Chapter XXII: Section III: Constitution 2.699 (1)

The year was southerly, rainy; no winds throughout.[700] Droughts having prevailed during the previous seasons of the year, the south winds towards the rising of Arcturus were attended with much rain. Autumn gloomy and cloudy, with copious rains. Winter southerly, damp, and soft. But long after the solstice, and near the equinox, much winterly weather out of season; and when now close to the equinox, northerly, and winterly weather for no long time. The spring again southerly, calm, much rain throughout until the dog-days. Summer fine and hot; great suffocating heats. The Etesian winds blew small and irregular; again, about the season of Arcturus, much rains with north winds. The year being southerly, damp, and soft towards winter, all were healthy, except those affected with phthisis, of whom we shall write afterwards.

3. Early in spring, along with the prevailing cold, there were many cases of erysipelas, some from a manifest cause, and some not.[701] They were of a malignant nature, and proved fatal to many; many had sore-throat and loss of speech. There were many cases of ardent fever, phrensy, aphthous affections of the mouth,[702] tumors on the genital organs; of ophthalmia, anthrax,[703] disorder of the bowels, anorexia, with thirst and without it; of disordered urine, large in quantity, and bad in quality; of persons affected with coma for a long time, and then falling into a state of insomnolency. There were many cases of failure of crisis, and many of unfavorable crisis; many of dropsy and of phthisis. Such were the diseases then epidemic.[704] There were patients affected with every one of the species which have been mentioned, and many died. The symptoms in each of these cases were as follows:

4. In many cases erysipelas, from some obvious cause, such as an accident, and sometimes from even a very small wound, broke out all over the body, especially, in persons about sixty years of age, about the head, if such an accident was neglected in the slightest degree; and this happened in some who were under treatment; great inflammation took place, and the erysipelas quickly spread all over.[705] In the most of them the abscesses ended in suppurations, and there were great fallings off (sloughing) of the flesh, tendons, and bones; and the defluxion which seated in the part was not like pus, but a sort of putrefaction, and the running was large and of various characters. Those cases in which any of these things happened about the head were accompanied with falling off of the hairs of the head and chin, the bones were laid bare and separated, and there were excessive runnings; and these symptoms happened in fevers and without fevers. But these things were more formidable in appearance than dangerous; for when the concoction in these cases turned to a suppuration, most of them recovered; but when the inflammation and erysipelas disappeared, and when no abscess was formed, a great number of these died.[706] In like manner, the same things happened to whatever part of the body the disease wandered, for in many cases both forearm and arm dropped off; and in those cases in which it fell upon the sides, the parts there, either before or behind, got into a bad state; and in some cases the whole femur and bones of the leg and whole foot were laid bare. But of all such cases, the most formidable were those which took place about the pubes and genital organs.[707] Such was the nature of these cases when attended with sores, and proceeding from an external cause; but the same things occurred in fevers, before fevers, and after fevers. But those cases in which an abscess was formed, and turned to a suppuration, or a seasonable diarrhœa or discharge of good urine took place, were relieved thereby: but those cases in which none of these symptoms occurred, but they disappeared without a crisis, proved fatal. The greater number of these erysipelatous cases took place in the spring, but were prolonged through the summer and during autumn.

5. In certain cases there was much disorder, and tumors about the fauces, and inflammations of the tongue, and abscesses about the teeth. And many were attacked with impairment or loss of speech;[708] at first, those in the commencement of phthisis, but also persons in ardent fever and in phrenitis.

6. The cases of ardent fever and phrenitis occurred early in spring after the cold set in, and great numbers were taken ill at that time, and these cases were attended with acute and fatal symptoms. The constitution of the ardent fevers which then occurred was as follows: at the commencement they were affected with coma, nausea, and rigors; fever not acute, not much thirst, nor delirium, slight epistaxis,[709] the paroxysms for the most part on even days; and, about the time of the paroxysms, forgetfulness, loss of strength and of speech, the extremities, that is to say, the hands and feet, at all times, but more especially about the time of the paroxysms, were colder than natural; they slowly and imperfectly became warmed, and again recovered their recollection and speech.[710] They were constantly affected either with coma, in which they got no sleep, or with insomnolency, attend with pains;[711] most had disorders of the bowels, attended with undigested, thin, and copious evacuations; urine copious, thin, having nothing critical nor favorable about it; neither was there any other critical appearance in persons affected thus; for neither was there any proper hemorrhage, nor any other of the accustomed evacuations, to prove a crisis. They died, as it happened, in an irregular manner, mostly about the crisis, but in some instances after having lost their speech for a long time, and having had copious sweats. These were the symptoms which marked the fatal cases of ardent fever; similar symptoms occurred in the phrenitic cases; but these were particularly free from thirst, and none of these had wild delirium[712] as in other cases, but they died oppressed by a bad tendency to sleep, and stupor.

7. But there were also other fevers, as will be described. Many had their mouths affected with aphthous ulcerations. There were also many defluxions about the genital parts, and ulcerations, boils (phymata), externally and internally, about the groins.[713] Watery ophthalmies of a chronic character, with pains; fungous excrescences of the eyelids, externally and internally, called fici, which destroyed the sight of many persons.[714] There were fungous growths, in many other instances, on ulcers, especially on those seated on the genital organs. There were many attacks of carbuncle (anthrax) through the summer, and other affections, which are called “the putrefaction” (_seps_); also large ecthymata,[715] and large tetters (_herpetes_) in many instances.

8. And many and serious complaints attacked many persons in the region of the belly. In the first place, tenesmus, accompanied with pain, attacked many, but more especially children, and all who had not attained to puberty; and the most of these died. There were many cases of lientery and of dysentery; but these were not attended with much pain.[716] The evacuations were bilious, and fatty, and thin, and watery; in many instances the disease terminated in this way, with and without fever; there were painful tormina and volvuli of a malignant kind; copious evacuations of the contents of the guts, and yet much remained behind; and the passages did not carry off the pains, but yielded with difficulty to the means administered; for in most cases purgings were hurtful to those affected in this manner; many died speedily, but in many others they held out longer. In a word, all died, both those who had acute attacks and those who had chronic, most especially from affections of the belly, for it was the belly which carried them all off.

9. All persons had an aversion to food in all the afore-mentioned complaints to a degree such as I never met with before,[717] and persons in these complaints most especially, and those recovering from them, and in all other diseases of a mortal nature. Some were troubled with thirst, and some not; and both in febrile complaints and in others no one drank unseasonably or disobeyed injunctions.

10. The urine in many cases was not in proportion to the drink administered, but greatly in excess; and the badness of the urine voided was great, for it had not the proper thickness, nor concoction, nor purged properly; for in many cases purgings by the bladder indicate favorably, but in the greatest number they indicated a melting of the body, disorder of the bowels, pains, and a want of crisis.[718]

11. Persons laboring under phrenitis and causus were particularly disposed to coma; but also in all other great diseases which occurred along with fever. In the main, most cases were attended either by heavy coma, or by short and light sleep.

12. And many other forms of fevers were then epidemic, of tertian, of quartan, of nocturnal,[719] of continual, of chronic, of erratic, of fevers attended with nausea, and of irregular fevers. All these were attended with much disorder, for the bowels in most cases were disordered, accompanied with rigors, sweats not of a critical character, and with the state of the urine as described. In most instances the disease was protracted, for neither did the deposits which took place prove critical as in other cases; for in all complaints and in all cases there was difficulty of crisis, want of crisis, and protraction of the disease, but most especially in these. A few had the crisis about the eightieth day, but in most instances it (the disease?) left them irregularly. A few of them died of dropsy without being confined to bed. And in many other diseases people were troubled with swelling, but more especially in phthisical cases.

13. The greatest and most dangerous disease, and the one that proved fatal to the greatest number, was the consumption.[720] With many persons it commenced during the winter, and of these some were confined to bed, and others bore up on foot; the most of those died early in spring who were confined to bed; of the others, the cough left not a single person, but it became milder through the summer; during the autumn, all these were confined to bed, and many of them died, but in the greater number of cases the disease was long protracted. Most of these were suddenly attacked with these diseases, having frequent rigors, often continual and acute fevers; unseasonable, copious, and cold sweats throughout; great coldness, from which they had great difficulty in being restored to heat; the bowels variously constipated, and again immediately in a loose state, but towards the termination in all cases with violent looseness of the bowels; a determination downwards of all matters collected about the lungs; urine excessive, and not good; troublesome melting. The coughs throughout were frequent, and sputa copious, digested, and liquid, but not brought up with much pain; and even when they had some slight pain, in all cases the purging of the matters about the lungs went on mildly. The fauces were not very irritable, nor were they troubled with any saltish humors; but there were viscid, white, liquid, frothy, and copious defluxions from the head. But by far the greatest mischief attending these and the other complaints, was the aversion to food, as has been described. For neither had they any relish for drink along with their food, but continued without thirst. There was heaviness of the body, disposition to coma, in most cases swelling, which ended in dropsy; they had rigors, and were delirious towards death.

14. The form of body peculiarly subject to phthisical complaints was the smooth, the whitish, that resembling the lentil; the reddish, the blue-eyed, the leucophlegmatic,[721] and that with the scapulæ having the appearance of wings: and women in like manner,[722] with regard to the melancholic and subsanguineous, phrenitic and dysenteric affections principally attacked them. Tenesmus troubled young persons of a phlegmatic temperament. Chronic diarrhœa, acrid and viscid discharges from the bowels, attacked those who were troubled with bitter bile.

15. To all those which have been described, the season of spring was most inimical, and proved fatal to the greatest numbers: the summer was the most favorable to them, and the fewest died then; in autumn, and under the Pleiades, again there died great numbers. It appears to me, according to the reason of things, that the coming on of summer should have done good in these cases; for winter coming on cures the diseases of summer, and summer coming on removes the diseases of winter. And yet the summer in question was not of itself well constituted, for it became suddenly hot, southerly, and calm; but, notwithstanding, it proved beneficial by producing a change on the other constitution.

16. I look upon it as being a great part of the art to be able to judge properly of that which has been written. For he that knows and makes a proper use of these things, would appear to me not likely to commit any great mistake in the art. He ought to learn accurately the constitution of every one of the seasons, and of the diseases; whatever that is common in each constitution and disease is good, and whatever is bad; whatever disease will be protracted and end in death, and whatever will be protracted and end in recovery; which disease of an acute nature will end in death, and which in recovery. From these it is easy to know the order of the critical days, and prognosticate from them accordingly. And to a person who is skilled in these things, it is easy to know to whom, when, and how aliment ought to be administered.[723]

SEC. 17. SIXTEEN CASES.[724]

CASE I.--In Thasus, the Parian who lodged above the Temple of Diana was seized with an acute fever, at first of a continual and ardent type; thirsty, inclined to be comatose at first, and afterwards troubled with insomnolency; bowels disordered at the beginning, urine thin. On the sixth day, passed oily urine, was delirious. On the seventh, all the symptoms were exacerbated; had no sleep, but the urine of the same characters, and the understanding disordered; alvine dejections bilious and fatty. On the eighth, a slight epistaxis; small vomiting of verdigris-green matters; slept a little. On the ninth, in the same state. On the tenth, all the symptoms gave way. On the eleventh, he sweated, but not over the whole body; he became cold, but immediately recovered his heat again. On the fourteenth, acute fever; discharges bilious, thin, and copious; substances floating in the urine; he became incoherent. On the seventeenth, in a painful state, for he had no sleep, and the fever was more intense. On the twentieth, sweated all over; apyrexia, dejections bilious; aversion to food, comatose. On the twenty-fourth, had a relapse. On the thirty-fourth, apyrexia; bowels not confined; and he again recovered his heat. Fortieth, apyrexia, bowels confined for no long time, aversion to food; had again slight symptoms of fever, and throughout in an irregular form; apyrexia at times, and at others not; for if the fever intermitted, and was alleviated for a little, it immediately relapsed again; he used much and improper food; sleep bad; about the time of the relapse he was delirious; passed thick urine at that time, but troubled, and of bad characters; bowels at first confined, and again loose; slight fevers of a continual type; discharges copious and thin. On the hundred and twentieth day he died. In this patient the bowels were constantly from the first either loose, with bilious, liquid, and copious dejection, or constipated with hot and undigested fæces; the urine throughout bad; for the most part coma, or insomnolency with pain; continued aversion to food. Ardent fever.

_Explanation of the characters._ It is probable that the weakness produced by the fever, the phrenitis, and affection of the hypochondrium caused death on the hundred and twentieth day.[725]

CASE II.--In Thasus, the woman who lodged near the Cold Water, on the third day after delivery of a daughter, the lochial discharge not taking place, was seized with acute fever, accompanied with rigors. But a considerable time before delivery she was feverish, confined to bed, and loathed her food. After the rigor which took place, continual and acute fevers, with rigors. On the eighth and following days, was very incoherent, and immediately afterwards became collected; bowels disordered, with copious, thin, watery, and bilious stools; no thirst. On the eleventh was collected, but disposed to coma; urine copious, thin, and black; no sleep. On the twentieth, slight chills, and immediately afterwards was warm; slight incoherence; no sleep; with regard to the bowels, in the same condition; urine watery, and copious. On the twenty-seventh, free from fever; bowels constipated; not long afterwards violent pain of the right hip-joint for a considerable time; fevers afterwards supervened; urine watery. On the fortieth, complaints about the hip-joint better; continued coughs, with copious, watery sputa; bowels constipated; aversion to food; urine the same; fever not leaving her entirely, but having paroxysms in an irregular form, sometimes present, sometimes not. On the sixtieth, the coughs left her without a crisis, for no concoction of the sputa took place, nor any of the usual abscesses; jaw on the right side convulsively retracted; comatose, was again incoherent, and immediately became collected; utter aversion to food; the jaw became relaxed; alvine discharges small, and bilious; fever more acute, affected with rigors; on the following days lost her speech, and again became collected, and talked. On the eightieth she died. In this case the urine throughout was black, thin, and watery; coma supervened; there was aversion to food, despondency, and insomnolency; irritability, restlessness; she was of a melancholic turn of mind.

_Explanation of the characters_. It is probable that the suppression of the lochial discharge caused death on the eightieth day.[726]

CASE III.--In Thasus, Pythion, who was lodged above the Temple of Hercules, from labor, fatigue, and neglected diet, was seized with strong rigor and acute fever; tongue dry, thirsty, and bilious; had no sleep; urine darkish, eneorema floating on the top of the urine, did not subside. On the second day, about noon, coldness of the extremities, especially about the hands and head; loss of speech and of articulation; breathing short for a considerable time; recovered his heat; thirst; passed the night quietly; slight sweats about the head. On the third, passed the day in a composed state; in the evening, about sunset, slight chills; nausea, agitation; passed the night in a painful state; had no sleep; small stools of compact fæces passed from the bowels. On the fourth, in the morning, composed; about noon all the symptoms became exacerbated; coldness, loss of speech, and of articulation; became worse; recovered his heat after a time; passed black urine, having substances floating in it; the night quiet; slept. On the fifth, seemed to be lightened, but a painful weight about the belly; thirsty, passed the night in a painful state. On the sixth, in the morning, in a quiet state; in the evening the pains greater; had a paroxysm; in the evening the bowels properly opened by a small clyster; slept at night. On the seventh, during the day, in a state of nausea, somewhat disturbed; passed urine of the appearance of oil; at night, much agitation, was incoherent, did not sleep. On the eighth, in the morning, slept a little; but immediately coldness, loss of speech, respiration small and weak; but in the evening recovered his heat again; was delirious, but towards day was somewhat lightened; stools small, bilious, and unmixed. On the ninth, affected with coma, and with nausea when roused; not very thirsty; about sunset he became restless and incoherent; passed a bad night. On the tenth, in the morning, had become speechless; great coldness; acute fever; much perspiration; he died. His sufferings were on the even days.

_Explanation of the characters._ It is probable that the excessive sweats caused death on the tenth day.[727]

CASE IV.--The patient affected with phrenitis, having taken to bed on the first day, vomited largely of verdigris-green and thin matters; fever, accompanied with rigors, copious and continued sweats all over; heaviness of the head and neck, with pain; urine thin, substances floating in the urine small, scattered, did not subside; had copious dejections from the bowels; very delirious; no sleep. On the second, in the morning, loss of speech; acute fever; he sweated, fever did not leave him; palpitations over the whole body, at night, convulsions. On the third, all the symptoms exacerbated; he died.

_Explanation of the characters._ It is probable that the sweats and convulsions caused death.[728]

CASE V.--In Larissa, a man, who was bald, suddenly was seized with pain in the right thigh; none of the things which were administered did him any good. On the first day, fever acute, of the ardent type, not agitated, but the pains persisted. On the second, the pains in the thigh abated, but the fever increased; somewhat tossed about; did not sleep; extremities cold; passed a large quantity of urine, not of a good character. On the third, the pain of the thigh ceased; derangement of the intellect, confusion, and much tossing about. On the fourth, about noon, he died. An acute disease.[729]

CASE VI.--In Abdera, Pericles was seized with a fever of the acute, continual type, with pain; much thirst, nausea, could not retain his drink; somewhat swelled about the spleen, with heaviness of the head. On the first day, had hemorrhage from the left nostril, but still the fever became more violent; passed much muddy, white urine, which when allowed to stand did not subside. On the second day, all the symptoms were exacerbated, yet the urine was thick, and more inclined to have a sediment; the nausea less; he slept. On the third, fever was milder; abundance of urine, which was concocted, and had a copious sediment; passed a quiet night. On the fourth, had a copious and warm sweat all over about noon; was free of fever, had a crisis, no relapse. An acute affection.[730]

CASE VII.--In Abdera, the young woman who was lodged in the Sacred Walk was seized with an ardent fever. She was thirsty, and could not sleep; had menstruation for the first time. On the sixth, much nausea, flushing, was chilly, and tossed about. On the seventh, in the same state; urine thin, but of a good color; no disturbance about the bowels. On the eighth, deafness, acute fever, insomnolency, nausea, rigors, became collected; urine the same. On the ninth, in the same state, and also on the following days; thus the deafness persisted. On the fourteenth, disorder of the intellect; the fever abated. On the seventeenth, a copious hemorrhage from the nose; the deafness slightly better; and on the following days, nausea, deafness, and incoherence. On the twentieth, pain of the feet; deafness and delirium left her; a small hemorrhage from the nose; sweat, apyrexia. On the twenty-fourth, the fever returned, deafness again; pain of the feet remained; incoherence. On the twenty-seventh, had a copious sweat, apyrexia; the deafness left her; the pain of her feet partly remained; in other respects had a complete crisis.

_Explanation of the characters._ It is probable that the restoration of health on the twentieth day was the result of the evacuation of urine.[731]

CASE VIII.--In Abdera, Anaxion, who was lodged near the Thracian Gates, was seized with an acute fever; continued pain of the right side; dry cough, without expectoration during the first days, thirst, insomnolency; urine well colored, copious, and thin. On the sixth, delirious; no relief from the warm applications. On the seventh, in a painful state, for the fever increased, while the pains did not abate, and the cough was troublesome, and attended with dyspnœa. On the eighth, I opened a vein at the elbow, and much blood, of a proper character, flowed; the pains were abated, but the dry coughs continued. On the eleventh, the fever diminished; slight sweats about the head; coughs, with more liquid sputa; he was relieved. On the twentieth, sweat, apyrexia; but after the crisis he was thirsty, and the expectorations were not good. On the twenty-seventh the fever relapsed; he coughed, and brought up much concocted sputa: sediment in the urine copious and white; he became free of thirst, and the respiration was good. On the thirty-fourth, sweated all over, apyrexia, general crisis.

_Explanation of the characters._ It is probable that the evacuation of the sputa brought about the recovery on the thirty-fourth day.[732]

CASE IX.--In Abdera, Heropythus, while still on foot, had pain in the head, and not long afterwards he took to bed; he lived near the High Street. Was seized with acute fever of the ardent type; vomitings at first of much bilious matter; thirst; great restlessness; urine thin, black, substances sometimes floating high in it, and sometimes not; passed the night in a painful state; paroxysms of the fever diversified, and for the most part irregular. About the fourteenth day, deafness; the fever increased; urine the same. On the twentieth and following days, much delirium. On the thirtieth, copious hemorrhage from the nose, and became more collected; deafness continued, but less; the fever diminished; on the following days, frequent hemorrhages, at short intervals. About the sixtieth, the hemorrhages ceased, but violent pain of the hip-joint, and increase of fever. Not long afterwards, pains of all the inferior parts; it then became a rule, that either the fever and deafness increased, or, if these abated and were lightened, the pains of the inferior parts were increased. About the eightieth day, all the complaints gave way, without leaving any behind; for the urine was of a good color, and had a copious sediment, while the delirium became less. About the hundredth day, disorder of the bowels, with copious and bilious evacuations, and these continued for a considerable time, and again assumed the dysenteric form with pain; but relief of all the other complaints. On the whole, the fevers went off, and the deafness ceased. On the hundred and twentieth day, had a complete crisis. Ardent fever.

_Explanation of the characters._ It is probable that the bilious discharge brought about the recovery on the hundred and twentieth day.[733]

CASE X.--In Abdera, Nicodemus was seized with fever from venery and drinking. At the commencement he was troubled with nausea and cardialgia; thirsty, tongue was parched; urine thin and dark. On the second day, the fever exacerbated; he was troubled with rigors and nausea; had no sleep; vomited yellow bile; urine the same; passed a quiet night, and slept. On the third, a general remission; amelioration; but about sunset felt again somewhat uncomfortable; passed an uneasy night. On the fourth, rigor, much fever, general pains; urine thin, with substances floating in it; again a quiet night. On the fifth, all the symptoms remained, but there was an amelioration. On the sixth, some general pains; substances floating in the urine; very incoherent. On the seventh, better. On the eighth, all the other symptoms abated. On the tenth, and following days, there were pains, but all less; in this case throughout, the paroxysms and pains were greater on the even days. On the twentieth, the urine white and thick, but when allowed to stand had no sediment; much sweat; seemed to be free from fever; but again in the evening he became hot, with the same pains, rigor, thirst, slightly incoherent. On the twenty-fourth, urine copious, white, with an abundant sediment; a copious and warm sweat all over; apyrexia; the fever came to its crisis.

_Explanation of the characters._ It is probable that the cure was owing to the bilious evacuations and the sweats.[734]

CASE XI.--In Thasus, a woman, of a melancholic turn of mind, from some accidental cause of sorrow, while still going about, became affected with loss of sleep, aversion to food, and had thirst and nausea. She lived near the Pylades, upon the Plain. On the first, at the commencement of night, frights, much talking; despondency, slight fever; in the morning, frequent spasms, and when they ceased, she was incoherent and talked obscurely; pains frequent, great, and continued. On the second, in the same state; had no sleep; fever more acute. On the third, the spasms left her; but coma, and disposition to sleep, and again awake, started up, and could not contain herself; much incoherence; acute fever; on that night a copious sweat all over; apyrexia, slept, quite collected; had a crisis. About the third day, the urine black, thin, substances floating in it generally round, did not fall to the bottom; about the crisis a copious menstruation.[735]

CASE XII.--In Larissa,[736] a young unmarried woman was seized with a fever of the acute and ardent type; insomnolency, thirst; tongue sooty and dry; urine of a good color, but thin. On the second, in an uneasy state, did not sleep. On the third, alvine discharges copious, watery, and greenish, and on the following days passed such with relief. On the fourth, passed a small quantity of thin urine, having substances floating towards its surface, which did not subside; was delirious towards night. On the sixth, a great hemorrhage from the nose; a chill, with a copious and hot sweat all over; apyrexia, had a crisis. In the fever, and when it had passed the crisis, the menses took place for the first time, for she was a young woman. Throughout she was oppressed with nausea, and rigors; redness of the face; pain of the eyes; heaviness of the head; she had no relapse, but the fever came to a crisis. The pains were on the even days.[737]

CASE XIII.--Apollonius, in Abdera, bore up (under the fever?) for some time, without betaking himself to bed. His viscera were enlarged, and for a considerable time there was a constant pain about the liver, and then he became affected with jaundice; he was flatulent, and of a whitish complexion. Having eaten beef, and drunk unseasonably, he became a little heated at first, and betook himself to bed, and having used large quantities of milk, that of goats and sheep, and both boiled and raw, with a bad diet otherwise, great mischief was occasioned by all these things; for the fever was exacerbated, and of the food taken scarcely any portion worth mentioning was passed from the bowels; the urine was thin and scanty; no sleep; troublesome meteorism; much thirst; disposition to coma; painful swelling of the right hypochondrium; extremities altogether coldish; slight incoherence, forgetfulness of everything he said; he was beside himself. About the fourteenth day after he betook himself to bed, had a rigor, became heated, and was seized with furious delirium; loud cries, much talking, again composed, and then coma came on; afterwards the bowels disordered, with copious, bilious, unmixed, and undigested stools; urine black, scanty, and thin; much restlessness; alvine evacuations of varied characters, either black, scanty, and verdigris-green, or fatty, undigested, and acrid; and at times the dejections resembled milk. About the twenty-fourth, enjoyed a calm; other matters in the same state; became somewhat collected; remembered nothing that had happened since he was confined to bed; immediately afterwards became delirious; every symptom rapidly getting worse. About the thirtieth, acute fever; stools copious and thin; was delirious; extremities cold; loss of speech. On the thirty-fourth he died. In this case, as far as I saw, the bowels were disordered; urine thin and black; disposition to coma; insomnolency; extremities cold; delirious throughout. Phrenitis.[738]

CASE XIV.--In Cyzicus,[739] a woman who had brought forth twin daughters, after a difficult labor, and in whom the lochial discharge was insufficient, at first was seized with an acute fever, attended with chills; heaviness of the head and neck, with pain; insomnolency from the commencement; she was silent, sullen, and disobedient; urine thin, and devoid of color; thirst, nausea for the most part; bowels irregularly disordered, and again constipated. On the sixth, towards night, talked much incoherently; had no sleep. About the eleventh day was seized with wild delirium, and again became collected; urine black, thin, and again deficient, and of an oily appearance; copious, thin, and disordered evacuations from the bowels. On the fourteenth, frequent convulsions; extremities cold; not in anywise collected; suppression of urine. On the sixteenth loss of speech. On the seventeenth, she died. Phrenitis.

_Explanation of the characters._ It is probable that death was caused, on the seventeenth day, by the affection of the brain consequent upon her accouchement.[740]

CASE XV.--In Thasus, the wife of Dealces, who was lodged upon the Plain, from sorrow was seized with an acute fever, attended with chills. From first to last she wrapped herself up in her bedclothes; still silent, she fumbled, picked, bored, and gathered hairs (from them); tears, and again laughter; no sleep; bowels irritable, but passed nothing; when directed, drank a little; urine thin and scanty; to the touch of the hand the fever was slight; coldness of the extremities. On the ninth, talked much incoherently, and again became composed and silent. On the fourteenth, breathing rare, large, at intervals; and again hurried respiration. On the sixteenth, looseness of the bowels from a stimulant clyster; afterwards she passed her drink, nor could retain anything, for she was completely insensible; skin parched and tense. On the twentieth, much talk, and again became composed; loss of speech; respiration hurried. On the twenty-first she died. Her respiration throughout was rare and large; she was totally insensible; always wrapped up in her bedclothes; either much talk, or complete silence throughout. Phrenitis.[741]

CASE XVI.--In Melibœa,[742] a young man having become heated by drinking and much venery, was confined to bed; he was affected with rigors and nausea; insomnolency and absence of thirst. On the first day much fæces passed from the bowels along with a copious flux; and on the following days he passed many watery. stools of a green color; urine thin, scanty, and deficient in color; respiration rare, large, at long intervals; softish distention of the hypochondrium, of an oblong form, on both sides; continued palpitation in the epigastric region throughout; passed urine of an oily appearance. On the tenth, he had calm delirium, for he was naturally of an orderly and quiet disposition; skin parched and tense; dejections either copious and thin, or bilious and fatty. On the fourteenth, all the symptoms were exacerbated; he became delirious, and talked much incoherently. On the twentieth, wild delirium, jactitation, passed no urine; small drinks were retained. On the twenty-fourth he died. Phrenitis.[743]

ON INJURIES OF THE HEAD.

THE ARGUMENT.

This treatise opens with a description of the bones of the head, which, although in most respects pretty accurate, is remarkable for containing an account of particular configurations of the cranium, and of certain varieties in the arrangement of the sutures, which it has puzzled modern authorities in anatomy to explain, otherwise than upon the supposition that the writer must have been but imperfectly acquainted with the subject. But as the work otherwise bears evidence that our author must have examined the bones of the head very carefully, and moreover, as in all his works he displays a wonderfully minute acquaintance with osteology, (to say nothing of the historical tradition, mentioned by Pausanias, that he was possessed of a skeleton, which at his death he bequeathed to the Temple of Apollo, at Delphi,) it seems incredible that he should have committed most glaring blunders in describing the prominent features of a part to which it is clear that he had paid very great attention. Moreover, the reputation of Hippocrates for accuracy stood so high, that an eminent authority does not hesitate to declare of him, that he was a man who knew not how to deceive or be deceived.[744] An easy way of getting rid of the difficulty would no doubt be, to adopt the conjecture advanced by Scaliger,[745] and in part approved of by Riolanus,[746] that the treatise had suffered much in early times, from the interpolations of ignorant transcribers; or to hold, with M. Malgaigne, that the whole work is to be condemned as spurious. But it would be a dangerous practice in ancient criticism, to reject as spurious a work which has such unexceptionable evidence in its favor, although it may contain matter which appears to us derogatory to the reputation of its author, and it will be admitted, by any competent judge who examines the arguments by Scaliger, that the proofs which he brings forward of great interpolations in this treatise, are generally of a very fanciful nature.

On a point so obscure, and which has puzzled so many eminent scholars, it is to be feared that I shall not be able to throw much additional light, but as, consistently with my general plan, I cannot well avoid stating some opinion on the question I shall endeavor to elucidate it in so far by giving in the first place a brief sketch of the information supplied by all the other ancient authorities who have touched upon this subject. I shall begin, then, with Aristotle, the contemporary of our author, who, in his work “On the History of Animals,” gives the following very inaccurate description of the sutures of the human skull: “The female cranium has one circular suture, but men generally three, which unite in one point. But a male skull has been seen not having a suture.”[747] Celsus describes the sutures in the following terms: “Ex ceteris, quo suturæ pauciores sunt, eo capitis valetudo commodior est. Neque enim certus eorum numerus est, sicut ne locus quidem. Ferè tamen duæ, super aures, tempora a superiori parte discernunt; tertia ad aures, occipitium a summo capite deducit; quarta, ab eodem vertice per medium caput ad frontem procedit; eaque modo sub imo capillo desinit, modo frontem ipsam secans inter supercilia finitur.” (viii., 1.) “Nam neque utique certa sedes, supra posui, suturarum est.” (viii., 4.) Pliny gives the following description of the head, which it is impossible not to recognize as having been borrowed from our author: “Vertices bini hominum tantum aliquibus. Capitis ossa plana, tenuia, sine medullis, serratis pectinatim structa compagibus.”[748] Of Ruffus Ephesius I may just mention, that his descriptions of the human body are in general remarkable for their correctness, which is not to be wondered at, as he would appear to have followed, in general, Erasistratus and the other authorities belonging to the great Alexandrian period in anatomy; and that he has described very accurately all the sutures of the human cranium, but says not a word of the different configurations of the head, as here given by our author.[749] We now come to Galen, who gives a very lengthy description of the various forms of the head, in nearly the same terms as our author, and after alluding to the uses of the sutures, the principal of which he holds to be to permit transpiration from the brain, he proceeds thus to describe the distribution of the sutures: “That there is one which runs straight along the middle of the head, (the sagittal?) and two transverse, (the coronal and lambdoid?) has been stated previously, and need not require many words in this place. For, the head being like an oblong sphere, one was justly made to extend straight through its middle from behind forwards, and two transverse sutures meet it, and the form of the three sutures is like the letter H. For the whole head being more elongated in this case than usual, and, as it were, compressed towards the ears, it was equitable that the number of the sutures should be unequal as to length and breadth, otherwise Nature would undeservedly have been named just, by Hippocrates, in thus giving equal gifts to the unequal. But it is not the case; for being most just, she formed the strongest suture which extends along the length of the head single, being thus proportionate to the width of the parts on both sides of it; namely, on the right and on the left; but she formed the transverse double in number, the one behind, as formerly said, called the lambdoid, and the other before, called the coronal, so that the bone of the head between these two sutures might be equal to those in the middle, on each side (the parietal bones?). The sutures of the head, in that configuration which is acuminated,[750] furnish a very great example of the justness of Nature. For there are three principal figures of the head: the one entirely opposed to the natural configuration already described, when the head loses both its protuberances, that behind and the other before, and is equal on all hands, and like a true sphere; and two others, the one form having no protuberance in front, and the other none in the occiput. The sutures of the spherical head are like the letter χ, two only in number, and intersecting one another; the one extending transverse from the one ear to the other, and the other extending straight through the middle of the vertex to the middle of the forehead. For, as when one part of the head is excessive, being longer than the other, it was just that the longer form should have more sutures, so, when both are alike, Nature bestowed an equal number on both. But in the head which wants the protuberance at the occiput, the straight and the coronal sutures remain, but the lambdoid is wanting (it being near to the protuberance that is wanting), so that the figure of the two resembles the letter T; as also when the protuberance of the head in front is wanting, the coronal at the same time is wanting, but there remains the one running lengthways and joining the lambdoid, and this form of construction is made to resemble the letter T. A fourth species of acuminated (sugar-loaf) head might be imagined, but which does not occur, with the head more prominent at the two ears than in front and behind.” He goes on to state the reasons why there is no such construction of the head as this, and concludes as follows: “Wherefore Hippocrates described four configurations, and the sutures of each, in the manner we have now said that they exist, being justly distributed to each configuration by Nature as to position and number.”[751] The description of the bones and sutures of the head, given in the Latin work “De Ossibus,” generally attributed to Galen, is to the same effect. The same number of distinct configurations of the head, and the same characters as regards the sutures, is also given by Avicenna, who professedly copies from Galen. (I., i., 5, 3.)

When examined together, these descriptions certainly must be admitted to have the appearance of being all derived from one original, namely, from our author, in this place; and taken literally, there can be no doubt that their meaning amounts to this: that the number of the sutures varies with the form of the head; that when there are protuberances both before and behind, the head in its upper part has two transverse sutures, namely, the coronal and the lambdoid, and one longitudinal, namely, the sagittal; that if the anterior protuberance be wanting, the coronal is wanting, and, if the posterior, the lambdoid. Now I need scarcely remark, that modern anatomists do not recognize such varieties in the configuration of the head nor in the numbers of the sutures, and that it is very rare indeed for either the coronal or the lambdoid suture to be found wanting. To all appearance, then, Galen was mistaken, and it only appears remarkable that, with all his knowledge of anatomy, theoretical and practical, and considering the opportunities which he must have possessed of examining human skeletons in Alexandria, he should have failed to observe and describe the bones of the cranium for himself.

Before stating my own conjectures on this question, it may be interesting to examine the solution of it attempted by authorities who lived about the period when the original study of human anatomy was revived in modern times. In the first place, then, I may mention that Ambrose Paré, who, I need scarcely say, was possessed of no mean talent for original observation, in treating of fractures of the head, adopts exactly the description given by Hippocrates; thus he describes “the bunches of the head” in nearly the same terms as our author, and adds, that such “bunches change the figure and site of the sutures,” and that “there be some skulls that want the foremost suture, and other some the hind, and sometimes none of the true sutures, but only the false, _or_ spurious, remain.”[752] Nay, it. cannot but appear remarkable, that Vesalius, the great antagonist of Galen and of the ancient authorities in general, in the present instance does not venture to call in question their opinion, but gives a description of the different forms of the head, and the varieties of the sutures, which scarcely at all differs from that given by Hippocrates.[753] It is singular, also, that certain other authorities, who were much more disposed to show a leaning to antiquity, such as Columbus, Eustachius, Fallopius, and Riolanus, should, in the present instance, have manifested a more independent spirit in challenging the authority of Hippocrates, though, at the same time, they show a disposition to find out some mode of bringing him clear off. Thus, for example, Riolanus is compelled to admit that there is no such variety in the forms and numbers of the sutures as Hippocrates describes; but he attempts to free him from error, by suggesting that the cases in which Hippocrates found them wanting must have been those of old men.[754] He also quotes some very extraordinary instances, in which something approaching the varieties described by our author had been remarked.[755] Fallopius does not hesitate, in his great anatomical work, to express the surprise he felt that all the authorities should have assented to the descriptions of the protuberances and sutures of the head given by Hippocrates; for that he, after having examined large heaps of crania in the Musea of Ferrara and Florence, had not found that they agreed with the descriptions given by Hippocrates; that he had seen crania without a suture, and yet not wanting in the protuberances; and in like manner, that he had seen the coronal suture obliterated, and yet the skull possessed its anterior prominence, and the lambdoid wanting, although the posterior protuberance was as usual. Altogether, then, in this work he modestly ventures to impugn the authority of Hippocrates.[756] In his work entitled “Expositio in Librum Galeni de Ossibus,” he adopts the same views, and there declares that he had never seen the sutures obliterated except from old age. But, in his work entitled “Expositio in Lib. Hippocrat. de Vulneribus Capitis,” he gives two suppositions, which he had devised in order to defend the authority of Hippocrates: first, that Hippocrates did not give these varieties of form as real, but as hypothetical; and second, that he merely described them as being the vulgar opinion, without pledging himself to the correctness of the description. These, as far as I am aware, are the only defences which have ever been set up for our author in this matter, and it must be admitted that they are not very satisfactory. I shall now present the reader with the conjectural explanation which has occurred to myself. I have imagined that what Hippocrates meant was to express himself to the following effect: when the forehead is remarkably prominent, and, at the same time, there is a great depression behind, the cranium, if looked upon from above, will show the coronal suture running across the fore part of the head, and the sagittal through its middle, while the lambdoid will be inconspicuous, from being below the level of the coronal. The two together, then, would form some resemblance to the letter T. When, on the other hand, the forehead is low, that is to say, wants its normal development, and the occiput is unusually prominent, the lambdoid suture joins the sagittal, so as to present some appearance of the same letter reversed. But in a square-built head, where the frontal and occipital regions have protuberances equally developed, the coronal and lambdoid sutures run nearly parallel to one another, and are joined in the middle by the sagittal, in which case the three sutures may be imagined to present some resemblance to the Greek letter Η. When there is no protuberance either before or behind, and the sagittal suture passes through the middle of the bone down to the nasal process, the coronal suture intersects it, so as to give them something like the shape of the Greek letter χ.[757] I offer this explanation, however, merely as a conjecture, and wish the reader to judge of it accordingly.

I now proceed to give an analysis of the contents of this treatise, and to attempt to form a correct estimate of their value.

Injuries of the cranial bones are divided by our author into five orders, as follows: 1, simple fractures, _or_ fissures of various kinds and sizes (§ 4); 2, contusion, without fracture or depression (§ 5); 3, fractures attended with depression (§ 6); 4, the _hedra_, that is to say, the indentation or cut in the outer table of the bone, and not necessarily attended either with fracture or contusion (§ 7); 5, the counter-fissure, or _fracture par contre-coup_ fracture and the severe contusion, require the operation of trepanning; whereas neither the _hedra_ (_or_ simple cut) nor the depressed fracture require it, and the counter-fissure does not admit it, owing to the obscurity of the symptoms with which it is attended (§ 9).

In the first place, the surgeon is to ascertain the nature and situation of the wound, by a careful investigation of all the circumstances of the case, but so as to avoid the use of the sound, if possible (§§ 9, 10).

Next are described the various kind of injury which the different sorts of weapons are most likely to inflict, and from the consideration of them the surgeon is to form an estimate of the probable nature of the accident (§ 11).

The characters of the _hedra_, or superficial injury of the cranium, and the difficulty of forming a correct estimate of it, when complicated by the presence of a suture, are strongly insisted upon (§ 12).

The principles upon which the treatment of injuries situated in different parts of the head should be treated, are carefully defined and stated. Great, and as now would be thought, superfluous directions are given, for ascertaining whether or not a fissure exists in the bone. The treatment, as far as applications go, is to be mild and desiccant. When a fracture cannot be made to disappear by scraping, the trepan is to be applied (§§ 13, 14).

The dangers which the bone incurs of becoming affected from the soft parts, are strongly insisted upon, and applications of a drying nature are prescribed (§ 15).

The condition of a piece of bone which is going to exfoliate is correctly and strikingly described (§ 16).

The treatment of depression is laid down, and the danger of applying the trepan in this case is strongly insisted upon (§ 17).

The peculiarities in the case of children are pointed out. Under certain circumstances, when there is contusion combined with the fracture, he admits of perforating the skull with a small trepan (§ 18).

When, after a severe injury, symptoms of irritation and inflammation appear to be coming on, the surgeon is to lose no time in proceeding to the operation. Some correct observations are made on the consequences of injuries of the head on other parts of the body (§ 19).

The treatment of erysipelatous inflammation is distinctly laid down (§20).

The operation of trepanning the skull is circumstantially described, and an interesting description is given of a mode of doing the operation peculiar to our author[758] (§ 21).

This, then, as far as I know, is the first exposition ever made of a highly important subject in surgery, upon which professional men are still greatly divided in opinion. I cannot, then, resist the temptation to offer some remarks on the views of practice here recommended, and to institute a comparison between them and certain methods of treatment which have been in vogue of late years.

I can scarcely doubt but it will be generally admitted that the exposition of the subject here given is remarkably lucid, that our author’s divisions of it are strongly marked, and his rules of practice, whether correct or not, distinctly laid down. At all events, it will not be affirmed that there is any confusion in his ideas, or that his principles of treatment are not properly defined. After all that has been written on injuries of the head, it would be difficult to point to any better arrangement of them than that of our author, into five orders: 1st, simple fractures without depression; 2d, contusions without fracture or depression; 3d, depression with fracture; 4th, simple incisions without fracture; 5th, fractures _par contre-coup_.

As regards the operation of trepanning the skull, then, our author’s rule of practice is sufficiently well defined: we are to operate in the first two of these cases, that is to say, in simple fractures and contusions, but not in the last three, that is to say, in fracture with depression, in simple incisions in the skull, and in the counter-fissure. To begin, then, with the examination of those cases in which the operation is proscribed: it is not to be had recourse to in the counter-fissure, because, from the nature of it, there is generally no rule by which its existence can be positively ascertained, and therefore the case is to be given up as hopeless.