fat. If it be viscid at the same time, it indicates also a wasting of the principal members. A frothy discharge proceeds from heat and flatulence. A green evacuation indicates immoderate heat, and the presence of bile. Black discharges consist either of black bile, or of common bile blackened by immoderate heat. This, he says, is the worst appearance of all. If blood is discharged after the fæces, it may be supposed to come from the small intestines; but if before, from the large; and if mixed with the fæces, it probably comes from the intermediate parts. See also Alsaharavius (Theor. ix), and Rhases (Cont. xxxi.) Rhases states that white fæces arise from jaundice. When the discharges are watery, the nourishment of the body is stopt.
The opinions of Hippocrates and Galen on this subject are correctly stated and explained by Prosper Alpinus (De Præsag. Vita et Morte ægrot. vii, 11.)
As concerning the alvine discharges, so also with respect to the urine; using that of healthy persons as a rule, we shall hence form our indications of that of persons in disease. That urine, therefore, is best, which is nearest to that of healthy persons. Such is that which is at the same time of a faintish golden, or faintish saffron colour, and which, moreover, is moderate as to consistence. There are three varieties of turbid urine; for, either straightway after being voided it deposits a sediment; or it always remains the same; or it is voided pure, but afterwards becomes turbid; of these, the third is bad, the first favorable the second intermediate between them. That which is wholly unconcocted, being altogether watery, is symptomatic of digestion being entirely gone in the venous system; and when it is passed frequently, the disease is called diabetes, which is the worst of unconcocted urines. Next to these is the thin and white urine, which resembles water. Nearly allied to these, is another kind of urine, appearing in many diseases, and which is very like to the thin and white. The palish is next to this. The pale may also be of a faintish golden colour, and is concocted in proportion as it partakes of this colour. It ought, however, to be as much different from water in thickness as in colour, if it is to be properly concocted. But if it preserve exactly its natural colour, and have a white, smooth, equable, and copious sediment, it is indicative of perfect digestion. A greater quantity than natural indicates that a crude humour is purged off; but if it is somewhat thicker than natural, and has a certain sediment, it is not then altogether unconcocted. But if it have gritty, scaly, furfuraceous, black, livid, green, or fetid sediments, such urine is altogether unconcocted and particularly mortal. But urine of a proper colour, and which at the same time has white, smooth, and equable sediments, or certain cloud-like appearances, or substances swimming in the middle of a like kind, is of all others the best. Of these characters, the sediment is of the most importance; next, the substances swimming in it; and third, the cloud-like appearances on its surface; and, on the whole, of the substances which float in the urine, the more they sink downwards so much the better.
Commentary. See Hippocrates (Prognost. ii, et de Vict. Acut. c. 46); Galen (Comment. de Crisibus, i, 12); Celsus (ii, 7); Theophilus (de Urinis); Actuarius (de Urinis); Abicianus (de Urinis; De Urinis secundum Syros, de Urinis secundum Persas, de Urinis Commentatio, ap. Phys. et Med. Græc. Minor. ed. Ideler); Aëtius (v); Avicenna (iv, 2, 1, Cantic. p. 1); Averrhoes (Collig. iv, 21); Haly Abbas (Theor. iv, 12, x, 10); Alsaharavius (Theor. viii); Rhases (ad Mansor. x, 30, and Contin. xxxi); Psellus (Opus Medicum.)
Of the ancient authorities who have treated of the urinary discharges, Theophilus and Actuarius are most particularly deserving of attention. Besides the watery portion, the ancients distinguished three distinct substances in the urine: 1st, the hypostasis or sediment, which is the part that falls to the bottom; 2d, the enæorema, or substances which float in the watery part, but have not weight to subside; 3d, the nubeculæ, or cloud-like appearances seen floating on the surface, or as they may be called the scum. All the different appearances which these substances put on, including every imaginary shade of colour, are described with surprising minuteness, and connected with the morbid conditions of the system which gives rise to them. In fact, there is no part of our task which we are obliged to discharge in so unsatisfactory a manner to ourselves as the present; for, to give our readers anything like a competent exposition of the knowledge possessed by the ancients on the morbid appearances of the urine, we would require to transfer to our pages the whole contents of the large treatise of Actuarius. We shall now give a few extracts from his work and that of Theophilus. They state that the urine of sedentary persons has more sediment than that of persons who pursue an active course of life; that the urine of women, from this cause, has generally more sediment than that of men; that of children more than that of adults; and that of persons who live grossly, than the urine of temperate persons. Theophilus thus delivers the characters of oily urine. When in fevers the urine assumes the colour of oil, it indicates that the fat of the body is melting down. When the appearances of the urine resemble oil still more, it indicates an increase of the melting of the fat; and when the urine in consistence and colour appears exactly like oil of a dark colour, it prognosticates a collapse and death. (§ 17.) This accords with what is stated in one of the aphorisms of Hippocrates: “When in ardent fevers the urine has an oily sediment, it prognosticates death.” The tare-like urine, as it was called from the resemblance of the sediments to the colour of the tare (ervum ervilia), but which might be better called the grumous, since, as Actuarius explains, they bear a close resemblance to clots of blood, is said by Theophilus to be indicative of melting of the flesh. The scaly urine derived its name from small substances resembling the husks or hulls of grain in the urine, and in febrile diseases was supposed to indicate great disorder of the general system, but otherwise to be connected with an affection of the bladder. The furfuraceous, which derived its name from the resemblance of the sediments to bran, was also held to be symptomatic of local disease of the bladder, or of constitutional disorder in fever. The gritty, so called from the resemblance of the substances in the water of the urine to large particles of ground grain, was reckoned by all the authorities, from Hippocrates downwards, as a very bad symptom in fevers. Fetid urine was supposed to indicate melting or putrefaction of the body. Actuarius gives a curious account of urine without sediment, which he ascribes to its being attracted to some part of the system which is the seat of inflammation or erysipelas. (v, 5.) The enæorema, or substances in the middle of the urine, are said by Actuarius sometimes to resemble spiders’ webs, sometimes specks of oil like what appears in fat broth when cooled, and at other times hairs, as will be more fully stated elsewhere. The nebulæ, or scum on the urine, is said to put on various appearances, as, for example, that of bullæ or bubbles, of which mention will be made in another place. From a passage in Theophilus (v, 8), it may be inferred that the ancients sometimes applied external heat as a test of the characters of the urine. On the main the differences in the colours of the urine were held to depend on the mixture of bile in the urine, and sometimes, though rarely, of blood.
As a specimen of the doctrines of the Arabians, although, in fact, entirely borrowed from the Greeks, we shall select a few of the observations of Haly Abbas and Alsaharavius. According to Haly, thinness of the urine indicates deficient digestion. Thickness, on the other hand, is the product of excessive digestion, or arises from the presence of pituitous humours in the body. When the sediment is white, it is a favorable symptom; when yellow, it is from yellow bile; when red, it is from a sanguineous plethora and imperfect digestion; and if of long continuance, it must proceed from inflammation of the liver. If, after intense redness, the urine becomes black, it is a most fatal symptom. When the urine is moderately fetid, it is connected with indigestion; but when very fetid, with putrefaction. Alsaharavius delivers the characters of the different kinds of urine in nearly the same terms. He properly cautions the physician not to allow himself to be imposed upon by the colour of the urine, which may sometimes acquire a tinge from the patient’s having taken saffron, cassia-fistula, or the like. Such tricks, he says, are often practised upon water doctors. According to Rhases, it is an unfavorable symptom when the urine does not become turbid in the course of the fever. Yellow urine without sediment is said to be unfavorable.
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.
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.)
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.
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.
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.
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.)
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.)
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.
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.
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.