THE ARGUMENT.
The ancient physicians commonly used the term Epidemic in the same sense as it is understood now, that is to say, as applying to any disease which attacks a multitude of persons in a locality at any particular period. This, as will be seen in our annotations below, is nearly the definition which Galen gives of it; and it is generally used by Hippocrates, in the first and third books of the “Epidemics,” in pretty much the same sense as it is used by our great modern authority on epidemics, Sydenham. But, although this be the strict sense in which the ancient authorities use the term, it must be borne in mind that, as applied to the whole seven books of the “Epidemics,” it must be taken in a much wider signification; for there are many things treated of in them to which the term epidemic can by no means be thus applied, such as surgical cases, fragments of anatomical descriptions, philosophical speculations, empirical remedies, general reflections on various topics, and so forth. In fact, the work entitled “The Books of Epidemics” can be viewed in no other light than as an Adversaria, or Memorandum Book, in which is collected a variety of isolated facts and detached observations, to serve as the materials for more elaborate and finished works on professional subjects. Indeed, Galen does not hesitate to give it as his opinion, that some of the most celebrated of our author’s productions, such as the “Aphorisms” and “Prognostics,” are in a great measure made up from the materials originally laid up in this capacious repertory of observations;[602] and, with regard to the former of these works, there is no person familiarly acquainted with it but must admit the truth of Galen’s remark. But, respecting the other, although it must be obvious, upon a comparison of them, that there is a close connection between it and the “Epidemics,” there can be no doubt that, in composing the “Prognostics,” Hippocrates availed himself of other materials ready prepared for his use, in the “Prorrhetics” and “Coan Prænotions” of his predecessors, the Asclepiadæ;[603] so that, of all his admired productions, it, perhaps, is the one which has the least pretension to any originality of matter. If it be thought strange that the term epidemics should have been applied to a work composed of such heterogeneous materials, I would remark, in explanation, that, although the subject-matters of which it consists are not all of this nature, the most valuable portion of them refers to epidemics, and it is not to be wondered at that the whole collection should have got its appellation from the most prominent subject to which it relates.
I shall now proceed to give a succinct analysis of the various subjects which are contained in the First and Third Books of the “Epidemics.”
The first book opens with a description of the leading phenomena of a certain season, which is called the First Constitution; it was southerly, coldish, rainy, clouded and misty, with some intervals of drought. The most noted diseases of spring in this constitution were causus and an epidemical parotitis. But the most important subject which is handled under this head, is an epidemic phthisis, of which a very interesting description is given.
The Second Constitution is described as being northerly and humid; humid ophthalmies, dysenteries, and diarrhœas are described among the prevailing diseases of the season; but the most marked affection which is said to have occurred in this constitution, is a continual fever of a serious character, which did not come to a crisis until after it had run a long course. It is described as passing off by deposits, and principally by dropsies, and an affection of the urinary organs. One cannot help being struck with the remark which Hippocrates makes, that he never knew a case prove fatal in which the strangury supervened. The directions as to the treatment he condenses into one general rule, which well deserves to be engraved in letters of gold, that “the aim of the physician should be to do good to his patient, or, at least, to do no harm.” The description of this constitution concludes with some general reflections on the prognostics in causus and phrenitis.
The Third Constitution is described as being of a very variable character; winter stormy, spring rainy, summer hot, autumn cold and dry. The ardent fevers (or causi) began early in the season, but did not assume a fatal character until autumn. This disease came to a crisis in four modes—by an epistaxis, by a copious flow of urine, by a deposit, or by an alvine discharge. In women, there was also sometimes a crisis by menstruation.
The Fourth Constitution is one which, by Galen and the other authorities, has been entitled the pestilential, and has attracted great attention, as being supposed to have derived its peculiar characters from the great Plague which prevailed during the Peloponnesian war, and which is described in so interesting a manner by Thucydides. Galen, not only in his Commentary, but in various other parts of his works, advocates this opinion, and it will be seen from what is stated in our annotations, that there is in reality a striking resemblance between the features of the plague, as delineated by Thucydides, and the epidemical diseases which are noticed by Hippocrates as having prevailed during this constitution. Of all the diseases here described the most remarkable is the erysipelas, which, although not of a very fatal character, was still of a formidable nature, as it frequently terminated in gangrene. Causus, phrenitis, and anthrax are also described as being common under this constitution. The last of these being a well-known symptom of the Oriental plague, it has naturally excited a good deal of speculation to determine whether or not our author here refers to the glandular plague. See our remarks on Epidem. III.
In these books it is remarkable that phthisis is treated of as a febrile disease, and in particular as supervening upon attacks of the semitertian. There seems reason to suppose that our author means to describe a hectic fever succeeding to intermittents, which had caused organic derangement of the internal viscera, more especially of the liver and spleen. See Paulus Ægineta, Book II., 32.
In the first book, fourteen cases of disease are related, and in the beginning of the third twelve, and sixteen in the end; thus making forty-two in all. It is worthy of remark, that in twenty-five of these the result was fatal. There is every reason, then, to suppose that they were selected for a purpose, but what that purpose was cannot now be easily determined. The most natural would, no doubt, have been to illustrate, by examples, the forms of the different diseases which are described as occurring during the Constitutions previously described. But there seems to be little or no reason to suppose that this is the object for which they are related. In proof of this, I may mention that there is not in the collection a single case of the epidemical erysipelas which is described as having been the prevailing disease during the fourth Constitution. Indeed it must strike everybody, who reads them carefully, as a singular feature in these cases, that the lineaments of a particular disease are seldom to be recognized, and this perhaps may be regarded as a proof of the faithfulness with which they have been copied from nature. In short, we here recognize the features of disease in the concrete, and not in the abstract. And is not this what we should expect in all true copies from Nature? How often does the candid physician find himself forced honestly to admit that he is at a loss what name to give to the combination of morbid actions which he is called upon to treat! The common herd of mankind would seem to fancy, as in Nature there are certain types of all animal and vegetable substances, and the botanist has no difficulty in classing such a plant, for example, as the conium maculatum; and the natural historian can readily pronounce that such a bird is the alcedo Ispida; that the physician, in like manner, upon examining the characteristic features of any case, should have no difficulty in pronouncing that it is pleuritis, for example, or pneumonia, or the like. But how often does it happen, that the complaint in question is an aggregate of symptoms, produced by peculiarities of constitution, and incidental circumstances, which, taken together, constitute an ensemble which does not well admit of being referred to any one of the general forms of disease described in our nosological systems? Now, I say the most wonderful feature in the cases related by Hippocrates, is that they are descriptive of the symptoms observed in certain diseased individuals, instead of being, what most modern cases are, symptoms drawn to correspond with certain ideal forms of disease. What, in my opinion, likewise adds very much to the value of these cases is, that (as Galen somewhere remarks in his Commentary) the author never aimed to make his Books of Epidemics a work on Therapeutics, and hence, in noting morbid phenomena, his mind in not warped by any particular hypothesis, nor by any selfish interest, in order to place some favorite mode of practice, advocated by himself, in a favorable light. May I be permitted here to remark, that the reader will be much struck with our author’s admirable talent for describing the phenomena of disease as they are actually presented to us, if he will compare the case related by him in these two books with those of almost any modern authority whatever;—for example, with those related by the late Dr. James Hamilton, in his celebrated work on Purgative Medicines. In the latter, you look in vain for the strongly-marked features which present themselves in all the cases related by our author,—for a description of the condition of the hypochondriac region,—of the state of the animal heat in the extremities,—of the minute characters of the alvine and urinary discharges,—of the respiration,—of the patients’ position in bed,—and many other symptoms, which are invariably noticed by Hippocrates. And what reasonable person will venture to deny, that the symptoms I have just now mentioned are most important features in every febrile disease, and that no one can be said to have a sufficient view of such a case, who does not take these into account? To confine our attention at present to only one of these symptoms,—can it ever be a matter of indifference what are the physical characters of so important an excretion as the urine? that is to say, whether the grosser particles of it, which usually fall to the bottom, be present in the urine or not? Yet in all the seventeen cases related in the modern work just now referred to, the characters of the urine are not given in a single instance. And although the object of the writer is to enforce his own peculiar views, as to the utility of purgative medicines in this disease, he scarcely ever gives the minute characters of the alvine discharges, as is uniformly the case with Hippocrates; or if they are noticed at all, it is in so confused a manner that the reader is at a loss to determine whether they are produced by the disease, or by the medicines which have been administered. For the issue of the case no obvious cause is stated, but the reader is expected to draw the conclusion that, as purgatives were freely given, and a considerable proportion of the cases did well,—(agreeably to the hackneyed rule, post quod, ergo propter quod,)—the purgatives brought about the fortunate result. Had the cases been fully and circumstantially detailed, it might have been found that, as in those related by Hippocrates, recovery was preceded by a critical discharge of urine, accompanied with a copious sediment; and then the more probable inference would have been, that the amendment was referable to it, and not to the purgative medicines which were administered. It is, I regret to say, a notable example of the want of logical training in the education of professional men, in the present age, that inferences regarding a peculiar method of practice were allowed to be founded upon narratives of observations so defective and one-sided as those I refer to.
I cannot quit the present subject of discussion, without saying a few words in reference to what must strike the reader as a singular feature in the cases related in the books of the Epidemics; I mean the general omission of any mention of treatment. The reader will find in our annotations various remarks of Galen on this head, from which he will learn that the Great Commentator inclines to the opinion, that in all these cases the usual routine of practice was followed, but that no mention is made of medicines, unless when there was some deviation from the established rules. For example, in a certain febrile case, it is stated that the patient was bled on the eighth day, and Galen contends that venesection is noticed in this instance, merely because it was contrary to the established rule of not bleeding after the fourth day; for that if the practice had been in accordance with the general rule, it would not have been noticed at all. Now it must be admitted, that this supposition is by no means improbable, and that examples of this usage are not wanting, even in the modern literature of medicine. To give an example, which just occurs to me; in not a few of the cases of cerebral disease related by Dr. Abercrombie, in his work “On the Brain,” there is no allusion whatever to remedies, although no one, who recollects the vigorous system of treatment then pursued by the profession in “Modern Athens,” will doubt for a moment that they must have been applied. As this eminent authority, then, when he believed that the treatment had no perceptible effect on the course which the disease ran, thought himself warranted in omitting all mention of it, it might be supposed, in like manner, that Hippocrates may have passed over the remedies applied, from some such motive or consideration. But another reason for the absence of remedies in these Reports may be readily supposed. May not Hippocrates have been at first quite undecided what was the proper plan of treatment to be adopted in those cases, and thought it the wisest course to attempt nothing rashly, but to be for a season the quiet spectator of the course which the diseases in question were naturally disposed to run, before attempting to interfere in the struggle between morbific agents with which he was imperfectly acquainted, and their great physician, as he held Nature to be?[604] And however much the advocates for a bold system of treating diseases may be disposed to deride this expectant method, which Asclepiades contemptuously denominated “the contemplation of death,”[605] it does not want the sanction of a name which is second only to Hippocrates in the literature of epidemical fevers. Sydenham admits, that with all the diligence which he had applied to the study of these diseases, he was always greatly puzzled what plan of treatment to adopt at the first breaking out of a new epidemic, and that it was only “ingenti adhibita cautela intentisque animi nervis,” that he could make up his mind what course of treatment to adopt in such an emergency. Need it be wondered at, then, that two thousand years earlier the modest mind of our great author should have hesitated for a time, before deciding how to act under similar circumstances? I must own, therefore, that I have long inclined to the opinion, that, distracted with the conflicting plans of treatment adopted by his contemporaries, Hippocrates at first did little or nothing in the treatment of epidemical fevers, and that it was only after a patient study of their symptoms, and many cautious trials, that he ventured to lay down those excellent rules of treatment which he has described so admirably in his work “On Regimen in Acute Diseases.” This, however, is merely my individual opinion, and the reader must receive it as such.
M. Littré, in the Argument prefixed to his translation of the Epidemics, enters very fully into the discussion of the question regarding the nature of the diseases which are treated of in the course of this work. This is a task, however, which I deem it superfluous to undertake at any length, as I have stated my opinions on this subject in the Commentaries on the Second Book of Paulus Ægineta, and after maturely weighing what has been elicited by subsequent inquirers, I find no cause to retract any of the opinions which are there advanced. That the causus of Hippocrates, and the other ancient authorities, was not the typhus of the more temperate parts of Europe, but a bilious fever, of the remittent type, must be quite apparent to every person at all acquainted with the medical literature of febrile diseases. M. Littré’s researches lead him to exactly the same conclusion, and much deference is due to his judgment in this case, as it must be admitted that a French physician is now very favorably situated for contrasting the diseases of temperate and hot climates, owing to the familiar intercourse which at present subsists between Paris and Algiers. Of all the materials which he has collected from the observations of French physicians in Algeria, the most interesting are those which he draws from a work on Fevers, by M. Maillot. The description which is there given of “la fièvre algide,” is so striking, and is so much calculated to illustrate the nature of the fevers which are treated of in this work of Hippocrates, that I shall not scruple to quote it entire.
“La fièvre algide (dit M. Maillot) n’est pas généralement, comme on le dit, la prolongation indéfinie du stade de froid; je l’ai vue rarement débuter de la sorte. Il y a même entre ces deux états une contraste frappante. Dans le premier stade des fièvres intermittentes, la sensation du froid est hors de toute proportion avec l’abaissement réel de la température de la peau, tandis que, dans la fièvre algide, le froid n’est pas perçu par le malade, alors que la peau est glacée. C’est ordinairement pendant la réaction que commencent les symptômes qui la caractérisent; souvent ils surviennent tout à coup au milieu d’une réaction qui paraissait franche. Au trouble de la circulation succède en peu d’instants et presque sans transition le ralentissement du pouls, qui devient bientôt très rare, fuit sous le doigt et disparaît; l’abaissement de la température du corps va vite et suit la progression promptement décroissante de la circulation; les extrémitiés, la face, le torse, se refroidissent successivement; l’abdomen seul conserve encore quelque temps un peu de chaleur; le contact de la peau donne la sensation de froid que procure le marbre. Les lèvres sont décolorées, l’haleine froide, la voix cassée, les battemens du cœur rares, incomplets, appréciables seulement par l’auscultation; les facultés intellectuelles sont intactes, et le malade se complaît dans cet état de repos, surtout lorsqu’il succède à une fièvre violente, la physionomie est sans mobilité, l’impassibilité la plus grande est peinte sur son visage; ses traits sont morts. La marche de cette fièvre est très insidieuse; il n’est peut-être personne, dont elle n’ait surpris la vigilance, avant d’être familiarisé avec l’observation des accidens de cette nature, on prend souvent pour une très grande amélioration due aux déplétions sanguines, le calme qui succède aux accidents inflammatoires; et plus d’une fois, dans de semblables circonstances, on n’a été détrompé que par la mort soudaine du malade. Toutes les fois qu’à une réaction plus on moins forte, on verra succéder tout à coup un ralentissement du pouls, avec pâleur de la langue et décoloration des lèvres, on ne devra hésiter à diagnostiquer une fièvre algide. La temporisation ici donne la mort, en quelques heures. Dans quelques cas très rares, j’ai cependant vu cet état algide se prolonger trois ou quatre jours. Le malade expire en conservant toutes ses facultés intellectuelles,[606] il s’éteint comme par un arrêt de l’innervation. Lorsque la mort n’est pas le terme de cet état morbide si grave, le pouls se relève; la peau reprend sa chaleur naturelle; quelquefois alors la réaction détermine une irritation de l’encéphale ou des voies digestives; mais rarement elle est assez intense pour qu’on soit obligé de la combattre par des déplétions sanguines.”[607] I shall add a remark, which M. Littré gives on the same authority: “J’ai tenu à mentionner ici l’impression qu’éprouva M. Maillot au début de sa pratique en Algérie, et qui est si instructive; car, aller subitement de France exercer la médecine dans un pays chaud, ou lire les observations d’Hippocrate, c’est tout un: l’impression est la même, le changement de scène est aussi grand.”[608]
I cannot help remarking in this place, however, that it appears to me singular, that M. Littré should represent the febris algida as being confined to southern climates, and should speak of it as being unknown in Paris; for, at all events, there seems to be no doubt that it prevails in a more northerly region, namely, in Holland. It is thus described by the celebrated Franciscus de le Boe (or Sylvius), who was professor of practical medicine at Leyden about the middle of the 17th century: “Febres algidæ observantur nonnunquam, non tantum frigore præsertim, sed frigore tantum molestæ: adeo ut aliquando et frequentius levis, aliquando et rarius nullus sequatur calor. Tales, etiam semper algidas in Nosocomio academico habuimus ita manifestas, ut non tantum incipiente, atque augescente, sed etiam vigente et déclinante, imò cessante paroxysmo, id est, semper tum suo, tum adstantium, tum medicorum sensu moleste ubique frigerent, nunquam teperent, minus calerent ullibi ægri. Suntque hæ algidæ graviores semper forsan quotidianæ.”[609] The febris algida is also named “rigor without heat,” by the Greek authorities, and “frigus quod non calefit” by the Arabians, who, like Sylvius, as quoted above, regard it as a variety of the quotidian intermittent. See Paulus Ægineta, Book II., 26.
M. Littré[610] quotes the remark of an excellent English authority on fever, J. Johnson,[611] that it is singular the effects of marsh effluvia should have escaped the observation of Hippocrates, more especially as the remittent and intermittent fevers, of which he treats so fully, are mostly derived from this source. Now I must say, that I am not aware of there being any passages in the works of Hippocrates where the effects of marsh effluvia in engendering such fevers are distinctly noticed; but if Hippocrates was ignorant of this fact, in the etiology of fevers, it was well known to Galen, as may be seen on reference to his very interesting work “On the Difference of Fevers.”[612] The Arabians also were familiar with the fact. See Avicenna, iv., 1, 2, 1.
In the treatise “On Airs,” which, although not admitted by us into the list of genuine works, has considerable pretension to be so regarded, the causes of fever are treated of with great precision, and there the pestilential fevers are said to derive their origin from miasma, but whether or not under this term be included marsh effluvia, cannot be determined. But perhaps a better reason might be assigned for there being little or no allusion to malaria in the works of Hippocrates, namely, that after all, this was not the cause of the epidemical diseases which he describes. The following extract from a work of very high authority on fever is well deserving of consideration in this place: “A question has arisen as to whether or not the inflammatory states of fever, in warm countries, are caused by malaria, or by the other causes now instanced (excess of heat, etc.). There can be no doubt that malaria very frequently produces in the plethoric, young, and robust, who have recently arrived in a hot climate, fever of an inflammatory and continued kind; but it must also be conceded that this fever chiefly occurs, even in persons thus constituted, during the dry season, and at times and in places where the existence of malaria is doubtful, or, at least, by no means proved. It is notoriously admitted that the inflammatory states of continued fever, in both the East and West Indies, appear among those soldiers, sailors, and civilians, who have not been long in a warm country, and who have not suffered from disease since their arrival; and that they take place chiefly during the dry and warm seasons, and in situations where the usual affects of malaria are never observed. This is the result of the experience of Jackson, Annesley, Boyle, Twining, Conwell, and the other experienced practitioners in warm countries. It agrees with my own observations, and is even admitted by Dr. Fergusson, who has gone much further than any one else in assigning malaria as the cause of intertropical fevers.”[613] I may mention, moreover, that Hippocrates and his contemporaries were evidently not ignorant of the fact, that the atmosphere in the vicinity of marshes and large rivers is unwholesome to the inhabitants of warm climates. See De Diæta, ii, 2.
The following are part of the conclusions which M. Littré draws from his investigations into the nature of the fevers described by Hippocrates. I quote them as being strongly confirmatory of the opinions delivered by me in the Commentary on the Second Book of Paulus Ægineta.
“Les fièvres décrites dans les Epidémies d’Hippocrate différent de nos fièvres continués.
“Les fièvres décrites dans les Epidémies ont, dans leur apparence générale, une similitude très grande avec celles des pays chauds.
“La similitude n’est pas moins grande dans les détails que dans l’ensemble.
“Dans les unes comme dans les autres les hypochondres sont pour un tiers des cas, le siége d’une manifestation toute spéciale.
“Dans les unes comme dans les autres, il y a une forte tendence ou réfroidissement du corps, à la sueur froide et à la lividité des extrémités.”
On almost all the other diseases treated of in these books, M. Littré’s opinions, in like manner, exactly coincide with those delivered by me in the above-mentioned work. Thus he arrives at the conclusion, that the Phrenitis and Lethargus of Hippocrates were varieties of the Causus. Compare Paulus Ægineta, Book III., 6, 9. He refers them to les fièvres pernicieuses comateuses pseudo-continués et les fièvres pernicieuses dolorantes pseudo-continués of M. Maillot. It would appear from the extracts which he quotes from a work of M. Roux, on the Diseases of Morea, that a similar tendency to pass into phrenitis and lethargy is still observable in the land of Greece. The fevers of the East Indies also, as described by Dr. Twining,[614] appear to partake very much of the same character. In a word, the conclusions to which a patient study of modern authorities on the subject have brought me amount to this; that the fevers described by Hippocrates in his “Epidemics,” are exactly the same as those which are now described as still prevailing in the land of Greece: that they correspond very well with those described by Cleghorn as occurring in Majorca; differ but little from those described by Pringle, Monro, and Sylvius, as happening in the Low Countries, and differ from those described by Twining, as happening in Bengal, only in a few particulars.
From the analysis of their contents given above it will readily be understood that the subject-matters of these two books are not arranged methodically. Indeed it is quite obvious from the nature of the work that the matters which are treated of in it had never been methodized by the author. Certainly then, as proposed by Desmair,[615] it would be a much more natural arrangement to give the four Constitutions of the season first, and then to give the forty-two cases together. But the present arrangement being of old standing, no editor has thought himself warranted to depart from it.
There are two important professional subjects of which it may appear surprising that there is no mention in the “Books of the Epidemics,” I mean sphygmology and contagion. Galen repeatedly declares it as his opinion, that Hippocrates paid no attention to the characters of the arterial pulse, and that the subject was not at all studied until after his time; and as far as I can see there is no ground for calling in question this opinion of Galen. Herophilus, in fact, would appear to have been the first person that made any progress in this study. It is more remarkable that Hippocrates should omit all allusion to the other subject, more especially as the contagiousness of certain diseases would appear to have been the popular belief of his age. Thus his contemporary, Thucydides, in describing the plague, expresses himself in such terms as puts it beyond a doubt that he regarded the disease as being of a contagious nature. And another contemporary, Isocrates, makes such observations on a certain case of empyema, by which he evidently means phthisis pulmonalis, as to show that it also was regarded as being communicable.[616] How the omission is to be accounted for I do not know, but certain it is that not the least reference to contagion, in any shape, is to be found in any of the Hippocratic treatises.