Dr. Ermerins, in the remaining part of his Essay, shows, in a very

lucid manner, that the rules of Prognosis laid down in this treatise by

Hippocrates, are manifestly those by which he is regulated in his other

works, and more especially in the Epidemics and Aphorisms. We must

not, however, occupy room with any further exposition of the contents

of this important treatise, which does equal credit to the author

himself, and to the medical system of education pursued in the learned

university from which it emanated.

* * * * *

I will now give some remarks and reflections of my own on the treatise

under consideration.

In this work, then, Hippocrates appears to have had for his object, to

give such a general description of the phenomena of disease as would

apply to all the disorders of the animal frame. With this intention

he brings into review the state of the countenance, the position of

the patient in bed, the movements of the hands, the respiration,

the sweats, the state of the hypochondria, dropsies which are the

consequences of acute diseases, the sleep, the urine, the alvine

dejections, the vomitings, and the sputa. In doing this, his uniform

practice is to contrast the healthy with the morbid appearances.

Although M. Littré regards it as a treatise on special Pathology, it

appears to me to be decidedly a general work on Semeiology. Certain it

is that all the best commentators, such as Erotian and Stephanus,[458]

decidedly regard it as a semeiological work. The class of ancient

writings with which it admits of being most closely compared, are

the works on the prognostics of the weather. On this subject Greek

literature contains several works of a very philosophical nature,

such as the Phænomena of Aratus, and several of the minor tracts of

Theophrastus. Now as the object of these authors was to connect the

most striking phenomena in the sky, the earth, and the sea, with

the changes in the weather, of which they are the precursors, so

the intention of the medical writer of Prognostics was to point out

the alterations in the animal frame, which certain preternatural

symptoms usually indicate. And as the utility of an acquaintance with

prognostics of the weather to the husbandman and sailor is sufficiently

obvious, the benefit to be derived from a knowledge of medical

prognostics by the physician is equally so. Our author, it will be seen

in the Preface to this work, enumerates three objects to be attained

by cultivating an acquaintance with prognostics; first, to attract the

confidence of one’s patients; second, to free the physician from blame

by enabling him to announce beforehand the issue of the disorder about

which he is consulted; and, third, to give him a decided advantage in

conducting the treatment by preparing him for remarkable changes in

the diseases before they occur. And, in like manner, I may be allowed

to remark, the master of a ship who shows himself prepared for all

changes of the weather, will naturally attract the confidence of those

intrusted to his charge; and whatever may be the result, he will be

freed from blame if his ship should be damaged in a storm which he had

previously predicted; and surely his knowledge of impending commotions

in the sea and sky, will be of advantage to him by enabling him to make

preparations for them.

Looking then to the importance of general Prognostics, I have often

wondered why this branch of Semeiology is no longer cultivated by the

profession. Did not the ancient physicians follow the best possible

plan when they first described the general phenomena of diseased

action, and then applied them to particular cases? Surely they did

right in first taking a comprehensive view of the whole subject of

disease before attempting to examine the different parts of it in

detail. This, in fact, constitutes the great superiority of the ancient

_savans_ over the modern, that the former possessed a much

greater talent for apprehending general truths than the latter, who

confine their attention to particular facts, and too much neglect the

observation of general appearances. I trust no one will be offended

if I venture to pronounce regarding the present condition of our

professional literature, that (to borrow an illustration from the Logic

of Kant) it is altogether Cyclopic,--that is to say, it wants the eye

of Philosophy, for, although we have learned to examine particular

objects with greater accuracy than our forefathers did, the sphere

of our mental vision, so to speak, is more confined than theirs, and

cannot embrace the same enlarged views of general subjects. Surely then

we might gain a useful lesson by endeavoring to combine their more

comprehensive views with our own more accurate and minute observation.

Some people may be inclined to think that we have greatly detracted

from the credit which Hippocrates has long enjoyed as being the

undoubted author of this work, by showing that in composing it he

was so much indebted to the labors of his predecessors. But I have

long been impressed with the conviction that in compositions even of

the highest order, there is much less originality than is generally

supposed, and that true genius frequently is displayed more in its

own felicitous way of dealing with materials formerly prepared and

collected for its use than in searching out new matter to work

upon,[459] and hence it will be found upon examination that many of the

most distinguished efforts of human intellect have consisted in the

successful performance of tasks which had been frequently attempted by

previous laborers in the same line. Many artists, before the time of

Phidias, had acquired reputation by their attempts at making the statue

of Jupiter;[460] but this did not deter him from undertaking the same

task: and we may well believe that he would avail himself of every

practical lesson which he could draw from the success or failure of his

predecessors, in perfecting that matchless performance which completely

cast all others into the background. The sad misfortunes of Œdipus had

been often represented on the Athenian stage before Sophocles made them

the subject of those inimitable dramas, which still enjoy an unrivalled

reputation, nor will it be often considered how much assistance he may

have derived from the labors of those who had gone before him. It is

well known that of all the literary performances of Aristotle, there

is no one which gained him so enduring a reputation as his Categories,

and yet it is admitted that his division of the subject into the ten

Predicaments, was taken from the Pythagorean philosopher Archytas;[461]

in short, the great merit of Aristotle on this as on many other

occasions, consisted in defining and arranging a subject on which much

had been previously effected by the labors of his predecessors. And, to

give one example more, long before the time of Galen, the temperaments,

and the facts in physiology and pathology bearing upon Hygiene, had

been frequently and successfully investigated, but he, by recasting all

these subject-matters into his _Ars Medica_, composed a work which

posterity regarded as his master-performance, and every word and tittle

of which, for a succession ages, were commented upon and admired in

the Schools of Medicine. And of all our Author’s admired performances,

there is perhaps no one which has exerted so great an influence upon

the literature of the profession as the present work, for all the

Greek, Roman, and Arabian writers on medicine, subsequent to him, make

use of his terms, and copy his descriptions of morbid phenomena.

THE BOOK OF PROGNOSTICS.

1. It appears to me a most excellent thing for the physician to

cultivate Prognosis; for by foreseeing and foretelling, in the presence

of the sick, the present, the past, and the future, and explaining

the omissions which patients have been guilty of,[462] he will be the

more readily believed to be acquainted with the circumstances of the

sick; so that men will have confidence to intrust themselves to such a

physician. And he will manage the cure best who has foreseen what is

to happen from the present state of matters. For it is impossible to

make all the sick well; this, indeed, would have been better than to

be able to foretell what is going to happen; but since men die, some

even before calling the physician, from the violence of the disease,

and some die immediately after calling him, having lived, perhaps,

only one day or a little longer, and before the physician could bring

his art to counteract the disease; it therefore becomes necessary to

know the nature of such affections, how far they are above the powers

of the constitution; and, moreover, if there be anything divine in the

diseases,[463] and to learn a foreknowledge of this also. Thus a man

will be the more esteemed to be a good physician, for he will be the

better able to treat those aright who can be saved, from having long

anticipated everything; and by seeing and announcing beforehand those

who will live and those who will die, he will thus escape censure.[464]

2. He should observe thus in acute diseases: first, the countenance

of the patient, if it be like those of persons in health, and more so,

if like itself, for this is the best of all; whereas the most opposite

to it is the worst, such as the following; _a sharp nose, hollow

eyes, collapsed temples_; _the ears cold, contracted, and their

lobes turned out_: _the skin about the forehead being rough,

distended, and parched_; _the color of the whole face being green,

black, livid, or lead-colored_.[465] If the countenance be such

at the commencement of the disease, and if this cannot be accounted

for from the other symptoms, inquiry must be made whether the patient

has long wanted sleep; whether his bowels have been very loose; and

whether he has suffered from want of food; and if any of these causes

be confessed to, the danger is to be reckoned so far less; and it

becomes obvious, in the course of a day and a night, whether or not the

appearance of the countenance proceeded from these causes.[466] But

if none of these be said to exist, and if the symptoms do not subside

in the aforesaid time, it is to be known for certain that death is at

hand. And, also, if the disease be in a more advanced stage either

on the third or fourth day, and the countenance be such, the same

inquiries as formerly directed are to be made, and the other symptoms

are to be noted, those in the whole countenance, those on the body, and

those in the eyes; for if they shun the light, or weep involuntarily,

or squint, or if the one be less than the other, or if the white of

them be red, livid, or has black veins in it; if there be a gum upon

the eyes, if they are restless, protruding, or are become very hollow;

and if the countenance be squalid and dark, or the color of the whole

face be changed--all these are to be reckoned bad and fatal symptoms.

The physician should also observe the appearance of the eyes from below

the eyelids in sleep; for when a portion of the white appears, owing to

the eyelids not being closed together, and when this is not connected

with diarrhœa or purgation from medicine, or when the patient does not

sleep thus from habit, it is to be reckoned an unfavorable and very

deadly symptom; but if the eyelid be contracted, livid, or pale, or

also the lip, or nose, along with some of the other symptoms, one may

know for certain that death is close at hand. It is a mortal symptom,

also, when the lips are relaxed, pendent, cold, and blanched.

3.[467] It is well when the patient is found by his physician

reclining upon either his right or his left side, having his hands,

neck, and legs slightly bent, and the whole body lying in a relaxed

state, for thus the most of persons in health recline, and these are

the best of postures which most resemble those of healthy persons. But

to lie upon one’s back, with the hands, neck, and the legs extended,

is far less favorable. And if the patient incline forward, and sink

down to the foot of the bed, it is a still more dangerous symptom; but

if he be found with his feet naked and not sufficiently warm, and the

hands, neck, and legs tossed about in a disorderly manner and naked,

it is bad, for it indicates aberration of intellect. It is a deadly

symptom, also, when the patient sleeps constantly with his mouth open,

having his legs strongly bent and plaited together, while he lies upon

his back; and to lie upon one’s belly, when not habitual to the patient

to sleep thus while in good health, indicates delirium, or pain in the

abdominal regions. And for the patient to wish to sit erect at the acme

of a disease is a bad symptom in all acute diseases, but particularly

so in pneumonia.[468] To grind the teeth in fevers, when such has not

been the custom of the patient from childhood, indicates madness and

death, both which dangers are to be announced beforehand as likely

to happen; and if a person in delirium do this it is a very deadly

symptom. And if the patient had an ulcer previously, or if one has

occurred in the course of the disease, it is to be observed; for if the

man be about to die the sore will become livid and dry, or yellow and

dry before death.[469]

4. Respecting the movement of the hands I have these observations to

make: When in acute fevers, pneumonia, phrenitis, or headache, the

hands are waved before the face, hunting through empty space, as if

gathering bits of straw, picking the nap from the coverlet, or tearing

chaff from the wall--all such symptoms are bad and deadly.[470]

5. Respiration, when frequent, indicates pain or inflammation in the

parts above the diaphragm: a large respiration performed at a great

interval announces delirium; but a cold respiration at nose or mouth

is a very fatal symptom. Free respiration is to be looked upon as

contributing much to the safety of the patient in all acute diseases,

such as fevers, and those complaints which come to a crisis in forty

days.[471]

6. Those sweats are the best in all acute diseases which occur on the

critical days, and completely carry off the fever. Those are favorable,

too, which taking place over the whole body, show that the man is

bearing the disease better. But those that do not produce this effect

are not beneficial. The worst are cold sweats, confined to the head,

face, and neck; these in an acute fever prognosticate death, or in a

milder one, a prolongation of the disease; and sweats which occur over

the whole body, with the characters of those confined to the neck, are

in like manner bad. Sweats attended with a miliary eruption, and taking

place about the neck, are bad; sweats in the form of drops and of

vapour are good. One ought to know the entire character of sweats, for

some are connected with prostration of strength in the body, and some

with intensity of the inflammation.[472]

7.[473] That state of the hypochondrium is best when it is free from

pain, soft, and of equal size on the right side and the left. But

if inflamed, or painful, or distended; or when the right and left

sides are of disproportionate sizes;--all these appearances are to

be dreaded. And if there be also pulsation in the hypochondrium, it

indicates perturbation or delirium; and the physician should examine

the eyes of such persons; for if their pupils be in rapid motion, such

persons may be expected to go mad. A swelling in the hypochondrium,

that is hard and painful, is very bad, provided it occupy the whole

hypochondrium; but if it be on either side, it is less dangerous

when on the left. Such swellings at the commencement of the disease

prognosticate speedy death; but if the fever has passed twenty days,

and the swelling has not subsided, it turns to a suppuration.[474] A

discharge of blood from the nose occurs to such in the first period,

and proves very useful; but inquiry should be made if they have

headache or indistinct vision; for if there be such, the disease will

be determined thither. The discharge of blood is rather to be expected

in those who are younger than thirty-five years. Such swellings as

are soft, free from pain, and yield to the finger, occasion more

protracted crises, and are less dangerous than the others. But if

the fever continue beyond sixty days, without any subsidence of the

swelling, it indicates that empyema is about to take place; and a

swelling in any other part of the cavity will terminate in like manner.

Such, then, as are painful, hard, and large, indicate danger of speedy

death; but such as are soft, free of pain, and yield when pressed

with the finger, are more chronic than these. Swellings in the belly

less frequently form abscesses than those in the hypochondrium; and

seldomest of all, those below the navel are converted into suppuration;

but you may rather expect a hemorrhage from the upper parts. But the

suppuration of all protracted swellings about these parts is to be

anticipated. The collections of matter there are to be thus judged of:

such as are determined outwards are the best when they are small, when

they protrude very much, and swell to a point; such as are large and

broad, and which do not swell out to a sharp point, are the worst. Of

such as break internally, the best are those which have no external

communication, but are covered and indolent; and when the whole

place is free from discoloration. That pus is best which is white,

homogeneous, smooth, and not at all fetid; the contrary to this is the

worst.

8.[475] All dropsies arising from acute diseases are bad; for they do

not remove the fever, and are very painful and fatal. The most of them

commence from the flanks and loins, but some from the liver; in those

which derive their origin from the flanks and loins the feet swell,

protracted diarrhœas supervene, which neither remove the pains in the

flanks and loins, nor soften the belly;[476] but in dropsies which are

connected with the liver there is a tickling cough, with scarcely any

perceptible expectoration, and the feet swell; there are no evacuations

from the bowels, unless such as are hard and forced; and there are

swellings about the belly, sometimes on the one side and sometimes on

the other, and these increase and diminish by turns.[477]

9. It is a bad symptom when the head, hands, and feet are cold, while

the belly and sides are hot; but it is a very good symptom when the

whole body is equally hot.[478] The patient ought to be able to turn

round easily, and to be agile when raised up; but if he appear heavy

in the rest of his body as well as in his hands and feet, it is more

dangerous; and if, in addition to the weight, his nails and fingers

become livid, immediate death may be anticipated; and if the hands and

feet be black it is less dangerous than if they be livid, but the other

symptoms must be attended to; for if he appear to bear the illness

well, and if certain of the salutary symptoms appear along with these

there may be hope that the disease will turn to a deposition, so that

the man may recover; but the blackened parts of the body will drop off.

When the testicles and members are retracted upwards, they indicate

strong pains and danger of death.[479]

10. With regard to sleep--as is usual with us in health, the patient

should wake during the day and sleep during the night. If this rule

be anywise altered it is so far worse: but there will be little harm

provided he sleep in the morning for the third part of the day; such

sleep as takes place after this time is more unfavorable; but the worst

of all is to get no sleep either night or day; for it follows from this

symptom that the insomnolency is connected with sorrow and pains, or

that he is about to become delirious.[480]

11. The excrement is best which is soft and consistent, is passed

at the hour which was customary to the patient when in health, in

quantity proportionate to the ingesta; for when the passages are such,

the lower belly is in a healthy state.[481] But if the discharges be

fluid, it is favorable that they are not accompanied with a noise,

nor are frequent, nor in great quantity; for the man being oppressed

by frequently getting up, must be deprived of sleep; and if the

evacuations be both frequent and large, there is danger of his falling

into deliquium animi.[482] But in proportion to the ingesta he should

have evacuations twice or thrice in the day, once at night and more

copiously in the morning, as is customary with a person in health. The

fæces should become thicker when the disease is tending to a crisis;

they ought to be yellowish and not very fetid. It is favorable that

round worms be passed with the discharges when the disease is tending

to a crisis.[483] The belly, too, through the whole disease, should be

soft and moderately distended; but excrements that are very watery, or

white, or green, or very red, or frothy, are all bad. It is also bad

when the discharge is small, and viscid, and white, and greenish, and

smooth; but still more deadly appearances are the black, or fatty, or

livid, or verdigris-green, or fetid. Such as are of varied characters

indicate greater duration of the complaint, but are no less dangerous;

such as those which resemble scrapings,[484] those which are bilious,

those resembling leeks, and the black; these being sometimes passed

together, and sometimes singly.[485] It is best when wind passes

without noise, but it is better that flatulence should pass even

thus than that it should be retained; and when it does pass thus, it

indicates either that the man is in pain or in delirium, unless he

gives vent to the wind spontaneously.[486] Pains in the hypochondria,

and swellings, if recent, and not accompanied with inflammation,

are relieved by borborygmi supervening in the hypochondrium, more

especially if it pass off with fæces, urine, and wind; but even

although not, it will do good by passing along, and it also does good

by descending to the lower part of the belly.[487]

12. The urine is best when the sediment is white, smooth, and

consistent during the whole time, until the disease come to a crisis,

for it indicates freedom from danger, and an illness of short

duration; but if deficient, and if it be sometimes passed clear, and

sometimes with a white and smooth sediment, the disease will be more

protracted, and not so void of danger. But if the urine be reddish,

and the sediment consistent and smooth, the affection, in this case,

will be more protracted than the former, but still not fatal.[488] But

farinaceous sediments in the urine are bad, and still worse are the

leafy;[489] the white and thin are very bad, but the furfuraceous are

still worse than these. Clouds carried about in the urine are good

when white, but bad if black. When the urine is yellow and thin, it

indicates that the disease is unconcocted; and if it (the disease)

should be protracted, there may be danger lest the patient should not

hold out until the urine be concocted.[490] But the most deadly of

all kinds of urine are the fetid, watery, black, and thick; in adult

men and women the black is of all kinds of urine the worst, but in

children, the watery.[491] In those who pass thin and crude urine for

a length of time, if they have otherwise symptoms of convalescence, an

abscess may be expected to form in the parts below the diaphragm.[492]

And fatty substances floating on the surface are to be dreaded, for

they are indications of melting. And one should consider respecting

the kinds of urine, which have clouds, whether they tend upwards or

downwards, and the colors which they have and such as fall downwards,

with the colors as described, are to be reckoned good and commended;

but such as are carried upwards, with the colors as described, are to

be held as bad, and are to be distrusted.[493] But you must not allow

yourself to be deceived if such urine be passed while the bladder is

diseased; for then it is a symptom of the state, not of the general

system, but of a particular viscus.[494]

13. That vomiting is of most service which consists of phlegm and

bile mixed together, and neither very thick nor in great quantity; but

those vomitings which are more unmixed are worse. But if that which is

vomited be of the color of leeks or livid, or black, whatever of these

colors it be, it is to be reckoned bad; but if the same man vomit all

these colors, it is to be reckoned a very fatal symptom. But of all

the vomitings, the livid indicates the most imminent danger of death,

provided it be of a fetid smell. But all the smells which are somewhat

putrid and fetid, are bad in all vomitings.[495]

14. The expectoration in all pains about the lungs and sides, should

be quickly and easily brought up, and a certain degree of yellowness

should appear strongly mixed up with the sputum. But if brought up long

after the commencement of the pain, and of a yellow or ruddy color, or

if it occasions much cough, or be not strongly mixed, it is worse; for

that which is intensely yellow is dangerous, but the white, and viscid,

and round, do no good. But that which is very green and frothy is bad;

but if so intense as to appear black, it is still more dangerous than

these; it is bad if nothing is expectorated, and the lungs discharge

nothing, but are gorged with matters which boil (as it were) in the

air-passages. It is bad when coryza and sneezing either precede or

follow affections of the lungs, but in all other affections, even the

most deadly, sneezing is a salutary symptom.[496] A yellow spittle

mixed up with not much blood in cases of pneumonia, is salutary and

very beneficial if spit up at the commencement of the disease, but if

on the seventh day, or still later, it is less favorable. And all sputa

are bad which do not remove the pain. But the worst is the black, as

has been described. Of all others the sputa which remove the pain are

the best.[497]

15. When the pains in these regions do not cease, either with

the discharge of the sputa, nor with alvine evacuations, nor from

venesection, purging with medicine, nor a suitable regimen, it is to

be held that they will terminate in suppurations.[498] Of empyemata

such as are spit up while the sputum is still bilious, are very fatal,

whether the bilious portion be expectorated separate, or along with

the other; but more especially if the empyema begin to advance after

this sputum on the seventh day of the disease. It is to be expected

that a person with such an expectoration shall die on the fourteenth

day, unless something favorable supervene. The following are favorable

symptoms: to support the disease easily, to have free respiration, to

be free from pain, to have the sputa readily brought up, the whole body

to appear equally warm and soft, to have no thirst, the urine, and

fæces, sleep, and sweats to be all favorable, as described before; when

all these symptoms concur, the patient certainly will not die; but if

some of these be present and some not, he will not survive longer than

the fourteenth day. The bad symptoms are the opposite of these, namely,

to bear the disease with difficulty, respiration large and dense, the

pain not ceasing, the sputum scarcely coughed up, strong thirst, to

have the body unequally affected by the febrile heat, the belly and

sides intensely hot, the forehead, hands, and feet cold; the urine, and

excrements, the sleep, and sweats, all bad, agreeably to the characters

described above; if such a combination of symptoms accompany and either

on the ninth or eleventh. Thus then one may conclude regarding this

expectoration, that it is very deadly, and that the patient will not

survive until the fourteenth day. It is by balancing the concomitant

symptoms whether good or bad, that one is to form a prognosis; for thus

it will most probably prove to be a true one. Most other suppurations

burst, some on the twentieth, some on the thirtieth, some on the

fortieth, and some as late as the sixtieth day.[499]

16. One should estimate when the commencement of the suppuration will

take place, by calculating from the day on which the patient was first

seized with fever, or if he had a rigor, and if he says, that there is

a weight in the place where he had pain formerly, for these symptoms

occur in the commencement of suppurations. One then may expect the

rupture of the abscesses to take place from these times according to

the periods formerly stated. But if the empyema be only on either side,

one should turn him and inquire if he has pain on the other side; and

if the one side be hotter than the other, and when laid upon the sound

side, one should inquire if he has the feeling of a weight hanging from

above, for if so, the empyema will be upon the opposite side to that on

which the weight was felt.[500]

17. Empyema may be recognized in all cases by the following symptoms:

In the first place, the fever does not go off, but is slight during the

day, and increases at night, and copious sweats supervene, there is a

desire to cough, and the patients expectorate nothing worth mentioning,

the eyes become hollow, the cheeks have red spots on them, the nails of

the hands are bent, the fingers are hot especially their extremities,

there are swellings in the feet, they have no desire of food, and

small blisters (phlyctænæ) occur over the body. These symptoms attend

chronic empyemata, and may be much trusted to; and such as are of short

standing are indicated by the same, provided they be accompanied by

those signs which occur at the commencement, and if at the same time

the patient has some difficulty of breathing. Whether they will break

earlier or later may be determined by these symptoms; if there be

pain at the commencement, and if the dyspnœa, cough, and ptyalism be

severe, the rupture may be expected in the course of twenty days or

still earlier; but if the pain be more mild, and all the other symptoms

in proportion, you may expect from these the rupture to be later; but

pain, dyspnœa, and ptyalism, must take place before the rupture of the

abscess. Those patients recover most readily whom the fever leaves the

same day that the abscess bursts,--when they recover their appetite

speedily, and are freed from the thirst,--when the alvine discharges

are small and consistent, the matter white, smooth, uniform in color,

and free of phlegm, and if brought up without pain or strong coughing.

Those die whom the fever does not leave, or when appearing to leave

them it returns with an exacerbation; when they have thirst, but no

desire of food, and there are watery discharges from the bowels; when

the expectoration is green or livid, or pituitous and frothy; if all

these occur they die, but if certain of these symptoms supervene, and

others not, some patients die and some recover, after a long interval.

But from all the symptoms taken together one should form a judgment,

and so in all other cases.

18. When abscesses form about the ears, after peripneumonic

affections, or depositions of matter take place in the inferior

extremities and end in fistula, such persons recover. The following

observations are to be made upon them: if the fever persist, and the

pain do not cease, if the expectoration be not normal, and if the

alvine discharges be neither bilious, nor free and unmixed; and if the

urine be neither copious nor have its proper sediment, but if, on the

other hand, all the other salutary symptoms be present, in such cases

abscesses may be expected to take place. They form in the inferior

parts when there is a collection of phlegm about the hypochondria; and

in the upper when the hypochondria continue soft and free of pain, and

when dyspnœa having been present for a certain time, ceases without any

obvious cause.[501] All deposits which take place in the legs after

severe and dangerous attacks of pneumonia, are salutary, but the best

are those which occur at the time when the sputa undergo a change;

for if the swelling and pain take place while the sputa are changing

from yellow and becoming of a purulent character, and are expectorated

freely, under these circumstances the man will recover most favorably

and the abscess becoming free of pain, will soon cease; but if the

expectoration is not free, and the urine does not appear to have the

proper sediment, there is danger lest the limb should be maimed, or

that the case otherwise should give trouble. But if the abscesses

disappear and go back, while expectoration does not take place, and

fever prevails, it is a bad symptom; for there is danger that the man

may get into a state of delirium and die. Of persons having empyema

after peripneumonic affections, those that are advanced in life run

the greatest risk of dying; but in the other kinds of empyema younger

persons rather die.[502] In cases of empyema treated by the cautery or

incision, when the matter is pure, white, and not fetid, the patient

recovers; but if of a bloody and dirty character, he dies.[503]

19. Pains accompanied with fever which occur about the loins and

lower parts, if they attack the diaphragm, and leave the parts below,

are very fatal. Wherefore one ought to pay attention to the other

symptoms, since if any unfavorable one supervene, the case is hopeless;

but if while the disease is determined to the diaphragm, the other

symptoms are not bad, there is great reason to expect that it will

end in empyema.[504] When the bladder is hard and painful, it is an

extremely bad and mortal symptom, more especially in cases attended

with continued fever; for the pains proceeding from the bladder alone

are enough to kill the patient; and at such a time the bowels are

not moved, or the discharges are hard and forced. But urine of a

purulent character, and having a white and smooth sediment, relieves

the patient. But if no amendment takes place in the characters of the

urine, nor the bladder become soft, and the fever is of the continual

type, it may be expected that the patient will die in the first stages

of the complaint. This form attacks children more especially, from

their seventh to their fifteenth year.[505]

20. Fevers come to a crisis on the same days as to number on which men

recover and die. For the mildest class of fevers, and those originating

with the most favorable symptoms, cease on the fourth day or earlier;

and the most malignant, and those setting in with the most dangerous

symptoms, prove fatal on the fourth day or earlier. The first class of

them as to violence ends thus: the second is protracted to the seventh

day, the third to the eleventh, the fourth to the fourteenth, the

fifth to the seventeenth, and the sixth to the twentieth. Thus these

periods from the most acute disease ascend by fours up to twenty. But

none of these can be truly calculated by whole days, for neither the

year nor the months can be numbered by entire days. After these in the

same manner, according to the same progression, the first period is

of thirty-four days, the second of forty days, and the third of sixty

days. In the commencement of these it is very difficult to determine

those which will come to a crisis after a long interval; for these

beginnings are very similar, but one should pay attention from the

first day, and observe further at every additional tetrad, and then one

cannot miss seeing how the disease will terminate. The constitution

of quartans is agreeable to the same order. Those which will come to

a crisis in the shortest space of time, are the easiest to be judged

of; for the differences of them are greatest from the commencement,

thus those who are going to recover breathe freely, and do not suffer

pain, they sleep during the night, and have the other salutary

symptoms, whereas those that are to die have difficult respiration, are

delirious, troubled with insomnolency, and have other bad symptoms.

Matters being thus, one may conjecture, according to the time, and each

additional period of the diseases, as they proceed to a crisis. And

in women, after parturition, the crises proceed agreeably to the same

ratio.[506]

21. Strong and continued headaches with fever, if any of the deadly

symptoms be joined to them, are very fatal. But if without such

symptoms the pain be prolonged beyond twenty days, a discharge of blood

from the nose or some abscess in the inferior parts may be anticipated;

but while the pain is recent, we may expect in like manner a discharge

of blood from the nose, or a suppuration, especially if the pain be

seated above the temples and forehead; but the hemorrhage is rather to

be looked for in persons younger than thirty years, and the suppuration

in more elderly persons.[507]

22. Acute pain of the ear, with continual and strong fever, is to be

dreaded; for there is danger that the man may become delirious and die.

Since, then, this is a hazardous spot, one ought to pay particular

attention to all these symptoms from the commencement. Younger persons

die of this disease on the seventh day, or still earlier, but old

persons much later; for the fevers and delirium less frequently

supervene upon them, and on that account the ears previously come to

a suppuration, but at these periods of life, relapses of the disease

coming on generally prove fatal. Younger persons die before the ear

suppurates; only if white matter run from the ear, there may be hope

that a younger person will recover, provided any other favorable

symptom be combined.[508]

23. Ulceration of the throat with fever, is a serious affection,

and if any other of the symptoms formerly described as being bad,

be present, the physician ought to announce that his patient is in

danger.[509] Those quinsies are most dangerous, and most quickly prove

fatal, which make no appearance in the fauces, nor in the neck, but

occasion very great pain and difficulty of breathing; these induce

suffocation on the first day, or on the second, the third, or the

fourth.[510] Such as, in like manner, are attended with pain, are

swelled up, and have redness (erythema) in the throat, are indeed very

fatal, but more protracted than the former, provided the redness be

great.[511] Those cases in which both the throat and the neck are red,

are more protracted, and certain persons recover from them, especially

if the neck and breast be affected with erythema, and the erysipelas

be not determined inwardly.[512] If neither the erysipelas disappear

on the critical day, nor any abscess form outwardly, nor any pus be

spit up, and if the patient fancy himself well, and be free from

pain, death, or a relapse of the erythema is to be apprehended. It

is much less hazardous when the swelling and redness are determined

outwardly; but if determined to the lungs, they superinduce delirium,

and frequently some of these cases terminate in empyema.[513] It is

very dangerous to cut off or scarify enlarged uvulæ while they are red

and large, for inflammations and hemorrhages supervene; but one should

try to reduce such swellings by some other means at this season. When

the whole of it is converted into an abscess, which is called Uva, or

when the extremity of the variety called Columella is larger and round,

but the upper part thinner, at this time it will be safe to operate.

But it will be better to open the bowels gently before proceeding to

the operation, if time will permit, and the patient be not in danger of

being suffocated.[514]

24. When the fevers cease without any symptoms of resolution

occurring, and not on the critical days, in such cases a relapse may

be anticipated.[515] When any of the fevers is protracted, although

the man exhibits symptoms of recovery, and there is no longer pain

from any inflammation, nor from any other visible cause, in such a

case a deposit, with swelling and pain, may be expected in some one

of the joints, and not improbably in those below. Such deposits occur

more readily and in less time to persons under thirty years of age;

and one should immediately suspect the formation of such a deposit, if

the fever be protracted beyond twenty days; but to aged persons these

less seldom happen, and not until the fever be much longer protracted.

Such a deposit may be expected, when the fever is of a continual type,

and that it will pass into a quartan, if it become intermittent, and

its paroxysms come on in an irregular manner, and if in this form it

approach autumn. As deposits form most readily in persons below thirty

years of age, so quartans most commonly occur to persons beyond that

age. It is proper to know that deposits occur most readily in winter,

that then they are most protracted, but are less given to return.[516]

Whoever, in a fever that is not of a fatal character, says that he has

pain in his head, and that something dark appears to be before his

eyes, and that he has pain at the stomach, will be seized with vomiting

of bile; but if rigor also attack him, and the inferior parts of the

hypochondrium are cold, vomiting is still nearer at hand; and if he

eat or drink anything at such a season, it will be quickly vomited.

In these cases, when the pain commences on the first day, they are

particularly oppressed on the fourth and the fifth; and they are

relieved on the seventh, but the greater part of them begin to have

pain on the third day, and are most especially tossed on the fifth,

but are relieved on the ninth or eleventh; but in those who begin to

have pains on the fifth day, and other matters proceed properly with

them, the disease comes to a crisis on the fourteenth day. But when in

such a fever persons affected with headache, instead of having a dark

appearance before their eyes, have dimness of vision, or flashes of

light appear before their eyes, and instead of pain at the pit of the

stomach, they have in their hypochondrium a fulness stretching either

to the right or left side, without either pain or inflammation, a

hemorrhage from the nose is to be expected in such a case, rather than

a vomiting. But it is in young persons particularly that the hemorrhage

is to be expected, for in persons beyond the age of thirty-five,

vomitings are rather to be anticipated. Convulsions occur to children

if acute fever be present, and the belly be constipated, if they cannot

sleep, are agitated, and moan, and change color, and become green,

livid, or ruddy. These complaints occur most readily to children which

are very young up to their seventh year; older children and adults are

not equally liable to be seized with convulsions in fevers, unless some

of the strongest and worst symptoms precede, such as those which occur

in frenzy. One must judge of children as of others, which will die

and which recover, from the whole of the symptoms, as they have been

specially described.[517] These things I say respecting acute diseases,

and the affections which spring from them.

25. He who would know correctly beforehand those that will recover,

and those that will die, and in what cases the disease will be

protracted for many days, and in what cases for a shorter time, must

be able to form a judgment from having made himself acquainted with

all the symptoms, and estimating their powers in comparison with one

another, as has been described, with regard to the others, and the

urine and sputa, as when the patient coughs up pus and bile together.

One ought also to consider promptly the influx of epidemical diseases

and the constitution of the season.[518] One should likewise be well

acquainted with the particular signs and the other symptoms, and

not be ignorant how that, in every year, and at every season, bad

symptoms prognosticate ill, and favorable symptoms good, since the

aforesaid symptoms appear to have held true in Libya, in Delos, and in

Scythia;[519] from which it may be known that, in the same regions,

there is no difficulty in attaining a knowledge of many more things

than these; if having learned them, one knows also how to judge and

reason correctly of them. But you should not complain because the name

of any disease may happen not to be described here, for you may know

all such as come to a crisis in the afore-mentioned times, by the same

symptoms.[520]

APPENDIX

TO

THE BOOK OF PROGNOSTICS.

As announced in the Preliminary Discourse (Sect. II., 18), I shall

now proceed to give an abstract of the principal matters contained

in the SECOND BOOK OF PRORRHETICS, which appear to me to be

highly interesting, and as they relate to the subjects treated of in

the Prognostics, they may be more suitably introduced here than in any

other place.

The author commences the treatise with expressing his disapproval of

certain modes of making prognostics which he had seen practiced. He

says he had heard of many and famous predictions having been made by

physicians, such as he himself did not pretend that he could make.

Such, for example, as for a physician to call in upon a patient who was

looked upon as being in a desperate condition by another physician, and

predict that he would not die, but would lose his sight. Or to predict

with regard to another patient supposed to be in a bad way, that he

will recover, but will become lame of a hand. And of a third who, to

all appearance, cannot recover, to predict that he will get well,

but that his toes will blacken and putrefy. Similar predictions are

related under this class. Another mode of prediction is to prophecy to

buyers and traders, to one death, to another madness, and to the rest

diseases, and that from what is now occurring, or has occurred before,

and all the predictions to turn out true. Another kind of predictions

relates to Athletæ, and those who practice gymnastic and laborious

exercises for the cure of diseases, where the practitioner pretends to

so much exactness, that if the patient is guilty of any act of omission

or commission in regard to food, drink, or venery, the physician

will detect it. He himself makes no pretensions to any such skill in

divination, but announces it as his object to describe the symptoms

by which it may be known whether a man will die or live, and whether

his disease will be of short or of long duration. With regard to the

predictions of abscesses, lameness, death, or madness, the author holds

that they can only be made after the morbid conditions leading to them

have fairly set in. He strongly disapproves of all ostentatious modes

of making predictions, and gives it as his advice that in all such

cases the greatest prudence and reserve should be observed, since if a

man become an adept in this art of prognostications, he will gain great

credit with his patient, whereas if he fall into mistakes, he will

incur odium, and will be looked upon as being deranged.

With regard to the prognostics made by those who practice gymnastics,

he recommends them not to be made in a charlatan manner, but with

suitable caution, and directs minute attention to be paid to the

circumstances of the patient, which one has superior advantages in

observing under this system. He says, for example, that a physician who

feels a patient’s belly and pulse, pays attention to the breathing at

the nostrils, and listens to the speech, and sound of the respiration,

will be less likely to be deceived in forming a prognostic on his

patients than he who neglects these things. He expresses himself,

however, as being incredulous as to the possibility of detecting any

little transgressions of orders which a patient may commit, although

greater departures from instructions may be suspected. After some

general observations in respect to diet, and other matters relating to

it, he proceeds to a more circumstantial description of the symptoms

upon which a prognosis is to be founded. And first, with regard to the

alvine dejections, those of persons who live a laborious life, and use

food and drink sparingly, are small and hard, and are passed every day,

every third day, or every fourth day, but if they pass the last period

there is danger of the man’s being seized with fever or diarrhœa. When

the stools are so liquid that they do not assume a shape, they are all

of a worse character in these cases. The dejections of persons who lead

an active life are less copious than those of the indolent, provided

they use the same amount of food. Liquid dejections taking place on the

seventh day, and quickly coming to a crisis, are beneficial, if they

occur all at once, and are not repeated. But if accompanied with fever,

or if the diarrhœa is prolonged, all such dejections are bad, whether

bilious, pituitous, or of indigested matters, and require a particular

regimen and mode of treatment.

With regard to the urine, it should be in proportion to the drink that

is taken, and somewhat thicker than the fluid that is drunk. If it be

more copious than natural, this indicates either that the patient has

disobeyed orders as to the amount of his drink, or that his body is in

a state of atrophy. If the urine is passed in deficient quantity, with

a noise, it indicates either that the man stands in need of purging, or

that the bladder is diseased. A small quantity of blood passed without

fever and pain does not indicate anything bad, but proves a solution to

a state of lassitude. But if in large quantity, with the addition of

any of these symptoms, it is to be dreaded. But if the urine be passed

with pain, and if pus be passed along with the urine in a fever, the

physician should announce that the patient will thus be relieved of his

complaints.[521] Thick urine having a thin sediment indicates some pain

and swelling about the joints. All the other sediments which occur in

the urine of persons who practice exercises are connected with disease

about the bladder; this will be clearly shown by the obstinate pains

with which they are accompanied. The author, although he states that he

had been conversant with the teachers of prognostics from urine, and

their children and disciples, seems to express himself doubtful as to

the possibility of acquiring a great degree of accuracy in regard to

these matters.

Respecting dropsy, consumption, gout, and epilepsy, he states generally

that if they are hereditary they are difficult to remove. A favorable

prognosis is to be formed in dropsy when the patient’s viscera are

sound, when his strength is firm, the digestion and respiration

natural, when he is free of pain, the temperature of the body moderate,

and when there is no wasting of the extremities. It is favorable when

there is no cough, thirst, nor dryness of the tongue, when the bowels

are easily moved by medicine, and when, at other times, the dejections

are consistent. Dropsy, supervening, along with fever, upon a great

discharge of blood, is of a most intractable nature, and the physician

should intimate the danger to some other person beforehand. When great

swellings suddenly subside and rise again, there is more hope in such a

case than in dropsies connected with a discharge of blood. He concludes

his observations on dropsies with the remark, that they are apt to

deceive the patients, so that they desert their physicians and thus

perish.

With regard to consumptive patients, he says, he has the same

observations to make with regard to the sputa and cough as he had

written with regard to empyema.[522] If the patient is to recover,

the sputa should be white, equable, of one color, without phlegm; the

defluxion from the head should be determined to the nose; there should

be no fever, nor anorexia, nor thirst; the alvine discharges firm,

proportionate to the ingesta, and the patient should not get thin.

The best form of the chest is when it is quadrangular and hairy, and

when the cartilage is small, and covered with flesh. Young persons,

who become affected with empyema from determination (metastasis?), or

fistula, or from any other similar cause, or from the retrocession

of an abscess, do not recover unless many of the favorable symptoms

combine in the case. They die, most commonly, in autumn, which proves

peculiarly fatal in protracted diseases. Of all others, virgins, and

women suffering from amenorrhœa, seldomest recover; and in their cases

there is no hope unless menstruation be restored. All sexes, he seems

to say (but the meaning appears to me rather ambiguous), have a better

chance of recovery, when there is a discharge of blood, especially in

those cases in which there are pains in the back and chest, connected

with black bile; and if, after the evacuation, there be a remission

of the pain; if the cough and fever do not set in; and if the thirst

be tolerable. He seems to state (but the text is in an unsatisfactory

condition), that relapses take place unless there be deposits in the

place, the best of which are those which contain most blood; and that

in those cases in which there are pains in the chest, if the patients

get emaciated, and cough, and a dyspnœa supervenes, without fever

or empyema, they should be asked whether, when they cough, and have

difficulty of breathing, the sputa be compact, and attended with little

smell.

With regard to persons affected with the gout, those who are aged,

have tofi in their joints, who have led a hard life, and whose bowels

are constipated, are beyond the power of medicine to cure. But, the

best natural remedy for them is an attack of dysentery, or other

determination to the bowels. Persons, under opposite circumstances, may

be cured by a skilful physician.

The prognosis in epilepsy is unfavorable when the disease is

congenital, and when it endures to manhood, and when it occurs to a

grown person, and without any obvious cause. When connected with the

head it is particularly to be apprehended, but least so when it seems

to be derived from the hands or feet. The cure may be attempted in

young persons, but not in old.

In the case of children, he mentions various complaints, such as

distortion of the eyes, tubercles about the neck, pain in the bowels,

omental hernia, etc., which, upon inquiry, will be found to be the

consequences of an attack of epilepsy.

The judgment to be formed in the case of ulcers is to be founded on the

age of the patient, the situation of the sore, and its appearance.

Strumous tubercles, which end in suppuration, occur most frequently in

young persons. Adults are subject to bad favi, internal cancers, and

herpetic sores, after epinyetis, until they pass sixty. Old persons are

subject to cancers, both deep-seated and superficial, which never leave

them. They are particularly intractable when seated in the armpits, the

loins, and the thighs.

Of affections of the joints, the most dangerous are those seated in the

thumb and great toe. When there is a chronic sore on the side of the

tongue the surgeon should examine whether it be not occasioned by the

sharp edge of a tooth.[523]

The most dangerous wounds are those which implicate the large veins

(blood-vessels), in the neck and groin; then those of the brain and

liver; next, those of the bowels and bladder. These cases are all

dangerous, but not uniformly fatal, as some suppose. Much depends upon

constitution, as to liability to fever and inflammation after a wound.

Sometimes, also, the wounds of smaller vessels prove fatal by inducing

hemorrhage, fever, or delirium. In all recent wounds, however, the

physician should endeavor to afford assistance.

Of spreading ulcers, the most fatal are such mortifications as are

very deep, black, and dry; and those are bad and dangerous which are

accompanied with a black ichorous discharge. Those which are white and

mucous are less dangerous, but are more subject to relapse, and become

inveterate. Herpes is the least dangerous of the spreading sores,

but is most difficult to remove about deep-seated cancers.[524] An

ephemeral fever, with very white and thick pus, is beneficial in such a

case; also, sphacelus of a nerve, of a bone, or of both, in deep-seated

and black mortifications. For a free discharge of pus takes place and

carries off the mortification.

The prognostics in wounds of the head are given in nearly the same

terms as laid down in the treatise on that subject, and therefore I

need not enter minutely into an exposition of what is stated regarding

them here. Those in the upper part of the head, more especially if they

implicate a suture, are said to be particularly dangerous. The author

directs the surgeon to inquire whether, at the time of the accident,

the patient fell down or became comatose, as in this case greater

danger is to be apprehended.

Large wounds of the joints, if they involve the connecting nerves,

necessarily leave the limb maimed. Several other observations connected

with these injuries are added, of which one of the most important

is the direction to practice flexion and extension of the limb,

frequently, with the view, no doubt, of preventing rigidity of the

joint.

Large excisions in the arm becoming inflamed end in suppurations, which

require to be evacuated by the knife or cautery. Injuries of the spinal

marrow, whether from disease or accident, are attended with loss of

motion and sensibility, retention of the alvine and urinary discharges;

but, after a time, involuntary evacuations take place, which are soon

followed by death. When the throat is frequently filled with blood,

and there is no headache or cough, nor any other morbid symptoms, the

physician should examine whether there be not an ulcer or a leech in

the part.

With regard to the eyes, the prognostics are given with so much

prolixity of detail that I must be content with a brief abstract of

them. Much attention is paid to the characters of the discharge from

the eyes in diseases of them, namely, of the glutinous matter and

tears; thus, if the gum be white and soft, the tears mixed with it not

very hot, and the swelling light and loose, under these circumstances

the eyelids are glued up during the night, so that the eye is free of

pain, and thus the disease is without danger, and of short duration.

The other appearances of the eye, and the discharges, are also minutely

given. When the discharge is green or livid, the tears copious and

hot, a burning heat in the head, and pains darting through the head to

the eye, there must necessarily be ulceration in the eye; and there is

much reason to apprehend that it will burst. If, when one can get a

sight of the eye, it should be found burst, and the pupil projecting

above the rupture, it is bad and difficult to restore; and, if there

be sloughing, the eye will be wholly useless. According to the form

and depth of the ulcers must be the subsequent cicatrices. These are

minutely described according to their different varieties. Mention is

also made of the prognostics from the eyes in fevers, as described by

the author in another work. It is most likely that allusion is here

made to the first book of “Prorrhetics.” In conclusion, the surgeon is

directed to pay great attention to the state of the urine in diseases

of the eyes.

Dysenteries, when they set in with fever, alvine discharges of a mixed

character, or with inflammation of the liver, or of the hypochondrium,

or of the stomach, such as are painful, with retention of the food

and thirst, all these are bad; and the more of these symptoms there

are, the greater the danger; and the fewer, the more hope is there of

recovery. Children from five to ten years of age are the most apt to

die of this complaint; the other ages less so. Such dysenteries as

are of a beneficial nature, and are attended with blood and scrapings

of the bowels, cease on the seventh, or fourteenth, or twentieth, or

thirtieth day, or within that period. In such cases even a pregnant

woman may recover and not suffer abortion.

All cases of lientery are said to be of a bad character when they are

continued and protracted, both day and night, and when the dejections

are either very crude, or black, soft, and fetid; for they occasion

thirst and determine the fluids otherwise than to the bladder, give

rise to ulcerations (aphthæ?) in the mouth, redness and ephelis[525] of

all colors, and at the same time the belly is in a state of ferment,

and has a foul, wrinkled appearance externally. This disease is most

to be dreaded by old persons; it is formidable to men of middle age,

but less so in the other ages. The indications of cure, it is acutely

stated, are to determine the fluids to the urine, to relieve the body

from its atrophy, and change the color of the skin.

All the other varieties of diarrhœa without fever are of short

duration and mild; for they will all cease when washed out, or of their

own accord. The discharge may be predicted as about to cease when,

upon touching the belly, there is no movement, and flatulence passes

with the discharge. Eversion of the gut takes place in the case of

middle-aged persons having piles, of children affected with the stone,

and in protracted and intense discharges from the bowels, and of old

persons having mucous concretions (scybalæ?).

Women may be judged of whether they are in a fit state for conception

or not by attending to the following circumstances:--In the first place

to their shapes. Women of smaller stature more readily conceive than

taller persons; the thin than the fat; the white than the ruddy; the

dark than the pale; those who have prominent veins than the contrary.

In oldish women it is bad to have much flesh, but a good thing to

have swelled and large breasts. In addition, inquiry should be made

whether or not the menstruation be regular as to time and quantity.

And it should be ascertained whether the uterus be healthy, of a dry

temperament, and soft; neither in a state of retraction nor prolapsus;

and its mouth neither turned aside, nor too close, nor too open. When

any of these obstructions come in the way, it is impossible that

conception can take place.

Such women as cannot conceive, but appear green, without fever, and the

viscera are not in fault; these will say that the head is pained, and

that the menstrual discharge is vitiated and irregular. But such of

these as have the proper color, are of a fat habit of body, the veins

are inconspicuous, they have no pains, and the menses either never

appear at all, or are scanty and intense, and this is one of the most

difficult states of sterility to remove. In other cases the health is

not to blame, but the fault lies in the position of the womb. The other

contingencies in this place are attended with pains, discoloration, and

wasting.

Ulceration in the womb from parturition, an abscess of a chronic

nature, or from any other cause, is necessarily accompanied with

fevers, buboes, and pains in the place; and if the lochial discharge

be also suppressed, all these evils are more intense and inveterate,

along with pains of the hypochondrium and head. And when the ulcer

heals, the part necessarily is smoother and harder, and the woman is

less adapted for conception. If, however, the ulceration be in the

right side only, the woman may conceive of a female child, or if in

the left, of a male. When a woman cannot conceive, and fever comes on

with a slight cough, inquiry should be made whether she has any ulcer

about the uterus, or any other of the complaints I have described; for

if she has no complaint in that region to account for her loss of flesh

and sterility, it may be expected that she will have vomiting of blood,

and the catamenia will necessarily be suppressed. But if the fever be

carried off by the evacuation of blood, and if the catamenia appear,

she will then prove with child. But if looseness of the bowels having a

bad character take place before there is an evacuation of blood, there

is danger lest the woman perish before a vomiting of blood can take

place.

In cases of false conception, in which women are deceived by the

non-appearance of the menses, and by the increase of the belly and

movement in it, they will be found to have had headache and pains about

the neck and hypochondria, and there is no milk in the breasts except a

little of a watery character. But when the swelling of the womb passes

away they will conceive, unless there be any other impediment. For

this affection is beneficial in so far as it produces a change in the

uterus, so that afterwards the woman may prove with child. Women with

child have not these pains unless the headache be habitual to them,

and in addition they have milk in their breasts. Women affected with

chronic discharges are to be asked whether they have pains in the head

and loins, and in the lower part of the belly, and whether their teeth

be set on edge, and if they have dimness of sight, and noises in their

ears. Such women as vomit bile for several days while in a fasting

state, though they are not with child nor have fever, are to be asked

whether they have vomited up round lumbrici, and if they say not, they

should be warned that this will happen to them. This affection happens

principally to married women, then to virgins, and less seldom to other

people.

Pains without fever are not deadly, but mostly prove protracted, and

have many changes and relapses. Several varieties of headache are

described, and the prognosis in each laid down. The natural cure of

them is a coryza, a discharge of mucus from the nose, or sneezing.

Pains spreading from the head to the neck and back, are relieved by

abscesses, expectoration of pus, hemorrhoids, exanthemata on the body,

or pityriasis on the head.

Heaviness and pruritus in the head, either in a part or through the

whole of it, if, on inquiry, they extend to the tip of the tongue,

indicate a confirmed disease, and one difficult to remove. They are

best removed by the occurrence of an abscess. But those cases which

are accompanied with vertigo are difficult to cure, and are apt to

pass into mania. Other diseases in the head, of a very strong and

protracted character, occur to both men and women, but especially to

young persons, and virgins at the season of manhood, and especially at

the catamenial period. Women, however, are less subject to pruritus and

melancholic affections than the men, unless the menses have disappeared.

Both men and women who have long had a bad color, but not in the form

of jaundice, are subject to headaches, eat stones and earth, and have

piles. Those who have green colors, without decided jaundice, are

affected in like manner, only instead of eating stones and earth, they

are more subject to pains in the hypochondriac region. Persons who are

pale for a length of time, and have the face tumid, will be found to

have headache, or pains about the viscera, or some disease in the anus;

and in most cases, not one, but many, or all these evils make their

appearance.

Nyctalopia is most apt to attack young persons, either males or

females, and to pass off spontaneously on the fortieth day or in seven

months, and in some cases it endures for a whole year. Its duration

may be estimated from the strength of the disease and the age of the

patient. They are relieved by deposits which determine downwards, but

these rarely occur in youth. Married women and virgins that have the

menstrual discharge regular are not subject to the complaint. Persons

having protracted defluxions of tears who are attacked with nyctalopia,

are to be questioned whether they had any previous complaint in the

head.

Such persons as have frequent pains in the vertex and temples, without

fever or loss of color, unless they have some other obvious deposit in

the face, or speak in a rough tone, or have pain in the teeth, may be

expected to have a hemorrhage from the nose. Those who have bleeding at

the nose, although they may appear to be otherwise in good health, will

be found to have enlarged spleen, or pain in the head, or flashes of

light before their eyes. Most of these patients have both headache and

affection of the spleen.

The gums are diseased and the mouth fetid in persons who have enlarged

spleens. But persons who, although they have enlarged spleens, are

exempt from hemorrhages and fœtor of the mouth have malignant ulcers

on the legs and black cicatrices. But if they have any obvious deposit

in the countenance, or if their speech be rough, or if they have

toothache, a hemorrhage from the nose may be expected. Those who have

great swellings below the eyes will be found to have enlarged spleens.

And if there come on swellings in the feet, and if they appear to be

dropsical, the belly and loins must be attended to.

Distortions of the countenance, if not sympathetic with some other

part of the body, quickly pass off either spontaneously or by remedial

means. The others are of an apoplectic nature. In other cases, when

the diseased part wastes from want of motion, there can be no relief

afforded. But when wasting does not take place there may be recovery.

With regard to the time when this may occur, it is to be prognosticated

by attending to the severity of the disease, to its duration, to the

age of the patient, and to the season, it being known that of all

cases the inveterate, and such as are the consequences of repeated

attacks, are the worst, and the most difficult to remove, and those in

aged persons. Autumn and winter are more unfavorable seasons for such

complaints than spring and summer.

Pains in the shoulder, which, passing down the arms, occasion torpor

and pains, do not usually terminate in deposits, but the patients

get better by vomiting black bile. But when the pains remain in the

shoulders, or extend to the back, the patients are relieved by vomiting

pus or black bile. They are to be judged of thus:--If their breathing

be free, and if they be slender, it is rather to be expected that they

will vomit black bile. But if they have more difficulty of breathing,

and if there is any unusual color on the countenance, whether reddish

or black, it is to be expected that they will rather spit blood. It

should also be attended to whether there be swellings on the feet. This

disease attacks men most violently from forty to sixty years of age. At

this period of life ischiatic diseases are most troublesome.

Ischiatic diseases are to be thus judged of:--In the case of old

persons, when the torpor and coldness of the loins and legs are very

strong, and when they lose the power of erections, and the bowels are

not moved, or with difficulty, and the fæces are passed with much

mucus, the disease will be very protracted, and it should be announced

beforehand that the disease will not last shorter time than a year

from its commencement; and amendment is to be looked for in spring

and summer. Ischiatic diseases are no less painful in young men, but

are of shorter duration, for they pass off in forty days; and neither

is the torpor great, nor is there coldness of the legs and loins. In

those cases in which the disease is seated in the loins and leg, but

the patient does not suffer so much as to be confined to bed, examine

whether any concretions have taken place in the hip-joint, and make

inquiry whether the pain extends to the groin; for if both these

symptoms be present, the disease will be of long duration. And the

physician should also inquire whether there be torpor in the thigh, and

if it extend to the ham; and if he says so, he is to be again asked if

it spreads along the leg to the ankle of the foot. Those who confess

to the most of these symptoms are to be told that the limb will be

sometimes hot and sometimes cold; but those persons in whom the pain

leaves the loins, and is turned downwards, are to be encouraged; but

when the disease does not leave the hip and loins, such persons are

to be warned that it is to be dreaded. In those cases in which there

are pains and swellings about the joints, and they do not pass off,

after the manner of gout, you will find the bowels enlarged, and a

white sediment in the urine; and, if you inquire, the patient will

admit that the temples are often pained, and he will say that he has

nightly sweats. If the urine have not this sediment, nor do the sweats

take place, there is danger either that the joints will become lame,

or that the tumor called meliceris will form in it. This disease forms

in those persons who in their youth had epistaxis, and in whom it

had ceased afterwards. They are to be interrogated whether they had

discharges of blood in their youth, and if they have pruritus in the

breast and back. And the same thing happens to those who have severe

pains in the bowels, without disorder of them, or who have hemorrhoids.

This is the origin of these complaints. But if the patients have a

bad color, they are to be interrogated whether their head be pained,

for they will say that it is. In those cases in which the bowels are

pained on the right side, the pains are stronger, and especially when

the pain terminates in the hypochondrium at the liver. Such pains are

immediately relieved if borborygmi take place in the belly. But when

the pain ceases, they pass thick and green urine. The disease is not

deadly, but very protracted. But when the disease is already of long

standing, the patients have dimness of sight in consequence of it.

But they are to be interrogated whether, when young, they had a flow

of blood, and regarding the dimness of vision, the greenness of the

urinary discharge, and regarding the borborygmi, if they took place and

gave relief; for they will confess to all these symptoms.

Lichen, leprosy, and leucè, when they occur in young children and

infants, or when they appear at first small, and gradually increase

in the course of a long time--in these cases the eruption is not to

be regarded as a deposit, but as a disease; but when they set in rank

and suddenly, this case is a deposit. Leucè also arises from the most

fatal diseases, such as the disease called phthisis;[526] but leprosy

and lichen are connected with black bile. These complaints are the more

easily cured the more recent they are, and the younger the patients,

and the more soft and fleshy the parts of the body in which they occur.

ON REGIMEN IN ACUTE DISEASES.

THE ARGUMENT.

In this treatise two very important questions are discussed: first, a

nosological question, regarding the proper distinction of diseases from

one another; and secondly, a therapeutical, respecting the rules by

which the regimen in acute diseases ought to be regulated. The former

of these is of a polemical nature, being an attack directed against

the physicians of the Cnidian school of medicine, who distinguished

diseases from one another in an arbitrary manner, from incidental

varieties in their constitution, and without proper attention to their

true constitution and identity. As will be seen in the annotations, the

Cnidians pretended to recognize several varieties of disease connected

with bile,--several fanciful divisions of diseases of the bladder,

and so forth; to which mode of distinguishing diseases there would

obviously be no end, since of incidental varieties in any case there

can be no limit. The other question discussed in this treatise relates

to what may justly be pronounced to be one of the most important points

connected with the practice of medicine, namely, the proper regimen

in acute diseases; that is to say, in idiopathic fevers and febrile

diseases, comprising most of those diseases now classed under the head

of _Zymotic_, and which constitute by far the highest item in

our bills of mortality at the present day. Our author distinguishes

them by the names of pleurisy, pneumonia, phrenitis, lethargy, causus,

and their cognate diseases, including fever of the continual type.

Now it is to be borne in mind, that the phrenitis,[527] lethargy, and

causus of Hippocrates, were all epidemic fevers, so that, with the

exception of pleurisy and pneumonia, all the diseases here treated of

are fevers of the country in which Hippocrates resided. One, then,

cannot well imagine a question which from the commencement of the

medical Art must have been felt of higher importance than this,--how

so numerous and formidable a class of diseases ought to be treated. In

the attempt to solve it, every imaginable mode of treatment, as might

have been expected beforehand, was tried, and its effects determined

by experience. Herodicus, the master of Hippocrates in gymnastics,

applied his panacea in the treatment of febrile diseases, and, as we

are informed, with the most disastrous results. “Herodicus,” says the

author of the sixth Book of Epidemics, “killed persons in fever by

promenading, much wrestling, and fomentations.” (§ iii., 18.) It may

_now_ appear wonderful that so extraordinary a mode of practice

should have ever been attempted in this case; but while men of all

ranks continue to resort for the cure of all sorts of diseases to any

individual who has got a single hobby with which he constantly works to

his own profit, whether it be _gymnastics_, or _shampooing_,

or the _wet sheet_, we may expect to hear that such rash

experiments have been repeated. Truly mankind pay as dearly for their

tame submission to the insane practices of professional chiefs, as the

Greeks are represented by the poet to have suffered from the follies of

their princes:

“Quicquid delirant Reges, plectuntur Achivi.”[528]

And surely it is much to be desired that men would learn a lesson from

the Past, and not allow every new page in the history of society and of

the profession to furnish a repetition of the oft-told tale of supine

credulity on the one side, and of audacious folly on the other. From

what has been stated, it will readily be understood that it was soon

settled that active exercise is inadmissible in febrile diseases.[529]

It would next come to be determined, what rule was to be followed with

regard to the administration of food in fevers. On this point, as will

be seen below in our annotations, the most diametrically opposite plans

of treatment were essayed. One authority administered the most highly

nutritious articles of food, namely, fleshes, to his patients, while,

on the other hand, some wasted them by enforcing a total abstinence

for several days. Experience, we may be well assured, was not long in

deciding against both the starving and the glutting system: the palled

appetite would soon refuse to accept of solids, and the parched tongue

would speedily crave some allowance of liquids. Even before the days

of Hippocrates, there is every reason to suppose that these extreme

modes of treatment had been abandoned; but still he complains that

in his time many important points in the treatment of acute diseases

were wholly undetermined, such as the following: whether plain drink,

that is to say water, was to be administered;--or, water seasoned

by the admixture of something farinaceous, such as the decoction of

barley;--whether the same should be given so thick as to constitute a

nutritious gruel, or strained so as to form merely a drink;--whether

wine should be given in small quantity, or more copiously;--whether any

of these things should be given from the commencement of the disease,

or not until after an interval of certain days. Hippocrates informs us

that the most discordant opinions prevailed upon these points, and his

professed object, in this treatise, is to reduce the rules of practice

to certain fixed principles. How our author performs this task, the

reader is left to judge for himself; it may be interesting, however,

to know, that Galen with all his devoted admiration of Hippocrates,

is not disposed to admit that his solution of the question at issue

is quite lucid and satisfactory. This opinion Galen pronounces on two

separate occasions; in his commentary on this treatise, and in his

great Work “On the Tenets of Hippocrates and Plato.” As I look upon his

observations contained in the latter Work to be of great importance

toward understanding the bearing of this treatise, I shall not scruple

to introduce a translation of the greater part of them in this place.

The ninth book of the Work we have mentioned opens with an elaborate

disquisition on the logical principles which ought to guide us in

deciding with regard to identity and difference, both in Philosophy and

Medicine: on the former of these subjects he quotes freely from Plato,

and on the other from Hippocrates. Coming, then, to the question in

hand, he says:--“And thus Hippocrates proceeded in the work ‘On the

Regimen of Acute Diseases,’ finding fault with the Cnidian physicians,

as being ignorant of the differences of diseases with regard to genus

and species; and he himself points out the definitions according to

which that which appears to be one, being divided becomes many, not

only in the case of diseases, but also in that of all other things; in

which we find that many of the most celebrated physicians fall into

mistakes, even with regard to the remedies. For some, coming to the

particular use of them, have established a most immethodical method

of instruction; whilst others, stating a very general precept, lay

down a rule which at first sight appears very methodical, but in truth

is very bad, and hence they disagree among themselves; some, as for

example those treating of the remedy for a certain affection, such

as pleurisy, declaring it to be venesection, others purging, some

fomentations by means of sponges, and others of bags, or something

of the like kind. And they differ, in the same manner, with regard

to the use and disuse of the bath, of oxymel, of hydromel, and of

water, of wine, and of ptisan, either giving of the strained juice

only, or of the barley portion only; and some, with regard to food,

giving discordant decisions as to the differences of the sick, and

the indications which a pleuritic affection requires. And that he, as

being the first discoverer, has handled these subjects in rather a

confused manner, I have shown in my Commentary on the treatise which

has been improperly entitled, ‘Against the Cnidian Sentences,’ and ‘On

the Ptisan.’ But in order that those who are desirous of learning,

may have a clear exposition of this question in a brief form, I

shall not scruple to give here a summary of it. In the commencement

of pleuritic attacks, when the side is just beginning to be pained,

inasmuch as the nature of the disease is not yet obvious, he directs

fomentations, otherwise called heating applications, to be tried,

and he explains the materials of which they consist. And then, if

the complaint is not removed, it is to be ascertained whether the

patient took food recently, and whether the bowels have been moved,

and he gives instructions what should be done in these cases. But

if the disease does not yield to these means, he gives definitions

of those cases which require venesection and purging, and those in

which one should use hydromel for drink, or oxymel, or water until

the crisis, without giving any food; and those in which the juice of

ptisan is to be used, or the barley along with it, and when food is to

be administered. In like manner, with regard to the administration of

wine, it is determined in what cases it is to be given, and in what

not, and when, and of what quality. And in like manner respecting

baths, and other matters of the like kind. And as a twofold mistake

is committed with regard to the divisions (of diseases), some doing

it in a deficient manner, and others carrying this process to excess,

Hippocrates, finding fault with both, expresses himself thus, in the

beginning of the book: ‘Some of them, indeed, were not ignorant of the

many varieties of each complaint, and their manifold division, but when

they wish to tell clearly the members (species?) of each disease, they

do not write correctly; for the species would be almost innumerable

if every symptom experienced by the patients were held to constitute

a disease, and receive a different name.’ And again, respecting the

remedies, as being deficient, he writes thus: ‘And not only do I not

give them credit on this account, but also because those they use are

few in number.’ Afterwards, assuming what is of great importance to the

question, he does not give a clear solution of it, and therefore the

whole bearing of the question is misunderstood by many physicians. I

have, therefore, given an exposition of the whole subject, in my first

Commentary ‘On the Regimen of Acute Diseases;’ and it is necessary to

show the import of it briefly. The question is given by Hippocrates

in the following terms: ‘But it appears to me that those things are

more especially deserving of being consigned to writing, which are

undetermined by physicians, notwithstanding that they are of vital

importance, and either do much good or much harm. By undetermined, I

mean such as those: wherefore certain physicians, during their whole

lives, are constantly administering untrained ptisans, and fancy they

thus accomplish the cure properly, whereas others take great pains

that the patient may not swallow a particle of the barley (thinking it

would do much harm), but strain the juice through a cloth before giving

it: others, again, will neither give thick ptisan nor the juice, some

until the seventh day of the disease, and some until after the crisis.

Physicians are not in the practice of mooting such questions, nor

perhaps, if mooted, would a solution of them be readily found, although

the whole Art is thereby exposed to much censure from the vulgar, who

fancy that really there is no such science as Medicine, since, in

acute diseases, practitioners differ so much among themselves, that

those things which one administers, as thinking it the best that can

be given, another holds to be bad.’ And a little afterwards: ‘I say,

then, that this question is a most excellent one, and allied to very

many others, and some of the most vital importance in the Art: for,

that it can contribute much to the recovery of the sick, and to the

preservation of health in the case of those who use it well, and that

it promotes the strength of those who take gymnastic exercises, and is

useful to whatever one may wish to apply it.’ The inquiry regarding

the differences of opinion among practitioners, he says, is of the

greatest consequence, not only to the sick, for the recovery of health,

but also to those in health, for the preservation of it, and to those

who practise it for the recovery and preservation of deportment. And

he afterwards adds, ‘to whatever one may wish;’ as indicating that

the solution of this inquiry is applicable not only to medicine but

to all the other arts to which one may choose to apply it. For it is

wonderful that physicians practising an art, in which the remedies

applied may be determined by experience whether they are beneficial or

hurtful, should yet make the most conflicting statements respecting

those things which are beneficial and those which are prejudicial. For,

in philosophy, it is not to be wondered at that there should be no end

to most disputes, since these things cannot be clearly determined by

experience; and therefore some hold that the world is uncreated, some

that it was created, some that there is nothing beyond its boundary,

some that there is, and some declaring what that which is contained

is, and some pronouncing it to be a vacuum, having no substance in it,

and some holding that worlds in inconceivable numbers, and infinite,

exist. For such discrepancy of opinion cannot be set at rest by any

clear appeal to the senses. But it is not so with respect to the

benefit or injury derived from remedies administered to the body,

since the differences among physicians, in this case, may be decided

by experience, as to which of them are beneficial and which injurious.

Wherefore the solution of this question is not very clearly stated by

Hippocrates, and on that account it has excited the observation of

almost all the commentators on this book. It is this: some of the sick

require abstinence from food, until the disease come to a crisis, and

some require food, and of these some require the unstrained ptisan,

and some the strained, as also some require still more substantial

food, and, moreover, some require oxmyel, or hydromel, and some water,

or wine. Wherefore to those physicians who have cultivated the Art

upon experience alone, that only appears beneficial which perchance

has seemed useful in most cases. Neither do they venture to try the

opposite mode of regimen, for fear of failure. He alone, then, who

knows the constitution of the sick, and the nature of the disease, and

the powers of the remedy which is administered, and the time in which

it ought to be used, will be able rationally to devise the remedy to be

applied, and confirm his expectation of it by experience.”

Galen gives other remarks, not devoid of interest, on the same subject,

but these want of room obliges me to pass by. I may mention, however,

that after giving, in the form of extract, the passage on wine (§ 12),

he makes the remark, that if the question be put whether wine should be

given to persons in fever, the proper answer to it would be, that it is

to be given in some certain cases, and in others not. (See tom. v., p.

773, ed. Kühn.) Thus far Galen.

Before quitting this subject, I would beg leave to make a few remarks

on some points of medical practice which are here treated of, and

which appear to me to be either overlooked, or not satisfactorily

determined at the present day; and also upon some modern innovations on

the practice of the ancients. As far as I have observed, it is quite

a common practice now to administer food, such as farinaceous gruels,

or animal broths, without much reserve, after evacuation of the system

either by purging or bleeding. Now it will be seen that Hippocrates

forbids food to be administered at such a season, as the body, being

weakened by the depletion, is unable to digest it properly, and

consequently what is given as a support to the frame proves a load to

it. To the reason here assigned for this practice, might be added that

the vascular system, having been emptied, greedily absorbs the food

before it is properly digested. I am not sure that this physiological

principle is stated in any of the works of Hippocrates, but it is

frequently to be met with in the works of Galen, and in those of the

toxicologists, from Nicander to Actuarius. See PAULUS ÆGINETA,