Book Second

Book Second

SECT. I.—ON FEVERS, FROM THE WORKS OF GALEN AND SEVERAL OTHERS.

After having treated of those things which relate to the preservation of health, we now come to the treatment of persons already in disease, and shall begin with homogeneous disorders as being the most simple. These are what are called Fevers. Wherefore, using again principally Oribasius’ Epitome of the Works of Galen and several others on this subject, we shall add a very few things omitted by them.

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COMMENTARY. The following ancient authorities may be consulted on the subject of fever: Hippocrates (Epidem. et alibi); Galen (Comment. in Hippocr. Epidem., de Differentiis Febrium, Meth. Med. viii, Therap. ad Glauc. i, De Typis, de Crisibus et alibi); Celsus (iii); Pseudo-Dioscorides (Euporist. ii); Oribasius (Synop. vi, Euporist.); Aretæus (Morb. Acut. ii, 4); Aëtius (v); C. Aurelianus (Pass. Acut. ii, 10); Alexander Trallian (xii); Alexander Aphrodisiensis (Probl. i, 84, de Febribus); Actuarius (Meth. Med. iii); Pliny (Hist. Nat. xxviii, 66, xxx, 30); Palladius (de Febribus); Michael Psellus (Opus Medicum); Synesius (de Febribus); Leo (ap. Ermerins Anecdota Græca); Stephanus (Comment. in Prognost. Hippocrat. ed. Dietz); Constantinus Africanus (de Febribus); Serenus Samonicus; Vindicianus (Epistola ap. Fabricii Bibl. Græc. tom. xiii); Avicenna (iv, i); Syrasis, Avicennæ Expositor; Haly Abbas (Theor. viii, Pract. viii); Alsaharavius (Theor. vi, Pract. xxxii); Serapion (tr. vi); Avenzoar (iii, 7); Averrhoes (Collig. vii); Rhases (ad Mans. x, Contin. xxx.)

All the ancient authorities held that a fever consists of a preternatural increase of the Innate, or, as it is now called, Animal heat, which they considered as the instrument by which the soul performs all the functions of the body. See Alexander Aphrod. (de Feb.) Thus, Palladius defines a fever to be “a preternatural heat, which begins in the heart, and is diffused by the arteries over the whole body, sensibly injuring the actions of the body.” Hippocrates, Galen, Aëtius, Alexander Trallian, Psellus, Leo, and Actuarius give similar definitions. Cælius Aurelianus says of Asclepiades: “Febrium ponit signum calorem plurimum.” (Morb. Acut. i, 14.) Isidorus defines a fever thus: “Febris a fervore dicta est; est enim abundantia caloris.” (Orig.) Hippocrates, however, the great opponent of hypothesis in medicine, insists that there is more in a fever than a simple excess of pure heat; or, in other words, that the essence of fever is heat mixed up with noxious qualities. (De Vet. Med. § 17.) The celebrated Erasistratus maintained an opinion, lately revived by Clutterbuck and Broussais, that fevers and inflammations are identical. See Milligan’s Celsus (p. 13 and 112); and Cælius Aurelianus (de Acut. Morb. ii, 3.) He further taught that in fevers the blood of the veins is thrown into the arteries. (Plutarch de Placit. Philos. v, 29.)

The Arabians adopt the opinions of Hippocrates, Alexander, and Galen. Thus, for example, Haly Abbas defines fever to be a preternatural heat proceeding from the heart, and diffused by the arteries over all parts of the body. According to him there are three kinds of fevers. The first, are seated in the spirits, and affect only the heat of the body: these are called ephemeral fevers. The second, originate in a vitiated state of the fluids, which impart a preternatural degree of heat to the heart, whence it is diffused over all the body. The third arise in the vital organs and solid parts, from which heat is transmitted to the heart. (Pract. viii, 2.) See also, in particular, Rhases (Cont. xxx.)

SECT. II.—OF THE PRINCIPAL CONSIDERATIONS TO BE INQUIRED INTO WITH REGARD TO FEBRILE AFFECTIONS.

The first thing to be considered is, whether the disease will prove fatal or not; then, if it is not to prove fatal, whether it will be acute or chronic (these considerations apply to other great disorders); and, third, whether it will come to a crisis all at once (which is peculiar to fevers), or be resolved gradually.

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COMMENTARY. This Section, and great part of the contents of this book are taken from Galen (Therap. ad Glauc. i,) or from Oribasius (Synops. vi.)

SECT. III.—FROM GALEN, WHAT TO CALL THE COMMENCEMENT OF THE DISEASE.

As headach is not the same complaint as fever, so neither are insomnolency, loss of appetite, heaviness of the whole body, and a sense of lassitude; and yet each of these symptoms, although different from fever, announces its approach. A fever setting in, and more especially in an acute manner, cannot escape our notice, nor even that of a person unacquainted with these matters. Or, if we should suppose that it might escape us, I should wonder if the patient himself could be ignorant of it for more than an hour. Wherefore I call that time the commencement of the disorder, when those who are beginning clearly to be affected with the fever betake themselves to bed.

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COMMENTARY. The whole of this Section is taken from Galen (de Diebus criticis), where the question is fully discussed. Aëtius, like our author, defines the commencement of a fever to be the time when the strength of the patient being overcome by the complaint, he is obliged to take to bed. On this point the Arabians venture to differ from the Greeks. Thus, Rhases and Avicenna reckon the commencement from the time when the patient first feels a departure from health.

The disagreement among the authorities upon this point is to be regretted, as it tends to obscure the doctrine of the critical days.

SECT. IV.—HOW TO KNOW WHETHER THE DISEASE WILL PROVE FATAL OR NOT.

These are fatal symptoms: A deathlike countenance, sharp nose, hollow eyes, and the other symptoms described by Hippocrates, when they do not proceed from watchfulness, or evacuation, or want of food; also, intolerance of the light, shedding tears from no external cause, there being no particular affection of the eyes; or the one eye appearing less than the other; or the white of the eyes becoming red, or livid, or black, or having a muddiness in them; and the white of the eyes appearing during sleep, the eyelids not being closed, unless this symptom proceed from a great evacuation, or from habit. Likewise grinding the teeth, a state of delirium, picking at flocks of wool, or bits of chaff, are not favorable. Attention should also be paid to the patient’s mode of lying. To lie on one’s back, as it were, in a relaxed state, and to sink downwards in bed, are indications of extreme debility. It is still worse to have a cold respiration at the mouth and nostrils; and a pulse obscure, dense, and intermitting, and profuse sweatings with syncope are most mortal symptoms. If all the symptoms we have mentioned, or even more appear, or if they be fewer in number but strong, and if they be without any of the favorable ones, death is inevitable. The breathing free, pulse natural, soundness of intellect, being well disposed to take whatever is offered, the appearance of countenance and mode of reclining like those of persons in health,—all these symptoms are favorable and prognosticate recovery; and, in general, whatever symptom is contrary to the natural state indicates an unfavorable, whereas, what is correspondent, indicates a favorable termination. Concerning the prognosis from the urine, alvine discharges, and sputa, we will speak soon.

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COMMENTARY. The great master of prognostics is Hippocrates, whose system of medicine was entirely based on the observation of the favorable and unfavorable symptoms of disease. It would appear that the first advances in this art were made in the temples of the gods, and especially of Æsculapius, which the sick were in the practice of resorting to in order to ascertain the issue of their maladies. See a very ingenious and learned disquisition, ‘de Hippocratis Doctrina a Prognostice oriunda,’ by F. Z. Ermerins, M.D. The works of Hippocrates, especially the ‘Prorrhetica and Coacæ,’ contain a rich treasure of observations which cannot be too much explored by the student of medicine. His prognostics are founded upon the appearances of the face, eyes, tongue, the voice, hearing, the state of the hypochondriac region, the abdomen, the general system, sleep, respiration, and the excretions. We can do little more, in this place, than express our high sense of the value of the ‘Hippocratic Treatises on Prognostics,’ and recommend the study of them to all members of the profession who would wish to learn the true inductive system of cultivating medicine. We shall give as a specimen of Hippocrates’ and Galen’s labours, in this department, a few of Galen’s remarks on the causes of the symptoms, as described by Hippocrates. It is one of the prognostics of Hippocrates, that profuse perspiration in acute fevers is unfavorable; and, in explanation of this, Galen states that a critical sweat may indeed be favorable; but that such as are profuse and continued indicate a complete prostration of the vital powers. A fixedness of the eyes is said by Hippocrates to be a fatal symptom; the reason of which, according to Galen, is, that it proceeds from paralysis, or insensibility of the muscles of the eye. Hippocrates mentions it as an unfavorable symptom when the patient lies with his mouth open; and Galen attributes this symptom to the origin of the nerves, that is to say, the brain, undergoing pressure. Hippocrates states, that involuntary discharges from the bowels are an unfavorable symptom; and Galen justly remarks that they indicate great insensibility.

The Prognostics and Aphorisms of Hippocrates are further illustrated by the learned and interesting Commentaries of Stephanus Sophista, Theophilus, and Damascius, which were published a few years ago by Dietz. From the nature of their works, it is impossible to give any satisfactory outline of their contents within our narrow limits. We shall merely give one specimen of them. It is stated in one of the Aphorisms of Hippocrates, that dyspnœa and delirium occurring together in fever, indicate a fatal termination. Upon which Theophilus and Damascius remark, that the one symptom implies disease of the heart and the other of the brain. (Ed. Dietz. T. H., p. 415.)

Celsus gives an elegant translation of this part of the works of Hippocrates. The following is his version of the description of the Facies Hippocratica: “Ad ultima jam ventum esse testantur, nares acutæ, collapsa tempora, concavi oculi, frigidæ languidæque aures et imis partibus leniter versæ, cutis circa frontem dura et intenta, color aut niger aut perpallidus.” Other unfavorable symptoms are also strikingly portrayed: “Mali morbi testimonium est vehementer et crebro spirare: a sexto die cepisse inhorrescere; pus expuere; vix excreare; dolorem habere continuum; difficulter ferre morbum; jactare brachia et crura; sine voluntate lachrimare; habere humorem glutinosum dentibus inhærentem; cutem circa umbilicum et pubem macram, præcordia inflammata, dolentia, dura, tumida, intenta, magisque si hæc dextra parte, quam sinistra est; periculosissimum tamen est, si venæ quoque ibi vehementer agituntur.”

Aëtius and Oribasius, like our author, borrow almost every thing from Hippocrates and Galen.

Rhases and Avicenna, particularly the latter, treat of the prognostics in fever very fully. Avicenna, like Hippocrates, sets down deafness as an unfavorable symptom. Hippocrates had stated, that jaundice coming on before the seventh day is unfavorable; but Averrhoes affirms, that all the Indian and Persian physicians reckoned it a favorable symptom. Rhases considers yellowness of the skin an unfavorable symptom, unless the fever be of a bilious nature. Alsaharavius says it is an unfavorable complication when it does not prove critical. It is proper to mention here that Hippocrates modifies the above prognostic by stating in one of his aphorisms, that jaundice coming on on the 7th, 9th, 11th, or 14th day is favorable. (iv. 64.) Alsaharavius states it as a dangerous symptom, when the patient lies on his back with his legs drawn up. This agrees with the prognostic of Celsus “Mors denuntiatur ubi æger supinus cubat, eique genua contracta sunt.” Avicenna and Averrhoes state it as a fatal symptom when the patient sinks down in bed and exposes his hands and feet. (Averrhoes, Comment. in Cant. Avicennæ.)

According to Rhases it is a bad symptom when the patient has lost his modesty, so as to expose freely those parts of the body that should be covered. He holds also that it is a bad symptom when the vomitings resemble verdigris. (Ad Mansor. x, 21.)

Prosper Alpinus gives an admirable account of the prognostics in diseases. See his work, ‘De Præsagiendâ Morte et Vitâ ægrotantium,’ passim. He agrees with the ancients, that deafness is an unfavorable symptom, unless it occur at the time of a crisis. Like the ancients, he considers the absence of thirst an unfavorable symptom in ardent diseases, as indicating that the system is insensible of its wants.

SECT. V.—HOW TO KNOW IF THE DISEASE WILL BE OF LONG DURATION.

The duration of the disease may be ascertained from four things: from the movement of the disease itself, from the habit of the patient, from the pulse, and from the species of the fever. From the movement of the disease thus: if the four periods of a particular paroxysm have passed over quickly and in the least possible time, the disease will be an acute one, the furthest bound of which will be the seventh day, and generally it will come to a crisis on the fourth. If the periods of the first paroxysm occupy more time than this, but do not exceed twelve hours, the disease will still be an acute one, which will terminate within the fourteenth day. If it extend longer, so that the commencement and augmentation of the paroxysm alone occupy a longer period than a day or a night, such a disease will prove a long one. If the disease have no particular paroxysms, but consist of one continued paroxysm, as it were, from beginning to end, as in synochous fevers, even in this case you may call the disease an acute one. It may be judged of from the habit of the patient; for if the face and the rest of the body are already considerably wasted, an acute disease is indicated; but if nowise reduced, a chronic one; for a great collection of offending matter is indicated, which will require a length of time for its concoction. It may be judged of from the pulse: thus, a great, strong, quick, and dense pulse, is indicative of an acute disease, but the contrary of a chronic. From the species of the fever, inasmuch as hot and ardent fevers indicate an acute, whereas gentler, and, as it were, smothered fevers indicate a chronic one.

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COMMENTARY. Celsus thus states the prognostics of a protracted fever: “Signa quædam sunt, ex quibus colligere possumus, morbum, etsi non interemerit, longius tamen tempus habiturum: ubi frigidus sudor inter febres non acutas circa caput tantum, et cervices oritur: aut ubi, febre non quiescente, corpus insudat: aut ubi corpus modo frigidum, modo calidum est, et color alius ex alio fit: aut ubi, quod inter febres aliqua parte abscessit, ad sanitatem non pervenit: aut ubi æger pro spatio parum emacrescit: item si urina modo liquida et pura est, modo habet quædam subsidentia; si lævia atque alba rubraque sunt, quæ in eâ subsidunt; aut si quasdam quasi miculas repræsentet; aut si bullulas excitat.”

Galen has given a full exposition of these symptoms in his Commentary on the Prognostics of Hippocrates, from which Aëtius, Oribasius, and our author have borrowed largely. Rhases, Avicenna, but most especially Haly Abbas, treat at great length of this subject. See also Averrhoes (Commentaries on the Cantica of Avicenna.)

SECT. VI.—HOW TO KNOW IF THE DISEASE WILL TERMINATE BY A CRISIS, OR BY RESOLUTION.

This may be ascertained from what has been already said, namely, the species of the fever and its duration, and perhaps from the species of the fever alone. For hot and ardent fevers are of short duration, and usually terminate with some critical evacuation; whereas the gentler kinds prove more chronic, and have a tendency to abscess. From what has been said, it appears that we may prognosticate not only when the disease will come to a crisis, but also how it will terminate; for acute diseases generally terminate by critical evacuation, and the chronic by abscess.

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COMMENTARY. A similar statement is made by Aëtius (v, 22.) See also Averrhoes (Comment. in Cantica Avicennæ.)

SECT. VII.—ON CRITICAL DAYS.

Of the critical days, some terminate the disease frequently, faithfully, well, completely, clearly, decidedly; and others contrariwise to these. But the 13th has been shown to possess an intermediate character. Some of these are such as to prove critical if they experience even the most moderate impetus of nature, such as the 7th and 14th; whilst most of them prove critical in violent commotions of the system, but not otherwise. Neither are the favorable all equally favorable, nor the unfavorable all equally unfavorable; nor is their favorableness and unfavorableness according to any order. Those in the first rank of favorable days may be arranged thus: the best of all are the 7th and 14th, next to them the 9th, and 11th, and 20th; and near to them the 17th and 5th, after these the 4th, after it the 3d and 18th. Opposed to them, of the second rank, are these: the worst, which proves obscurely critical with danger, and is, as it were, diametrically opposed to the 7th, is the 6th: near to it are the 8th and 10th, after these the 12th, 16th, and 19th. Intermediate between these is the 13th, being neither so objectionable as those of the second rank, nor so powerful in freeing from diseases as those of the first. The critical days then are thus arranged according to their degree by Galen. Numerically thus: the favorable are the 3d, 4th, 5th, 7th, 9th, 11th, 14th, 17th, 18th, 20th; the unfavorable, the 6th, 8th, 10th, 12th, 16th, 19th; the intermediate, the 13th. Some of the critical days give information concerning the others, and are hence called indicatory by Hippocrates, because they indicate the crisis that is to happen on another critical day. Thus the 4th indicates a crisis on the 7th, by inducing sweats, perspirations, or some such particular evacuation, or by displaying certain signs which had not formerly taken place, or some symptoms of concoction. Galen says that the 4th is indicatory of the 6th, although it be unfavorable, as the 11th is of the 14th, and the 17th of the 20th. Until the 14th day the crises are the most decided, next to these until the 20th; from the 20th to the 40th they gradually lose their decided character. Of these, the first in degree are the 27th, 34th, and 40th, after which are the 24th and 32d. The other numbers intermediate between the 20th and 40th are indeterminate, and those after the 40th are not properly critical, as they terminate diseases by concoctions and abscesses rather than by crises. Hippocrates seems entirely to disregard all those after the 40th day, yet he enumerates the 60th, 80th, and 100th. After these, he says that some diseases prove critical in seven months, some in seven years, and others, as it would appear, in twice or thrice seven years.

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COMMENTARY. The Father of Medicine who was profoundly skilled in Semeiology, appears to have attached great importance to the observance of the critical days. At first, as Galen remarks, he seems to have been undecided respecting certain days, and, accordingly, he gives a somewhat different list of them in his ‘Prognostics’ and ‘Aphorisms,’ from what he has given in his ‘Epidemics.’ His latter list of critical days differs little or nothing from that of Galen.

Galen reposes such confidence in the doctrine of critical days, that he affirms that, by a proper observance of them, the physician may be able to prognosticate the very hour when a fever will terminate. The following is his list: The 7th is particularly favorable; next, the 14th; next to these, the 9th, 11th, and 20th; then the 17th and 5th; afterwards the 4th, 3d, and 18th. The 6th is very doubtful and unfavorable; the 8th and 10th, like the 6th; the 12th, 16th, and 19th, like the 8th and 10th. Intermediate between these two lists of favorable and unfavorable days is the 13th. He informs us that Diocles and Archigenes held the 21st to be particularly favorable, but he agrees with Hippocrates in rejecting it and adopting the 20th.

Celsus follows the system of Archigenes. He says, “κρίσιμοι dies erant, dies tertius, quintus, septimus, nonus, undecimus, quartus-decimus, unus et vicesimus; ita ut summa potentia septimo, deinde quarto-decimo, deinde uni et vicesimo daretur.” But he does not hesitate, afterwards, to express his distrust in the whole system; for, he adds, “verum in his quidem antiquos tunc celebres Pythagorici numeri fefellerunt; cum hic quoque medicus non numerare dies debeat, sed ipsas accessiones intueri.”

The Greek writers subsequent to Galen adopt his system, with little or no alteration. Aëtius arranges the critical days thus: First in order, the 7th and 14th; then the 9th and 11th; next to them the 17th and 5th; then, the 4th; and afterwards the 3d and 20th. The 6th is usually bad.

The last of the ancient authorities, Actuarius, is very full and confident in laying down the received doctrines, with regard to the critical days. He follows Galen.

The Arabians, with scarce one exception, adopt the Galenic system. Avicenna, who treats of the critical days very fully, mentions the list of them given by Hippocrates and Galen, and also that by Archigenes, but decides in favour of the former.

Rhases mentions the critical days in the following terms: The 3d is critical in very acute fevers; the 4th is indicative of the 7th and 6th; the 5th is favorable; the 6th generally unfavorable; the 7th is a particularly favorable or unfavorable crisis; the 8th rarely critical, but if it be, unfavorable; the 11th critical and indicative of the 14th; the 12th rarely critical, and like the 8th; the 13th rarely critical; the 14th, critical and favorable; the 15th like the 13th; the 16th like the 12th; the 17th like the 9th, and indicative of the 20th; the 18th rarely critical, or unfavorable; the 19th rarely critical, or, if so, not bad; the 20th next to the 14th, and favorable; the 21st sometimes critical, but less frequently so than the 20th; the 24th resembling the 20th; after these the 27th, 31st, 37th, and 40th are critical. Averrhoes remarks, that great deference is due to Rhases’ opinion upon this subject, since it was confirmed by experience, in more than ten thousand cases, in an infirmary (in infirmaria Relenson). His list is very little different from that of Galen. In his ‘Continens,’ he gives an account of the system of Archigenes, but prefers that of Hippocrates. (xxxii.)

Averrhoes states that the medical world was divided between the systems of Archigenes and Galen, but he inclines to the side of the latter in this case, although on most occasions given to dispute his authority.

Avenzoar, upon the whole, nearly agrees with Rhases, but expresses himself undecided with regard to the 20th and 21st days. His authority must also be allowed to be of great weight upon this subject, if we may believe Averrhoes, that he lived to the age of one hundred and thirty-five, and practised medicine from his fortieth year.

To the first class of critical days, according to Haly Abbas, belong the 7th and 14th; to the second, the 11th and 20th; to the third, the 4th, 17th, and 21st; and to the fourth, the 3d, 5th, 9th, and 18th.

Alsaharavius gives a similar list to Haly’s. He inclines rather to the 20th than the 21st day.

Galen, and most of the ancient authorities, believed that the critical days are influenced by the moon. Actuarius, in particular, attributes much to the influence of the sun and moon in influencing the course of fevers.

Prosper Alpinus gives a correct summary of the ancient doctrines respecting the critical days. (De præs. Vita et Morte ægrot. vi, 4.)

SECT. VIII.—THAT CRITICAL SYMPTOMS APPEARING IN THE COMMENCEMENT ARE UNFAVORABLE.

The signs of concoction are never unfavorable, for concoction always take place when nature prevails, and therefore the signs of it are always favorable. But the critical signs may sometimes appear unfavorably, owing to the crisis partaking of a double character (as was said with regard to the critical days), being sometimes favorable and sometimes unfavorable. They ought not therefore to appear at the commencement, nor during the increase of the disease, but after its acme, at which time nature is prevailing over the disease.

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COMMENTARY. The opinion here delivered is derived originally from Galen, but is maintained also by Oribasius, and the other authorities. It requires no comment.

SECT. IX.—HOW TO JUDGE BEFOREHAND OF A FUTURE CRISIS.

If the paroxysms increase in violence, occur earlier, and become much stronger; if they invade on the third day; and if symptoms of concoction appear in the urine, alvine discharges, and sputa, the disease will certainly soon come to a crisis. If the attack is slow, and if the paroxysms occur at the same hour every day, you may expect that the crisis will not take place till after a longer time. And those fevers which make their attack with rigors cannot terminate until the rigor abate; for until that occur it is impossible for the disease to have attained its acme, and therefore much less is it reasonable to expect that it is upon the decline.

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COMMENTARY. This Section is copied from Oribasius. (Synops. vi, 3.) The subject is fully treated of by Galen (de Crisibus.) Rhases describes very accurately the symptoms of an approaching crisis, such as, confusion of the understanding, vertigo, headach, inquietude, involuntary flow of tears, pain of the stomach, &c. He warns the inexperienced not to be alarmed at the violence of the precursory symptoms. (x, 26.) Avicenna, Averrhoes, Haly Abbas, and Alsaharavius, though they treat of the subject very fully, supply no original views.

See an ample account of the ancient opinions in Prosper Alpinus. (De Præs. Vita et Morte ægrot. vi.)

SECT. X.—HOW TO RECOGNIZE A PRESENT CRISIS.

Restlessness precedes every crisis, and if the crisis be to take place by day, it will occur by night; or if the crisis be to take place during the night, it will occur by day; and then certain symptoms supervene, such as headach not previously occurring, sympathetic pain of the neck, retraction of the hypochondrium, sudden difficulty of breathing, and other dangerous symptoms which did not manifest themselves before then take place. And if, when these occur, the pulse, instead of sinking, is increased in magnitude and becomes stronger, and the critical day approaches, and if it be one of the favorable, you may not only anticipate a crisis, but also a good one. And be not then alarmed if you see the patient become delirious and disturbed, for these are indications of the humours being carried upwards; in like manner as certain other symptoms indicate their being determined downwards, such as pain of the belly, gripes about the navel, pain in the loins, borborygmi, and other similar symptoms, when they occur. In addition to these, if the patient was accustomed to have a hemorrhoidal discharge, and if the period of it be at hand, and in like manner with respect to the menstrual discharge (if the patient be a woman), it is not unlikely that the crisis may take place by such an evacuation. And a critical sweat is recognized by a precursory moistness of the skin (especially if occurring upon one of the days called indicatory), and by openness of the pores. From these you may recognize crises by evacuations upwards; for, in addition to the aforesaid, you ought to examine the face of the patients, and whether there be palpitation in any part, or throbbing of the temporal arteries; or if the cheek, nose, or eye be redder than usual, you ought the rather to anticipate the coming crisis. But if they shed tears involuntarily, or fancy that they see sparks of light, and constantly carry their hands to their nose as if to rub it, then indeed you may see not only an approaching but a present flow of blood; for when they rub it once or twice the blood straightway breaks forth. Pungent pain at the stomach, and trembling of the under-lip often indicate a crisis by vomiting. These considerations are sufficient, but to them may be joined the age and constitution of the patient, as strengthening the anticipation; to which may be added, the season of the year and the present constitution. For if the patient be a child, or otherwise by nature warm and full of blood, you may still more form this anticipation; or if formerly, when in health or disease, as we remarked before, an evacuation of blood appeared, this circumstance alone may be sufficient to make you expect a hemorrhagy. And if the season of the year be summer, or, if not summer, if the present state of the weather be hot, and if the patient had often experienced a crisis at that season by hemorrhage, if the body be plethoric, if there is retention of the customary evacuations, all these things ought to strengthen your expectations. In like manner you ought to judge of the other evacuations; or, if none of these symptoms should appear, but if there be uneasiness occurring on one of the critical days after the 20th; or if, when the disease is at its acme, pains should seize certain joints, or near the ears, or in other parts; or if not pains, but local sweats should occur unceasingly in any part of the body, then indeed you may expect a crisis to take place by abscess, and in that part where the sweats, pains, or swelling occurred.

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COMMENTARY. This is taken with very slight alterations from Galen (Therap. ad Glauc. i: see also, de Crisibus, iii, 2.) The critical evacuations enumerated by Galen are, those by vomiting, by the belly, by urine, by sweats, by hemorrhage from the nose, by hemorrhoids, by the menses in women, by abscesses of the parotid glands, and by determination to the knees, feet, or some other parts not vital. He says there are three ways in which a fever may terminate favorably, namely, by an evacuation, by an imperfect crisis without an evacuation, and by resolution, that is to say, when the febrile symptoms go off gradually. There are likewise three unfortunate terminations; for the patient may die suddenly with much agitation, or in consequence of a metastasis, or he may be slowly wasted by a marasmus.

Averrhoes enumerates the same kinds of critical evacuation as Galen, and otherwise treats of them very judiciously. (Collig. iv, 39.) Avicenna gives a long account of all the circumstances attending the crisis, but he copies closely from Galen and Hippocrates. (iv, 2, 1.) Haly Abbas, in like manner, is sensible and correct, but borrows from the Greeks. (Theor. x, 10.) The account given by Rhases is excellent, but it differs little from our author’s. (Ad Mansor. x, 27.) In his ‘Continens,’ he gives a full exposition of the Galenic doctrines, with his own Commentaries. He states, that a crisis may take place in six ways: by hemorrhage at the nose, by an alvine evacuation, by vomiting, by a discharge of urine, by a sweat, or by an aposteme. (xxxi.)

SECT. XI.—HOW TO DETERMINE WHETHER A PAST CRISIS BE FAVORABLE.

If a proper evacuation takes place after the concoction, and the fever is resolved by the critical evacuation; if the patient is freed from all other symptoms; if his colour has improved in proportion to the evacuation; if his pulse has become more regular, and his strength better in rising out of bed; and, what is the most salutary symptom of all, if these are accompanied by repose of the constitution, this may be pronounced to be the best possible crisis. If any of these be wanting, the goodness of the crisis will diminish proportionally to the force of the diminution.

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COMMENTARY. This requires no Commentary. See, however, more fully, Galen and Rhases (l. c.)

SECT. XII.—ON THE PULSE, FROM THE WORKS OF GALEN.

The pulse is a movement of the heart and arteries, taking place by a diastole and systole. Its object is twofold; for, by the diastole, which is, as it were, an unfolding and expansion of the artery, the cold air enters, ventilating and resuscitating the animal vigour, and hence the formation of the vital spirits; and by the systole, which is, as it were, a falling down and contraction of the circumference of the artery towards the centre, the evacuation of the fuliginous superfluities is effected. The arteries themselves are oblong hollow vessels like the veins, but consist of two coats, in order to fit them for the afore-mentioned motion, and because they have to contain blood and spirits. They arise from the heart, and are distributed to all parts of the body; and, therefore, all the arteries pulsate in a similar manner, and like the heart, so that from one of them you may judge concerning all the rest. But the movement of all cannot be equally well observed; for those which are situated in parts not fleshy may be more conveniently felt, whereas those that are in fleshy parts are more indistinct. Nor is any one more conveniently situated for being felt than the one at the wrist. The first kind of pulses is in regard to the time of their motion, as observed in systole and diastole. Its differences are, the quick, slow, and moderate; because every body which is moved must be moved quickly, slowly, or intermediately, as to time; that is quick which is moved over a great distance in a short time; that is slow which is moved over a short distance in a long time; and that is moderate which is intermediate as to motion. The second kind of pulses is in regard to the extent of the diastole. For, since every body has three dimensions, length, breadth, and depth, and an artery is a body, it follows, that an artery must have these dimensions. When, therefore, an animal is in its natural state, you will find its arteries dilated moderately every way; but when not in its natural state, its dilatation will be deficient, or exceed according to some one of its dimensions. In calculating this, you must remember the natural state of the pulse; and if it is found to exceed in breadth, you must call it broad; if in length, long; and if in depth, high or deep. It is clear that the opposites to these, or those that are deficient, are to be named the narrow, the short, and the low. And with regard to those which are altered from the natural state in all their dimensions, that which is every way diminished is called small, and that which is every way increased, great. The third kind of pulses is with regard to the tone of the vital strength. The varieties are three, the strong, the weak, and the moderate. The strong is that which strikes the finger of the physician strongly, and the weak, feebly and faintly; while the moderate is intermediate between them, and is held by some to be the natural one; for that the pulse is rendered stronger by passion and baths, not being naturally so. In reply to which, Galen contends that a pulse rendered stronger by non-natural causes soon undergoes a change; and that, therefore, a strong pulse, which does not readily change, may be natural and moderate. The fourth kind is in regard to the consistence of the instrument, I mean the body of the artery. In this respect there are three differences; for the artery is either harder than natural, and is called a hard pulse; or softer, and is called a soft, or intermediate, and is called in this respect moderate. The fifth kind is in regard to the contents of the artery; and their differences are, the full, the empty, and the moderate, since every vessel must be full, empty, or moderately full of liquids. A full pulse, then, as Archigenes defines it, is one which indicates an artery that is completely full, and the impression of which is, that it is distended with fluids; and an empty one conveys an impression as if its contents were full of bubbles of air, so that the finger, when pressed upon it, seems to fall into an empty space. These five kinds of pulses regard one motion of the artery. And since the quality of the heat in the heart may be more developed than usual in the artery, some have hence reckoned a sixth kind of pulses. Of the other kinds, whether they are in regard to one or more pulsations, they derive their character either from the time of rest, or the rhythm, or their equality and inequality, or their regularity and irregularity. The kind, then, in regard to the time of rest, which is the seventh in order, is divided into the dense, the rare, and the moderate. And, since an artery has a double motion, composed of two opposite movements, it must of necessity have two seasons of rest: the one after the diastole before the systole, the other after the systole before the diastole, which to most people appears imperceptible; and, therefore, the interval of rest between two motions has been chosen. When, therefore, there is a long interval of rest, the pulse is called rare; when short, dense; and when intermediate, moderate. The eighth kind is in respect to rhythm. Rhythm, then, in general, is the ratio and proportion of one time to another. In regard to the pulse, it is, according to some, the ratio of the time of motion to the time of rest, as of the systole and diastole, to the intermediate time of rest; but, according to others, it is the ratio of a time of motion and rest to another time of motion and rest, or of motion to motion.

Of rhythm, then, there are two varieties, the rhythmic and the arhythmic. Of the arhythmic, there is a threefold difference: first, when there is a slight departure from rhythm; second, when there is a greater; and third, when there is no rhythm at all. Thus, for example; in a child, if his pulse has the rhythm of childhood, it is called its proper rhythm; if it has that of an adult, it is said to be an improper rhythm; or if it preserve no ratio at all, it is said to be devoid of rhythm.

The ninth kind of pulses is found in all the other kinds already mentioned; namely, that which regards equality and inequality, which may be remarked either in one pulse, or in many, which last is called the systematic, of which we must speak first, as being more clear. An equal pulse, then, is that which is alike in order, as regards magnitude, strength, frequency, and certain other, or indeed all its other, characters. The unequal pulse is that which is unlike in order. For, if all are alike, as, for example, all deficient in magnitude, such a pulse is called equal. But if the first, second, and third appear alike, but the fourth unlike, it is clear that such a pulse is unequal as to magnitude. Of this kind are the intermitting and the intercurrent. For not only after one or more great pulsations may one smaller occur; but sometimes this motion is wholly lost, and one pulsation is said to be wanting. The other kind, the intercurrent, is the opposite to this; for when we are expecting an interval of rest, a supernumerary pulsation, as it were, occurs. When the second is a little smaller than the first, and the third than the second, and the fourth than the third in like manner, and so onwards, such pulses are called sharp-tailed or myuri, deriving their names from figures terminating in a sharp point. Such as are altogether diminished, and never cease from this state, terminate in a total loss of motion, and are called failing or fainting myuri. There are two varieties in respect to those which fail, for some of them persevere in that state of smallness in which they terminated, whilst others attain again their original magnitude, or less or more, and these are called recurrent myuri. Pulses also are called myuri, from their inequality in regard to one pulsation, concerning which we will speak presently. And this is the nature of that inequality of pulse, called systematic. But it takes place with regard to one pulse, or one part of an artery, or more, as perhaps with regard to motion, for the inequality is observed on one part of the artery, when the motion of the artery upon the finger begins one way and terminates another, beginning quicker, and terminating slower, or reversely. This happens in a threefold manner, the motion either remaining constant, or being interrupted, or recurring and beating double, as it were. If, then, remaining constant and uninterrupted, it should change from quickness to slowness, or conversely, such a pulse is said to be, and is of unequal velocity. But if, after being interrupted by an interval of rest, it again appear quicker, it is called the goat-leap or dorcadissans, the term being derived from the animal dorcas, which, in jumping aloft, stops in the air, and then, unexpectedly, takes another and a swifter spring than the former. But if after the diastole it recur, and before a complete systole take place, strike the finger a second time, such a pulse is called a reverberating one, or dicrotos, from its beating twice. You may see such a thing take place upon a stithy, when a hammer, swung by the hand, first strikes the stithy, and afterwards, recoiling from the reaction of the stithy, strikes of itself a second or third time. And not only may an inequality in the time of motion take place as to one pulsation in one part of an artery, but also in regard to the strength of the power; not so, however, in regard to the extent of dilatation (for it is impossible that the same pulse in the same place should be great and small at the same time), nor in regard to the other kinds of pulses. But in different places different parts of an artery may exhibit a double inequality in one pulsation. For the motion may continue constant, and be swifter at one finger and slower at another; or it may intermit, and one finger may perceive it, and another not. And also, in regard to the extent of the diastole, the same inequality becomes apparent in different places. Of this kind are the myuri, diminishing once and again at one pulsation; for, if at the inner finger the pulse should be great and swelled up, but under the external at the thumb of the patient it appear smaller, such a pulse is called myurus, from its resemblance to the tail of a mouse; or meiurus, from its being diminished like a tail. But if the pulse appear great, and swelled under the middle finger, but smaller on each side, Archigenes called this impulse innuens et circumnuens, i.e. the declining, and the declining on both hands, wishing to mark the smallness of the diastole, with the declination, as it were, of the two extremities; for these parts do not appear as if they were cut short, but as if they were bent in, and a little contracted on each side, and hence the pulse is curtailed (myurus) on both sides.

And when the inequality as to magnitude takes place at different times, such pulses become undulatory and vermicular. And if irregularity of position be joined to them, they are called spasmodic and vibratory. Let us begin with the undulatory, in which the whole artery is not dilated at the same time, according to the same inequality, but this part of it first, that second, that third, and that fourth, the motion continuing constant like the swelling of the waves. And some have the wave carried straight forward, some obliquely; some have a sufficient altitude in a short expansion as to length, and some conversely; some have a broad, and some a narrow, and they have the like inequality in regard to quickness and strength. When the undulatory is wholly diminished in size, it is called the vermicular, which resembles the motion of a worm. As the undulatory pulse, when it goes on diminishing, terminates in the vermicular, so in like manner does the vermicular in the ant-like, or formicans, when, most of its motions being lost, it terminates in one, and it a very small motion. It is called formicans from its resemblance to the ant (formica), on account of its smallness and kind of motion. The ant-like pulse (called formicans) is very small, there being none smaller than it; and, in like manner, it is of all others the most indistinct and dense, but is not quick, as Archigenes supposed. Nearly allied to it is the hectic. For as there is a hectic fever, so is there also a hectic pulse, which undergoes little or no variation, but remains always alike contracted as it first began, and never expanding, the whole habit being turned into disease. The spasmodic pulses appear as if they were dragged, stretched, and drawn by the extremities, conveying the sensation of a stretched cord. But no such thing takes place in the vibratory; for in them the dilatation is greater, as if different parts of the artery were carried upwards at one and the same time. They may be resembled to darts, which, when thrown with force, are carried along with a vibratory motion. The pulse is serrated when part of the artery seems to be dilated and part not; the artery itself also appearing to be harder than natural. This pulse has some of the characters of the vibratory, and is quick and dense, but not always great. In addition to those mentioned, there is a tenth kind of pulses arising from inequality, namely, that with regard to regularity and irregularity. The unequal pulses being divided into those which are alike as to periods, and those which are wholly unlike, the regular and irregular are formed according to each of these divisions; from the equality of periods the regular is formed, and from the entire inequality the irregular. The equal pulse is also always regular (since consequently we call it alike); but the unequal is not altogether irregular; for, supposing it to have no equality, and yet to preserve a certain period, such, for example, as to extent of diastole, if there are two great and one small, then again two great and one small, and so on successively, such a pulse would be called anomalous, that is to say, unequal, but regular. But, if it not only had no equality, but likewise no order in its inequality, such a pulse would be not only unequal, but also irregular, and in like manner with regard to the other kinds. Of the irregular, some are altogether so, observing no period whatever; others are indeed regular as to periods, but, having no continued order, they may in this respect be called irregular, but in so far they observe a certain period regularly, they being regulated as to their periods. As if, for example, there were two great and two small, then three great and three small, and four great and an equal number small; and, returning again, two great and two small, three great and as many small, and so on in like manner. It is to be remarked that, of all the other opposite kinds, there is one intermediate between the two extremes, but that there is none between the equal and unequal, and the regular and irregular, unless you choose to call the one which is regular as to periods the medium between the regular and irregular. And the intermediate pulses of all the other kinds are the natural, except that which relates to strength and weakness, as we showed. But, in those we have been describing, the equal alone is the natural, and all the others are not natural, namely, the unequal, the regular, and the irregular. These are all the kinds of pulses and their generic differences. Some add two others to these, the one in regard to the position of the artery, according as it seems to be carried upwards or downwards, to the right or to the left, and the other in regard to the times of expansion. But these we treated of along with the undulatory and vibratory. And we, for the sake of brevity, have only delivered the simple varieties; but, from what has been said, one may easily connect them, and discover those which arise from their combinations.

The causes affecting the pulses are next to be treated of, with which is connected the prognosis from them. We shall begin with those which respect magnitude, because it is more obvious than the others. A great pulse is produced either by some urgent necessity, such as an excess of heat in the heart requiring refrigeration, and, as it were, ventilation from without; or it may arise from leanness of the body, as we shall soon show. The excess of heat is occasioned either by natural causes, such as the ages of manhood and youth, or simply a hot season, place, or a warmer temperament; or by non-natural causes, such as the air which surrounds us being hotter than common, hot baths, exercises, food, wine, heating medicines; or by preternatural causes, such as a hot intemperament, putrefaction of the fluids, passion, or the like. You may judge of these classes of pulse from the following observations. Those which are natural are permanent and not very susceptible of change, whilst the others readily change, so that often while you examine them, or generally after a very short time, they will altogether alter. A pulse also which owes its greatness to a hot bath has softness for an accompaniment; and hardness is generally combined with greatness proceeding from a hot intemperament, especially when combined with dryness of the system. Those who have undergone moderate friction or exercise have a pulse intermediate between hardness and softness; but they have the parts about the chest warmer than natural, which is the case also with those in a passion. Those that are influenced by food, the use of wine, or rage, have vehemence joined to greatness. Those who wish to conceal anger, or something which they have done without permission of the physician, (such as if a person has taken a heating medicine, and wishes to conceal it from the physician, who inquires about it while he feels the pulse,) in such persons a manifest inequality is joined to greatness. To the discovery of this state other considerations may contribute, such as the habit of the patient, as if he appeared to be fond of taking medicines, or his disposition, as if it be bad, and cunning at concealments. A pulse which is great from putrefaction of the fluids has a contraction more hasty than natural joined to its greatness. To form a great pulse, an urgent necessity is not alone sufficient; but the vital powers must also contribute, and a condition of the instrument or artery intermediate between hardness and softness. When the heat, therefore, is increased in the heart by any of the above-mentioned causes, in the first place the pulse becomes great, and, the greatness not being able to supply the want, quickness is straightway joined to it; and if that is not sufficient, density is superadded. Small, slow, and rare pulses are formed by the opposite causes. But when a change first takes place from a great, quick, and dense pulse to their opposites, namely, when the necessity is at an end, the first character of the pulse is not the first that leaves it, but it loses first that which it last acquired, becoming first rare, then slow and last small. But if the slowness and smallness should go on increasing, the rarity will again change to density, in order that the necessary want may be supplied. Such are the causes of greatness, quickness, density, and their opposite pulses. To these we shall connect the alteration of the pulse in regard to one dimension only. Breadth alone then is increased, principally by a redundancy of humidity, either natural, or from external causes, as loftiness is occasioned by the softness of the instrument, assisted by the vital power; but length is rendered apparent by the dryness and melting of the surrounding flesh, the other dimensions being contracted. For an artery cannot, in fact, become longer than natural; and this ought more properly to be called the lean pulse, as the opposite one, namely, that which is increased only in breadth and depth, should be called the fat. The pulse sometimes falls under the opposite characters to this, when it is restrained as to any of its dimensions, and appears low, narrow, and short, when it is not so in reality, but seems so, owing to the thickness of the fat, flesh, or membranes which press upon it. Sometimes, too, the whole seems small, when it is not so in reality; and feeble in like manner. And what do I say? Sometimes an asphyxy, or complete loss of pulsation, hath seemed to take place over the whole arteries, when there is no such thing in reality; and this has happened, more especially to those who have felt them carelessly, when the motion, being really indistinct, escapes notice, owing to the quantity of flesh; for it is impossible that a complete asphyxy could take place while the man is alive. In like manner again in the emaciated, small pulses appear great. When, therefore, the body is greatly wasted, the artery which runs along the spine has often been felt by persons touching the abdomen, and also the pulses in members which before used not to be felt. Wherefore we must attend to all circumstances, that we may not be mistaken in our diagnosis. A strong pulse is occasioned by the force of the natural faculty, when not counteracted by any other cause, such as the want failing, or from hardness of the instrument. But a feeble pulse may arise from weakness of the natural powers alone, although no other causes contribute. For a strong pulse stands in need of all the other causes for its formation; but the feeble is produced by weakness alone. The originally strong pulse accompanies moderate ages, seasons, places, and temperaments; but the feeble the immoderate. A pulse changing from feebleness to strength is formed by the vital faculty growing strong, from a preceding state of debility. It is strengthened either by things within the body, such as concoction of the fluids, or an excretion of them, or passion; or by externals, such as wines, food, exercises, and whatever will rectify the intemperament. The natural powers are weakened by want of food, watchfulness, immoderate evacuations, grief, cares, and more especially pains inducing syncope, and whatever forms an intemperament. Some inexperienced persons have thought a hard pulse strong, but a person of experienced understanding and touch will not mistake them; for a strong pulse, being mostly accompanied with greatness, is swelled up to loftiness and strikes the finger forcibly; but the hard does not admit of greatness, on account of the unyielding state of the artery. Wherefore a pulse becomes hard owing to the hardness of the artery. This is occasioned by immoderate cold, or dryness, or tension proceeding from inflammation, or spasm. To the hardness, moreover, are joined smallness, quickness, and sometimes density instead of greatness accompanying, owing to the exciting want. A soft pulse follows a humid state of the artery. An artery is rendered more humid by things not preternatural, such as more liquid food, immoderate baths, much sleep, a more abundant diet, and hilarity; and by preternatural causes, such as coma, lethargy, dropsy, and the other pituitous affections. A full pulse indicates an abundance of fluids, or plethora from food, or from drinking wine, as the empty, on the other hand, indicates deficiency of food or evacuation. When the body of the artery feels warmer under the finger, this indicates great heat in the heart, while the rest of the body is cold, or a certain spasmodic state of the arteries, which are warmed by the violent motion. Archigenes says that the place of the artery will particularly be found warmer in catochus and in those who are about to be affected with somnolency. With regard to rhythm, when the ratio of the times of motion and rest is equal, it indicates a proper temperament of the body, or no great departure from it, as in early age, and the otherwise well-regulated bodies. But when the time of rest is greater than that of motion, this indicates that heat prevails, as in adults and those of the adjoining ages; as, in aged bodies, which are entirely cold, the time of motion is greater than that of rest. It is to be remarked that inequality in regard to rhythm, being the measure of that as to quickness and density, this holds the place as it were of the matériel to the rhythm.

The intermittent and intercurrent pulses take place when the powers are oppressed, and, as it were, borne down; but the intercurrent indicates a lesser, and the intermittent a greater injury. And, in general, that state in which the powers are oppressed and borne down, changes the pulses to inequality and irregularity in every other respect, and also in regard to strength and greatness. The pulses called myuri, being shown to be of two kinds, (for they are found either in that inequality called systematic, or in regard to one pulsation), the failing or fainting evince the last prostration of the powers; but, when they return, or are recurrent, they indicate that the powers are weak, but that they are struggling, contending, and have not yet submitted. As to the myuri, in regard to one pulsation, called the failing, and the failing on both hands (innuentes et circumnuentes), these happen to persons who are gradually wasted by inflammations not yet resolved, and to those who are wasted from whatever cause, the bodies around the arteries being melted down. Pulses of unequal velocity, and those called dorcadissantes or goat-leap, principally accompany febrile heat. But if the pulse render the commencement of the diastole feeble, and increase in velocity towards the end and beginning of the systole, this indicates that putrefaction is prevailing, nature hastening on the discharge of the fuliginous superfluities. But if, on the other hand, it render the commencement of the systole feeble, and rather make speed towards the diastole, you may be sure that the heat is prevailing, and longing for refrigeration. These in fever are, for the most part, accompanied by density, and sometimes greatness, if the powers be not restrained by the hardness of the instrument. When the hardness of the artery increases, and the powers are not weakened, the double or reverberating pulse is formed. The undulatory pulse most commonly attends the more humid affections, such in particular as anasarcous swellings, lethargy, and peripneumony. When the powers of life are beginning to fail, but are still making a faint struggle, the undulatory pulse sinks into the vermicular; but when they decline to their lowest ebb, this last passes into the ant-like or formicans. The hectic particularly attends those in consumption and marasmus. The spasmodic pulse takes place when the origin of the nerves is suffering from some inflammatory affection, as in frenzy and acute attacks of epilepsy, when those affected with them die while they are yet warm, contrariwise to those in syncope, for they are alive after they have become cold. The clonodic or vibratory pulse takes place when the wants of the system require a great diastole, and the vital powers are sufficient for that purpose, but are opposed by the body of the artery; which, from its hardness, cannot be expanded to a large diastole, as happens in great inflammations and chronic obstructions. The serrated pulse is indicative of inflammation, and particularly in some tendinous parts. It is no less so of pleurisy, and when slight, indicates that the inflammation is gentle, and easily to be concocted; but when intense, that it is severe and of difficult concoction, and will be attended with urgent danger, if the powers be weak, or, if they be strong, that it will be slowly concocted, for it will either terminate in empyema, or a consumptive marasmus will supervene. One ought also to know that irregularity of the pulse commonly accompanies its inequalities; for you will rarely find an unequal pulse orderly. Wherefore, the lesser constitutional injuries occasion unequal and regular pulses, but the greater, unequal and irregular.

These are the simple causes of the pulses and their prognosis, and from them the compound, as we stated when treating of their differences, may easily be discovered.

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COMMENTARY. The ancient authorities on the pulse are the following: Celsus (iii, 6); Galen (Libel. de Pulsi. ad Tirones; de different. Puls., de Dignos. Puls., de Caus. Puls., de Præsag. ex Puls., Synopsis librorum de Puls.); Philaretus (de Pulsu); Theophilus Protospatharius (de Pulsibus ap. Ermerins Anecd. Med. Gr.); Actuarius (de Diagnosi); Avicenna (i, 2, 3); Averrhoes (Collig. iv, 16); Haly Abbas (Theor. vii); Alsaharavius (Theor. vii); Rhases (ad Mansor. x, 32; Contin. xxxi); Psellus (Opus Medicum apud Boissonade, Anecdota Græca.)

Prosper Alpinus gives an excellent exposition of the ancient doctrines on the pulse (de præs. Vit. et Morte ægrot. iv, 3); Le Clerc’s account is not so accurate (Hist. de la Méd.) Wetsch’s is tolerably correct (de Pulsu.)

Hippocrates, although Galen affirms that he was not entirely unacquainted with the pulse, does not appear to have attached much importance to the observation of it, for he generally neglects to mention its characters, where we would most expect to find them stated, as, for example, when he is detailing the symptoms of epidemical fevers. Celsus, too, expresses himself in doubtful terms respecting the indications furnished by the pulse: “Venis enim maxime credimus, fallacissimæ rei; quia sæpe istæ leniores, celerioresve sunt, et ætate, et sexu, et corporum naturâ; et plerumque satis sano corpore, si stomachus infirmus est, nonnunquam etiam incipiente febre, subeunt et quiescunt; ut imbecillus is videri possit, cui facile laturo gravis instat accessio. Contra sæpe eas concitat et resolvit sol, et balneum, et exercitatio, et metus, et ira, et quilibet alius animi affectus.” Aretæus and Cælius Aurelianus are indeed sufficiently minute and accurate in detailing the characters of the pulse, while describing the symptoms of various diseases, but neither of them has written expressly on the subject; and, as the works of Herophilus, Agathinus, Magnus, Athenæus, and Archigenes are entirely lost, Galen must be considered as our first and great authority on the pulse—we might almost have said our sole authority, for all subsequent writers were content to adopt his system, without the slightest alteration. As our author’s account of the subject is professedly taken from the elaborate treatises of Galen, it may, perhaps, appear unnecessary to attempt any further exposition of the system; but the importance of the subject, and, we may add, its novelty to modern readers, have induced us to make some detached observations upon it, in order to explain some parts of it which are confessedly obscure, and to answer certain objections which have been stated against it, by modern writers who have not properly understood its principles.

We shall first notice the objection stated to Galen’s Theory of Respiration by Van Helmont, who, although compelled to admit the ingenuity of Galen’s system, pretends to differ from him respecting the final cause of arterial action and respiration, which, he maintains, is not refrigeration, but the maintenance of animal heat. (Opera, p. 112.) But if he had read Galen’s work ‘de Usu Respirationis’ carefully, he would have found that this is the very sense which Galen attaches to the terms refrigeration and ventilation. Van Helmont states, as a new discovery, that a sort of concoction of the blood takes place in the left ventricle of the heart. But he might have found this doctrine also in the works of Galen.

According to Galen, the pulse consists of four parts: of a diastole and a systole with two intervals of rest, one after the diastole before the systole, and the other after the systole before the diastole. He maintains that by practice and attention all these parts can be distinguished. (De Dignos. Puls. iii, 3.)

The first distinctions of the pulse are derived from the extent of the diastole, according to its three dimensions, namely, length, breadth, and depth. These give rise to the characters long, broad, and deep or high. Le Clerc renders the last by élevé. A long pulse, of course, refers solely to the impression on the finger, as in reality one pulse cannot properly be said to be longer than another; but when a person is lean a larger portion of the artery can be felt under the finger than when he is fat.

The character deep or high is easily understood, and is evidently produced by a free dilatation of the artery. It does not indeed appear evident how there can be a difference between a deep and a broad pulse, if the dilatation of an artery were equal on all sides; but Galen positively affirms that it is a fact ascertained by ample experience, that sometimes there is a free dilatation of the artery upwards with a contracted one laterally, constituting a high and narrow pulse; and, on the other hand, that there is often a free dilatation laterally with a contracted one upwards, constituting a low and broad pulse. He gives directions for detecting these peculiarities of the artery. (De Diff. Puls. iii, 2.)

The characters of quick and slow are derived from the length of time occupied in the actions of systole and diastole. They seem to be sufficiently well marked, and yet Fyens denied that there is any difference between frequency and quickness. However, many of our late authorities in medicine acknowledge a distinction between these two characters, and they appear to us sufficiently obvious. In fact, Galen establishes the distinction in the most satisfactory manner. (De Dignos. ii.)

The distinctions of strong and feeble are derived from the force with which the artery strikes the finger. No one can possibly mistake them.

The relaxation and constriction of the arterial tube give rise to the characters of soft and hard, which are so obvious that they cannot be misunderstood. The character of hardness is called tension by Galen, who states that it is characteristic of inflammation.

The next class of pulses derive their characters from the time which elapses between two diastoles or pulsations of the artery. They are called dense and rare, in the ancient system, being used in the same sense that frequent and slow are in modern works.

The terms equal and unequal (or, as they might have been translated, equable and unequable) arise from the constancy or inconstancy of any peculiar character of the arterial pulsation. The regular and irregular are distinguished from these, inasmuch as a series of pulsations, although unequal may be regular, when they observe a certain ratio, as when four strong pulsations are succeeded by a feeble one, and this series goes on successively.

An inequality may take place in respect to one pulsation; for the dilatation of the artery may be interrupted, and then completed, when it is called dorcadissans, caprizans or goat-leap; or the stroke may be suddenly repeated, when it is called dicrotos, which may be translated the double, reverberating, or rebounding pulse. The term dorcadissans is derived from dorcas, an animal generally supposed to have been the goat, but it is now satisfactorily ascertained that it was the antelope dorcas or gazelle; and, in the Latin translations of Avicenna and Haly Abbas, it is rendered gazellans. It is said that when this animal leaps upwards it at first takes a short spring, then seems to make a sudden stop, and afterwards takes a much larger and swifter bound. This character was applied to the pulse when an imperfect dilatation of the artery is succeeded by a fuller and a stronger one. (Galen, de diff. Puls. i, 28.) It is thus described by Haly Abbas: “Gazellans pulsus est qui cum a celeritate incipiat antequam percussiat stat, dehinc velociter movetur: vocatur autem hujusmodi gazelenus suâ ex similitudine caprioli saltu: quum capriolus quem Gazel Arabicè vocant cum saltum dederit pedes tollit et suspensus pauco videtur tempore atque sic ad terram velociùs redit.” The translator of Alsaharavius renders it by fusalis. It is correctly stated by Fouquet that the second pulsation is necessarily larger than the first. The dicrotos consists of two pulsations, following upon one another so rapidly as to form, as it were, but one beat of the artery. In the translation of Alsaharavius it is called mallearis, and is thus defined: “Est autem pulsus mallearis qui percutit manum et recedit, deinde redit et percutit secundario.”

When there is a succession of pulsations which diminish in magnitude regularly, such a system of pulses is called myuri, that is to say, decurtate or sharp-tailed, from their supposed resemblance to the tapering tail of a mouse. Those who are acquainted with the Scholiast on Hephæstion, and the other ancient writers on prosody, will readily recognize a term with which they are familiar. Galen inclines to the opinion that this state of the artery is connected with an intemperament of the portion where the expansion is limited. Of these pulses, some end in complete asphyxia, and hence are called swooning, failing, or fainting myuri, (Le Clerc renders it by le myurus defaillant;) and others again gradually recover their former magnitude, and are called recurrent myuri. Nearly allied to these are the innuentes et circumnuentes, for which it is scarcely possible to find any appropriate term in English. Le Clerc thus renders and explains this pulse, in French: “Le myurus qui va en baissant de côté et d’autre, c’est a dire qui frappe moins sensiblement le premier et le dernier doigt que celui ou ceux du milieu.” It consists, as Avicenna explains, of a double myurus, which swells out in the middle, and diminishes at both extremities. It was therefore a sort of double inclined plane. The myurus, and the innuens et circumnuens, are thus described by Haly Abbas: “Est autem et in hac specie unius pulsationis pulsus qui muris cauda appellatur; quique inclinus vocatur pulsus. Et qui muris cauda vocatur fit cum arteria dilatatur sub primo digito qui a superioribus est grossa, et sub secundo minus grossa, sub tertio parva, sub quarto minima. Inclinus autem pulsus est qui sub duobus mediis movetur digitis grossus et sub extremis hinc et inde subtilis et tenuis; aut medium ejus elatum est, et extremitates demissæ, videturque tangenti arteriæ extrema ad inferiora declinari.” Sprengel appears to think that the pulsus inclinus of Haly Abbas is one first described by him, but there can be no doubt of its being identical with the innuens et circumnuens (νενυκὼς καὶ περινενευκὼς) of Galen’s system. It is likewise the same as the pulsus inclinatus of Rhases, who says it occurs in hectic fevers and consumption. Galen attempts to explain this pulse by referring it to weakness of the vessel and an unequal wasting of the parts around, which convey the impression, when several fingers are applied together, as if the vessel swelled out in the middle. (De Diff. Puls. ii.)

In the spasmodic pulse, the artery is said to convey the sensation of a string or cord tightly stretched, which, when touched, starts from its place. It seems to be the pulsus tortuosus of Alsaharavius, and is commonly met with when convulsions are impending.

The vibratory derives its name from an imaginary resemblance to the motions of a rod or dart when thrown into the air, and it can only take place when the artery is hard, and the strength good. Le Clerc renders it le pouls dardant. It is generally named thrilling in modern works. According to Actuarius, it is hard, quick, and dense, and indicates inflammation of nervous parts.

The undulatory derives its name from a supposed resemblance to the rolling of the waves, and can only take place when the artery is particularly soft, being accompanied with an unequal elevation of it in the diastole. It is thus described by Rhases: “Undosus vero est qui secundum latitudinem, magnum digiti occupat locum, cum lenitate et repletione, cum eo tamen non est magna elevatio neque subita, sed videtur quod elevationem ejus una post aliam contingit, donec fit ut undis assimilatur, quarum una aliam sequitur.” It is the pulsus fluctuosus of Haly Abbas, and the pulsus fluens of C. Aurelianus. (Morb. Acut. ii, 32.) Le Clerc renders it ondoyant.

The vermicular differs from the last mentioned only in magnitude and strength, being soft, small, and weak. Nearly allied to it is the formicans or ant-like pulse, which is one of the last degree of weakness, smallness, and density. They are thus described by Rhases: “Vermicolosi forma est ut forma undosi, in elevatione quæ secundum diastolem eadem invenitur, non tamen est latus, neque plenus, cujus inundatio existit debilis, qui vermibus per foramen arteriæ discurrentibus assimulatur: formicans vero pulsus adeo invenitur in ultimo parvitatis, et spissitudinis consistere, ut pulsui pueri recens nati assimuletur.” According to Galen the formicans is a pulse which it requires great experience to detect. (De Dignos. Puls. ii, 1.) Haly Abbas states that it is the termination of the vermicular. It is the pulsus formicabilis of Cælius Aurelianus. The Chinese compare the formicans to a silk thread, a capillary tube, or a hair.

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.)

SECT. XIII.—ON THE ALVINE DISCHARGES.

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.

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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.)

SECT. XIV.—ON THE INDICATIONS FROM THE URINE.

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.

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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.

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SECT. XXX.—THE CURE OF ARDENT FEVERS.

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

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

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

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

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

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

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

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

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

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

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

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

SECT. XXXII.—DIAGNOSIS OF HECTIC FEVERS.

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

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

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

SECT. XXXIII.—THE CURE OF HECTIC FEVERS.

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

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

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

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

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

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

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

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

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

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

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

SECT. XXXIV.—ON SEMI-TERTIANS.

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

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

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

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

SECT. XXXV.—ON EPIDEMIC DISEASES.

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

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

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

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

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

(De Rerum Nat. vi, 1100.)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It is greatly to be regretted that Galen has given us no description of the dreadful plague which prevailed in his time. It appears that he fled from Rome for fear of infection. He alludes to it, indeed, in several parts of his works, but in very brief terms, only mentioning that it put on the appearance of dysentery; and in one place he strongly commends the celebrated theriac as a most efficacious remedy for the prevention and cure of pestilential disorders; and elsewhere he speaks favorably of the Armenian bole. Of the writers on medicine posterior to him, Oribasius and Aëtius, like our author, give no further information on this important subject than what is contained in the brief extract from the works of Ruffus; and the others, with the exception of Nonnus and Psellus, do not treat of the disease at all, unless in an incidental manner. Nonnus, after briefly stating the causes of the plague, proceeds to lay down the principles for conducting the treatment. He recommends clysters, and, if the stomach be loaded with phlegm, emetics: if there be a fulness of blood, he approves of venesection; and also speaks well of giving diuretics. When symptoms of ardent fever are present, he directs cold drink to be given freely, in order to extinguish the febrile heat. He also recommends apomel, the water of ptisan with the seed of bastard saffron, or Armenian bole, or lapis lazuli. Psellus merely mentions, in very general terms, a few of the common symptoms of the plague. (Opus Medicum.) Actuarius, treating of anthrax, mentions that it sometimes take place in epidemical affections. (Meth. Med. ii, 36.)

Before proceeding to the Arabian authorities, we shall give a brief abstract of Procopius’ description of the dreadful plague which desolated the Roman empire in the reign of Justinian. Its usual precursors were certain delirious fantasies and disturbed dreams, after which the fever made its attack suddenly. The early symptoms, however, were not well marked, for there was neither increased heat nor discoloration of the skin, nor did the patient apprehend danger. Generally on the first or second day, but in a few instances somewhat later, buboes appeared not only in the groin, but also in the armpits and below the ears. Some were affected with deep coma, and others with wild delirium. Some died from sphacelus of the buboes, which, when inspected by the physicians after death, presented the appearance of a coal or carbuncle (anthrax). Some died at the commencement, and others after the lapse of several days. In certain cases the skin was covered over with black phlyctænæ of the size of a lentil, which were usually succeeded by sudden death. Others were unexpectedly cut off by a discharge of blood. To women in the puerperal state it proved particularly fatal. When the buboes came to a proper suppuration, they generally proved a favorable crisis; but when they did not suppurate, they were commonly followed by a wasting of the thigh. One of the common consequences of the fever was an affection of the organs of speech. All the usual prognostics proved fallacious, and the effects of the common remedies were uncertain. In some cases the bath proved beneficial, and in others it had a contrary effect. At one time the amount of deaths in Constantinople ranged from five to ten thousand each day. (De Bello Pers. 22, 23.) This pestilence is described likewise by Agathias (v), and by Evagrius (Hist. Eccles. iv, 29.) It resembled the plague of Avignon, described by Guy of Cauliac.

The symptoms of the plague, as enumerated by Avicenna, are as follows: Heat, and strong inflammation within, but which are not perceived outwardly; respiration large, fetid, and frequent; intense thirst, dryness of the tongue, with nausea and loss of appetite, such as, if not contended against, will prove fatal; enlarged spleen, great anxiety and restlessness, dry cough, prostration of the powers approaching to syncope; delirium, retraction of the hypochondria, insomnolency, with tepid heat of the body. Sometimes there are yellow, whitish, or red eruptions on the skin, which are of short continuance; or else aphthæ and ulcers in the mouth. The pulse is generally frequent, small, and becomes stronger towards night. Occasionally there are dropsical swellings. The discharges from the bowels are bilious, mixed, fetid, unnatural, and sometimes contain black bile; at other times they are frothy and fetid, or unctuous, being produced by melting of the fat. The urine is watery, bilious, and melancholic. There is sometimes vomiting of black, but more frequently of yellow bile. There are often fetid sweats. The disease usually terminates with syncope, coldness of the extremities, lethargy, spasms, and convulsions. Some of the most fatal varieties of the plague are not marked by any striking symptoms, neither the heat, pulse, nor urine being much affected. Fetid breath, as indicating putrefaction about the heart, is a most mortal symptom. The treatment must commence with venesection, if there be a plethora of blood, or with purging, if the body be loaded with other humours. The apartments of the sick are to be cooled, and the air of them corrected: they are to be cooled by cold odoriferous fruits, camphor, rose-water, or, if possible, by introducing a stream of water into them. The fetid air may be corrected by fumigations with camphor, myrtles, quinces, ebony, &c.; by sprinkling the apartments with vinegar and assafœtida, and correcting the putridity with lignum aloes, frankincense, musk, storax, sandarach, mastich, juniper, bays, and the like. (It may be proper to mention that arsenical fumigations are approved of by Muratori, Lind, and Russel, but condemned by Mead.) As a preservative from the plague, he recommends, in particular, exercise and restricted diet. Haly evidently copies his description. (Theor. v, 11.)

Rhases agrees with Hippocrates in stating, that pestilential fevers are distinguished by great heat internally, while the surface of the body is cool. The symptoms, as detailed by him, are vomiting and diarrhœa, pain and distension of the belly, coldness of the extremities, urine showing a tendency to putrefaction, discharge of blood from the nose, heat about the breast, singultus tendinum, blackness of the tongue, bulimia, &c. He particularly states that a black discharge from the bowels is a most fatal symptom. Like Avicenna, he gives directions to perform fumigations with camphor, musk, myrrh, bdellium, frankincense, and the like. He mentions that, during the prevalence of a certain pestilence, it was found that hunters escaped the contagion. Like Avicenna, he approves of bloodletting. See Continens (xxx.) He also recommends cold drink and the cold bath. Calefacients and wine, unless diluted with much cold water, he disapproves of. He, like the other Arabian authorities, joins Galen in speaking favorably of Armenian bole and the theriac. (Ad Mansor. iv, 25.)

The belief that the plague is preceded by extraordinary phenomena in the earth and sky is very ancient. Thucydides concludes his brief account of the last attack of the plague on Athens with the remark, that at that time there were many earthquakes at Athens and other places. (iii, 87.) Manilius says such plagues as that of Athens are commonly prognosticated by comets and other celestial fires. Diodorus Siculus mentions that the Athenian plague was preceded by earthquakes of extraordinary severity. (xii, 59.)

While explaining the symptoms and treatment of the plague, as detailed in the works of the ancient authors, we have purposely omitted to notice its contagious nature, as we wished to give one connected view of the ancient opinions regarding CONTAGION. Before entering upon this disquisition, we think it proper to acknowledge the assistance which we have derived from the writings of Fracastorius, Paulinus, Mead, Marx, Omodei, and Winterbottom, leaving it to the reader to determine, after comparing our humble attempt with their learned labours, whether or not our industry and research have contributed in anywise to throw additional light upon this important subject.

The earlier ancient authors appear to have entertained no suspicions of contagion as a cause of febrile or of other complaints. Homer, as formerly stated, evidently refers the origin of the plague which prevailed in the Grecian army during the siege of Troy to the heat of the sun. The works of the fathers of History and of Medicine have likewise been ransacked in vain, for any traces of the doctrine of contagion. Thucydides, therefore, appears to be the first author (if we except the Mosaic description of leprosy) who makes any positive allusion to the contagious nature of diseases. From his description of the plague of Athens, there can be no doubt that he wishes it to be understood, that the disease was transmitted from one person to another; for he mentions that physicians were more attacked by it than any others, as having most intercourse with the sick; and he afterwards describes the terror which the citizens felt to approach those labouring under the disease, and intimates that it was often contracted by such intercourse. The language of Lucretius, who copies his description, and gives it a poetical form, is still more precise:—

“——nullo cessabant tempore apisci Ex aliis alios avidi contagia morbi.”

(L. 1235.)

And afterwards,

“Qui fuerant autem præsto contagibus ibant.”

(L. 1241.)

Ovid, in like manner, says of the dead bodies:

“Afflatuque nocent et agunt contagia latè.”

(Metam. v, 551.)

And so also, Silius Italicus:

“Et posuere avidæ mortis contagia pestes.”

(Lib. xiv.)

The historians we must dismiss in a few words, with stating that allusions to the infectious nature of certain diseases are to be met with in Livy, Dionysius the Halicarnassian, Diodorus Siculus, Appian, Plutarch, Quintus Curtius, Dio Cassius, Eusebius, Gregory of Nyssa, and Evagrius. Procopius was a non-contagionist.

The philosopher Aristotle, in one of his problems, makes it a question why the plague is the only disease which infects those who approach the sick. (Probl. i.) There is a curious passage in the works of the orator Isocrates, which shows that consumption was reckoned contagious in his days. (Æginet.) The elder Pliny mentions the contagion of the pestilence. (Hist. Nat. xxxiii, 80.)

Virgil mentions the infectious nature of certain diseases of cattle. (Ecl. i, Georg. iii, 464.) The ancient writers on veterinary surgery and agriculture in like manner state that the plague and scabies of cattle are infectious. See Columella (vi, 5); Vegetius (Mulomed. iii, 23.)

The philosopher Marcus Antoninus alludes to the plague as being contagious. (ix, 2.) Chrysostom does the same. (In Joan. Orat. lvii.) The language of Seneca is very precise: “Itaque ut in pestilentiâ cavendum est ne corruptis jam corporibus et morbo flagrantibus assideamus, quia pericula trahemus, afflatuque ipso laborabimus.” (De Tranquil. vii.) To these we may join Isidorus Hispalensis, a much later writer: “Pestilentia est contagium quod quum unum apprehenderit celeriter ad plures transit.” And, in another place: “Pestilentia est morbus latè vagans et contagio suo quæ contigerit interimens.” Alexander Aphrodisiensis intimates that pestilential fevers are contagious, but common fevers not so. (Probl. ii, 42.)

Aretæus appears to be the first medical author who alludes to contagion in unequivocal terms. He says of elephantiasis, that it is as infectious as the plague, being communicated by respiration. Cælius Aurelianus, who was probably nearly contemporary with him, mentions as contagious diseases the plague, incubus, hydrophobia, and elephantiasis. Galen expresses his sentiments on the contagious nature of certain diseases in the following terms: “That a pestilential state of the atmosphere produces fever, is unknown to no one possessed of good understanding; and, also, that it is dangerous to associate with persons having the plague, for there is a risk of catching it, like the itch and ophthalmy. It is dangerous also to live with those labouring under consumption, and, in a word, with all those having a putrid respiration of such a nature as to render the houses in which they lie fetid.” (De Diff. Febr. i, 3.) Aëtius (xiii, 120) and our author (iv, i) state their decided opinion of the infectious nature of the plague and elephantiasis. Oribasius, Alexander, Synesius, Palladius, Actuarius, and all the Latin medical authors, with the exception of Cælius Aurelianus, have omitted to make any allusion to the contagious nature of diseases.

Of the Arabians, Rhases mentions, as diseases “which are transmitted from one person to another,” lepra (elephantiasis?), itch, consumption, and pestilential fever. These, he says, prove infectious, when one is shut up in a narrow house along with those labouring under them, or when one sits in the wind blowing from them. He states afterwards that ophthalmy and malignant pustules are sometimes contagious. (Ad Mansor. iv, 24; see also Contin. xxxiii, 5.) By malignant pustules he means the smallpox. Avicenna and Haly Abbas give the same list of contagious diseases. Avicenna says that smallpox and measles are of all diseases the most contagious. Of the other Arabians, Avenzoar alone, while treating of elephantiasis, alludes to the doctrine of contagion.

Having now done with the ancient authorities, we shall only give further the declaration of the celebrated Boccacio regarding the plague of Florence: “E fu questa pestilenza di maggior forza, percio che essa dagl’ infermi di quella per lo communicare insieme s’avventava a’ sani non altramenti che faccia il fuoco alle cose secche o unte, quando molto gli sono avvicinate.” (Decameron, Introduzione.)

The result of our investigations into the opinions of the ancients on this subject leads us to the conclusion, that all, or at least the most intelligent of the medical authorities, held that the plague is communicated, not by any specific virus, but in consequence of the atmosphere around the sick being contaminated with putrid effluvia. Hence, they maintained that mild fevers (συνηθεῖς) which show no tendency to putrescency are not communicable from one person to another. See Alexander Aphrodisiensis, (l. c.) Fracastorius, in like manner, considered putrefaction as the source of all contagion. (De Contag. i); and nearly the same opinion was maintained by the learned Fernel, Franciscus de Pedemont, Ingrassius, Ficinus, and others. (See Prælect. Mar. 77.) Although Galen several times speaks of a poison being formed in the human body, he means that the animal fluids are so altered as to become deleterious, and does not hold that there is any specific virus transmitted from one person to another. (De Loc. Affect. v, 7, vi, 5; Epidem. iii.)

We may take this opportunity of stating that, after a pretty extensive investigation into the histories of pestilential epidemics, we have come to the conclusion that the plague has almost invariably assumed one or other of the following phases: 1st. That of cholera and dysentery. The plague described by Thucydides, and that of Ingrassias, and many other pestilential epidemics described in ancient and modern times, including the Asiatic cholera of the present age, belong to this class. 2d. That of profuse; and, as they have been termed, syncoptic sweats. The celebrated epidemic of the fifteenth century, now so admirably illustrated by M. Hecker, is the best marked instance which we possess of this form of the disease. M. Hecker, indeed, supposes that the Cardiac disease of the ancients was of a similar nature to the sweating sickness. But it strikes us (although we must admit that we have not had time to consider this point maturely), that the syncoptic fever or cardiac disease of the ancients, was not of a pestilential nature. 3d. The other form is the Glandular plague, which many late authorities would consider as the only form of the disease; but as we think erroneously, since the other types are often mixed up with this in the same epidemic. Thus in the plague of Aleppo, during the years 1760, 1761, and 1762, although the ordinary form of the disease was the glandular, a considerable proportion of the cases assumed the first form which we have noticed. And in the plague of Athens, although it commonly put on the appearance of the first form, it would appear probable, from the obscure allusion to cutaneous eruptions in the description of Thucydides, that a certain proportion of the cases were of the second type. The three forms then would appear to us to be as closely allied to one another as diphtherite, ulcerous sore-throat, and scarlatina are; that is to say, that they are all varieties of one species of disease.

SECT. XXXVII.—ON THE TREATMENT OF THOSE WHO ARE SEIZED WITH SYNCOPE FROM CRUDE HUMOURS.

Some are seized with fever while having a great collection of crude humours, and while the mouth of the stomach is at the same time disordered. In them the hypochondrium is distended with flatulence, the orifice of the stomach is more swelled than natural; in some the complexion is turned to a more white and watery, and in others to a blacker. None of these can bear the abstraction of blood without the most imminent danger; but they require evacuation, although they cannot endure phlebotomy nor purging, for even without them they are disposed to fall suddenly into a state of syncope. They are to be cured, then, by friction. It will be proper, at the commencement of the disease, to begin with rubbing the limbs from above, downwards, with moderately rough linen cloths, and afterwards, the whole arms from above, downwards. But when the limbs have been sufficiently warmed, and there is danger of a sense of lassitude, we must use a relaxing oil, and avoid all astringents. When it is winter, we must also use a sudorific one, such as the Sicyonian oil, or that of chamomile. After rubbing the limbs freely, we must next rub off the oil, and proceed to the spine, which we must rub in like manner, and then immediately return to the legs, and from them to the arms again, and afterwards to the spine again, continuing this practice for a whole day. Honied water, in which hyssop has been boiled, is most beneficial in these cases. And they must neither get farinaceous food, nor soup, nor water, nor be permitted at all to drink freely; but they ought to be contented with honied water alone for the first three days, and be rubbed in succession. If the strength be moderately good, and the contents of the stomach do not pass properly downwards, you may venture with a clyster. But if there is a greater overflow of the superfluities than proper upon the stomach, you must first boil the honied water well, for thus it will be less laxative; but when the belly is looser than proper, you must not thus stop it, but, instead of the honied water, give the juice of ptisan. But if the discharge still continue, we must support with a gruel made from chondrus. But if we ascertain from the weakness of the pulse that the powers of the system are prostrated, it will be proper to give bread out of diluted wine, provided there be no inflammation of the stomach or liver. But should they be inflamed at the same time that the body is loaded with crude humours, the state of the patient is hopeless. If you perceive that the humours are thick, give oxymel always instead of honied water; if it is summer, the patient hot, and fond of cold drink, give him cold oxymel; but when in winter, it must be hot. Baths are most prejudicial to such persons. If, when you are called, syncope has already come on, and the parts which I have mentioned are free from inflammation, give a small bit of bread out of wine, and proceed straightway to the friction in the manner I have described. In those cases in which the syncope is occasioned by yellow bile infesting the mouth of the stomach, we must give cold drink, and administer wine that is thin, of a bright yellow colour, and old.

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COMMENTARY. This Section is taken either from Oribasius (Synops. vi, 27), or Aëtius (v, 97.) These authors, however, merely abridge the account of this subject which is given by Galen. (Meth. Med. xii, 5, and Therap. ad Glauc. i.) Syncope, according to the explanation of Galen, is a sudden prostration of the vital powers, without suspension of the respiration, as in deliquium animi. Our author has given a very correct account of Galen’s treatment. He states that, the system labouring under a load, the great indication is evacuation, but that venesection cannot be borne in such cases. In short, he insists that our great dependence must be placed on friction, for the application of which he gives very minute directions. When the pulse suddenly sinks and becomes irregular, he administers wine, unless there be inflammation of the stomach or liver. In cases complicated with crude humours, he pronounces the bath to be most prejudicial, and also disapproves of very cold or very warm air. He is most particular in his directions for the selection of the most proper wine to be used, and gives some interesting observations on the principal Greek and Roman wines used in his time. He concludes his remarks with stating that thick wines ought to be avoided as injurious, and such as are watery and thin as ineffectual, whereas those of a middling kind are to be selected. He particularly praises the Ariusian and the Lesbian. The Falernian he condemns, as being too fragrant and austere, which qualities render it injurious to the head.

Alexander disagrees with Galen as to several of the points of treatment laid down by him. He insists that Galen’s rigid rules for applying strong friction, at the same time that abstinence is enjoined, are such as no ordinary powers of constitution could bear up under; and, therefore, he recommends to rub first, and then to give some light nourishment, such as thin ptisan, oxymel, and bread soaked in wine, when the strength is greatly overpowered. Nay, when the powers of the constitution are in danger of sinking under the weight of the load, he suggests the propriety of having recourse to venesection; and accounts for the benefit derived from this evacuation upon the same principle that a fire which is like to be extinguished by an excessive load of green fuel burns brighter when part is taken off. This is an ingenious explanation of the manner in which bleeding proves useful in cases of congestive fevers. Respecting the use of wine and the bath, his views are similar to those of Galen. He approves very much of administering a light-coloured diffusible wine when the powers of the system are much sunk.

Avicenna adheres closely to the principles of treatment laid down by Galen; and, therefore, says nothing of venesection. (iv, 1, 2, 58.) Rhases treats this complication of fever in like manner. He calls it “Febris syncoptica, ex humorum copiâ et cruditate nata.” (Ad Mansor. x, 14.) He mentions emetics, but approves most particularly of friction. (Contin. xxx.)

Averrhoes contends that, in such a case, it is lawful for a Mussulman to drink wine, although forbidden by the Prophet. He approves also of friction. (Collig. vii, 16.)

Prosper Alpinus informs us that the Methodists, in such cases, gave wine and aromatics, and used every means to rouse the system. (Med. Method, vi, 9.)

SECT. XXXVIII.—OF THOSE WHO HAVE FALLEN INTO SYNCOPE FROM THIN HUMOURS.

Those who have fallen into a state of syncope from thin humours, must be treated quite oppositely to the manner described, for you will find the diagnostic symptoms quite different. They must be supported by taking a little food frequently. And their case is to be thought hopeless when the liver or stomach is inflamed at the same time that the powers are gone. In these affections, the expression of the countenance speedily becomes death-like. It is necessary to support their strength with food, but their skin must be condensed instead of being rarefied as in the former case. The air must be cooled, and they must be rubbed with astringent ointments. They must be furnished with food not very laxative, also bread and gruels from chondrus, with autumnal fruits that are austere, and not apt to spoil; these, either by themselves or with bread. A watery wine taken from the beginning with the food will be beneficial.

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COMMENTARY. This is taken from Galen. (Meth. Med. xii, 6.) See also Oribasius (Synops. vi, 27); Aëtius (v, 98.) In this case Alexander recommends nearly the same plan of treatment as Galen. He recommends for food things which are incrassant and anti-discutient, such as the juice of halica, succory, lettuces, apples, pomegranates, pears, &c. They must be administered, however, in small quantities. He approves of giving a weak watery wine, not very old. He recommends friction with tonic and incrassant oils, such as the oil of apples, and other applications of a like nature.

Avicenna, Averrhoes, and Rhases treat the case exactly as our author.

SECT. XXXIX.—ON THE OTHER CAUSES WHICH OCCASION SYNCOPE.

There are four other causes from which men fall into syncope; namely, violent pain, watchfulness, too great evacuation, and sometimes motion when in a state of delirium. To these, if you please, you may add a fifth, namely, an intemperament of the primary organs. Death takes place most quickly when the heart is affected, next, when the brain, but not so when the liver.

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COMMENTARY. See, in like manner, Galen (Meth. Med. xii, 7); Oribasius (Synops. vi, 28); Aëtius (v, 99.)

From the Commentaries on the last three Sections it will be seen that Galen and his followers, whether Greek or Arabian, consider syncope in the light of a symptom or complication of fever. But it is treated of as a distinct disease by Celsus, Cælius Aurelianus, and Aretæus; by the former two under the name of morbus cardiacus, and by the last under that of syncope. We think ourselves called upon in this place to give a brief exposition of their views.

Celsus treats of morbus cardiacus after phrenitis, because, as he says, persons affected with phrenitis are apt to fall into the other. He calls it a great weakness of the body, which, owing to the languid state of the stomach, is melted by immoderate sweating. It is recognized by a small and weak pulse, immoderate sweats, breaking out from the chest and neck, the feet and legs alone being dry and cold. He adds, it is a sort of acute disease. His treatment consists in applying a repressing cataplasm to the præcordia, and next, in stopping the sweats by friction with sour oil, roses, &c., or with some cerate similarly prepared. If the sweating gains ground, the body is to be anointed with parget, litharge, Cimolian earth, or sprinkled with the powder of them. The patient is to be lightly covered, laid in a place not too warm, with open windows, so that a current of air may reach him. Light food is to be frequently administered, and also, if necessary, wine neither too strong nor too weak, which may be given with barley-meal, if the patient has not taken other food. If he cannot take food, he is to be first treated with the affusion of cold water; and if his stomach have lost its tone, he is to be allowed to vomit before taking food. If the stomach still reject the food, he is first to take a cupful of wine, which is to be repeated after an hour, and then the whole body is to be anointed with pounded bulbi (onions?), which will have the effect of making the stomach retain the wine, and thereby heat will be restored to the whole body and strength to the veins. As a last resource, he recommends an injection of ptisan or gruel. Fragrant things may also be applied to the nose, such as roses and wine; and if the extremities be cold, they are to be chafed with hot hands smeared with oil. If the violence of the sweating be thus checked, and life prolonged, the time thus gained will be of some assistance. Means are afterwards to be taken to prevent a relapse. (iii, 19.)

Cælius, the Methodist, treats so fully of the cardiac passion, that we feel at a loss how to give a competent outline of it within our limits. The followers of Asclepiades, he says, held it to be a swelling about the heart, connected with congestion; but, according to Soranus, the great master of the Methodists, the heart is not primarily affected; and he holds it to be an acute and sudden prostration, by which the distribution of particles over the passages of the body is stopped. The causes of it are many; such as protracted indigestion, intoxication, baths after food, vomiting after supper, and depressing passions, by which the body is dissolved into sweats. It takes place most frequently, he says, in continual, ardent, and inflammatory fevers on the sixth day. His description is too lengthy to find a place here. Suffice it to say that when the affection is at its height, the pulse is small, tremulous, and creeping; there is a profuse, viscid, and fœtid sweat over the chest, face, and perhaps the whole body, with failing respiration, pallid countenance, hollow eyes, and so forth. Some of the preceding authorities, such as Asclepiades and Themison, held that it was generally, but not always attended with fever; and with them he pretty nearly agrees. As we have already hinted, he is not disposed to admit that it is a primary affection of the heart, but rather holds it to be a disorder of the general system. Having discussed, in two chapters, the diagnosis, first, between it and affection of the stomach, and then between it and critical sweats, he comes to the treatment. The patient is to be laid in a cool and well-ventilated apartment, to be covered over with light clothes, and to have his face, neck, and chest sponged with cold water and vinegar; and if the sweating continue, astringents and obstruents, such as alum and Samian earth, are to be added; or the body may be anointed with astringent oils; but, in particular, various applications of a fragrant and astringent nature are to be made to the chest. He recommends great caution in the administration of food and drink; directs that the mouth should be rinsed with something cooling; and, in process of time, that various articles of a restorative nature should be given for food, and at last, wine, about the choice of which he is very scrupulous, approving, in general terms, of such as is white, well clarified, and subaustere, and in particular of the Surrentine, the Falernian, the Chian, and the Lesbian. He cautions, however, not to give too much at a time. When there is great prostration of the vital powers, he approves of ligatures to the extremities, and the application of cupping instruments, with great heat to the præcordia. When all other means fail, the patient is to be supported by administering nourishing things in clysters. Such is his own mode of treatment. He afterwards animadverts freely upon the practice of the other sects.

Although Aretæus treats of syncope as a separate disease, he holds that it derives its origin from causus, or ardent fever. He pronounces it to be a loosening of the vital cords, and that its seat is the heart; hence his chapter on the treatment is entitled, on the cure of cardiacs. The symptoms, he holds, mark an affection of the heart, namely, small and weak pulse, great palpitation, throbbing of the heart, fainting, unrestrainable sweats, &c.

His treatment is little different from that of Alexander in syncoptic fever. Thus he begins with venesection, unless otherwise contra-indicated, justifying this practice by the pithy remark that the powers of the system may be reduced by suffocation as well as by want. He recommends, however, that blood should be taken in moderation, and that some wine should be given immediately afterwards, unless inflammation be present. Wine, he remarks, in inflammations, adds to the disease, but, in ordinary cases, to the strength. When general bleeding cannot be borne, he advises cupping in a guarded manner. He approves of bathing the head with cooling things, of cool air, and of all things that are grateful to the senses. When the system is quite sunk, and the extremities cold, he recommends wine guardedly with light soups. The wine, he says, should be fragrant and not very astringent, but should be given with moderation, unless the sweats are very profuse and the skin cold, when he advises wine to be given to any extent, wine in such cases being the last hope of life. He directs further that the patient should be kept up with encouraging words, and the application of fragrant and astringent things, such as alum, rose-water, and the like. He is to be exposed to fragrant and cool air, and, if the sweats persist, obstruent substances, such as Samian earth, &c., are to be added to the applications, and a sponge soaked in cold water is to be applied to the face. Stimulants and rubefacients are to be applied to the extremities. He concludes with remarking that convalescence is often prevented by latent inflammations, which end in marasmus, in which cases the physician must endeavour by gestation, friction, baths, and the administration either of a woman’s milk or that of an ass to support the strength. (De Cur. Acut. ii, 3.)

Aëtius also has a separate chapter on cardiacs, although he holds syncope to be symptomatic of acute fever. We need not enter upon an exposition of his views further than to mention that he is of opinion that the part originally affected is the cardiac orifice of the stomach. (ix, 1.)

By cardiac disease in fevers the ancients would seem to have meant to describe a febrile affection, attended with congestion and great nausea. Such a variety of remittent fever is described by the late Dr. Robert Jackson as still occurring in warm climates. The symptoms are great nausea, sluggishness, obscure, weak pulse, and deep respiration. He recommends bleeding, and afterwards stimulant applications to the extremities. (On Fever, p. 193.)

Since writing the above we have had an opportunity of consulting Hecker’s ‘Epidemics of the Middle Ages,’ and beg to refer our readers to it (p. 306) for an ingenious disquisition on the cardiac disease.

SECT. XL.—ON PAIN.

A torpid pain is occasioned by a cold affection; a throbbing is characteristic of a strong inflammation. But, if a person feel as if pierced by a sharp-pointed instrument, or bored by a wimble, this kind of pain is peculiar to the thick intestine, i. e. the colon. The pungent is seated in the membranes. The darting pain attends the most vehement attacks, not only of hemicrania, but also of cephalæa. It is said to be darting when it commences in the seat of the affection, as from a root, and spreads quickly to the surrounding parts. Stretching pains take place in the nerves, when they are affected and stretched towards both extremities. But the nerves are not liable to be affected with lateral distensions. The membrane under the skin when distended occasions tensive and torpid pains; those between the flesh, as it were, divellent. For they are many, have irregular insertions, and surround the flesh. But the pains proceeding from the membranes which surround the bone, are deep-seated, and seem to proceed from the bones themselves. Wherefore, when no external cause of the pain is apparent, you must consider the patient’s preceding regimen. If it has been more inactive than usual, or if he has been taking more nutritive food than common, or if any evacuation has been suppressed,—if any or all of these circumstances be observed, plethora is the cause of the pain, and you must evacuate him as quickly as possible; for, by this means you will be enabled with all safety to use such remedies as are fitted to repel the defluxions from the affected parts. If the part be distended with a fulness of blood, open a large vein near it immediately; but when bad humours alone are the cause, you must purge; and, when both meet together, you must use both evacuations, beginning with the bleeding. If, after both these remedies have been tried, the pain continue, it is clear that the offending matter has become fixed in the part affected; and it is also clear, that the cure will be accomplished by discutient remedies. In like manner, we may cure pains from flatulence, by soothing them with attenuant food and injections, and opening the pores of the containing part with cataplasms, irrigations, and fomentations. If a swelling bearing down and pressing upon the part be the cause of the pain, it must be removed; but, if it proceed from a pungent humour, attenuant and calefacient things are most improper. Dill boiled in oil is anodyne and soporific, and the green more than the dry.

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COMMENTARY. This Section is taken from Oribasius (Synops. vi, 29), or Aëtius (v, 100.) All these authors, however, merely abridge the account given by Galen. (Meth. Med. xii, 8, and de Locis Affect. ii.) In the latter work he gives a most ingenious dissertation on the different kinds of pain, and the states of the body in which they occur; but, as our author has given a summary of his observations, we think it unnecessary to go over the same ground. We shall, therefore, merely notice some of his remarks on the treatment, as delivered in the other work. When the pain is connected with flatulence, it is to be removed by food, drink, cataplasms, and fomentations of an attenuant nature. When pungent humours are the cause of the pain, they are to be treated by evacuants, diluents, or narcotics. When occasioned by thick and viscid humours, he forbids narcotics, the action of which, being frigorific, renders them thicker, and the containing parts more compact. In all such cases, therefore, he holds that opium and hyoscyamus, although they afford a temporary relief from pain, act prejudicially. He also proscribes things of a very hot nature, both internally and externally, and recommends to give attenuants, or things of an incisive nature. He in particular commends garlic, which he calls the theriac of rustics. As to external applications, he directs, in febrile cases, first a dry fomentation of millet-seeds, and, if it is not successful, friction with subtile or attenuant oils, and the fat of fowls.

Aëtius defines pain to be a sensation produced by a sudden change of temperament, or a solution of continuity. In illustration of the former cause, he remarks that all sudden changes from heat to cold, or vice versa, occasion severe pains. To the latter he refers rupture, contusion, and erosion of the parts. Rupture is produced by tension, contusion by weight, and erosion by some pungent quality. These causes of pain ought to be particularly attended to, and the treatment modified accordingly. His subsequent account is exactly the same as our author’s.

The different kinds of pain are fully treated of by Avicenna (i, 2, 3, 20), and by Haly Abbas (Theor. vi, 16.) Averrhoes has delivered the treatment of this complication of fever in nearly the same terms as Galen. When the pain is occasioned by warm air or flatulence, he particularly commends cupping applied with great heat. He agrees with Galen in condemning narcotics, when the exciting cause is of a cold nature. He also joins him in condemning hot fomentations and clysters, when the pain of the bowels is occasioned by a hot humour. (Collig. vii, 18.) See Rhases (Cont. xxxiii.)

SECT. XLI.—ON COLLIQUATIVE DIARRHŒA OR MELTING.

When anything is discharged from the bowels which was not part of the food or drink that was taken, but of the fluids of the body which had flowed to them, (resembling the yellow bile which is continually discharged by vomiting and purging, but differing from it in fetor; and in this, that the alvine discharge is of a darker yellow, of the consistence of the sordes balneorum, oily, and adipose,) the disease is called colliquation or melting. At first the fat and newly-made flesh are dissolved and melted by the heat of the fever; but as the evil is protracted, some of the solid parts themselves are melted down. In this most unfavorable state of fever, a draught of cold water from the coolest fountain is the most proper remedy; likewise cold cataplasms and epithems ought to be applied to the chest and hypochondriac regions, and cooling food to be given.

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COMMENTARY. Galen mentions that a colliquative discharge from the bowels was a common symptom of the fatal plague which prevailed in his time. He adds that the fæces were generally of a deep yellow colour, and always fetid. (Comment. in Hippocrat. Epidem. iii.) In another place, he states that it is a fatal practice to bleed or purge in cases of fever complicated with diarrhœa. (Therap. ad Glauc. i.)

Our author borrows from Oribasius (Synops. vi, 30), or Aëtius (v, 91.)

The Arabians treat febrile melting upon general principles, as explained under the head of Diarrhœa.

On the colliquative diarrhœa in fevers, see, further, Prosper Alpinus (de Præs. Vita et Morte Ægrot. vii, 11), and Fabius Paulinus (Prælect. Marc. p. 343.)

SECT. XLII.—ON WATCHFULNESS IN FEVERS.

Those who are much troubled with insomnolency, we are to direct to have their legs and hands bound with ligatures at the time when they were accustomed to go to rest; and make them keep their eyelids open, or wink, until they are sufficiently fatigued; then we suddenly loosen the ligatures, remove the lamp, and order complete stillness to be preserved. But, when the insomnolency is obstinate, we must bathe the forehead during the decline of the paroxysm with the decoction of the heads of the black poppy, and direct the patient to snuff up the dried and powdered husk of the white poppy; or from the root of the mandragora pounded with wine and rose oil in equal quantities, we make an emollient ointment (malagma), and smear the forehead with it. Or we use, during the paroxysms, wild thyme boiled in must with melilot. Or, taking the pounded heads of poppies, we make a cataplasm of it with bread and rose oil, or cerate. And the greatest attention ought to be paid to the food. Let about three spoonfuls of the seeds of the white poppy be added to the patient’s gruels; and let his pot-herbs be prepared by adding to them as many of the leaves of the black poppy, if green, as can be contained within three fingers; or otherwise, three or four dried heads may be boiled with them and taken. If, even by these means, sleep cannot be procured, let him be smeared with the juice of poppy or of mandragora. But the electuary composed from the heads of poppies, and, particularly that which is drunk with sodden wine, to the amount of a spoonful, or a spoonful and a half, often disposes to sleep. Those who are not troubled with fulness of the head may use the following fumigations in the decline: Of Indian leaf, of amomum, of costus, of arnabo, of each ℥ j, of the fruit of the balsam tree lb. j, of storax, of ammoniac perfume, of Scythian bdellium, of the root of the mandragora, and juice of poppy, as much; use as a fumigation with cypress-wood.

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COMMENTARY. We are informed by Celsus that Asclepiades trusted almost entirely to gentle friction in such cases. (iii, 18.)

Our author, as usual, copies freely from Oribasius. (See Synops. vi, 31.) Nearly the same directions are given by Aëtius. (v, 116.) Those in the beginning of the Section are from Galen; the remaining part is from Herodotus and Philumenus.

Nonnus gives a correct account of the established rules of treatment in such cases. Thus, he directs us to use ligatures, and apply friction, to the extremities; and, if this treatment have not the desired effect, to have recourse to soporific decoctions, or liniments prepared with poppies, opium, mandragora, &c., or even to give internally an infusion of poppy heads. (Epitome, 145.)

The directions given by Avicenna are so like our author’s that we must suppose them copied from him. He directs us first to try the effect of fatiguing the patient by talking loud to him, placing many candles in his chamber, and applying ligatures to his extremities. When this method does not succeed, he recommends the soporific applications mentioned by our author. When there is nothing to forbid the use of it, he permits the syrup of poppies. (iv, i, 2, 20.) Haly Abbas likewise recommends poppies externally and internally. (Pract. iii, 23.) Averrhoes briefly directs food and applications of a soporific nature. (Collig. vii, 2.) Rhases mentions our author’s plan of treatment, and further seems to approve of liniments made of mandrogora, opium, henbane, and the juice of lettuces. (Cont. xxxi.)

Cælius Aurelianus remarks that the indiscreet use of soporifics may bring on lethargy. According to Prosper Alpinus, the Methodists approved of fomentations, consisting of soporific medicines, such as lettuces, opium, and the like. (Med. Meth. vi, 8.)

The earlier of the modern writers on medicine approve of applying to the nose a sponge soaked in a soporific liniment prepared from opium, henbane, mandrake, cicuta, lettuce, and the like. (See Theodoricus, iii, 8.)

SECT. XLIII.—THE CURE OF CATAPHORA OR SOMNOLENCY.

Sponge the forehead with oxycrate of the temperature of new milk; put tight ligatures round the extremities; and apply to the nose strong-smelling things of an incisive quality. In the remissions, apply cupping instruments between the shoulders along the spine. When the disease is protracted, errhines must be tried during the remission. Let the food consist of things having incisive and dividing properties, as recommended by us in our general directions regarding the health.

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COMMENTARY. The treatment mentioned by our author is recommended by almost all the other authorities both before and after his time. See, in particular, Oribasius (Synops. vi, 33); Aëtius (v, 117); Nonnus (Epitome, 146); Avicenna (iv, 1, 2, 18); Haly Abbas (Pract. iii, 23.)

Prosper Alpinus gives an excellent account of the practice of the Methodists. It consisted of painful friction, tight ligatures, rubefacients applied to the extremities or head, sternutatories, and, in short, everything calculated to rouse. (Med. Meth. vi, 7.)

SECT. XLIV.—THE CURE OF HEADACH IN FEVERS.

When headach proves troublesome in fevers, after the accustomed evacuations, in the decline of the paroxyms, the head ought to be anointed, first with the common oil from unripe olives, or with rose oil, to which a very small quantity of vinegar has been added; which, if it be the summer season, and the fever of the ardent type, may be used cold; but, in winter, if the fever be not ardent, it must be hot or tepid. In the oil may be boiled the juice of wild thyme and knot-grass (polygonum); and in summer, the heads of the poppy, or the poppy itself may be added, as in winter, a moderate quantity of the hogs-fennel may be substituted in place of it. When the pain continues in the forehead, if the open of the head be bare, a poultice may be applied to it, made of old barley-meal and knot-grass; or, in like manner, of bread and roses, or of some myrtle or wild thyme. Some are rather benefited by an admixture of pennyroyal, and others, when the affection was of a hot nature, have rather been remedied, by having flea-wort (psyllium) added to the barley-flour, or even by this substance alone, when boiled to the consistence of bird-lime. It must be frequently changed. Coriander with barley-meal may be used in like manner. Aloes with vinegar are also to be rubbed in, or myrrh and ammoniac in like manner, and crocomagma. Pulsatory pains are dispelled by rue and mint, with bread, to which a little rose oil has been added. When the pain does not yield to the afore-mentioned remedies, we must first cut the hair close by the skin, and then rub some of the oily embrocations over it all; after which cupping-instruments are to be applied to the hind-head, and the extremities to be bound with ligatures, and chafed. Leeches also are a proper application. But if a catarrh or defluxion raise the pain in the head, we must apply the remedies which will afterwards be described in the proper place. But if exhalations from the stomach have been carried upwards, and hurt the head, we must attend to them, as is stated below.

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COMMENTARY. Part of the directions delivered by Celsus for the treatment of headach deserves to be given in his own language: “Si capitis dolores sunt, rosam cum aceto miscere oportet, et in id ingerere: deinde habere duo pittacia, quæ frontis latitudinem longitudinemque æquent: ex his invicem alterum in aceto et rosâ habere, alterum in fronte: aut intinctam iisdem lanam succidam imponere. Si acetum offendit purâ rosâ uterdum est, si rosa ipsa lædit, oleo acerbo.” If this does not succeed, he recommends other more refrigerant applications prepared with iris, poppies, ceruse, litharge, &c. (iii, 10, 112.)

When headach occurs towards the beginning of fever, Galen bleeds once and again, if there be nothing to contra-indicate depletion, and more especially if the patient be plethoric. He then attends whether it arise from fumes proceeding from the stomach, or constipation of the bowels, and corrects these conditions accordingly. If it make its attack after the seventh day, he first evacuates the bowels by clysters, then cups the back part of the head or neck, or uses paregoric applications, such as rose oil, with some vinegar, if in summer; but, if in winter, especially in persons of a cold temperament, the oil of chamomile, with a fifth part of vinegar. See further ‘De Med. sec. Locos.’ (ii.)

Alexander recommends attention as to whether the headach be connected with the crisis, and in that case he cautions against meddlesome interferences, which may do more harm than good. When any applications are admissible, he recommends that they be of a cooling and soporific nature. (i, 10.)

Aëtius likewise recommends bleeding, purging, and vomiting, when not contra-indicated; and gives very proper directions about the local applications. He directs us to soak a handful of wool in some cooling fluid, and, holding it above the head, to squeeze out the fluid, so that it may fall upon the head from a height. (v, 100.)

Palladius says that headach in fevers is occasioned by repletion and distension of the veins, owing to fumes arising from the stomach. (De Febribus, 13.) Nonnus merely abridges our author’s account. (Epit. 147.)

Avicenna’s directions about the local applications are brief, and similar to those of the Greeks. (iv, i, 2, 19.) Haly Abbas recommends bleeding and attention to the state of the stomach, for the relief of which he in certain cases permits the use of wine. (Pract. iii, 20.) Rhases joins preceding authorities in recommending vinegar and rose oil to be poured upon the head. They are to be used cold in summer, but hot if in winter. (Cont. xxx.)

We have seen that Celsus approved of cold and astringent applications to the head. The Methodists condemned this practice, and recommended hot water to be poured upon the open of the head. Hippocrates seems to allude to this practice, when he says: “Much hot water poured upon the head removes fever.” (Aphor. vii, 42.) Prosper Alpinus gives an excellent account of the Methodical treatment. (Med. Meth. ii, 6.)

SECT. XLV.—ON THE CURE OF STOMACH AFFECTIONS.

If the stomach be weak, we must apply strengthening cataplasms to it, such as those made of dates and wine, and of barley-meal and saffron, and of mastich and aloes; and use embrocations from wormwood, the oil of apples, and of mastich, nard, and wine; and if hot, we must add cooling things, such as the juices of gourd, lettuce, purslain, nightshade, endive, and unripe grapes. But if the bowels appear to be inflamed, it will be proper to add to the embrocations some of the relaxing medicines, such as oil of chamomile and of privet, the grease of a cock or goose and bdellium, ammoniac, or the like; and to the cataplasms, the seed of parsley and fenugreek, the flowers of the marshmallows and chamomile; and, in a word, let the application be a compound of relaxing, attenuant, bitter, and astringent properties.

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COMMENTARY. Celsus notices these affections. When there is pain and inflammation about the præcordia, he recommends us to use at first repellent cataplasms, and, when the inflammation abates, to exchange these for hot fomentations, whereby the remains of the complaint will be removed. Pain without inflammation requires no application, as it will be carried off by the fever itself. (iii, 10.)

Galen treats of all sorts of applications for affections of the stomach in his work, ‘De Med. sec. Locos’ (viii.) Our author follows Aëtius. (v, 95.)

For atony of the stomach, Alexander recommends the applications mentioned by our author. When there is ardor of the stomach, a seasonable draught of cold water, he says, may do much good, whereas, if unseasonably given, it will prove highly dangerous. For atony of the stomach, he also recommends hot wine, if not contra-indicated; and most especially friction of the extremities. When it can be borne, the bath, he says, proves beneficial in cases of atony. When there is a sense of cold, he recommends poppies and wormwood. When the stomach is loaded with offensive humours, he directs an emetic of oil and water to be given. This remedy, he adds, sometimes operates downwards with the best effects, and he directs its purgative operation to be promoted by giving suppositories. He concludes, with recommending the stomach to be strengthened by giving a decoction of wormwood with wine, but forbids this medicine until the fever be abated. (xii, 3.)

Of the Arabian authors, Serapion’s account is the fullest, but it is taken almost word for word from Alexander. (vi, 19.) Rhases states that he had often seen bad consequences arise from evacuation having been practised before attending to the stomach. (Contin. xxv.)

SECT. XLVI.—ON INORDINATE CHILLS AND RIGORS IN FEVERS.

When rigors are critical, we must not interfere with them, nor attempt to put an end to the struggle; and a chill succeeding to a sweat will readily pass away and give no trouble. But when the rigor and chills are protracted, and more particularly, if occasioned by a collection of cold phlegm, we are first to apply ligatures round the limbs in various ways, and then anoint them with the oil of chamomile, or of privet, or of iris; or, if a stronger application be required, we may add to the oil some pepper, or the seed of the rosemary, or adarce, or castor, and the whole body is to be gently rubbed with these things. And in order that the oil may not readily run off, a small quantity of wax may be melted with it. Or, if it is the rigor not attended with heat, we must use the most powerful restorative ointments (acopa), and also dropaces and sinapisms. Proper fomentations ought likewise to be got ready. The acrid-scented things are likewise proper, such as calamint, pennyroyal, and hyssop. Before the attack, we should likewise give for drink honied water, in which pepper and rue have been boiled. And we should likewise give of the Cyrenaic juice, to the size of a millet, two hours before the paroxysm, mixing it up with boiled honey; and we are to give the juice of the laserwort in like manner. And the composition for quartans, made from the Cyrenaic juice, has proved beneficial to many. And some, by going into a bath of hot oil, have shaken off obstinate rigors, as Archigenes affirms. But Galen recommends, before the attack, rubbing the skin with southernwood, or dried calamint, or the leaves and flowers of flea-bane (conyza), or with costus, or pellitory, these two last with oil. By these means the rigors will nearly or altogether cease.

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COMMENTARY. These febrile symptoms are treated of by Celsus at considerable length. (iii, 11, 12.) He properly recommends fomentations of a hot and dry nature, and friction with calefacient oils. When produced by a bilious defluxion upon the stomach, he gives saltish water so as to operate as an emetic. He makes mention of the bath, and in certain cases allows wine. For Galen’s sentiments, see ‘de Diff. Febr.’ (ii), ‘de Causis Sympt.’ (ii, 5), ‘de Inequali Intemp.,’ ‘de Tremore, Palp. et Rigore.’ The last-mentioned work, in particular, contains some ingenious speculations on the nature of rigors. Our author has mentioned Galen’s treatment. Hippocrates pronounces a rigor occurring in continued fever, when the patient is become weak, a mortal symptom. (Aphor.)

Aëtius states that tremors take place in fevers for the most part owing to errors in eating and drinking. Holding them to be connected with disorder of the spinal marrow, he directs us to apply to the back wool soaked in some stimulant oil, or to put the patient into a bath of oil. He recommends castor, both when taken by the mouth and applied externally with the embrocations. (v, 130.)

According to the explanation of Palladius, rigors and tremors are occasioned by fumes or vapours arising in the internal parts, and being diffused over the body. (24.)

The treatment recommended by Haly Abbas is simple and judicious. He directs us to give draughts of hot water, to put the patient’s feet into hot water, and to rub the feet, and, if necessary, the other parts of the body, with calefacient oils and the like. (Pract. iii, 20.)

Avicenna gives a very accurate account of the different modes of treatment, but they are much the same as our author’s. He approves of ligatures to the extremities, of rubbing them with stimulant oils, or even with liniments prepared with assafœtida and mustard. He says the bath of hot oil is very beneficial. He also recommends draughts of hot water, and potions containing opium, which, he remarks, will procure sleep and perspiration. In certain cases he allows hot wine, which had been recommended by Hippocrates. (Aph. vii, 56.) He directs us to open the bowels with the hiera, or pills of assafœtida. (iv, i, 2.) Rhases particularly commends a draught of hot water. (Cont. xxx.)

SECT. XLVII.—ON SWEATS.

We must allow critical sweats to go on until they produce the necessary evacuation, and assist by means of moderate heat and rest, and by not wiping away the sweat (for one brings on another), by washing the mouth with warm liquids, by warm drinks, and by sleep. The sweats which occur in the decline of a fever are to be treated like the critical. Sudorific remedies are sufficiently treated of in the 48th section of the First Book. But when the sweats exceed in quantity, they must be wiped off, and the covering of clothes lightened, so as to cool the patient. For, by exceeding, they occasion lassitude, and often bring on syncope. Let, therefore, the covering be light and moistened; let the air be cooled; and let ventilation be used during sleep. Let the black myrtle, pounded, be sprinkled on the body, and gall, and the bark of the pine, in like manner. Let amber and polenta, with astringent wine, be applied to the proper parts; and let the face be sponged with oxycrate. Archigenes uses quicklime and the burned lees of wine in these cases, and for the rigor not succeeded by heat; for both, he says, when heated, become dry. He also orders us to bathe the middle parts of the body with the juice of plantain, or coriander, or purslain, or cabbage, that they may obstruct the passages of the sweat. In sleep, pieces of cloth smeared with Cimolian earth, dissolved in water, are to be applied to the back and chest; and the whole body should be anointed with the oil of roses, or of apples, or of lentisk, or of myrtle, or with the cerates from them. But fatty substances are particularly adapted to them; for, by shutting up the insensible pores, they prevent the passage of the fluid. It is clear that dry food and moderately astringent wines are befitting to them; but much drink should be avoided, and, in particular, all things of a very liquid nature, and likewise frequent washings of the mouth. But, if possible, gestation should be taken in a cold state of the air. The extremities in particular are to be cooled by these means. For those sweats which are extorted by spasms and pains, tight ligatures, or fomentations, are to be applied to the extremities, and they may be relieved by gently rubbing with woollen cloths.

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COMMENTARY. Hippocrates has delivered many interesting remarks on sweats which occur in fevers. (See Epidem., Aphor., Prognost. passim.) Febrile sweats, attended with miliary eruptions, are held to be unfavorable. “In general,” he says, “sweats proceed either from resolution of the body, or the intensity of the inflammation.” (Prog.) In general he holds that febrile sweats, unless they occur on critical days are unfavorable. (Aphor.)

Galen remarks that profuse sweats are occasioned by rarity (i. e. relaxation) of the body, or redundance of the superfluity, or thinness thereof. The perspiration is checked, on the other hand, either because the superfluity is small in quantity, thick, and viscid; or because the pores of the skin are constricted. Either state, he adds, may arise from atony of the natural powers of the flesh. (De Causis Sympt. iii, 9.) He says, in another place, that for the removal of copious sweats astringent and refrigerant remedies are indicated, and that everything of a relaxing nature ought to be avoided. He recommends cold wine, and forbids all hot things, also ligatures to the extremities, emetics, and motion. He approves of cool air medicated by sprinkling the apartment of the sick with austere things, such as myrtles, vine shoots, and roses. (Therap. ad Glauc. ii.)

Celsus directs us, when the febrile sweats are slight, to rub the body with oil, and, when more profuse, with roses, quince ointment, or myrtle oil, to which austere wine is to be added. (iii, 6.)

Constantinus Africanus and his prototype Synesius concur in directing colliquative sweats to be checked by rubbing the body with oil of myrtles, of roses, &c. They commend an epitheme made of a decoction of roses, the flowers of the wild pomegranate, galls, and myrtle leaves, to which a proper proportion of oil is to be added. They also direct us to place beside the patient vessels filled with water, to sprinkle the apartment with myrtles, roses, &c. to give him the syrup of roses, in cold water, and to avoid exercise.

Actuarius takes notice of the miliary eruption which sometimes accompanies profuse sweats. He reckons it an unfavorable symptom. (Meth. Med. i, 58.) He also makes mention of other cutaneous eruptions, some resembling those produced by nettles, or the bites of gnats, and others of a red or black colour. (Ibid.)

Serapion recommends styptic and desiccative applications, such as galls, frankincense, alum, the flowers of vine, myrtles, and the like. (De Antidotis, vi, 20.)

Haly Abbas briefly recommends friction with styptic oils, and to remove the patient to a cool apartment. (Pract. iii, 24.)

Alsaharavius, in like manner, recommends friction with astringent oils, such as those prepared with roses, pomegranates, and the like. (xxxi, 2, 8.)

Avicenna and Rhases adopt the same plan of treatment as our author. The latter directs us to rub the body with rose oil, or myrtle oil, to sprinkle the patient with rose water in the decoction of myrtles, to fan him, and to lay in his chamber the tops of cooling herbs and trees. (Contin. xxxi.)

Prosper Alpinus informs us that the Methodists approved of cool air, of sprinkling the face with cold fluids, of rubbing the body with styptic oils, and of giving astringent wines internally. He also mentions the application of snow over the arteries of the extremities, and pouring cold water over those of the wrist. It is to be regretted, however, that this author too frequently omits to quote his ancient authorities. (See Medic. Method., vi, 18, and vii, 3.)

SECT. XLVIII.—ON COUGH IN FEVERS.

We must endeavour to remove a cough in fevers, more especially in such as come on with rigors, for it exasperates the fever when it is subsiding. We must give lozenges from boiled honey to hold below the tongue, for these melt and remove the substances which obstruct respiration. The time for using them is at the acme of the paroxysm, and a short time before the attack. Well-boiled hydromel must likewise be given. When there is no suspicion of the nerves being affected, in process of time you may give oxymel with confidence, or if not it, the decoction of hyssop, which is a remedy also for rigors. If the fever is not of the ardent kind, you may give castor, which is also of use to the nervous system. Electuaries may be used, made of the kernels of the common and wild pine, iris, linseed, bitter almonds, and nettle-seed. But the most of these may be mixed with the food. Turpentine-rosin should be given in an egg. To the chest and the parts about the trachea, apply a sulphurated woollen cloth, and oil of rue, or of iris, or of dill. Tight ligatures long applied are excellent for stopping cough, I mean to the middle and extremities. Nor will it be unsuitable to use for the cough stavesacre dried, which may be chewed with dried grapes or mastich. The extremities may be rubbed, chafed, and bound with ligatures, and afterwards the retracted parts unbound. But if the cough annoys, owing to the acrid nature of the fever, we must use a gargle of tepid water. Cold water also is often useful; and, in like manner, gargles of oxycrate, or of the decoctions of dates, roses, or liquorice. Moderately cooling things are also to be laid over the bowels and heart.

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COMMENTARY. Galen gives some ingenious remarks on the causes of coughing. He states that when any substance becomes fixed in the trachea, as it is a cartilaginous and hard tube, and incapable of contraction, nature brings on coughing, by which a violent expiration of air is induced. A cough, then, is nothing but a violent expiration by which nature endeavours to expel any body that obstructs the air-passages; and, when she cannot accomplish this at the first effort, she repeats it once and again until she effect her purpose. He goes on to state, that such fluids as are very watery, instead of being brought up, are merely divided or cut asunder by the current of air, while such as are thick and viscid, adhere so closely to the sides of the windpipe that they cannot be removed, and hence violent efforts are necessary to effect the discharge of them. (De Causis Sympt. ii, 4.) He treats fully of compositions for coughs in his work ‘De Comp. Med. sec. Loc.’ (vii.) See the 28th Section of the Third Book.

Avicenna recommends cough pills and lohocks made with poppies, the cold medulla of fruit, starch, and the like. (iv, i, 2.)

The prescriptions of Serapion contain liquorice, sweet almonds, tragacanth, and the like. (De Antidotis, vii, 17.) Those of Haly Abbas are very similar. (Pract. iii, 22.)

A receipt is given by Rhases for cough pills, the principal ingredients of which are tragacanth, sweet almonds, poppy seed, gum Arabic, and Armenian bole. (Divis. i, 52.) Many such receipts are given by Myrepsus.

SECT. XLIX.—ON SNEEZING.

Sneezing frequently occurring in fevers is troublesome, for it determines to the head and weakens the strength, and, in some cases, it produces a discharge of blood. Such are the bad effects of sneezing, which ought therefore, to be contended against. It is restrained by rubbing the nose, forehead, and eyes; by yawning, frequent friction of the roof of the mouth, eructation, stretching of the loins, raising the head, turning to the side, gently chafing the extremities, anointing the masseter muscles, pouring hot oil into the ears, applying a warm cushion under the chin. It is proper to avoid being roused suddenly from sleep, and also smoke, dust, acrid smells, pepper, castor, mustard, and mint. The smell of apples and polenta is proper, for it blunts the desire of sneezing. The empty sea-sponges do the same. When there is a frequent desire of sneezing without the ability, let the lips be composed, let the patient smell to acrid substances, and let the mind be relaxed.

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COMMENTARY. Galen explains that sneezing is a still more violent effort of nature than coughing, and that its intention is to remove irritating matters from the parts about the nose. (De Caus. Sympt. ii, 4.)

Avicenna gives ample directions for the treatment of sneezing; but they are evidently copied from our author. (iv, 1, 2.) The same may be said of Haly Abbas. (Pract. iii, 22.) Rhases recommends us to give warm gruel internally, to pour warm water on the head, and to apply oil of gourd, of roses, and the like, to the nostrils. (Cont. xxxi.)

Cassius Medicus discusses the question why rubbing the nose and eyes stops sneezing. He supposes that it is by occasioning a discharge from these parts, whereby the exciting cause is removed. (Probl. 45.)

SECT. L.—ON LOSS OF APPETITE.

When loss of appetite is occasioned by depraved humours, we must give those kinds of food and drink which will either clear away such humours by vomiting, or downwards by the bowels, or those that by dilution will render them better. You have the materials of these things treated of in the First Book of this work. Should the loss of appetite be occasioned by debility, since all debility is owing to an intemperament of the parts, we must cure the species of intemperament by its contraries. Wherefore we will give a more particular account of loss of appetite in treating of stomach complaints in the Third Book. But in fevers we must straightway endeavour to bring back the appetite with aromatics, more particularly by giving polenta moistened with water, or oxycrate, or diluted wine, or a decoction of some of the fragrant and astringent fruits; by gentle unction and moderate friction of the whole body, by chafing, by bathing the face, and swallowing a small quantity of water; and, by putting the fingers down the throat, the stomach has been roused to bring up the food, more especially if the fluid discharged be bilious or acid. After the first days, cataplasms of dates, of apples, of the wild wine, of wormwood, and of aloes, ought to be applied over the stomach. Let a variety of simple food be prepared, and from grain, having some difference from the common articles, but not very different from those used in fevers; and among them those fruits which do not readily turn acid, nor are very sweet, but are ripe; however, they are not to be eaten to satiety, but only so as to whet the appetite for other food. While they are eating, the most delicious articles ought to be present, which may have the power to provoke and incite the desire. After the fever is gone, should the want of appetite continue during the recovery, yellow parsnip boiled with oxymel, and lettuces, and pickled olives, and capers, and pickles, the bulbi, and every other stomachic should be thought of; and, in particular, those things should be recollected in which the patient delighted most when in good health. Walking, gestation, vociferation, calefacient plasters, frictions, and exercises ought to be had recourse to. And drinking the propoma from wormwood, or from aloes, or swallowing the vinegar of squills to the amount of a mystrum, have proved excellent remedies.

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COMMENTARY. Galen’s explanation of the philosophy of the sense of appetite is very interesting. He remarks that the appetite is a refined species of touch, the seat of which is the mouth of the stomach, which, therefore, is supplied with nerves direct from the brain. He goes on to remark, that the earth is to plants what the stomach is to animals, supplying them with abundance of food as long as it is moistened by seasonable rains; but, when it becomes parched with drought, the plants in like manner are dried up for want of nutriment. (This comparison is borrowed without acknowledgment from Aristotle.) To animals, then, as not being fixed to the earth (with a few exceptions), nature bestowed a stomach which is to them a repository of food, such as the earth is to plants, and she further gave them a sense of want by which they have the desire of being filled with food and drink in due season. This desire of being filled is called the appetite, which arises from a sense of want, when the veins of the stomach absorb, and, as it were, suck from it, whereby a painful feeling is excited, the proper cure of which is a supply of food. The sensation then of sucking constitutes hunger. The loss of appetite may arise either from the sense of the sucking being lost, or from the process of sucking (absorption?) not taking place, or from the body not being evacuated. (De Causis Sympt. i, 7.) He treats of stomach affections very fully in his work ‘De Med. sec. Locos.’ (viii.)

Treatment similar to our author’s is recommended by Alexander (vii, 7), and by Oribasius (Synops. vi, 35.)

Avicenna evidently takes his plan of treatment from our author, for he recommends emetics, and afterwards fragrant things, with a plaster composed of fruits laid over the stomach, and wormwood, aloes, &c., internally. (iv, 1, 2, 26.) Among the causes of loss of appetite mentioned by him in another place are general disorder of the constitution in fevers, severe thirst, repletion with depraved humours, and insensibility of the mouth of the stomach, so that it does not perceive the suction of the veins. (iii, 13, 2, 7.)

Haly’s treatment is nearly the same. He recommends fragrant food and fragrant wine after the acme of the fever, gentle laxatives, and such modes of exercise as he can bear. (Pract. iii, 21.)

SECT. LI.—ON BULIMOS OR INORDINATE HUNGER.

If want of appetite should pass into the opposite state, I mean an excessive atrophy, called bulimos, we must resuscitate such persons with roasted pork, or kids, and other savoury things; and, in a word, with every strong-scented thing, if the acute stage of the fever be past. We must bind the extremities, and rouse, by pinching the cheeks, and pulling the hair and ears. When recovered, we must give bread that has been dipped in diluted wine, or any other diffusible thing.

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COMMENTARY. According to Galen, bulimos is occasioned by a want connected with atony, and coldness of the stomach. (De Caus. Sympt. i, 7.) Alexander, on the other hand, says, that it arises from inordinate heat and weakness of the stomach. He informs us that the vulgar practice consisted in giving fragrant things, binding the extremities, rousing by pinching, giving bread soaked in wine, and, in short, administering every thing calculated to cool and strengthen the body. Others, he says, give opium in cold water, in order to extinguish the heat of the stomach. However, he disapproves of all these things, and recommends food of difficult digestion. He relates the case of a woman affected with bulimia who was cured by having a purgative powder given to her, which occasioned the discharge of a worm more than twelve cubits long. (vii, 6.)

Aëtius and Oribasius adopt the theory of Galen, and recommend nearly the same treatment as our author. Aëtius also directs us to apply over the stomach cooling cataplasms made of dates, quinces, or polenta, boiled in diluted wine.

Serapion remarks that bulimos is distinguished from the canine appetite, by the desire in the former complaint being for proper articles of food, whereas, in the latter, it is for depraved or improper food. His treatment in most respects is like our author’s. He also recommends a mixture of old odoriferous wine, camphor, and lignum aloes. (ii, 11.)

Avicenna and Haly Abbas agree with Galen in stating that bulimos is connected with a cold intemperament of the stomach, whereby the sensibility and attractive power of the stomach are diminished. Their treatment in principle is quite similar to our author’s. In extreme cases they agree with Galen in recommending the theriac. One of Rhases’ authorities recommends cardamom, cubebs, and the like. (Cont. xi.)

The classical reader is referred to Callimachus for a grand poetical description of Bulimia. (Hymnus in Cererem.)

SECT. LII.—ON THE CANINE APPETITE.

Although this symptom seldom occurs during fevers, it sometimes does afterwards; and, since it is allied to loss of appetite, as being the opposite extreme, it will not be improper to treat of inordinate appetite, both of them being in excess. Since, therefore, this affection is generally occasioned by an acid phlegm, we must use those things which will divide and dissipate it. Such, in particular, are all sweet and saline things, and those which are called heating detergents. We must, therefore, give largely of the heating wines. Such are the yellow in colour, and those which are red without being styptic. We must also give them the sweeter kind, although they should not be thirsty. When they come to dinner, we must give them first all fatty things, and everything beside which is prepared with much oil, and has no austere or astringent property. These, although they should not overcome the cause of the complaint, at all events, destroy the insatiable desire of food; but abstinence from them lessens the collection of phlegm in the stomach. We must also give pickles, and after them, plenty of the afore-mentioned wines to be drank. By persevering with these things for some time, the complaint subsides.

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COMMENTARY. According to Galen, one of the causes of the canine appetite is an acid cacochymy, and another is an immoderate evacuation of the whole body, occasioned either by strong heat or weakness of the retentive faculty. (u. a.) Hippocrates recommends the liberal use of wine, in one of his Aphorisms (ii, 21); and Galen, in his Commentary on the same, states that the wine should be tawny-coloured or red, and devoid of astringency. In another place, he directs us to purge away the offending humour with the hiera of aloes. (De Med. sec. Locos. viii.)

Our author borrows part from Oribasius. (Synops. vi, 34.)

Alsaharavius recommends the same plan of treatment as the Greeks, when the disease is connected with a cold intemperament; but when with a hot, he directs us to have recourse to bleeding, cold fruits, and cooling applications over the stomach. (Pract. xvi, 11.)

Rhases and Avicenna approve in general of our author’s plan of treatment, to which, however, they suggest some improvements: when the cause of the complaint is an acid phlegm, they direct us to give fatty things, with mustard, pepper, garlic, and the like. When connected with black bile, they approve of bleeding. When it arises from worms, they, of course, approve of anthelmintics. Sarac, one of Rhases’ authorities, recommends emetics and purgatives, with a cupping instrument applied over the stomach. (Contin. xi.)

Serapion’s treatment is entirely like our author’s. (ii, 10.)

SECT. LIII.—ON THIRST.

A protracted thirst may be supposed to be occasioned by dryness, or heat of the parts, by which liquids pass from the mouth to the stomach; and the natural cure of dryness is sleep, and of heat, watching. Some become thirsty from wine, or the heating nature of their food, in which case, the proper cure is cold drink. But some desire drink of a bad quality, as they do food corresponding to the prevailing cacochymy. I have known persons seized with unquenchable thirst, of which they died, who had eaten of the vipers called dipsades, and others who had got drunk upon old wine; and also persons on board of a ship, who, when their fresh water failed them, had drunk of sea-water, have all died. Febrile thirst may be mitigated, by pouring upon the head the coldest oil, or rose oil. But the best remedy for thirst is the seed of the black lettuce, chewed, or the liquorice; or, seed of the cucumber may be retained in the mouth. Give also the following pill, called adipson: Of garden cucumber, dr. viij; of tragacanth, dr. iv; dissolve the tragacanth in the white of fresh eggs, and when dissolved, add to the pounded seeds of the cucumber; and when softened, form pills, which dry in the shade. Give one of these pills to hold below the tongue, and drink the fluid of it as it dissolves. Give also, to swallow, the decoction of quinces, or of pears, or of medlars, or of the tendrils of the vine, or the juice of the pomegranate.

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COMMENTARY. The greater part of this Section is taken from Galen (de Caus. Symp. l. c.), who, as usual, handles the subject very philosophically. Oribasius treats of it in nearly the same terms as our author. (Synops. vi, 37, 38, 39.) Aëtius remarks that there are two causes of thirst, a want of humidity, or a redundance of heat. In fevers, then, both these causes cooperate to occasion thirst; for there is excess of heat originally, and dryness comes on owing to the fluids of the body being consumed by the febrile heat. (v, 119.)

The question was keenly agitated in the ancient schools of medicine, whether cold drink might be safely given in fevers. Hippocrates was a great advocate for this practice, giving his patients barley-water and acidulated draughts very freely at all periods. Asclepiades, on the other hand, as Celsus and Alexander inform us, forbade even to wash the patient’s mouth with water during the first stage of a fever. Celsus is disposed to hold a middle course between these opposite methods of practice. He particularly approves of washing the mouth and fauces frequently with cold water, because, as Erasistratus had properly remarked, these parts often required cold liquids, while the internal parts are not in want of them. Philumenus (ap. Aëtium) also strongly recommends gargles, but forbids cold drink freely until after the acme of the fever. Alexander informs us that the celebrated Archigenes allowed his patients the free use of cold water and acidulated drinks. He himself does not speak very decidedly for or against this practice, but, upon the whole, is disposed to think well of it, unless there be inflammation, hardness, or swelling anywhere. He approves, however, of cold applications externally: and, accordingly, directs us to apply to the region of the stomach a bladder filled with cold water, ice, or some cooling decoction.

Of the Arabians, Serapion expresses himself most decidedly in favour of cold drink. Avicenna forbids much to be given at a time. See also Haly Abbas (Pract. iii, 22); Alsaharavius (Pract. xvi, 14); Averrhoes (Collig. vii, 24); and Rhases (Contin. xxx.)

The pill mentioned in the end of the Section is from Dioscorides.

Prosper Alpinus represents the Methodists to have disapproved of the free use of cold water in fever. (Med. Meth. vi, 7.)

The highest of the ancient authorities, as for example, Galen, Avicenna, and Averrhoes, agreed in allowing wine, much diluted with water, in fevers. Galen says, the wine should be attenuant and of a light colour. According to Avicenna, wine thus plenteously diluted with water is preferable to plain water, as it promotes perspiration.

Fabius Paulinus gives an admirable exposition of the philosophical doctrines of the ancients on this subject. He remarks that there are three distinct species of thirst. The first is occasioned by the fauces and œsophagus being drier or hotter than natural. This state, if it supervene upon sleep, is to be cured by watchfulness, or vice versa. In the second, the veins over the whole body are filled with hot and acrid humours. In the third, the mouth of the stomach, lungs, or heart are preternaturally hot or dry. (Marc. Prælect. 315.)

SECT. LIV.—ON THE ROUGHNESS OF THE TONGUE.

We may moisten asperity of the tongue, by making the patients retain in the mouth a decoction of linseed. But it will be more efficacious if sebesten plums be boiled with the linseed. Having immersed the finger in this liquor, and rubbed the tongue with it, let them rinse the mouth with clear water, or let them clean it with a sponge, and then anoint it with rose oil. And the oil of roses mixed with honey also answers well. Likewise the juice of the purslain retained in the mouth, and the sumach used for condiments, when mixed with honied water, have a good effect. Damascenes, also, and the bones of the sebesten plum retained in the mouth, and rolled on the tongue, and the stem of the lettuce, answer well. Archigenes says, that the Indian salt, which, in colour and consistence is like the common salt, but which resembles honey in taste, when chewed to the size of a lentil, or, at most, of a bean, moistens greatly. They should lie upon the side (for lying upon the back dries greatly), and they ought to keep the mouth shut, because keeping it open allows the moisture to dry up. Sneezing properly produced, moistens the tongue more effectually than any other means.

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COMMENTARY. This Section is taken from Oribasius. (Synops. vi, 43.)

Aëtius recommends nearly the same treatment. He also states, that when the roughness of the tongue is difficult to remove, it may sometimes be accomplished by rubbing it with the fat of fowls or with fresh butter. (v, 118.)

Cælius Aurelianus directs the tongue to be cleaned with a sponge squeezed out of hot water. Avicenna recommends for this purpose an instrument called chaizaran, and also directs us to use sugar, or a sponge with a small quantity of salt and rose oil. He likewise makes mention of the salt brought from India, possessing the colour of salt and the taste of honey. (iv, 1, 2, 22.) The Pseudo-Dioscorides recommends mint triturated with honey, red sumach, and rose oil with honey, or by itself. (Euporist. ii, 18.)

Prosper Alpinus held that the Indian salt, mentioned by our author and Avicenna, was the same as our sugar. But this opinion was controverted by Carolus Arantius, (Baptista Fieræ Cœna.) Sprengel, accordingly, maintains that the Greeks and Romans were utterly unacquainted with our sugar. (Rei Herb. Hist., and Notæ in Dioscoridem, ii, 104.) The mel arundinum appears, in fact, to have been a natural concretion, and it was most probably the same as the Indian salt. See Dr. Milward’s Letter to Sir Hans Sloane. The cane from which the ancient sugar was procured is now called by botanists the bambusa arundinacea, or bamboo cane. See Book First, 96.

SECT. LV.—ON NAUSEA.

When nausea comes on without being produced artificially, it is a clear inference that noxious humours are vexing the stomach. Some feel uneasy, but vomit nothing, the humour being retained in the coats. When the humours are pituitous, we must get them concocted by rest, spare diet, and sleep. But the thinner may be ejected by vomiting, produced either with the juice of ptisan, or with honied water. But those which are viscid and thick, stand in need of attenuant remedies, such as oxymel, and the like. But, when a noxious fluid is detained in the coats, the powder from aloes, called picra, is beneficial, but astringents are pernicious; whereas, if there be much fluid, but not of a noxious kind, astringents will be beneficial, but the aloetic medicine will bring on marasmus. When cold is joined to humidity, we must mix calefacients with astringents. The symptom of the affection being of a cold nature is that there is no thirst, nor sensation of heat.

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COMMENTARY. Oribasius recommends the same treatment. (Synops. vi, 40.) Our author appears to have condensed the lengthy account given by Galen and Aëtius. (ix, v.)

Alexander also treats of the subject at great length, but we can only afford room for a few extracts. When the nausea arises from plethora, he directs bleeding; and when the plethora is connected with vitiated humours, he recommends both bleeding and purging. When bilious or melancholic humours occasion the nausea, he recommends dilution at first by giving tepid water or the like, and then evacuations of them by purging or emetics. When the humour is an acrid or sweet phlegm, he recommends oxymel, radishes, and the like. When a serous and thin humour is impacted in the stomach, he evacuates it by procuring vomiting with tepid water or ptisan. (vii, 13.)

Serapion appears to have copied from our author. (iii, 5.) See Avicenna (iii, xiii, 5, 8.) Rhases applies over the stomach a cold plaster with snow. When the nausea is oppressive, he promotes vomiting with tepid water. (Cont. xi.)

SECT. LVI.—ON VOMITING OF BILE.

To those who vomit bile, a cataplasm must be applied, made of dates, the rind of pomegranate, and gall, boiled in wine or oxycrate, along with pounded bread. And acacia, hypocystis, and the flowers of the wild pomegranate and sumach, ought to be added to the cataplasm. A cupping-instrument also, when applied with a strong heat, is of great service. Food ought to be given frequently in small quantities. To those who vomit black bile and have the stomach inflated, apply sponges soaked in hot vinegar of the most acrid qualities, or a cataplasm of the leaves of the ivy boiled in wine.

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COMMENTARY. This is taken from Oribasius (Synops. vi, 41.)

Alexander states that the proper remedies for vomiting occasioned by a redundance of bile are diluents and refrigerants. He recommends internally ptisan, lettuces with a small quantity of vinegar, &c. For drink, he particularly approves of cold water, but forbids much to be given at a time. When the strength fails, he permits a small proportion of hydromel, wine, or the like, to be added to the water. In certain cases, when the patient is troubled with insomnolency, he directs us to add the heads of poppies to his drink. He also recommends external applications possessed of tonic, cooling, and repellent properties. (vii, 17.)

Serapion recommends us not to interfere with a critical vomiting. When it is continued, he directs us to give clysters and gentle purgatives at first, and afterwards vegetable acids and astringents. When these remedies fail, he directs us, if the strength be good, to bleed from the arm. He also makes mention of external applications, possessed of astringent and refrigerant properties. (iii, 15.) Haly Abbas, in like manner, cautions against stopping a critical vomiting. (iii, 24.) Alsaharavius prescribes draughts of tepid water at first, and afterwards the infusion of wormwood or of aloes. He also recommends external applications of a strengthening nature. (Pract. xvi, 20.) Avicenna’s plan of treatment appears to have been copied from our author’s. (iv, i, 2.) Rhases recommends acid drinks, such as the decoction of pomegranates and the like. (Cont. xi.)

According to Prosper Alpinus, the treatment of the Methodists consisted in administering sub-acid fruits, the juice of wormwood or of mint in wine, and in applying externally tonic epithemes, containing sumach, galls, mastich, and the like. (Med. Meth. xii, 11.)

SECT. LVII.—ON HICCOUGH.

Singultus is occasioned either by fulness, or emptiness; or by the presence of acrid and pungent humours in the stomach, and when they are vomited, it ceases. And many, if they only take the medicine composed of the three kinds of pepper, and drink wine immediately after, have hiccough. And it is well known that many people hiccup when the food spoils on the stomach. Many also hiccup from rigors. We will find an emetic a proper remedy in cases which are occasioned by fulness or pungency, and warmth in those from cold; and, when the complaint is occasioned by a plethora of humours, there is need of strong evacuation. This may be accomplished by sneezing, but when emptiness is the cause, sneezing will not cure it; for in such cases, we must give rue with wine, or nitre in honied water, or hartwort, or carrot, or cumin, or ginger, or calamint, or Celtic nard. These are the remedies for such cases as are occasioned by corruption of the food, cold, or plethora. When a redundance of cold and viscid humours is the cause, give castor to the amount of three oboli to drink in oxycrate, and the same thing will be of use when applied externally to the skin, along with old Sicyonian oil. The vinegar of squills or oxymel may also be drunk with advantage. Retaining the breath is likewise of great use.

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COMMENTARY. This Section is copied from Oribasius (Synops. vi, 42.)

According to Galen’s explanation, hiccough is occasioned by any exciting cause which rouses the stomach to violent emotions. He states that sneezing proves a cure to it. (De Caus. Sym. iii, 6.) Celsus says, in like manner, ‘Singultus sternutamento finitur.’ He states that frequent and unusual hiccuping is symptomatic of an inflamed liver. (ii, 7.) Aëtius, in like manner, says that singultus in fevers often arises from inflammation of the stomach and neighbouring parts. He treats of the complaint at great length. When it arises from pungent humours, he gives first emetics, and afterwards narcotics, such as opium, &c. He also applies a cupping instrument with great heat to the breast, stomach, and back, in certain cases. (ix, 5.)

Alexander gives an interesting account of this affection, for which he recommends various remedies. When connected with inflammation of the stomach or liver, he begins with bleeding. When it is occasioned by thick and viscid humours, he recommends an oxymel of squills, the composition of which he minutely describes. He also speaks favorably of emetics. When the humours are of a pungent nature he approves of diluents and the drinking of tepid water. Sometimes, he adds, he has known a draught of cold water prove effectual. (vii, 15.)

When singultus is connected with a cold cause, the author of the ‘Euporista,’ ascribed to Dioscorides, recommends us to put the feet into hot water, to take tepid draughts, and apply hot fomentations to the stomach. (ii, 4.)

Though there is perhaps nothing original in the views of the Arabians, they treat of hiccough very fully and accurately. Among the causes of it, mentioned by Alsaharavius, is inflammation of the stomach and liver, in which case he recommends venesection. When connected with excessive heat of these parts, he approves of cold air, cold drink, and refrigerant draughts, containing prunes, tamarinds, camphor, &c. (xvi, 18.) The causes of hiccough, according to Serapion, are evacuation, repletion, pungent and cold humours. His remedies are emetics, calefacients, and attenuants, which are to be directed according to the nature of the exciting cause. (iii, 17.) See also Avicenna (iii, 13, v, 25); Rhases (Divis. 62, ad Mansor. ix, 65, Cont. xi.) Rhases recommends calefacients, such as cumin, pepper, rue, and the like, in vinegar. He also approves of emetics and laxatives.

Prosper Alpinus says that the ancient Methodists approved of oily emetics. (Meth. Med. vi, 8.) It will be remarked, that our author states that many persons are seized with hiccough if they take peppers with wine. Prosper Alpinus mentions that they had this effect on him (de Præs. V. et M. ægr. iii, 9); and I have further to state the same of myself.

Rogerius, probably copying from Rhases (for the practice of the earlier modern physicians is mostly borrowed from the Arabians), recommends principally calefacient, attenuant, and carminative medicines, mixed with gentle laxatives, such as prunes. (iii, 21.)

SECT. LVIII.—ON CONSTIPATION AND LOOSENESS OF THE BOWELS IN FEVERS.

Those things which remedy a dry state of the bowels are treated of in the First Book sufficiently. But since a humid or loose state of the bowels may prevail in fevers, this also must be treated of; for many are cut off not by the fever itself, but by this symptom alone. In the commencement, we must not interfere with the discharge when it proceeds from corruption of the food and indigestion; but when the evacuation becomes immoderate, it must be restrained. If the discharges are of an acrid nature, that which is given should consist of good juices, and be otherwise thick, such as spoon-meats from pearl-spelt (chondrus) and ptisan. Baths are also befitting after the complaint has become concocted. But when the discharges consist of phlegm and are watery, on the other hand, the food ought to be of a more dry and heating nature, as far as the fever will permit. Of this kind, are those things which are prepared from heating condiments. But they must abstain from baths, unless otherwise required. When the digestive faculty is in an atonic state, we must give food and applications of an astringent nature; the food consisting of things in particular, to which pomegranates, apples, pears, or medlars have been added, or these fruits themselves, and thin fragrant wine of an astringent quality; and the applications are to be cataplasms made of polenta, and dates, and wormwood, roses, myrtles, and such like things. It must be considered also, to what part these cataplasms are to be applied, I mean the region of the stomach, the lower belly, or perhaps the loins. Bloody discharges are restrained and dried up by remedies containing fine flour of polenta, with frankincense, or manna mixed with wine, or oxycrate. When the watery discharge is acrid, it must be sweetened by a lavement either with water alone, or the juice of ptisan, or of chondrus, or rice, or tragum, not once, but often; and afterwards there are to be added dried roses, or myrtles, and sometimes galls; and an egg with rose oil, and a thin astringent wine, or the decoction of roses, may be injected or applied to the anus, which will blunt the desire of going to stool. But when the calls are frequent, a clew formed of warm threads may be applied to the anus.

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COMMENTARY. Galen forbids venesection when the fever is complicated with diarrhœa. (Therap. ad Glauc. i.)

When the body is constipated, Celsus recommends laxatives, diuretics, and sudorifics. He adds, it may also be proper to let blood, practise gestation, enjoin abstinence from food and drink, and keep the patient from sleeping. He likewise recommends the bath, both of tepid water and of oil. When the bowels are loose he enjoins rest and sleep, gives medicines to restrain sweating, and forbids all exercise except gentle gestation. He also directs us to excite vomiting by copious draughts of tepid water, unless the complaint be of long standing, or there be pain of the throat, præcordia, or side. (iii, 6.)

Alexander forbids narcotics, unless in cases of extreme urgency. Avicenna joins him in laying down this injunction, and otherwise directs us to treat the diarrhœa febrilis upon general principles. (iii, 16, 1, 4.) Haly Abbas treats fever, when complicated with constipation, by giving gentle laxatives, such as prunes and tamarinds, or, if these prove injurious to the stomach, by administering clysters. When the diarrhœa is complicated with a discharge of blood, he approves of adding to the other medicines Armenian earth, purslain, sumach, or such like astringents. (Pract. iii, 24.) See Serapion (iii, 17); Rhases (Divis. 67.)

According to Prosper Alpinus, the ancient Methodists approved of astringent applications and astringent clysters for febrile diarrhœa. (Med. Meth. vi, 10.) Sydenham and Van Swieten agree with Alexander and Avicenna in forbidding to stop diarrhœa in fevers by means of opiates, unless in extreme cases.

SECT. LIX.—ON TRICKLING OF BLOOD AND HEMORRHAGE FROM THE NOSE.

Since a trickling of blood indicates a fulness in the whole body, or in the head, being occasioned either by expression or contraction, and as a free evacuation would relax them, and diminish the quantity, it may be proper to evacuate where nature points. With this view, I have ventured, in cases of quartan epistaxis, to open the vessels in the nostrils with the reed called typha. We must not be contented with a small evacuation, but must take away blood in proportion to the strength. Spontaneous hemorrhages from the nose in fevers, when critical, are not to be interfered with; but yet, if the flow of blood be immoderate, it ought to be restrained. In the first place, tight ligatures ought to be applied to the patient’s extremities, and his head elevated. It would appear that a ligature to the privy parts, is particularly adapted for restraining bleeding from the nose. The nostrils ought not to be wiped, nor the part irritated, so that a clot of blood may be allowed to form. Let the nose be cooled by a sponge soaked in oxycrate, and the nostril plugged up with a pledget dipped in some of the astringent applications. The composition of them, and the rest of the treatment, we will deliver more fully in the following Book, “on topical affections.”

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COMMENTARY. Hippocrates declares that profuse bleeding at the nose indicates a disposition to convulsions, which venesection is calculated to remove. (Prædict. i, 21.) Galen, in his Commentary, remarks that the convulsions are brought on by the unseasonable use of cold applications to stop the hemorrhage. He strongly recommends bleeding from the arm of the side from which the blood flows. In another place, he states that epistaxis in acute fevers is an unfavorable symptom. (In iii, Epidem. Comment.)

Aëtius mentions that Hippocrates had declared a bleeding from the nose on the fourth day of a fever to be a very bad symptom. He recommends encouraging the bleeding by irritating the nostrils with a stalk of grass. Our author, it will be observed, directs this operation to be performed until the typha, a species of grain several times mentioned by Theophrastus (Hist. Plant.); by Galen (de Aliment. i, 13); and by Alexander Trallian (vii, 5.) Sprengel makes it to be a species of secale or rye; but Stackhouse, the English editor of Theophrastus, is of opinion that it was the triticum spelta, or spelt.

When it is judged proper to restrain the hemorrhage, Avicenna recommends ligatures to the extremities and cold and styptic applications to the nose and adjoining parts, (iv, i, 2, 14, and iii, v, 1.) Serapion agrees with most of the ancient authorities in commending a mixture of frankincense and aloes, when applied on the down of a hare. He also directs us to apply a sponge soaked in cold water to the temples and forehead. (ii, 13.) When bleeding at the nose occurs in a fever, Rhases forbids us to stop it, unless it prove excessive; in which case, he directs us to apply a cupping instrument, without scarification, to the hypochondrium; to tie ligatures about the testicles; to pour cold water on the head; and to drink cold water. (Divis. 40.)

Considering how full and accurate our author and the others are in treating of the complications of fever, it is singular that they should all have passed by a profuse discharge of blood per anum, although it had been noticed by Hippocrates. In one of his Aphorisms he says: “When, in cases of fever, there is a quantity of blood discharged, the bowels get into a loose state.” His commentators Theophilus and Damascius say, in explanation, that the natural heat of the intestines being wasted by the discharge of blood, they lose their power of retention. (Ed. Dietz, ii, 401.)

SECT. LX.—ON DELIQUIUM ANIMI OR SWOONING.

When the fainting is occasioned by cholera, diarrhœa, or other repeated and copious evacuations, we must sprinkle water upon the patient, twist his nose, rub over the orifice of the stomach, and encourage vomiting; and we should also irritate the throat with our fingers or the introduction of a feather. Several strong ligatures are likewise to be applied; when the evacuations are downwards, to the arms; and, when upwards, to the legs. The patients are also to be placed in an easy, erect posture, and a cupping-instrument applied, so as to produce revulsion to the opposite part of the body. Wine and water relieves prostration of strength occasioned by frequent evacuations, provided there be no inflammation of any visceral part, nor violent headach, nor delirium, nor ardent fever unconcocted, to contra-indicate it; for in such cases wine will do much mischief. And if it be summer, and the patient of a hot temperament, and addicted to drink cold things, we may give cold drink; but if the contrary, warm. When the deliquium is occasioned by profuse sweats, we are to constrict the skin, as formerly said, and allow a free current of cool air. In defluxions on the stomach, none of these things is fitting, unless the application of strengthening things to the belly and stomach, and bathing them; for baths are most beneficial in cases of stomach defluxions, but greatly aggravate hemorrhages and sweatings. Those who have fainting fits from plethora, must abstain from wine, and food, and from baths too, if there be fever. And we must give them honied water having thyme, marjoram, pennyroyal, or hyssop boiled in it. Oxymel also is beneficial to them. But if the faintings proceed from depraved humours contained in the stomach, we must prescribe a vomit with water and oil—at the same time tickling the throat with the finger or a feather. But if vomiting cannot be thereby procured, we must give pure oil, which will often evacuate downwards. And wormwood is applicable in such cases. But if the faintings are occasioned by weakness of the stomach, we must use tonic medicines, as formerly stated in the Section which treats of this affection, and rub the extremities. When they proceed from exposure to immoderate heat, we are to prescribe the bath; or, when from excessive cold, we must use the medicine containing the three peppers, and pepper itself. Those who fall into fainting fits owing to great heat, or insolation, or from remaining long in the bath, may be cured by being sprinkled with cold water, and exposed to the wind; by having their stomach rubbed, and getting wine and food. But if the swooning be occasioned by the greatness of the inflammation, or bad nature of the fever in the attacks, and if the patient is cold, we ought to rub his limbs strongly, chafe him, apply ligatures, force him to keep awake, and abstain from food. And these things are to be done previous to the paroxysm. But those who have faintings from dryness, should get for food two or three hours before the paroxysm either the juice of chondrus, or bread out of water, along with the kernels of the pomegranate, or apples, or pears. But if great danger be anticipated, we must also give wine. Those who have sudden attacks of fainting are to be thus treated. And in all cases we are to find out the cause of the deliquium, and direct our attention to it. And sometimes the greatest care must be bestowed upon this symptom, which threatens danger, or death itself.

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COMMENTARY. Nearly the same account of deliquium animi in fevers is given by Aëtius (v, 101 et seq.), and by Oribasius (de Morb. Curat. iii, 7.) But all these authors are, in fact, indebted to Galen. (Therap. ad Glauc. i.) Aëtius thus states the distinction between syncope and deliquium: “Deliquium makes its attack suddenly, depriving the person of sense and motion, but is not necessarily accompanied with sweats; but syncope seizes upon persons both when asleep and when awake, and is necessarily attended with sweats, called syncoptic.”

Alexander delivers a full account of the subject; but his principles of treatment scarcely differ in any respect from those of Galen. (xii, 13.)

Haly Abbas directs us, when the deliquium proceeds from a defluxion of humours upon the stomach, to apply ligatures to the extremities, to dash water on the face, to fan it, and to give vinegar and pepper. He recommends us to prevent sleep, which has a tendency to extinguish the powers of the primary viscera, by occasioning a determination inwardly. When it proceeds from dryness, he directs us to give wine, the decoction of quinces, of apples, and the like. If it happen at the commencement, he recommends a piece of bread soaked in wine to be given. (Pract. iii, 25.)

The Arabians in general do not acknowledge the distinction between syncope and deliquium. See Averrhoes (Colliget. vii, 16); Serapion (vi, 19); Rhases (ad Mansor. x, 13.)

Avicenna seems to point at the distinction, but it is not perceived by his translator. Rhases recommends the same treatment as Haly Abbas. He approves of hot wine, food of easy digestion, sprinkling of the face with cold water, and the application of ligatures to the extremities. (Contin. xxxi.)

SECT. LXI.—ON THE TREATMENT OF ULCERATION UPON THE OS SACRUM.

This affection occurs most frequently in protracted fevers, owing to the patients having been long confined to bed. When, therefore, the part begins to appear red, we make a circular piece of wool, of the proper magnitude, and lay it below the part, and afterwards prepare a rose or myrtle cerate, containing litharge or ceruse, and apply it. When there is inflammation, we may use a cataplasm of bread, with nightshade, or knot-grass, or plantain, or tender cabbage. But if the ulceration be spreading, we are to use a cataplasm of dried lentils, along with the inner rind of the pomegranate.

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COMMENTARY. This Section is taken from Oribasius (Synops. vi, 44.)

Aëtius remarks that, in prolonged fevers, the fleshy parts of the body being wasted, ulceration takes place in those parts upon which the patient lies. These sores, he adds, spread deep, and have hard thick edges. When the back becomes red and painful, he directs us to surround the adjoining parts with a circle of wool, so as to relieve the affected part from the effects of pressure; and then a cerate of rose or myrtle oil, containing litharge, ceruse, and burnt barley is to be applied. He particularly commends a composition consisting of litharge, oil, wax, and honey, mixed with rose-oil. In short, his plan of treatment, like our author’s, is borrowed from Oribasius. He concludes with directing the use of milder applications when the ulceration has stopped spreading. (v, 127.)

Alsaharavius directs us to treat the redness of the back occasioned by lying long in bed with the flower of millet, barley, or lentils. When pustules form and break, he recommends an ointment containing ceruse to be applied. (Pract. xxix, 1, 26.)

Appendix to the Commentary on Book Second.

ON SMALLPOX AND MEASLES.

The reader, we are sure, would be disappointed, if we were to quit the subject of Fever without touching upon the history of Smallpox and Measles. We will, therefore, conformably with our general plan, give a brief abstract of the descriptions of these diseases which we meet with in the works of the ancient physicians. In the first place, then, we may mention that, after having read, we may say, every word of every ancient writer on medicine that has come down to us, we can confidently affirm that the Greeks and Romans are altogether silent on the subject, and that we are indebted to the Arabians for the earliest accounts which we have of these diseases. Rhases, indeed, pretends (provided the Introduction to his ‘Treatise on Smallpox’ be not spurious) that Galen had delivered some imperfect descriptions of smallpox; but he would appear to have been led into this mistake by following some inaccurate translation of the works of Galen into the Syriac language; for no passages which would justify the interpretation which Rhases puts upon them are now to be found in the original. Lately, Dr. Bateman attempted to show that allusions to measles and smallpox are to be met with in the works of several of the Greek authors; but we entirely agree with Drs. Mead and Freind, who maintain the contrary. In an Arabian MS. preserved in the University of Leyden, it is stated that the smallpox and measles first appeared in Arabia about the year 572, P.C. See Reiske (Opuscula Medica, p. 10.)

Although Rhases be the most ancient writer whose account of smallpox and measles has come down to us, he does not pretend to have been the first of his countrymen who had noticed them, but gives extracts from the works of the elder Mesue, the elder Serapion and Aaron, wherein mention is made of them. According to Rhases, the common cause of smallpox is a fermentation in the blood; and hence the disease is most apt to seize children, whose blood is hotter than that of other persons. He was well aware, however, that the disease is capable of being propagated by contagion, for he ranks the pestilential fever or smallpox among the diseases “qui transeunt ab uno ad alios.” The symptoms, as described by him, are, continued fever, pain in the back, itching at the nose, disturbed sleep, and afterwards redness and fulness of the face, pain of the throat, difficulty of breathing, dryness of the mouth, thick spittle, hoarseness, headach, inquietude; and these symptoms are followed by the characteristic eruption of the smallpox or measles; but in the case of the latter there is more anxiety of mind, sick qualms, and heaviness of heart; and in that of the former there is more pain in the back, heat, and inflammation of the whole body, especially in the throat, with a shining redness. He then lays down the rules of treatment. He directs us to bleed from the arm at the commencement, provided the patient be more than fourteen years old, but by a cupping instrument if he be younger. He forbids us, however, to abstract blood after the eruption is come out. He allows light kinds of animal food, with acids; and for drink he recommends water cooled with snow, or cold spring water, or some diluent and acid draught, such as barley-water acidulated with pomegranate juice. Aaron, one of his authorities, forbids, however, the administration of cold water when the eruption is coming out. He directs the chamber to be sprinkled with cold water, and even at a certain stage permits the patient to go into the cold bath. He recommends abstinence from new milk, wine, dates, honey, mutton, beef, shell-fish, and all high-seasoned and heating things. The rest of his general treatment we need not give in detail. Suffice it to say, that the medicines recommended by him are, for the most part, vegetable acids and astringents. Upon the whole, the earlier part of his treatment consists of bleeding, cold drinks, and acid draughts. For hastening the eruption, when that is desirable, he directs us to wrap up the patient closely in clothes; to rub his body all over; to keep him in a room not very cold; to give him some cold water to drink; to put on a double shirt; and to place near him two small basins of very hot water, one before and the other behind him, so that the vapour may be diffused all over his body, except the face; but he prudently directs us not to allow the moisture to cool upon the body, but to get it carefully wiped off. All furnaces and hot baths he condemns, as overheating and weakening. He very much commends figs for promoting the eruption. He afterwards gives very minute directions about the treatment of particular parts, such as the eyes, the throat, and the nose. For the eyes, he recommends various astringent lotions or collyria, such as galls and rose-water, sumach, pomegranate rind, &c. The care of the throat he justly holds to be a very important consideration, and recommends bleeding when there is acute pain, and gargling with cold water, or with astringent decoctions, such as those of acid pomegranates, sumach, and the juice of mulberries. When the pustules on the limbs are large, he directs us to open them; and when there is great pain in the soles, he recommends them to be rubbed with warm oil, or the feet to be put into hot water. When the pustules seem to stand in need of ripening, he directs the body to be fomented with the steam arising from a hot decoction of chamomile, violets, and the like; and, when too humid, the patient is to be laid on pounded roses, rice-meal, or millet seed. For removing the scabs and eschars, he recommends us to rub them with the warm oil of sesame, or oil of pistaches; but the larger are to be cut off carefully without any application of oil. For removing the specks on the eye he recommends many stimulant collyria, containing antimony, verdigris, sal ammoniac, tutty, camphor, &c. For removing cicatrices or marks on other parts of the body, he mentions various applications, containing litharge, bastard spurge, &c. When the belly is loose, either in smallpox or measles, which, as he remarks, is commonly the case on the decline of the fever, he recommends abstinence from all laxative things, and commends barley-gruel, to which the meal of pomegranate seeds may be added; or, if the looseness increase, gum arabic, &c. may be added to the drink. He adds, that it sometimes happens that the bowels require to be opened, and he directs this to be done by means of myrobalans, prunes, and the like. When in measles there is much appearance of vitiated bile, he directs the discharge of it to be promoted. He points out the difference between distinct and confluent smallpox; and remarks that the latter is far more dangerous than the other. He also correctly states that when, in measles or smallpox, the eruption is suddenly determined inwardly, it is a fatal symptom. He all along inculcates that measles and smallpox are nearly allied to each other.

Georgius, one of the authorities quoted in his ‘Continens,’ says that measles arise from blood mixed with much bile, and smallpox from gross blood mixed with much humidity. He states that the danger is proportionate to the pain in the throat and difficulty of breathing. The elder Serapion, as quoted by him in the same work, directs, if it is the winter season, the wood of tamarisk, &c. to be burned beside the patient.

In his work ‘Ad Mansorem,’ he recommends nearly the same treatment as that which we have been detailing from his Tractatus on Smallpox; but does not speak so decidedly in favour of cold drink.

Avicenna’s description of smallpox and measles is very similar to that of Rhases. He confidently pronounces them to be contagious diseases. He states correctly, that when smallpox proves fatal, it is usually from the affection of the throat, or from the bowels becoming ulcerated. Sometimes, he adds, the disease superinduces bloody urine. He agrees with Rhases that measles is a bilious affection, and that it differs from smallpox only in this, that in the former the morbific matter is in smaller quantity, and does not pass the cuticle. His treatment also is little different. At any period during the first four days he approves of venesection, but forbids it afterwards. He recommends cooling and diluent draughts prepared from tamarinds and the like. He prescribes figs to facilitate the eruption of the pustules, and forbids cold drink after they begin to come out. When the pustules are large and fully formed, he approves of letting out their contents with a gold needle. His treatment of the throat, eyes, belly, and hands is nearly the same as that recommended by Rhases. When ulcers are formed after the falling off of the eschars, he directs them to be dressed with the white ointment, composed of ceruse and litharge. (iii, 1, 4.)

Serapion’s account of smallpox and measles, as is remarked by Haly Abbas, is very defective. He treats of them along with apostemes, and his description of the symptoms is far from being accurate.

Avenzoar, in his Treatise on Epidemical Diseases, treats incidentally of measles and smallpox, for the cure of which he recommends principally gentle purgatives, such as tamarinds, with cooling and acid drinks. (iii, 3, 4.)

Alsaharavius also mentions them briefly among the pestilential diseases; but his description of them is not to be compared with that of Rhases.

According to Haly Abbas, variola is produced either by external causes, such as a pestilential state of the atmosphere, or from respiring the air of a place which has been tainted with the effluvia from the pustules of persons affected with the disease; or it may arise from an ebullition of the blood when it is loaded with gross humours which nature endeavours to cast outwards. He then briefly describes several varieties of the disease, differing from one another in degrees of malignity; and among them he ranks rubeola, which is occasioned, he says, by a hot thin blood, and is not of a bad nature. In it, he says, the eruption, when at its height, resembles millet seeds, or is somewhat larger, the colour is red, and the pustules discharge nothing. The precursory symptoms of smallpox are fever, swelling of the face, itching of the nose, inflammation and redness in the face and other members, heaviness of the head, and roughness of the throat. (Theor. viii, 14.) With regard to the treatment of variola and rubeola, he recommends venesection during any of the first three days; or, if the patient be a child, he directs us to apply a cupping instrument to the back. The patient is then to be made to drink barley-water in which jujubes and sebesten plums have been boiled; syrup of poppies is to be added, if the cough be troublesome, or the pain of the throat severe; and spoon-meats prepared with spinage, orach, and the like, are to be given. When the eruption does not come properly out, he recommends a decoction of fennel, lentils, figs, &c. to be taken cold.—By the way, this practice is favorably mentioned by Fracastorius, a writer of the 16th century (De Morb. Cont.) For asperity in the chest he recommends the mucilage of fleawort, linseed, and the like, and forbids all heating things. The patient is to be kept upon a low diet, as in other fevers; and his apartment is to be fumigated with aromatics, such as sandal-wood, myrtles, and roses. When the belly is constipated, he directs barley-water with manna, prunes, and the like; or, if loose, barley-water with myrtle seeds, gum Arabic, Armenian, or Cretan earth (chalk?). He forbids purgatives after the seventh day, especially in rubeola, as there is danger of diarrhœa or dysentery being superinduced; and, if these affections should come on, he directs them to be stopped with astringents. He recommends particular attention to the eyes at the commencement, and with this intention directs them to be bathed with an astringent decoction. No animal food is to be allowed until the eruption and heat are gone.

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