The clinic does not form a particular branch of medical science ; it embraces all, and makes the application of them at the bedside - it constitutes the highest degree of medical teaching. There, the master unites, constantly, example to precept - practice to theory. Nothing is better calculated to mature the experience of young men, than those lessons which are given at the bedside of the sick, when he who has charge of the patients, unites profound instruction with great probity ; and by this last term we comprehend, with a modern professor, candor, frankness, justice, humanity, and disinterestedness. M. Bouillaud insists, justly,
on the necessity of joining moral qualities to knowledge in the practice and teaching of Medicine. He clearly demonstrates, that in default of morality, the most beneficent act is only an instrument of deception, and a dangerous weapon, in unsafe hands. He defines the true physician to be an honest man, instructed in the art of healing. Vir probus medendi peritus ; a definition which cannot be too much popularized, for it shows to the public what are the qualities they must seek in a man to whom they confide their health.( Essai de Philos. Medicale. Paris, 1837, p. 239)
It was as much by his virtues as by his genius, that Hippocrates gained universal approbation. These virtues shine with great eclat in the clinical observations which he has transmitted to us. He never appears there as laboring for a reputation ; the sole desire that animates him is, to be useful to his fellows, in enlightening them on the means of preserving health, or in curing diseases. He avows, with an ingenuousness that finds few imitators, his reverses and faults, convinced, doubtless, that instruction is as much given in pointing out an error, as in showing the truth.
The most ancient collection of clinics bears the title of Epidemics. These sort of afflictions leave in the minds of the people such impressions of astonishment and terror, that other than medical writers have not disdained to trace their history, as extraordinary events of interest to posterity. It was then entirely natural that physicians should relate detailed accounts of them ; not for the simple purpose of interesting or gratifying the curiosity of the reader, but in the hope of finding some means to prevent the return of similar pests, or of moderating their effects.
To attain this end, physicians proposed, in the first place, to ascertain the cause of epidemics. The following is their reasoning, to prove that it is always in the atmosphere: " Some diseases," say they, " come from the regimen, others from the air which we breath to maintain life. Where several persons are attacked at the same time and place by the same disease, we must seek the cause in that which is most common to all, and this is the atmosphere. It is manifest, then, that these affections do not proceed from the regimen, because they attack every one indifferently ; men as well as women ; hard drinkers as well as those who drink only water ; the industrious as well as the idle ; those who live luxuriously as well as those who have only bread for food. So then, when an epidemic prevails, the cause certainly does not exist in our regimen, but in the air we inspire, receiving from it some deleterious element.(Hippocratic Works. Treatise on the Nature of Man, Vol. 1, sec. 10 and 11. Gardeil)
This reasoning cannot be objected to unless it be thought too absolute, for epidemic affections may be developed under the influence of a bad alimentation, in countries where famine prevails, in besieged cities, in ships, etc. ; others spring from moral causes, such as the discouragement which follows a retreat, religious exaltation produced by fanatical preaching, or from persecutions.(Raphania, or the disease of fanatics, scurvy, and convulsions of St. Medard, etc)
Nevertheless, it cannot be denied that the air is the most active medium - the most powerful vehicle of epidemics, especially of those that ravage large districts, and for a considerable length of time.
Another very important observation, which did not escape the Asclepiadse, is that during the reign of epidemics, the most varied intercurrent affections have a particular physiognomy which is common to all, and which gives them a familiar likeness.
Besting upon this double basis, the Hippocratic writers believe it important to note with care, the state of the atmosphere before and during the epidemics, and they have described with not less exactness, the general character of intercurrent diseases. In this way, connecting the meteorological phenomena with the morbid ones observed during a season or a year, they describe what has been named the epidemic constitution of that season or year. They hoped, that after having thus described a great number of medical constitutions, they would be able to ascertain what atmospheric conditions habitually preceded and accompanied different epidemics, so that it would be possible, in certain cases, to foresee the advent of the scourge, and prepare for it.
Such was the hope also of Sydenham and Stohl, worthy emulators of Hippocrates, when they, with admirable patience, prepared their tables of medical constitutions. Too few physicians have had the courage to follow in their footsteps. The happy mortal to whom is reserved the honor of determining the relation or law that connects epidemics with certain states of the atmosphere, has not yet appeared.
Seven books of the Hippocratic collection bear the title of Epidemics. Nevertheless, the first and the third alone are devoted, effectively, to the description of epidemic constitutions, and appear to follow each other. On this account, they are considered as being connected, and are separated from the others, which are not supposed to belong to Hippocrates. He describes in the first place, the most remarkable atmospheric conditions ; afterwards, the general character exhibited by intercurrent diseases by the constitution ; finally, he traces the particular history of some diseases. The following extract will enable the reader to judge of the method and talent for observation displayed by the author.
FIRST CONSTITUTION. ( Works of Hippocrates, by Littre, Vol. 2, p. 599. Epidemics, Book 1, sec. 1)
" In the island of Thasos, during autumn, towards the equinox, and whilst the Pleiades were at the horizon, (that is, for those fifty days after the autumnal equinox), there were gentle, continuous and abundant showers, southerly winds, and open winter, with slight breezes from the north, and dryness ; in sum the whole winter seemed like spring. The spring season, in its turn, was marked by south winds, coolness and slight showers. The summer was in general, cloudy without rain ; the monsoon seldom blew, and with but little force or regularity.
" All the atmospheric conditions having been southern and dry, an interval in this constitution, opposite and northern, occurring in the beginning of spring, developed some cases of remitting fever ; but they were generally moderate. There were but few attended with nasal hemorrhage, and no one died. Tumors were developed in several persons - on one side only in the greater number ; but no one had so much fever as to be obliged to keep his bed ; though some had a little heat of skin. These tumors disappeared in all cases without any difficulty ; there was no suppuration, which so often happens with tumors arising from other causes. They were large, soft, diffused, without inflammation or pain, and disappeared without any critical sign. They were manifested in youths, in men in the flower of their age, and especially in those who took gymnastic exercises ; few women were attacked. The greater number of the afflicted had dry coughs, with hoarseness, but no expectoration."
Very soon, in some, but later in others, there was developed a painful inflammation of the testicle, some times on one side, then on both. Fever was not always present, but there was much suffering. It is to be added, that the Thasians did not seek medical " advice."
The above is an account of the Medical Constitution for the end of winter and the spring. The author describes consecutively, that of the summer and autumn, after which he reports some historical particulars.
" First patient - Philiscus - lived near the wall. He took to bed. First day : acute fever, sweat ; a bad night. Second day : general exacerbation ; in the evening, a small injection procured favorable evacuation ; a tranquil night. Third day : in the morning, and until mid-day, the fever appeared to have ceased, but towards evening, acute fever, with sweat ; tongue begins to be dry ; urine dark ; he passed a painful night, without sleep, and had hallucinations on all subjects. Fourth day i general aggravation ; dark urine ; the night was passed better, and the urine better colored. Fifth day ; towards the middle of the day, he had a slight epistaxis of very dark blood ; urine varied, a cloudy substance similar to sperm, floating in it, but without precipitating ; after a supository, he passed a little feces, with wind. The night was uncomfortable ; short naps ; he talked much in a rambling way ; all the extremities were cold, and could not be warmed ; he passed dark urine ; slept a little towards day ; became speechless ; cold sweat and livid extremities. He died about the middle of the sixth day.
" In this patient the respiration was, to the end, full and slow, as if he had to remember to breathe. The spleen was swelled and formed a round tumor: the cold sweat continued till the last: the access was every other day."
The above tableau gives an idea of the whole of the morbid phenomena, though it leaves something to desire, as we shall show presently. There is no comparison possible between a narration thus made and the miserable votive tablets suspended on the columns of the temples. The first and third books on Epidemics include together forty-two particular histories, similar to that given above. Twenty-five of these terminated fatally, and seventeen, only, favorably.
Certain critics have taken occasion, from this frightful mortality, to blame the curative method of Hippocrates ; but they show that they are superficial observers, or they would have seen that Hippocrates only gives the detailed history of the gravest and most remarkable cases. The proportion of fatal cases would have been much less, if he had included all his cases. This conclusion is not a conjecture - it is proven from many passages of our author ; among others, in a remark cited above, in the description of the first medical constitution: "All the atmospheric conditions having been southern and dry, an interval in which the constitution was opposite and boreal, at the beginning of spring, originated some fevers. These fevers were generally moderate ; a few had nasal hemorrhages, but none died."
A reproach much better founded might be made to the clinical relations of the old man of Cos, viz : for having said nothing, or next to nothing, of the regimen and treatment to which he submitted the sick. This omission is keenly felt, rendering it impossible for the reader to appreciate the curative method of the physician. It forms an important vacuum in the history of the disease ; for it is evident that the therapeutic or hygienic means employed during the course of a disease affect the progress and duration of it, however simple they may have been. It is not a matter of indifference, for example, whether a sick person be placed in a convenient chamber, warmed and ventilated, or in a small, obscure, cold, and infected apartment ; or whether he is permitted to drink wine without discretion, or only to have pure water.
The five other books on Epidemics contain clinical observations, collected without order, and relating to all sorts of diseases. A great number of these histories are only simple notes or detached reflections ; some, however, are edited with taste and completeness. The mention made in these, of the treatment, shows a progress, compared with the preceding ones. Here is one of the best, I think, though not one of the longest.
Edematous swelling during pregnancy ; great dyspnea ; expectoration of a large amount of pituitous matter ; improvement.
11 The sister of Harpalides, being in the fourth or fifth month of pregnancy, an aqueous swelling commenced at the feet and around the eyes ; the skin became swelled up, as in phlegmatic persons ; dry cough ; sometimes orthopnea ; the dyspnea and suffocation were such that the patient sat up in her bed, being unable to lie down ; and if she felt sleepy, it was when sitting up. Beyond this there was little fever : the fetus was for a long time still, as if it were dead, and it fell about, following the position of the woman. The dyspnea persisted for two months ; but the patient making use of Egyptian beans, (nymphcea nelumbo, Lin.), prepared with honey and with a honeyed eclegma, and drinking the cumin of Ethiopia, in wine, her condition improved ; her expectoration became abundant, looked mucoid and white ; the dyspnea ceased. She brought forth a female child." (Works of Hippocrates, - Epidemics, book vii)
From History of Medicine by P.V. Renouard M.D.