Chapter XXVIII: Section III: Constitution 2.699 (7)

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

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

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

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

[694] Galen has given us a lengthy Commentary on this case, but a great part of it relates to the characters and to other matters not of any very great importance in this place. As he remarks, it is a striking example of an acute fever induced by immoderate fatigue. It appears from his Commentary, moreover, that some of the older authorities had added “drinking” to the excesses which induced his affection; that is to say, they proposed to read πότων instead of πόνων. The symptoms, upon reference to the Prognostics, are all such as indicated a fatal result, namely, the blackish and thin urine, “the fumbling with the bedclothes,” the coldness and lividity of the extremities, the meteorism, and so forth.

[695] In Galen’s Commentary on this case there is not much of any great interest to the professional reader of the present day. He animadverts again on the omission of all mention of the treatment, although, as he states, venesection and the other usual means had no doubt been tried; indeed the report implies as much. Hippocrates, he repeats, never thinks of mentioning the usual routine of practice, as he takes it for granted that the reader will understand that it was not neglected. It is only on special occasions, then, that he thinks of making any particular reference to the treatment. Galen remarks, that ileus being an inflammation of the upper intestines, is a particularly dangerous affection.

[696] As remarked by Galen in his Commentary, this was no doubt a case of ardent fever _or_ caucus, complicated with an incidental miscarriage. There is no reason for looking upon it as being a case of puerperal fever. Galen thinks that the last word (caucus) is an addition made by the copyists, having been transferred from the Glossarium to the text in the course of transcription. Galen, as usual, directs attention to the characters of the urine, which in this case are particularly unfavorable, being defective both in quantity and quality.

[697] Galen’s remarks on the circumstances of this case are sufficiently to the purpose, but there is nothing very striking in them. He states that the abortion may have been occasioned either by external causes--such as the application of pessaries for this purpose, and the like--or internal, such as hemorrhage from the neck of the uterus. and so forth. As in the former case, he pronounces the last word (phrenitis) to be an addition to the text, as Hippocrates never enters upon the diagnosis of diseases, as is done in the work On Diseases. I suppose he means that our author’s real works are all founded on Prognosis; whereas the other, being derived from the Cnidian school, is founded on Diagnosis. See our observations on this subject in the Preliminary Discourse, and the Argument to the Prognostics.

[698] Galen remarks, that with such a combination of fatal symptoms, namely, coldness of the extremities, fetid vomiting, etc., it is wonderful that this patient stood out until the fourteenth day. He thinks, however, that this is to be explained from her age and constitution. He justly remarks that the occurrence of the epistaxis could not be supposed sufficient to carry of such a combination of unfavorable symptoms. He once more protests against the last word of the report (causus) being admitted as genuine. He confesses himself unable to determine whether “The Liars’ Market” was in Athens or elsewhere.

[699] This is entitled the pestilential constitution by Galen. By constitution, he explains, is meant not only the preternatural state of the atmosphere, but also of everything else which influences the state of the general health.

[700] Galen remarks, that in the First Book of the Epidemics three constitutions of the year are described and also that others are described in the Second Book; but that these are not carefully drawn out for publication like those of the First and Third. He further remarks on this head, that the constitution of the season might prepare us for the putrid diseases, which are described below, as heat is the active, and humidity the material, cause of all putrefaction.

[701] Galen remarks that erysipelas is occasioned by a bilious defluxion, but that it is not always of a malignant and putrid nature; on the contrary, when the defluxion is mild, and the bile which produces it is natural, it is not attended with any considerable injury to the body, if properly managed; but that the humor which produced the erysipelas about to be described was not such, but of a malignant, corrosive, and septic nature, being engendered by the humid and calm state of the weather in such persons as were of a choleric constitution.

[702] According to Galen, aphthæ in general are superficial ulcerations in the mouth, produced by the acrimony of the nurse’s milk, and which are easily removed by an astringent application. But in the present instance the aphthæ were of a malignant nature.

[703] The carbuncle (anthrax), Galen says, is always dangerous, and the product of bad humors. See PAULUS ÆGINETA, Vol. II., pp. 78, 79. Galen, in his excellent work On the Difference of Fevers, writes thus: “In constitutions of the year, similar to those which Hippocrates describes as taking place in Cranon (See Ep. ii.). I have known cases of anthrax prevailing epidemically in no few numbers, the formation and other symptoms of which were exactly as described by him.” (Tom. vii., p. 293; ed. Kühn.)

[704] Galen explains under this head that the term _epidemic_ is not applied to any one disease, but that when many cases of any disease occur at the same time in a place, the disease is called an epidemic; and that when it is remarkably fatal it is called a plague.

[705] The history of the epidemical erysipelas here described cannot fail to prove interesting to the modern reader. I need scarcely remark that epidemics of a similar nature are occasionally met with in Great Britain at the present day. I myself have encountered two such epidemics in the locality where I am now writing, the one in 1823, and the other in 1846. As described by Hippocrates, the disease sometimes supervened upon a slight injury, and generally terminated in gangrene. On epidemical erysipelas, see De Haen (Ratio Medendi), Bartholinus (Hist. Anatom. Rat. Hist., 56), Wells (Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge), Cooper’s Surgical Dictionary; and Cyclopædia of Practical Medicine, under _Erysipelas_.

[706] Galen amply confirms this statement, that when erysipelas fixes on a particular part of the body it is more formidable in appearance than in reality, and that the disease is attended with most danger when it leaves an external member, and is determined inwardly.

[707] The classical reader will here call to his recollection a striking passage in the celebrated description of the Plague of Athens, as given by Thucydides: “For the mischief, being at first seated in the head, spread over the whole body, and if one survived the most formidable symptoms, an attack on the extremities manifested itself; for it was determined to the genital organs and to the hands and feet, and many escaped with losing them, and some with the loss of their eyes.” (ii., 49.) The passage is thus rendered by Lucretius:

“tamen in nervos huic morbus et artus
Ibat et in partes genitales corporis ipsas;
Et graviter partim metuentes limina lethi
Vivebant ferro privati parte virili:
Et manibus sine nonnulli pedibusque manebant
In vita tamen et perdebant lumina partim.”
(vi., 1203.)

Lucretius, it will be remarked, understands the historian to mean that the mortified parts were amputated; and this opinion, although rejected by most of our non-professional editors of Thucydides, is confirmed by what Galen says in his Commentary on this passage, namely, that in erysipelas of the genital organs “we (meaning the physicians of his own time) are often obliged to excise the putrid parts, and apply the cautery to them.” I would here further point out a singular mistake into which Dr. Bloomfield falls in his note on this passage of Thucydides; he says that the words of the original (ἄκρας χεῑρας καὶ πόδας) “can only signify the ends of or lower joints of the fingers and toes.” No one who is acquainted with the language of our author will require to be told that this is an entire misconception. In the works of Hippocrates χεῖρες is often put for the arms, and χεῖρες ἄκραι are always applied to the hands.

[708] Upon reference to the Glossary of Erotian, the Commentary of Galen, and the Annotations of Foës and Littré, the reader will see that there is great difficulty in determining the text in this place. After examining all that has been written on the subject, one cannot come to any satisfactory conclusion as to the true reading. I have adopted the meaning which seems to suit best with the passage. The professional reader will scarcely require to be reminded that in cases of phthisis there is often a notable impairment of the voice.

[709] Galen makes the important remark on this word, that, in febrile diseases, epistaxis is always a bad symptom.

[710] This obliviousness is a feature of the plague, as described by Thucydides: “And some, when they first left their beds, were seized with an utter forgetfulness of all things, and knew not themselves nor their relatives.” (l. c.)

[711] Our author alludes to the affection called coma vigil by the later authorities. In this affection, as Galen remarks, the patient lies with his eyes shut, but can get no sound sleep. This, of course, is so much more the case provided pain be present, as it necessarily will prevent the occurrence of sleep. See Galen’s tract On Coma.

[712] The low muttering delirium of typhoid fevers is here evidently alluded to. Galen, in his Commentary, guards the reader against supposing that the fever passed into lethargus.

[713] This description apparently can refer to nothing but pestilential buboes.

[714] It is impossible not to recognize this as a description of _purulent ophthalmia_. Celsus thus describes the ficus: “Est etiam ulcus quod a fici similitudine σύκωσις Græcis nominatur, ubi caro excrescit; et id quidem generale est. Sub eo vero duæ species aunt. Alterum ulcus durum et rotundum est: alterum humidum et inæquale. Ex duro exiguum quoddam et glutinosum exit: ex humido plus, et mali odoris.” See the Lexicons of Hesychius and Phavorinus, and also PAULUS ÆGINETA, Book III., 3. It will be remarked that Hippocrates also makes mention of fungous excrescences about the pudenda. Were they syphilitic? In other words, did they derive their origin from elephantiasis? See the Annotations on PAULUS ÆGINETA, Book IV., 1, Sydenham Society’s edition.

[715] The meaning of this term is not precisely determined. Galen’s account of it may apply both to exanthemata, and pustulæ. The description of the eruption in the Plague of Athens is likewise vague and indeterminate. (Thucyd, ii., 49.)

[716] These intestinal complaints are all mentioned in the description of the Plague at Athens. (l. c.) Upon reference to the Commentary of Galen, the reader will remark that there is a question here respecting the reading.

[717] Galen, in his Commentary, makes the remark that he observed the same symptom in the plague which raged in his time.

[718] It will readily be understood that a colliquative diabetes would prove a very unfavorable complication of these complaints.

[719] By nocturnal fevers, according to Galen, was meant quotidians, which had their paroxysms during the night. Foës inclines to think that diurnal should also be inserted in this place. These nocturnal fevers are thus described by D. Monro: “The sick were restless and uneasy _at night_; but commonly felt themselves cooler and lighter in the daytime: and although they had no cold fit, as the fever came on _at nights_, and many of them no breathing sweat, as they became cooler and freer from the fever in the morning; yet the fits were so remarkable, that many of the patients used to say that they had a regular fit of an ague _every night_, and some few that they had the fit every second _night_.” (Army Diseases, etc., p. 158.)

[720] The account of the origin and progress of consumption here given is, upon the whole, wonderfully correct. Common experience seems to have decided that spring and autumn are the most fatal seasons to phthisical patients. Avicenna makes the remark, which is very important, and deserves to be kept in mind, that by phthisis, in this place, Hippocrates most probably meant hectic fever, connected with disease of the internal viscera, which had been in an inflamed state during the acute attack of the fever. (iii., 1, 3, 67.)

[721] I shall not enter into a discussion of the different readings of this interesting passage. I may mention that our great pathological authority on phthisis, Dr. Louis, agrees with Hippocrates in deciding that the lymphatic temperament constitutes a more or less marked predisposition to the development of phthisis. (p. 483.) Galen describes the phlegmatic temperament as being attended with a soft and slightly tumid skin. He attributes the disease in their case to a cacochymy, that is to say, to cachexia. I need scarcely remark that this opinion is strongly advocated by one of the highest authorities of the day, I mean Sir James Clark. See his treatise on Tubercular Phthisis. Galen gives a discussion on the color of the eyes, about which there is some difficulty, as the ancient terms which relate to colors are not very well defined. The term here used (χαροπὸς) may signify either blue or gray. Galen considers this color of the eyes as a symptom of a cold and humid temperament.

[722] There is an ambiguity in the part of the sentence which relates to women, as Galen states in his Commentary. Galen does not hesitate to declare that women are more subject to phthisis than men, an opinion upon which modern authorities are not at all agreed. See the recent publications of Louis and Clark on Phthisis.

[723] The last paragraph, and the latter clause of the preceding one, were at first attached to the end of the subsequent cases, and were transferred to their present position by Dioscorides the commentator a short time before Galen. They evidently embody a most distinct and admirable enumeration of the general facts with which the practical physician ought to make himself acquainted.

[724] We learn from the Commentary of Galen that some of the older critics supposed that the sixteen cases about to be related had been selected by Hippocrates in illustration of his doctrines, as laid down in the preceding description of what is generally entitled the Pestilential Season. Galen, however, does not incline to this opinion.

[725] This is an example of one of those protracted fevers of an intermittent type, which, as I have been informed by an intelligent physician who practiced for several years in the Ionian Islands, are so common in the climate of Greece. There is not much of any particular value in Galen’s Commentary on this case. He informs us that one of the older commentators absurdly maintained the opinion that the country of this patient was given because, according to Asclepiades, the inhabitants of Paros were most especially benefited by bleeding. But, as Galen says, this remark is particularly out of place here, since no mention of venesection occurs in the report. Galen, and after him Foës, have given very lengthy and elaborate disquisitions on the nature of oily urine. The result is, that it is an unfavorable, but not necessarily a fatal, character. It is minutely described by the later authorities on urology, namely, Theophilus and Actuarius. See also the Commentary on PAULUS ÆGINETA, Book II., 14, Sydenham Society’s edition.

[726] This appears clearly to be a case of fever, complicated with, but not produced by parturition. Galen, however, seems to ascribe the fever and its fatal results to the retention of the lochial discharge. The characters of the urine, he properly remarks, are unfavorable, being copious, thin, and black. He also calls attention to the want of proper concoction in the sputa, to which he attributes the fatal relapse.

[727] Galen’s Commentary on this case is written in his usual light and diffuse style, but contains very little which is calculated to throw light on the text, or on the nature of the disease which is here described. If any one find difficulty in comprehending the characters of the respiration, as given in this narrative, he can turn to Galen’s work, On Difficulty of Breathing, where they are explained very fully. I may just mention that by shortness of breath (βραχύπνοος) was understood, by Hippocrates and Galen, frequency of the act of respiration.

[728] This case, as Galen remarks, is an instance of the most acute form of phrenitis. He states that he himself had met with cases of phrenitis in which the patients had died on the fourth and fifth day, but that he had never seen a case which proved so suddenly fatal as the present one. He further makes some very interesting reflections on the suddenness of the attack in such cases, which is the more wonderful, as the exciting cause of them must be gradually collecting in the system, and acquiring strength and intensity, and it is singular that it should then be developed all at once, and cut off the patient in a very short time, as if he had swallowed poison, or had been stung by a venomous animal. He compares the latency of the febrile humor in the system to that of the mad dog, which will remain for a long time in the body of a person who had been bitten, and then all at once will manifest its effects, by inducing the rage. For the ancient views on the subject of Hydrophobia, see PAULUS ÆGINETA, Book V., 4, Sydenham Society’s edition.

[729] Galen, in his Commentary on this case, enters into a train of reflections how a physician ought to proceed when called in to a patient so circumstanced. He ought, in the first place, as the Commentator properly remarks, to make careful inquiry, in order to find out whether the pain in the limb be occasioned by any external cause, as persons often meet with local injuries by sudden twisting and movements of their limbs, or even by laying a limb uncomfortably in bed, without being aware of it. When no such cause of the complaint can be discovered, Galen says the physician should try to ascertain whether or not it be connected with the regimen or temperament of the patient. If it shall turn out that the body is in a plethoric state, general bleeding must be had recourse to, before any local applications are made to the part. It is then to be fomented, and liquid and heating medicines applied to it. Whether or not this was the mode of treatment which Hippocrates adopted in this case, Galen cannot take upon himself to affirm, as no mention is made in the report of venesection, nor of the particular remedies which were used. I am of opinion that this is one of the most interesting cases in the whole Collection, for I believe it to be a faithful report of a disease which on three several occasions I have met with during an active professional practice of thirty years, and which I have not seen described elsewhere. In all my cases, indeed, the patients were from twelve to sixteen years old, but in other respects the symptoms were the same as here described by Hippocrates. In every one of the cases the patient was seized with pain and swelling of the thigh, attended with high fever, great jactitation, and partial delirium. They all proved fatal in the course of three or four days. Whether the disease be connected with diffuse inflammation of the areolar substance, or with inflammation of the veins, or whether it be a general fever complicated with a local affection of the limb, or what may be the exact nature of the affection, I have not been able to determine. From what is stated above, it will be clearly seen how justly Hippocrates deserves the compliment paid to him by Galen, of having been, of all medical authorities, the most careful in observing the phenomena of disease. (Opera Galeni, tom. vii., p. 829, ed. Kühn.)

[730] Galen remarks, that this is one of those cases which appear formidable to the inexperienced, but which those who are practiced in the art judge of as being likely to come to a speedy crisis. He adverts to the slight swelling of the spleen and the characters of the urine, which soon showed a proper sediment, as being particularly favorable symptoms. The more that we study Hippocratic medicine, we shall be the more convinced that too little attention has been paid of late years to the physical characters of the urine in all febrile complaints.

[731] Galen’s Commentary on this case is unusually brief. He holds it to be a case connected with general plethora, as indicated by the good color of the urine. He once more makes the remark that a favorable issue of the case might have been anticipated, from the characters of the urine.

[732] Galen remarks in his Commentary, that of all the cases related in the First and Third Books of the Epidemics, this is the only one in which Hippocrates says that the patient was bled, not, he adds, that this was the only case in which venesection was adopted, but because, although the general rule was not to bleed after the fourth day, the patient, in the present instance, was bled on the eighth. Many others, he says, were no doubt bled on the second, third, and fourth days, but of these bleedings, and the other means used, Hippocrates in general takes no notice, except that he sometimes states, in order to render the malignity of the disease more apparent, that it was nowise benefited by the remedies applied. In other cases he adds, he would appear, from the words he uses (such as “as far as I am aware”), not to have attended the patient at the commencement. Galen further directs attention to the characters of the expectoration, the concoction of which he looks upon as having proved the means of carrying off this fever. Galen has reviewed the symptoms of this case very fully, and in a most interesting manner, in the Second Book of his work, On Difficulty of Breathing, see ed. Kühn, tom. vii., p. 854, etc. That it was a case of fever complicated with pleurisy seems clear, as Galen remarks. Galen further treats of the characters of the sputa in this case, in the First Book of his work, On Crises. Upon reference to the edition of Littré, it will be seen that unfortunately there is considerable variation in the readings of this passage.

[733] On this case Galen makes the remark that this patient must have had a strong constitution, otherwise it could not have withstood such an affection. He adds that, moreover, his pulse must have possessed strength, but that, as formerly said by him, this department of prognostics is altogether omitted by Hippocrates, in his reports of febrile cases. He further remarks that the respiration and appetite were not to complain of, and the only bad symptom was the thinness and blackness of the urine, which therefore required a long time for nature to overcome, by occasioning hemorrhage, pain of the hip-joint, and determination downwards. He adds, that great diseases require decided crises, and that even with those now mentioned, the disease was not entirely removed in this case, until concoction in the urine took place.

[734] Galen passes over this case without any remark worth mentioning. I cannot but think that the abundant sediment in the urine, which preceded the favorable crisis, is a fact in the case well deserving to be noticed. Galen, however, in the present instance, omits all notice of it, and ascribes the recovery to the profuse sweat.

[735] The only thing of importance in Galen’s Commentary on this case is the remark that this woman’s melancholy was most probably connected with suppression of the menses, and that to this cause the dark color of the urine in the present instance is most probably to be ascribed. To the critical evacuations by the sweat and menstruation he attributes the recovery.

[736] There were several ancient cities of this name, but there can be no doubt that the one here referred to is the celebrated city of Thessaly. See Strabo, Geograph. ix.

[737] Galen considers it a remarkable feature in this case that although the crisis occurred on the sixth day, there was no relapse. The recovery he ascribes to the copious menstruation which then took place for the first time. He also calls attention to the characters of the urine, which, he says, are those which usually accompany delirium, although this is omitted in the Prognostics.

[738] Galen, in his Commentary, merely remarks that Hippocrates, at the conclusion of the report, briefly enumerates the more prominent symptoms from which a fatal result might have been confidently prognosticated. By enlarged viscera, in this case, we are informed by Galen in another place, that our author meant inflammation and swelling (Comment. in Rat. Vict. in Acut. c. iii.) There can be no doubt that by viscera Hippocrates meant the liver and spleen (see the work just referred to). Galen briefly remarks on this case towards the end of the Second Book of his work, On Difficulty of Breathing.

[739] Cyzicus was a flourishing city on the Propontis. See Strabo, Geogr. xii.; and Pliny, H. N. v. 32.

[740] Galen, in his Commentary, accounts for this fatal disease upon the supposition that the uterus was inflamed, and affected the brain by sympathy, hence maniacal delirium and convulsions were the consequence. Galen, both in his Commentary, and in his work On Crises, refers to this case, in confirmation of his doctrine of critical days.

[741] I will venture to affirm, without much fear of contradiction, that in all the works on medicine, both ancient and modern, there is not to be found so vivid a delineation of the symptoms of fever, complicated with effusion on the brain. Those who have added new features to the picture, have thereby detracted from the general effect. Galen, in his Commentary, insists more especially on the character of the respiration, but there does not appear to me to be any particular obscurity about it. He also touches on this case towards the end of the Second Book, On Difficulty of Breathing. After reading all his prolix disquisition on the subject, one does not feel much better instructed on the subject. Galen, at times, nay, very frequently, seems to forget a favorite saying of his own, namely. that he who would wish to lay in a copious store of knowledge during life, should trouble himself little about words, and attend principally to things.

[742] There were two Thessalian cities of this name, the one in Estiæotis, and the other in Magnesia. This would appear to be the latter. See Pliny, H. N. iv., 9; and Livy, xliv., 13.

[743] Galen’s Commentary contains few observations of much interest, and which are not sufficiently obvious. Excesses in drinking and debauchery, he remarks, hurt the nerves and the origin of them, that is to say, the brain. Thus he accounts for the delirium with which this case of fever was attended. All the other prominent symptoms, such as the palpitation in the epigastric region, the swelling of the hypochondrium, and the like, were noticed previously. Galen also reviews the symptoms of this case in his work On Difficulty of Breathing, II.

[744] “Hippocrates qui tam fallere quam falli nescit.” (Macrobius in Somn. Scipionis, i., 6.)

[745] Hippocratis Coi de Cap. Vuln., etc., a Francisco Vertuniano. Ejusdem textus Græcus a J. Scalig. Castigatus, etc.

[746] Comment. de Ossibus.

[747] Hist. Animal., i., 7. In reference to this description, it is stated by Vesalius, who in the course of his life had examined a great number of crania, that it is very rare indeed to meet with a skull in which the sutures are wanting. He accounts for the statement made by Herodotus (Hist. ix.) and Aristotle (1. c.), respecting skulls without sutures, upon the supposition that the observations of these authors must have been made upon those of old persons, in whom the sutures are often very indistinct. (Chirurg. Magn., i., 17.)

[748] H. N., xi., 48; ed. Hardouin.

[749] De Partib. Animal., p. 34; ed. Londin.

[750] Φοεός. The exact meaning of this term is well defined by Eustathius in his Commentary on Homer (ad Iliad., ii., 219), ό ἐις ὀξὺ λήγονσαν ἔχων τὴν κεφαλήν. It is excellently expressed by Damm as follows: “One whose head diminishes towards the top like a sugar-loaf.” (Lexicon Homericum in voce Φοεός.)

[751] De Usu Partium, ix., 17.

[752] Surgery, v., 4.

[753] Chirurg. Mag., i., 17.

[754] It is well known that in very advanced age the sutures get nearly effaced. See the Cyclopædia of Anatomy, vol. i., p. 745.

[755] Comment. de Ossibus.

[756] Obs. Anatom.

[757] This letter was very varied in form. See Galen and Foës.

[758] The operation consisted in sawing the bone nearly through, and leaving it in this state until it exfoliated, or until the bone could be separated from the dura mater without violence. See below.

[759] It is no doubt true that a simple cut in the outer table of the bone, when accompanied with concussion or contusion, may produce fatal effects within, and this, in fact, is stated by our author; but, of itself, as he says, the simple incision or _hedra_ cannot be of a dangerous nature, nor require any recourse to instruments. The cases related by M. Littré in the Argument were all evidently complicated with contusion, and are thus referable to the second class of these injuries. It is most worthy of remark, that in the very interesting account of “slicing cuts,” given in Mr. Guthrie’s excellent work, On Injuries of the Head, the result, without any operation, by the most simple system of treatment, was in general very favorable. (pp. 95, 96.) On these cuts and superficial injuries of the skull, see further Hennen (pp. 283, 284), Thomson (pp. 51, 52), and Chelius (vol. i., p. 388).

[760] London and Edinburgh Medical Journal, 1844.

[761] Although, as we have stated, Dr. Laurie’s rule of practice now be to use the trephine on the preventive principle, it is probable that most of his cases occurred at a period when the practice of Mr. Abernethy was universally followed. His statistics therefore are no test of the results of the operation, when performed on the preventive principle.

[762] See Lawrence’s Clinical Lecture in the Medical Gazette, vol. xxi., p. 345; and Guthrie’s work, On Injuries of the Head, p. 113.

[763] See De Articulis, § 50; and Mochlicus, § 36.

[764] On hypertrophy and swelling of the brain after injuries, see the very interesting observations made by Mr. Guthrie, in his work on Injuries of the Head, p. 125.

[765] It is proper to mention in this place that Quesnay, with great good sense, discusses the question, whether or nor the separation of the pericrunium in this case be a sure indication of matter being collected within the cranium. He decides in the negative. (p. 17, Syd. Soc. edition of Selected Mem. of the Acad. of Surgery.)

[766] I ought to mention, however, in this place, that in simple undepressed fractures, Pott allows of the operation as a preventive; that, at least, is one of his objects in having recourse to the operation. (p. 130.)

[767] Ambrose Paré expresses very strongly the difficulty of forming a correct prognosis in injuries of the head: “Ex quo intelligere licet, multos ab exiguis vulneribus mortem oppetere, alios ex ingentibus et penitus magnis desperatisque convalescere.” (Opera, ix., 9.)

[768] Injuries of the Head, p. 148.

[769] Aphor. v., 68.

[770] See the Argument to the treatise, On Regimen in Acute Diseases.

[771] Opera, ix., 10.

[772] Sir Astley Cooper mentions an instance in which 208 ounces of blood were abstracted from a patient!! In Quesnay’s Memoir there is nothing more common than to find it reported that he had bled a patient three or four times in the course of a day. In one case 160 ounces were taken in nine days; “but,” it is gravely added, “two years elapsed before she was quite well again.”

[773] IV., 5, 3, 1.

[774] The principles upon which depletion by bleeding and purging should be regulated are fully stated and discussed by Galen, in the Fourth Book of his great work on Therapeutics. The rule is briefly given by Hippocrates in his Second Aphorism: “respect being paid to place, season, age, and the disease in which it is proper or not.”

[775] See Aphor. v., 18, 22; and § 12 of this treatise. The professional authorities of the present day are not agreed as to the expediency of using poultices or cold lotions in injuries of the scalp. Guthrie and Hennen recommend the latter; but South, in the edition of Chelius, prefers the former.

[776] This is related of Philagrius in a very interesting scholium on the Aphorism just quoted. See Scholia in Hippocrat. et Galen., tom. ii., p. 457; ed. Dietz.

[777] Perhaps the meaning here is, that when the forehead is much elevated, and the occiput much depressed, if one looks down upon the skull from above, the sagittal and coronal sutures will present the appearance of the letter Τ.

[778] The meaning, I suppose, may be, that when the forehead is very low, and when the occiput is protuberant, if one looks down upon the skull from above, the sagittal and lambdoidal sutures will present the appearance of the letter Τ reversed.

[779] The meaning would appear to be, that in a square-built head, that is to say, when it is prominent both before and behind, the coronal and sagittal sutures run nearly parallel to one another, and the sagittal connects them together in the middle. In this case they would present the appearance of the letter Η reversed.

[780] Perhaps this alludes to the form of the head in which the sagittal suture passes through the middle of the os frontis down to the nose, in which case we may imagine that the coronal suture intersects the lambdoidal in such a manner as to have some resemblance to the letter χ. It is to be borne in mind, that the character of this letter was very variable in ancient writing. Ruffus Ephesius describes the sagittal suture as sometimes passing down the middle of the frontal bone.

[781] This passage was considered by Scaliger as a gloss, but as interpreted by M. Littré, whom I have followed, the meaning is quite suitable. See his note, h. 1.

[782] It is difficult to say what can be meant by caruncles in this place, but still I agree with M. Littré that Scaliger was not warranted in proposing to eject the passage from the text as an interpolation. Unless the _glandulæ Pacchioni_ are meant (and the description must be admitted not to be quite applicable to them), I cannot pretend to explain or account for the description.

[783] I need scarcely remark, that if by this is strictly meant that wounds in the posterior part of the head are less dangerous than those in the anterior, the statement is at variance with the experience of certain modern authorities. See, in particular, Pott and Liston, p. 46. At the same time, it is, no doubt, anatomically correct, that the occipital bone can bear more violence, without being seriously fractured, than the frontal or parietal bones, and it is worthy of remark, that the views and experience of Mr. Guthrie are very consonant with those of Hippocrates. He says: “The result of my experience on this point is, that brain is more rarely lost from the fore part of the head with impunity, than from the middle part; and that a fracture of the skull, with even a lodgment of a foreign body, and a portion of the bone in the brain, may be sometimes borne without any great inconvenience in the back part.... I have never seen a person live with a foreign body lodged in the anterior lobe of the brain, although I have seen several recover with the loss of a portion of the brain at this part. My experience, then, leads me to believe, that an injury of apparently equal extent is more dangerous on the forehead than on the side or middle of the head, and much less so on the back part than on the side. A fracture of the vertex is of infinitely less importance than one of the base of the cranium, which, although not necessarily fatal, is always attended with the utmost danger.” (On Injuries of the Head, p. 3.) I feel difficulty in reconciling these discordant results of modern experience. Perhaps the fact of the matter is, that injuries on the upper part of the occipital region are the least dangerous of any, whereas those in the lower part of it, are particularly fatal.

[784] Vidus Vidius thus explains the _hedra_ or _sedes_: “Inciditur os ita ut teli vestigium remaneat, quod genus fracturæ appellatur a Hippocrate ἒδρα, id est sedes, quum (ut ipse inquit) appareat in osse qua telum insederit; fit autem ab acuto telo, quod et ipse in sequentibus, et Galenus, in Commentario, in librum memoriæ prodidit, quum sub telo acuto incidi os dixit. Requirit autem sedes ut incisum os nullo modo ad cerebri membranam inclinatur.” (Chirurg. Græc., p. 71.) Andreas à Cruce defines it thus: “Potissimum vero sedes vocatur ubi osse in suo statu remanente qua parte telum insederit apparet.” (De Vulneribus, 1. 2.) By _hedra_ would appear to have been understood a dint, or impression, left in a bone by a blow which has not produced fracture or depression. It was also applied to a cut or slash affecting only the outer plate of the skull. Hippocrates, it will be remarked, pronounces this sort of injury not to be dangerous of itself, but M. Littré relates a case taken from the “Journal de Médecine,” in which a sabre-cut, which only penetrated through the external plate of the cranium, and did not touch the internal, proved fatal. (Op. Hippocrat. iii., p. 170.) Our author, in the latter part of this paragraph, mentions cursorily injury of the skull at a suture, and more circumstantially in the twelfth paragraph. This accident is very correctly described by the later writers, under the name of _diastasis_. See Heliodorus (ap. Chirurg. Veteres, p. 100), and Archigenes (ibid., p. 117). Pott declares that he did not remember having ever seen a single instance of recovery when there was separation of the bones at a suture. Morgagni, in like manner, represents the case as being of a particularly serious character. (De Caus. et Sed. Morb.) I once saw a strongly marked case in which there was a considerable separation of the bones at the upper part of the temporal suture, along with an extensive wound, unguardedly inflicted by the scalpel of a juvenile surgeon, in order to explore the nature of the accident. As might have been expected, under these circumstances, the case had a fatal issue. Mr. Guthrie writes thus of _diastasis_: “It is well known, that when a violent shock has been received on the head, particularly by a fall on the vertex, the sutures are often separated to a considerable extent; _these cases usually terminate fatally_.” (p. 135.)

[785] The meaning here is somewhat obscure, but as Arantius states in his commentary on this tract, our author probably means that a fissure is necessarily complicated with a contusion, or, in other words, that there can be no fissure without contusion.

[786] Arantius and Porralius, in their conjoined commentary on this treatise, mention that in contusion sometimes only the outer plate of the skull is contused, but the inner is depressed upon the dura mater. This is a case of which we have examples in modern surgery; but it does not appear clearly to be alluded to in this place by our author. Mr. Guthrie, indeed, understands the ἀπήχημα of the Greek authors, and _resonitus_ of the Latin, to apply to this variety of fracture; but he appears to me to be mistaken, for these terms unquestionable refer to the _contre-coup_, of which we will treat presently. Quesnay, indeed, uses the term _contre-coup_ in this double sense, but, as I think, very injudiciously, as it tends to introduce confusion of ideas; for assuredly the case of a fracture on a different part of the head from that which received the blow, and a fracture on the inner plate of the skull from an injury on the outer, are quite different cases. See Quesnay, etc., p. 20, Syd. Soc. edit.

[787] The expressions in this place are somewhat confused, but the meaning evidently is, that without fracture there can be no depression.

[788] This third mode of fracture is thus defined by Celsus: “At ubi medium desedit, eandem cerebri membranam os urget; interdum etiam ex fractura quibusdam velut aculeis pungentibus,” (viii., 4.) Hippocrates, it will be remarked, makes no mention of spiculæ in his description of depression. Galen describes two varieties of depression; in the one the depressed portion retains its situation, and in the other it rises again to its former level. (De Caus. Morb.) Hippocrates does not appear to have been acquainted with the latter. Modern experience has shown that it sometimes occurs in children.

[789] It is almost impossible to know what to make of this passage, owing to the corrupt state of the text.

[790] The nature of this mode of injury is explained in the annotations on the third paragraph. It does not appear clear why our author has given two separate descriptions of this injury. He describes, it will be remarked, several varieties of it, according as it is complicated or not with contusion and fracture. Galen uses _hedra_ in one place. (Meth. Med. vi.) The term _hedra_ is rendered _teli sedes_ by the Latin translators of the Greek medical authors. (See Asellii Comment. in Hippocrat. de Vuln. Capit.) It is used also by Ambrose Paré, Wiseman, and all our earlier writers on surgery. Wiseman thinks the term most appropriate when applied to wounds inflicted by a pole-axe, halberd, or the like. (v. 9.) Paré applies it to a kind of injury, in which the bone is not broken through, but the print of the weapon is left on the skull. (xx., 7.) Fallopius gives an interesting discussion on it. (In librum Hippocrat. de Vuln. Capit.) The term incision, borrowed from Paulus Ægineta, has been since used in its stead. See Quesnay, on the Use of the Trepan, p. 29, Syd. Soc. edition; and on simple incisions or sabre-cuts, see, in particular, Mr. Guthrie, Injuries of the Head, p. 86.

[791] This, it will readily be perceived, is the _fractura per resonitum_, that is to say, the _fracture par contre-coup_, or counter-fissure of modern authorities. Except Paulus Ægineta, I am not aware that any of the ancient authorities question the occurrence of this species of the accident, and with the exception of Vidus Vidius, Guido, Fallopius, and Dinus de Garbo, it is generally recognized by the best modern authorities, from Bertaphalia and Andreas à Cruce, down to Sir Astley Cooper and Mr. Liston. Mr. Guthrie, indeed, remarks, that in recent times there has been no well-authenticated instance of fracture on the one side of the head from a blow on the other. Such cases, however, are not wanting in the works of the earlier modern authorities. Quesnay writes thus: “We find in authors, also, many cases of fracture by _contre-coup_, from one part of the head to the part opposite: and in honor of the ancients we may cite the case related by Amatus, who applied the trepan to the part of the head opposite to the wound, when he found that the symptoms were not relieved by applying it on the side wounded, and that the patient suffered from severe pain on the other side. This second trepan proved very apropos, for it allowed the escape of pus, which had collected under the skull.” (On the use of the Trepan.) All our modern authorities, including Mr. Guthrie, admit the reality of the case in which fracture of the base of the skull is produced by a blow on the upper part of the head. In imitation of our author, this case was denominated “infortunium” by the earlier authorities, such as Asellius and Porralius, being accounted an irremediable misfortune, because its seat could not be detected; and it is noticed in the following terms by Sir Astley Cooper, who did not trouble himself much about the writings of his predecessors, but formed his opinions from actual observation: “When the basis of the skull is fractured from a high fall, from the whole pressure of the body resting upon that part, on opening the brain and tearing up the dura mater, extravasated blood is commonly observed; _this kind of fracture must inevitably prove fatal, nor can it be discovered till after death_.” (Lectures, xiii.)

[792] Whatever opinion may now be formed of the rule of practice here laid down, all must admit that it is clearly stated and distinctly defined. We have seen above that our author describes five modes of injury in the skull, namely, the incision or indentation, confined to its outer table; the contusion; the direct fracture; the fracture _par contre-coup_; and the depression. He now states decidedly that it is only in the case of contusion and simple fracture, that the trepan can be applied with advantage. I have entered so fully into the _rationale_ of this practice in the Argument, that I do not think it necessary to say more on the subject in this place.

[793] This passage indicates strongly our author’s partiality for prognostics, or rather, I should say, for prorrhetics. It would appear to have been a primary consideration with him, in all cases, to secure the physician from blame, and to teach him how to gain the confidence of the patient and his attendants. Few who have practiced medicine for a great many years, will question the propriety of these rules of conduct, or doubt the importance of taking all honorable steps to ensure the confidence and good-will of patients and their friends.

[794] There is a remark made by Arantius and Porralius on the latter part of this paragraph, which, although it appears to be scarcely warranted by anything in the text of our author, I quote for its importance, as showing that the earlier authorities were well aware of the danger and impropriety of treating injuries of the head in children by instruments: “Sed præ ceteris illud notandum quod dixerit (_nudato osse_) quasi dicat, eo non denudato quamvis calliso aut fisso, quod raro accidit, non esse tamen sectione denudandam calvariam: nam in pueris, ubi decidunt non raro accidit ut eorum collidatur calvaria, frangaturque, cute integra, quod etsi accidat, et tactu hoc probe precipiatur, sanguisque e venis effusus sub cute fluctua, abstinendum tamen a sectione est, neminem enim servatum vidi, cui sectio adhibita sit, propterea quod eorum calor facile dissipetur, eoque magis, quum gemitu et clamore caput valdè incelescat, et ad fluxiones suscipiendas proclive reddatur,” (Comm. in Hip. de Vuln. Cap.) It will be seen at § 18, that our author allowed the application of a small trepan in children when strongly indicated.