Chapter XXVII: Section III: Constitution 2.699 (6)

[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.