In this treatise two very important questions are discussed: first, a nosological question, regarding the proper distinction of diseases from one another; and secondly, a therapeutical, respecting the rules by which the regimen in acute diseases ought to be regulated. The former of these is of a polemical nature, being an attack directed against the physicians of the Cnidian school of medicine, who distinguished diseases from one another in an arbitrary manner, from incidental varieties in their constitution, and without proper attention to their true constitution and identity. As will be seen in the annotations, the Cnidians pretended to recognize several varieties of disease connected with bile,—several fanciful divisions of diseases of the bladder, and so forth; to which mode of distinguishing diseases there would obviously be no end, since of incidental varieties in any case there can be no limit. The other question discussed in this treatise relates to what may justly be pronounced to be one of the most important points connected with the practice of medicine, namely, the proper regimen in acute diseases; that is to say, in idiopathic fevers and febrile diseases, comprising most of those diseases now classed under the head of Zymotic, and which constitute by far the highest item in our bills of mortality at the present day. Our author distinguishes them by the names of pleurisy, pneumonia, phrenitis, lethargy, causus, and their cognate diseases, including fever of the continual type. Now it is to be borne in mind, that the phrenitis,[527] lethargy, and causus of Hippocrates, were all epidemic fevers, so that, with the exception of pleurisy and pneumonia, all the diseases here treated of are fevers of the country in which Hippocrates resided. One, then, cannot well imagine a question which from the commencement of the medical Art must have been felt of higher importance than this,—how so numerous and formidable a class of diseases ought to be treated. In the attempt to solve it, every imaginable mode of treatment, as might have been expected beforehand, was tried, and its effects determined by experience. Herodicus, the master of Hippocrates in gymnastics, applied his panacea in the treatment of febrile diseases, and, as we are informed, with the most disastrous results. “Herodicus,” says the author of the sixth Book of Epidemics, “killed persons in fever by promenading, much wrestling, and fomentations.” (§ iii., 18.) It may now appear wonderful that so extraordinary a mode of practice should have ever been attempted in this case; but while men of all ranks continue to resort for the cure of all sorts of diseases to any individual who has got a single hobby with which he constantly works to his own profit, whether it be gymnastics, or shampooing, or the wet sheet, we may expect to hear that such rash experiments have been repeated. Truly mankind pay as dearly for their tame submission to the insane practices of professional chiefs, as the Greeks are represented by the poet to have suffered from the follies of their princes:
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.)
The reader will no doubt have been struck with the remark of Galen, in the extract given above, that our author’s plan in the present work is deficient in method, because he himself was the discoverer of the subject-matters to which it relates. Galen then seems to have been of opinion that it was too much to expect from any individual, that he should produce a work which would be remarkable at the same time for the originality of its materials, and for the methodical arrangement of them. In confirmation of Galen’s judgment in this case, I would direct attention to the difference that there is between this treatise and the “Prognostics;” for all must admit that the matters of which the latter work is composed are admirably methodized, and we have shown above that they were derived in a great measure from the previous labors of the Asclepiadæ.
Those who composed what are called “The Cnidian Sentences”[531] have described accurately what symptoms the sick experience in every disease, and how certain of them terminate; and in so far a man, even who is not a physician, might describe them correctly, provided he put the proper inquiries to the sick themselves what their complaints are. But those symptoms which the physician ought to know beforehand without being informed of them by the patient, are, for the most part, omitted, some in one case and some in others, and certain symptoms of vital importance for a conjectural judgment.[532] But when, in addition to the diagnosis, they describe how each complaint should be treated, in these cases I entertain a still greater difference of opinion with them respecting the rules they have laid down; and not only do I not agree with them on this account, but also because the remedies they use are few in number; for, with the exception of acute diseases, the only medicines which they give are drastic purgatives, with whey, and milk at certain times. If, indeed, these remedies had been good and suitable to the complaints in which they are recommended, they would have been still more deserving of recommendation, if, while few in number, they were sufficient; but this is by no means the case. Those, indeed, who have remodeled these “Sentences” have treated of the remedies applicable in each complaint more in a medical fashion. But neither have the ancients written anything worth mentioning respecting regimen, although this be a great omission. Some of them, indeed, were not ignorant of the many varieties of each complaint, and their manifold divisions, but when they wish to tell clearly the numbers (species?) of each disease they do not write correctly;[533] for their species would be almost innumerable if every symptom experienced by the patients were held to constitute a disease, and receive a different name.[534]
2. For my part, I approve of paying attention to everything relating to the art, and that those things which can be done well or properly should all be done properly; such as can be quickly done should be done quickly; such as can be neatly done should be done neatly; such operations as can be performed without pain should be done with the least possible pain; and that all other things of the like kind should be done better than they could be managed by the attendants. But I would more especially commend the physician who, in acute diseases, by which the bulk of mankind are cut off, conducts the treatment better than others. Acute diseases are those which the ancients named pleurisy, pneumonia, phrenitis, lethargy, causus, and the other diseases allied to these, including the continual fevers. For, unless when some general form of pestilential disease is epidemic, and diseases are sporadic and [not] of a similar character, there are more deaths from these diseases than from all the others taken together.[535] The vulgar, indeed, do not recognize the difference between such physicians and their common attendants, and are rather disposed to commend and censure extraordinary remedies. This, then, is a great proof that the common people are most incompetent, of themselves, to form a judgment how such diseases should be treated: since persons who are not physicians pass for physicians owing most especially to these diseases, for it is an easy matter to learn the names of those things which are applicable to persons laboring under such complaints. For, if one names the juice of ptisan, and such and such a wine, and hydromel, the vulgar fancy that he prescribes exactly the same things as the physicians do, both the good and the bad, but in these matters there is a great difference between them.
3. 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 these, wherefore certain physicians, during their whole lives, are constantly administering unstrained ptisans, and fancy they thus accomplish the cure properly, whereas others take great pains that the patient should 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.[536] Physicians are not in the practice of mooting such questions; nor, perhaps, if mooted, would a solution of them be found; although the whole art is thereby exposed to much censure from the vulgar, who fancy that there really 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, in this respect, they might say that the art of medicine resembles augury, since augurs hold that the same bird (omen) if seen on the left hand is good, but if on the right bad: and in divination by the inspection of entrails you will find similar differences; but certain diviners hold the very opposite of these opinions.[537] I say, then, that this question is a most excellent one, and allied to very many others, 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 are well; and that it promotes the strength of those who use gymnastic exercises, and is useful to whatever one may wish to apply it.
4. Ptisan, then, appears to me to be justly preferred before all the other preparations from grain in these diseases, and I commend those who made this choice,[538] for the mucilage of it is smooth, consistent, pleasant, lubricant, moderately diluent, quenches thirst if this be required, and has no astringency; gives no trouble nor swells up in the bowels, for in the boiling it swells up as much as it naturally can. Those, then, who make use of ptisan in such diseases, should never for a day allow their vessels to be empty of it, if I may say so, but should use it and not intermit, unless it be necessary to stop for a time, in order to administer medicine or a clyster. And to those who are accustomed to take two meals in the day it is to be given twice, and to those accustomed to live upon a single meal it is to be given once at first, and then, if the case permit, it is to be increased and given twice to them, if they appear to stand in need of it. At first it will be proper not to give a large quantity nor very thick, but in proportion to the quantity of food which one has been accustomed to take, and so as that the veins may not be much emptied. And, with regard to the augmentation of the dose, if the disease be of a drier nature than one had supposed,[539] one must not give more of it, but should give before the draught of ptisan, either hydromel or wine, in as great quantity as may be proper; and what is proper in each case will be afterward stated by us. But if the mouth and the passages from the lungs be in a proper state as to moisture, the quantity of the draught is to be increased, as a general rule, for an early and abundant state of moisture indicates an early crisis, but a late and deficient moisture indicates a slower crisis.[540] And these things are as I have stated for the most part; but many other things are omitted which are important to the prognosis, as will be explained afterwards. And the more that the patient is troubled with purging, in so much greater quantity is it to be given until the crisis, and moreover until two days beyond the crisis, in such cases as it appears to take place on the fifth, seventh, or ninth day, so as to have respect both for the odd and even day; after this the draught is to be given early in the day, and the other food in place is to be given in the evening. These things are proper, for the most part, to be given to those who, from the first, have used ptisan containing its whole substance; for the pains in pleuritic affections immediately cease of their own accord whenever the patients begin to expectorate anything worth mentioning, and the purgings become much better, and empyema much more seldom takes place, than if the patients used a different regimen, and the crises are more simple, occur earlier, and the cases are less subject to relapses.
5. Ptisans are to be made of the very best barley, and are to be well boiled, more especially if you do not intend to use them strained. For, besides the other virtues of ptisan, its lubricant quality prevents the barley that is swallowed from proving injurious, for it does not stick nor remain in the region of the breast; for that which is well boiled is very lubricant, excellent for quenching thirst, of very easy digestion, and very weak, all which qualities are wanted. If, then, one do not pay proper attention to the mode of administering the ptisan, much harm may be done; for when the food is shut up in the bowels, unless one procure some evacuation speedily, before administering the draught, the pain, if present, will be exasperated; and, if not present, it will be immediately created, and the respiration will become more frequent, which does mischief, for it dries the lungs, fatigues the hypochondria, the hypogastrium, and diaphragm. And moreover if, while the pain of the side persists, and does not yield to warm fomentations, and the sputa are not brought up, but are viscid and unconcocted, unless one get the pain resolved, either by loosening the bowels; or opening a vein, whichever of these may be proper;—if to persons so circumstanced ptisan be administered, their speedy death will be the result.[541] For these reasons, and for others of a similar kind still more, those who use unstrained ptisan die on the seventh day, or still earlier, some being seized with delirium, and others dying suffocated with orthopnœa and râles.[542] Such persons the ancients thought struck, for this reason more especially, that when dead the affected side was livid, like that of a person who had been struck. The cause of this is that they die before the pain is resolved, being seized with difficulty of respiration, and by large and rapid breathing, as has been already explained, the spittle becoming thick, acid, and unconcocted, cannot be brought up, but, being retained in the bronchi of the lungs, produces râles; and, when it has come to this, death, for the most part, is inevitable; for the sputa being retained prevent the breath from being drawn in, and force it speedily out, and thus the two conspire together to aggravate the mischief; for the sputa being retained renders the respiration frequent, while the respiration being frequent thickens the sputa, and prevents them from being evacuated. These symptoms supervene, not only if ptisan be administered unseasonably, but still more if any other food or drink worse than ptisan be given.
6. For the most part, then, the results are the same, whether the patient have used the unstrained ptisan or have used the juice alone; or even only drink; and sometimes it is necessary to proceed quite differently. In general, one should do thus: if fever commences shortly after taking food, and before the bowels have been evacuated, whether with or without pain, the physician ought to withhold the draught until he thinks that the food has descended to the lower part of the belly; and if any pain be present, the patient should use oxymel, hot if it is winter, and cold if it is summer; and, if there be much thirst, he should take hydromel and water.[543] Then, if any pain be present, or any dangerous symptoms make their appearance, it will be proper to give the draught neither in large quantity nor thick, but after the seventh day, if the patient be strong. But if the earlier-taken food has not descended, in the case of a person who has recently swallowed food, and if he be strong and in the vigor of life, a clyster should be given, or if he be weaker, a suppository is to be administered, unless the bowels open properly of themselves. The time for administering the draught is to be particularly observed at the commencement and during the whole illness; when, then, the feet are cold, one should refrain from giving the ptisan, and more especially abstain from drink; but when the heat has descended to the feet, one may then give it; and one should look upon this season as of great consequence in all diseases, and not least in acute diseases, especially those of a febrile character, and those of a very dangerous nature. One may first use the juice, and then the ptisan, attending accurately to the rules formerly laid down.
7. When pain seizes the side, either at the commencement or at a later stage, it will not be improper to try to dissolve the pain by hot applications.[544] Of hot applications the most powerful is hot water in a bottle, or bladder, or in a brazen vessel, or in an earthen one; but one must first apply something soft to the side, to prevent pain. A soft large sponge, squeezed out of hot water and applied, forms a good application; but it should be covered up above, for thus the heat will remain the longer, and at the same time the vapor will be prevented from being carried up to the patient’s breath, unless when this is thought of use, for sometimes it is the case. And further, barley or tares may be infused and boiled in diluted vinegar, stronger than that it could be drunk, and may then be sewed into bladders and applied; and one may use bran in like manner. Salts or toasted millet in woolen bags are excellent for forming a dry fomentation, for the millet is light and soothing. A soft fomentation like this soothes pains, even such as shoot to the clavicle. Venesection, however, does not alleviate the pain unless when it extends to the clavicle. But if the pain be not dissolved by the fomentations, one ought not to foment for a length of time, for this dries the lungs and promotes suppuration; but if the pain point to the clavicle, or if there be a heaviness in the arm, or about the breast, or above the diaphragm, one should open the inner vein at the elbow, and not hesitate to abstract a large quantity, until it become much redder, or instead of being pure red, it turns livid,[545] for both these states occur. But if the pain be below the diaphragm, and do not point to the clavicle, we must open the belly either with black hellebore[546] or peplium,[547] mixing the black hellebore with carrot or seseli,[548] or cumin, or anise, or any other of the fragrant herbs; and with the peplium the juice of sulphium[549] (asafœtida), for these substances, when mixed up together, are of a similar nature.[550] The black hellebore acts more pleasantly and effectually than the peplium, while, on the other hand, the peplium expels wind much more effectually than the black hellebore, and both these stop the pain, and many other of the laxatives also stop it, but these two are the most efficacious that I am acquainted with. And the laxatives given in draughts are beneficial, when not very unpalatable owing to bitterness, or any other disagreeable taste, or from quantity, colour, or any apprehension. When the patient has drunk the medicine, one ought to give him to swallow but little less of the ptisan than what he had been accustomed to; but it is according to rule not to give any draughts while the medicine is under operation;[551] but when the purging is stopped then he should take a smaller draught than what he had been accustomed to, and afterwards go on increasing it progressively, until the pain cease, provided nothing else contra-indicate. This is my rule, also, if one would use the juice of ptisan, (for I hold that it is better, on the whole, to begin with taking the decoction at once, rather than by first emptying the veins before doing so, or on the third, fourth, fifth, sixth, or seventh day, provided the disease has not previously come to a crisis in the course of this time), and similar preparations to those formerly described are to be made in those cases.
8. Such are the opinions which I entertain respecting the administering of the ptisan; and, as regards drinks, whichsoever of those about to be described may be administered, the same directions are generally applicable. And here I know that physicians are in the practice of doing the very reverse of what is proper, for they all wish, at the commencement of diseases, to starve their patients for two, three, or more days, and then to administer the ptisans and drinks; and perhaps it appears to them reasonable that, as a great change has taken place in the body, it should be counteracted by another great change. Now, indeed, to produce a change is no small matter, but the change must be effected well and cautiously, and after the change the administration of food must be conducted still more so. Those persons, then, would be most injured if the change is not properly managed, who used unstrained ptisans; they also would suffer who made use of the juice alone; and so also they would suffer who took merely drink, but these least of all.
9. One may derive information from the regimen of persons in good health what things are proper; for if it appear that there is a great difference whether the diet be so and so, in other respects, but more especially in the changes, how can it be otherwise in diseases, and more especially in the most acute? But it is well ascertained that even a faulty diet of food and drink steadily persevered in, is safer in the main as regards health than if one suddenly change it to another. Wherefore, in the case of persons who take two meals in the day, or of those who take a single meal, sudden changes induce suffering and weakness; and thus persons who have not been accustomed to dine, if they shall take dinner, immediately become weak, have heaviness over their whole body, and become feeble and languid, and if, in addition, they take supper, they will have acid eructations, and some will have diarrhœa whose bowels were previously dry, and not having been accustomed to be twice swelled out with food and to digest it twice a day, have been loaded beyond their wont. It is beneficial, in such cases, to counterbalance this change, for one should sleep after dinner, as if passing the night, and guard against cold in winter and heat in summer; or, if the person cannot sleep, he may stroll about slowly, but without making stops, for a good while, take no supper, or, at all events, eat little, and only things that are not unwholesome, and still more avoid drink, and especially water. Such a person will suffer still more if he take three full meals in the day, and more still if he take more meals; and yet there are many persons who readily bear to take three full meals in the day, provided they are so accustomed. And, moreover, those who have been in the habit of eating twice a day, if they omit dinner, become feeble and powerless, averse to all work, and have heartburn; their bowels seem, as it were, to hang loose, their urine is hot and green, and the excrement is parched; in some the mouth is bitter, the eyes are hollow, the temples throb, and the extremities are cold, and the most of those who have thus missed their dinner cannot eat supper; or, if they do sup, they load their stomach, and pass a much worse night than if they had previously taken dinner. Since, then, an unwonted change of diet for half a day produces such effects upon persons in health, it appears not to be a good thing either to add or take from. If, then, he who was restricted to a single meal, contrary to usage, having his veins thus left empty during a whole day, when he supped according to custom felt heavy, it is probable that if, because he was uneasy and weak from the want of dinner, he took a larger supper than wont, he would be still more oppressed; or if, wanting food for a still greater interval, he suddenly took a meal after supper, he will feel still greater oppression. He, then, who, contrary to usage, has had his veins kept empty by want of food, will find it beneficial to counteract the bad effects during that day as follows: let him avoid cold, heat, and exertion, for he could bear all these ill; let him make his supper considerably less than usual, and not of dry food, but rather liquid; and let him take some drink, not of a watery character, nor in smaller quantity than is proportionate to the food, and on the next day he should take a small dinner, so that, by degrees, he may return to his former practice. Persons who are bilious in the stomach bear these changes worst, while those who are pituitous, upon the whole, bear the want of food best, so that they suffer the least from being restricted to one meal in the day, contrary to usage. This, then, is a sufficient proof that the greatest changes as to those things which regard our constitutions and habits are most especially concerned in the production of diseases, for it is impossible to produce unseasonably a great emptying of the vessels by abstinence, or to administer food while diseases are at their acme, or when inflammation prevails; nor, on the whole, to make a great change either one way or another with impunity.[552]
10. One might mention many things akin to these respecting the stomach and bowels, to show how people readily bear such food as they are accustomed to, even if it is not naturally good, and drink in like manner, and how they bear unpleasantly such food as they are not accustomed to, even although not bad, and so in like manner with drink; and as to the effects of eating much flesh, contrary to usage, or garlic, or asafœtida, or the stem of the plant which produces it, or things of a similar kind possessed of strong properties, one would be less surprised if such things produce pains in the bowels, but rather when one learned what trouble, swelling, flatulence, and tormina the cake (maza) will raise in the belly when eaten by a person not accustomed to it; and how much weight and distention of the bowels bread will create to a person accustomed to live upon the maza; and what thirst and sudden fullness will be occasioned by eating hot bread, owing to its desiccant and indigestible properties; and what different effects are produced by fine and coarse bread when eaten contrary to usage, or by the cake when unusually dry, moist, or viscid; and what different effects polenta produces upon those who are accustomed and those who are unaccustomed to the use of it; or drinking of wine or drinking of water, when either custom is suddenly exchanged for the other; or when, contrary to usage, diluted wine or undiluted has been suddenly drunk, for the one will create water-brash in the upper part of the intestinal canal and flatulence in the lower, while the other will give rise to throbbing of the arteries, heaviness of the head, and thirst; and white and dark-colored wine, although both strong wines, if exchanged contrary to usage, will produce very different effects upon the body, so that one need the less wonder that a sweet and strong wine, if suddenly exchanged, should have by no means the same effect.
11. Let us here briefly advert to what may be said on the opposite side; namely, that a change of diet has occurred in these cases, without any change in their body, either as to strength, so as to require an increase of food, or as to weakness, so as to require a diminution. But the strength of the patient is to be taken into consideration, and the manner of the disease, and of the constitution of the man, and the habitual regimen of the patient, not only as regards food but also drink. Yet one must much less resort to augmentation, since it is often beneficial to have recourse to abstraction, when the patient can bear it, until the disease having reached its acme and has become concocted. But in what cases this must be done will be afterwards described. One might write many other things akin to those which have been now said, but there is a better proof, for it is not akin to the matter on which my discourse has principally turned, but the subject-matter itself is a most seasonable proof. For some at the commencement of acute diseases have taken food on the same day, some on the next day; some have swallowed whatever has come in their way, and some have taken cyceon.[553] Now all these things are worse than if one had observed a different regimen; and yet these mistakes, committed at that time, do much less injury than if one were to abstain entirely from food for the first two or three days, and on the fourth or fifth day were to take such food; and it would be still worse, if one were to observe total abstinence for all these days, and on the following days were to take such a diet, before the disease is concocted;[554] for in this way death would be the consequence to most people, unless the disease were of a very mild nature. But the mistakes committed at first were not so irremediable as these, but could be much more easily repaired. This, therefore, I think a strong proof that such or such a draught need not be prescribed on the first days to those who will use the same draughts afterwards. At the bottom, therefore, they do not know, neither those using unstrained ptisans, that they are hurt by them, when they begin to swallow them, if they abstain entirely from food for two, three, or more days; nor do those using the juice know that they are injured in swallowing them, when they do not commence with the draught seasonably. But this they guard against, and know that it does much mischief, if, before the disease be concocted, the patient swallow unstrained ptisan, when accustomed to use strained. All these things are strong proofs that physicians do not conduct the regimen of patients properly, but that in those diseases in which total abstinence from food should not be enforced on patients that will be put on the use of ptisans, they do enforce total abstinence; that in those cases in which there should be no change made from total abstinence to ptisans, they do make the change; and that, for the most part, they change from abstinence to ptisans, exactly at the time when it is often beneficial to proceed from ptisans almost to total abstinence, if the disease happen to be in the state of exacerbation.[555] And sometimes crude matters are attracted from the head, and bilious from the region near the chest, and the patients are attacked with insomnolency, so that the disease is not concocted; they become sorrowful, peevish, and delirious; there are flashes of light in their eyes, and noises in their ears; their extremities are cold, their urine unconcocted; the sputa thin, saltish, tinged with an intense colour and smell; sweats about the neck, and anxiety; respiration, interrupted in the expulsion of the air,[556] frequent and very large; expression of the eyelids dreadful; dangerous deliquia; tossing of the bedclothes from the breast; the hands trembling, and sometimes the lower lip agitated. These symptoms, appearing at the commencement, are indicative of strong delirium, and patients so affected generally die, or if they escape, it is with a deposit, hemorrhage from the nose, or the expectoration of thick matter, and not otherwise. Neither do I perceive that physicians are skilled in such things as these; how they ought to know such diseases as are connected with debility, and which are further weakened by abstinence from food, and those aggravated by some other irritation; those by pain, and from the acute nature of the disease, and what affections and various forms thereof our constitution and habit engender, although the knowledge or ignorance of such things brings safety or death to the patient. For it is a great mischief if to a patient debilitated by pain, and the acute nature of the disease, one administer drink, or more ptisan, or food, supposing that the debility proceeds from inanition. It is also disgraceful not to recognize a patient whose debility is connected with inanition, and to pinch him in his diet; this mistake, indeed, is attended with some danger, but much less than the other, and yet it is likely to expose one to much greater derision, for if another physician, or a private person, coming in and knowing what has happened, should give to eat or drink those things which the other had forbidden, the benefit thus done to the patient would be manifest. Such mistakes of practitioners are particularly ridiculed by mankind, for the physician or non-professional man thus coming in, seems as it were to resuscitate the dead. On this subject I will describe elsewhere the symptoms by which each of them may be recognized.
12. And the following observations are similar to those now made respecting the bowels. If the whole body rest long, contrary to usage, it does not immediately recover its strength; but if, after a protracted repose, it proceed to labor, it will clearly expose its weakness. So it is with every one part of the body, for the feet will make a similar display, and any other of the joints, if, being unaccustomed to labor, they be suddenly brought into action, after a time. The teeth and the eyes will suffer in like manner, and also every other part whatever. A couch, also, that is either softer or harder than one has been accustomed to will create uneasiness, and sleeping in the open air, contrary to usage, hardens the body. But it is sufficient merely to state examples of all these cases. If a person having received a wound in the leg, neither very serious nor very trifling, and he being neither in a condition very favorable to its healing nor the contrary, at first betakes himself to bed, in order to promote the cure, and never raises his leg, it will thus be much less disposed to inflammation, and be much sooner well, than it would have been if he had strolled about during the process of healing; but if upon the fifth or sixth day, or even earlier, he should get up and attempt to walk, he will suffer much more then than if he had walked about from the commencement of the cure, and if he should suddenly make many laborious exertions, he will suffer much more than if, when the treatment was conducted otherwise, he had made the same exertions on the same days. In fine, all these things concur in proving that all great changes, either one way or another, are hurtful. Wherefore much mischief takes place in the bowels, if from a state of great inanition more food than is moderate be administered (and also in the rest of the body, if from a state of great rest it be hastily brought to greater exertion, it will be much more injured), or if from the use of much food it be changed to complete abstinence, and therefore the body in such cases requires protracted repose, and if, from a state of laborious exertion, the body suddenly falls into a state of ease and indolence, in these cases also the bowels would require continued repose from abundance of food, for otherwise it will induce pain and heaviness in the whole body.
13. The greater part of my discourse has related to changes, this way or that. For all purposes it is profitable to know these things, and more especially respecting the subject under consideration,—that in acute diseases, in which a change is made to ptisans from a state of inanition, it should be made as I direct; and then that ptisans should not be used until the disease be concocted, or some other symptom, whether of evacuation or of irritation, appear in the intestines, or in the hypochondria, such as will be described. Obstinate isomnolency impairs the digestion of the food and drink, and in other respects changes and relaxes the body, and occasions a heated state, and heaviness of the head.[557]
14. One must determine by such marks as these, when sweet, strong, and dark wine, hydromel, water and oxymel, should be given in acute diseases.[558] Wherefore the sweet affects the head less than the strong, attacks the brain less, evacuates the bowels more than the other, but induces swelling of the spleen and liver; it does not agree with bilious persons, for it causes them to thirst; it creates flatulence in the upper part of the intestinal canal, but does not disagree with the lower part, as far as regards flatulence; and yet flatulence engendered by sweet wine is not of a transient nature, but rests for a long time in the hypochondria. And therefore it in general is less diuretic than wine which is strong and thin; but sweet wine is more expectorant than the other. But when it creates thirst, it is less expectorant in such cases than the other wine, but if it do not create thirst, it promotes expectoration better than the other. The good and bad effects of a white, strong wine, have been already frequently and fully stated in the disquisition on sweet wine; it is determined to the bladder more than the other, is diuretic and laxative, and should be very useful in such complaints; for if in other respects it be less suitable than the other, the clearing out of the bladder effected by it is beneficial to the patient, if properly administered. There are excellent examples of the beneficial and injurious effects of wine, all which were left undetermined by my predecessors. In these diseases you may use a yellow wine, and a dark austere wine for the following purposes: if there be no heaviness of the head, nor delirium, nor stoppage of the expectoration, nor retention of the urine, and if the alvine discharges be more loose and like scrapings than usual, in such cases a change from a white wine to such as I have mentioned, might be very proper. It deserves further to be known, that it will prove less injurious to all the parts above, and to the bladder, if it be of a more watery nature, but that the stronger it is, it will be the more beneficial to the bowels.
15. Hydromel, when drunk in any stage of acute disease, is less suitable to persons of a bilious temperament, and to those who have enlarged viscera, than to those of a different character; it increases thirst less than sweet wine; it softens the lungs, is moderately expectorant, and alleviates a cough; for it has some detergent quality in it, whence it lubricates the sputum.[559] Hydromel is also moderately diuretic, unless prevented by the state of any of the viscera. And it also occasions bilious discharges downwards, sometimes of a proper character, and sometimes more intense and frothy than is suitable; but such rather occurs in persons who are bilious, and have enlarged viscera. Hydromel rather produces expectoration, and softening of the lungs, when given diluted with water.[560] But unmixed hydromel, rather than the diluted, produces frothy evacuations, such as are unseasonably and intensely bilious, and too hot; but such an evacuation occasions other great mischiefs, for it neither extinguishes the heat in the hypochondria, but rouses it, induces inquietude, and jactitation of the limbs, and ulcerates the intestines and anus. The remedies for all these will be described afterwards. By using hydromel without ptisans, instead of any other drink, you will generally succeed in the treatment of such diseases, and fail in few cases; but in what instances it is to be given, and in what it is not to be given, and wherefore it is not to be given,—all this has been explained already, for the most part. Hydromel is generally condemned, as if it weakened the powers of those who drink it, and on that account it is supposed to accelerate death; and this opinion arose from persons who starve themselves to death, some of whom use hydromel alone for drink, as fancying that it really has this effect. But this is by no means always the case. For hydromel, if drunk alone, is much stronger than water, if it do not disorder the bowels; but in some respects it is stronger, and in some weaker, than wine that is thin, weak, and devoid of bouquet. There is a great difference between unmixed wine and unmixed honey, as to their nutritive powers, for if a man will drink double the quantity of pure wine, to a certain quantity of honey which is swallowed, he will find himself much stronger from the honey, provided it do not disagree with his bowels, and that his alvine evacuations from it will be much more copious. But if he shall use ptisan for a draught, and drink afterward hydromel, he will feel full, flatulent, and uncomfortable in the viscera of the hypochondrium; but if the hydromel be taken before the draught, it will not have the same injurious effects as if taken after it, but will be rather beneficial. And boiled hydromel has a much more elegant appearance than the unboiled, being clear, thin, white, and transparent, but I am unable to mention any good quality which it possesses that the other wants. For it is not sweeter than the unboiled, provided the honey be fine, and it is weaker, and occasions less copious evacuations of the bowels, neither of which effects is required from the hydromel. But one should by all means use it boiled, provided the honey be bad, impure, black, and not fragrant, for the boiling will remove the most of its bad qualities and appearances.
16. You will find the drink, called oxymel, often very useful in these complaints, for it promotes expectoration and freedom of breathing. The following are the proper occasions for administering it. When strongly acid it has no mean operation in rendering the expectoration more easy, for by bringing up the sputa, which occasion troublesome hawking, and rendering them more slippery, and, as it were, clearing the windpipe with a feather, it relieves the lungs and proves emollient to them; and when it succeeds in producing these effects it must do much good. But there are cases in which hydromel, strongly acid, does not promote expectoration, but renders it more viscid and thus does harm, and it is most apt to produce these bad effects in cases which are otherwise of a fatal character, when the patient is unable to cough or bring up the sputa. On this account, then, one ought to consider beforehand the strength of the patient, and if there be any hope, then one may give it, but if given at all in such cases it should be quite tepid, and in by no means large doses. But if slightly acrid it moistens the mouth and throat, promotes expectoration, and quenches thirst; agrees with the viscera seated in the hypochondrium, and obviates the bad effects of the honey; for the bilious quality of the honey is thereby corrected. It also promotes flatulent discharges from the bowels, and is diuretic, but it occasions watery discharges and those resembling scrapings, from the lower part of the intestine, which is sometimes a bad thing in acute diseases, more especially when the flatulence cannot be passed, but rolls backwards; and otherwise it diminishes the strength and makes the extremities cold, this is the only bad effect worth mentioning which I have known to arise from the oxymel. It may suit well to drink a little of this at night before the draught of ptisan, and when a considerable interval of time has passed after the draught there will be nothing to prevent its being taken. But to those who are restricted entirely to drinks without draughts of ptisan, it will therefore not be proper at all times to give it, more especially from the fretting and irritation of the intestine which it occasions, (and these bad effects it will be the more apt to produce provided there be no fæces in the intestines and the patient is laboring under inanition,) and then it will weaken the powers of the hydromel. But if it appears advantageous to use a great deal of this drink during the whole course of the disease, one should add to it merely as much vinegar as can just be perceived by the taste, for thus what is prejudicial in it will do the least possible harm, and what is beneficial will do the more good. In a word, the acidity of vinegar agrees rather with those who are troubled with bitter bile, than with those patients whose bile is black; for the bitter principle is dissolved in it and turned to phlegm, by being suspended in it; whereas black bile is fermented, swells up, and is multiplied thereby: for vinegar is a melanogogue. Vinegar is more prejudicial to women than to men, for it creates pains in the uterus.
17. I have nothing further to add as to the effects of water when used as a drink in acute diseases; for it neither soothes the cough in pneumonia, nor promotes expectoration, but does less than the others in this respect, if used alone through the whole complaint. But if taken intermediate between oxymel and hydromel, in small quantity, it promotes expectoration from the change which it occasions in the qualities of these drinks, for it produces, as it were, a certain overflow. Otherwise it does not quench the thirst, for it creates bile in a bilious temperament, and is injurious to the hypochondrium; and it does the most harm, engenders most bile, and does the least good when the bowels are empty; and it increases the swelling of the spleen and liver when they are in an inflamed state; it produces a gurgling noise in the intestines and swims on the stomach; for it passes slowly downwards, as being of a coldish and indigestible nature, and neither proves laxative nor diuretic; and in this respect, too, it proves prejudicial, that it does not naturally form fæces in the intestines: and, if it be drunk while the feet are cold, its injurious effects will be greatly aggravated, in all those parts to which it may be determined. When you suspect in these diseases either strong heaviness of the head, or mental alienation, you must abstain entirely from wine, and in this case use water, or give weak, straw colored wine, entirely devoid of bouquet, after which a little water is to be given in addition; for thus the strength of the wine will less affect the head and the understanding: but in which cases water is mostly to be given for drink, when in large quantity, when in moderate, when cold, and when hot; all these things have either been discussed already or will be treated of at the proper time. In like manner, with respect to all the others, such as barley-water, the drinks made from green shoots, those from raisins, and the skins of grapes and wheat, and bastard saffron, and myrtles, pomegranates, and the others, when the proper time for using them is come, they will be treated of along with the disease in question, in like manner as the other compound medicines.[561]
18. The bath is useful in many diseases, in some of them when used steadily, and in others when not so. Sometimes it must be less used than it would be otherwise, from the want of accommodation; for in few families are all the conveniences prepared, and persons who can manage them as they ought to be. And if the patient be not bathed properly, he may be thereby hurt in no inconsiderable degree, for there is required a place to cover him that is free of smoke, abundance of water, materials for frequent baths, but not very large, unless this should be required. It is better that no friction should be applied, but if so, a hot soap (smegma)[562] must be used in greater abundance than is common, and an affusion of a considerable quantity of water is to made at the same time and afterwards repeated. There must also be a short passage to the basin, and it should be of easy ingress and egress. But the person who takes the bath should be orderly and reserved in his manner, should do nothing for himself, but others should pour the water upon him and rub him, and plenty of waters, of various temperatures, should be in readiness for the douche, and the affusions quickly made;[563] and sponges should be used instead of the comb (strigil), and the body should be anointed when not quite dry. But the head should be rubbed by the sponge until it is quite dry; the extremities should be protected from cold, as also the head and the rest of the body; and a man should not be washed immediately after he has taken a draught of ptisan or a drink; neither should he take ptisan as a drink immediately after the bath. Much will depend upon whether the patient, when in good health, was very fond of the bath, and in the custom of taking it: for such persons, especially, feel the want of it, and are benefited if they are bathed, and injured if they are not. In general it suits better with cases of pneumonia than in ardent fevers; for the bath soothes the pain in the side, chest, and back; concocts the sputa, promotes expectoration, improves the respiration, and allays lassitude; for it soothes the joints and outer skin, and is diuretic, removes heaviness of the head, and moistens the nose. Such are the benefits to be derived from the bath, if all the proper requisites be present; but if one or more of these be wanting, the bath, instead of doing good, may rather prove injurious; for every one of them may do harm if not prepared by the attendants in the proper manner. It is by no means a suitable thing in these diseases to persons whose bowels are too loose, or when they are unusually confined, and there has been no previous evacuation; neither must we bathe those who are debilitated, nor such as have nausea or vomiting, or bilious eructations; nor such as have hemorrhage from the nose, unless it be less than required at that stage of the disease, (with those stages you are acquainted:) but if the discharge be less than proper, one should use the bath, whether in order to benefit the whole body or the head alone. If then the proper requisites be at hand, and the patient be well disposed to the bath, it may be administered once every day, or if the patient be fond of the bath there will be no harm, though he should take it twice in the day. The use of the bath is much more appropriate to those who take unstrained ptisan, than to those who take only the juice of it, although even in their case it may be proper; but least of all does it suit with those who use only plain drink, although, in their case too it may be suitable; but one must form a judgment from the rules laid down before, in which of these modes of regimen the bath will be beneficial, and in which not. Such as want some of the requisites for a proper bath, but have those symptoms which would be benefited by it, should be bathed; whereas those who want none of the proper requisites, but have certain symptoms which contra-indicate the bath, are not to be bathed.