“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, Book V., 2, Syd. Soc. edit.
I would beg leave to call the attention of my professional readers to the guarded and judicious manner in which pleurisy is treated by our author, beginning with hot fomentations to the side, and gradually advancing to the more active means, namely, purging and venesection. It will be remarked that Hippocrates holds depletion to be the only legitimate mode of removing the pain of the side, and that his commentator, in illustration of his meaning, pointedly condemns the use of narcotics in this case. Now this is a most important consideration, as bearing on a mode of practice which has obtained much favor of late years; I allude, of course, to the treatment by a combination of mercurials and opium. The experience of some thirty years would seem to decide in its favor, but how often have certain methods of treatment in other cases obtained the sanction of professional favor for a much longer period, and yet in the end been abandoned as positively prejudicial? In my younger days I knew old practitioners, of the highest reputation, who administered these medicines in scrofula,—in cancer,—in every case! One cannot think of the changes in professional opinions on the mercurial treatment of syphilis, since the days of John Hunter, without the most painful feeling of distrust in all modes of treatment where one cannot recognize some reasonable bond of connection between the remedy applied and the effects produced, or where long experience and analogy are in favor of them, and where the judgment runs no risk of being imposed upon by fallacious appearances and collateral circumstances. In a word, who does not feel disposed, in the practice of medicine, constantly to recur to the great truth proclaimed by our author in his first Aphorism? “Experience is fallacious, and judgment is difficult.”
I am almost afraid further to put the question to the profession of the present day, whether or not the administration of antimonials in pleuro-pneumonia be an improvement on the ancient practice, or the reverse? Shall we say, then, that experience has decided that this substance (antimony), which, when applied to the cuticle, or to its prolongation, the epithelium of the stomach and bowels, occasions pain, heat, and vascular congestion, produces the very opposite effects on the lungs, when absorbed into the blood and conveyed to them? I dare not venture to answer these questions myself, but suggest them as deserving to be reconsidered, with serious impartiality, by the profession. I trust, however, it will not be supposed that I incline to stand up for ancient modes of practice, because they are old, or to condemn modern methods because they are new; I merely state the reflections which the comparison of ancient and modern usages, on this important subject, has suggested to me.
Our author, it will be seen, attaches much importance to the administration of the ptisan, or decoction of barley, in pleuro-pneumonia. Our modern Hippocrates, I mean, of course, Sydenham, was equally partial to this practice,[530] which is still very much followed on the continent.
It will be remarked, that Hippocrates says nothing of counter-irritants to the skin, in the treatment of pleurisy, all his external applications being of the soothing kind. The stimulant treatment, however, is not altogether modern, having been recommended in certain cases by the Arabians. (See Paulus Æegineta, Vol. I., p. 501.) Celsus also approves of sinapisms to the side. (iv., 6.)
The use of the bath and of the douche, or affusion of hot water in febrile diseases, is an important question, which well deserves to be reconsidered by the profession. (See the annotations on § 18.)