[685] This complication cannot fail to attract attention, from its resemblance to an epidemic which prevailed in Scotland in the year 1843. In this epidemic, as in the present case, the fever was very subject to relapses and to jaundice at an early stage. Hippocrates, in one of his Aphorisms, pronounces jaundice in fevers before the seventh day to be a fatal symptom. (iv., 62, 64.) Galen justly thinks it somewhat singular that no further mention of the jaundice is made in the course of the report; but he inclines from this to draw the conclusion that it remained in the same state throughout. As there was no crisis by the stomach, the bowels, the urine, or sweat, he concludes that the jaundice could not have been carried off. From all that has been said, he adds, it is clear that the organ primarily affected was the liver. Galen, then, decidedly opposes the view taken in the Explanation of the Characters respecting the cause of this man’s death, which he contends was not connected with any suppression of the alvine discharges, but with the affection of the liver. On the Scotch Epidemic, see Ed. and Lond. Med. Journal, March, 1844.
[686] Most of the ancient authorities regarded deafness as an unfavorable symptom in fevers. See Paulus Ægineta, Book II., 4. The modern are divided in opinion on this point. Pringle and Huxham regard it as a favorable symptom, but Home looks upon it as unfavorable.
[687] Here again Galen mentions the absurd notion of Sabinus the commentator, that this man’s disease was occasioned by the locality in which he was laid. Galen, on the other hand, thinks it likely that the patient was conveyed to the garden as being a favorable situation for a person ill of fever. He further alludes to this case in the Second Book of his work On Critical Days.
[688] Galen remarks, that as there is no mention of a single favorable symptom up to this date, the patient would certainly have died if he had not been of a vigorous constitution.
[689] Thus, as Galen remarks, after two ineffectual attempts, Nature accomplished a cure on the fortieth day.
[690] There is not much to remark in this case. A modern reader will suspect that there had been cerebral disease before the attack of the fever, and that matters had been brought to a crisis by the drinking of wine. Indeed Galen, in his Commentary, remarks that the precursory symptoms indicate a congestion of humors in the brain, which of course would be much aggravated by the wine, the brain then being, as he says, in a bad state; and the patient having inflicted an additional injury to the organ, by means of the drink, brought on the acute attack, which proved fatal in five days. The deafness, delirium, spasms, and bilious vomitings all indicate a cerebral affection. The state of the hypochondria, as described in the report, Galen would seem to attribute to a spasmodic affection of the diaphragm, from sympathy with the brain. Retraction of the hypochondrium is pronounced to be a bad symptom in the First Book of the Prorrhetics. Galen justly contends that there is no reason in this case to suspect any inflammation in that region.
[691] Galen’s remarks on this case are unusually brief; he attributes the fever to a bilious plethora, and states that the result was such as might have been anticipated from a knowledge of the critical days, and of the characters of the urine. Indeed the latter appear to me well deserving of attention.
[692] This is in many respects an interesting case, and more especially, from its being stated that the disease was complicated with hereditary consumption. Galen, in his Commentary, remarks that some authorities denied that any disease is congenital, but this opinion he decidedly rejects. The phthisical affection, however, as he justly remarks, would not have occasioned so sudden an issue if it had not been complicated with a complete prostration of the natural powers. He insists strongly on the striking description here given of the total loss of the natural appetite, both in regard to food and drink. Of course, no worse state of the system can be imagined than that in which it is totally insensible to its own wants, nay, that it loathes the very articles which it stands most in need of. Galen properly remarks in another place (Comment. I., in Epid. i.), that it is an extremely unfavorable symptom when in an ardent fever there is no thirst. The small abscess about the nates would seem to have been an incidental complication. It would appear to be now settled by the best pathological authorities that there is no natural alliance between phthisis and fistula in ano, as was at one time suspected. See Andral (Cliniq. Médicale, tom. iv., p. 308), and Louis (On Phthisis, p. 89, Sydenham Society’s edition). The affection of the fauces and throat, which is described as having attacked the patient at “the commencement of the disease,” would appear to have been a common complication of that epidemic. It is noticed in the First Book of the Epidemics. Foës remarks, however, that some had referred it to that redness of the fauces to which persons laboring under consumption are liable. Compare Louis, l. c. p. ii., § 12. Galen makes mention of a difference of reading in the MSS. he used in reference to the Critical Days.
[693] On this brief case Galen has left a lengthy and elaborate Commentary, abounding in most interesting matters on a variety of subjects; as, for example, the different readings and opinions of the more ancient commentators on the characters at the end of this and the other reports; on the formation of the Hippocratic Collection, and the extraordinary zeal of the Ptolemies in procuring books for their great Library at Alexandria, and so forth. There is not much in it, however, which bears directly on the present case, and therefore we shall give but a very brief abstract of it. It appears from Galen that there was a considerable diversity of readings in the latter part of it, more especially in regard to the number of days the patient lived; some of the old authorities having placed the death on the fifth, some on the seventh, and others on the eighth. Galen inclines to hold by the text as we now have it, and maintains, apparently with good reason, that under such a combination of fatal symptoms it was not likely that the patient’s strength should have stood out longer than the fourth day. Another curious subject connected with this case which Galen slightly touches upon, but without throwing any light upon it, is the omission of the treatment. He justly remarks, that if Hippocrates treated the patient himself, or superintended the treatment as managed by another, it is singular that there is no mention of a clyster having been administered, nor of a cataplasm having been applied, nor of venesection having been practiced. I shall not attempt to solve the question here propounded by Galen. See the Argument. His Commentary also contains an interesting discussion on the meaning of the expression “respiration elevated.” To give the sum of what has been advanced on this subject in a few words, it may signify laborious breathing so as to move the labia of the nose; or it may mean simply orthopnœa, or it may signify laborious respiration, attended with elevation of the chest. By the way, this is evidently the “sublimis anhelitus” of Horace, in his famous ode entitled “Nireus.” I have often wondered that such a learned physician as Julius Cæsar Scaliger, in his celebrated critique on Horace in his Poetics, should have remarked on this expression: “Ex toto Galeno non intelligo quid sit sublimis anhelitus.” Galen, in fact, treats fully of the “sublimis anhelitus” in various parts of his works. See in particular On Difficulty of Breathing.
[694] Galen has given us a lengthy Commentary on this case, but a great part of it relates to the characters and to other matters not of any very great importance in this place. As he remarks, it is a striking example of an acute fever induced by immoderate fatigue. It appears from his Commentary, moreover, that some of the older authorities had added “drinking” to the excesses which induced his affection; that is to say, they proposed to read πότων instead of πόνων. The symptoms, upon reference to the Prognostics, are all such as indicated a fatal result, namely, the blackish and thin urine, “the fumbling with the bedclothes,” the coldness and lividity of the extremities, the meteorism, and so forth.