[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.