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.