Synochous fevers are produced sometimes by effervescence of the
blood alone, and sometimes by putrefaction of the same, arising from
obstruction, and have, therefore, but one paroxysm from beginning to
end. The symptoms are, pulse very great, strong, quick, dense, equable;
but they are not pungent; and the urine is little different from the
natural. The cure of them consists in bloodletting _ad deliquium_. And
those who are affected with these fevers, and are not bled, run the most
imminent danger. But if anything should prevent us from having recourse
to phlebotomy, we must use such other remedies as are calculated to
remove obstructions, those which evacuate, and such as will allay the
effervescence of the blood. But when in these cases you remark symptoms
of concoction of the humours, and there is neither inflammation,
œdematous swelling, nor scirrhus in any important part, nor any part
cold, so as that the evil may be determined to it, you may boldly give
cold water, more especially if the patient has been accustomed to cold
drink.
* * * * *
COMMENTARY. After what we have said in the preceding section, and in the
section on Ephemerals, it will be unnecessary to enter into any detailed
account of the ancient opinions with regard to the nature of synochus. It
is to be distinctly recollected, however, that all the authorities from
Hippocrates to Actuarius held, with Galen, that the synochi are produced
either by an ebullition of the blood, as in the case of neglected
ephemerals, or from putrefaction of this fluid. (See Meth. Med. ix.)
In other parts of his works Galen seems, indeed, to hold that these
fevers are connected with corruptions of the bile, and we shall not
attempt to defend him from the charges of inconsistence and contradiction
with which he is assailed by Avicenna and Averrhoes. His treatment is
well deserving of our attention. He inculcates with becoming earnestness
that the great remedies for synochous fevers are bleeding and cold
drink. He approves of bleeding _ad deliquium animi_, and relates an
interesting case of its good effects. (Meth. Med. ix.) When the pulse is
large and firm, he insists that no considerations of age, strength, or
any other circumstance, ought to deter the physician from abstracting
blood freely. He directs the apartments of the sick to be kept cool and
well ventilated, and to have the floors sprinkled and rendered fragrant
by means of suitable flowers. The diet is to be of a light and diluent
nature, especially at the acme of the fever. (Therap. ad Glauc. i.) He
forbids the bath when inflammation is present. (Hyg.)
Aëtius conducts the treatment upon the same principles as Galen, and the
directions which he gives for the application of the different remedies
are most important. He states most decidedly, that unless venesection
is had recourse to, the patient will be in the utmost danger, and can
only be saved by the strength of his constitution, or some critical
evacuation. When the stomach is loaded, however, he forbids depletion,
because, by emptying the veins, the distribution of the crudities in
the _primæ viæ_ will be accelerated. When the menstrual or hemorrhodial
discharge is expected, he directs us to bleed less profusely than
otherwise. Persons of a hard, sanguine, and compact habit of body are
said to bear bleeding best. In practising venesection, he directs the
physician to pay more attention to the strength of the patient than to
the period of the fever. He is particularly earnest in recommending the
use of cold drink: he directs it to be given at the acme of the disease,
but not at the commencement. He forbids us to administer it freely when
there is obstruction or inflammation of an internal viscus; and states
many serious evils which may arise from the unseasonable administration
of cold water, although it be an excellent remedy when given at the
proper time. With regard to diet, he directs nothing but ptisan to be
given for the first three days. On the fourth he recommends the bath.
Through the whole course of the fever the food is to be light, unless the
powers of the patient be very feeble.
As the other Greek authorities differ in no material respect from the
principles of treatment laid down by Galen and Aëtius, we need not enter
upon any minute exposition of their views of practice. As a specimen,
however, of the practice of the later authors, we shall briefly mention
that of Synesius and Constantinus Africanus. They approve of bleeding,
unless the stomach be loaded with crudities; in which case they forbid
the operation until these are concocted or discharged. They recommend
diluents; and, if the belly is constipated, clysters, with decoctions,
containing tamarinds, damascenes, manna, and the like. To remove the
remains of the febrile excitement in the decline of the fever, they
direct medicines of a refrigerant nature to be given, such as camphor,
the seeds of melons, cucumbers, gourds, and the like.
Palladius gives the following directions for the treatment of fevers
in general. In all these diseases the skilful physician ought to know
and understand accurately the constitution and temperament of the sick;
and the peculiar form of the fever, and the formation, movement, onset,
increase, and acme of every disease, and the analogies of the paroxysms,
and the returns of the periods. And the first and general object in
all these diseases is to clear the body of impurities, and render it
perspirable; and the second in order is to contend with the prevailing
cause; for the work of the physician in all cases is to rectify whatever
is amiss about the body. (De Febribus, 29.)
Celsus recommends venesection in all fevers at the commencement, provided
the patient is not very young, weak, or has crudities in his stomach;
but after the fourth day he does not approve of it. He also makes some
ingenious remarks on the contrary methods of giving water and wine in
cases of fever. He recommends the latter when there is cold, torpor, and
restlessness. He likewise mentions the affusion of cold water and oil,
with the intention of changing the morbid state of action.
In the Epistle of Vindicianus, physician to the Emperor Valentinian,
there is an interesting history of a fever, arising from indigestion
and obstruction of the bowels, brought on by excess in eating and
drinking. In this case Vindicianus, in opposition to the advice of the
other professional attendants, would not administer a clyster, and gave
his patient nothing but salt and water, which procured first copious
perspirations, and afterwards free evacuations of the bowels. He then
directed him to use the bath, and completed the cure by giving wormwood
to remove obstructions. This is a well-marked case of intestinal fever.
(Fabricii Bibl. Græc. t. xiii.)
We may state the general characters of the urine as given in an
interesting little treatise, ‘On the Urine,’ lately published by Ideler.
In synochous fevers, as being connected with fulness of blood, the urine
is red, thick, and indicating by its colour and consistence the want of
concoction. (De Urinis Commentatio.)
Haly Abbas, during the first three days, strongly recommends venesection,
which, he says, will either have the effect of cutting short the fever
at once, or of rendering it milder. His other remedies are altogether
refrigerant, consisting of acidulated drinks, and gentle purgatives,
such as prunes, tamarinds, and the like. Alsaharavius, in like manner,
recommends depletion, and the refrigerant plan of treatment.
Serapion strongly recommends bleeding, _ad deliquium animi_, which,
he says, will probably have the effect of procuring discharges from
the bowels, and of promoting perspiration. He admits of venesection
even after the sixth or seventh day, when other circumstances indicate
it. He further prescribes refrigerant remedies, such as tamarinds,
cassia-fistula, and the like.
Averrhoes, although he approves of venesection, condemns Galen’s
direction to carry it the length of bringing on _deliquium animi_. He
also cautions against carrying the administration of cold drink too far.
Avenzoar strongly recommends bleeding _ad deliquium_. Avicenna likewise
approves of this practice. When the strength does not permit to carry
depletion so far, he directs us to open the temporal veins, or to
abstract blood by cupping. In such cases he also recommends purgatives
and refrigerant medicines. Towards the conclusion of the fever he directs
the trochisks of camphor to be given.
Rhases gives an excellent account of synochus. His remedies are bleeding,
gentle purgatives, acidulated drinks, restricted diet, and complete
abstinence from wine. He particularly recommends aloes as a purgative.
(See, in particular, Contin. xxx, v, 2.) He approves of the bath, but
prefers delaying the use of it until the decline of the fever. He is
very decided in recommending bleeding, unless the patient be of a weak
constitution, or his system loaded with crudities. After the fever is
concocted, he approves of giving cold water freely for drink.