APPENDIX TO THE WORK
ON
REGIMEN IN ACUTE DISEASES.
THE ARGUMENT.
No one can read this piece attentively without coming to the conclusion that it is not a natural continuation of the subject discussed in the preceding work, but that it is made up, in a considerable measure, of materials extracted from it. Expositions of subjects which are there given methodically are here presented in a disjointed form; and rules of practice there laid down with precision are here often delivered in a vague and indefinite shape. Still, however, it must be admitted, that the reverse is sometimes the case, and that what is presented imperfect in the former part of the work is here sometimes reproduced very much improved. It has been therefore a matter of much dispute among the critics whether this portion be the composition of Hippocrates, or whether it be altogether the work of a different hand. The most probable conjecture respecting it seems to be, that as Hippocrates in the preceding part several times announces his intention of giving a continuation of the subject, some one of his immediate disciples undertook the work which he had thus promised, and composed this treatise from fragments left by the author himself, and from materials collected from his other works. As stated by Galen in his Commentary, and as we have explained in our remarks on the “Aphorisms,” in the second section of the Preliminary Discourse, it was a common practice, in ancient times, to add appendices to popular works. I can have no hesitation, then, in following the example of M. Littré, who recognizes it as an appendix to the preceding work. But I must say that I rather incline, with Galen, to think that there are many things in it which cannot have come from Hippocrates, than to hold with M. Littré that it is nearly or altogether his composition. But however that may be, it indisputably contains much interesting matter, for which we have every reason to believe that we are indebted to Hippocrates, either directly or at second hand. I shall now give a brief abstract of its contents.
He commences with some general observations on the nature and treatment of causus, the endemial fever of Greece. What is said on this head is much to the purpose, but incomplete. Then there is given a general rule for bleeding in diseases which certainly is well deserving of attention at the present day, when professional opinions on this point of medical practice are very much unsettled. Nowadays we have abandoned all general rules of practice, and profess to be guided solely by experience; but how variable and uncertain are its results in the present case! I myself—albeit but verging towards the decline of life—can well remember the time when a physician would have run the risk of being indicted for culpable homicide if he had ventured to bleed a patient in common fever; about twenty-five years ago venesection in fever, and in almost every disease, was the established order of the day; and now what shall I state as the general practice that has been sanctioned by the experience of the present generation? I can scarcely say, so variable has the practice in fever and in many other diseases become of late years. One thing is remarkable in the present work with regard to venesection in pneumonia and pleurisy, namely, that it is directed to be carried the length of inducing deliquium animi, contrary to the practice laid down in the preceding work, and to the rule which was followed by all the other ancient authorities. Another of the rules regarding bleeding here delivered is also deserving of attention, namely, that in inflammatory diseases it is improper to purge before bleeding, but that venesection should precede all other means of cure.
The section in which cynanche is treated of appears to me to be highly interesting and important. I think it may be a question whether the prognostic spirit of Hippocrates and his followers had not in a great measure anticipated all the results of modern diagnosis.
After this there follows some additional account of causus, which, although out of place, contains observations of considerable interest.
To the treatment of pleurisy and pneumonia we have already alluded, but the subject is so interesting that we cannot dismiss it with so brief a notice. In the ancient method of treating fevers and febrile affections three main objects would appear to have been kept in view: 1st, by depletions, to remove the morbid fluids from the general system, or to draw them off from a particular spot in which they had fixed; 2d, by diluents, to supply the waste of fluids occasioned by the preternatural heat of the body; and, 3d, to support the strength by a suitable supply of such nutriment as the system is then capable of receiving.
Now with regard to venesection, it will be seen in this and the preceding work that the practice is regulated by certain well-marked indications, namely, the seat of the pain, the condition of the patient, and the characters of the sputa. The purging is regulated by the state of matters below the chest, it being held as a general rule that clysters should be administered regularly every day during the first days of the fever. After purging comes the cooling drinks, such as oxymel. The administration of farinaceous food in a liquid state, that is to say, of unstrained ptisan, is to be regulated by the state of the sputa and urinary sediment, namely, when the sputa have put on a purulent appearance, and the sediment has become copious and reddish. Now this certainly seems to be a very intelligible and judicious rule for the administration of nutritious articles in febrile diseases. I need scarcely remark that at the present time there is scarcely a rule of practice in medicine which is worse defined than this respecting the administration of wine and other alimentary substances in febrile diseases. In proof of what is now stated, I would beg leave to refer the reader to what will be admitted to be one of the best authorities in modern literature on fever, I mean to Dr. Tweedie’s elaborate article on this subject, in the “Cyclopædia of Medicine.” It will be seen, at vol. ii., p. 208, that the rules for the administration of wine and other articles of food are by no means well defined. A cool skin and a soft pulse, when combined with debility, are the indications upon which most stress is laid; but the pulse, as long ago it was pronounced by Celsus to be, is “res fallacissima,” and of this the excellent author seems to have been sensible; for the injunctions which he gives to regulate the administration of the wine and other articles, by the effects they produce, sufficiently show that he was sensible how deficient in precision our knowledge of the subject is at present. At the same time he makes it appear that he was well aware of one important fact in the treatment of febrile diseases, which, although distinctly recognized by Hippocrates, is still frequently overlooked by ordinary practitioners, namely, that in convalescence the stomach partakes of the general debility, and is unable to digest food in any great quantity at that time.[564] M. Littré further calls attention to another rule for the administration of wine, lately laid down by Dr. Stokes, of Dublin, which is certainly a most important one, provided it is confirmed by time and experience. It is founded on auscultation, and is to this effect; that when the impulse of the heart is abnormally weak, and when there is a diminution of the proportion between the two bruits, or when there is a preponderance in the sound of the second bruit, wine may be freely administered. Now, as I have said, this rule, if sanctioned by ample experience, is undoubtedly a most excellent one; but I may be allowed to remark, that my own observations on the heart in fever have led me to the conclusion that, as I have stated respecting the pulse, its sounds are very fallacious; and I must say that the rule of Hippocrates appears more likely to prove a certain guide in this instance. For is it not a natural view of the subject, that wine and other articles of food should be withheld while the emunctories are not in a condition to cast off the recrementitous superfluities of the system; but that when the secretions are properly established, alimentary substances may be safely administered?[565]
There is another point connected with the regimen in acute diseases on which I have a remark or two to make—it is the administration of animal matters in a fluid state, such as beef-tea, or soups from fowls. These we see frequently administered in febrile cases by practitioners of the present day, but by the ancient authorities they would appear to have been entirely rejected. Which party is the safer guide in this case? For my own part, I have long thought that animal matters, when introduced into the system while in a febrile state, have a tendency to become putrid, and thereby to occasion an increase of the heat and general disorder.
After some defective observations on dysentery, our author treats of tetanus; but here Galen objects to the characters which he gives of the urine, and to his practice as regards the administration of wine. His views, however, are not very different from those which now prevail.