Chapter 33

[624]The nature of the continual fevers of the ancients is fully explained in the Commentary on the twenty-seventh section of the Second Book ofPaulus Ægineta. Galen, in his Commentary on this passage, marks their nature very distinctly in few words. He says that such fevers as have an exacerbation of fever ending in complete apyrexia are called intermittents, whereas such as do not end in a complete remission of the fever are called continual. See further De Diff. Febr., ii., 2. In a word, the continual fevers were decidedly of the remittent type. See further Donald Monro’s work on Army Diseases, in the beginning of the chapter on the Bilious Remittent Fever.[625]The introduction of phthisis in this place has created some difficulty in the interpretation, as may be seen on reference to Galen and Littré. Galen gives a very interesting account of the way in which interpolations often took place. (Opera, tom. v., p. 356.)[626]The text of this last sentence is in an unsettled state. The following would be a translation of it as it stands in the Basle edition of Galen’s Works: “Of all the cases described under this constitution, those alone which were of a phthisical character proved fatal. But they (the phthisical affections?) did not supervene upon the other fevers.” Provided this be the true meaning of the passage, it would merit great attention, as seeming to contain a declaration that intermittent fevers superinduced an immunity to phthisis. I need not say that this supposed fact has been exciting a great deal of interest lately in the profession, more especially in France.[627]It is to be borne in mind that the autumn began with the rising of Arcturus, and ended with the setting of the Pleiades. The setting of the Pleiades then indicated the commencement of winter. The classical reader will find the different seasons, strikingly defined by the rising and setting of the stars, in Virgil’s Georgics. See in particular Georg. i., 221.[628]Galen thus explains the origin of the ophthalmies. He says, the constitution of the air being not only cold and humid, but attended also with hurricanes. The eyes were thus injured, and consequently were the first part of the body to show symptoms of disease. The dysenteric and other alvine complaints which followed, he ascribes to the constriction of the skin induced by the cold, and to the humoursæ of the system aggravated and increased by the humid state of the season. These humours being thus shut up by the occlusion of the pores of the skin, part of them were determined to the intestines, occasioning diarrhœa, tenesmus, dysentery, etc.; some to the bladder, inducing strangury; and some to the mouth of the stomach, occasioning vomiting.[629]Galen states in his Commentary that the phrenitis is connected with inflammation of the parts about the brain. We have mentioned before that the phrenitis of the ancients was a febrile affection, and not idiopathic inflammation of the brain, as is generally supposed.[630]According to Galen, the causiorardent fevers are occasioned by yellow bile collected about the vessels of the liver and stomach, and the tertians by the same diffused over the whole body.[631]Galen states in his Commentary that children are peculiarly subject to convulsions owing to the weakness of their nervous system. He adds, that in their case convulsions are not attended with so much danger as in other cases. See the Hippocratic treatise On Dentition.[632]The fever here described is evidently the semitertian. SeePaulus Ægineta, Book II., 34. “The true semitertian,” says M. Bartels, as quoted by M. Littré, “is a real complication of an intermittent fever with another fever of a continual type. It does not show itself but rarely in our countries; but it is more frequent in the hotter countries of Europe, although the false semitertian has oftener than once been confounded with the true. In the true, the intermittent fever is tertian; the non-intermittent is quotidian.” See also Galen, Opera, tom. v., p. 362; ed. Basil.[633]The text here is in an unsatisfactory state, and, as usual in such cases, no ingenuity nor pains can do much to mend it. See Foës and Littré. I have translated the disputed words “not resolved,” which seems to me to agree best with the sense. Every practical physician knows that swellings of the glands, which continue long and do not suppurate, are unfavorable in fevers.[634]The modern physician will not fail to be struck with this observation as to the termination of certain cases of fever in determination to the kidneys. Galen remarks in his Commentary on this passage, that as the general system is often purged by the bowels, so is it also sometimes by the kidneys and bladder. This, he adds, is a protracted and painful mode of resolution in fevers. The reader will remark the characters of the urine as stated below by our author. One cannot help being struck with his statement, that all these cases recovered. I am not aware of any modern observations bearing on this point.[635]There is considerable difficulty here in determining the reading. See Littré, whom I have followed.[636]I need scarcely remark that this passage is of classical celebrity. Galen, in his Commentary, remarks that the first time he read it he thought it unworthy of Hippocrates to lay it down as a rule of practice, that “the physician should do good to his patient, or at least no harm;” but that, after having seen a good deal of the practice of other physicians, and observed how often they were justly exposed to censure for having bled, or applied the bath, or given medicines, or wine unseasonably, he came to recognize the propriety and importance of the rule laid down by Hippocrates. The practice of certain physicians, Galen remarks, is like playing at the dice, when what turns up may occasion the greatest mischief to their patients. The last clause of this passage is very forcibly put. Galen, however, informs us that in some of the MSS. instead of “art” he found “nature;” that is to say, that the physician is “the minister (orservant) of nature.” Either of the readings, he remarks, will agree very well with the meaning of the passage.[637]The reader will find it interesting to refer here to the Prognostics. See also the Commentary of Galen. Let me here impress upon the reader the necessity of making frequent comparisons of the Prognostics with this work, if he would wish rightly to apprehend the bearing and meaning of the latter. That the Epidemics are entirely founded upon the principles of prognosis there can be no doubt.[638]It is to be recollected that the rising of Arcturus marked the beginning of autumn, and the setting of the Pleiades the end of it. See above.[639]The season of the Dog-star was immediately after the summer solstice, namely, when the sun enters the constellation Leo. The classical reader will readily bring to his recollection the lines of Horace, which are descriptive of this season:“Jam Procyon furit;Et stella vesani Leonis,Sole dies referente siccos.”[640]Galen, in his Commentary, remarks that the attacks of paraplegia (that is to say, of apoplexy) were brought on by the cold winds of the winter succeeding to a humid autumn.[641]The causiorardent fevers, it is worthy of remark, began this season in spring, but were not of a fatal character until autumn. In modern times the bilious remittent fever has uniformly been found to be most aggravated in autumn, and hence it has been named by some authorities the autumnal remittent fever. See the works of Sydenham, Pringle, Monro, and Cleghorn. Monro mentions that he seldom saw it in spring, but that it is common in the neighborhood of London towards the end of summer and beginning of autumn. All these authorities are agreed that it is of a highly bilious nature.[642]Monro mentions epistaxis as occurring in the autumnal remittent fever; he says it did not prove a crisis in any case.[643]The complication of the autumnal remittent fever with jaundice is noticed by Sir John Pringle (Obs. iii., 4), and by Monro (On Army Diseases, p. 161). Galen, in his Commentary, remarks that when nature is unable to evacuate the bile, it is collected in the skin, and occasions jaundice. He adds, that the occurrence of the jaundice in this case was unfavorable, owing to its taking place before the seventh day. When occurring on the seventh day, jaundice was reckoned a favorable symptom. See On Crises, 3; Aphorism, iv., 62, 64.[644]The reader may feel interested to learn Galen’s hypothesis by which he accounts for the hemorrhage in this case. He says it is produced by the redundancy of yellow bile, which, being mixed up with the blood and heating it, is carried up to the head, where it produces rupture of the vessels and hemorrhage.[645]Modern observations have confirmed this account of the generally fatal issue of febrile diseases after parturition. In the Hippocratic work On Diseases, fever after delivery in a woman is reckoned among the cases which generally prove fatal.[646]I would again request the attention of my contemporaries to the characters of the urine before a crisis, as given by Hippocrates; and, in confirmation of them I will venture to introduce here an extract from Donald Monro’s admirable account of the autumnal remittent fever: “The urine in the beginning was commonly of a high color, though sometimes it was pale and limpid; but when the fever came to remit, there was often a small sediment after each paroxysm; and as the fever was going off,it let fall a sediment in all.” (Army Diseases, etc., p. 159.) The absence of the sediment in the urine before the crisis is an important fact in the history of febrile diseases, which I have reason to think is not now sufficiently adverted to.[647]Galen does not hesitate to give it as his opinion that the dysentery was owing to the bile not being properly purged off by the urine.[648]The reader will find it interesting here to mark the alliance between the causus and phrenitis, to which we formerly adverted. Galen remarks that both arise from the same humour, that is to say, bile, which when it collects in the veins of the lower part of the body gives rise to causus; but from the beginning of autumn to the equinox, produces phrenitis by being determined to the brain.[649]This is perhaps the most striking account of an aggravated form of causus which is anywhere to be found. Although less finished than the celebrated picture of the disease given by Aretæus, it is evidently more original. In fact, any human production which is very original cannot well be finished, and consequently a very finished work can scarcely be expected to be very original.[650]It is impossible to overrate the importance of these observations on crises in fevers, provided they be correct and confirmed by general experience. Monro, without appearing to have our author in view, seems to give an ample confirmation of his doctrines on crises as here laid down.[651]From Galen’s Commentary it appears that the text here is in a doubtful state. See also Littré.[652]Allusion is here made to the symptoms of delirium as described in the fourth paragraph of the Prognostics. See Galen’s Commentary on this passage.[653]What an admirable and comprehensive enumeration of all the circumstances upon which the prognosis and diagnosis of diseases are to be founded! Here we find nothing either wanting or redundant; and with what conciseness and precision the whole is stated! Galen gives an elaborate and, upon the whole, a very interesting Commentary on this section, but does not supply any new views, and there are few terms in it requiring explanation.[654]Having already stated in this work, as well as in the Commentary onPaulus Ægineta, Book II., 27, my opinion respecting the nature of the continual fevers, I need not enlarge on the subject in this place. Whoever wishes for more information may find much to interest him in the Commentary of Galen. Respecting the septans and nonans, he remarks, that, although conversant with fevers from his youth, he had never met with any cases of these.[655]Galen, in illustration, states that epilepsy is sometimes carried off by an attack of quartan fever.[656]The semitertian was always looked upon as a very formidable form of fever. SeePaulus Ægineta, Book II., 34. Galen gives a prolix, but not a very distinct account of it.[657]Galen, in his Commentary, states that he had often seen persons in consumption attacked with tertian and quotidian intermittents, but admits that he had no more experience of quintans than he had of septans and nonans. Avicenna. however, is not so sceptical as to the occurrence of these rare forms of intermittents. Indeed he says, he had often met with quintans, and that a trustworthy physician of great experience had assured him that he had met with nonans. (iii., 1, 3, 67.) Rhazes also would appear to acknowledge the occurrence of all these varieties of intermittent fever. (Contin., xxx., 10, 1, 409.)[658]The text is much improved in Littré’s edition, so that the meaning is pretty intelligible without any commentary. Galen states in explanation, that the three varieties of fever are thus marked and distinguished from one another: in the first, the fever attains its height at the commencement, and gradually diminishes until the crisis; in the second, it begins mild, and gradually reaches its height at the crisis; in the third, the fever begins mild, gradually attains its height, and then gradually subsides until the crisis.[659]These are all febrile diseases, and for the most part of the ardent type. In order to enter properly into the spirit of them, the reader will find it necessary to revert frequently to the Prognostics, and compare the parallel passages. See also the Argument.[660]Galen, in his Commentary, remarks that the fatal issue of this case might have been anticipated after the return of the fever on the third day, with a complication of bad symptoms, such as great thirst, dry tongue, black urine, delirium, coldness of the extremities, and so forth. The modern reader will be struck with the description of the respiration, namely, that the patient seemed like a person who forgot for a time thebesoin de respirer, and then, as it were, suddenly recollected himself. Such is the meaning of the expression as explained by Galen in his Commentary, and in his work On Difficulty of Breathing. By “rare” is always meant “few in number.” The reader will remark that this is a striking case of a fever having regular exacerbations on the even days, and slight remissions on the uneven.[661]This, it will be remarked, is a case of fever induced from obvious causes, namely, excessive fatigue and dissipation. We must take into account, however, the febrile constitution of the season. According to Galen, the fatal result could have been confidently foreseen from the seventh day. The distention in the hypochondriac region here described would appear to have been meteorism. The throbbing in this region was no doubt owing no the same cause. The rash was most probable miliary. It is described as resemblingvari(ἴονθοι), by which was probably meantacne. SeePaulus Ægineta, Vol. I., p. 454. Upon reference to the Prognostics, it will be remarked that the characters of the urine are all bad, that is to say, it was either suppressed, or the sediment was either wanting or black and farinaceous. See Prognost. 12. By “black,” as applied to the urine, is to be understood “a dark-red color,” like that of wine.[662]There is nothing in this case very remarkable, or which stands in need of elucidation; but yet the reader may feel interested in Galen’s reflections upon it. The recovery he holds to have been unexpected, as a different result might have been anticipated from the characters of the alvine discharge, and of the urine at the commencement. The favorable change he attributes to the swelling of the spleen, whereby the peccant humors were attracted to it; and he further remarks, that as the swelling of the spleen diminished, the humors are described as having passed down to the extremities, after having first affected the groin of the side on which the spleen is situated. He further calls attention to the improved characters of the urine when the swelling of the spleen and pains of the limbs supervened. Still, however, he adds, there was a remnant of the cacochymy in the system which gave rise to the relapse on the fourteenth day, so that the complete crisis did not take place until the seventeenth day.[663]This is evidently a well-marked case of puerperal fever, or of fever complicated with the puerperal state. There is nothing particularly interesting in Galen’s commentary on it. He states that the application made in order to remove the suppression of the lochial discharge may either have been a pessary or a suppository. It seems most likely to have been the former. On the composition of the ancient pessaries, seePaulus Ægineta, Book VII., 24. He remarks that the symptoms first stated are unfavorable, but not necessarily fatal, until we come to the coldness of the extremities, which is an extremely mortal symptom in the beginning of a disease when combined with a very violent fever. The modern reader will be struck with the expression that “the attendants seldom put her in mind” to make water; it is very descriptive, however, of the state of stupor the patient was in when she was so insensible that she did not attend to the calls of nature.[664]Galen remarks that it was reckoned very extraordinary for a rigor not to be followed by febrile heat. See Comment. et de Rigore; de Diff. Febr., ii.; and Foës’s long annotations on this passage.[665]It will be remarked that the characters of the urine throughout are favorable. Though darkish at first, this was reckoned not unfavorable, as being connected with the lochial discharge. (See Galen. Comment. 2, Epid. iii.) The sediments afterwards are all of good omen; but, as Galen remarks, its first characters indicated a prolonged fever.[666]On the Critical Days, seePaulus ÆginetaBook II., 7.[667]On comparing the symptoms here enumerated with the Prognostics, it will be remarked that none of them are of fatal omen. But the white sediment, and afterwards the reddish color of the urine, while they indicated recovery, at the same time prognosticated a protracted attack of fever. See Prognost., 12. The reader will further remark that there is an absence of all the decidedly fatal symptoms, such as delirium, coldness of the extremities at the commencement, and so forth.[668]The rapid recovery in this case would seem to be partly attributable to the decided plan of treatment, namely, the copious affusion of hot water on the head. Hippocrates probably had it in view when he wrote the forty-second Aphorism of the Seventh Book: “In fever not connected with bile, if a large quantity of hot water be poured over the head, it proves a resolution of the fever.” Galen points it out as a remarkable circumstance, that in this case the crisis took place without concoction of the urine, in consequence of the hemorrhage from the nose, and the sweating.[669]In this case, as Galen remarks, the continued sweats, unfavorable condition of the hypochondriac region, and the black urine, precluded all hopes of recovery. He thinks our author related the case as an instance of sudden death in fever, this patient having died on the fourth day after the attack (the first not being counted). See his Commentary. He also makes reflections upon this case in his work On Difficulty of Breathing, where he points out the danger of meteorism of the hypochondriac region as being necessarily accompanied with dyspnœa, and connected with inflammation (2).[670]This case, as Galen remarks, is interesting from the suddenness of the fatal result. We should not hesitate nowadays to set it down as a case of malignant erysipelas; the pain, swelling, and bullæ of the foot and ankle must have been of this nature. By the way, these bullæ, when not followed by suppuration, are represented in the Coacæ Prænotiones, as a fatal symptom. Galen thinks it strange that this patient was not bled, but accounts for it by supposing that Hippocrates had been called in too late. He remarks on this case in the Second Book of his work On Difficulty of Breathing.[671]Galen looks upon this patient as an exampleorparadigm of general principles in Prognostics. Thus, with regard to the characters of the urine, it is stated that on the eleventh day the urine was thin, of a good color, and having many substances floating about in it, but without sediment. Thus matters remained until the sixteenth, when the urine became somewhat thicker, and had a slight sediment. Now Galen remarks (as the reader will find on turning to the Book of Prognostics) that these characters of the urine are indicative of recovery after a protracted disease. Galen further points out that no one of the fatal symptoms are mentioned, and that swellings of the parotid glands and the dysenteric affections of the bowels indicated that the crisis would be distant. He also calls attention to the case as confirmatory of the doctrines of Critical Days. In the Second Book of his work On Difficulty of Breathing, he makes some remarks, of no great importance however, on the meteorism of the hypochondriac region, as noticed in this case.[672]In this case, as Galen remarks, the characters of the urine from the first were such as to indicate a fatal and speedy result. On the second day the urine was turbid, and without any sediment; on the third day the same, and consequently confirming the anticipation of the disease proving mortal; on the fourth, oily urine, with epistaxis, so that it was not to be wondered at that the patient died on the sixth. Indeed, when we further take into account the state of the breathing, the coldness of the extremities, the meteorism of the hypochondriac region, and the subsultus tendinum, it is difficult to imagine a more hopeless case of fever. Having mentioned “oily urine,” it may be well to state its characters, as fully given by one of the later authorities on urology, namely Theophilus. He says, when the urine in fevers assumes the color of oil, it indicates that the fat of the body is melting down; when the appearance of the urine still more resembles oil, it shows a still greater melting; and when the urine in consistence and color exactly resembles oil of a dark color, it prognosticates a fatal collapse. (De Urinis, 17; ed. Ideler.) On this subject, see further some very interesting observations by Foës, in his annotations on this passage (p. 988). With regard to the respiration in this case, see also the remarks of Galen in the Third Book of his work On Difficulty of Breathing (tom. vii., p. 932; ed. Kühn). As Galen here remarks, Hippocrates explains the meaning of this passage in one of his Aphorisms, where he writes thus: “In fevers, when the respiration stops, it is a bad symptom, for it prognosticates convulsion.”[673]According to Galen, this case is an instructive example of the danger of neglecting the diet at the commencement of complaints which appear unimportant. This man, having taken supper at the beginning of a fever which appeared slight, suffered therefrom as the result showed; that is to say, vomiting ensued, followed by serious symptoms, among which Galen particularizes, as indicating a fatal result, urine at first thick and without sediment, and afterwards oily. So much importance did the ancient physicians attach to observations on the urine in fevers! Galen further calls attention to the fact, that the patient died on a critical day, that is to say, on the eleventh.[674]Galen, in the commentary, makes a remark regarding this report, which appears more important to him than it will do to most modern readers, namely, that he wonders Hippocrates did not state the age of this patient. He adds, that it is very rare for a pregnant woman to have such a serious fever without parting with her child. He thinks the patient, in the present instance, owed her recovery to the strength of her constitution, as “urine white, and not of a good color,” in combination with the other bad symptoms, indicated an unfavorable result. By the way, upon reference to the Basle edition of Galen, and to Foës’s annotations on this case, it will be seen that there is a difference of reading in the words descriptive of the urine, that is to say, some read ἀχρόων, some εὑχρόων. Certainly it appears to me that Foës is right in preferring the latter. The decided crisis, it will be remarked, took place on a critical day, that is to say, the fourteenth, by a sweat.[675]Here again Galen calls attention principally to the characters of the urine, which is first described as being “of a good color, but thin.” Now, by a good color of the urine, Galen observes, was meant of a slightly yellow color. In this case, as usual, the crisis was marked by a sediment in the urine.[676]Œuvres d’Hippocrate, tom. iii., Arg., pp. xxxvi.-xlii. tom. v., pp. 57–70.[677]There is some doubt, however, even on this head; indeed Riolanus does not scruple to affirm, with a considerable degree of plausibility, that Ruffus must have lived after Galen, since he is nowhere mentioned by the latter. (Anthropographia, i., 5.)[678]In illustration, consult Plutarch (Placit. Philosoph., v., 29).[679]De Differ. Feb., i., 7; tom. vii., p. 296, ed. Kühn.[680]Commentary onPaulus Ægineta, Book II., 16, 36; IV., 25, Syd. Soc. edition.[681]Disquisitio Historico-Medica de Natura Morbi Atheniensium. Stuttgart, 1831.[682]On this case Galen has left very lengthy and elaborate commentaries, containing much important and amusing matter, but not a little verbose trifling, to say the least. Our limits, as well as our tastes, dispose us to be very sparing in our extracts from them. Passing over his remarks on the solecism in syntax, with which the Report commences, and his observations on the absence of all mention of the exciting causes, as is the usual practice of our author, I shall proceed to state what Galen says on the apparent neglect of venesection in a case where it would certainly appear to have been clearly indicated. In this case, as Galen remarks, one or other of these suppositions may be made: either that bleeding was not practiced, or that the author did not think of mentioning the practice here, as supposing that it would be taken for granted that it was applied. Now, he adds, the former supposition is very improbable, considering how partial our author shows himself to this practice in his works which are unquestionably genuine, such as On the Regimen in Acute Diseases, the Aphorisms, the work On the Articulations, and even in this very book, where in one place he mentions that he abstracted blood copiously on the eighth day. If, then, he bled so late in febrile diseases, Galen contends that he was not likely to neglect the operation in an earlier stage, when so much more demanded. He argues further, that in many of the other reports of cases he neglects to mention that the usual routine of practice was followed: and therefore he inclines to the opinion that it is omitted to be mentioned here, because the author supposed there could be no question on this point, more especially as it was his universal rule to bleed in all great complaints, when not prevented by the age or powers of the patient. He afterwards insists strongly on venesection having been indicated in this case, in order to procure revulsion from the brain. As usual with the commentator, he calls attention to the characters of the urine, and explains the meaning of the term “cloudy,” as applied to theeneorema, or substances floating in the urine, by which he contends is to be understood a color intermediate between white and black. What follows in this very lengthy Commentary is very interesting in a general point of view as regards the views of some of the older commentators, but is not directly applicable to the present case. His observations on the characters affixed to this and many of the subsequent cases have been noticed in the Argument. The reader will further remark of this case that it is an instance of fever passing into a deposit (orabscess), and the latter into strangury, of which our author had made mention in the First Book of the Epidemics. I may further mention that the reader will find much interesting matter in Galen’s work On Trembling, in illustration of the nature of the attack under which the patient labored.[683]Galen, in his Commentary, communicates a singular notion which one of the earlier commentators maintained respecting the name of the place where this patient was laid, that is to say, that this new wall, having been recently washed with quicklime, had been the cause of this patient’s illness. Galen, however, rejects this paltry conceit. He says on his own authority, that there being three distinct classes of fever, namely, the ephemeral, the hectic, and those connected with putrid humors, the present case belongs to the last of these.[684]Galen compares the characters of the urine with their indications as given in the Prognostics. None of them are favorable, although not decidedly fatal.[685]This complication cannot fail to attract attention, from its resemblance to an epidemic which prevailed in Scotland in the year 1843. In this epidemic, as in the present case, the fever was very subject to relapses and to jaundice at an early stage. Hippocrates, in one of his Aphorisms, pronounces jaundice in fevers before the seventh day to be a fatal symptom. (iv., 62, 64.) Galen justly thinks it somewhat singular that no further mention of the jaundice is made in the course of the report; but he inclines from this to draw the conclusion that it remained in the same state throughout. As there was no crisis by the stomach, the bowels, the urine, or sweat, he concludes that the jaundice could not have been carried off. From all that has been said, he adds, it is clear that the organ primarily affected was the liver. Galen, then, decidedly opposes the view taken in the Explanation of the Characters respecting the cause of this man’s death, which he contends was not connected with any suppression of the alvine discharges, but with the affection of the liver. On the Scotch Epidemic, see Ed. and Lond. Med. Journal, March, 1844.[686]Most of the ancient authorities regarded deafness as an unfavorable symptom in fevers. SeePaulus Ægineta, Book II., 4. The modern are divided in opinion on this point. Pringle and Huxham regard it as a favorable symptom, but Home looks upon it as unfavorable.[687]Here again Galen mentions the absurd notion of Sabinus the commentator, that this man’s disease was occasioned by the locality in which he was laid. Galen, on the other hand, thinks it likely that the patient was conveyed to the garden as being a favorable situation for a person ill of fever. He further alludes to this case in the Second Book of his work On Critical Days.[688]Galen remarks, that as there is no mention of a single favorable symptom up to this date, the patient would certainly have died if he had not been of a vigorous constitution.[689]Thus, as Galen remarks, after two ineffectual attempts, Nature accomplished a cure on the fortieth day.[690]There is not much to remark in this case. A modern reader will suspect that there had been cerebral disease before the attack of the fever, and that matters had been brought to a crisis by the drinking of wine. Indeed Galen, in his Commentary, remarks that the precursory symptoms indicate a congestion of humors in the brain, which of course would be much aggravated by the wine, the brain then being, as he says, in a bad state; and the patient having inflicted an additional injury to the organ, by means of the drink, brought on the acute attack, which proved fatal in five days. The deafness, delirium, spasms, and bilious vomitings all indicate a cerebral affection. The state of the hypochondria, as described in the report, Galen would seem to attribute to a spasmodic affection of the diaphragm, from sympathy with the brain. Retraction of the hypochondrium is pronounced to be a bad symptom in the First Book of the Prorrhetics. Galen justly contends that there is no reason in this case to suspect any inflammation in that region.[691]Galen’s remarks on this case are unusually brief; he attributes the fever to a bilious plethora, and states that the result was such as might have been anticipated from a knowledge of the critical days, and of the characters of the urine. Indeed the latter appear to me well deserving of attention.[692]This is in many respects an interesting case, and more especially, from its being stated that the disease was complicated with hereditary consumption. Galen, in his Commentary, remarks that some authorities denied that any disease is congenital, but this opinion he decidedly rejects. The phthisical affection, however, as he justly remarks, would not have occasioned so sudden an issue if it had not been complicated with a complete prostration of the natural powers. He insists strongly on the striking description here given of the total loss of the natural appetite, both in regard to food and drink. Of course, no worse state of the system can be imagined than that in which it is totally insensible to its own wants, nay, that it loathes the very articles which it stands most in need of. Galen properly remarks in another place (Comment. I., in Epid. i.), that it is an extremely unfavorable symptom when in an ardent fever there is no thirst. The small abscess about the nates would seem to have been an incidental complication. It would appear to be now settled by the best pathological authorities that there is no natural alliance betweenphthisisandfistula in ano, as was at one time suspected. See Andral (Cliniq. Médicale, tom. iv., p. 308), and Louis (On Phthisis, p. 89, Sydenham Society’s edition). The affection of the fauces and throat, which is described as having attacked the patient at “the commencement of the disease,” would appear to have been a common complication of that epidemic. It is noticed in the First Book of the Epidemics. Foës remarks, however, that some had referred it to that redness of the fauces to which persons laboring under consumption are liable. Compare Louis, l. c. p. ii., § 12. Galen makes mention of a difference of reading in the MSS. he used in reference to the Critical Days.[693]On this brief case Galen has left a lengthy and elaborate Commentary, abounding in most interesting matters on a variety of subjects; as, for example, the different readings and opinions of the more ancient commentators on the characters at the end of this and the other reports; on the formation of the Hippocratic Collection, and the extraordinary zeal of the Ptolemies in procuring books for their great Library at Alexandria, and so forth. There is not much in it, however, which bears directly on the present case, and therefore we shall give but a very brief abstract of it. It appears from Galen that there was a considerable diversity of readings in the latter part of it, more especially in regard to the number of days the patient lived; some of the old authorities having placed the death on the fifth, some on the seventh, and others on the eighth. Galen inclines to hold by the text as we now have it, and maintains, apparently with good reason, that under such a combination of fatal symptoms it was not likely that the patient’s strength should have stood out longer than the fourth day. Another curious subject connected with this case which Galen slightly touches upon, but without throwing any light upon it, is the omission of the treatment. He justly remarks, that if Hippocrates treated the patient himself, or superintended the treatment as managed by another, it is singular that there is no mention of a clyster having been administered, nor of a cataplasm having been applied, nor of venesection having been practiced. I shall not attempt to solve the question here propounded by Galen. See the Argument. His Commentary also contains an interesting discussion on the meaning of the expression “respiration elevated.” To give the sum of what has been advanced on this subject in a few words, it may signify laborious breathing so as to move the labia of the nose; or it may mean simply orthopnœa, or it may signify laborious respiration, attended with elevation of the chest. By the way, this is evidently the “sublimis anhelitus” of Horace, in his famous ode entitled “Nireus.” I have often wondered that such a learned physician as Julius Cæsar Scaliger, in his celebrated critique on Horace in his Poetics, should have remarked on this expression: “Ex toto Galeno non intelligo quid sit sublimis anhelitus.” Galen, in fact, treats fully of the “sublimis anhelitus” in various parts of his works. See in particular On Difficulty of Breathing.

[625]The introduction of phthisis in this place has created some difficulty in the interpretation, as may be seen on reference to Galen and Littré. Galen gives a very interesting account of the way in which interpolations often took place. (Opera, tom. v., p. 356.)

[626]The text of this last sentence is in an unsettled state. The following would be a translation of it as it stands in the Basle edition of Galen’s Works: “Of all the cases described under this constitution, those alone which were of a phthisical character proved fatal. But they (the phthisical affections?) did not supervene upon the other fevers.” Provided this be the true meaning of the passage, it would merit great attention, as seeming to contain a declaration that intermittent fevers superinduced an immunity to phthisis. I need not say that this supposed fact has been exciting a great deal of interest lately in the profession, more especially in France.

[627]It is to be borne in mind that the autumn began with the rising of Arcturus, and ended with the setting of the Pleiades. The setting of the Pleiades then indicated the commencement of winter. The classical reader will find the different seasons, strikingly defined by the rising and setting of the stars, in Virgil’s Georgics. See in particular Georg. i., 221.

[628]Galen thus explains the origin of the ophthalmies. He says, the constitution of the air being not only cold and humid, but attended also with hurricanes. The eyes were thus injured, and consequently were the first part of the body to show symptoms of disease. The dysenteric and other alvine complaints which followed, he ascribes to the constriction of the skin induced by the cold, and to the humoursæ of the system aggravated and increased by the humid state of the season. These humours being thus shut up by the occlusion of the pores of the skin, part of them were determined to the intestines, occasioning diarrhœa, tenesmus, dysentery, etc.; some to the bladder, inducing strangury; and some to the mouth of the stomach, occasioning vomiting.

[629]Galen states in his Commentary that the phrenitis is connected with inflammation of the parts about the brain. We have mentioned before that the phrenitis of the ancients was a febrile affection, and not idiopathic inflammation of the brain, as is generally supposed.

[630]According to Galen, the causiorardent fevers are occasioned by yellow bile collected about the vessels of the liver and stomach, and the tertians by the same diffused over the whole body.

[631]Galen states in his Commentary that children are peculiarly subject to convulsions owing to the weakness of their nervous system. He adds, that in their case convulsions are not attended with so much danger as in other cases. See the Hippocratic treatise On Dentition.

[632]The fever here described is evidently the semitertian. SeePaulus Ægineta, Book II., 34. “The true semitertian,” says M. Bartels, as quoted by M. Littré, “is a real complication of an intermittent fever with another fever of a continual type. It does not show itself but rarely in our countries; but it is more frequent in the hotter countries of Europe, although the false semitertian has oftener than once been confounded with the true. In the true, the intermittent fever is tertian; the non-intermittent is quotidian.” See also Galen, Opera, tom. v., p. 362; ed. Basil.

[633]The text here is in an unsatisfactory state, and, as usual in such cases, no ingenuity nor pains can do much to mend it. See Foës and Littré. I have translated the disputed words “not resolved,” which seems to me to agree best with the sense. Every practical physician knows that swellings of the glands, which continue long and do not suppurate, are unfavorable in fevers.

[634]The modern physician will not fail to be struck with this observation as to the termination of certain cases of fever in determination to the kidneys. Galen remarks in his Commentary on this passage, that as the general system is often purged by the bowels, so is it also sometimes by the kidneys and bladder. This, he adds, is a protracted and painful mode of resolution in fevers. The reader will remark the characters of the urine as stated below by our author. One cannot help being struck with his statement, that all these cases recovered. I am not aware of any modern observations bearing on this point.

[635]There is considerable difficulty here in determining the reading. See Littré, whom I have followed.

[636]I need scarcely remark that this passage is of classical celebrity. Galen, in his Commentary, remarks that the first time he read it he thought it unworthy of Hippocrates to lay it down as a rule of practice, that “the physician should do good to his patient, or at least no harm;” but that, after having seen a good deal of the practice of other physicians, and observed how often they were justly exposed to censure for having bled, or applied the bath, or given medicines, or wine unseasonably, he came to recognize the propriety and importance of the rule laid down by Hippocrates. The practice of certain physicians, Galen remarks, is like playing at the dice, when what turns up may occasion the greatest mischief to their patients. The last clause of this passage is very forcibly put. Galen, however, informs us that in some of the MSS. instead of “art” he found “nature;” that is to say, that the physician is “the minister (orservant) of nature.” Either of the readings, he remarks, will agree very well with the meaning of the passage.

[637]The reader will find it interesting to refer here to the Prognostics. See also the Commentary of Galen. Let me here impress upon the reader the necessity of making frequent comparisons of the Prognostics with this work, if he would wish rightly to apprehend the bearing and meaning of the latter. That the Epidemics are entirely founded upon the principles of prognosis there can be no doubt.

[638]It is to be recollected that the rising of Arcturus marked the beginning of autumn, and the setting of the Pleiades the end of it. See above.

[639]The season of the Dog-star was immediately after the summer solstice, namely, when the sun enters the constellation Leo. The classical reader will readily bring to his recollection the lines of Horace, which are descriptive of this season:“Jam Procyon furit;Et stella vesani Leonis,Sole dies referente siccos.”

“Jam Procyon furit;Et stella vesani Leonis,Sole dies referente siccos.”

“Jam Procyon furit;

Et stella vesani Leonis,

Sole dies referente siccos.”

[640]Galen, in his Commentary, remarks that the attacks of paraplegia (that is to say, of apoplexy) were brought on by the cold winds of the winter succeeding to a humid autumn.

[641]The causiorardent fevers, it is worthy of remark, began this season in spring, but were not of a fatal character until autumn. In modern times the bilious remittent fever has uniformly been found to be most aggravated in autumn, and hence it has been named by some authorities the autumnal remittent fever. See the works of Sydenham, Pringle, Monro, and Cleghorn. Monro mentions that he seldom saw it in spring, but that it is common in the neighborhood of London towards the end of summer and beginning of autumn. All these authorities are agreed that it is of a highly bilious nature.

[642]Monro mentions epistaxis as occurring in the autumnal remittent fever; he says it did not prove a crisis in any case.

[643]The complication of the autumnal remittent fever with jaundice is noticed by Sir John Pringle (Obs. iii., 4), and by Monro (On Army Diseases, p. 161). Galen, in his Commentary, remarks that when nature is unable to evacuate the bile, it is collected in the skin, and occasions jaundice. He adds, that the occurrence of the jaundice in this case was unfavorable, owing to its taking place before the seventh day. When occurring on the seventh day, jaundice was reckoned a favorable symptom. See On Crises, 3; Aphorism, iv., 62, 64.

[644]The reader may feel interested to learn Galen’s hypothesis by which he accounts for the hemorrhage in this case. He says it is produced by the redundancy of yellow bile, which, being mixed up with the blood and heating it, is carried up to the head, where it produces rupture of the vessels and hemorrhage.

[645]Modern observations have confirmed this account of the generally fatal issue of febrile diseases after parturition. In the Hippocratic work On Diseases, fever after delivery in a woman is reckoned among the cases which generally prove fatal.

[646]I would again request the attention of my contemporaries to the characters of the urine before a crisis, as given by Hippocrates; and, in confirmation of them I will venture to introduce here an extract from Donald Monro’s admirable account of the autumnal remittent fever: “The urine in the beginning was commonly of a high color, though sometimes it was pale and limpid; but when the fever came to remit, there was often a small sediment after each paroxysm; and as the fever was going off,it let fall a sediment in all.” (Army Diseases, etc., p. 159.) The absence of the sediment in the urine before the crisis is an important fact in the history of febrile diseases, which I have reason to think is not now sufficiently adverted to.

[647]Galen does not hesitate to give it as his opinion that the dysentery was owing to the bile not being properly purged off by the urine.

[648]The reader will find it interesting here to mark the alliance between the causus and phrenitis, to which we formerly adverted. Galen remarks that both arise from the same humour, that is to say, bile, which when it collects in the veins of the lower part of the body gives rise to causus; but from the beginning of autumn to the equinox, produces phrenitis by being determined to the brain.

[649]This is perhaps the most striking account of an aggravated form of causus which is anywhere to be found. Although less finished than the celebrated picture of the disease given by Aretæus, it is evidently more original. In fact, any human production which is very original cannot well be finished, and consequently a very finished work can scarcely be expected to be very original.

[650]It is impossible to overrate the importance of these observations on crises in fevers, provided they be correct and confirmed by general experience. Monro, without appearing to have our author in view, seems to give an ample confirmation of his doctrines on crises as here laid down.

[651]From Galen’s Commentary it appears that the text here is in a doubtful state. See also Littré.

[652]Allusion is here made to the symptoms of delirium as described in the fourth paragraph of the Prognostics. See Galen’s Commentary on this passage.

[653]What an admirable and comprehensive enumeration of all the circumstances upon which the prognosis and diagnosis of diseases are to be founded! Here we find nothing either wanting or redundant; and with what conciseness and precision the whole is stated! Galen gives an elaborate and, upon the whole, a very interesting Commentary on this section, but does not supply any new views, and there are few terms in it requiring explanation.

[654]Having already stated in this work, as well as in the Commentary onPaulus Ægineta, Book II., 27, my opinion respecting the nature of the continual fevers, I need not enlarge on the subject in this place. Whoever wishes for more information may find much to interest him in the Commentary of Galen. Respecting the septans and nonans, he remarks, that, although conversant with fevers from his youth, he had never met with any cases of these.

[655]Galen, in illustration, states that epilepsy is sometimes carried off by an attack of quartan fever.

[656]The semitertian was always looked upon as a very formidable form of fever. SeePaulus Ægineta, Book II., 34. Galen gives a prolix, but not a very distinct account of it.

[657]Galen, in his Commentary, states that he had often seen persons in consumption attacked with tertian and quotidian intermittents, but admits that he had no more experience of quintans than he had of septans and nonans. Avicenna. however, is not so sceptical as to the occurrence of these rare forms of intermittents. Indeed he says, he had often met with quintans, and that a trustworthy physician of great experience had assured him that he had met with nonans. (iii., 1, 3, 67.) Rhazes also would appear to acknowledge the occurrence of all these varieties of intermittent fever. (Contin., xxx., 10, 1, 409.)

[658]The text is much improved in Littré’s edition, so that the meaning is pretty intelligible without any commentary. Galen states in explanation, that the three varieties of fever are thus marked and distinguished from one another: in the first, the fever attains its height at the commencement, and gradually diminishes until the crisis; in the second, it begins mild, and gradually reaches its height at the crisis; in the third, the fever begins mild, gradually attains its height, and then gradually subsides until the crisis.

[659]These are all febrile diseases, and for the most part of the ardent type. In order to enter properly into the spirit of them, the reader will find it necessary to revert frequently to the Prognostics, and compare the parallel passages. See also the Argument.

[660]Galen, in his Commentary, remarks that the fatal issue of this case might have been anticipated after the return of the fever on the third day, with a complication of bad symptoms, such as great thirst, dry tongue, black urine, delirium, coldness of the extremities, and so forth. The modern reader will be struck with the description of the respiration, namely, that the patient seemed like a person who forgot for a time thebesoin de respirer, and then, as it were, suddenly recollected himself. Such is the meaning of the expression as explained by Galen in his Commentary, and in his work On Difficulty of Breathing. By “rare” is always meant “few in number.” The reader will remark that this is a striking case of a fever having regular exacerbations on the even days, and slight remissions on the uneven.

[661]This, it will be remarked, is a case of fever induced from obvious causes, namely, excessive fatigue and dissipation. We must take into account, however, the febrile constitution of the season. According to Galen, the fatal result could have been confidently foreseen from the seventh day. The distention in the hypochondriac region here described would appear to have been meteorism. The throbbing in this region was no doubt owing no the same cause. The rash was most probable miliary. It is described as resemblingvari(ἴονθοι), by which was probably meantacne. SeePaulus Ægineta, Vol. I., p. 454. Upon reference to the Prognostics, it will be remarked that the characters of the urine are all bad, that is to say, it was either suppressed, or the sediment was either wanting or black and farinaceous. See Prognost. 12. By “black,” as applied to the urine, is to be understood “a dark-red color,” like that of wine.

[662]There is nothing in this case very remarkable, or which stands in need of elucidation; but yet the reader may feel interested in Galen’s reflections upon it. The recovery he holds to have been unexpected, as a different result might have been anticipated from the characters of the alvine discharge, and of the urine at the commencement. The favorable change he attributes to the swelling of the spleen, whereby the peccant humors were attracted to it; and he further remarks, that as the swelling of the spleen diminished, the humors are described as having passed down to the extremities, after having first affected the groin of the side on which the spleen is situated. He further calls attention to the improved characters of the urine when the swelling of the spleen and pains of the limbs supervened. Still, however, he adds, there was a remnant of the cacochymy in the system which gave rise to the relapse on the fourteenth day, so that the complete crisis did not take place until the seventeenth day.

[663]This is evidently a well-marked case of puerperal fever, or of fever complicated with the puerperal state. There is nothing particularly interesting in Galen’s commentary on it. He states that the application made in order to remove the suppression of the lochial discharge may either have been a pessary or a suppository. It seems most likely to have been the former. On the composition of the ancient pessaries, seePaulus Ægineta, Book VII., 24. He remarks that the symptoms first stated are unfavorable, but not necessarily fatal, until we come to the coldness of the extremities, which is an extremely mortal symptom in the beginning of a disease when combined with a very violent fever. The modern reader will be struck with the expression that “the attendants seldom put her in mind” to make water; it is very descriptive, however, of the state of stupor the patient was in when she was so insensible that she did not attend to the calls of nature.

[664]Galen remarks that it was reckoned very extraordinary for a rigor not to be followed by febrile heat. See Comment. et de Rigore; de Diff. Febr., ii.; and Foës’s long annotations on this passage.

[665]It will be remarked that the characters of the urine throughout are favorable. Though darkish at first, this was reckoned not unfavorable, as being connected with the lochial discharge. (See Galen. Comment. 2, Epid. iii.) The sediments afterwards are all of good omen; but, as Galen remarks, its first characters indicated a prolonged fever.

[666]On the Critical Days, seePaulus ÆginetaBook II., 7.

[667]On comparing the symptoms here enumerated with the Prognostics, it will be remarked that none of them are of fatal omen. But the white sediment, and afterwards the reddish color of the urine, while they indicated recovery, at the same time prognosticated a protracted attack of fever. See Prognost., 12. The reader will further remark that there is an absence of all the decidedly fatal symptoms, such as delirium, coldness of the extremities at the commencement, and so forth.

[668]The rapid recovery in this case would seem to be partly attributable to the decided plan of treatment, namely, the copious affusion of hot water on the head. Hippocrates probably had it in view when he wrote the forty-second Aphorism of the Seventh Book: “In fever not connected with bile, if a large quantity of hot water be poured over the head, it proves a resolution of the fever.” Galen points it out as a remarkable circumstance, that in this case the crisis took place without concoction of the urine, in consequence of the hemorrhage from the nose, and the sweating.

[669]In this case, as Galen remarks, the continued sweats, unfavorable condition of the hypochondriac region, and the black urine, precluded all hopes of recovery. He thinks our author related the case as an instance of sudden death in fever, this patient having died on the fourth day after the attack (the first not being counted). See his Commentary. He also makes reflections upon this case in his work On Difficulty of Breathing, where he points out the danger of meteorism of the hypochondriac region as being necessarily accompanied with dyspnœa, and connected with inflammation (2).

[670]This case, as Galen remarks, is interesting from the suddenness of the fatal result. We should not hesitate nowadays to set it down as a case of malignant erysipelas; the pain, swelling, and bullæ of the foot and ankle must have been of this nature. By the way, these bullæ, when not followed by suppuration, are represented in the Coacæ Prænotiones, as a fatal symptom. Galen thinks it strange that this patient was not bled, but accounts for it by supposing that Hippocrates had been called in too late. He remarks on this case in the Second Book of his work On Difficulty of Breathing.

[671]Galen looks upon this patient as an exampleorparadigm of general principles in Prognostics. Thus, with regard to the characters of the urine, it is stated that on the eleventh day the urine was thin, of a good color, and having many substances floating about in it, but without sediment. Thus matters remained until the sixteenth, when the urine became somewhat thicker, and had a slight sediment. Now Galen remarks (as the reader will find on turning to the Book of Prognostics) that these characters of the urine are indicative of recovery after a protracted disease. Galen further points out that no one of the fatal symptoms are mentioned, and that swellings of the parotid glands and the dysenteric affections of the bowels indicated that the crisis would be distant. He also calls attention to the case as confirmatory of the doctrines of Critical Days. In the Second Book of his work On Difficulty of Breathing, he makes some remarks, of no great importance however, on the meteorism of the hypochondriac region, as noticed in this case.

[672]In this case, as Galen remarks, the characters of the urine from the first were such as to indicate a fatal and speedy result. On the second day the urine was turbid, and without any sediment; on the third day the same, and consequently confirming the anticipation of the disease proving mortal; on the fourth, oily urine, with epistaxis, so that it was not to be wondered at that the patient died on the sixth. Indeed, when we further take into account the state of the breathing, the coldness of the extremities, the meteorism of the hypochondriac region, and the subsultus tendinum, it is difficult to imagine a more hopeless case of fever. Having mentioned “oily urine,” it may be well to state its characters, as fully given by one of the later authorities on urology, namely Theophilus. He says, when the urine in fevers assumes the color of oil, it indicates that the fat of the body is melting down; when the appearance of the urine still more resembles oil, it shows a still greater melting; and when the urine in consistence and color exactly resembles oil of a dark color, it prognosticates a fatal collapse. (De Urinis, 17; ed. Ideler.) On this subject, see further some very interesting observations by Foës, in his annotations on this passage (p. 988). With regard to the respiration in this case, see also the remarks of Galen in the Third Book of his work On Difficulty of Breathing (tom. vii., p. 932; ed. Kühn). As Galen here remarks, Hippocrates explains the meaning of this passage in one of his Aphorisms, where he writes thus: “In fevers, when the respiration stops, it is a bad symptom, for it prognosticates convulsion.”

[673]According to Galen, this case is an instructive example of the danger of neglecting the diet at the commencement of complaints which appear unimportant. This man, having taken supper at the beginning of a fever which appeared slight, suffered therefrom as the result showed; that is to say, vomiting ensued, followed by serious symptoms, among which Galen particularizes, as indicating a fatal result, urine at first thick and without sediment, and afterwards oily. So much importance did the ancient physicians attach to observations on the urine in fevers! Galen further calls attention to the fact, that the patient died on a critical day, that is to say, on the eleventh.

[674]Galen, in the commentary, makes a remark regarding this report, which appears more important to him than it will do to most modern readers, namely, that he wonders Hippocrates did not state the age of this patient. He adds, that it is very rare for a pregnant woman to have such a serious fever without parting with her child. He thinks the patient, in the present instance, owed her recovery to the strength of her constitution, as “urine white, and not of a good color,” in combination with the other bad symptoms, indicated an unfavorable result. By the way, upon reference to the Basle edition of Galen, and to Foës’s annotations on this case, it will be seen that there is a difference of reading in the words descriptive of the urine, that is to say, some read ἀχρόων, some εὑχρόων. Certainly it appears to me that Foës is right in preferring the latter. The decided crisis, it will be remarked, took place on a critical day, that is to say, the fourteenth, by a sweat.

[675]Here again Galen calls attention principally to the characters of the urine, which is first described as being “of a good color, but thin.” Now, by a good color of the urine, Galen observes, was meant of a slightly yellow color. In this case, as usual, the crisis was marked by a sediment in the urine.

[676]Œuvres d’Hippocrate, tom. iii., Arg., pp. xxxvi.-xlii. tom. v., pp. 57–70.

[677]There is some doubt, however, even on this head; indeed Riolanus does not scruple to affirm, with a considerable degree of plausibility, that Ruffus must have lived after Galen, since he is nowhere mentioned by the latter. (Anthropographia, i., 5.)

[678]In illustration, consult Plutarch (Placit. Philosoph., v., 29).

[679]De Differ. Feb., i., 7; tom. vii., p. 296, ed. Kühn.

[680]Commentary onPaulus Ægineta, Book II., 16, 36; IV., 25, Syd. Soc. edition.

[681]Disquisitio Historico-Medica de Natura Morbi Atheniensium. Stuttgart, 1831.

[682]On this case Galen has left very lengthy and elaborate commentaries, containing much important and amusing matter, but not a little verbose trifling, to say the least. Our limits, as well as our tastes, dispose us to be very sparing in our extracts from them. Passing over his remarks on the solecism in syntax, with which the Report commences, and his observations on the absence of all mention of the exciting causes, as is the usual practice of our author, I shall proceed to state what Galen says on the apparent neglect of venesection in a case where it would certainly appear to have been clearly indicated. In this case, as Galen remarks, one or other of these suppositions may be made: either that bleeding was not practiced, or that the author did not think of mentioning the practice here, as supposing that it would be taken for granted that it was applied. Now, he adds, the former supposition is very improbable, considering how partial our author shows himself to this practice in his works which are unquestionably genuine, such as On the Regimen in Acute Diseases, the Aphorisms, the work On the Articulations, and even in this very book, where in one place he mentions that he abstracted blood copiously on the eighth day. If, then, he bled so late in febrile diseases, Galen contends that he was not likely to neglect the operation in an earlier stage, when so much more demanded. He argues further, that in many of the other reports of cases he neglects to mention that the usual routine of practice was followed: and therefore he inclines to the opinion that it is omitted to be mentioned here, because the author supposed there could be no question on this point, more especially as it was his universal rule to bleed in all great complaints, when not prevented by the age or powers of the patient. He afterwards insists strongly on venesection having been indicated in this case, in order to procure revulsion from the brain. As usual with the commentator, he calls attention to the characters of the urine, and explains the meaning of the term “cloudy,” as applied to theeneorema, or substances floating in the urine, by which he contends is to be understood a color intermediate between white and black. What follows in this very lengthy Commentary is very interesting in a general point of view as regards the views of some of the older commentators, but is not directly applicable to the present case. His observations on the characters affixed to this and many of the subsequent cases have been noticed in the Argument. The reader will further remark of this case that it is an instance of fever passing into a deposit (orabscess), and the latter into strangury, of which our author had made mention in the First Book of the Epidemics. I may further mention that the reader will find much interesting matter in Galen’s work On Trembling, in illustration of the nature of the attack under which the patient labored.

[683]Galen, in his Commentary, communicates a singular notion which one of the earlier commentators maintained respecting the name of the place where this patient was laid, that is to say, that this new wall, having been recently washed with quicklime, had been the cause of this patient’s illness. Galen, however, rejects this paltry conceit. He says on his own authority, that there being three distinct classes of fever, namely, the ephemeral, the hectic, and those connected with putrid humors, the present case belongs to the last of these.

[684]Galen compares the characters of the urine with their indications as given in the Prognostics. None of them are favorable, although not decidedly fatal.

[685]This complication cannot fail to attract attention, from its resemblance to an epidemic which prevailed in Scotland in the year 1843. In this epidemic, as in the present case, the fever was very subject to relapses and to jaundice at an early stage. Hippocrates, in one of his Aphorisms, pronounces jaundice in fevers before the seventh day to be a fatal symptom. (iv., 62, 64.) Galen justly thinks it somewhat singular that no further mention of the jaundice is made in the course of the report; but he inclines from this to draw the conclusion that it remained in the same state throughout. As there was no crisis by the stomach, the bowels, the urine, or sweat, he concludes that the jaundice could not have been carried off. From all that has been said, he adds, it is clear that the organ primarily affected was the liver. Galen, then, decidedly opposes the view taken in the Explanation of the Characters respecting the cause of this man’s death, which he contends was not connected with any suppression of the alvine discharges, but with the affection of the liver. On the Scotch Epidemic, see Ed. and Lond. Med. Journal, March, 1844.

[686]Most of the ancient authorities regarded deafness as an unfavorable symptom in fevers. SeePaulus Ægineta, Book II., 4. The modern are divided in opinion on this point. Pringle and Huxham regard it as a favorable symptom, but Home looks upon it as unfavorable.

[687]Here again Galen mentions the absurd notion of Sabinus the commentator, that this man’s disease was occasioned by the locality in which he was laid. Galen, on the other hand, thinks it likely that the patient was conveyed to the garden as being a favorable situation for a person ill of fever. He further alludes to this case in the Second Book of his work On Critical Days.

[688]Galen remarks, that as there is no mention of a single favorable symptom up to this date, the patient would certainly have died if he had not been of a vigorous constitution.

[689]Thus, as Galen remarks, after two ineffectual attempts, Nature accomplished a cure on the fortieth day.

[690]There is not much to remark in this case. A modern reader will suspect that there had been cerebral disease before the attack of the fever, and that matters had been brought to a crisis by the drinking of wine. Indeed Galen, in his Commentary, remarks that the precursory symptoms indicate a congestion of humors in the brain, which of course would be much aggravated by the wine, the brain then being, as he says, in a bad state; and the patient having inflicted an additional injury to the organ, by means of the drink, brought on the acute attack, which proved fatal in five days. The deafness, delirium, spasms, and bilious vomitings all indicate a cerebral affection. The state of the hypochondria, as described in the report, Galen would seem to attribute to a spasmodic affection of the diaphragm, from sympathy with the brain. Retraction of the hypochondrium is pronounced to be a bad symptom in the First Book of the Prorrhetics. Galen justly contends that there is no reason in this case to suspect any inflammation in that region.

[691]Galen’s remarks on this case are unusually brief; he attributes the fever to a bilious plethora, and states that the result was such as might have been anticipated from a knowledge of the critical days, and of the characters of the urine. Indeed the latter appear to me well deserving of attention.

[692]This is in many respects an interesting case, and more especially, from its being stated that the disease was complicated with hereditary consumption. Galen, in his Commentary, remarks that some authorities denied that any disease is congenital, but this opinion he decidedly rejects. The phthisical affection, however, as he justly remarks, would not have occasioned so sudden an issue if it had not been complicated with a complete prostration of the natural powers. He insists strongly on the striking description here given of the total loss of the natural appetite, both in regard to food and drink. Of course, no worse state of the system can be imagined than that in which it is totally insensible to its own wants, nay, that it loathes the very articles which it stands most in need of. Galen properly remarks in another place (Comment. I., in Epid. i.), that it is an extremely unfavorable symptom when in an ardent fever there is no thirst. The small abscess about the nates would seem to have been an incidental complication. It would appear to be now settled by the best pathological authorities that there is no natural alliance betweenphthisisandfistula in ano, as was at one time suspected. See Andral (Cliniq. Médicale, tom. iv., p. 308), and Louis (On Phthisis, p. 89, Sydenham Society’s edition). The affection of the fauces and throat, which is described as having attacked the patient at “the commencement of the disease,” would appear to have been a common complication of that epidemic. It is noticed in the First Book of the Epidemics. Foës remarks, however, that some had referred it to that redness of the fauces to which persons laboring under consumption are liable. Compare Louis, l. c. p. ii., § 12. Galen makes mention of a difference of reading in the MSS. he used in reference to the Critical Days.

[693]On this brief case Galen has left a lengthy and elaborate Commentary, abounding in most interesting matters on a variety of subjects; as, for example, the different readings and opinions of the more ancient commentators on the characters at the end of this and the other reports; on the formation of the Hippocratic Collection, and the extraordinary zeal of the Ptolemies in procuring books for their great Library at Alexandria, and so forth. There is not much in it, however, which bears directly on the present case, and therefore we shall give but a very brief abstract of it. It appears from Galen that there was a considerable diversity of readings in the latter part of it, more especially in regard to the number of days the patient lived; some of the old authorities having placed the death on the fifth, some on the seventh, and others on the eighth. Galen inclines to hold by the text as we now have it, and maintains, apparently with good reason, that under such a combination of fatal symptoms it was not likely that the patient’s strength should have stood out longer than the fourth day. Another curious subject connected with this case which Galen slightly touches upon, but without throwing any light upon it, is the omission of the treatment. He justly remarks, that if Hippocrates treated the patient himself, or superintended the treatment as managed by another, it is singular that there is no mention of a clyster having been administered, nor of a cataplasm having been applied, nor of venesection having been practiced. I shall not attempt to solve the question here propounded by Galen. See the Argument. His Commentary also contains an interesting discussion on the meaning of the expression “respiration elevated.” To give the sum of what has been advanced on this subject in a few words, it may signify laborious breathing so as to move the labia of the nose; or it may mean simply orthopnœa, or it may signify laborious respiration, attended with elevation of the chest. By the way, this is evidently the “sublimis anhelitus” of Horace, in his famous ode entitled “Nireus.” I have often wondered that such a learned physician as Julius Cæsar Scaliger, in his celebrated critique on Horace in his Poetics, should have remarked on this expression: “Ex toto Galeno non intelligo quid sit sublimis anhelitus.” Galen, in fact, treats fully of the “sublimis anhelitus” in various parts of his works. See in particular On Difficulty of Breathing.

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