Front Page Titles (by Subject) PRECEPTS OF HIPPOCRATES. - The Writings of Hippocrates and Galen
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PRECEPTS OF HIPPOCRATES. - Hippocrates, The Writings of Hippocrates and Galen 
The Writings of Hippocrates and Galen. Epitomised from the Original Latin translations, by John Redman Coxe (Philadelphia: Lindsay and Blakiston, 1846).
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PRECEPTS OF HIPPOCRATES.
SECTION I.—TREATISE VII.
With respect to this treatise, Haller says, that although spurious, it is by no means unimportant. Its commencement and conclusion appear to be derived from Hippocrates, to whose brevity and gravity it approximates. It gives advice to the physician concerning his fees, his remedies, and food. Treats of consultations, and denounces the impudence of quackery. In short, like the preceding treatise, it contains many general precepts that are well calculated to excite reflection in a philosophic physician, and to prove useful to him.
Opportunity is the work of a moment; itself, of short duration. Aid from medicine is sometimes the work of time, but not unfrequently, it is immediately called for. This is to be well considered in our intercourse with the sick, who require to be treated, not from mere probabilities, but by observation in connexion with reason. Reflection is a well-regulated remembrance of events perceptible to the senses. Events are evident facts, which are transmitted to the mind through the medium of the senses. Impressions thus frequently produced, the regular train of such events, antecedently and subsequent, is preserved by memory. Reasoning becomes allowable, provided it is based on the complete train of events which are retraced by memory in their proper order and succession. It would seem that nature is impelled to its various changes and movements by many different causes, which serve to illustrate it; because the event that ensues is fixed and certain, and the mind can only become acquainted with it in the way I have pointed out, the only way in which it can arrive at certainty. If, on the contrary, our reasoning is not founded on an evident chain of certain facts, but merely of probable events, the most fatal consequences may result from the opinions that may be formed; resembling the case of a traveller in an unknown and trackless country. Such persons, therefore, who practise medicine on such doubtful principles, deserve to suffer for their bad success. Is it not sufficient that the unhappy patient is prostrated by sickness, without having it augmented through the unskilfulness of his physician? I repeat therefore, that success cannot be anticipated from reasoning alone, but through the agency of the means above referred to. The mere babbler is certain of nothing, and is replete with error and deceit. An accurate attention to events, without neglecting attending circumstances, can alone promote that sure and certain practice which is called medicine. It is this only that can render the physician useful to those around him.
No difficulty should be made at receiving information from the most illiterate, provided it appears that they have some knowledge of the subject under consideration. It was thus, I think, that our art had its origin; collecting together, from all quarters, a body of facts. We ought not to neglect what chance may present, especially if it be reiterated; listening with attention in order to profit, and not repulsing our informant, by boasting of our cures, and deeming his experience void of utility. Doubts as to remedies spoken of as if alone appropriate, are highly proper. This does not imply obstinacy; all diseases, from a variety of circumstances, require at times a difference of treatment.
A point deserving of attention in medicine, is respecting the fee of the physician. If he commences by speaking of payment, the patient will presume that he will not be neglected. By not attending to this, he will be led to imagine that your attendance will be irregular. I apprehend therefore that a stipulation as to this particular is perfectly correct, except in cases of an acute nature. Here, the rapidity of the disease admits of no delay; and humanity will lead the physician to think more of the esteem he may acquire, than of mere profit. It is far preferable in such cases to bear the ingratitude of those you preserve, than to stipulate for payment whilst the patient is in danger. It is true, some persons who under the pretence of the hospitality afforded, or the facility of cure, object to payment. Such are worthy of contempt alone. The sick should be considered in the light of the shipwrecked mariner. And where is the real physician who will not rather faithfully afford his services, than act with inhumanity and rigour? Wherefore, when you have made yourself acquainted with the disease, pursue a regular mode of treatment, and neglect nothing that may prove conducive to a cure. Your views as to payment should be moderate, yet sufficient to recompense your labour, without however despising wealth. And with respect to the poor, to visit them gratuitously; preferring thus the pleasure of a grateful mind, to the increase of pomp and parade. Strangers and the poor demand peculiar attention from the physician, for no one can have a proper regard for medicine, who forgets his duty to his fellow-creatures. Some, on their recovery from sickness, appreciating the danger they have gone through, extol the benevolence of their physician, repaying thus a debt of gratitude. It is highly praiseworthy to give advice, preservative of health, and even of bodily appearance. The ignorant physician cannot comprehend such wholesome preventive admonitions; but being carried away by self-sufficiency, he evinces by his conduct that his standing is misplaced, and his sole desire is that of gain; hence he demands payment both from the rich and poor. Proud in prosperity, he spares no expense in his luxurious habits, and cares not for the faults he commits, under a conviction of impunity; but if adversity overtakes him, he is submissive and base in the extreme. The true physician earnestly strives to avoid mistakes, and by this, deservedly merits the name of master of his art. In the pursuit of his duty, he neglects nothing, not even to those in the most abject poverty, for good faith and justice accompany him in all his actions. The reverse of this, is evident in those of an opposite character. Dangerous diseases they sedulously avoid, and undertake those only that can give them éclat. Consultation with other physicians they carefully shun, by declaring their want of confidence in their opinion and judgment. Their patients consequently experience all the unhappy effects, resulting from their imprudent choice. A better selection might at least have proved beneficial, a circumstance of no trifling importance at times, even if inadequate to a perfect cure. The same reasons that led them to have recourse to quacks, the hope of a speedy and perfect restoration to health, frequently induce great impatience and neglect in the due continuance of remedies, or in perpetually changing them.
If, now, you would institute a comparison as to the ingratitude of patients, it will be seen that for the most part all are deficient in a due recognition of the services of the physician. The poor, at first, are mild and obedient, but ingratitude and ill behaviour too often succeed. The affluent, in sickness, are exuberant in their professions and promises; but in health, when reminded of payment, they excuse their neglect by their rents not being received, and then think no more on the subject. Enough, however, on this head. The physician must act according to circumstances.
A physician, if embarrassed by the state of the patient, or by the novelty of the disease, ought to feel no repugnance in calling for aid in consultation, for it often happens that in a dangerous and unyielding disease, anxiety leads to the omission of much that might be useful, by destroying that presence of mind which is so highly necessary to the medical man. Many regard it as a right, that in consultation, their opinion should be acquiesced in; or perhaps they sustain it by calling in question that of others. Now I am persuaded, that a physician who is prompt to blame others, must render himself contemptible: it is the common practice of quacks. Consultations, however, are not constituted on such illiberal principles, for it is fully admitted, that with even the highest attainment of medicine, still, much is wanting to be known.
These particulars being thus disposed of, one still remains to be noticed, as marking the accomplished practitioner, viz., the due encouragement of the sick, and checking that anxiety with regard to the progress of disease, which so usually is present. Such anxiety is extremely prejudicial, and he who knows how to prevent or allay it, is of infinite service. How many fall victims to this despair that invades them! When, therefore, any one is charged with the care of the sick, their confidence will be gained by stating that our art consists in following nature, and not striving to oppose her. Any other plan will prove unsuccessful. In truth, health is that natural state, in which foreign agencies are not employed, but a certain harmony of action existing between the air and heat and the concoction of the humours. Nature exerts herself in the promotion of health, by means of our food, and the appropriate functions of the body, unless, indeed, some malformation exists from birth, in which case attempts to remedy it should be made; for all derangement is unnatural, even although it may progress but slowly.
The physician should carefully avoid all affectation, such as the use of perfumes and similar superfluities. His dress should be neat and decent, without an admixture of finery or ostentation. An excess of attention, even to this, is sometimes morbid; of little importance, if duly confined, but when carried to an extreme, it is injurious to him. I would on no account depreciate gentility. It is essential to him in his pursuits; but it is important that he should know its boundaries, and its true intent. In a public discourse, he should not be too flowery or poetical in his remarks; they rather proceed from idleness or ignorance, than from real knowledge. All information, if even the offspring of deep research, is to be carefully avoided, if it has no bearing on the subject before us. This is particularly the case in medicine, which is sufficiently attractive in itself, and requires not the foreign aid of ornament.
They who begin the study of medicine late in life are much to blame. Self-experience is insufficient; that of others is often of great importance;—but their memory of what has been handed down, is so confused as to confound and render useless all they say.—They talk of their superior knowledge, as if desirous to instruct the friends around their patients, who have attended to receive their orders. For my part, when called in consultation with such boasters, I do not stop to argue with them about the disease, but come at once to the point, by asking what plan they propose for adoption. As they may chance to know something of what should be done, although otherwise deficient, I desire only their practical information, and pay no attention to their assumed knowledge in the principles of the art.—Experience, constant, and of long continuance, can alone lead to a full and thorough acquaintance with them. Those who profess to understand them, may be allowed the privilege of talking; but their practice must be deemed the test of their knowledge.
A severe regimen, if not too long continued, increases the desire for food, but if not cautiously administered, it will augment disease. Should all the wishes of a blind man be indulged, how much injury would it not be productive of, even in those which he might most particularly desire.
Some few remarks of an aphoristic character here follow.—Ed.
Sudden changes of the air are to be carefully avoided.
In youth every thing seems pleasing;—such is not the case in age.
Difficulty in speaking may arise from some disease, or from imperfection in the organs of hearing;—from too rapid pronunciation, or extreme rapidity in the evolution of ideas.—Such is by no means uncommon in those who pursue the different paths of science.
Youth is sometimes the best remedy in slight affections.
The continuance of disease, with no alteration, indicates that it will prove of long duration.
Diseases are terminated by crises.
Little is required to cure, unless the part affected is of great importance.
As we suffer by sympathy from the affections of others, so also will pain in one part of the system sympathetically call into action other parts.
We should bear with patience the complaints of those in pain.
Extreme labour is deserving of some indulgence.
A healthy locality is very desirable.
THE BOOK OF PROGNOSTICS.
This book is uniformly considered as one of the genuine writings of Hippocrates. In the preface to it, Haller speaks of it as “containing all the symptoms, good or bad, of diseases, as derived from every source, and arranged in a natural order, which is unusual for him. The first symptoms are drawn from the countenance, the mouth, the lips, and eyes: next, from the decubitus; then from the appearance of wounds or ulcers; from tossing about of the hands, or picking the bedclothes; from respiration, sweat, the state of the hypochondria, swelling of them, or of the belly. It next treats of suppuration; of dropsical symptoms in acute diseases; of the power of the patient in sustaining his disease; his limbs, &c., as to colour, temperature, and sense of feeling. Of sleep, alvine discharges, urine, vomiting, sputation, and of empyema from an acute disease; of auricular abscess—paraphrenitis—inflammation of the bladder; general termination of fever, acute pain of the head, and ears; ulcers of the throat, and angina; tumour of the uvula; termination of fever in abscess; prognostics of vomiting, and of nasal hemorrhage, and convulsions. Towards the conclusion, Hippocrates demonstrates the absolute necessity of the various symptoms enumerated, as the basis of a faithful prognosis. Adding that those symptoms, which in Greece are good or bad, are equally the same in every other country: that even in Scythia, whoever is acquainted with them, is capable of prognosticating. The same prognosis holds good in relation to diseases not mentioned, but which terminate on the same days. The careful observation of epidemics and of the atmospheric constitution, is enforced. The pulse alone seems to be here overlooked.”
In addition to the above from Haller, I shall introduce a few preliminary remarks from Gardeil, who, among other particulars, states that it has been well translated by M. le Febre-Villebrune—a work I have not seen. After saying that the first section of Fœsius contains none of the writings ascribed to Hippocrates, he thus proceeds: “It is unquestionably one of the most precious of the writings of the father of medicine. In it, the physician will find the foundation of the whole doctrine of crises, of urines, expectoration, hemorrhages, abscesses, &c., and every where a master’s hand is apparent, so that it appears perfect and complete. Such is not the case with the aphorisms,—and I think every physician would find it useful to commit it to memory. Its brevity is its principal defect. It is nevertheless highly probable, that many of our present race of doctors will ridicule many things that are to be found therein, more especially the statement relating to urines; for it is now beneath their dignity to examine the urine of the sick, or even their expectoration for the most part! My own constant observation of the urine, preserved in glasses for inspection, has confirmed me in my opinion of the correctness of the Hippocratic doctrines. In respect to the pulse, which Hippocrates attended to but in a very slight degree, I think we err in depending so much upon it to the exclusion of those particulars almost entirely, in which he had the greatest confidence.”—Ed.
A physician should endeavour to become acquainted with the phenomena of diseases. He who can inform the sick, not only of their present state, but of what preceded and of what may be expected, and point out what they have omitted to mention, will readily be esteemed as being perfectly acquainted with their disease, and they will therefore with confidence commit themselves to his care. A foresight of what is to be expected, enables him the better to fix upon his plan of treatment: a certain cure at all times is impossible, although of more importance than a foreknowledge of events. Some are carried off by the violence of disease before a physician is called on; others, immediately after; some survive for a day, others longer; time is not always afforded to employ fully the resources of our art. It is of consequence however in all cases, to know if the nature of the disorder transcends the power of the constitution; or if there is not in it something supernatural; (ϑειον τι. Hipp.; divinum, Hall., Fœs.) In all cases we ought to be acquainted with what may take place, as a means of acquiring a just celebrity, and of meriting the character of an experienced practitioner; for if a disease is capable of cure, he is the best qualified to effect it who can best guard against the evils anticipated: moreover, by being capable of prognosticating the event either of death or recovery, all blame is avoided.
In acute diseases, the first thing to be noticed is the countenance. Does it look like that of health? especially is it perfectly natural? The more it differs therefrom the worse. A sharp nose, hollow eyes, temples collapsed, the brows knit, ears cold and contracted, and their lobes inverted, the forehead hard, dry, and tense, the whole countenance pallid, greenish, black, livid or of a leaden hue. If at the commencement of disease such is the aspect, without other accompanying symptoms, in order to form a right judgment, it will be proper to inquire whether it may not depend on excessive want of rest, on violent purgation, or even on want of food. In either case, the state of the countenance is of less consequence, and the disordered system may be restored in twenty-four hours; but if it arises from other causes, and does not change in that space of time, we may safely affirm that death is not far distant. If the disease is of more than three or four days’ standing, and the countenance has assumed the above-described appearance, we must examine into the causes that could especially lead to it; at the same time attending to the signs that may exist in other parts of the body.
In examining the eyes, we should ascertain if the light affects them, or involuntary tears flow; if squinting attends, or one eye seems smaller than the other; if the white is of a reddish hue, or the lids of a livid tint, with the small vessels turgid with dark blood, the cornea coated with sordes, the globe of the eye turned upwards or pressed forward, or deeply ensconced in the orbit, with diminished transparency, and the whole countenance changed in colour; such symptoms should be considered of the worst character, and even mortal. The eyes sometimes are seen in sleep, from the lids not closing; if this is customary to the individual, it is less important, or when it arises from a diarrhœa, or from a purgative; otherwise it is a bad symptom, and usually portends death.
If the eyelids, the nares, or lips are convulsed, or cold, pale, or livid, accompanied by any other bad symptom, death is not far distant. So also may it be said when the lips remain flaccid, cold, and pallid.
With respect to the decubitus of the patient, that situation is best, that approaches nearest to that of health—as lying on the side, with the arms, neck, and legs slightly bended, with a gentle moisture over the surface? To lie on the back, with rigid neck and limbs, is bad; but if the patient slides from the pillow towards the foot of the bed, it is infinitely worse. The feet uncovered and cold, the legs, and arms, and neck the same, and in continual jactitation, are symptoms indicating great anxiety. Sleeping on the back, with the mouth constantly open, and the legs strongly interlocked, is fatal. Lying on the belly, if unusual in health, is symptomatic of delirium or severe pain. Sitting upright at the acme of the disease, is bad in all acute cases, but in pulmonic affections, indicates the greatest danger. Gritting of the teeth in fever, unless it be a long-existing habit, is a sign of approaching delirium and death: if occurring in the state of delirium, it is fatal.
Sores, both old and recent, should be noticed. If the disease is mortal, they become livid, dry, or pallid, and quite dry shortly before death.
My remarks as to the motions of the hands are the following. In acute fevers, pulmonary inflammation, phrenitis or headache, if the patient moves them before his face, to and fro, as if catching at flies or motes, or picks the bedclothes or the walls, his state is desperate.
Frequent respiration denotes pain or inflammation above the diaphragm; deep and very slow respiration announces delirium; cold exspiration from the nose and mouth is mostly a fatal sign. An easy breathing in acute diseases, with fever which terminates within forty days, is very salutary.
Sweats are beneficial in all acute diseases, if they occur on critical days, and remove the fever. Likewise when they are universal, and do not weaken the patient; otherwise they are injurious. Cold sweats, or, if limited to the head, the face, or neck, are bad, and if associated with violent fever, indicate death. If the fever is moderate, they indicate a long disease. If they form in drops, like millet seed, about the neck only, it is bad; but if universal over the body, it is a favourable symptom. Sweats arising from debility, or from violent inflammation, are never salutary.
The state of the hypochondria is best when no pain is felt there, and when they are equably soft. If inflammation and pain attend, with tension and inequality, danger is to be suspected. If pulsation is felt in them, it indicates great disturbance, or delirium. The eyes should be inspected, for if much agitated, madness is to be feared. Hard and painful tumours in the hypochondria, if extensive, are very bad; but if on one side only, the danger is less, particularly if in the left side. Death may be soon expected, if this state continues; or, if the fever and swelling extend beyond twenty days, suppuration ensues. A bleeding from the nose, of a salutary tendency, sometimes takes place within a week, which may be expected if the patient complains of headache and disturbed vision, and is under thirty-five years of age. Tumours, soft, and unaccompanied by pain, and yielding to the touch, are longer in duration, but less dangerous. If fever attends, and they do not recede within sixty days, an abscess may be expected. Such is the case in whatever part of the belly the tumour exists;—and all such as are large, hard, and very painful, announce the danger of speedy death. If soft and less painful, death is more remote. Abdominal tumours are less liable to form abscesses, if seated in the epigastrium, than if in the hypochondria. If below the umbilicus, suppuration seldom occurs. Hæmorrhage is more common from tumours above the umbilicus. Suppuration, however, is to be apprehended under all these circumstances,—and in considering this chance, we may conclude that tumours pointing outwards are least dangerous, even if extensive, whilst smaller ones, deeply seated, if free of pain, and the surface retains its natural appearance, are not often hazardous. When suppuration ensues, that pus is best that is white, smooth, and soft to the touch, without any offensive odour. It is bad in proportion as it varies from this standard.
Dropsies, supervening acute diseases, are all dangerous. They do not dispel the fever, but are accompanied with much pain, and are usually fatal. Some have their origin in the iliac regions, some in the lumbar, and others proceed from the liver. In the former, the feet swell, and obstinate diarrhœa attends, without diminution of the pain, or of the aqueous depositions. In the latter case, continual disposition to cough exists, which is harsh and dry; the legs swell, and costiveness ensues, with much pain and little evacuation. Swellings of the belly are occasionally seen, sometimes on one, sometimes on the other side; sometimes they are persistent, and at times disappear.
Coldness of the head, feet, and hands, conjoined with heat in the breast and belly, is a bad symptom. The best state consists in an equable and mild temperature over the whole body. An easy change of position is favourable; but a feeling of heaviness and weight in so doing is dangerous. If to this is added a lividity of the nails and fingers, death is close at hand; a dark or black appearance of those parts is less to be dreaded. All conjoined symptoms are to be noticed; for if the patient appears to bear his illness pretty well, and others equally favourable ensue, the formation of an abscess may be hoped for, that will prove beneficial, and the mortified parts may happily separate. A retraction of the testes and scrotum and penis are significative of severe pain and danger of death.
With respect to sleep, it ought to approximate to that of health, resting at night, and awake during the day. The reverse of this is bad. It is true that sleep from six to ten in the morning is less injurious than after that period; but it is far worse not to be able to sleep at all; whether arising from pain, or fatigue, it may portend delirium.
Those alvine discharges are the best, which have a due consistence, without being hard, and which take place at the accustomed time of health, and in quantity proportioned to the food taken in. Such are indicative of a healthy state of the bowels. If the stools are liquid, it is better that they should not be frequent and large, or accompanied with flatus. They disturb the patient—prevent sleep—and often, if too copious and frequent, induce fainting. According to the nature of the food, and its amount, two or three discharges by day, and one during the night may be considered as right, the largest in the morning, as usual in health. This, however, depends on habit. As a crisis approaches, the discharges ought to become more consistent, and of a yellowish tinge, without any very bad odour;—round worms discharged at the same time are deemed to be favourable.
In all diseases, a soft and un-enlarged belly, is a good sign. If the discharges are very liquid, white, green, or very red and frothy, all such are bad; so are also such as are small, tenacious, whitish, or greenish. The worst discharges are black, oily, livid, eruginous, and extremely fetid. Those of a mixed character may continue for a longer time, but are equally dangerous; also such as resemble the washings of flesh, bilious, porraceous, black; sometimes separately, at times commingled. Wind discharged with little or no noise is favourable; but it is better to be so discharged than to be retained. When passed with crepitus, it often indicates pain or delirium, unless indeed this is done at the caprice of the sick.
Swelling and pain in the præcordia, if recent, and not attended with inflammation, pass off by rumbling in those parts, especially if superadded to this, there is a fæcal discharge, with wind and urine; the gradual descent of the rumbling to the lower bowels is of itself a source of relief.
Urine, which, up to the crisis, deposits a white, light, and equable sediment, is the best, and denotes a short and not dangerous disease. If it be irregular, sometimes without, sometimes with a sediment, the disease will be longer in duration, and more uncertain. When it is red, and the sediment likewise, it will be longer, but safer. The sediment resembling coarse meal is bad; yet worse if it has the appearance of small scales. White and very tender sediment is pernicious; the worst of all is the branlike sediment. White clouds in the urine are good; black clouds are bad. As long as the urine continues red and limpid, no coction ensues in the disease; if this symptom is prolonged there is much danger lest the disease should be fatal before concoction can take place. The worst urine is that whose odour is fetid, and clear as water, or black and thick; of these the black is the most dangerous, both in man and woman, but the aqueous in children. If the urine continues thin and crude, whilst the other symptoms are more favourable, an abscess below the diaphragm may be apprehended. A greasy, web-like appearance on the surface of the urine, denotes a colliquation, and the danger of consumption. The clouds in the urine should be examined, whether they are high in it, or fall to the bottom; the latter, if of the good colours stated above, is favourable: but the reverse, if the colour is of the bad ones enumerated. In order to avoid deception in prognosis from urine, careful examination should be made whether any particular disease of the bladder exists; in such a case, the symptoms are declaratory only of the bladder, and not of the system.
Of vomiting.—The vomiting of bile and phlegm, if not too excessive, is very beneficial. Either of them, singly discharged, is less favourable. If the discharge is green, livid, or black, it is a bad sign; but dangerous in the extreme, should all of them combine. A livid-coloured discharge, of an extreme fetor, denotes death. Fetor of any kind in the discharges from vomiting is always bad.
Of sputation.—The expectoration in all diseases of the lungs and breast ought to be prompt and easy, and of a yellow uniform tinge. If after some continuance of pain, it is yellow or red, with much coughing, and not well mixed, it is a bad sign. A yellow unmixed sputation is bad. If white, viscid, and globular, this is also unfavourable, as is also that which is grayish and frothy. If not well mixed, and if black, it is highly dangerous. If nothing is discharged by coughing, but the rattling in the throat evinces the surcharge of the lungs, it is very bad. In all diseases of the lungs, coryza and sneezing, whether preceding or succeeding the attack, are dangerous; but in other, and even dangerous diseases, sneezing is a good symptom. Yellow expectoration, with a slight intermixture of blood, in the onset of peripneumonia, is salutary; but if this extends to the seventh day and more, less so. All sputation, unaccompanied by relief, is bad, especially if black. All are beneficial when they afford relief. Whenever, in these cases, relief is unobtained by expectoration, purging, bleeding, or by other remedies, or by diet, suppuration may be expected. If suppuration ensues whilst the expectoration continues bilious, whether alone or mingled with pus, it is very pernicious, especially if the pus is thus apparent with the bilious expectoration on the seventh day of the disease; for the danger of death on the fourteenth day is great, unless some favourable symptom should occur in the interval. Thus, if the patient sustains his disease with ease, breathes and expectorates with facility and with less pain, has his body of an equable temperature and softness, and is not very thirsty; if, also, the urine, stools, sleep, sweat, and other signs are favourable, as previously mentioned, every hope may be entertained of a happy termination; but if several of these good symptoms are wanting, he will not survive the fourteenth day. If, on the contrary, the disease is badly supported, the breathing quick and frequent, pain unmitigated, expectoration difficult, thirst extreme, unequal heat of the body, the belly and breast very hot, forehead, hands, and feet, cold,—sweat, sleep, urine, stools, of a bad character; all these are dangerous symptoms; for if any of them are conjoined with bilious and purulent expectoration, the patient will die on the ninth or eleventh day. In these conjunctures, such sputation must be deemed fatal, and as announcing death before the fourteenth day. By a comparative estimate of these good and bad signs, we deduce the prognosis, and thereby look into futurity.
Some of these abscesses break on the twentieth day, some on the thirtieth and fortieth, whilst a few extend to sixty days. We may presume that suppuration has commenced from the day that fever has shown itself, or previous chills, particularly if the patient complains of a great weight, instead of pain of the affected part, for such is the usual mode of an incipient suppuration. The time of the abscess breaking will be as above stated, reckoning from the beginning of the disease. In order to know on which side, or if only on one, the abscess exists, the patient should be turned on each alternately, and thereby ascertain if he suffers pain in one alone, and feels a greater heat in either; if lying on the sound side he feels as it were a weight pressing above it, the abscess exists in the side in which the weight is felt. The general diagnosis of an empyemaa is as follows. The fever is permanent, slightly remitting during the day, but augmenting at night, with copious sweat, cough, and tracheal irritation, with but trifling expectoration. The eyes become hollow, the cheeks red, the nails curved, the fingers become hot at their extremities; the feet swell, and the appetite is lost; pustules arise over all the body. In all chronic abscesses of the thorax, these symptoms appear, and may be depended upon unhesitatingly. But in recent empyema, the symptoms previously mentioned as occurring at the beginning of a suppuration, are present, to which may be added great difficulty of respiration. As to the prognosis in empyema, the following symptoms will guide us, as to the period of their rupture. If at the commencement there is severe pain and oppression, with cough unaccompanied by expectoration, it may be expected on the twentieth day or sooner; if the pain is moderate, the other symptoms existing as above, it will rupture later,—but previous to this event, the pain, oppression, and cough, will greatly augment. After the rupture of the abscess, those escape, in whom the fever terminates the same day, with a return of appetite and cessation of thirst. The fæces are small in amount and solid; expectoration is easy and without severe coughing, of well-concocted pus, of a uniform colour, and unmixed with phlegm: a cure soon follows. In proportion as the existing symptoms differ, in the same degree will health be postponed. If the fever does not cease, or if afterwards it returns with violence, attended with nausea, thirst, diarrhœa; if the matter expectorated is greenish, livid, and frothy, and pituitous, death will assuredly follow; but if only a part of these symptoms take place, some will die, whilst others recover after a long time. All these and every other symptom are to be attended to, in forming a prognosis. In pulmonic diseases, if abscesses about the ears ensue, or about the lower limbs, these depositions are favourable, and cure will follow. It is to be noticed in these cases, that when fever continues, with unmitigated pain, and expectoration is unduly small in amount; the stools neither bilious nor well mingled; the urine trifling, with little sediment, whilst other symptoms are favourable, such metastases may be looked for. Abscesses form in the lower extremities, when pain and inflammation about the hypochondria have existed; but in the upper extremities, when they have been free from those attendants, and the difficult breathing has subsided without any evident cause. Abscesses in the legs in dangerous peripneumonies, are always favourable; the most so, are those that take place at the time of a change in the expectoration. If swelling and pain take place, when the expectoration becomes purulent, and easily discharged, the patient will certainly recover, and the abscess will soon heal without pain. But if the sputation is bad, and the urine affords a bad sediment, there is danger of the abscess causing lameness, or great trouble. And should such abscesses disappear, and expectoration not follow, but the fever continuing, delirium and death are to be looked for. Internal abscesses from peripneumonies are usually fatal to old people. Young people are more in danger from abscesses elsewhere.
Fever, accompanied with pain in the loins or lower limbs, becomes dangerous by metastasis to the diaphragm. Other attendant signs are to be attended to, for if they are bad, the state of the patient is hopeless. If, on the contrary, they are favourable, an internal abscess may be anticipated. In all abscesses, opened either by cautery or incision, if the pus is white, and not offensive, health will follow; but if it be sanious and muddy, death is to be looked for.
Of Symptoms derived from the Bladder.—A hard and painful bladder is altogether dangerous and fatal, especially if accompanied with continued fever. The pains of the bladder are of themselves adequate to produce death. They induce such obstinate constipation, that the hardened mass can only be removed by force. If the urine becomes purulent, with a white and light sediment, the danger is removed; but if, notwithstanding, the pain continues, the tension of the bladder also, and the fever, there is every reason to expect a speedy death. This state is most usual in youth, between seven and fifteen years.
Of Fevers and their Crises.—The day on which fevers terminate, is ascertained, from observation, long continued, of the day of the recovery or death of the sick.
The mildest fevers, accompanied by the most favourable symptoms, usually terminate on the fourth day or sooner. Those of a worse character, and most unfavourable symptoms, end in death on or before the fourth day. Such is the shortest course they run. The second series terminate on the seventh day; the third on the eleventh; the fourth extends to fourteen days; the fifth to seventeen days; the sixth to twenty. Thus all acute diseases terminate in from four to twenty days, with intervals of about four days. An absolute accuracy cannot be attained; for neither are the years or months determined by a precision in days.a Another series then occurs, in which the first circuit extends to thirty-four days, the second to forty, the third to sixty days. To ascertain at first the crisis of diseases of long duration, is very difficult; it is equally so as to their absolute commencement. Strict observation is necessary from the first, and thenceforward by quaternary periods, in order to discover how the disease will end. The same order is observed in our judgment as to quartan fevers. It is easy to predict the event in diseases of a short course, for their character is different from the beginning. Such as tend to recovery, are accompanied with easy respiration, without pain; the patient sleeps well, and other good symptoms attend. Those tending to death are in all respects the reverse, and have delirium, with all the train of dangerous symptoms. Such being the case, we form our prognosis, near the period of their crisis, from their duration, and from every existing circumstance. In predicting the events which follow delivery in females, we are to reckon from that period.
In fever with violent and continual headache, with other dangerous symptoms, death generally ensues; but should it extend to twenty days, without other bad symptoms, a bleeding from the nose, or an abscess in the lower parts, may be expected. These may also be looked for at the commencement, if the pain is felt in the temples and forehead. Hemorrhage is more common under thirty-five years, and abscess after that age.
Acute ear-ache, with continued fever of extreme violence, is a most dangerous, symptom; it indicates delirium and death, and therefore demands particular attention to every other symptom from the very beginning. Death takes place, in youth, within seven days, but in adults at a much later period: the fever and delirium in these are much less intense, and the suppuration of the ears is enabled to take place. Relapses are more likely to carry them off. The former perish before suppuration is established, unless a flow of whitish pus ensues, when there is some hope, more especially if some favourable symptom should show itself.
Ulcers of the fauces, with fever, are very dangerous, particularly if any of the bad symptoms enumerated appear. Quinsies are most dangerous, and speedily prove fatal, whenever they are unattended by any sensible appearance in the neck or fauces, but are accompanied by violent pain and orthopnœa. Death in such cases often happens in twenty-four hours, although it may be deferred to the second, third, or even the fourth day. If a tumour and redness attends, the danger is imminent, and in proportion to the inflammation; but the termination is more distant. When the inflammation occupies both the throat and fauces, the period may be of yet further extension. Some under these circumstances escape; especially if the redness of the neck extends to the breast, and should not strike in. But if this erysipelas does not recede on the critical days, and no external tumefaction appears, if no pus is coughed up, the patient free from pain, and seeming well, death is indicated, or a retrocession of the erysipelas. It is less dangerous when the swelling and redness soon appear externally; but should the disease extend to the lungs, delirium follows, and it not unfrequently terminates in empyema.
When the uvula is red and tumid, there is danger in burning, scarifying, or cutting it, for it is followed by inflammation and hemorrhage. Other measures must therefore be duly employed to relieve it. But if it becomes paler, and the relaxation gives the round appearance at its extremity of a grape, whilst its upper part appears thin, it may then be safely removed. It is proper to purge gently before the operation, if the hazard of immediate suffocation will admit of the delay.
When fevers disappear without the accompanying favourable signs at the critical periods, a relapse may be apprehended. If they continue for a long period without any inflammation or other manifest cause of pain, an abscess with tumour and pain in some of the joints, especially of the lower extremities, may be looked for;—such occur more speedily, and more frequently in persons under thirty years of age, and rarely until the fever has continued more than twenty days. Old people seldom suffer in this way, even in fevers of the longest duration. Such abscesses occur in continued fever; but if it is erratic in its type, and comes and goes, it will, as autumn advances, be likely to assume the quartan form. And, as above stated, abscesses are more common before the age of thirty, so after that period and in old age, quartan fevers are predominant. Abscesses are more common in the winter; they are longer in healing, but are less liable to recur.
Of vomiting.—Whoever labouring under a fever that is not dangerous, complains of violent headache, with cardialgia, and nubiculæ floating before his eyes, will vomit up bile. If rigor accompanies those symptoms, and the inferior parts of the præcordia are cold, the vomiting is at hand and will be hastened by eating or drinking. Those who suffer from headache at the time of attack will have it augmented on the fourth and fifth days, and on the seventh it will terminate. It is more usual for the headache to begin on the third day; the fifth is then the worst, and the ninth or eleventh it ceases. Should it begin on the fifth day, and be in other respects as above mentioned, the disease ends on the fourteenth. Such is the case with adults, both males and females, in tertians especially. In young people also, but more so in continued fever, and those of a true tertian type. When in these sorts of fever headache occurs, and weakness of vision, or sparks appear, with tension of one or the other hypochondria, without pain or inflammation, epistaxis and not vomiting may be expected. This, especially in young people; it is not so common beyond thirty, and in advanced life: in these, vomiting may be expected.
Of convulsions.—When children have an acute fever, with costiveness, insomnia, and are readily terrified and cry, with frequent change of colour from florid to pale or yellowish, convulsions may be anticipated. These readily take place from the slightest causes in infancy to seven years; beyond that period, convulsions in fever are more uncommon, without the attendance of such dangerous symptoms as are seen in phrenitis. Our prognosis in the diseases of children, both of health and death is, as in other cases, to be deduced from all those symptoms that have been mentioned: we mean in acute diseases, and those which result from them. Now, whoever wishes to foretell whether health or death will take place, or whether the disease will be long or short, ought to make himself fully acquainted with all the symptoms and their respective strength, especially as to those derived from urine, and from expectoration in which there is a mixture of pus and bile. He must also be able to determine promptly, the nature of existing epidemics, and the constitution of the atmosphere—never forgetting, that in every year and season bad symptoms are the evidences of ensuing evil, and good ones of a fortunate issue. Such as I have described, are equally true as to Lybia, Delos, or Scythia. The verification of our prognosis in those regions will not surprise, if given with deliberate judgment, and an accurate estimate of all the symptoms. Those diseases that have not here been spoken of by name, are all to be judged of by the same indications when their crises occur in the same periods.
[a ]This section, under the head of Semeiotica, vel “Ea de quæ Signis agunt,” contains six treatises.—Σημειωτιχη,—pars medicinæ quæ signa morborum dijudicat.—Lexicon Hederici.—“Semeiosis, significatio, notatio, aut designatio dicitur. Comprehendit sub se Dignotionem et Prænotionem: et pars medicinæ doctrinam signorum diagnosticorum et prognosticorum comprehendens, vocatur Semeiotica, rectius Semiologia, estque pars medicinæ, signorum omnium differentias et vires expendens.”—Castelli Lex. Med.
[a ]Vomica, εμπυημα.
[a ]Owing to the frequent intercalation of the Greek calendar.