Chapter XI: Section III (4)

22. And, in addition to these, there are many eunuchs among the Scythians, who perform female work, and speak like women. Such persons are called effeminates.[445] The inhabitants of the country attribute the cause of their impotence to a god, and venerate and worship such persons, every one dreading that the like might befall himself; but to me it appears that such affections are just as much divine as all others are, and that no one disease is either more divine or more human than another, but that all are alike divine, for that each has its own nature, and that no one arises without a natural cause.[446] But I will explain how I think that the affection takes its rise. From continued exercise on horseback they are seized with chronic defluxions in their joints (_kedmata_[447]) owing to their legs always hanging down below their horses; they afterwards become lame and stiff at the hip-joint, such of them, at least, as are severely attacked with it. They treat themselves in this way: when the disease is commencing, they open the vein behind either ear, and when the blood flows, sleep, from feebleness, seizes them, and afterwards they awaken, some in good health and others not. To me it appears that the semen is altered by this treatment, for there are veins behind the ears which, if cut, induce impotence; now, these veins would appear to me to be cut.[448] Such persons afterwards, when they go in to women and cannot have connection with them, at first do not think much about it, but remain quiet; but when, after making the attempt two, three, or more times, they succeed no better, fancying they have committed some offence against the god whom they blame for the affection, they put on female attire, reproach themselves for effeminacy, play the part of women, and perform the same work as women do. This the rich among the Scythians endure, not the basest, but the most noble and powerful, owing to their riding on horseback; for the poor are less affected, as they do not ride on horses. And yet, if this disease had been more divine than the others, it ought not to have befallen the most noble and the richest of the Scythians alone, but all alike, or rather those who have little, as not being able to pay honors to the gods, if, indeed, they delight in being thus rewarded by men, and grant favors in return; for it is likely that the rich sacrifice more to the gods, and dedicate more votive offerings, inasmuch as they have wealth, and worship the gods; whereas the poor, from want, do less in this way, and, moreover, upbraid the gods for not giving them wealth, so that those who have few possessions were more likely to bear the punishments of these offences than the rich. But, as I formerly said, these affections are divine just as much as others, for each springs from a natural cause, and this disease arises among the Scythians from such a cause as I have stated. But it attacks other men in like manner, for whenever men ride much and very frequently on horseback, then many are affected with rheums in the joints, sciatica, and gout, and they are inept at venery. But these complaints befall the Scythian, and they are the most impotent of men for the aforesaid causes, and because they always wear breeches, and spend the most of their time on horseback,[449] so as not to touch their privy parts with the hand, and from the cold and fatigue they forget the sexual desire, and do not make the attempt until after they have lost their virility.[450] Thus it is with the race of the Scythians.

23. The other races in Europe differ from one another, both as to stature and shape, owing to the changes of the seasons, which are very great and frequent, and because the heat is strong, the winters severe, and there are frequent rains, and again protracted droughts, and winds, from which many and diversified changes are induced. These changes are likely to have an effect upon generation in the coagulation of the semen, as this process cannot be the same in summer as in winter, nor in rainy as in dry weather; wherefore, I think, that the figures of Europeans differ more than those of Asiatics; and they differ very much from one another as to stature in the same city; for vitiations of the semen occur in its coagulation more frequently during frequent changes of the seasons, than where they are alike and equable. And the same may be said of their dispositions, for the wild, and unsociable, and the passionate occur in such a constitution; for frequent excitement of the mind induces wildness, and extinguishes sociableness and mildness of disposition, and therefore I think the inhabitants of Europe more courageous than those of Asia; for a climate which is always the same induces indolence, but a changeable climate, laborious exertions both of body and mind; and from rest and indolence cowardice is engendered, and from laborious exertions and pains, courage. On this account the inhabitants of Europe are more warlike than the Asiatics, and also owing to their institutions, because they are not governed by kings like the latter, for where men are governed by kings there they must be very cowardly, as I have stated before; for their souls are enslaved, and they will not willingly, or readily undergo dangers in order to promote the power of another; but those that are free undertake dangers on their own account, and not for the sake of others; they court hazard and go out to meet it, for they themselves bear off the rewards of victory, and thus their institutions contribute not a little to their courage.[451]

Such is the general character of Europe and Asia.[452]

24. And there are in Europe other tribes, differing from one another in stature, shape, and courage: the differences are those I formerly mentioned, and will now explain more clearly. Such as inhabit a country which is mountainous, rugged, elevated, and well watered, and where the changes of the seasons are very great, are likely to have great variety of shapes among them, and to be naturally of an enterprising and warlike disposition;[453] and such persons are apt to have no little of the savage and ferocious in their nature; but such as dwell in places which are low-lying, abounding in meadows and ill ventilated, and who have a larger proportion of hot than of cold winds, and who make use of warm waters--these are not likely to be of large stature nor well proportioned, but are of a broad make, fleshy, and have black hair; and they are rather of a dark than of a light complexion, and are less likely to be phlegmatic than bilious; courage and laborious enterprise are not naturally in them, but may be engendered in them by means of their institutions. And if there be rivers in the country which carry off the stagnant and rain water from it, these may be wholesome and clear; but if there be no rivers, but the inhabitants drink the waters of fountains, and such as are stagnant and marshy, they must necessarily have prominent bellies and enlarged spleens. But such as inhabit a high country, and one that is level, windy, and well-watered, will be large of stature, and like to one another; but their minds will be rather unmanly and gentle. Those who live on thin, ill-watered, and bare soils, and not well attempered in the changes of the seasons, in such a country they are likely to be in their persons rather hard and well braced, rather of a blond than a dark complexion, and in disposition and passions haughty and self-willed. For, where the changes of the seasons are most frequent, and where they differ most from one another, there you will find their forms, dispositions, and nature the most varied. These are the strongest of the natural causes of difference, and next the country in which one lives, and the waters; for, in general, you will find the forms and dispositions of mankind to correspond with the nature of the country; for where the land is fertile, soft, and well-watered, and supplied with waters from very elevated situations, so as to be hot in summer and cold in winter, and where the seasons are fine, there the men are fleshy, have ill-formed joints,[454] and are of a humid temperament; they are not disposed to endure labor, and, for the most part, are base in spirit; indolence and sluggishness are visible in them, and to the arts they are dull, and not clever nor acute. When the country is bare, not fenced, and rugged, blasted by the winter and scorched by the sun, there you may see the men hardy, slender, with well-shaped joints,[454] well-braced, and shaggy; sharp industry and vigilance accompany such a constitution; in morals and passions they are haughty and opinionative, inclining rather to the fierce than to the mild; and you will find them acute and ingenious as regards the arts, and excelling in military affairs; and likewise all the other productions of the earth corresponding to the earth itself.[455] Thus it is with regard to the most opposite natures and shapes; drawing conclusions from them, you may judge of the rest without any risk of error.

ON THE PROGNOSTICS.

THE ARGUMENT.

Of the genuineness of this work I have treated in the Preliminary Discourse, and have also briefly touched upon its relation to two other important treatises in the Hippocratic collection, the “Prorrhetics” and the “Coacæ Prænotiones.” The latter subject I am now to resume, and in doing so I mean to avail myself of the talented dissertation of Dr. Ermerins, to which also I have already made allusion. Indeed I am persuaded that I cannot do a more acceptable service to my profession in Britain than by laying before them a brief exposition of the important views brought forward in this “Dissertatio Inauguralis.”[456]

After some preliminary observations on the ancient Temples of Health, which are mainly derived from Sprengel’s “History of Medicine”[457] he passes on to consider the opinion stated by this author and others before his time, that the first book of the “Prorrhetics” and the “Coacæ Prænotiones” are the results of isolated observations made upon the sick in the Asclepion of Cos. The probability of this opinion being well founded he shows to be very great; and he next endeavors to solve the question whether the first book of the “Prorrhetics” be derived from the “Coacæ Prænotiones,” or whether the latter be the more modern work of the two. He comes to the conclusion that the “Prorrhetics” is the more ancient work, for the following reasons: 1st. Because in it the names of the patients are frequently given, which is rarely the case in the “Coacæ Prænotiones.” 2d. Because queries and doubts are oftener found in this book than in the other, when one takes into account the number of presages. 3d. Because the number of observations which this book contains is much smaller than those which the “Coacæ” embrace. 4th. This is confirmed by the circumstance that the enunciations of the prognoses are far less extended in the “Prorrhetics,” whence it is clearly proved that they are not derived from so great a field of observations as those we meet with in the other work. He then gives a most lucid view of the parallelism which subsists between the “Prorrhetica” and the “Coacæ,” and, as the results of his observations upon them, he draws the following most important conclusions:

1. “By a most fortunate occurrence certain monuments of the medical art, as cultivated by the Asclepiadæ, are preserved to us in the first “Prorrhetics” and the “Prænotiones Coacæ” which books appear to be fragments and excerpts from the histories of diseases and cures which were formerly found on the votive tablets of the Coan temple.

2. This sacerdotal medicine was at first a certain medical divination, which, as it was the offspring of pure observation, so the system of prognostics of the Coans was altogether aloof from the theories and systems of the philosophers, and is therefore to be reckoned most worthy of our attention, both from the great love of observation which we admire in it, and from the exquisite and beautiful sense of the simple truth which it evinces.

3. We must keep in view the origin of these presages from individual observations gradually collected, in order that we may have a knowledge of this system of prognostic semeiology. Hence we comprehend how we meet with so many doubtful propositions, and so many uncertain and vague remarks, and that imperfect etiology which confounded causes with their effects, and again, the latter with the former.

4. The readers must particularly keep before their eyes this origin, and the antiquity of those writings, if they would pass a correct judgment on the merits of the Asclepiadæ towards the art of medicine. Whatever in their works we have the pleasure of possessing, all attest the infancy of the art; many things are imperfect, and not unfrequently do we see them, while in the pursuit of truth, groping, as it were, and proceeding with uncertain steps, like men wandering about in darkness; but yet the method which they applied, and to which they would seem to have betaken themselves of their own accord, was so excellent, that nothing could surpass it. It was the same method which Hippocrates himself always adopted, and which, in fine, Lord Bacon, many ages afterwards, commended as the only instrument by which truth in medicine can be found out.

5. As this method is founded on true induction, so are its dicta to be held the more worthy of admiration, the more they possess a universal signification. To give an example; what assiduous observation, and what abundance of rational experience, must have been required for enunciating the following admirable truth, and, as it were, law of nature: “Those things which bring alleviation with bad signs, and do not remit with good, are troublesome and difficult.”

6. Many passages bear reference to the condition of the vital powers, which they took into account at all times, both in making presages and in exercising the art. For, although they had not our theories of the vital force, they perceived its effects very well by observation; and for this very reason, that they did not search for the art in theories, but in observation alone, we owe so many excellent things to them, since they did not adapt their observation to theories, but related a trustworthy and faithful history of the operations of nature.

7. They sought after many things from a comparison of health with disease, in which also they rightly calculated the manners and customs of men. Thus they call that, in the first place, the best mode of reclining, which is adopted by the patient when in good health, and hence they estimate the other modes as being less good, or altogether unfavorable. Nor did they only compare health with disease, but they compared also the symptoms of diseases with one another, and interpreted the one from the other. Thus they first depict and pronounce a favorable opinion on the best kind of excretions, and then they described the other abnormal kinds, and pass an unfavorable judgment on them.

8. They particularly relate the operations of a _natura medicatrix_, which, in a region such as Greece is, and in athletic, strong bodies, on which they appear to have practised the art, and for the most part in acute diseases, and the few chronic ones derived from them which they have left described, might especially be looked for. Hence that doctrine of crises most deserving of attention, the rudiments, indeed, of which we only have here preserved, but a just notion of which we may easily draw from these fragments.

9. The Asclepiadæ would appear to have accommodated and directed their art to this natural Therapia. Hence the advice that convulsions arising from a great hemorrhage, forcibly stopped, should be cured by the abstraction of blood. It is to be regretted that but a few monuments of their practice remain; but these embrace admirable imitations of nature, and the most prudent caution in administering remedies.

10. Neither did they neglect surgery, but deliver many excellent remarks on things pertaining to wounds, ulcers, and fractures.

11. Although it cannot be made out for certain that everything which is preserved in these writings existed before Hippocrates, there can be no doubt that many of them are more ancient than he. And although we may attribute some things rather to Hippocrates himself, it is nevertheless certain that the method of deducing the art from observation and comparison had existed before him. Some may, perhaps, object that these books are to be attributed to the youth of Hippocrates, and that the others, more elaborate and perfect, had proceeded from the same person in his old age; but this supposition we may refute by a single argument, namely, that it would be absurd to ascribe so many observations about so many diseases to one man.

12. From the whole Coan system of cultivating medicine, the best hopes might justly have been expected; and from what follows it will be seen that the result did not disappoint this expectation.”

These deductions, I must say, appear to be most legitimately drawn; and having thus satisfactorily made out that the “Coacæ Prænotiones” are founded on the “Prorrhetics,” Dr. Ermerins proceeds to make an interesting comparison between the former and the book of “Prognostics.” Here again we can only find room for the general conclusions.

1. “We have compared together two monuments of antiquity embracing entirely the same doctrine, so that we may hold it as put out of all doubt that they must have derived their origin from the same school, only the one yields to the other in antiquity, as its more expanded mode of expression shows.

2. The more recent work is attributed to Hippocrates by all the critics and interpreters; the most ancient authors have made mention of it, and all the characteristic marks by which the genuine works of Hippocrates are distinguished from the spurious, without doubt, are found in it; for whether you look to the brevity and gravity of the language, or the paucity of the reasonings, the correctness of the observations, or the dialect in which they are expressed, or, in fine, its agreement with the whole Hippocratic doctrine,--all these attest that “the divine old man” is the author of this work.

3. From a comparison of the “Coacæ Prænotiones” with the “Prognostics,” it is as clear as the light of day that Hippocrates composed this work from them, in such a manner that he circumscribed many of the symptoms, limited the enunciations, and amplified them all by his own experience in the medical Art. Hence the Prognostics may not inaptly be called the Commentary of Hippocrates on the “Coacæ Prænotiones.”

4. With regard to the exquisite and artificial order, in which we see many things proposed in his book, we agree entirely with Sprengel, who thinks that they have proceeded from a more recent describer. This is confirmed by our comparison of both works.

5. This work exhibits the fundamental principles and originals of the Hippocratic doctrine, and although we hardly know anything as to the manlier in which Hippocrates composed his writings, and of the form which he gave them, it does not seem at all out of the way to hold this book to be the oldest of all the works which “the Father of Medicine” has left to us.

6. Inasmuch as this work is entitled the Book of Prognostics, so it turns on the _prescience_ πρόνοια, that is to say, the foreknowledge of the physician, which Hippocrates recommends to physicians for three reasons: first, for the confidence of mankind, which it will conciliate to the physician; then because it will free the practitioner from all blame, if he has announced beforehand the fatal result of diseases; and further, as being a very great instrument in effecting the cure.

7. Like the Coan priests, Hippocrates drew his Prognostics from a comparison of disease with health. This he held to be of so great importance, that he first delivers physiological semeiotics, and then adds pathological.

8. In calculating and judging of signs he neglected neither age nor sex, and, in the first place, directed his mind to the power of habit on the human body.

9. Nor did Hippocrates stop here, but directed care to be had of the attack of epidemics, and the condition of the season.

10. The Prognostics of Hippocrates are not of one time or place, but extend through every age, and through the whole world; inasmuch as the prognostic signs have been proved to be true in Libya, in Delos, and in Scythia, and it should be well known that every year, and at every season of the year, bad symptoms bode ill, and good symptoms good.

11. But he who would wish to know properly beforehand those who will recover from a disease, and those who will die, and those in whom the disease will persevere for many days, and those in whom it will last for a few, should be able to comprehend and estimate the doctrine of all the signs, and weigh in his mind and compare together their strength. The Hippocratic foreknowledge rests not only on the observation of the signs, but also on the understanding of them.

12. The Book of Prognostics exhibits observations of acute diseases, and of chronic arising from them, in which Hippocrates has diligently noted the times and modes of the crises.

13. Such is the authority of critical days and signs, that in those fevers which cease without the symptoms of resolution, and not upon critical days, a relapse is to be expected.

14. The series of critical days which Hippocrates delivers, proceeds solely upon the observation of nature. Yet neither can any of them be exactly numbered by entire days, since neither the year nor the months are usually numbered by entire days.”

Dr. Ermerins, in the remaining part of his Essay, shows, in a very lucid manner, that the rules of Prognosis laid down in this treatise by Hippocrates, are manifestly those by which he is regulated in his other works, and more especially in the Epidemics and Aphorisms. We must not, however, occupy room with any further exposition of the contents of this important treatise, which does equal credit to the author himself, and to the medical system of education pursued in the learned university from which it emanated.

* * * * *

I will now give some remarks and reflections of my own on the treatise under consideration.

In this work, then, Hippocrates appears to have had for his object, to give such a general description of the phenomena of disease as would apply to all the disorders of the animal frame. With this intention he brings into review the state of the countenance, the position of the patient in bed, the movements of the hands, the respiration, the sweats, the state of the hypochondria, dropsies which are the consequences of acute diseases, the sleep, the urine, the alvine dejections, the vomitings, and the sputa. In doing this, his uniform practice is to contrast the healthy with the morbid appearances. Although M. Littré regards it as a treatise on special Pathology, it appears to me to be decidedly a general work on Semeiology. Certain it is that all the best commentators, such as Erotian and Stephanus,[458] decidedly regard it as a semeiological work. The class of ancient writings with which it admits of being most closely compared, are the works on the prognostics of the weather. On this subject Greek literature contains several works of a very philosophical nature, such as the Phænomena of Aratus, and several of the minor tracts of Theophrastus. Now as the object of these authors was to connect the most striking phenomena in the sky, the earth, and the sea, with the changes in the weather, of which they are the precursors, so the intention of the medical writer of Prognostics was to point out the alterations in the animal frame, which certain preternatural symptoms usually indicate. And as the utility of an acquaintance with prognostics of the weather to the husbandman and sailor is sufficiently obvious, the benefit to be derived from a knowledge of medical prognostics by the physician is equally so. Our author, it will be seen in the Preface to this work, enumerates three objects to be attained by cultivating an acquaintance with prognostics; first, to attract the confidence of one’s patients; second, to free the physician from blame by enabling him to announce beforehand the issue of the disorder about which he is consulted; and, third, to give him a decided advantage in conducting the treatment by preparing him for remarkable changes in the diseases before they occur. And, in like manner, I may be allowed to remark, the master of a ship who shows himself prepared for all changes of the weather, will naturally attract the confidence of those intrusted to his charge; and whatever may be the result, he will be freed from blame if his ship should be damaged in a storm which he had previously predicted; and surely his knowledge of impending commotions in the sea and sky, will be of advantage to him by enabling him to make preparations for them.

Looking then to the importance of general Prognostics, I have often wondered why this branch of Semeiology is no longer cultivated by the profession. Did not the ancient physicians follow the best possible plan when they first described the general phenomena of diseased action, and then applied them to particular cases? Surely they did right in first taking a comprehensive view of the whole subject of disease before attempting to examine the different parts of it in detail. This, in fact, constitutes the great superiority of the ancient _savans_ over the modern, that the former possessed a much greater talent for apprehending general truths than the latter, who confine their attention to particular facts, and too much neglect the observation of general appearances. I trust no one will be offended if I venture to pronounce regarding the present condition of our professional literature, that (to borrow an illustration from the Logic of Kant) it is altogether Cyclopic,--that is to say, it wants the eye of Philosophy, for, although we have learned to examine particular objects with greater accuracy than our forefathers did, the sphere of our mental vision, so to speak, is more confined than theirs, and cannot embrace the same enlarged views of general subjects. Surely then we might gain a useful lesson by endeavoring to combine their more comprehensive views with our own more accurate and minute observation.

Some people may be inclined to think that we have greatly detracted from the credit which Hippocrates has long enjoyed as being the undoubted author of this work, by showing that in composing it he was so much indebted to the labors of his predecessors. But I have long been impressed with the conviction that in compositions even of the highest order, there is much less originality than is generally supposed, and that true genius frequently is displayed more in its own felicitous way of dealing with materials formerly prepared and collected for its use than in searching out new matter to work upon,[459] and hence it will be found upon examination that many of the most distinguished efforts of human intellect have consisted in the successful performance of tasks which had been frequently attempted by previous laborers in the same line. Many artists, before the time of Phidias, had acquired reputation by their attempts at making the statue of Jupiter;[460] but this did not deter him from undertaking the same task: and we may well believe that he would avail himself of every practical lesson which he could draw from the success or failure of his predecessors, in perfecting that matchless performance which completely cast all others into the background. The sad misfortunes of Œdipus had been often represented on the Athenian stage before Sophocles made them the subject of those inimitable dramas, which still enjoy an unrivalled reputation, nor will it be often considered how much assistance he may have derived from the labors of those who had gone before him. It is well known that of all the literary performances of Aristotle, there is no one which gained him so enduring a reputation as his Categories, and yet it is admitted that his division of the subject into the ten Predicaments, was taken from the Pythagorean philosopher Archytas;[461] in short, the great merit of Aristotle on this as on many other occasions, consisted in defining and arranging a subject on which much had been previously effected by the labors of his predecessors. And, to give one example more, long before the time of Galen, the temperaments, and the facts in physiology and pathology bearing upon Hygiene, had been frequently and successfully investigated, but he, by recasting all these subject-matters into his _Ars Medica_, composed a work which posterity regarded as his master-performance, and every word and tittle of which, for a succession ages, were commented upon and admired in the Schools of Medicine. And of all our Author’s admired performances, there is perhaps no one which has exerted so great an influence upon the literature of the profession as the present work, for all the Greek, Roman, and Arabian writers on medicine, subsequent to him, make use of his terms, and copy his descriptions of morbid phenomena.

THE BOOK OF PROGNOSTICS.

1. It appears to me a most excellent thing for the physician to cultivate Prognosis; for by foreseeing and foretelling, in the presence of the sick, the present, the past, and the future, and explaining the omissions which patients have been guilty of,[462] he will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician. And he will manage the cure best who has foreseen what is to happen from the present state of matters. For it is impossible to make all the sick well; this, indeed, would have been better than to be able to foretell what is going to happen; but since men die, some even before calling the physician, from the violence of the disease, and some die immediately after calling him, having lived, perhaps, only one day or a little longer, and before the physician could bring his art to counteract the disease; it therefore becomes necessary to know the nature of such affections, how far they are above the powers of the constitution; and, moreover, if there be anything divine in the diseases,[463] and to learn a foreknowledge of this also. Thus a man will be the more esteemed to be a good physician, for he will be the better able to treat those aright who can be saved, from having long anticipated everything; and by seeing and announcing beforehand those who will live and those who will die, he will thus escape censure.[464]

2. He should observe thus in acute diseases: first, the countenance of the patient, if it be like those of persons in health, and more so, if like itself, for this is the best of all; whereas the most opposite to it is the worst, such as the following; _a sharp nose, hollow eyes, collapsed temples_; _the ears cold, contracted, and their lobes turned out_: _the skin about the forehead being rough, distended, and parched_; _the color of the whole face being green, black, livid, or lead-colored_.[465] If the countenance be such at the commencement of the disease, and if this cannot be accounted for from the other symptoms, inquiry must be made whether the patient has long wanted sleep; whether his bowels have been very loose; and whether he has suffered from want of food; and if any of these causes be confessed to, the danger is to be reckoned so far less; and it becomes obvious, in the course of a day and a night, whether or not the appearance of the countenance proceeded from these causes.[466] But if none of these be said to exist, and if the symptoms do not subside in the aforesaid time, it is to be known for certain that death is at hand. And, also, if the disease be in a more advanced stage either on the third or fourth day, and the countenance be such, the same inquiries as formerly directed are to be made, and the other symptoms are to be noted, those in the whole countenance, those on the body, and those in the eyes; for if they shun the light, or weep involuntarily, or squint, or if the one be less than the other, or if the white of them be red, livid, or has black veins in it; if there be a gum upon the eyes, if they are restless, protruding, or are become very hollow; and if the countenance be squalid and dark, or the color of the whole face be changed--all these are to be reckoned bad and fatal symptoms. The physician should also observe the appearance of the eyes from below the eyelids in sleep; for when a portion of the white appears, owing to the eyelids not being closed together, and when this is not connected with diarrhœa or purgation from medicine, or when the patient does not sleep thus from habit, it is to be reckoned an unfavorable and very deadly symptom; but if the eyelid be contracted, livid, or pale, or also the lip, or nose, along with some of the other symptoms, one may know for certain that death is close at hand. It is a mortal symptom, also, when the lips are relaxed, pendent, cold, and blanched.

3.[467] It is well when the patient is found by his physician reclining upon either his right or his left side, having his hands, neck, and legs slightly bent, and the whole body lying in a relaxed state, for thus the most of persons in health recline, and these are the best of postures which most resemble those of healthy persons. But to lie upon one’s back, with the hands, neck, and the legs extended, is far less favorable. And if the patient incline forward, and sink down to the foot of the bed, it is a still more dangerous symptom; but if he be found with his feet naked and not sufficiently warm, and the hands, neck, and legs tossed about in a disorderly manner and naked, it is bad, for it indicates aberration of intellect. It is a deadly symptom, also, when the patient sleeps constantly with his mouth open, having his legs strongly bent and plaited together, while he lies upon his back; and to lie upon one’s belly, when not habitual to the patient to sleep thus while in good health, indicates delirium, or pain in the abdominal regions. And for the patient to wish to sit erect at the acme of a disease is a bad symptom in all acute diseases, but particularly so in pneumonia.[468] To grind the teeth in fevers, when such has not been the custom of the patient from childhood, indicates madness and death, both which dangers are to be announced beforehand as likely to happen; and if a person in delirium do this it is a very deadly symptom. And if the patient had an ulcer previously, or if one has occurred in the course of the disease, it is to be observed; for if the man be about to die the sore will become livid and dry, or yellow and dry before death.[469]

4. Respecting the movement of the hands I have these observations to make: When in acute fevers, pneumonia, phrenitis, or headache, the hands are waved before the face, hunting through empty space, as if gathering bits of straw, picking the nap from the coverlet, or tearing chaff from the wall--all such symptoms are bad and deadly.[470]

5. Respiration, when frequent, indicates pain or inflammation in the parts above the diaphragm: a large respiration performed at a great interval announces delirium; but a cold respiration at nose or mouth is a very fatal symptom. Free respiration is to be looked upon as contributing much to the safety of the patient in all acute diseases, such as fevers, and those complaints which come to a crisis in forty days.[471]

6. Those sweats are the best in all acute diseases which occur on the critical days, and completely carry off the fever. Those are favorable, too, which taking place over the whole body, show that the man is bearing the disease better. But those that do not produce this effect are not beneficial. The worst are cold sweats, confined to the head, face, and neck; these in an acute fever prognosticate death, or in a milder one, a prolongation of the disease; and sweats which occur over the whole body, with the characters of those confined to the neck, are in like manner bad. Sweats attended with a miliary eruption, and taking place about the neck, are bad; sweats in the form of drops and of vapour are good. One ought to know the entire character of sweats, for some are connected with prostration of strength in the body, and some with intensity of the inflammation.[472]

7.[473] That state of the hypochondrium is best when it is free from pain, soft, and of equal size on the right side and the left. But if inflamed, or painful, or distended; or when the right and left sides are of disproportionate sizes;--all these appearances are to be dreaded. And if there be also pulsation in the hypochondrium, it indicates perturbation or delirium; and the physician should examine the eyes of such persons; for if their pupils be in rapid motion, such persons may be expected to go mad. A swelling in the hypochondrium, that is hard and painful, is very bad, provided it occupy the whole hypochondrium; but if it be on either side, it is less dangerous when on the left. Such swellings at the commencement of the disease prognosticate speedy death; but if the fever has passed twenty days, and the swelling has not subsided, it turns to a suppuration.[474] A discharge of blood from the nose occurs to such in the first period, and proves very useful; but inquiry should be made if they have headache or indistinct vision; for if there be such, the disease will be determined thither. The discharge of blood is rather to be expected in those who are younger than thirty-five years. Such swellings as are soft, free from pain, and yield to the finger, occasion more protracted crises, and are less dangerous than the others. But if the fever continue beyond sixty days, without any subsidence of the swelling, it indicates that empyema is about to take place; and a swelling in any other part of the cavity will terminate in like manner. Such, then, as are painful, hard, and large, indicate danger of speedy death; but such as are soft, free of pain, and yield when pressed with the finger, are more chronic than these. Swellings in the belly less frequently form abscesses than those in the hypochondrium; and seldomest of all, those below the navel are converted into suppuration; but you may rather expect a hemorrhage from the upper parts. But the suppuration of all protracted swellings about these parts is to be anticipated. The collections of matter there are to be thus judged of: such as are determined outwards are the best when they are small, when they protrude very much, and swell to a point; such as are large and broad, and which do not swell out to a sharp point, are the worst. Of such as break internally, the best are those which have no external communication, but are covered and indolent; and when the whole place is free from discoloration. That pus is best which is white, homogeneous, smooth, and not at all fetid; the contrary to this is the worst.

8.[475] All dropsies arising from acute diseases are bad; for they do not remove the fever, and are very painful and fatal. The most of them commence from the flanks and loins, but some from the liver; in those which derive their origin from the flanks and loins the feet swell, protracted diarrhœas supervene, which neither remove the pains in the flanks and loins, nor soften the belly;[476] but in dropsies which are connected with the liver there is a tickling cough, with scarcely any perceptible expectoration, and the feet swell; there are no evacuations from the bowels, unless such as are hard and forced; and there are swellings about the belly, sometimes on the one side and sometimes on the other, and these increase and diminish by turns.[477]

9. It is a bad symptom when the head, hands, and feet are cold, while the belly and sides are hot; but it is a very good symptom when the whole body is equally hot.[478] The patient ought to be able to turn round easily, and to be agile when raised up; but if he appear heavy in the rest of his body as well as in his hands and feet, it is more dangerous; and if, in addition to the weight, his nails and fingers become livid, immediate death may be anticipated; and if the hands and feet be black it is less dangerous than if they be livid, but the other symptoms must be attended to; for if he appear to bear the illness well, and if certain of the salutary symptoms appear along with these there may be hope that the disease will turn to a deposition, so that the man may recover; but the blackened parts of the body will drop off. When the testicles and members are retracted upwards, they indicate strong pains and danger of death.[479]

10. With regard to sleep--as is usual with us in health, the patient should wake during the day and sleep during the night. If this rule be anywise altered it is so far worse: but there will be little harm provided he sleep in the morning for the third part of the day; such sleep as takes place after this time is more unfavorable; but the worst of all is to get no sleep either night or day; for it follows from this symptom that the insomnolency is connected with sorrow and pains, or that he is about to become delirious.[480]

11. The excrement is best which is soft and consistent, is passed at the hour which was customary to the patient when in health, in quantity proportionate to the ingesta; for when the passages are such, the lower belly is in a healthy state.[481] But if the discharges be fluid, it is favorable that they are not accompanied with a noise, nor are frequent, nor in great quantity; for the man being oppressed by frequently getting up, must be deprived of sleep; and if the evacuations be both frequent and large, there is danger of his falling into deliquium animi.[482] But in proportion to the ingesta he should have evacuations twice or thrice in the day, once at night and more copiously in the morning, as is customary with a person in health. The fæces should become thicker when the disease is tending to a crisis; they ought to be yellowish and not very fetid. It is favorable that round worms be passed with the discharges when the disease is tending to a crisis.[483] The belly, too, through the whole disease, should be soft and moderately distended; but excrements that are very watery, or white, or green, or very red, or frothy, are all bad. It is also bad when the discharge is small, and viscid, and white, and greenish, and smooth; but still more deadly appearances are the black, or fatty, or livid, or verdigris-green, or fetid. Such as are of varied characters indicate greater duration of the complaint, but are no less dangerous; such as those which resemble scrapings,[484] those which are bilious, those resembling leeks, and the black; these being sometimes passed together, and sometimes singly.[485] It is best when wind passes without noise, but it is better that flatulence should pass even thus than that it should be retained; and when it does pass thus, it indicates either that the man is in pain or in delirium, unless he gives vent to the wind spontaneously.[486] Pains in the hypochondria, and swellings, if recent, and not accompanied with inflammation, are relieved by borborygmi supervening in the hypochondrium, more especially if it pass off with fæces, urine, and wind; but even although not, it will do good by passing along, and it also does good by descending to the lower part of the belly.[487]

12. The urine is best when the sediment is white, smooth, and consistent during the whole time, until the disease come to a crisis, for it indicates freedom from danger, and an illness of short duration; but if deficient, and if it be sometimes passed clear, and sometimes with a white and smooth sediment, the disease will be more protracted, and not so void of danger. But if the urine be reddish, and the sediment consistent and smooth, the affection, in this case, will be more protracted than the former, but still not fatal.[488] But farinaceous sediments in the urine are bad, and still worse are the leafy;[489] the white and thin are very bad, but the furfuraceous are still worse than these. Clouds carried about in the urine are good when white, but bad if black. When the urine is yellow and thin, it indicates that the disease is unconcocted; and if it (the disease) should be protracted, there may be danger lest the patient should not hold out until the urine be concocted.[490] But the most deadly of all kinds of urine are the fetid, watery, black, and thick; in adult men and women the black is of all kinds of urine the worst, but in children, the watery.[491] In those who pass thin and crude urine for a length of time, if they have otherwise symptoms of convalescence, an abscess may be expected to form in the parts below the diaphragm.[492] And fatty substances floating on the surface are to be dreaded, for they are indications of melting. And one should consider respecting the kinds of urine, which have clouds, whether they tend upwards or downwards, and the colors which they have and such as fall downwards, with the colors as described, are to be reckoned good and commended; but such as are carried upwards, with the colors as described, are to be held as bad, and are to be distrusted.[493] But you must not allow yourself to be deceived if such urine be passed while the bladder is diseased; for then it is a symptom of the state, not of the general system, but of a particular viscus.[494]

13. That vomiting is of most service which consists of phlegm and bile mixed together, and neither very thick nor in great quantity; but those vomitings which are more unmixed are worse. But if that which is vomited be of the color of leeks or livid, or black, whatever of these colors it be, it is to be reckoned bad; but if the same man vomit all these colors, it is to be reckoned a very fatal symptom. But of all the vomitings, the livid indicates the most imminent danger of death, provided it be of a fetid smell. But all the smells which are somewhat putrid and fetid, are bad in all vomitings.[495]

14. The expectoration in all pains about the lungs and sides, should be quickly and easily brought up, and a certain degree of yellowness should appear strongly mixed up with the sputum. But if brought up long after the commencement of the pain, and of a yellow or ruddy color, or if it occasions much cough, or be not strongly mixed, it is worse; for that which is intensely yellow is dangerous, but the white, and viscid, and round, do no good. But that which is very green and frothy is bad; but if so intense as to appear black, it is still more dangerous than these; it is bad if nothing is expectorated, and the lungs discharge nothing, but are gorged with matters which boil (as it were) in the air-passages. It is bad when coryza and sneezing either precede or follow affections of the lungs, but in all other affections, even the most deadly, sneezing is a salutary symptom.[496] A yellow spittle mixed up with not much blood in cases of pneumonia, is salutary and very beneficial if spit up at the commencement of the disease, but if on the seventh day, or still later, it is less favorable. And all sputa are bad which do not remove the pain. But the worst is the black, as has been described. Of all others the sputa which remove the pain are the best.[497]

15. When the pains in these regions do not cease, either with the discharge of the sputa, nor with alvine evacuations, nor from venesection, purging with medicine, nor a suitable regimen, it is to be held that they will terminate in suppurations.[498] Of empyemata such as are spit up while the sputum is still bilious, are very fatal, whether the bilious portion be expectorated separate, or along with the other; but more especially if the empyema begin to advance after this sputum on the seventh day of the disease. It is to be expected that a person with such an expectoration shall die on the fourteenth day, unless something favorable supervene. The following are favorable symptoms: to support the disease easily, to have free respiration, to be free from pain, to have the sputa readily brought up, the whole body to appear equally warm and soft, to have no thirst, the urine, and fæces, sleep, and sweats to be all favorable, as described before; when all these symptoms concur, the patient certainly will not die; but if some of these be present and some not, he will not survive longer than the fourteenth day. The bad symptoms are the opposite of these, namely, to bear the disease with difficulty, respiration large and dense, the pain not ceasing, the sputum scarcely coughed up, strong thirst, to have the body unequally affected by the febrile heat, the belly and sides intensely hot, the forehead, hands, and feet cold; the urine, and excrements, the sleep, and sweats, all bad, agreeably to the characters described above; if such a combination of symptoms accompany and either on the ninth or eleventh. Thus then one may conclude regarding this expectoration, that it is very deadly, and that the patient will not survive until the fourteenth day. It is by balancing the concomitant symptoms whether good or bad, that one is to form a prognosis; for thus it will most probably prove to be a true one. Most other suppurations burst, some on the twentieth, some on the thirtieth, some on the fortieth, and some as late as the sixtieth day.[499]

16. One should estimate when the commencement of the suppuration will take place, by calculating from the day on which the patient was first seized with fever, or if he had a rigor, and if he says, that there is a weight in the place where he had pain formerly, for these symptoms occur in the commencement of suppurations. One then may expect the rupture of the abscesses to take place from these times according to the periods formerly stated. But if the empyema be only on either side, one should turn him and inquire if he has pain on the other side; and if the one side be hotter than the other, and when laid upon the sound side, one should inquire if he has the feeling of a weight hanging from above, for if so, the empyema will be upon the opposite side to that on which the weight was felt.[500]