misrepresentation of our author’s rule of practice in this case. See
the fourth section of the preceding part.
[567] The causes _of_ ardent fever of the ancients was decidedly
the same as the bilious remittent fever of modern authors. See
PAULUS ÆGINETA, Vol. I., p. 262. We shall find many cases
of it related in the Epidemics. In fact the causus is the ordinary
fever of Greece and other countries bordering upon the Mediterranean.
Galen, in his Commentary on this section, mentions that he had known it
generally superinduced by drinking wine after great fatigue in summer.
There can be no doubt that this was the fever of which Alexander the
Great died. The description of the disease in his case, as given by
Arrian from the Royal Journals (βασίλειοι ἑφημερίδες), has so much the
air of truth, and withal appears to me so interesting, that I shall be
excused introducing it in this place. “And the Royal Journals ran thus:
that he drank at a jollification in the house of Medius; then rising
up and being bathed, slept, and again supped with Medius, and again
drank until the night was far advanced; that giving over drinking he
bathed; and having bathed, ate a little, and slept there, because he
was already feverish; that being carried on a little to the sacrifices,
he performed them according to his daily practice; that the sacrifices
being performed, he reclined in the dining-room (ἀνδρὼν) until the
dusk of evening, and there gave orders to the commander respecting
the march and voyage, that those who had to proceed on foot should be
prepared for marching on the fourth day, and those who were to sail
on the fifth; that he was carried hence upon a couch to the river,
and being placed in a boat was taken across the river to the garden,
and then being again bathed, that he rested. Next day, that he again
was bathed and performed the appointed sacrifices; and going into a
chamber, that he reclined and conversed with Medius, and gave orders
to the commanders to meet him in the morning. That having done these
things, he took a little supper; and having been carried back to the
chamber, that he was in a continued state of fever during the whole
night; that next day he bathed, and after the bath performed the
sacrifices; that he gave orders to Nearchus and the other commanders
respecting the voyage, that it should take place on the third day;
that next day he bathed again, and performed the appointed sacrifices;
that the religious rites being over, he did not cease to be feverish,
but that calling the commanders he gave orders for having every thing
in readiness for the voyage; that he was bathed next day, and being
bathed was already in a bad state. That next day being carried to
the house adjoining the bath, he performed the appointed sacrifices;
that he was in a bad state, but yet that he called to him the chiefs
of his commanders, and again gave orders respecting the voyage; that
the following day he was carried with difficulty to the religious
rites and sacrificed, and that notwithstanding he gave orders to the
commanders respecting the voyage. That next day, although already in a
bad state, he performed the appointed sacrifices; that he gave orders
that the commanders should watch in the saloon, and the chiliarchs and
pentacosiarchs before the doors; and that being altogether now in a
bad state, he was carried from the garden to the palace. That when the
commanders came in he recognized them, but did not speak, being now
speechless; that he was in a bad state of fever during that night and
day, and during another night and day. Thus it is written in the Royal
Journals.” Thus far the report is no doubt to be strictly depended
upon; the historical embellishments added to it from other sources can
have no interest to the professional reader. (Appiani Exped. Alexandr.,
vii., 37.) It deserves to be remarked, as a remarkable feature in this
case, that the mind appears to have been pretty entire during the whole
course of the fever. Now, this is one of the characteristics of causus
as described by Aretæus (Morb. Acut., ii., 4). It is further one of the
most marked features of the yellow fever, which, from all I can learn
of it, would appear decidedly to be an aggravated form of causus.
[568] Galen admits that he did not understand the exact import of this
term.
[569] This is a general rule of such importance that Galen wonders our
author did not embody it in one of his Aphorisms. Galen’s observations
on venesection in this commentary, and in his two treatises on
this subject, are highly important. It will be remarked that three
circumstances are held to form indications of the necessity for
bleeding: first, if the disease be of a strong nature; second, if the
patient be in the vigor of life; and, third, if his strength be entire.
[570] This section, as Galen remarks, contains a list of the principal
cases in which venesection is to be had recourse to.
[571] I need scarcely point out to the professional reader that these
symptoms are very descriptive of congestion in the brain, threatening
an attack either of apoplexy or epilepsy. See the treatise on the
Sacred Disease.
[572] Meaning apparently the great vessels. See Galen’s Commentary.
[573] The description here given of cynanche, more especially of
the variety in which the ulceration spreads down to the trachea and
produces engorgement of the lungs, is most characteristic, and bespeaks
a great practical acquaintance with the disease. Judged of in a
becoming spirit of candor, it must be admitted that even at the present
day we have scarcely made any advancement in our knowledge of this
subject. What are our descriptions of ulcerous sore-throat, diptherite,
œdema glottidis, croup, and laryngismus stridulus, but reproductions
in a divided and (may I be allowed to suggest?) a less accurate form,
of the general views here presented by our author? For an abstract of
the views of the other ancient authorities in medicine, see PAULUS
ÆGINETA, Book III., 27. Aretæus deserves particularly to be
consulted (Morb. Acut., i., 7). It will be remarked that our author
speaks of a spontaneous determination to the skin, as being calculated
to remove the urgent symptoms within. Galen, in commenting upon this
clause, states that some physicians were in the practice of applying to
the skin certain medicines possessed of ulcerative powers, in order to
determine to the surface, and thus imitate Nature’s mode of cure.
[574] Though the contents of this section are by no means devoid of
interest, it must be obvious to the reader that the observations on
causus are out of place here. See the Commentary of Galen.
[575] I would beg leave to direct the attention of the medical reader
to the observations of our author in this and many other places on
the characters of the urine in fevers. That in febrile diseases the
sediment is wanting previous to the crisis, and that at and after
the crisis, when favorable, the sediment becomes remarkably copious,
I believe to be certain facts; and yet I question if, with all our
boasted improvements in urology, they be generally known and attended
to. I have called attention in the Argument to the important rule of
practice which our author founds on the state of the urine at the
crisis.
[576] He means by this, that the disease is not of an intermittent type.
[577] This seems the most appropriate meaning in this place, but the
passage may also signify “a state of great emphysema or meteorism.” See
Galen.
[578] It is impossible not to recognize here a brief sketch of
_delirium tremens_. The trembling hands from drinking, with the
subsequent delirium, can leave no doubts on the subject. See further
Littré, tom. ii., p. 382.
[579] The fruit of the _pinus pinaster_. See PAULUS ÆGINETA, Vol. III.,
p. 301.
[580] It will be remarked, that in this place the author directs that
the bleeding should be carried to a greater extent than in the former
part of this treatise. In general, the ancient authorities forbade the
abstraction of blood until it induced lipothymia. This is decidedly the
rule of practice laid down by Aretæus (De Curat. Morb. Acut., ii., 1).
[581] Galen, in his Commentary, remarks that this account of dysentery
is vague, the species of dysentery here alluded to not being properly
defined.
[582] This case is vague and undefined. I suppose the author alludes to
opisthotonos in this sentence, and to emprosthotonos in the succeeding
part of this section.
[583] _Bryonia dioica._ See Dierbach, etc., p. 131.
[584] Galen, in his Commentary, remarks that the modes of solution in
fevers are not completely given in this place; for example, our author
omits those by the uterus and the nose.
[585] The text is in a very unsettled state.
[586] The substance of this section occurs in the preceding part of
this work, which certainly amounts to a strong presumption that the
present treatise is not genuine. Very similar views are also laid down
in the treatise On Ancient Medicine.
[587] On the Dietetics of the ancients, see the Commentary on
PAULUS ÆGINATA, Vol. I., pp. 106–86.
[588] By dry cholera would seem to be meant flatulent colic. See
Galen’s Commentary. It is also described below, and further with great
accuracy by Alexander Trallian (vii., 16).
[589] Galen, in his Commentary on this section, finds many things
imperfectly stated, and therefore unworthy of his great author. For
example, he remarks, only two varieties of dropsy are mentioned,
namely, anasarca and tympanites; whereas there are three at least,
and some even describe four varieties. By the three kinds of dropsy,
Galen and the other ancient authorities meant anasarca, ascites,
and tympanitis. (See PAULUS ÆGINETA, Book III., 48). That
tympanites should have been ranked with dropsy need excite no wonder,
when we consider the resemblance of this affection to ascites. In fact
I have known cases of tympanites in which paracentesis was performed
by inexperienced surgeons under the impression that they were cases
of ascites. See some elaborate annotations on this head by Ermerins
(Specimen Hist. Med., p. 125), and by Littré (Op. Hippocrat., tom.
iv., p. 415). With regard to venesection in dropsy, Galen remarks that
the rule of practice is not laid down here with sufficient precision;
it is only when the dropsy is connected with the suppression of the
hemorrhoidal or menstrual discharge, or when the patient is in a
plethoric state, that blood can be abstracted with advantage. He also
finds fault with the directions for the subsequent treatment, as not
being accurately given. He justly remarks, that none but persons in the
vigor of life and in good health would be able to digest dark-colored
wine and pork after venesection. I may mention further that the text
is faulty, that the words ἐγχειρέων γίνεσθαι ἄφυκτος should have been
written ἀποκτέινει δ’ ἐυθὺς ὁ ὔδερος ἐφὴν γένηται. He attributes the
mistake to the first amanuensis who wrote the words in question.
[590] In reference to this practice Horace says:
“Si noles sanus curres hydropicus.” (Serm. I., 1.)
[591] Galen finds many things in this section also carelessly and
confusedly written, and therefore unworthy of Hippocrates. For example,
the list of cases in which purging is inapplicable, Galen holds to be
incomplete; and even in some of the cases specified by Hippocrates he
demurs to admit his views to be correct; for example, in diseases of
the spleen he contends that melanogogues are strongly indicated. Many
more of the rules he considers to be vaguely and inaccurately stated.
Altogether, then, he holds that it is a loss of time to devote much
attention to writings of such a stamp; but, he shrewdly remarks, there
is no persuading many people to study only such writings as are clear,
and to leave such as are not so to the writers themselves; for it is
just that, as they have paid no regard that we should understand what
they have written, we should not be very anxious to find out and learn
what they say.
[592] Galen correctly remarks that this rule is applicable in certain
cases, but not in all.
[593] As Galen remarks in his Commentary, something appears to be
wanting here in order to indicate the disease to which these directions
apply. Perhaps, as he suggests afterwards, they are meant to apply to
general pains.
[594] The Cantharis of the ancients was indisputably the _Mylabris
cichorii_, or _M. Fusselini_. It continued to be used in
ancient times as a diuretic, (see PAULUS ÆGINETA, Vol. III.,
p. 153;) and is well known in the East at the present day.
[595] All the remaining part of this work evidently consists of
fragments put together, without any method or arrangement. Though
not devoid of interest, they decidedly have no connection with the
treatise On Regimen in Acute Diseases. Indeed an impartial examination
of the whole Appendix must satisfy any one that there are but too good
grounds for holding with Galen, that the whole work is a disorderly
compilation, which, although it may have been made up of notes written
or dictated by Hippocrates, had certainly not been published by him.
[596] It most probably is the _Reseda mediterranea_. See
PAULUS ÆGINETA, Vol. III., p. 331.
[597] This description has always been regarded as very obscure.
According to Galen it is the operation which was afterwards named
_anabrochismus_. See PAULUS ÆGINETA, Vol. III., pp. 262, 269. M. Littré
gives the following interesting observations on this passage by M.
Malgaigne: “Quoiqu’il semble que l’auteur emploie deux fils, cependant
il n’est fait mention que d’une aiguille. Il paraît bien indiqué que
l’aiguille traverse deux plis transverseaux en marchant de haut en bas.
Voici comment je traduirais le passage en question: pour le trichiasis,
avec une aiguille armée d’un fil, traversé de haut en bas le point le
plus élevé (ou la base); de la paupière supérieure, après lui avoir
fait former un pli, et repasser l’aiguille de la même manière un peu
plus bas (ou près du bord libre); rapprochez les extrémités du fil, et
fixez-les par un nœud: puis laissez-les tomber d’eux-mêmes. Si cela
réussit, c’est bien: si non, it faudra recommencer.” (Op. Hippocrat.,
tom. iii., p. xliv). In my Commentary on PAULUS ÆGINETA, (Vol. II.,
p. 163.) I have in so far fallen into the mistake of supposing this
description to apply to the lower eyelid, and M. Ermerins would appear
to have done the same. See Littré, l. c. The operation by the ligature
on hemorrhoids will be found more circumstantially described in the
treatise on that subject, of which a translation is given in this
volume.
[598] For the weights and measures mentioned here, and in other
parts of our author’s works, see the Comment. on the last section of
PAULUS ÆGINETA, Syd. Soc. edit.
[599] A mineral, consisting principally of sulphate of copper. See
PAULUS ÆGINETA, Vol. III., pp. 400–2.
[600] The μηκώνιον was applied to three totally distinct substances;
1st, To a sort of opium, that is to say, the expressed juice of the
poppy (see PAULUS ÆGINETA, Vol. III., p. 280); 2d, to the _Euphorbia
peplus_, L., (see Appendix to Dunbar’s Greek Lexicon, under the
name): and, 3d, to the excrement of new-born children. It is singular
that the learned Foës, in his Œconomia Hippocratica, should apply
it in this place to the last of these; for if Hippocrates had used
such a substance medicinally, we may be well assured that it would
not have been overlooked by Dioscorides and Galen. There is every
reason, however, to suppose that it is the same as the πέπλος of
Dioscorides and Galen, that is to say, the _Euphorbia peplus_, which
was recommended as a drastic purgative by all the ancient authorities
on the Materia Medica, and consequently would be a medicine very
applicable either in coma or dropsy.
[601] All the commentators admit that the last section is obscure. It
would appear to me that Galen understands the expression τὸ ἀπὸ τῶν
κοπρἰων as applying ἑδρικοῖς, that is to say, to affections of the
anus. I have followed Littré in giving the passage a very different
interpretation, but I am by no means sure that Galen may not be right.
[602] De Diebus Decretoriis, i.
[603] See the Argument of the Prognostics.
[604] Μηδὲν εἰκῆ, μηδὲν ὑπερορῇν. (Epid. vi., 2, 12). Νούσων φύσιες
ἰητροί· ἀνεθρίσκει ἡ φύσις αὐτὴ ἐωυτῇ τὰς ἐφόδους· ἀπαίδευτος ἡ φύσις
ἐοῦσα καὶ οὐ μαθοῦσα τὰ δέοντα ποίει. (Ibid. vi., 5, 1.)
[605] Galen, De Venesect. adv. Erasist., c. iii.
[606] One cannot help being struck with the resemblance between this
description and a passage in Aretæus’s chapter on Causus: Ψυχῆς
κατάστασις, ἄισθησις σύμπασα καθαρὴ, διάνοια λεπτὴ, γνώμη μαντικὴ, κ.
τ. λ. In the yellow fever of the West Indies, which would certainly
appear to me to be a variety of the causus, the mind is said to be
wonderfully entire to the last. Dr. Fergusson gives a very striking
instance of this in describing the case of Sir James Leith, the British
Governor of Guadaloupe.
[607] Traité des Fièvres ou Irritations Cérébro-spinales
intermittentes, d’après des Observations recueillies en France, en
Corse et en Afrique. Paris, 1836.
[608] Œuvres d’Hippocrate, etc., tom. ii., p. 565.
[609] Prax. Med. nova Idea, i., 31.
[610] Tom. ii., p. 565.
[611] On the Influence of Tropical Climates.
[612] Tom. vii., p. 290; ed. Kühn.
[613] Copland’s Dictionary of Practical Medicine, P. iv., p. 974.
[614] Clinical Observations on the more important Diseases of Bengal.
Calcutta, 1835.
[615] Epidém. d’Hippocrate.
[616] See _Ægineta_. The narrative contains the most distinct and
unequivocal traces of the belief in the contagiousness of consumption.
[617] Thasus is an island in the Ægean sea, off the coast of Thrace,
which bears the modern name of Thaso _or_ Tasso. It was in a
flourishing condition in the time of Hippocrates, and a tributary to
Athens, but revolted from that power after its disasters in Sicily
during the Peloponnesian war. See Herodot., vi., 47; Thucydid., i.,
101; viii., 66. Galen states that it is cold, with a northerly exposure.
[618] According to Galen, in his Commentary on this passage, the
setting of the Pleiades takes place fifty days after the autumnal
equinox. See the Argument to the treatise On Airs, etc.
[619] We have already stated that the ardent fevers or causi, of which
repeated mention is made in the Hippocratic treatises, were fevers of
the remittent type, in short that they were the same as the bilious
remittent fevers of Pringle and Monro.
[620] I need scarcely say that the disease here described is _cynanche
parotidæa_ or _parotitis_. It is a remarkable proof of our author’s
talent for observation, that he has pointed out the tendency of the
disease to be complicated with swelling and inflammation of the
testicles. Altogether the description of the disease here given is
quite applicable to the _mumps_ of modern times. As stated by him, the
swelling of the testicles is generally painful. See the Commentary of
Galen.
[621] On reference to Galen’s Commentary it will be seen that anciently
the reading of this passage was reckoned equivocal. According to one of
the readings, the meaning is that those who were sick did not require
to come to the Iatrium for advice. See also Littré’s annotations on
this passage.
[622] Galen thinks our author expresses himself confusedly in this
place, but Littré justly defends him from this charge. According to
Littré, Hippocrates means that those who had been long affected with
consumption (the term used, ὑποφθειρομένων, rather signifies had
obscure symptoms of consumption), then betook themselves to bed; but
those who were in a doubtful state, then first manifested signs of
confirmed phthisis; and, finally, that there were some who then for the
first time felt the attack of phthisis, and that these were persons who
were predisposed to it. According to Galen, the phthisical constitution
is marked by a narrow and shallow chest, with the scapulæ protuberant
behind like wings; and hence he says chests of this construction
have been named alar. He further states that there are two forms of
consumption, the one originating in a defluxion from the head, and the
other being connected with the rupture of a vessel in the lungs. I may
be allowed to mention in this place, in confirmation of our author’s
accuracy of observation with regard to the connection of hemoptysis
with phthisis, that Louis found hemoptysis to a greater or less extent
in two thirds of his cases. (Researches on Phthisis, p. 166, Sydenham
Society edition.) The same author relates several cases in which death
occurred suddenly and unexpectedly, as Hippocrates states to have
happened to some of his patients. (Ibid.)
[623] I am of opinion that the species of phthisis noticed in the
latter part of this section was the acute form of phthisis described
by Louis (p. 351). Our author, it will be remarked, states that his
patients were mostly delirious when near death. Louis, in like manner,
mentions delirium in, I believe, every one of the cases of acute
phthisis which he relates. Galen justly remarks, that, in the ordinary
forms of phthisis, delirium is not a common symptom. I would also call
attention to our author’s observation regarding the inflamed state of
the fauces, which is also amply confirmed by the observation of Louis
in this form of phthisis.
[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 of PAULUS 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 causi _or_ ardent 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. See
PAULUS 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 (_or_ servant) 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 causi _or_ ardent 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
on PAULUS 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. See PAULUS 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 the _besoin 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 resembling _vari_
(ἴονθοι), by which was probably meant _acne_. See PAULUS
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, see PAULUS 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, see PAULUS ÆGINETA Book 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 example _or_ paradigm 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 on PAULUS 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 the _eneorema_,
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 (_or_
abscess), 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. See PAULUS 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
between _phthisis_ and _fistula 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.
[694] Galen has given us a lengthy Commentary on this case, but a great
part of it relates to the characters and to other matters not of any
very great importance in this place. As he remarks, it is a striking
example of an acute fever induced by immoderate fatigue. It appears
from his Commentary, moreover, that some of the older authorities had
added “drinking” to the excesses which induced his affection; that is
to say, they proposed to read πότων instead of πόνων. The symptoms,
upon reference to the Prognostics, are all such as indicated a fatal
result, namely, the blackish and thin urine, “the fumbling with
the bedclothes,” the coldness and lividity of the extremities, the
meteorism, and so forth.
[695] In Galen’s Commentary on this case there is not much of any great
interest to the professional reader of the present day. He animadverts
again on the omission of all mention of the treatment, although, as he
states, venesection and the other usual means had no doubt been tried;
indeed the report implies as much. Hippocrates, he repeats, never
thinks of mentioning the usual routine of practice, as he takes it for
granted that the reader will understand that it was not neglected.
It is only on special occasions, then, that he thinks of making any
particular reference to the treatment. Galen remarks, that ileus being
an inflammation of the upper intestines, is a particularly dangerous
affection.
[696] As remarked by Galen in his Commentary, this was no doubt a
case of ardent fever _or_ caucus, complicated with an incidental
miscarriage. There is no reason for looking upon it as being a case
of puerperal fever. Galen thinks that the last word (caucus) is an
addition made by the copyists, having been transferred from the
Glossarium to the text in the course of transcription. Galen, as usual,
directs attention to the characters of the urine, which in this case
are particularly unfavorable, being defective both in quantity and
quality.
[697] Galen’s remarks on the circumstances of this case are
sufficiently to the purpose, but there is nothing very striking in
them. He states that the abortion may have been occasioned either
by external causes--such as the application of pessaries for this
purpose, and the like--or internal, such as hemorrhage from the neck
of the uterus. and so forth. As in the former case, he pronounces the
last word (phrenitis) to be an addition to the text, as Hippocrates
never enters upon the diagnosis of diseases, as is done in the work
On Diseases. I suppose he means that our author’s real works are all
founded on Prognosis; whereas the other, being derived from the Cnidian
school, is founded on Diagnosis. See our observations on this subject
in the Preliminary Discourse, and the Argument to the Prognostics.
[698] Galen remarks, that with such a combination of fatal symptoms,
namely, coldness of the extremities, fetid vomiting, etc., it is
wonderful that this patient stood out until the fourteenth day.
He thinks, however, that this is to be explained from her age and
constitution. He justly remarks that the occurrence of the epistaxis
could not be supposed sufficient to carry of such a combination of
unfavorable symptoms. He once more protests against the last word of
the report (causus) being admitted as genuine. He confesses himself
unable to determine whether “The Liars’ Market” was in Athens or
elsewhere.
[699] This is entitled the pestilential constitution by Galen. By
constitution, he explains, is meant not only the preternatural state of
the atmosphere, but also of everything else which influences the state
of the general health.
[700] Galen remarks, that in the First Book of the Epidemics three
constitutions of the year are described and also that others are
described in the Second Book; but that these are not carefully drawn
out for publication like those of the First and Third. He further
remarks on this head, that the constitution of the season might prepare
us for the putrid diseases, which are described below, as heat is the
active, and humidity the material, cause of all putrefaction.
[701] Galen remarks that erysipelas is occasioned by a bilious
defluxion, but that it is not always of a malignant and putrid nature;
on the contrary, when the defluxion is mild, and the bile which
produces it is natural, it is not attended with any considerable injury
to the body, if properly managed; but that the humor which produced
the erysipelas about to be described was not such, but of a malignant,
corrosive, and septic nature, being engendered by the humid and calm
state of the weather in such persons as were of a choleric constitution.
[702] According to Galen, aphthæ in general are superficial ulcerations
in the mouth, produced by the acrimony of the nurse’s milk, and which
are easily removed by an astringent application. But in the present
instance the aphthæ were of a malignant nature.
[703] The carbuncle (anthrax), Galen says, is always dangerous, and the
product of bad humors. See PAULUS ÆGINETA, Vol. II., pp. 78,
79. Galen, in his excellent work On the Difference of Fevers, writes
thus: “In constitutions of the year, similar to those which Hippocrates
describes as taking place in Cranon (See Ep. ii.). I have known cases
of anthrax prevailing epidemically in no few numbers, the formation and
other symptoms of which were exactly as described by him.” (Tom. vii.,
p. 293; ed. Kühn.)
[704] Galen explains under this head that the term _epidemic_ is
not applied to any one disease, but that when many cases of any disease
occur at the same time in a place, the disease is called an epidemic;
and that when it is remarkably fatal it is called a plague.
[705] The history of the epidemical erysipelas here described cannot
fail to prove interesting to the modern reader. I need scarcely remark
that epidemics of a similar nature are occasionally met with in
Great Britain at the present day. I myself have encountered two such
epidemics in the locality where I am now writing, the one in 1823, and
the other in 1846. As described by Hippocrates, the disease sometimes
supervened upon a slight injury, and generally terminated in gangrene.
On epidemical erysipelas, see De Haen (Ratio Medendi), Bartholinus
(Hist. Anatom. Rat. Hist., 56), Wells (Transactions of a Society
for the Improvement of Medical and Chirurgical Knowledge), Cooper’s
Surgical Dictionary; and Cyclopædia of Practical Medicine, under
_Erysipelas_.
[706] Galen amply confirms this statement, that when erysipelas fixes
on a particular part of the body it is more formidable in appearance
than in reality, and that the disease is attended with most danger when
it leaves an external member, and is determined inwardly.
[707] The classical reader will here call to his recollection a
striking passage in the celebrated description of the Plague of Athens,
as given by Thucydides: “For the mischief, being at first seated in
the head, spread over the whole body, and if one survived the most
formidable symptoms, an attack on the extremities manifested itself;
for it was determined to the genital organs and to the hands and feet,
and many escaped with losing them, and some with the loss of their
eyes.” (ii., 49.) The passage is thus rendered by Lucretius:
“tamen in nervos huic morbus et artus
Ibat et in partes genitales corporis ipsas;
Et graviter partim metuentes limina lethi
Vivebant ferro privati parte virili:
Et manibus sine nonnulli pedibusque manebant
In vita tamen et perdebant lumina partim.”
(vi., 1203.)
Lucretius, it will be remarked, understands the historian to mean
that the mortified parts were amputated; and this opinion, although
rejected by most of our non-professional editors of Thucydides, is
confirmed by what Galen says in his Commentary on this passage, namely,
that in erysipelas of the genital organs “we (meaning the physicians
of his own time) are often obliged to excise the putrid parts, and
apply the cautery to them.” I would here further point out a singular
mistake into which Dr. Bloomfield falls in his note on this passage of
Thucydides; he says that the words of the original (ἄκρας χεῑρας καὶ
πόδας) “can only signify the ends of or lower joints of the fingers and
toes.” No one who is acquainted with the language of our author will
require to be told that this is an entire misconception. In the works
of Hippocrates χεῖρες is often put for the arms, and χεῖρες ἄκραι are
always applied to the hands.
[708] Upon reference to the Glossary of Erotian, the Commentary of
Galen, and the Annotations of Foës and Littré, the reader will see that
there is great difficulty in determining the text in this place. After
examining all that has been written on the subject, one cannot come to
any satisfactory conclusion as to the true reading. I have adopted the
meaning which seems to suit best with the passage. The professional
reader will scarcely require to be reminded that in cases of phthisis
there is often a notable impairment of the voice.
[709] Galen makes the important remark on this word, that, in febrile
diseases, epistaxis is always a bad symptom.
[710] This obliviousness is a feature of the plague, as described by
Thucydides: “And some, when they first left their beds, were seized
with an utter forgetfulness of all things, and knew not themselves nor
their relatives.” (l. c.)
[711] Our author alludes to the affection called coma vigil by the
later authorities. In this affection, as Galen remarks, the patient
lies with his eyes shut, but can get no sound sleep. This, of course,
is so much more the case provided pain be present, as it necessarily
will prevent the occurrence of sleep. See Galen’s tract On Coma.
[712] The low muttering delirium of typhoid fevers is here evidently
alluded to. Galen, in his Commentary, guards the reader against
supposing that the fever passed into lethargus.
[713] This description apparently can refer to nothing but pestilential
buboes.
[714] It is impossible not to recognize this as a description of
_purulent ophthalmia_. Celsus thus describes the ficus: “Est
etiam ulcus quod a fici similitudine σύκωσις Græcis nominatur,
ubi caro excrescit; et id quidem generale est. Sub eo vero duæ
species aunt. Alterum ulcus durum et rotundum est: alterum humidum
et inæquale. Ex duro exiguum quoddam et glutinosum exit: ex humido
plus, et mali odoris.” See the Lexicons of Hesychius and Phavorinus,
and also PAULUS ÆGINETA, Book III., 3. It will be remarked
that Hippocrates also makes mention of fungous excrescences about
the pudenda. Were they syphilitic? In other words, did they derive
their origin from elephantiasis? See the Annotations on PAULUS
ÆGINETA, Book IV., 1, Sydenham Society’s edition.
[715] The meaning of this term is not precisely determined. Galen’s
account of it may apply both to exanthemata, and pustulæ. The
description of the eruption in the Plague of Athens is likewise vague
and indeterminate. (Thucyd, ii., 49.)
[716] These intestinal complaints are all mentioned in the description
of the Plague at Athens. (l. c.) Upon reference to the Commentary of
Galen, the reader will remark that there is a question here respecting
the reading.
[717] Galen, in his Commentary, makes the remark that he observed the
same symptom in the plague which raged in his time.
[718] It will readily be understood that a colliquative diabetes would
prove a very unfavorable complication of these complaints.
[719] By nocturnal fevers, according to Galen, was meant quotidians,
which had their paroxysms during the night. Foës inclines to think that
diurnal should also be inserted in this place. These nocturnal fevers
are thus described by D. Monro: “The sick were restless and uneasy _at
night_; but commonly felt themselves cooler and lighter in the daytime:
and although they had no cold fit, as the fever came on _at nights_,
and many of them no breathing sweat, as they became cooler and freer
from the fever in the morning; yet the fits were so remarkable, that
many of the patients used to say that they had a regular fit of an
ague _every night_, and some few that they had the fit every second
_night_.” (Army Diseases, etc., p. 158.)
[720] The account of the origin and progress of consumption here given
is, upon the whole, wonderfully correct. Common experience seems
to have decided that spring and autumn are the most fatal seasons
to phthisical patients. Avicenna makes the remark, which is very
important, and deserves to be kept in mind, that by phthisis, in this
place, Hippocrates most probably meant hectic fever, connected with
disease of the internal viscera, which had been in an inflamed state
during the acute attack of the fever. (iii., 1, 3, 67.)
[721] I shall not enter into a discussion of the different readings of
this interesting passage. I may mention that our great pathological
authority on phthisis, Dr. Louis, agrees with Hippocrates in deciding
that the lymphatic temperament constitutes a more or less marked
predisposition to the development of phthisis. (p. 483.) Galen
describes the phlegmatic temperament as being attended with a soft
and slightly tumid skin. He attributes the disease in their case to a
cacochymy, that is to say, to cachexia. I need scarcely remark that
this opinion is strongly advocated by one of the highest authorities
of the day, I mean Sir James Clark. See his treatise on Tubercular
Phthisis. Galen gives a discussion on the color of the eyes, about
which there is some difficulty, as the ancient terms which relate to
colors are not very well defined. The term here used (χαροπὸς) may
signify either blue or gray. Galen considers this color of the eyes as
a symptom of a cold and humid temperament.
[722] There is an ambiguity in the part of the sentence which relates
to women, as Galen states in his Commentary. Galen does not hesitate to
declare that women are more subject to phthisis than men, an opinion
upon which modern authorities are not at all agreed. See the recent
publications of Louis and Clark on Phthisis.
[723] The last paragraph, and the latter clause of the preceding one,
were at first attached to the end of the subsequent cases, and were
transferred to their present position by Dioscorides the commentator
a short time before Galen. They evidently embody a most distinct and
admirable enumeration of the general facts with which the practical
physician ought to make himself acquainted.
[724] We learn from the Commentary of Galen that some of the older
critics supposed that the sixteen cases about to be related had been
selected by Hippocrates in illustration of his doctrines, as laid
down in the preceding description of what is generally entitled the
Pestilential Season. Galen, however, does not incline to this opinion.
[725] This is an example of one of those protracted fevers of an
intermittent type, which, as I have been informed by an intelligent
physician who practiced for several years in the Ionian Islands, are so
common in the climate of Greece. There is not much of any particular
value in Galen’s Commentary on this case. He informs us that one
of the older commentators absurdly maintained the opinion that the
country of this patient was given because, according to Asclepiades,
the inhabitants of Paros were most especially benefited by bleeding.
But, as Galen says, this remark is particularly out of place here,
since no mention of venesection occurs in the report. Galen, and after
him Foës, have given very lengthy and elaborate disquisitions on the
nature of oily urine. The result is, that it is an unfavorable, but not
necessarily a fatal, character. It is minutely described by the later
authorities on urology, namely, Theophilus and Actuarius. See also the
Commentary on PAULUS ÆGINETA, Book II., 14, Sydenham Society’s
edition.
[726] This appears clearly to be a case of fever, complicated with, but
not produced by parturition. Galen, however, seems to ascribe the fever
and its fatal results to the retention of the lochial discharge. The
characters of the urine, he properly remarks, are unfavorable, being
copious, thin, and black. He also calls attention to the want of proper
concoction in the sputa, to which he attributes the fatal relapse.
[727] Galen’s Commentary on this case is written in his usual light
and diffuse style, but contains very little which is calculated to
throw light on the text, or on the nature of the disease which is here
described. If any one find difficulty in comprehending the characters
of the respiration, as given in this narrative, he can turn to Galen’s
work, On Difficulty of Breathing, where they are explained very
fully. I may just mention that by shortness of breath (βραχύπνοος)
was understood, by Hippocrates and Galen, frequency of the act of
respiration.
[728] This case, as Galen remarks, is an instance of the most acute
form of phrenitis. He states that he himself had met with cases of
phrenitis in which the patients had died on the fourth and fifth day,
but that he had never seen a case which proved so suddenly fatal as the
present one. He further makes some very interesting reflections on the
suddenness of the attack in such cases, which is the more wonderful, as
the exciting cause of them must be gradually collecting in the system,
and acquiring strength and intensity, and it is singular that it should
then be developed all at once, and cut off the patient in a very short
time, as if he had swallowed poison, or had been stung by a venomous
animal. He compares the latency of the febrile humor in the system to
that of the mad dog, which will remain for a long time in the body of
a person who had been bitten, and then all at once will manifest its
effects, by inducing the rage. For the ancient views on the subject
of Hydrophobia, see PAULUS ÆGINETA, Book V., 4, Sydenham
Society’s edition.
[729] Galen, in his Commentary on this case, enters into a train
of reflections how a physician ought to proceed when called in to
a patient so circumstanced. He ought, in the first place, as the
Commentator properly remarks, to make careful inquiry, in order to
find out whether the pain in the limb be occasioned by any external
cause, as persons often meet with local injuries by sudden twisting
and movements of their limbs, or even by laying a limb uncomfortably
in bed, without being aware of it. When no such cause of the complaint
can be discovered, Galen says the physician should try to ascertain
whether or not it be connected with the regimen or temperament of the
patient. If it shall turn out that the body is in a plethoric state,
general bleeding must be had recourse to, before any local applications
are made to the part. It is then to be fomented, and liquid and heating
medicines applied to it. Whether or not this was the mode of treatment
which Hippocrates adopted in this case, Galen cannot take upon himself
to affirm, as no mention is made in the report of venesection, nor of
the particular remedies which were used. I am of opinion that this
is one of the most interesting cases in the whole Collection, for I
believe it to be a faithful report of a disease which on three several
occasions I have met with during an active professional practice of
thirty years, and which I have not seen described elsewhere. In all
my cases, indeed, the patients were from twelve to sixteen years old,
but in other respects the symptoms were the same as here described by
Hippocrates. In every one of the cases the patient was seized with pain
and swelling of the thigh, attended with high fever, great jactitation,
and partial delirium. They all proved fatal in the course of three or
four days. Whether the disease be connected with diffuse inflammation
of the areolar substance, or with inflammation of the veins, or whether
it be a general fever complicated with a local affection of the limb,
or what may be the exact nature of the affection, I have not been able
to determine. From what is stated above, it will be clearly seen how
justly Hippocrates deserves the compliment paid to him by Galen, of
having been, of all medical authorities, the most careful in observing
the phenomena of disease. (Opera Galeni, tom. vii., p. 829, ed. Kühn.)
[730] Galen remarks, that this is one of those cases which appear
formidable to the inexperienced, but which those who are practiced in
the art judge of as being likely to come to a speedy crisis. He adverts
to the slight swelling of the spleen and the characters of the urine,
which soon showed a proper sediment, as being particularly favorable
symptoms. The more that we study Hippocratic medicine, we shall be the
more convinced that too little attention has been paid of late years to
the physical characters of the urine in all febrile complaints.
[731] Galen’s Commentary on this case is unusually brief. He holds it
to be a case connected with general plethora, as indicated by the good
color of the urine. He once more makes the remark that a favorable
issue of the case might have been anticipated, from the characters of
the urine.
[732] Galen remarks in his Commentary, that of all the cases related
in the First and Third Books of the Epidemics, this is the only one
in which Hippocrates says that the patient was bled, not, he adds,
that this was the only case in which venesection was adopted, but
because, although the general rule was not to bleed after the fourth
day, the patient, in the present instance, was bled on the eighth. Many
others, he says, were no doubt bled on the second, third, and fourth
days, but of these bleedings, and the other means used, Hippocrates in
general takes no notice, except that he sometimes states, in order to
render the malignity of the disease more apparent, that it was nowise
benefited by the remedies applied. In other cases he adds, he would
appear, from the words he uses (such as “as far as I am aware”), not to
have attended the patient at the commencement. Galen further directs
attention to the characters of the expectoration, the concoction of
which he looks upon as having proved the means of carrying off this
fever. Galen has reviewed the symptoms of this case very fully, and
in a most interesting manner, in the Second Book of his work, On
Difficulty of Breathing, see ed. Kühn, tom. vii., p. 854, etc. That it
was a case of fever complicated with pleurisy seems clear, as Galen
remarks. Galen further treats of the characters of the sputa in this
case, in the First Book of his work, On Crises. Upon reference to
the edition of Littré, it will be seen that unfortunately there is
considerable variation in the readings of this passage.
[733] On this case Galen makes the remark that this patient must have
had a strong constitution, otherwise it could not have withstood such
an affection. He adds that, moreover, his pulse must have possessed
strength, but that, as formerly said by him, this department of
prognostics is altogether omitted by Hippocrates, in his reports of
febrile cases. He further remarks that the respiration and appetite
were not to complain of, and the only bad symptom was the thinness and
blackness of the urine, which therefore required a long time for nature
to overcome, by occasioning hemorrhage, pain of the hip-joint, and
determination downwards. He adds, that great diseases require decided
crises, and that even with those now mentioned, the disease was not
entirely removed in this case, until concoction in the urine took place.
[734] Galen passes over this case without any remark worth mentioning.
I cannot but think that the abundant sediment in the urine, which
preceded the favorable crisis, is a fact in the case well deserving to
be noticed. Galen, however, in the present instance, omits all notice
of it, and ascribes the recovery to the profuse sweat.
[735] The only thing of importance in Galen’s Commentary on this case
is the remark that this woman’s melancholy was most probably connected
with suppression of the menses, and that to this cause the dark color
of the urine in the present instance is most probably to be ascribed.
To the critical evacuations by the sweat and menstruation he attributes
the recovery.
[736] There were several ancient cities of this name, but there can
be no doubt that the one here referred to is the celebrated city of
Thessaly. See Strabo, Geograph. ix.
[737] Galen considers it a remarkable feature in this case that
although the crisis occurred on the sixth day, there was no relapse.
The recovery he ascribes to the copious menstruation which then took
place for the first time. He also calls attention to the characters of
the urine, which, he says, are those which usually accompany delirium,
although this is omitted in the Prognostics.
[738] Galen, in his Commentary, merely remarks that Hippocrates, at
the conclusion of the report, briefly enumerates the more prominent
symptoms from which a fatal result might have been confidently
prognosticated. By enlarged viscera, in this case, we are informed by
Galen in another place, that our author meant inflammation and swelling
(Comment. in Rat. Vict. in Acut. c. iii.) There can be no doubt that
by viscera Hippocrates meant the liver and spleen (see the work just
referred to). Galen briefly remarks on this case towards the end of the
Second Book of his work, On Difficulty of Breathing.
[739] Cyzicus was a flourishing city on the Propontis. See Strabo,
Geogr. xii.; and Pliny, H. N. v. 32.
[740] Galen, in his Commentary, accounts for this fatal disease upon
the supposition that the uterus was inflamed, and affected the brain by
sympathy, hence maniacal delirium and convulsions were the consequence.
Galen, both in his Commentary, and in his work On Crises, refers to
this case, in confirmation of his doctrine of critical days.
[741] I will venture to affirm, without much fear of contradiction,
that in all the works on medicine, both ancient and modern, there
is not to be found so vivid a delineation of the symptoms of fever,
complicated with effusion on the brain. Those who have added new
features to the picture, have thereby detracted from the general
effect. Galen, in his Commentary, insists more especially on the
character of the respiration, but there does not appear to me to be any
particular obscurity about it. He also touches on this case towards the
end of the Second Book, On Difficulty of Breathing. After reading all
his prolix disquisition on the subject, one does not feel much better
instructed on the subject. Galen, at times, nay, very frequently, seems
to forget a favorite saying of his own, namely. that he who would wish
to lay in a copious store of knowledge during life, should trouble
himself little about words, and attend principally to things.
[742] There were two Thessalian cities of this name, the one in
Estiæotis, and the other in Magnesia. This would appear to be the
latter. See Pliny, H. N. iv., 9; and Livy, xliv., 13.
[743] Galen’s Commentary contains few observations of much interest,
and which are not sufficiently obvious. Excesses in drinking and
debauchery, he remarks, hurt the nerves and the origin of them, that
is to say, the brain. Thus he accounts for the delirium with which
this case of fever was attended. All the other prominent symptoms,
such as the palpitation in the epigastric region, the swelling of
the hypochondrium, and the like, were noticed previously. Galen
also reviews the symptoms of this case in his work On Difficulty of
Breathing, II.
[744] “Hippocrates qui tam fallere quam falli nescit.” (Macrobius in
Somn. Scipionis, i., 6.)
[745] Hippocratis Coi de Cap. Vuln., etc., a Francisco Vertuniano.
Ejusdem textus Græcus a J. Scalig. Castigatus, etc.
[746] Comment. de Ossibus.
[747] Hist. Animal., i., 7. In reference to this description, it is
stated by Vesalius, who in the course of his life had examined a great
number of crania, that it is very rare indeed to meet with a skull in
which the sutures are wanting. He accounts for the statement made by
Herodotus (Hist. ix.) and Aristotle (1. c.), respecting skulls without
sutures, upon the supposition that the observations of these authors
must have been made upon those of old persons, in whom the sutures are
often very indistinct. (Chirurg. Magn., i., 17.)
[748] H. N., xi., 48; ed. Hardouin.
[749] De Partib. Animal., p. 34; ed. Londin.
[750] Φοεός. The exact meaning of this term is well defined by
Eustathius in his Commentary on Homer (ad Iliad., ii., 219), ό ἐις
ὀξὺ λήγονσαν ἔχων τὴν κεφαλήν. It is excellently expressed by Damm as
follows: “One whose head diminishes towards the top like a sugar-loaf.”
(Lexicon Homericum in voce Φοεός.)
[751] De Usu Partium, ix., 17.
[752] Surgery, v., 4.
[753] Chirurg. Mag., i., 17.
[754] It is well known that in very advanced age the sutures get nearly
effaced. See the Cyclopædia of Anatomy, vol. i., p. 745.
[755] Comment. de Ossibus.
[756] Obs. Anatom.
[757] This letter was very varied in form. See Galen and Foës.
[758] The operation consisted in sawing the bone nearly through, and
leaving it in this state until it exfoliated, or until the bone could
be separated from the dura mater without violence. See below.
[759] It is no doubt true that a simple cut in the outer table of the
bone, when accompanied with concussion or contusion, may produce fatal
effects within, and this, in fact, is stated by our author; but, of
itself, as he says, the simple incision or _hedra_ cannot be of a
dangerous nature, nor require any recourse to instruments. The cases
related by M. Littré in the Argument were all evidently complicated
with contusion, and are thus referable to the second class of these
injuries. It is most worthy of remark, that in the very interesting
account of “slicing cuts,” given in Mr. Guthrie’s excellent work, On
Injuries of the Head, the result, without any operation, by the most
simple system of treatment, was in general very favorable. (pp. 95,
96.) On these cuts and superficial injuries of the skull, see further
Hennen (pp. 283, 284), Thomson (pp. 51, 52), and Chelius (vol. i., p.
388).
[760] London and Edinburgh Medical Journal, 1844.
[761] Although, as we have stated, Dr. Laurie’s rule of practice now
be to use the trephine on the preventive principle, it is probable
that most of his cases occurred at a period when the practice of Mr.
Abernethy was universally followed. His statistics therefore are no
test of the results of the operation, when performed on the preventive
principle.
[762] See Lawrence’s Clinical Lecture in the Medical Gazette, vol.
xxi., p. 345; and Guthrie’s work, On Injuries of the Head, p. 113.
[763] See De Articulis, § 50; and Mochlicus, § 36.
[764] On hypertrophy and swelling of the brain after injuries, see
the very interesting observations made by Mr. Guthrie, in his work on
Injuries of the Head, p. 125.
[765] It is proper to mention in this place that Quesnay, with great
good sense, discusses the question, whether or nor the separation of
the pericrunium in this case be a sure indication of matter being
collected within the cranium. He decides in the negative. (p. 17, Syd.
Soc. edition of Selected Mem. of the Acad. of Surgery.)
[766] I ought to mention, however, in this place, that in simple
undepressed fractures, Pott allows of the operation as a preventive;
that, at least, is one of his objects in having recourse to the
operation. (p. 130.)
[767] Ambrose Paré expresses very strongly the difficulty of forming a
correct prognosis in injuries of the head: “Ex quo intelligere licet,
multos ab exiguis vulneribus mortem oppetere, alios ex ingentibus et
penitus magnis desperatisque convalescere.” (Opera, ix., 9.)
[768] Injuries of the Head, p. 148.
[769] Aphor. v., 68.
[770] See the Argument to the treatise, On Regimen in Acute Diseases.
[771] Opera, ix., 10.
[772] Sir Astley Cooper mentions an instance in which 208 ounces of
blood were abstracted from a patient!! In Quesnay’s Memoir there is
nothing more common than to find it reported that he had bled a patient
three or four times in the course of a day. In one case 160 ounces were
taken in nine days; “but,” it is gravely added, “two years elapsed
before she was quite well again.”
[773] IV., 5, 3, 1.
[774] The principles upon which depletion by bleeding and purging
should be regulated are fully stated and discussed by Galen, in the
Fourth Book of his great work on Therapeutics. The rule is briefly
given by Hippocrates in his Second Aphorism: “respect being paid to
place, season, age, and the disease in which it is proper or not.”
[775] See Aphor. v., 18, 22; and § 12 of this treatise. The
professional authorities of the present day are not agreed as to the
expediency of using poultices or cold lotions in injuries of the scalp.
Guthrie and Hennen recommend the latter; but South, in the edition of
Chelius, prefers the former.
[776] This is related of Philagrius in a very interesting scholium on
the Aphorism just quoted. See Scholia in Hippocrat. et Galen., tom.
ii., p. 457; ed. Dietz.
[777] Perhaps the meaning here is, that when the forehead is much
elevated, and the occiput much depressed, if one looks down upon the
skull from above, the sagittal and coronal sutures will present the
appearance of the letter Τ.
[778] The meaning, I suppose, may be, that when the forehead is very
low, and when the occiput is protuberant, if one looks down upon the
skull from above, the sagittal and lambdoidal sutures will present the
appearance of the letter Τ reversed.
[779] The meaning would appear to be, that in a square-built head, that
is to say, when it is prominent both before and behind, the coronal and
sagittal sutures run nearly parallel to one another, and the sagittal
connects them together in the middle. In this case they would present
the appearance of the letter Η reversed.
[780] Perhaps this alludes to the form of the head in which the
sagittal suture passes through the middle of the os frontis down to the
nose, in which case we may imagine that the coronal suture intersects
the lambdoidal in such a manner as to have some resemblance to the
letter χ. It is to be borne in mind, that the character of this letter
was very variable in ancient writing. Ruffus Ephesius describes the
sagittal suture as sometimes passing down the middle of the frontal
bone.
[781] This passage was considered by Scaliger as a gloss, but as
interpreted by M. Littré, whom I have followed, the meaning is quite
suitable. See his note, h. 1.
[782] It is difficult to say what can be meant by caruncles in this
place, but still I agree with M. Littré that Scaliger was not warranted
in proposing to eject the passage from the text as an interpolation.
Unless the _glandulæ Pacchioni_ are meant (and the description
must be admitted not to be quite applicable to them), I cannot pretend
to explain or account for the description.
[783] I need scarcely remark, that if by this is strictly meant that
wounds in the posterior part of the head are less dangerous than those
in the anterior, the statement is at variance with the experience of
certain modern authorities. See, in particular, Pott and Liston, p.
46. At the same time, it is, no doubt, anatomically correct, that
the occipital bone can bear more violence, without being seriously
fractured, than the frontal or parietal bones, and it is worthy of
remark, that the views and experience of Mr. Guthrie are very consonant
with those of Hippocrates. He says: “The result of my experience on
this point is, that brain is more rarely lost from the fore part of
the head with impunity, than from the middle part; and that a fracture
of the skull, with even a lodgment of a foreign body, and a portion
of the bone in the brain, may be sometimes borne without any great
inconvenience in the back part.... I have never seen a person live with
a foreign body lodged in the anterior lobe of the brain, although I
have seen several recover with the loss of a portion of the brain at
this part. My experience, then, leads me to believe, that an injury of
apparently equal extent is more dangerous on the forehead than on the
side or middle of the head, and much less so on the back part than on
the side. A fracture of the vertex is of infinitely less importance
than one of the base of the cranium, which, although not necessarily
fatal, is always attended with the utmost danger.” (On Injuries of the
Head, p. 3.) I feel difficulty in reconciling these discordant results
of modern experience. Perhaps the fact of the matter is, that injuries
on the upper part of the occipital region are the least dangerous of
any, whereas those in the lower part of it, are particularly fatal.
[784] Vidus Vidius thus explains the _hedra_ or _sedes_:
“Inciditur os ita ut teli vestigium remaneat, quod genus fracturæ
appellatur a Hippocrate ἒδρα, id est sedes, quum (ut ipse inquit)
appareat in osse qua telum insederit; fit autem ab acuto telo, quod
et ipse in sequentibus, et Galenus, in Commentario, in librum memoriæ
prodidit, quum sub telo acuto incidi os dixit. Requirit autem sedes
ut incisum os nullo modo ad cerebri membranam inclinatur.” (Chirurg.
Græc., p. 71.) Andreas à Cruce defines it thus: “Potissimum vero sedes
vocatur ubi osse in suo statu remanente qua parte telum insederit
apparet.” (De Vulneribus, 1. 2.) By _hedra_ would appear to have
been understood a dint, or impression, left in a bone by a blow which
has not produced fracture or depression. It was also applied to a cut
or slash affecting only the outer plate of the skull. Hippocrates, it
will be remarked, pronounces this sort of injury not to be dangerous
of itself, but M. Littré relates a case taken from the “Journal de
Médecine,” in which a sabre-cut, which only penetrated through the
external plate of the cranium, and did not touch the internal, proved
fatal. (Op. Hippocrat. iii., p. 170.) Our author, in the latter
part of this paragraph, mentions cursorily injury of the skull at
a suture, and more circumstantially in the twelfth paragraph. This
accident is very correctly described by the later writers, under the
name of _diastasis_. See Heliodorus (ap. Chirurg. Veteres, p.
100), and Archigenes (ibid., p. 117). Pott declares that he did not
remember having ever seen a single instance of recovery when there
was separation of the bones at a suture. Morgagni, in like manner,
represents the case as being of a particularly serious character.
(De Caus. et Sed. Morb.) I once saw a strongly marked case in which
there was a considerable separation of the bones at the upper part
of the temporal suture, along with an extensive wound, unguardedly
inflicted by the scalpel of a juvenile surgeon, in order to explore
the nature of the accident. As might have been expected, under these
circumstances, the case had a fatal issue. Mr. Guthrie writes thus of
_diastasis_: “It is well known, that when a violent shock has been
received on the head, particularly by a fall on the vertex, the sutures
are often separated to a considerable extent; _these cases usually
terminate fatally_.” (p. 135.)
[785] The meaning here is somewhat obscure, but as Arantius states in
his commentary on this tract, our author probably means that a fissure
is necessarily complicated with a contusion, or, in other words, that
there can be no fissure without contusion.
[786] Arantius and Porralius, in their conjoined commentary on this
treatise, mention that in contusion sometimes only the outer plate of
the skull is contused, but the inner is depressed upon the dura mater.
This is a case of which we have examples in modern surgery; but it
does not appear clearly to be alluded to in this place by our author.
Mr. Guthrie, indeed, understands the ἀπήχημα of the Greek authors, and
_resonitus_ of the Latin, to apply to this variety of fracture;
but he appears to me to be mistaken, for these terms unquestionable
refer to the _contre-coup_, of which we will treat presently.
Quesnay, indeed, uses the term _contre-coup_ in this double sense,
but, as I think, very injudiciously, as it tends to introduce confusion
of ideas; for assuredly the case of a fracture on a different part of
the head from that which received the blow, and a fracture on the inner
plate of the skull from an injury on the outer, are quite different
cases. See Quesnay, etc., p. 20, Syd. Soc. edit.
[787] The expressions in this place are somewhat confused, but the
meaning evidently is, that without fracture there can be no depression.
[788] This third mode of fracture is thus defined by Celsus: “At ubi
medium desedit, eandem cerebri membranam os urget; interdum etiam ex
fractura quibusdam velut aculeis pungentibus,” (viii., 4.) Hippocrates,
it will be remarked, makes no mention of spiculæ in his description of
depression. Galen describes two varieties of depression; in the one
the depressed portion retains its situation, and in the other it rises
again to its former level. (De Caus. Morb.) Hippocrates does not appear
to have been acquainted with the latter. Modern experience has shown
that it sometimes occurs in children.
[789] It is almost impossible to know what to make of this passage,
owing to the corrupt state of the text.
[790] The nature of this mode of injury is explained in the annotations
on the third paragraph. It does not appear clear why our author has
given two separate descriptions of this injury. He describes, it will
be remarked, several varieties of it, according as it is complicated
or not with contusion and fracture. Galen uses _hedra_ in one
place. (Meth. Med. vi.) The term _hedra_ is rendered _teli
sedes_ by the Latin translators of the Greek medical authors. (See
Asellii Comment. in Hippocrat. de Vuln. Capit.) It is used also by
Ambrose Paré, Wiseman, and all our earlier writers on surgery. Wiseman
thinks the term most appropriate when applied to wounds inflicted by a
pole-axe, halberd, or the like. (v. 9.) Paré applies it to a kind of
injury, in which the bone is not broken through, but the print of the
weapon is left on the skull. (xx., 7.) Fallopius gives an interesting
discussion on it. (In librum Hippocrat. de Vuln. Capit.) The term
incision, borrowed from Paulus Ægineta, has been since used in its
stead. See Quesnay, on the Use of the Trepan, p. 29, Syd. Soc. edition;
and on simple incisions or sabre-cuts, see, in particular, Mr. Guthrie,
Injuries of the Head, p. 86.
[791] This, it will readily be perceived, is the _fractura per
resonitum_, that is to say, the _fracture par contre-coup_, or
counter-fissure of modern authorities. Except Paulus Ægineta, I am not
aware that any of the ancient authorities question the occurrence of
this species of the accident, and with the exception of Vidus Vidius,
Guido, Fallopius, and Dinus de Garbo, it is generally recognized by the
best modern authorities, from Bertaphalia and Andreas à Cruce, down
to Sir Astley Cooper and Mr. Liston. Mr. Guthrie, indeed, remarks,
that in recent times there has been no well-authenticated instance of
fracture on the one side of the head from a blow on the other. Such
cases, however, are not wanting in the works of the earlier modern
authorities. Quesnay writes thus: “We find in authors, also, many
cases of fracture by _contre-coup_, from one part of the head
to the part opposite: and in honor of the ancients we may cite the
case related by Amatus, who applied the trepan to the part of the
head opposite to the wound, when he found that the symptoms were not
relieved by applying it on the side wounded, and that the patient
suffered from severe pain on the other side. This second trepan
proved very apropos, for it allowed the escape of pus, which had
collected under the skull.” (On the use of the Trepan.) All our modern
authorities, including Mr. Guthrie, admit the reality of the case in
which fracture of the base of the skull is produced by a blow on the
upper part of the head. In imitation of our author, this case was
denominated “infortunium” by the earlier authorities, such as Asellius
and Porralius, being accounted an irremediable misfortune, because its
seat could not be detected; and it is noticed in the following terms by
Sir Astley Cooper, who did not trouble himself much about the writings
of his predecessors, but formed his opinions from actual observation:
“When the basis of the skull is fractured from a high fall, from the
whole pressure of the body resting upon that part, on opening the brain
and tearing up the dura mater, extravasated blood is commonly observed;
_this kind of fracture must inevitably prove fatal, nor can it be
discovered till after death_.” (Lectures, xiii.)
[792] Whatever opinion may now be formed of the rule of practice here
laid down, all must admit that it is clearly stated and distinctly
defined. We have seen above that our author describes five modes of
injury in the skull, namely, the incision or indentation, confined
to its outer table; the contusion; the direct fracture; the fracture
_par contre-coup_; and the depression. He now states decidedly
that it is only in the case of contusion and simple fracture, that the
trepan can be applied with advantage. I have entered so fully into the
_rationale_ of this practice in the Argument, that I do not think
it necessary to say more on the subject in this place.
[793] This passage indicates strongly our author’s partiality for
prognostics, or rather, I should say, for prorrhetics. It would appear
to have been a primary consideration with him, in all cases, to secure
the physician from blame, and to teach him how to gain the confidence
of the patient and his attendants. Few who have practiced medicine
for a great many years, will question the propriety of these rules
of conduct, or doubt the importance of taking all honorable steps to
ensure the confidence and good-will of patients and their friends.
[794] There is a remark made by Arantius and Porralius on the latter
part of this paragraph, which, although it appears to be scarcely
warranted by anything in the text of our author, I quote for its
importance, as showing that the earlier authorities were well aware of
the danger and impropriety of treating injuries of the head in children
by instruments: “Sed præ ceteris illud notandum quod dixerit (_nudato
osse_) quasi dicat, eo non denudato quamvis calliso aut fisso, quod
raro accidit, non esse tamen sectione denudandam calvariam: nam in
pueris, ubi decidunt non raro accidit ut eorum collidatur calvaria,
frangaturque, cute integra, quod etsi accidat, et tactu hoc probe
precipiatur, sanguisque e venis effusus sub cute fluctua, abstinendum
tamen a sectione est, neminem enim servatum vidi, cui sectio adhibita
sit, propterea quod eorum calor facile dissipetur, eoque magis, quum
gemitu et clamore caput valdè incelescat, et ad fluxiones suscipiendas
proclive reddatur,” (Comm. in Hip. de Vuln. Cap.) It will be seen at
§ 18, that our author allowed the application of a small trepan in
children when strongly indicated.
[795] This passage is rendered as follows by Celsus: “Igitur, ubi
ea percussa, protinus requirendum est, num bilem is homo vomuerit;
num oculi ejus obcæcati sint; num obmutuerit; num per nores auresque
sanguis ei effiuxerit: num conciderit, num sine sensu quasi dormiens
jacuerit. Hæc enim non nisi osse fracto eveniunt; atque, ubi
inciderunt, scire licet, necessariam, sed difficilem curationem
esse.” (viii., 4.) Now, although it is no doubt true, as remarked by
Pott (Injuries of the Head, § 4), that these symptoms sometimes take
place, without there being any fracture of the skull, and that, on the
other hand, as had been previously pointed out by Paré and Le Dran,
fractures do sometimes take place without being accompanied by all
these symptoms, still there can be no doubt that as a general rule
the doctrine of Celsus is correct, and that, at all events, a case is
to be treated as serious in which these symptoms occur. With regard
to one of the characteristics of a fracture, thus noticed by Celsus,
a modern authority of great experience, but little acquaintance with
ancient learning, observes, “Blood flowing from the nose and ears is a
symptom attending fracture of the skull. It may be consequent on mere
concussion, a vibration which ruptures the membranes; but oftener it is
a consequence of fissure across the bone.” (Institutes of Surgery, by
Sir Charles Bell, vol., i, p. 173.)
[796] The separation of the bones at a suture, usually called
_diastasis_, is noticed in the annotations on § 8. I have also
alluded, in my analysis of the Fifth Book of the Epidemics, to the case
in which the author, generally supposed by ancient authorities to be
Hippocrates, mistook a suture for a fracture of the skull. See Epidem.
v., 14; and Celsus, viii., 4.
[797] On the terms which occur parenthetically, the philological reader
may consult the note of Stephanus, contained in the edition of Erotian
by Franzius, under ἑδράιως. I may here remark, that it is difficult to
account for the frequent repetition of these words in parentheses.
[798] It will be remarked that, as a general rule, Hippocrates forbids
us to apply the trepan at the sutures, but, notwithstanding this
prohibition, it would appear to have been departed from in two cases
related in the Sixth Book of the Epidemics. (See § 27 and 28.) The
rule, however, to avoid the application of the trepan at the sutures,
was generally observed by nearly all the modern authorities down to
Pott, and even he admits that the sutures should be avoided when the
trephine may with equal utility be set on any other part. Louis, in
a paper lately reprinted from the Memoirs of the Royal Academy of
Surgery, by the Sydenham Society, gives an interesting examination
of the doctrine of the ancient and modern authors on this rule of
practice. Most of the authorities quoted by him are averse to the
application of the trepan over sutures, except when very urgently
required. C. Porralius, in his marginal notes on Arantius’s Commentary
on this work of Hippocrates, assigns three reasons for avoiding the
sutures in this operation: 1st, because the bone is weak at that place;
2dly, because the membrane there being in close connection with the
bone, is in danger of being injured; 3dly, because, by the contraction
of the callus, the transpiration there will be stopped. The last of
these reasons is based on the physiological doctrine of the ancient
authorities respecting the uses of the sutures, one of which was, to
permit transpiration from the brain. See Galen, de Usu Partium, ix., 1,
2.
[799] Our author, it will be remarked, forbids liquid applications,
tents, cataplasms, and bandages, in wounds of the head. He seems to
have approved most of things of a drying nature. The other authorities
would appear to differ considerably in their views regarding the proper
principles upon which wounds on the head are to be treated. Celsus
directs us, after laying bare the dura mater by trepanning, to apply
strong vinegar to it, and when the membrane is inflamed, he approves of
tepid rose-water. (viii., 4.) Paulus Ægineta, after the operation of
trepanning, directs a piece of cloth, or small ball of wool dipped in
oil, to be applied to the part. I believe they all agreed in rejecting
sutures. See Galen, de Med. sec. Genera III.
[800] Hippocrates would seem to hold the fanciful idea, that the
forehead is environed by the rest of the head, and that afflux of blood
takes place from the parts around to it. Scaliger rejects this passage
as containing a doctrine wholly unworthy of our author.
[801] The danger of incisions, in the temporal region, is adverted to
in several parts of the Hippocratic Collection, as in the work On the
Articulations, in the Prorrhetics, and the Coan Prænotions. Even at the
present day, when the treatment of hemorrhage is better understood than
in the days of the great Fathers of Grecian medicine, a large incision
in that quarter is regarded with considerable apprehension. Convulsion,
that is to say, tetanus, was supposed to be the frequent, if not the
invariable, result of a wound in the temporal muscle. Pott, indeed,
contends that lock-jaw is not necessarily produced by a wound there; he
admits, however, that the application of the trepan to the temple is
not often successful, but the reason of this he contends is, that in
these fractures the breach generally extends to the base of the skull
(§ 5). Quesnay, however, inclines to support the views of Hippocrates.
(On the Use of the Trepan, p. 15, Syd. Soc. edit.) Scultet, in like
manner, pronounces decidedly that a wound in the temple is a very
dangerous affair. (Armam. Chirurg. Tabl. xxxi.)
[802] The _maza_ was evidently a poultice prepared with barley-meal
and vinegar, or water. See the Annotations on the treatise On Ancient
Medicine.
[803] Celsus translates this passage as follows: “At si ne tum quidem
rima manifesta est, inducendum supra os atramentum scriptorium est,
deinde scalpro id deradendum; nigritiem enim continet, si quid fissum
est.” (viii., 4.) Arantius properly remarks, that the ancient ink must
not be confounded with the modern, which is composed principally of
copperas and galls. It was, no doubt, the milder kind prepared from the
soot of pines with gum which was used in this case. On the writing-ink
of the ancients, see Dioscorides (M. M., v., 182) and Pliny (H. N.,
xxxv., 6).
[804] The text in the beginning of this paragraph is in a very
unsatisfactory state. It seems pretty clear, however, that in this
place our author describes caries of the bone brought on by an
unhealthy state of the integuments. The description--allowance being
made for the corruption of the text--is sufficiently distinct, and
most probably has reference to that condition of the parts which is
so graphically described by Pott as forming “a puffy, circumscribed,
indolent tumour of the scalp, and a spontaneous separation of the
pericranium from the skull under such tumour.”
[805] Our author in this place would appear to treat of incipient
hernia cerebri, as immediately before he treats of fungous ulcers on
the pericranium. Galen in like manner, praises powerfully dessicant
medicines upon the authority of Meges the Sidonian, who, he says, had
great experience in these cases. He speaks of the plaster called Isis
as being a most efficacious application to the dura mater, when laid
bare. Its principal ingredients are of an escharotic and detergent
nature, such as squama æris, burnt copper, ammoniac salts, myrrh,
aloes, and the like. See PAULUS ÆGINETA, Vol. III., p. 564.
Galen concludes his remarks on this subject with stating that, before
getting into an inflamed state, the dura mater, as being of a dry
nature, endures the most powerful medicines. (Meth. Med., vi., at the
end.)
[806] This description of a piece of bone which is going to exfoliate,
is remarkably correct. Compare it with the following narrative: “A
girl of ten or twelve years of age was struck on the head by an iron
rod falling on her; the blow caused no wound, and the young woman was
soon well, with the exception of a fixed pain of no great extent, which
remained over one of the parietal bones. The pain continued for several
years. M. Mareschal, who was at last consulted, considered it necessary
to trepan. He exposed the bone at the painful part, and applied one
crown of a trepan; he observed, _that the bone, when sawed, appeared
dry, like a skull that had been buried_.” (Quesnay, on the Use of
the Trepan.) This agrees excellently with the description given by
Hippocrates. It is to be regretted, however, that the text here; as
far as regards one word ἀποστρακὸς, is in a very unsatisfactory state.
The conjectural emendation of Schneider (ἀπεσκληκὸς) seems to be a
plausible emendation, but it is not adopted by Littré.
[807] Our author delivers the same doctrine in the work On the
Articulations, and states that extensive fractures of the bones are
often less dangerous than others which appear not so formidable. I
need scarcely remark that modern experience has confirmed the truth
of this position. How often has it been seen that one patient died
from a slight injury to the skull, while another recovered from an
extensive fracture of it? Mr. Guthrie appears in so far to agree in
opinion with our author, that extensive fractures are less dangerous
than they appear; he says, “Mr. Keate, who has had great opportunities
for observation in St. George’s Hospital, has invariably remarked that
the symptoms dependent on extravasation have been less severe in the
first instance, in proportion as the separation of the edges of the
fracture have been greater one from the other, or when the sutures have
yielded to the shock and have been separated. It has been stated from
the earliest antiquity, that the greater the fracture, the less the
concussion of the brain.” (p. 56.) See the Argument.
[808] It will be remarked as a striking feature in our author’s views
of practice in injuries of the head, not to interfere with fractures
attended with depression. See the Argument, where the rationale of this
practice is fully discussed.
[809] Although these directions of our author regarding the treatment
of children be most important, I am not aware that any other of the
ancient authorities has shown his sense of their value of them by
repeating them. It is well known that in children there is but one
table, and that it is very thin. Our author, as remarked above, does
not entirely omit the operation in the case of children, but uses a
small trepan.
[810] The reader will again remark an instance of our author’s fondness
for prognosis, and his observance of the rule at all times to prevent
the surgeon from committing himself by attempting hopeless cases.
Celsus, writing in the same spirit, says, “Ante omnia scire medicum
oportere, quæ vulnera insanabilia sint, quæ difficilem curationem
habeant; ... non attingere, _nec subire speciem ejus, ut occisi, quem
sors ipsius intermit_.” (v., 26.)
[811] This is an opinion held by all the ancient authorities. Some
interesting cases in point are related in the First Book of the
Continens of Rhazes. It was explained on the principle that the
cerebral nerves decussate. (See Aretæus, on the Causes of Disease, i.,
7.) Modern experience, in the main, is in accordance with the ancient
on this point. Paralysis has generally been found on the opposite side
to that which has received the injury. See Thomson’s Observations,
etc., p. 52; Larrey’s Mem. de Chirurg., iv., p. 180; Hennen’s
Principles, p. 301.
[812] This passage is thus translated by Celsus: “Si sub prima
curatione febris intenditur, brevesque somni, et iidem per summa
tumultuosi sunt, ulcus madet, neque alitur, et in cervicibus glandulæ
oriuntur, magni dolores sunt, cibique super hoc fastidium increscit,
tum demum ad manum scalprumque veniendum est.” (vii., 4.)
[813] The practice advocated in this paragraph is alluded to by Paulus
Ægineta, in his chapter on Fractures of the Skull. (vi., 90.)
[814] The operation here described by our author is the more deserving
of attention, as it appears to have been peculiar to him. It is not
described by Celsus, Paulus Ægineta, Albucasis, nor any one of the
ancient authorities, as far as I can find; neither am I aware of its
having been attempted in modern times. The object of it, however, seems
to be very rational, namely, to avoid doing serious injury to the dura
mater by tearing the bone forcibly from it at once.
[815] The instrument here used is named πρίων χαρακτὸς; and, as far as
I can see, was the same as the modiolus of Celsus, and the χοινικὶς
of the later authorities. It would certainly appear to have been a
circular saw, and consequently not unlike our modern trephine. See the
figures and the Argument.
[816] The following sentence, taken from Sir Charles Bell’s description
of the operation, looks like a translation of this passage of
Hippocrates; but it is well known that our English surgeon was not
guilty of reading Greek! “Withdraw your trephine from time to time,
brush it, and run the flat probe round the circular cut.” The specillum
of the ancient surgeons was, in most respects, not unlike our modern
probe.
[817] The meaning here would seem to be, that the bone does not
extend so deep as might be supposed. See Foës, Œcon. Hippoc., under
ἐπιπολαιότερον ὀστέου.
Transcriber’s Notes:
1. Obvious printers’, punctuation and spelling errors have been
corrected silently.
2. Where hyphenation is in doubt, it has been retained as in the
original.
3. Some hyphenated and non-hyphenated versions of the same words have
been retained as in the original.
4. Possible errors in Greek words or phrases have been retained as in
original.
5. Italics are shown as _xxx_.