SECT. IX.—ON LETHARGY.
Lethargy, which is a lesion of the rational part, has the same seat as frenzy, I mean the brain, but the matter which causes it is of an opposite nature; for it is occasioned by a humid and cold phlegm irrigating the brain. It is attended with an obscure fever, which is not very pungent, and with somnolency. The pulse is large, rare, and undulatory; the respiration is very rare and weak. Lethargies are altogether disposed to sleep; are roused with difficulty; can scarcely be made to answer questions; are forgetful and delirious; they yawn frequently, and remain sometimes with their jaws distended, as forgetting to shut their mouths; their evacuations by the belly are generally watery, but sometimes, on the contrary, the belly is dry; their urine is like that of cattle. Some have tremblings and sweatings. Carus being occasioned by the same matter as lethargy differs from it in this, that fever precedes carus and is more violent, whereas it is subsequent in lethargy; and in this respect also, that carus often supervenes upon other complaints, for it often follows paroxysms of fevers, epilepsy, and compression of the brain, as from the bone in fractures, or from the meningophylax pressing upon the anterior ventricle of the brain; whereas lethargy has a certain peculiar formation.
The cure of lethargy. When the strength permits, we must open a vein; but, when it does not, we must use acrid clysters. We must also lay the patient in an apartment of large size, and having a moderate degree of light, and apply to the head an embrocation of oil to which castor has been added. Some, instead of the oil, use vinegar and rose-oil with the castor, by which they strengthen and warm the head at the same time. And, having anointed the rest of the body, particularly the extremities, with old oil, they stimulate them with calcined nitre, pellitory, pepper, or the granum cnidium. It is also possible, by making them into cerate with castor, to use them in this way. We must likewise apply strong-scented things, triturating thyme, marjoram, and pennyroyal, with vinegar. We may smear the mouth and palate with mustard pounded in a small quantity of honey, and we may even remove with the fingers the phlegm which adheres to it. And, if they will admit it, it is proper to use a masticatory consisting of oxymel with hyssop, pennyroyal, marjoram, or mustard itself. We may give also in their drink things of a diffusible nature, more particularly the diospolites, to the amount of a spoonful, with oxycrate. When there is chronic trembling, we must give two or three scruples of castor; or, if there be a redundance of humours, and there be nothing to contra-indicate the use of it, we may add a scruple of scammony to the castor. When the disease is protracted, the head must be shaved and fomented with salt, millet, and the like, in small bags; and sinapisms are to be applied to the whole head, and medicines used to excite sneezing. Afterwards we may apply dry cupping, with much heat, or cupping with scarifications, to the back part of the head. It will be necessary to attend to the natural evacuations by means of clysters and diuretics. Apply to the lower part of the belly an embrocation with oil of rue, or Sicyonian oil with some castor. We must also attend particularly to the deglutition, injecting, by means of a vessel with a narrow mouth, warm water, to which has been added some sweet potion, more especially apomel. And, if there be inflammation in the intermediate parts, we must cure it with embrocations and cataplasms. To the nose is to be applied mustard triturated with vinegar, or burnt castor. Their food should consist of ptisan, or the decoction of oats, or that of alica, with oxymel, salt, or pennyroyal, sometimes giving of it every day, and sometimes only every alternate day. After food, ligatures are to be applied to the extremities, which may also be bent back; and the limbs are to be pinched; and sometimes we may even tear the hair violently in order to rouse them. Rubefacients to the thighs and legs are also proper. When the affection is in the decline, we may enjoin suitable gestation, direct the bath to be taken, and a restorative regimen to be used properly.
Commentary. See Hippocrates (de Morbis, iii, 5); Celsus (iii, 20); Galen (Meth. Med. xiii); Aretæus (Cur. Morb. Acut. i, 2); Oribasius (Synops. viii, 1); Aëtius (vi, 3); Alexander (i, 14); Actuarius (Meth. Med. iv, 2); Nonnus (c. 22); Octavius Horatianus (ii, 2); Cælius Aurelianus (de Morb. Acut. i, 2); Avicenna (iii, i, 3, 7); Serapion (i, 17); Mesne (de Ægrit. Cap. 22); Haly Abbas (Theor. ix. 5, and Pract. v, 15); Rhases (Divis. c. 6, Contin. 1.)
The ancients, it will be remarked, ascribe the disease to serious congestion, which is a very plausible theory. All the other authorities recommend nearly the same treatment as our author.
There can be no doubt that by lethargus Hippocrates meant a remittent fever, resembling the causus. The other authorities on this subject also describe the disease as a febrile affection.
Aëtius, as usual, is minute and judicious. He remarks that purging is not only useful, by producing evacuation of the bowels, but also by occasioning revulsion. When the disease comes on after frenzy, he forbids venesection, but otherwise approves of it. He and Alexander strongly commend castor. Alexander directs venesection, if the patient’s strength permit; the application of vinegar and rose-oil to the head; and, when the disease is on the decline, applications containing castor and other such stimulants. It is to be remarked, by the way, that Haly Abbas states this as the mode of treatment directed by Alexander Aphrodisiensis, from which it may be inferred that A. Trallian and A. Aphrodisiensis were the same person.
Celsus speaks favorably of the affusion of cold water.
Aretæus gives the plan of treatment very circumstantially, but his chapter on the symptoms of lethargy is lost. He lays it down that the disease is the counterpart to phrenitis, being occasioned by a cold humour oppressing the brain. The principle of his treatment seems to be to produce revulsion; for which purpose he recommends drastic purgatives and stimulant applications of all kinds to the skin. He is guarded in speaking of bleeding.
The methodical treatment recommended by Cælius Aurelianus is not much different from that of the other sects. He approves of bleeding, of shaving the head, and applying cupping-instruments to it, or else leeches; of making the patient lie in a bright light; of using gentle means to rouse him; but he justly condemns Diocles for recommending measures of great severity, which, he says, will but increase the disorder of the brain. He also disapproves of the practice of Praxagoras, who gave wine and hot stimulants; and further ridicules him for neglecting the head, and merely applying fomentations to the feet. He does not approve of Asclepiades’ practice of treating the disease with strong sternutatories, sinapisms to the head, and analeptics. He finds fault with Themison for making his patient lie in a dark place. He also condemns Themison’s practice of giving aloes by the mouth before food, as it will make the food in the stomach spoil, that is to say, will interrupt the digestive process, or, in case of its not operating downwards, will be absorbed, and increase the constitutional disorder. He further disapproves of Themison’s practice of carrying gestation to an inconsiderate length. He likewise condemns the use of the cold bath, which had been recommended by Themison. He then gives an account of the practice enjoined by Heraclides Tarentinus, the empiric, which, of course, he does not approve of; although, judging of it from modern views, we do not think it particularly objectionable. We dare not enter upon the detail of it, owing to its length.
The Arabians generally treat of it by the name of sirsen frigidum. Like the other authorities, Haly Abbas states the causes of the disease to be a cold and humid intemperament of the brain, or a collection of pituitous humours. As stated above, he quotes the practice of Alexander with approbation. He particularly recommends acrid clysters, drastic purgatives, shaving the head, applying stimulants to it, rubbing the feet, and in certain cases sternutatories. Rhases does not mention venesection; but Avicenna and most of his countrymen do. Avicenna and Mesue recommend emetics. Their treatment otherwise, like our author’s, consists of acrid clysters, friction of the extremities, masticatories, calefacient and repellent applications to the head. With regard to the last, Mesue may be consulted with advantage. Rhases, in his ‘Continens,’ recommends bleeding, fetid pills, leeches, cupping, and afterwards sternutatories, friction of the extremities, and so forth.