Part 45

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COMMENTARY. The great master of prognostics is Hippocrates, whose system of medicine was entirely based on the observation of the favorable and unfavorable symptoms of disease. It would appear that the first advances in this art were made in the temples of the gods, and especially of Æsculapius, which the sick were in the practice of resorting to in order to ascertain the issue of their maladies. See a very ingenious and learned disquisition, ‘de Hippocratis Doctrina a Prognostice oriunda,’ by F. Z. Ermerins, M.D. The works of Hippocrates, especially the ‘Prorrhetica and Coacæ,’ contain a rich treasure of observations which cannot be too much explored by the student of medicine. His prognostics are founded upon the appearances of the face, eyes, tongue, the voice, hearing, the state of the hypochondriac region, the abdomen, the general system, sleep, respiration, and the excretions. We can do little more, in this place, than express our high sense of the value of the ‘Hippocratic Treatises on Prognostics,’ and recommend the study of them to all members of the profession who would wish to learn the true inductive system of cultivating medicine. We shall give as a specimen of Hippocrates’ and Galen’s labours, in this department, a few of Galen’s remarks on the causes of the symptoms, as described by Hippocrates. It is one of the prognostics of Hippocrates, that profuse perspiration in acute fevers is unfavorable; and, in explanation of this, Galen states that a critical sweat may indeed be favorable; but that such as are profuse and continued indicate a complete prostration of the vital powers. A fixedness of the eyes is said by Hippocrates to be a fatal symptom; the reason of which, according to Galen, is, that it proceeds from paralysis, or insensibility of the muscles of the eye. Hippocrates mentions it as an unfavorable symptom when the patient lies with his mouth open; and Galen attributes this symptom to the origin of the nerves, that is to say, the brain, undergoing pressure. Hippocrates states, that involuntary discharges from the bowels are an unfavorable symptom; and Galen justly remarks that they indicate great insensibility.

The Prognostics and Aphorisms of Hippocrates are further illustrated by the learned and interesting Commentaries of Stephanus Sophista, Theophilus, and Damascius, which were published a few years ago by Dietz. From the nature of their works, it is impossible to give any satisfactory outline of their contents within our narrow limits. We shall merely give one specimen of them. It is stated in one of the Aphorisms of Hippocrates, that dyspnœa and delirium occurring together in fever, indicate a fatal termination. Upon which Theophilus and Damascius remark, that the one symptom implies disease of the heart and the other of the brain. (Ed. Dietz. T. H., p. 415.)

Celsus gives an elegant translation of this part of the works of Hippocrates. The following is his version of the description of the Facies Hippocratica: “Ad ultima jam ventum esse testantur, nares acutæ, collapsa tempora, concavi oculi, frigidæ languidæque aures et imis partibus leniter versæ, cutis circa frontem dura et intenta, color aut niger aut perpallidus.” Other unfavorable symptoms are also strikingly portrayed: “Mali morbi testimonium est vehementer et crebro spirare: a sexto die cepisse inhorrescere; pus expuere; vix excreare; dolorem habere continuum; difficulter ferre morbum; jactare brachia et crura; sine voluntate lachrimare; habere humorem glutinosum dentibus inhærentem; cutem circa umbilicum et pubem macram, præcordia inflammata, dolentia, dura, tumida, intenta, magisque si hæc dextra parte, quam sinistra est; periculosissimum tamen est, si venæ quoque ibi vehementer agituntur.”

Aëtius and Oribasius, like our author, borrow almost every thing from Hippocrates and Galen.

Rhases and Avicenna, particularly the latter, treat of the prognostics in fever very fully. Avicenna, like Hippocrates, sets down deafness as an unfavorable symptom. Hippocrates had stated, that jaundice coming on before the seventh day is unfavorable; but Averrhoes affirms, that all the Indian and Persian physicians reckoned it a favorable symptom. Rhases considers yellowness of the skin an unfavorable symptom, unless the fever be of a bilious nature. Alsaharavius says it is an unfavorable complication when it does not prove critical. It is proper to mention here that Hippocrates modifies the above prognostic by stating in one of his aphorisms, that jaundice coming on on the 7th, 9th, 11th, or 14th day is favorable. (iv. 64.) Alsaharavius states it as a dangerous symptom, when the patient lies on his back with his legs drawn up. This agrees with the prognostic of Celsus “Mors denuntiatur ubi æger supinus cubat, eique genua contracta sunt.” Avicenna and Averrhoes state it as a fatal symptom when the patient sinks down in bed and exposes his hands and feet. (Averrhoes, Comment. in Cant. Avicennæ.)

According to Rhases it is a bad symptom when the patient has lost his modesty, so as to expose freely those parts of the body that should be covered. He holds also that it is a bad symptom when the vomitings resemble verdigris. (Ad Mansor. x, 21.)

Prosper Alpinus gives an admirable account of the prognostics in diseases. See his work, ‘De Præsagiendâ Morte et Vitâ ægrotantium,’ passim. He agrees with the ancients, that deafness is an unfavorable symptom, unless it occur at the time of a crisis. Like the ancients, he considers the absence of thirst an unfavorable symptom in ardent diseases, as indicating that the system is insensible of its wants.

SECT. V.—HOW TO KNOW IF THE DISEASE WILL BE OF LONG DURATION.

The duration of the disease may be ascertained from four things: from the movement of the disease itself, from the habit of the patient, from the pulse, and from the species of the fever. From the movement of the disease thus: if the four periods of a particular paroxysm have passed over quickly and in the least possible time, the disease will be an acute one, the furthest bound of which will be the seventh day, and generally it will come to a crisis on the fourth. If the periods of the first paroxysm occupy more time than this, but do not exceed twelve hours, the disease will still be an acute one, which will terminate within the fourteenth day. If it extend longer, so that the commencement and augmentation of the paroxysm alone occupy a longer period than a day or a night, such a disease will prove a long one. If the disease have no particular paroxysms, but consist of one continued paroxysm, as it were, from beginning to end, as in synochous fevers, even in this case you may call the disease an acute one. It may be judged of from the habit of the patient; for if the face and the rest of the body are already considerably wasted, an acute disease is indicated; but if nowise reduced, a chronic one; for a great collection of offending matter is indicated, which will require a length of time for its concoction. It may be judged of from the pulse: thus, a great, strong, quick, and dense pulse, is indicative of an acute disease, but the contrary of a chronic. From the species of the fever, inasmuch as hot and ardent fevers indicate an acute, whereas gentler, and, as it were, smothered fevers indicate a chronic one.

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COMMENTARY. Celsus thus states the prognostics of a protracted fever: “Signa quædam sunt, ex quibus colligere possumus, morbum, etsi non interemerit, longius tamen tempus habiturum: ubi frigidus sudor inter febres non acutas circa caput tantum, et cervices oritur: aut ubi, febre non quiescente, corpus insudat: aut ubi corpus modo frigidum, modo calidum est, et color alius ex alio fit: aut ubi, quod inter febres aliqua parte abscessit, ad sanitatem non pervenit: aut ubi æger pro spatio parum emacrescit: item si urina modo liquida et pura est, modo habet quædam subsidentia; si lævia atque alba rubraque sunt, quæ in eâ subsidunt; aut si quasdam quasi miculas repræsentet; aut si bullulas excitat.”

Galen has given a full exposition of these symptoms in his Commentary on the Prognostics of Hippocrates, from which Aëtius, Oribasius, and our author have borrowed largely. Rhases, Avicenna, but most especially Haly Abbas, treat at great length of this subject. See also Averrhoes (Commentaries on the Cantica of Avicenna.)

SECT. VI.—HOW TO KNOW IF THE DISEASE WILL TERMINATE BY A CRISIS, OR BY RESOLUTION.

This may be ascertained from what has been already said, namely, the species of the fever and its duration, and perhaps from the species of the fever alone. For hot and ardent fevers are of short duration, and usually terminate with some critical evacuation; whereas the gentler kinds prove more chronic, and have a tendency to abscess. From what has been said, it appears that we may prognosticate not only when the disease will come to a crisis, but also how it will terminate; for acute diseases generally terminate by critical evacuation, and the chronic by abscess.

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COMMENTARY. A similar statement is made by Aëtius (v, 22.) See also Averrhoes (Comment. in Cantica Avicennæ.)

SECT. VII.—ON CRITICAL DAYS.

Of the critical days, some terminate the disease frequently, faithfully, well, completely, clearly, decidedly; and others contrariwise to these. But the 13th has been shown to possess an intermediate character. Some of these are such as to prove critical if they experience even the most moderate impetus of nature, such as the 7th and 14th; whilst most of them prove critical in violent commotions of the system, but not otherwise. Neither are the favorable all equally favorable, nor the unfavorable all equally unfavorable; nor is their favorableness and unfavorableness according to any order. Those in the first rank of favorable days may be arranged thus: the best of all are the 7th and 14th, next to them the 9th, and 11th, and 20th; and near to them the 17th and 5th, after these the 4th, after it the 3d and 18th. Opposed to them, of the second rank, are these: the worst, which proves obscurely critical with danger, and is, as it were, diametrically opposed to the 7th, is the 6th: near to it are the 8th and 10th, after these the 12th, 16th, and 19th. Intermediate between these is the 13th, being neither so objectionable as those of the second rank, nor so powerful in freeing from diseases as those of the first. The critical days then are thus arranged according to their degree by Galen. Numerically thus: the favorable are the 3d, 4th, 5th, 7th, 9th, 11th, 14th, 17th, 18th, 20th; the unfavorable, the 6th, 8th, 10th, 12th, 16th, 19th; the intermediate, the 13th. Some of the critical days give information concerning the others, and are hence called indicatory by Hippocrates, because they indicate the crisis that is to happen on another critical day. Thus the 4th indicates a crisis on the 7th, by inducing sweats, perspirations, or some such particular evacuation, or by displaying certain signs which had not formerly taken place, or some symptoms of concoction. Galen says that the 4th is indicatory of the 6th, although it be unfavorable, as the 11th is of the 14th, and the 17th of the 20th. Until the 14th day the crises are the most decided, next to these until the 20th; from the 20th to the 40th they gradually lose their decided character. Of these, the first in degree are the 27th, 34th, and 40th, after which are the 24th and 32d. The other numbers intermediate between the 20th and 40th are indeterminate, and those after the 40th are not properly critical, as they terminate diseases by concoctions and abscesses rather than by crises. Hippocrates seems entirely to disregard all those after the 40th day, yet he enumerates the 60th, 80th, and 100th. After these, he says that some diseases prove critical in seven months, some in seven years, and others, as it would appear, in twice or thrice seven years.

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COMMENTARY. The Father of Medicine who was profoundly skilled in Semeiology, appears to have attached great importance to the observance of the critical days. At first, as Galen remarks, he seems to have been undecided respecting certain days, and, accordingly, he gives a somewhat different list of them in his ‘Prognostics’ and ‘Aphorisms,’ from what he has given in his ‘Epidemics.’ His latter list of critical days differs little or nothing from that of Galen.

Galen reposes such confidence in the doctrine of critical days, that he affirms that, by a proper observance of them, the physician may be able to prognosticate the very hour when a fever will terminate. The following is his list: The 7th is particularly favorable; next, the 14th; next to these, the 9th, 11th, and 20th; then the 17th and 5th; afterwards the 4th, 3d, and 18th. The 6th is very doubtful and unfavorable; the 8th and 10th, like the 6th; the 12th, 16th, and 19th, like the 8th and 10th. Intermediate between these two lists of favorable and unfavorable days is the 13th. He informs us that Diocles and Archigenes held the 21st to be particularly favorable, but he agrees with Hippocrates in rejecting it and adopting the 20th.

Celsus follows the system of Archigenes. He says, “κρίσιμοι dies erant, dies tertius, quintus, septimus, nonus, undecimus, quartus-decimus, unus et vicesimus; ita ut summa potentia septimo, deinde quarto-decimo, deinde uni et vicesimo daretur.” But he does not hesitate, afterwards, to express his distrust in the whole system; for, he adds, “verum in his quidem antiquos tunc celebres Pythagorici numeri fefellerunt; cum hic quoque medicus non numerare dies debeat, sed ipsas accessiones intueri.”

The Greek writers subsequent to Galen adopt his system, with little or no alteration. Aëtius arranges the critical days thus: First in order, the 7th and 14th; then the 9th and 11th; next to them the 17th and 5th; then, the 4th; and afterwards the 3d and 20th. The 6th is usually bad.

The last of the ancient authorities, Actuarius, is very full and confident in laying down the received doctrines, with regard to the critical days. He follows Galen.

The Arabians, with scarce one exception, adopt the Galenic system. Avicenna, who treats of the critical days very fully, mentions the list of them given by Hippocrates and Galen, and also that by Archigenes, but decides in favour of the former.

Rhases mentions the critical days in the following terms: The 3d is critical in very acute fevers; the 4th is indicative of the 7th and 6th; the 5th is favorable; the 6th generally unfavorable; the 7th is a particularly favorable or unfavorable crisis; the 8th rarely critical, but if it be, unfavorable; the 11th critical and indicative of the 14th; the 12th rarely critical, and like the 8th; the 13th rarely critical; the 14th, critical and favorable; the 15th like the 13th; the 16th like the 12th; the 17th like the 9th, and indicative of the 20th; the 18th rarely critical, or unfavorable; the 19th rarely critical, or, if so, not bad; the 20th next to the 14th, and favorable; the 21st sometimes critical, but less frequently so than the 20th; the 24th resembling the 20th; after these the 27th, 31st, 37th, and 40th are critical. Averrhoes remarks, that great deference is due to Rhases’ opinion upon this subject, since it was confirmed by experience, in more than ten thousand cases, in an infirmary (in infirmaria Relenson). His list is very little different from that of Galen. In his ‘Continens,’ he gives an account of the system of Archigenes, but prefers that of Hippocrates. (xxxii.)

Averrhoes states that the medical world was divided between the systems of Archigenes and Galen, but he inclines to the side of the latter in this case, although on most occasions given to dispute his authority.