SECT. I.—ON FEVERS, FROM THE WORKS OF GALEN AND SEVERAL OTHERS.
After having treated of those things which relate to the preservation of health, we now come to the treatment of persons already in disease, and shall begin with homogeneous disorders as being the most simple. These are what are called Fevers. Wherefore, using again principally Oribasius’ Epitome of the Works of Galen and several others on this subject, we shall add a very few things omitted by them.
Commentary. The following ancient authorities may be consulted on the subject of fever: Hippocrates (Epidem. et alibi); Galen (Comment. in Hippocr. Epidem., de Differentiis Febrium, Meth. Med. viii, Therap. ad Glauc. i, De Typis, de Crisibus et alibi); Celsus (iii); Pseudo-Dioscorides (Euporist. ii); Oribasius (Synop. vi, Euporist.); Aretæus (Morb. Acut. ii, 4); Aëtius (v); C. Aurelianus (Pass. Acut. ii, 10); Alexander Trallian (xii); Alexander Aphrodisiensis (Probl. i, 84, de Febribus); Actuarius (Meth. Med. iii); Pliny (Hist. Nat. xxviii, 66, xxx, 30); Palladius (de Febribus); Michael Psellus (Opus Medicum); Synesius (de Febribus); Leo (ap. Ermerins Anecdota Græca); Stephanus (Comment. in Prognost. Hippocrat. ed. Dietz); Constantinus Africanus (de Febribus); Serenus Samonicus; Vindicianus (Epistola ap. Fabricii Bibl. Græc. tom. xiii); Avicenna (iv, i); Syrasis, Avicennæ Expositor; Haly Abbas (Theor. viii, Pract. viii); Alsaharavius (Theor. vi, Pract. xxxii); Serapion (tr. vi); Avenzoar (iii, 7); Averrhoes (Collig. vii); Rhases (ad Mans. x, Contin. xxx.)
All the ancient authorities held that a fever consists of a preternatural increase of the Innate, or, as it is now called, Animal heat, which they considered as the instrument by which the soul performs all the functions of the body. See Alexander Aphrod. (de Feb.) Thus, Palladius defines a fever to be “a preternatural heat, which begins in the heart, and is diffused by the arteries over the whole body, sensibly injuring the actions of the body.” Hippocrates, Galen, Aëtius, Alexander Trallian, Psellus, Leo, and Actuarius give similar definitions. Cælius Aurelianus says of Asclepiades: “Febrium ponit signum calorem plurimum.” (Morb. Acut. i, 14.) Isidorus defines a fever thus: “Febris a fervore dicta est; est enim abundantia caloris.” (Orig.) Hippocrates, however, the great opponent of hypothesis in medicine, insists that there is more in a fever than a simple excess of pure heat; or, in other words, that the essence of fever is heat mixed up with noxious qualities. (De Vet. Med. § 17.) The celebrated Erasistratus maintained an opinion, lately revived by Clutterbuck and Broussais, that fevers and inflammations are identical. See Milligan’s Celsus (p. 13 and 112); and Cælius Aurelianus (de Acut. Morb. ii, 3.) He further taught that in fevers the blood of the veins is thrown into the arteries. (Plutarch de Placit. Philos. v, 29.)
The Arabians adopt the opinions of Hippocrates, Alexander, and Galen. Thus, for example, Haly Abbas defines fever to be a preternatural heat proceeding from the heart, and diffused by the arteries over all parts of the body. According to him there are three kinds of fevers. The first, are seated in the spirits, and affect only the heat of the body: these are called ephemeral fevers. The second, originate in a vitiated state of the fluids, which impart a preternatural degree of heat to the heart, whence it is diffused over all the body. The third arise in the vital organs and solid parts, from which heat is transmitted to the heart. (Pract. viii, 2.) See also, in particular, Rhases (Cont. xxx.)
SECT. II.—OF THE PRINCIPAL CONSIDERATIONS TO BE INQUIRED INTO WITH REGARD TO FEBRILE AFFECTIONS.
The first thing to be considered is, whether the disease will prove fatal or not; then, if it is not to prove fatal, whether it will be acute or chronic (these considerations apply to other great disorders); and, third, whether it will come to a crisis all at once (which is peculiar to fevers), or be resolved gradually.
Commentary. This Section, and great part of the contents of this book are taken from Galen (Therap. ad Glauc. i,) or from Oribasius (Synops. vi.)
SECT. III.—FROM GALEN, WHAT TO CALL THE COMMENCEMENT OF THE DISEASE.
As headach is not the same complaint as fever, so neither are insomnolency, loss of appetite, heaviness of the whole body, and a sense of lassitude; and yet each of these symptoms, although different from fever, announces its approach. A fever setting in, and more especially in an acute manner, cannot escape our notice, nor even that of a person unacquainted with these matters. Or, if we should suppose that it might escape us, I should wonder if the patient himself could be ignorant of it for more than an hour. Wherefore I call that time the commencement of the disorder, when those who are beginning clearly to be affected with the fever betake themselves to bed.
Commentary. The whole of this Section is taken from Galen (de Diebus criticis), where the question is fully discussed. Aëtius, like our author, defines the commencement of a fever to be the time when the strength of the patient being overcome by the complaint, he is obliged to take to bed. On this point the Arabians venture to differ from the Greeks. Thus, Rhases and Avicenna reckon the commencement from the time when the patient first feels a departure from health.
The disagreement among the authorities upon this point is to be regretted, as it tends to obscure the doctrine of the critical days.
SECT. IV.—HOW TO KNOW WHETHER THE DISEASE WILL PROVE FATAL OR NOT.
These are fatal symptoms: A deathlike countenance, sharp nose, hollow eyes, and the other symptoms described by Hippocrates, when they do not proceed from watchfulness, or evacuation, or want of food; also, intolerance of the light, shedding tears from no external cause, there being no particular affection of the eyes; or the one eye appearing less than the other; or the white of the eyes becoming red, or livid, or black, or having a muddiness in them; and the white of the eyes appearing during sleep, the eyelids not being closed, unless this symptom proceed from a great evacuation, or from habit. Likewise grinding the teeth, a state of delirium, picking at flocks of wool, or bits of chaff, are not favorable. Attention should also be paid to the patient’s mode of lying. To lie on one’s back, as it were, in a relaxed state, and to sink downwards in bed, are indications of extreme debility. It is still worse to have a cold respiration at the mouth and nostrils; and a pulse obscure, dense, and intermitting, and profuse sweatings with syncope are most mortal symptoms. If all the symptoms we have mentioned, or even more appear, or if they be fewer in number but strong, and if they be without any of the favorable ones, death is inevitable. The breathing free, pulse natural, soundness of intellect, being well disposed to take whatever is offered, the appearance of countenance and mode of reclining like those of persons in health,—all these symptoms are favorable and prognosticate recovery; and, in general, whatever symptom is contrary to the natural state indicates an unfavorable, whereas, what is correspondent, indicates a favorable termination. Concerning the prognosis from the urine, alvine discharges, and sputa, we will speak soon.
Commentary. The great master of prognostics is Hippocrates, whose system of medicine was entirely based on the observation of the favorable and unfavorable symptoms of disease. It would appear that the first advances in this art were made in the temples of the gods, and especially of Æsculapius, which the sick were in the practice of resorting to in order to ascertain the issue of their maladies. See a very ingenious and learned disquisition, ‘de Hippocratis Doctrina a Prognostice oriunda,’ by F. Z. Ermerins, M.D. The works of Hippocrates, especially the ‘Prorrhetica and Coacæ,’ contain a rich treasure of observations which cannot be too much explored by the student of medicine. His prognostics are founded upon the appearances of the face, eyes, tongue, the voice, hearing, the state of the hypochondriac region, the abdomen, the general system, sleep, respiration, and the excretions. We can do little more, in this place, than express our high sense of the value of the ‘Hippocratic Treatises on Prognostics,’ and recommend the study of them to all members of the profession who would wish to learn the true inductive system of cultivating medicine. We shall give as a specimen of Hippocrates’ and Galen’s labours, in this department, a few of Galen’s remarks on the causes of the symptoms, as described by Hippocrates. It is one of the prognostics of Hippocrates, that profuse perspiration in acute fevers is unfavorable; and, in explanation of this, Galen states that a critical sweat may indeed be favorable; but that such as are profuse and continued indicate a complete prostration of the vital powers. A fixedness of the eyes is said by Hippocrates to be a fatal symptom; the reason of which, according to Galen, is, that it proceeds from paralysis, or insensibility of the muscles of the eye. Hippocrates mentions it as an unfavorable symptom when the patient lies with his mouth open; and Galen attributes this symptom to the origin of the nerves, that is to say, the brain, undergoing pressure. Hippocrates states, that involuntary discharges from the bowels are an unfavorable symptom; and Galen justly remarks that they indicate great insensibility.
The Prognostics and Aphorisms of Hippocrates are further illustrated by the learned and interesting Commentaries of Stephanus Sophista, Theophilus, and Damascius, which were published a few years ago by Dietz. From the nature of their works, it is impossible to give any satisfactory outline of their contents within our narrow limits. We shall merely give one specimen of them. It is stated in one of the Aphorisms of Hippocrates, that dyspnœa and delirium occurring together in fever, indicate a fatal termination. Upon which Theophilus and Damascius remark, that the one symptom implies disease of the heart and the other of the brain. (Ed. Dietz. T. H., p. 415.)
Celsus gives an elegant translation of this part of the works of Hippocrates. The following is his version of the description of the Facies Hippocratica: “Ad ultima jam ventum esse testantur, nares acutæ, collapsa tempora, concavi oculi, frigidæ languidæque aures et imis partibus leniter versæ, cutis circa frontem dura et intenta, color aut niger aut perpallidus.” Other unfavorable symptoms are also strikingly portrayed: “Mali morbi testimonium est vehementer et crebro spirare: a sexto die cepisse inhorrescere; pus expuere; vix excreare; dolorem habere continuum; difficulter ferre morbum; jactare brachia et crura; sine voluntate lachrimare; habere humorem glutinosum dentibus inhærentem; cutem circa umbilicum et pubem macram, præcordia inflammata, dolentia, dura, tumida, intenta, magisque si hæc dextra parte, quam sinistra est; periculosissimum tamen est, si venæ quoque ibi vehementer agituntur.”
Aëtius and Oribasius, like our author, borrow almost every thing from Hippocrates and Galen.
Rhases and Avicenna, particularly the latter, treat of the prognostics in fever very fully. Avicenna, like Hippocrates, sets down deafness as an unfavorable symptom. Hippocrates had stated, that jaundice coming on before the seventh day is unfavorable; but Averrhoes affirms, that all the Indian and Persian physicians reckoned it a favorable symptom. Rhases considers yellowness of the skin an unfavorable symptom, unless the fever be of a bilious nature. Alsaharavius says it is an unfavorable complication when it does not prove critical. It is proper to mention here that Hippocrates modifies the above prognostic by stating in one of his aphorisms, that jaundice coming on on the 7th, 9th, 11th, or 14th day is favorable. (iv. 64.) Alsaharavius states it as a dangerous symptom, when the patient lies on his back with his legs drawn up. This agrees with the prognostic of Celsus “Mors denuntiatur ubi æger supinus cubat, eique genua contracta sunt.” Avicenna and Averrhoes state it as a fatal symptom when the patient sinks down in bed and exposes his hands and feet. (Averrhoes, Comment. in Cant. Avicennæ.)
According to Rhases it is a bad symptom when the patient has lost his modesty, so as to expose freely those parts of the body that should be covered. He holds also that it is a bad symptom when the vomitings resemble verdigris. (Ad Mansor. x, 21.)
Prosper Alpinus gives an admirable account of the prognostics in diseases. See his work, ‘De Præsagiendâ Morte et Vitâ ægrotantium,’ passim. He agrees with the ancients, that deafness is an unfavorable symptom, unless it occur at the time of a crisis. Like the ancients, he considers the absence of thirst an unfavorable symptom in ardent diseases, as indicating that the system is insensible of its wants.
SECT. V.—HOW TO KNOW IF THE DISEASE WILL BE OF LONG DURATION.
The duration of the disease may be ascertained from four things: from the movement of the disease itself, from the habit of the patient, from the pulse, and from the species of the fever. From the movement of the disease thus: if the four periods of a particular paroxysm have passed over quickly and in the least possible time, the disease will be an acute one, the furthest bound of which will be the seventh day, and generally it will come to a crisis on the fourth. If the periods of the first paroxysm occupy more time than this, but do not exceed twelve hours, the disease will still be an acute one, which will terminate within the fourteenth day. If it extend longer, so that the commencement and augmentation of the paroxysm alone occupy a longer period than a day or a night, such a disease will prove a long one. If the disease have no particular paroxysms, but consist of one continued paroxysm, as it were, from beginning to end, as in synochous fevers, even in this case you may call the disease an acute one. It may be judged of from the habit of the patient; for if the face and the rest of the body are already considerably wasted, an acute disease is indicated; but if nowise reduced, a chronic one; for a great collection of offending matter is indicated, which will require a length of time for its concoction. It may be judged of from the pulse: thus, a great, strong, quick, and dense pulse, is indicative of an acute disease, but the contrary of a chronic. From the species of the fever, inasmuch as hot and ardent fevers indicate an acute, whereas gentler, and, as it were, smothered fevers indicate a chronic one.
Commentary. Celsus thus states the prognostics of a protracted fever: “Signa quædam sunt, ex quibus colligere possumus, morbum, etsi non interemerit, longius tamen tempus habiturum: ubi frigidus sudor inter febres non acutas circa caput tantum, et cervices oritur: aut ubi, febre non quiescente, corpus insudat: aut ubi corpus modo frigidum, modo calidum est, et color alius ex alio fit: aut ubi, quod inter febres aliqua parte abscessit, ad sanitatem non pervenit: aut ubi æger pro spatio parum emacrescit: item si urina modo liquida et pura est, modo habet quædam subsidentia; si lævia atque alba rubraque sunt, quæ in eâ subsidunt; aut si quasdam quasi miculas repræsentet; aut si bullulas excitat.”
Galen has given a full exposition of these symptoms in his Commentary on the Prognostics of Hippocrates, from which Aëtius, Oribasius, and our author have borrowed largely. Rhases, Avicenna, but most especially Haly Abbas, treat at great length of this subject. See also Averrhoes (Commentaries on the Cantica of Avicenna.)
SECT. VI.—HOW TO KNOW IF THE DISEASE WILL TERMINATE BY A CRISIS, OR BY RESOLUTION.
This may be ascertained from what has been already said, namely, the species of the fever and its duration, and perhaps from the species of the fever alone. For hot and ardent fevers are of short duration, and usually terminate with some critical evacuation; whereas the gentler kinds prove more chronic, and have a tendency to abscess. From what has been said, it appears that we may prognosticate not only when the disease will come to a crisis, but also how it will terminate; for acute diseases generally terminate by critical evacuation, and the chronic by abscess.
Commentary. A similar statement is made by Aëtius (v, 22.) See also Averrhoes (Comment. in Cantica Avicennæ.)
SECT. VII.—ON CRITICAL DAYS.
Of the critical days, some terminate the disease frequently, faithfully, well, completely, clearly, decidedly; and others contrariwise to these. But the 13th has been shown to possess an intermediate character. Some of these are such as to prove critical if they experience even the most moderate impetus of nature, such as the 7th and 14th; whilst most of them prove critical in violent commotions of the system, but not otherwise. Neither are the favorable all equally favorable, nor the unfavorable all equally unfavorable; nor is their favorableness and unfavorableness according to any order. Those in the first rank of favorable days may be arranged thus: the best of all are the 7th and 14th, next to them the 9th, and 11th, and 20th; and near to them the 17th and 5th, after these the 4th, after it the 3d and 18th. Opposed to them, of the second rank, are these: the worst, which proves obscurely critical with danger, and is, as it were, diametrically opposed to the 7th, is the 6th: near to it are the 8th and 10th, after these the 12th, 16th, and 19th. Intermediate between these is the 13th, being neither so objectionable as those of the second rank, nor so powerful in freeing from diseases as those of the first. The critical days then are thus arranged according to their degree by Galen. Numerically thus: the favorable are the 3d, 4th, 5th, 7th, 9th, 11th, 14th, 17th, 18th, 20th; the unfavorable, the 6th, 8th, 10th, 12th, 16th, 19th; the intermediate, the 13th. Some of the critical days give information concerning the others, and are hence called indicatory by Hippocrates, because they indicate the crisis that is to happen on another critical day. Thus the 4th indicates a crisis on the 7th, by inducing sweats, perspirations, or some such particular evacuation, or by displaying certain signs which had not formerly taken place, or some symptoms of concoction. Galen says that the 4th is indicatory of the 6th, although it be unfavorable, as the 11th is of the 14th, and the 17th of the 20th. Until the 14th day the crises are the most decided, next to these until the 20th; from the 20th to the 40th they gradually lose their decided character. Of these, the first in degree are the 27th, 34th, and 40th, after which are the 24th and 32d. The other numbers intermediate between the 20th and 40th are indeterminate, and those after the 40th are not properly critical, as they terminate diseases by concoctions and abscesses rather than by crises. Hippocrates seems entirely to disregard all those after the 40th day, yet he enumerates the 60th, 80th, and 100th. After these, he says that some diseases prove critical in seven months, some in seven years, and others, as it would appear, in twice or thrice seven years.
Commentary. The Father of Medicine who was profoundly skilled in Semeiology, appears to have attached great importance to the observance of the critical days. At first, as Galen remarks, he seems to have been undecided respecting certain days, and, accordingly, he gives a somewhat different list of them in his ‘Prognostics’ and ‘Aphorisms,’ from what he has given in his ‘Epidemics.’ His latter list of critical days differs little or nothing from that of Galen.
Galen reposes such confidence in the doctrine of critical days, that he affirms that, by a proper observance of them, the physician may be able to prognosticate the very hour when a fever will terminate. The following is his list: The 7th is particularly favorable; next, the 14th; next to these, the 9th, 11th, and 20th; then the 17th and 5th; afterwards the 4th, 3d, and 18th. The 6th is very doubtful and unfavorable; the 8th and 10th, like the 6th; the 12th, 16th, and 19th, like the 8th and 10th. Intermediate between these two lists of favorable and unfavorable days is the 13th. He informs us that Diocles and Archigenes held the 21st to be particularly favorable, but he agrees with Hippocrates in rejecting it and adopting the 20th.
Celsus follows the system of Archigenes. He says, “κρίσιμοι dies erant, dies tertius, quintus, septimus, nonus, undecimus, quartus-decimus, unus et vicesimus; ita ut summa potentia septimo, deinde quarto-decimo, deinde uni et vicesimo daretur.” But he does not hesitate, afterwards, to express his distrust in the whole system; for, he adds, “verum in his quidem antiquos tunc celebres Pythagorici numeri fefellerunt; cum hic quoque medicus non numerare dies debeat, sed ipsas accessiones intueri.”
The Greek writers subsequent to Galen adopt his system, with little or no alteration. Aëtius arranges the critical days thus: First in order, the 7th and 14th; then the 9th and 11th; next to them the 17th and 5th; then, the 4th; and afterwards the 3d and 20th. The 6th is usually bad.
The last of the ancient authorities, Actuarius, is very full and confident in laying down the received doctrines, with regard to the critical days. He follows Galen.
The Arabians, with scarce one exception, adopt the Galenic system. Avicenna, who treats of the critical days very fully, mentions the list of them given by Hippocrates and Galen, and also that by Archigenes, but decides in favour of the former.
Rhases mentions the critical days in the following terms: The 3d is critical in very acute fevers; the 4th is indicative of the 7th and 6th; the 5th is favorable; the 6th generally unfavorable; the 7th is a particularly favorable or unfavorable crisis; the 8th rarely critical, but if it be, unfavorable; the 11th critical and indicative of the 14th; the 12th rarely critical, and like the 8th; the 13th rarely critical; the 14th, critical and favorable; the 15th like the 13th; the 16th like the 12th; the 17th like the 9th, and indicative of the 20th; the 18th rarely critical, or unfavorable; the 19th rarely critical, or, if so, not bad; the 20th next to the 14th, and favorable; the 21st sometimes critical, but less frequently so than the 20th; the 24th resembling the 20th; after these the 27th, 31st, 37th, and 40th are critical. Averrhoes remarks, that great deference is due to Rhases’ opinion upon this subject, since it was confirmed by experience, in more than ten thousand cases, in an infirmary (in infirmaria Relenson). His list is very little different from that of Galen. In his ‘Continens,’ he gives an account of the system of Archigenes, but prefers that of Hippocrates. (xxxii.)
Averrhoes states that the medical world was divided between the systems of Archigenes and Galen, but he inclines to the side of the latter in this case, although on most occasions given to dispute his authority.
Avenzoar, upon the whole, nearly agrees with Rhases, but expresses himself undecided with regard to the 20th and 21st days. His authority must also be allowed to be of great weight upon this subject, if we may believe Averrhoes, that he lived to the age of one hundred and thirty-five, and practised medicine from his fortieth year.
To the first class of critical days, according to Haly Abbas, belong the 7th and 14th; to the second, the 11th and 20th; to the third, the 4th, 17th, and 21st; and to the fourth, the 3d, 5th, 9th, and 18th.
Alsaharavius gives a similar list to Haly’s. He inclines rather to the 20th than the 21st day.
Galen, and most of the ancient authorities, believed that the critical days are influenced by the moon. Actuarius, in particular, attributes much to the influence of the sun and moon in influencing the course of fevers.
Prosper Alpinus gives a correct summary of the ancient doctrines respecting the critical days. (De præs. Vita et Morte ægrot. vi, 4.)
SECT. VIII.—THAT CRITICAL SYMPTOMS APPEARING IN THE COMMENCEMENT ARE UNFAVORABLE.
The signs of concoction are never unfavorable, for concoction always take place when nature prevails, and therefore the signs of it are always favorable. But the critical signs may sometimes appear unfavorably, owing to the crisis partaking of a double character (as was said with regard to the critical days), being sometimes favorable and sometimes unfavorable. They ought not therefore to appear at the commencement, nor during the increase of the disease, but after its acme, at which time nature is prevailing over the disease.
Commentary. The opinion here delivered is derived originally from Galen, but is maintained also by Oribasius, and the other authorities. It requires no comment.
SECT. IX.—HOW TO JUDGE BEFOREHAND OF A FUTURE CRISIS.
If the paroxysms increase in violence, occur earlier, and become much stronger; if they invade on the third day; and if symptoms of concoction appear in the urine, alvine discharges, and sputa, the disease will certainly soon come to a crisis. If the attack is slow, and if the paroxysms occur at the same hour every day, you may expect that the crisis will not take place till after a longer time. And those fevers which make their attack with rigors cannot terminate until the rigor abate; for until that occur it is impossible for the disease to have attained its acme, and therefore much less is it reasonable to expect that it is upon the decline.
Commentary. This Section is copied from Oribasius. (Synops. vi, 3.) The subject is fully treated of by Galen (de Crisibus.) Rhases describes very accurately the symptoms of an approaching crisis, such as, confusion of the understanding, vertigo, headach, inquietude, involuntary flow of tears, pain of the stomach, &c. He warns the inexperienced not to be alarmed at the violence of the precursory symptoms. (x, 26.) Avicenna, Averrhoes, Haly Abbas, and Alsaharavius, though they treat of the subject very fully, supply no original views.
See an ample account of the ancient opinions in Prosper Alpinus. (De Præs. Vita et Morte ægrot. vi.)
SECT. X.—HOW TO RECOGNIZE A PRESENT CRISIS.
Restlessness precedes every crisis, and if the crisis be to take place by day, it will occur by night; or if the crisis be to take place during the night, it will occur by day; and then certain symptoms supervene, such as headach not previously occurring, sympathetic pain of the neck, retraction of the hypochondrium, sudden difficulty of breathing, and other dangerous symptoms which did not manifest themselves before then take place. And if, when these occur, the pulse, instead of sinking, is increased in magnitude and becomes stronger, and the critical day approaches, and if it be one of the favorable, you may not only anticipate a crisis, but also a good one. And be not then alarmed if you see the patient become delirious and disturbed, for these are indications of the humours being carried upwards; in like manner as certain other symptoms indicate their being determined downwards, such as pain of the belly, gripes about the navel, pain in the loins, borborygmi, and other similar symptoms, when they occur. In addition to these, if the patient was accustomed to have a hemorrhoidal discharge, and if the period of it be at hand, and in like manner with respect to the menstrual discharge (if the patient be a woman), it is not unlikely that the crisis may take place by such an evacuation. And a critical sweat is recognized by a precursory moistness of the skin (especially if occurring upon one of the days called indicatory), and by openness of the pores. From these you may recognize crises by evacuations upwards; for, in addition to the aforesaid, you ought to examine the face of the patients, and whether there be palpitation in any part, or throbbing of the temporal arteries; or if the cheek, nose, or eye be redder than usual, you ought the rather to anticipate the coming crisis. But if they shed tears involuntarily, or fancy that they see sparks of light, and constantly carry their hands to their nose as if to rub it, then indeed you may see not only an approaching but a present flow of blood; for when they rub it once or twice the blood straightway breaks forth. Pungent pain at the stomach, and trembling of the under-lip often indicate a crisis by vomiting. These considerations are sufficient, but to them may be joined the age and constitution of the patient, as strengthening the anticipation; to which may be added, the season of the year and the present constitution. For if the patient be a child, or otherwise by nature warm and full of blood, you may still more form this anticipation; or if formerly, when in health or disease, as we remarked before, an evacuation of blood appeared, this circumstance alone may be sufficient to make you expect a hemorrhagy. And if the season of the year be summer, or, if not summer, if the present state of the weather be hot, and if the patient had often experienced a crisis at that season by hemorrhage, if the body be plethoric, if there is retention of the customary evacuations, all these things ought to strengthen your expectations. In like manner you ought to judge of the other evacuations; or, if none of these symptoms should appear, but if there be uneasiness occurring on one of the critical days after the 20th; or if, when the disease is at its acme, pains should seize certain joints, or near the ears, or in other parts; or if not pains, but local sweats should occur unceasingly in any part of the body, then indeed you may expect a crisis to take place by abscess, and in that part where the sweats, pains, or swelling occurred.
Commentary. This is taken with very slight alterations from Galen (Therap. ad Glauc. i: see also, de Crisibus, iii, 2.) The critical evacuations enumerated by Galen are, those by vomiting, by the belly, by urine, by sweats, by hemorrhage from the nose, by hemorrhoids, by the menses in women, by abscesses of the parotid glands, and by determination to the knees, feet, or some other parts not vital. He says there are three ways in which a fever may terminate favorably, namely, by an evacuation, by an imperfect crisis without an evacuation, and by resolution, that is to say, when the febrile symptoms go off gradually. There are likewise three unfortunate terminations; for the patient may die suddenly with much agitation, or in consequence of a metastasis, or he may be slowly wasted by a marasmus.
Averrhoes enumerates the same kinds of critical evacuation as Galen, and otherwise treats of them very judiciously. (Collig. iv, 39.) Avicenna gives a long account of all the circumstances attending the crisis, but he copies closely from Galen and Hippocrates. (iv, 2, 1.) Haly Abbas, in like manner, is sensible and correct, but borrows from the Greeks. (Theor. x, 10.) The account given by Rhases is excellent, but it differs little from our author’s. (Ad Mansor. x, 27.) In his ‘Continens,’ he gives a full exposition of the Galenic doctrines, with his own Commentaries. He states, that a crisis may take place in six ways: by hemorrhage at the nose, by an alvine evacuation, by vomiting, by a discharge of urine, by a sweat, or by an aposteme. (xxxi.)
SECT. XI.—HOW TO DETERMINE WHETHER A PAST CRISIS BE FAVORABLE.
If a proper evacuation takes place after the concoction, and the fever is resolved by the critical evacuation; if the patient is freed from all other symptoms; if his colour has improved in proportion to the evacuation; if his pulse has become more regular, and his strength better in rising out of bed; and, what is the most salutary symptom of all, if these are accompanied by repose of the constitution, this may be pronounced to be the best possible crisis. If any of these be wanting, the goodness of the crisis will diminish proportionally to the force of the diminution.
Commentary. This requires no Commentary. See, however, more fully, Galen and Rhases (l. c.)
SECT. XII.—ON THE PULSE, FROM THE WORKS OF GALEN.
The pulse is a movement of the heart and arteries, taking place by a diastole and systole. Its object is twofold; for, by the diastole, which is, as it were, an unfolding and expansion of the artery, the cold air enters, ventilating and resuscitating the animal vigour, and hence the formation of the vital spirits; and by the systole, which is, as it were, a falling down and contraction of the circumference of the artery towards the centre, the evacuation of the fuliginous superfluities is effected. The arteries themselves are oblong hollow vessels like the veins, but consist of two coats, in order to fit them for the afore-mentioned motion, and because they have to contain blood and spirits. They arise from the heart, and are distributed to all parts of the body; and, therefore, all the arteries pulsate in a similar manner, and like the heart, so that from one of them you may judge concerning all the rest. But the movement of all cannot be equally well observed; for those which are situated in parts not fleshy may be more conveniently felt, whereas those that are in fleshy parts are more indistinct. Nor is any one more conveniently situated for being felt than the one at the wrist. The first kind of pulses is in regard to the time of their motion, as observed in systole and diastole. Its differences are, the quick, slow, and moderate; because every body which is moved must be moved quickly, slowly, or intermediately, as to time; that is quick which is moved over a great distance in a short time; that is slow which is moved over a short distance in a long time; and that is moderate which is intermediate as to motion. The second kind of pulses is in regard to the extent of the diastole. For, since every body has three dimensions, length, breadth, and depth, and an artery is a body, it follows, that an artery must have these dimensions. When, therefore, an animal is in its natural state, you will find its arteries dilated moderately every way; but when not in its natural state, its dilatation will be deficient, or exceed according to some one of its dimensions. In calculating this, you must remember the natural state of the pulse; and if it is found to exceed in breadth, you must call it broad; if in length, long; and if in depth, high or deep. It is clear that the opposites to these, or those that are deficient, are to be named the narrow, the short, and the low. And with regard to those which are altered from the natural state in all their dimensions, that which is every way diminished is called small, and that which is every way increased, great. The third kind of pulses is with regard to the tone of the vital strength. The varieties are three, the strong, the weak, and the moderate. The strong is that which strikes the finger of the physician strongly, and the weak, feebly and faintly; while the moderate is intermediate between them, and is held by some to be the natural one; for that the pulse is rendered stronger by passion and baths, not being naturally so. In reply to which, Galen contends that a pulse rendered stronger by non-natural causes soon undergoes a change; and that, therefore, a strong pulse, which does not readily change, may be natural and moderate. The fourth kind is in regard to the consistence of the instrument, I mean the body of the artery. In this respect there are three differences; for the artery is either harder than natural, and is called a hard pulse; or softer, and is called a soft, or intermediate, and is called in this respect moderate. The fifth kind is in regard to the contents of the artery; and their differences are, the full, the empty, and the moderate, since every vessel must be full, empty, or moderately full of liquids. A full pulse, then, as Archigenes defines it, is one which indicates an artery that is completely full, and the impression of which is, that it is distended with fluids; and an empty one conveys an impression as if its contents were full of bubbles of air, so that the finger, when pressed upon it, seems to fall into an empty space. These five kinds of pulses regard one motion of the artery. And since the quality of the heat in the heart may be more developed than usual in the artery, some have hence reckoned a sixth kind of pulses. Of the other kinds, whether they are in regard to one or more pulsations, they derive their character either from the time of rest, or the rhythm, or their equality and inequality, or their regularity and irregularity. The kind, then, in regard to the time of rest, which is the seventh in order, is divided into the dense, the rare, and the moderate. And, since an artery has a double motion, composed of two opposite movements, it must of necessity have two seasons of rest: the one after the diastole before the systole, the other after the systole before the diastole, which to most people appears imperceptible; and, therefore, the interval of rest between two motions has been chosen. When, therefore, there is a long interval of rest, the pulse is called rare; when short, dense; and when intermediate, moderate. The eighth kind is in respect to rhythm. Rhythm, then, in general, is the ratio and proportion of one time to another. In regard to the pulse, it is, according to some, the ratio of the time of motion to the time of rest, as of the systole and diastole, to the intermediate time of rest; but, according to others, it is the ratio of a time of motion and rest to another time of motion and rest, or of motion to motion.
Of rhythm, then, there are two varieties, the rhythmic and the arhythmic. Of the arhythmic, there is a threefold difference: first, when there is a slight departure from rhythm; second, when there is a greater; and third, when there is no rhythm at all. Thus, for example; in a child, if his pulse has the rhythm of childhood, it is called its proper rhythm; if it has that of an adult, it is said to be an improper rhythm; or if it preserve no ratio at all, it is said to be devoid of rhythm.
The ninth kind of pulses is found in all the other kinds already mentioned; namely, that which regards equality and inequality, which may be remarked either in one pulse, or in many, which last is called the systematic, of which we must speak first, as being more clear. An equal pulse, then, is that which is alike in order, as regards magnitude, strength, frequency, and certain other, or indeed all its other, characters. The unequal pulse is that which is unlike in order. For, if all are alike, as, for example, all deficient in magnitude, such a pulse is called equal. But if the first, second, and third appear alike, but the fourth unlike, it is clear that such a pulse is unequal as to magnitude. Of this kind are the intermitting and the intercurrent. For not only after one or more great pulsations may one smaller occur; but sometimes this motion is wholly lost, and one pulsation is said to be wanting. The other kind, the intercurrent, is the opposite to this; for when we are expecting an interval of rest, a supernumerary pulsation, as it were, occurs. When the second is a little smaller than the first, and the third than the second, and the fourth than the third in like manner, and so onwards, such pulses are called sharp-tailed or myuri, deriving their names from figures terminating in a sharp point. Such as are altogether diminished, and never cease from this state, terminate in a total loss of motion, and are called failing or fainting myuri. There are two varieties in respect to those which fail, for some of them persevere in that state of smallness in which they terminated, whilst others attain again their original magnitude, or less or more, and these are called recurrent myuri. Pulses also are called myuri, from their inequality in regard to one pulsation, concerning which we will speak presently. And this is the nature of that inequality of pulse, called systematic. But it takes place with regard to one pulse, or one part of an artery, or more, as perhaps with regard to motion, for the inequality is observed on one part of the artery, when the motion of the artery upon the finger begins one way and terminates another, beginning quicker, and terminating slower, or reversely. This happens in a threefold manner, the motion either remaining constant, or being interrupted, or recurring and beating double, as it were. If, then, remaining constant and uninterrupted, it should change from quickness to slowness, or conversely, such a pulse is said to be, and is of unequal velocity. But if, after being interrupted by an interval of rest, it again appear quicker, it is called the goat-leap or dorcadissans, the term being derived from the animal dorcas, which, in jumping aloft, stops in the air, and then, unexpectedly, takes another and a swifter spring than the former. But if after the diastole it recur, and before a complete systole take place, strike the finger a second time, such a pulse is called a reverberating one, or dicrotos, from its beating twice. You may see such a thing take place upon a stithy, when a hammer, swung by the hand, first strikes the stithy, and afterwards, recoiling from the reaction of the stithy, strikes of itself a second or third time. And not only may an inequality in the time of motion take place as to one pulsation in one part of an artery, but also in regard to the strength of the power; not so, however, in regard to the extent of dilatation (for it is impossible that the same pulse in the same place should be great and small at the same time), nor in regard to the other kinds of pulses. But in different places different parts of an artery may exhibit a double inequality in one pulsation. For the motion may continue constant, and be swifter at one finger and slower at another; or it may intermit, and one finger may perceive it, and another not. And also, in regard to the extent of the diastole, the same inequality becomes apparent in different places. Of this kind are the myuri, diminishing once and again at one pulsation; for, if at the inner finger the pulse should be great and swelled up, but under the external at the thumb of the patient it appear smaller, such a pulse is called myurus, from its resemblance to the tail of a mouse; or meiurus, from its being diminished like a tail. But if the pulse appear great, and swelled under the middle finger, but smaller on each side, Archigenes called this impulse innuens et circumnuens, i.e. the declining, and the declining on both hands, wishing to mark the smallness of the diastole, with the declination, as it were, of the two extremities; for these parts do not appear as if they were cut short, but as if they were bent in, and a little contracted on each side, and hence the pulse is curtailed (myurus) on both sides.
And when the inequality as to magnitude takes place at different times, such pulses become undulatory and vermicular. And if irregularity of position be joined to them, they are called spasmodic and vibratory. Let us begin with the undulatory, in which the whole artery is not dilated at the same time, according to the same inequality, but this part of it first, that second, that third, and that fourth, the motion continuing constant like the swelling of the waves. And some have the wave carried straight forward, some obliquely; some have a sufficient altitude in a short expansion as to length, and some conversely; some have a broad, and some a narrow, and they have the like inequality in regard to quickness and strength. When the undulatory is wholly diminished in size, it is called the vermicular, which resembles the motion of a worm. As the undulatory pulse, when it goes on diminishing, terminates in the vermicular, so in like manner does the vermicular in the ant-like, or formicans, when, most of its motions being lost, it terminates in one, and it a very small motion. It is called formicans from its resemblance to the ant (formica), on account of its smallness and kind of motion. The ant-like pulse (called formicans) is very small, there being none smaller than it; and, in like manner, it is of all others the most indistinct and dense, but is not quick, as Archigenes supposed. Nearly allied to it is the hectic. For as there is a hectic fever, so is there also a hectic pulse, which undergoes little or no variation, but remains always alike contracted as it first began, and never expanding, the whole habit being turned into disease. The spasmodic pulses appear as if they were dragged, stretched, and drawn by the extremities, conveying the sensation of a stretched cord. But no such thing takes place in the vibratory; for in them the dilatation is greater, as if different parts of the artery were carried upwards at one and the same time. They may be resembled to darts, which, when thrown with force, are carried along with a vibratory motion. The pulse is serrated when part of the artery seems to be dilated and part not; the artery itself also appearing to be harder than natural. This pulse has some of the characters of the vibratory, and is quick and dense, but not always great. In addition to those mentioned, there is a tenth kind of pulses arising from inequality, namely, that with regard to regularity and irregularity. The unequal pulses being divided into those which are alike as to periods, and those which are wholly unlike, the regular and irregular are formed according to each of these divisions; from the equality of periods the regular is formed, and from the entire inequality the irregular. The equal pulse is also always regular (since consequently we call it alike); but the unequal is not altogether irregular; for, supposing it to have no equality, and yet to preserve a certain period, such, for example, as to extent of diastole, if there are two great and one small, then again two great and one small, and so on successively, such a pulse would be called anomalous, that is to say, unequal, but regular. But, if it not only had no equality, but likewise no order in its inequality, such a pulse would be not only unequal, but also irregular, and in like manner with regard to the other kinds. Of the irregular, some are altogether so, observing no period whatever; others are indeed regular as to periods, but, having no continued order, they may in this respect be called irregular, but in so far they observe a certain period regularly, they being regulated as to their periods. As if, for example, there were two great and two small, then three great and three small, and four great and an equal number small; and, returning again, two great and two small, three great and as many small, and so on in like manner. It is to be remarked that, of all the other opposite kinds, there is one intermediate between the two extremes, but that there is none between the equal and unequal, and the regular and irregular, unless you choose to call the one which is regular as to periods the medium between the regular and irregular. And the intermediate pulses of all the other kinds are the natural, except that which relates to strength and weakness, as we showed. But, in those we have been describing, the equal alone is the natural, and all the others are not natural, namely, the unequal, the regular, and the irregular. These are all the kinds of pulses and their generic differences. Some add two others to these, the one in regard to the position of the artery, according as it seems to be carried upwards or downwards, to the right or to the left, and the other in regard to the times of expansion. But these we treated of along with the undulatory and vibratory. And we, for the sake of brevity, have only delivered the simple varieties; but, from what has been said, one may easily connect them, and discover those which arise from their combinations.
The causes affecting the pulses are next to be treated of, with which is connected the prognosis from them. We shall begin with those which respect magnitude, because it is more obvious than the others. A great pulse is produced either by some urgent necessity, such as an excess of heat in the heart requiring refrigeration, and, as it were, ventilation from without; or it may arise from leanness of the body, as we shall soon show. The excess of heat is occasioned either by natural causes, such as the ages of manhood and youth, or simply a hot season, place, or a warmer temperament; or by non-natural causes, such as the air which surrounds us being hotter than common, hot baths, exercises, food, wine, heating medicines; or by preternatural causes, such as a hot intemperament, putrefaction of the fluids, passion, or the like. You may judge of these classes of pulse from the following observations. Those which are natural are permanent and not very susceptible of change, whilst the others readily change, so that often while you examine them, or generally after a very short time, they will altogether alter. A pulse also which owes its greatness to a hot bath has softness for an accompaniment; and hardness is generally combined with greatness proceeding from a hot intemperament, especially when combined with dryness of the system. Those who have undergone moderate friction or exercise have a pulse intermediate between hardness and softness; but they have the parts about the chest warmer than natural, which is the case also with those in a passion. Those that are influenced by food, the use of wine, or rage, have vehemence joined to greatness. Those who wish to conceal anger, or something which they have done without permission of the physician, (such as if a person has taken a heating medicine, and wishes to conceal it from the physician, who inquires about it while he feels the pulse,) in such persons a manifest inequality is joined to greatness. To the discovery of this state other considerations may contribute, such as the habit of the patient, as if he appeared to be fond of taking medicines, or his disposition, as if it be bad, and cunning at concealments. A pulse which is great from putrefaction of the fluids has a contraction more hasty than natural joined to its greatness. To form a great pulse, an urgent necessity is not alone sufficient; but the vital powers must also contribute, and a condition of the instrument or artery intermediate between hardness and softness. When the heat, therefore, is increased in the heart by any of the above-mentioned causes, in the first place the pulse becomes great, and, the greatness not being able to supply the want, quickness is straightway joined to it; and if that is not sufficient, density is superadded. Small, slow, and rare pulses are formed by the opposite causes. But when a change first takes place from a great, quick, and dense pulse to their opposites, namely, when the necessity is at an end, the first character of the pulse is not the first that leaves it, but it loses first that which it last acquired, becoming first rare, then slow and last small. But if the slowness and smallness should go on increasing, the rarity will again change to density, in order that the necessary want may be supplied. Such are the causes of greatness, quickness, density, and their opposite pulses. To these we shall connect the alteration of the pulse in regard to one dimension only. Breadth alone then is increased, principally by a redundancy of humidity, either natural, or from external causes, as loftiness is occasioned by the softness of the instrument, assisted by the vital power; but length is rendered apparent by the dryness and melting of the surrounding flesh, the other dimensions being contracted. For an artery cannot, in fact, become longer than natural; and this ought more properly to be called the lean pulse, as the opposite one, namely, that which is increased only in breadth and depth, should be called the fat. The pulse sometimes falls under the opposite characters to this, when it is restrained as to any of its dimensions, and appears low, narrow, and short, when it is not so in reality, but seems so, owing to the thickness of the fat, flesh, or membranes which press upon it. Sometimes, too, the whole seems small, when it is not so in reality; and feeble in like manner. And what do I say? Sometimes an asphyxy, or complete loss of pulsation, hath seemed to take place over the whole arteries, when there is no such thing in reality; and this has happened, more especially to those who have felt them carelessly, when the motion, being really indistinct, escapes notice, owing to the quantity of flesh; for it is impossible that a complete asphyxy could take place while the man is alive. In like manner again in the emaciated, small pulses appear great. When, therefore, the body is greatly wasted, the artery which runs along the spine has often been felt by persons touching the abdomen, and also the pulses in members which before used not to be felt. Wherefore we must attend to all circumstances, that we may not be mistaken in our diagnosis. A strong pulse is occasioned by the force of the natural faculty, when not counteracted by any other cause, such as the want failing, or from hardness of the instrument. But a feeble pulse may arise from weakness of the natural powers alone, although no other causes contribute. For a strong pulse stands in need of all the other causes for its formation; but the feeble is produced by weakness alone. The originally strong pulse accompanies moderate ages, seasons, places, and temperaments; but the feeble the immoderate. A pulse changing from feebleness to strength is formed by the vital faculty growing strong, from a preceding state of debility. It is strengthened either by things within the body, such as concoction of the fluids, or an excretion of them, or passion; or by externals, such as wines, food, exercises, and whatever will rectify the intemperament. The natural powers are weakened by want of food, watchfulness, immoderate evacuations, grief, cares, and more especially pains inducing syncope, and whatever forms an intemperament. Some inexperienced persons have thought a hard pulse strong, but a person of experienced understanding and touch will not mistake them; for a strong pulse, being mostly accompanied with greatness, is swelled up to loftiness and strikes the finger forcibly; but the hard does not admit of greatness, on account of the unyielding state of the artery. Wherefore a pulse becomes hard owing to the hardness of the artery. This is occasioned by immoderate cold, or dryness, or tension proceeding from inflammation, or spasm. To the hardness, moreover, are joined smallness, quickness, and sometimes density instead of greatness accompanying, owing to the exciting want. A soft pulse follows a humid state of the artery. An artery is rendered more humid by things not preternatural, such as more liquid food, immoderate baths, much sleep, a more abundant diet, and hilarity; and by preternatural causes, such as coma, lethargy, dropsy, and the other pituitous affections. A full pulse indicates an abundance of fluids, or plethora from food, or from drinking wine, as the empty, on the other hand, indicates deficiency of food or evacuation. When the body of the artery feels warmer under the finger, this indicates great heat in the heart, while the rest of the body is cold, or a certain spasmodic state of the arteries, which are warmed by the violent motion. Archigenes says that the place of the artery will particularly be found warmer in catochus and in those who are about to be affected with somnolency. With regard to rhythm, when the ratio of the times of motion and rest is equal, it indicates a proper temperament of the body, or no great departure from it, as in early age, and the otherwise well-regulated bodies. But when the time of rest is greater than that of motion, this indicates that heat prevails, as in adults and those of the adjoining ages; as, in aged bodies, which are entirely cold, the time of motion is greater than that of rest. It is to be remarked that inequality in regard to rhythm, being the measure of that as to quickness and density, this holds the place as it were of the matériel to the rhythm.
The intermittent and intercurrent pulses take place when the powers are oppressed, and, as it were, borne down; but the intercurrent indicates a lesser, and the intermittent a greater injury. And, in general, that state in which the powers are oppressed and borne down, changes the pulses to inequality and irregularity in every other respect, and also in regard to strength and greatness. The pulses called myuri, being shown to be of two kinds, (for they are found either in that inequality called systematic, or in regard to one pulsation), the failing or fainting evince the last prostration of the powers; but, when they return, or are recurrent, they indicate that the powers are weak, but that they are struggling, contending, and have not yet submitted. As to the myuri, in regard to one pulsation, called the failing, and the failing on both hands (innuentes et circumnuentes), these happen to persons who are gradually wasted by inflammations not yet resolved, and to those who are wasted from whatever cause, the bodies around the arteries being melted down. Pulses of unequal velocity, and those called dorcadissantes or goat-leap, principally accompany febrile heat. But if the pulse render the commencement of the diastole feeble, and increase in velocity towards the end and beginning of the systole, this indicates that putrefaction is prevailing, nature hastening on the discharge of the fuliginous superfluities. But if, on the other hand, it render the commencement of the systole feeble, and rather make speed towards the diastole, you may be sure that the heat is prevailing, and longing for refrigeration. These in fever are, for the most part, accompanied by density, and sometimes greatness, if the powers be not restrained by the hardness of the instrument. When the hardness of the artery increases, and the powers are not weakened, the double or reverberating pulse is formed. The undulatory pulse most commonly attends the more humid affections, such in particular as anasarcous swellings, lethargy, and peripneumony. When the powers of life are beginning to fail, but are still making a faint struggle, the undulatory pulse sinks into the vermicular; but when they decline to their lowest ebb, this last passes into the ant-like or formicans. The hectic particularly attends those in consumption and marasmus. The spasmodic pulse takes place when the origin of the nerves is suffering from some inflammatory affection, as in frenzy and acute attacks of epilepsy, when those affected with them die while they are yet warm, contrariwise to those in syncope, for they are alive after they have become cold. The clonodic or vibratory pulse takes place when the wants of the system require a great diastole, and the vital powers are sufficient for that purpose, but are opposed by the body of the artery; which, from its hardness, cannot be expanded to a large diastole, as happens in great inflammations and chronic obstructions. The serrated pulse is indicative of inflammation, and particularly in some tendinous parts. It is no less so of pleurisy, and when slight, indicates that the inflammation is gentle, and easily to be concocted; but when intense, that it is severe and of difficult concoction, and will be attended with urgent danger, if the powers be weak, or, if they be strong, that it will be slowly concocted, for it will either terminate in empyema, or a consumptive marasmus will supervene. One ought also to know that irregularity of the pulse commonly accompanies its inequalities; for you will rarely find an unequal pulse orderly. Wherefore, the lesser constitutional injuries occasion unequal and regular pulses, but the greater, unequal and irregular.
These are the simple causes of the pulses and their prognosis, and from them the compound, as we stated when treating of their differences, may easily be discovered.
Commentary. The ancient authorities on the pulse are the following: Celsus (iii, 6); Galen (Libel. de Pulsi. ad Tirones; de different. Puls., de Dignos. Puls., de Caus. Puls., de Præsag. ex Puls., Synopsis librorum de Puls.); Philaretus (de Pulsu); Theophilus Protospatharius (de Pulsibus ap. Ermerins Anecd. Med. Gr.); Actuarius (de Diagnosi); Avicenna (i, 2, 3); Averrhoes (Collig. iv, 16); Haly Abbas (Theor. vii); Alsaharavius (Theor. vii); Rhases (ad Mansor. x, 32; Contin. xxxi); Psellus (Opus Medicum apud Boissonade, Anecdota Græca.)
Prosper Alpinus gives an excellent exposition of the ancient doctrines on the pulse (de præs. Vit. et Morte ægrot. iv, 3); Le Clerc’s account is not so accurate (Hist. de la Méd.) Wetsch’s is tolerably correct (de Pulsu.)
Hippocrates, although Galen affirms that he was not entirely unacquainted with the pulse, does not appear to have attached much importance to the observation of it, for he generally neglects to mention its characters, where we would most expect to find them stated, as, for example, when he is detailing the symptoms of epidemical fevers. Celsus, too, expresses himself in doubtful terms respecting the indications furnished by the pulse: “Venis enim maxime credimus, fallacissimæ rei; quia sæpe istæ leniores, celerioresve sunt, et ætate, et sexu, et corporum naturâ; et plerumque satis sano corpore, si stomachus infirmus est, nonnunquam etiam incipiente febre, subeunt et quiescunt; ut imbecillus is videri possit, cui facile laturo gravis instat accessio. Contra sæpe eas concitat et resolvit sol, et balneum, et exercitatio, et metus, et ira, et quilibet alius animi affectus.” Aretæus and Cælius Aurelianus are indeed sufficiently minute and accurate in detailing the characters of the pulse, while describing the symptoms of various diseases, but neither of them has written expressly on the subject; and, as the works of Herophilus, Agathinus, Magnus, Athenæus, and Archigenes are entirely lost, Galen must be considered as our first and great authority on the pulse—we might almost have said our sole authority, for all subsequent writers were content to adopt his system, without the slightest alteration. As our author’s account of the subject is professedly taken from the elaborate treatises of Galen, it may, perhaps, appear unnecessary to attempt any further exposition of the system; but the importance of the subject, and, we may add, its novelty to modern readers, have induced us to make some detached observations upon it, in order to explain some parts of it which are confessedly obscure, and to answer certain objections which have been stated against it, by modern writers who have not properly understood its principles.
We shall first notice the objection stated to Galen’s Theory of Respiration by Van Helmont, who, although compelled to admit the ingenuity of Galen’s system, pretends to differ from him respecting the final cause of arterial action and respiration, which, he maintains, is not refrigeration, but the maintenance of animal heat. (Opera, p. 112.) But if he had read Galen’s work ‘de Usu Respirationis’ carefully, he would have found that this is the very sense which Galen attaches to the terms refrigeration and ventilation. Van Helmont states, as a new discovery, that a sort of concoction of the blood takes place in the left ventricle of the heart. But he might have found this doctrine also in the works of Galen.
According to Galen, the pulse consists of four parts: of a diastole and a systole with two intervals of rest, one after the diastole before the systole, and the other after the systole before the diastole. He maintains that by practice and attention all these parts can be distinguished. (De Dignos. Puls. iii, 3.)
The first distinctions of the pulse are derived from the extent of the diastole, according to its three dimensions, namely, length, breadth, and depth. These give rise to the characters long, broad, and deep or high. Le Clerc renders the last by élevé. A long pulse, of course, refers solely to the impression on the finger, as in reality one pulse cannot properly be said to be longer than another; but when a person is lean a larger portion of the artery can be felt under the finger than when he is fat.
The character deep or high is easily understood, and is evidently produced by a free dilatation of the artery. It does not indeed appear evident how there can be a difference between a deep and a broad pulse, if the dilatation of an artery were equal on all sides; but Galen positively affirms that it is a fact ascertained by ample experience, that sometimes there is a free dilatation of the artery upwards with a contracted one laterally, constituting a high and narrow pulse; and, on the other hand, that there is often a free dilatation laterally with a contracted one upwards, constituting a low and broad pulse. He gives directions for detecting these peculiarities of the artery. (De Diff. Puls. iii, 2.)
The characters of quick and slow are derived from the length of time occupied in the actions of systole and diastole. They seem to be sufficiently well marked, and yet Fyens denied that there is any difference between frequency and quickness. However, many of our late authorities in medicine acknowledge a distinction between these two characters, and they appear to us sufficiently obvious. In fact, Galen establishes the distinction in the most satisfactory manner. (De Dignos. ii.)
The distinctions of strong and feeble are derived from the force with which the artery strikes the finger. No one can possibly mistake them.
The relaxation and constriction of the arterial tube give rise to the characters of soft and hard, which are so obvious that they cannot be misunderstood. The character of hardness is called tension by Galen, who states that it is characteristic of inflammation.
The next class of pulses derive their characters from the time which elapses between two diastoles or pulsations of the artery. They are called dense and rare, in the ancient system, being used in the same sense that frequent and slow are in modern works.
The terms equal and unequal (or, as they might have been translated, equable and unequable) arise from the constancy or inconstancy of any peculiar character of the arterial pulsation. The regular and irregular are distinguished from these, inasmuch as a series of pulsations, although unequal may be regular, when they observe a certain ratio, as when four strong pulsations are succeeded by a feeble one, and this series goes on successively.
An inequality may take place in respect to one pulsation; for the dilatation of the artery may be interrupted, and then completed, when it is called dorcadissans, caprizans or goat-leap; or the stroke may be suddenly repeated, when it is called dicrotos, which may be translated the double, reverberating, or rebounding pulse. The term dorcadissans is derived from dorcas, an animal generally supposed to have been the goat, but it is now satisfactorily ascertained that it was the antelope dorcas or gazelle; and, in the Latin translations of Avicenna and Haly Abbas, it is rendered gazellans. It is said that when this animal leaps upwards it at first takes a short spring, then seems to make a sudden stop, and afterwards takes a much larger and swifter bound. This character was applied to the pulse when an imperfect dilatation of the artery is succeeded by a fuller and a stronger one. (Galen, de diff. Puls. i, 28.) It is thus described by Haly Abbas: “Gazellans pulsus est qui cum a celeritate incipiat antequam percussiat stat, dehinc velociter movetur: vocatur autem hujusmodi gazelenus suâ ex similitudine caprioli saltu: quum capriolus quem Gazel Arabicè vocant cum saltum dederit pedes tollit et suspensus pauco videtur tempore atque sic ad terram velociùs redit.” The translator of Alsaharavius renders it by fusalis. It is correctly stated by Fouquet that the second pulsation is necessarily larger than the first. The dicrotos consists of two pulsations, following upon one another so rapidly as to form, as it were, but one beat of the artery. In the translation of Alsaharavius it is called mallearis, and is thus defined: “Est autem pulsus mallearis qui percutit manum et recedit, deinde redit et percutit secundario.”
When there is a succession of pulsations which diminish in magnitude regularly, such a system of pulses is called myuri, that is to say, decurtate or sharp-tailed, from their supposed resemblance to the tapering tail of a mouse. Those who are acquainted with the Scholiast on Hephæstion, and the other ancient writers on prosody, will readily recognize a term with which they are familiar. Galen inclines to the opinion that this state of the artery is connected with an intemperament of the portion where the expansion is limited. Of these pulses, some end in complete asphyxia, and hence are called swooning, failing, or fainting myuri, (Le Clerc renders it by le myurus defaillant;) and others again gradually recover their former magnitude, and are called recurrent myuri. Nearly allied to these are the innuentes et circumnuentes, for which it is scarcely possible to find any appropriate term in English. Le Clerc thus renders and explains this pulse, in French: “Le myurus qui va en baissant de côté et d’autre, c’est a dire qui frappe moins sensiblement le premier et le dernier doigt que celui ou ceux du milieu.” It consists, as Avicenna explains, of a double myurus, which swells out in the middle, and diminishes at both extremities. It was therefore a sort of double inclined plane. The myurus, and the innuens et circumnuens, are thus described by Haly Abbas: “Est autem et in hac specie unius pulsationis pulsus qui muris cauda appellatur; quique inclinus vocatur pulsus. Et qui muris cauda vocatur fit cum arteria dilatatur sub primo digito qui a superioribus est grossa, et sub secundo minus grossa, sub tertio parva, sub quarto minima. Inclinus autem pulsus est qui sub duobus mediis movetur digitis grossus et sub extremis hinc et inde subtilis et tenuis; aut medium ejus elatum est, et extremitates demissæ, videturque tangenti arteriæ extrema ad inferiora declinari.” Sprengel appears to think that the pulsus inclinus of Haly Abbas is one first described by him, but there can be no doubt of its being identical with the innuens et circumnuens (νενυκὼς καὶ περινενευκὼς) of Galen’s system. It is likewise the same as the pulsus inclinatus of Rhases, who says it occurs in hectic fevers and consumption. Galen attempts to explain this pulse by referring it to weakness of the vessel and an unequal wasting of the parts around, which convey the impression, when several fingers are applied together, as if the vessel swelled out in the middle. (De Diff. Puls. ii.)
In the spasmodic pulse, the artery is said to convey the sensation of a string or cord tightly stretched, which, when touched, starts from its place. It seems to be the pulsus tortuosus of Alsaharavius, and is commonly met with when convulsions are impending.
The vibratory derives its name from an imaginary resemblance to the motions of a rod or dart when thrown into the air, and it can only take place when the artery is hard, and the strength good. Le Clerc renders it le pouls dardant. It is generally named thrilling in modern works. According to Actuarius, it is hard, quick, and dense, and indicates inflammation of nervous parts.
The undulatory derives its name from a supposed resemblance to the rolling of the waves, and can only take place when the artery is particularly soft, being accompanied with an unequal elevation of it in the diastole. It is thus described by Rhases: “Undosus vero est qui secundum latitudinem, magnum digiti occupat locum, cum lenitate et repletione, cum eo tamen non est magna elevatio neque subita, sed videtur quod elevationem ejus una post aliam contingit, donec fit ut undis assimilatur, quarum una aliam sequitur.” It is the pulsus fluctuosus of Haly Abbas, and the pulsus fluens of C. Aurelianus. (Morb. Acut. ii, 32.) Le Clerc renders it ondoyant.
The vermicular differs from the last mentioned only in magnitude and strength, being soft, small, and weak. Nearly allied to it is the formicans or ant-like pulse, which is one of the last degree of weakness, smallness, and density. They are thus described by Rhases: “Vermicolosi forma est ut forma undosi, in elevatione quæ secundum diastolem eadem invenitur, non tamen est latus, neque plenus, cujus inundatio existit debilis, qui vermibus per foramen arteriæ discurrentibus assimulatur: formicans vero pulsus adeo invenitur in ultimo parvitatis, et spissitudinis consistere, ut pulsui pueri recens nati assimuletur.” According to Galen the formicans is a pulse which it requires great experience to detect. (De Dignos. Puls. ii, 1.) Haly Abbas states that it is the termination of the vermicular. It is the pulsus formicabilis of Cælius Aurelianus. The Chinese compare the formicans to a silk thread, a capillary tube, or a hair.