Part 48

The causes which produce all these varieties of pulse, and the changes of the system which they indicate, are, upon the whole, pretty clearly explained by our author; and the reader who wishes to consult other abridgments of the doctrines of Galen, may find them in the works of Rhases, Haly Abbas, and Actuarius. We shall merely make a few more remarks upon some of the more obscure and least understood parts of the system.

Respecting the myuri, Galen states that they all indicate a prostration of the vital powers, but differing in degree, according to circumstances. When the pulse gradually becomes smaller, and in like manner recovers its magnitude gradually, and so on alternately, so as to form the recurrent myuri, it indicates an inferior degree of prostration; and, when the diminished state of pulsation continues permanent, a greater degree of oppression is indicated. In the former case the powers of the system seem able to struggle against the load, but in the latter they are completely overcome. This state is next in danger to that of complete asphyxia. These three are the worst kinds of pulse. The intermitting is said by him to be allied to these, being indicative of great danger, though inferior to that of those we have mentioned. Next to the intermitting is the intercurrent, which indicates that the powers of the system are strong, but oppressed, and contending against some great load. Galen was particularly apprehensive of the intermitting pulse, which he held to indicate that the system is struggling against some urgent cause. He remarks, however, that, when the pulse is otherwise strong and frequent, it indicates less danger than when it is weak and slow. But, upon the whole, he considered this kind of pulse so full of danger, that he affirms he had never known a person recover whose pulse intermitted during the interval of two pulsations. When the pulse intermits during the space of only one pulsation or a little more, he says he had often seen the patient recover. He also states that an intermitting pulse is less dangerous in old persons than in adults or children. Some, he says, affirm that they have seen cases of intermission which did not prove dangerous, but he believes that they had confounded rarity with intermission. The intermitting is to be distinguished from the rare by the length of the time of rest, and by the latter being often equable, whereas the former is always unequable. He says it is generally occasioned by frigidity of the heart. These doctrines may be traced through all the subsequent authorities, both Greek and Arabian, down to Actuarius.

Galen, Rhases, and Haly Abbas repeatedly inculcate that the undulatory pulse indicates an approaching crisis by a sweat. They describe it as being strong, full, soft, bounding, and unequable. According to Galen it is most commonly met with in lethargic affections, quotidian, marsh, and typhoid fevers. (De Præs. ii, 9.) It is also said to be common in sudden attacks of dropsy. (Ib.) In some instances, however, it is the precursor of some critical evacuation, such as that by the hemorrhoids, or by the bowels. (Synops. 22.) Actuarius particularly states that critical sweats are indicated by the undulatory pulse. (Meth. Med. ii, 2.)

The dicrotos is distinguished by a smaller pulsation suddenly succeeding to a larger one. Galen compares it to a hammer, which, when forcibly struck against the anvil, rebounds, and strikes it again. The artery in such cases is always strong and vibratory. Philaretus describes the pulsation as being hard, vehement, and rebounding. Galen says it can only occur when the powers of the system are strong, the artery hard, and the body oppressed with a redundance of humours. He repeatedly inculcates that it indicates an approaching crisis.

The singular pulse called dorcadissans, which we have translated goat-leap, is said by Galen to occur most frequently in affections of the heart and inflammations of the parts within the chest. (De Prognos. ii, 8.) It is the same as the pulse now called jerking, which the best authorities agree to be characteristic of pericarditis. In such cases, Hope says, the pulse is “full, hard, jerking, and often with a thrill.” (Diseases of the Heart, p. 99.) We suspect the modern term jerking, although perfectly intelligible to one experienced in the art of feeling pulses with discrimination, will be found fully as difficult to define as the dorcadissans of the ancients.

The vermicular appears to have been the same as that which is now sometimes denominated creeping. In fact, Galen derives its name from its resemblance to the motion of a creature creeping. (Synops. 22.) It is said by the ancient authorities to occur in cases of sudden prostration of the vital powers, produced by inordinate evacuations, such as hemorrhage, cholera, diarrhœa, and the like. (De Prognos. Puls. ii.)

The pulse called innuens et circumnuens, is said to occur only in cases of extreme debility and danger, more especially when attended with a great chill. It is connected, says Galen, with idiosyncrasy. (De Præs. ii, 11.) Is it the same as the pulse now named flickering?

Galen gives the following ingenious explanation why the pulse is contracted and frequent, in cases of acute inflammations. He remarks that, if a person have an inflammation in a limb, he will experience most ease in a state of complete rest; but if obliged, by some urgent necessity, to perform a journey, he will find that he can accomplish this most easily by taking short and frequent steps. In like manner, when any part is inflamed, it would afford most relief if the motion of the arteries could be altogether suspended for a time; but, as this cannot be, nature renders the dilatation as confined as possible, and makes up for its smallness by frequency. (De Usu Respirationis.)

SECT. XIII.—ON THE ALVINE DISCHARGES.

Of the alvine discharges, the best is that which is soft and compact, and is evacuated at the hour which is customary in health. Such excrement is yellowish, of the proper consistence, and not very fetid; for whatever is different from these is not good. That which resembles in colour the food which has been taken, or is thin, wants the natural juices, and is passed quickly, is indigested. But that which is intensely yellow, if evacuated in the beginning of a disease, indicates that the complaint is of a very bilious nature; but if after the acme, that the body is properly purged. The green is the sign of verdigris-green bile, but the black of black bile, or of adust blood mixed with it. The livid marks a coldness and considerable mortification of the internal parts. The oily is the mark of a melting of the fat in the body; as the glutinous, which is worse than the oily, is a mark of a melting of the parts of the animal. That which is very fetid is a mark of no small degree of putridity. With regard to them all, if the quality of the excrements does not correspond with the food which had been taken, you may thus judge of the affection. Of all kinds, the worst and most fatal is black, livid, oily, and what is hastily passed.

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COMMENTARY. See, in particular, Hippocrates (Prognost.); and Galen (de Crisibus, xi.) Galen remarks that the stomach may do its office properly, but that, owing to the heat of the neighbouring parts, the moisture may be dissipated, and the contents of the bowels rendered too dry; or that, owing to an imperfect distribution of the chyle, they may be too liquid. When the alvine discharges are soft and consistent, we are certain that both the digestive and distributive functions are properly performed, and likewise, that no part within the belly is in a state of inflammation. He afterwards makes many other ingenious observations on this subject, the importance of which, towards the restoration of health, is now generally admitted. He remarks, that, agreeably to the description of Hippocrates (Prognost.) the proper alvine evacuation ought to be yellowish; for, if very yellow, it indicates the presence of too much bile, or, if it do not partake of that colour at all, it indicates that the passage of the bile to the intestines is stopped. Rhases and Avicenna concur in this remark. Galen describes the frothy evacuation, which appears to be the same as the one resembling yeast, described by modern authorities. Hippocrates (Progn.) and Galen makes mention of a discharge, which consists of small, hard, and convoluted portions. Galen is of opinion that it is occasioned by constipation and heat of the bowels. According to Hippocrates, a discharge of black bile indicates that death is at hand. (Aphor.) Theophilus treats of this subject at such length that we cannot afford room for a proper outline of what is contained in his treatise. Bloody evacuations, he says, proceed either from disorder of the liver, ulceration of the intestines, or rupture of a vessel. Discharges of pus may come either from the liver, or from the stomach, or from the intestines. A viscid and fatty evacuation indicates melting of the body, and if attended with a fetid smell, putrefaction. Flatus in the bowels may either arise from flatulent humours forming in the bowels, or food dissolved into gases by the heat of the parts. (De Excrementis.)

The account of this subject given by Haly Abbas (Theor. vii, 16, and x, 10) is excellent, but principally collected from the Greek writers. An unctuous discharge, he remarks, is occasioned by a melting of the fat. If it be viscid at the same time, it indicates also a wasting of the principal members. A frothy discharge proceeds from heat and flatulence. A green evacuation indicates immoderate heat, and the presence of bile. Black discharges consist either of black bile, or of common bile blackened by immoderate heat. This, he says, is the worst appearance of all. If blood is discharged after the fæces, it may be supposed to come from the small intestines; but if before, from the large; and if mixed with the fæces, it probably comes from the intermediate parts. See also Alsaharavius (Theor. ix), and Rhases (Cont. xxxi.) Rhases states that white fæces arise from jaundice. When the discharges are watery, the nourishment of the body is stopt.

The opinions of Hippocrates and Galen on this subject are correctly stated and explained by Prosper Alpinus (De Præsag. Vita et Morte ægrot. vii, 11.)

SECT. XIV.—ON THE INDICATIONS FROM THE URINE.

As concerning the alvine discharges, so also with respect to the urine; using that of healthy persons as a rule, we shall hence form our indications of that of persons in disease. That urine, therefore, is best, which is nearest to that of healthy persons. Such is that which is at the same time of a faintish golden, or faintish saffron colour, and which, moreover, is moderate as to consistence. There are three varieties of turbid urine; for, either straightway after being voided it deposits a sediment; or it always remains the same; or it is voided pure, but afterwards becomes turbid; of these, the third is bad, the first favorable the second intermediate between them. That which is wholly unconcocted, being altogether watery, is symptomatic of digestion being entirely gone in the venous system; and when it is passed frequently, the disease is called diabetes, which is the worst of unconcocted urines. Next to these is the thin and white urine, which resembles water. Nearly allied to these, is another kind of urine, appearing in many diseases, and which is very like to the thin and white. The palish is next to this. The pale may also be of a faintish golden colour, and is concocted in proportion as it partakes of this colour. It ought, however, to be as much different from water in thickness as in colour, if it is to be properly concocted. But if it preserve exactly its natural colour, and have a white, smooth, equable, and copious sediment, it is indicative of perfect digestion. A greater quantity than natural indicates that a crude humour is purged off; but if it is somewhat thicker than natural, and has a certain sediment, it is not then altogether unconcocted. But if it have gritty, scaly, furfuraceous, black, livid, green, or fetid sediments, such urine is altogether unconcocted and particularly mortal. But urine of a proper colour, and which at the same time has white, smooth, and equable sediments, or certain cloud-like appearances, or substances swimming in the middle of a like kind, is of all others the best. Of these characters, the sediment is of the most importance; next, the substances swimming in it; and third, the cloud-like appearances on its surface; and, on the whole, of the substances which float in the urine, the more they sink downwards so much the better.

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COMMENTARY. See Hippocrates (Prognost. ii, et de Vict. Acut. c. 46); Galen (Comment. de Crisibus, i, 12); Celsus (ii, 7); Theophilus (de Urinis); Actuarius (de Urinis); Abicianus (de Urinis; De Urinis secundum Syros, de Urinis secundum Persas, de Urinis Commentatio, ap. Phys. et Med. Græc. Minor. ed. Ideler); Aëtius (v); Avicenna (iv, 2, 1, Cantic. p. 1); Averrhoes (Collig. iv, 21); Haly Abbas (Theor. iv, 12, x, 10); Alsaharavius (Theor. viii); Rhases (ad Mansor. x, 30, and Contin. xxxi); Psellus (Opus Medicum.)

Of the ancient authorities who have treated of the urinary discharges, Theophilus and Actuarius are most particularly deserving of attention. Besides the watery portion, the ancients distinguished three distinct substances in the urine: 1st, the hypostasis or sediment, which is the part that falls to the bottom; 2d, the enæorema, or substances which float in the watery part, but have not weight to subside; 3d, the nubeculæ, or cloud-like appearances seen floating on the surface, or as they may be called the scum. All the different appearances which these substances put on, including every imaginary shade of colour, are described with surprising minuteness, and connected with the morbid conditions of the system which gives rise to them. In fact, there is no part of our task which we are obliged to discharge in so unsatisfactory a manner to ourselves as the present; for, to give our readers anything like a competent exposition of the knowledge possessed by the ancients on the morbid appearances of the urine, we would require to transfer to our pages the whole contents of the large treatise of Actuarius. We shall now give a few extracts from his work and that of Theophilus. They state that the urine of sedentary persons has more sediment than that of persons who pursue an active course of life; that the urine of women, from this cause, has generally more sediment than that of men; that of children more than that of adults; and that of persons who live grossly, than the urine of temperate persons. Theophilus thus delivers the characters of oily urine. When in fevers the urine assumes the colour of oil, it indicates that the fat of the body is melting down. When the appearances of the urine resemble oil still more, it indicates an increase of the melting of the fat; and when the urine in consistence and colour appears exactly like oil of a dark colour, it prognosticates a collapse and death. (§ 17.) This accords with what is stated in one of the aphorisms of Hippocrates: “When in ardent fevers the urine has an oily sediment, it prognosticates death.” The tare-like urine, as it was called from the resemblance of the sediments to the colour of the tare (ervum ervilia), but which might be better called the grumous, since, as Actuarius explains, they bear a close resemblance to clots of blood, is said by Theophilus to be indicative of melting of the flesh. The scaly urine derived its name from small substances resembling the husks or hulls of grain in the urine, and in febrile diseases was supposed to indicate great disorder of the general system, but otherwise to be connected with an affection of the bladder. The furfuraceous, which derived its name from the resemblance of the sediments to bran, was also held to be symptomatic of local disease of the bladder, or of constitutional disorder in fever. The gritty, so called from the resemblance of the substances in the water of the urine to large particles of ground grain, was reckoned by all the authorities, from Hippocrates downwards, as a very bad symptom in fevers. Fetid urine was supposed to indicate melting or putrefaction of the body. Actuarius gives a curious account of urine without sediment, which he ascribes to its being attracted to some part of the system which is the seat of inflammation or erysipelas. (v, 5.) The enæorema, or substances in the middle of the urine, are said by Actuarius sometimes to resemble spiders’ webs, sometimes specks of oil like what appears in fat broth when cooled, and at other times hairs, as will be more fully stated elsewhere. The nebulæ, or scum on the urine, is said to put on various appearances, as, for example, that of bullæ or bubbles, of which mention will be made in another place. From a passage in Theophilus (v, 8), it may be inferred that the ancients sometimes applied external heat as a test of the characters of the urine. On the main the differences in the colours of the urine were held to depend on the mixture of bile in the urine, and sometimes, though rarely, of blood.

As a specimen of the doctrines of the Arabians, although, in fact, entirely borrowed from the Greeks, we shall select a few of the observations of Haly Abbas and Alsaharavius. According to Haly, thinness of the urine indicates deficient digestion. Thickness, on the other hand, is the product of excessive digestion, or arises from the presence of pituitous humours in the body. When the sediment is white, it is a favorable symptom; when yellow, it is from yellow bile; when red, it is from a sanguineous plethora and imperfect digestion; and if of long continuance, it must proceed from inflammation of the liver. If, after intense redness, the urine becomes black, it is a most fatal symptom. When the urine is moderately fetid, it is connected with indigestion; but when very fetid, with putrefaction. Alsaharavius delivers the characters of the different kinds of urine in nearly the same terms. He properly cautions the physician not to allow himself to be imposed upon by the colour of the urine, which may sometimes acquire a tinge from the patient’s having taken saffron, cassia-fistula, or the like. Such tricks, he says, are often practised upon water doctors. According to Rhases, it is an unfavorable symptom when the urine does not become turbid in the course of the fever. Yellow urine without sediment is said to be unfavorable.

Prosper Alpinus has stated correctly the doctrines of Hippocrates and Galen, but is entirely silent respecting those of Theophilus and Actuarius. (u. a.)

Besides the ancient authors referred to by us in this chapter, the works of the following writers de Urinis exist in manuscript, but have never been published: 1, Athenæus, quoted by DuCange (ex Cod. Colbert, 3614); 2, Constantinus Africanus (in Bibl. Cæsarea); 3, Joannes Episcopus (Cod. Reg. 3497); 4, Maximus Planudes and Meletius Monachus (Cod. Reg. 3175); 5, Nicephorus Blemmydes (in Bibl. Cæsarea); 6, Anonymus, &c. (Cod. Colb. 3614 and 4230, et in Bibl. Cæsar.); 7, Piropulus (in Bibl. Corsliniana, 448.) See Fabricii (Bibl. Grac. xiii, 779.) The treatise of Abicianus, noticed by Fabricius, has been published by Ideler. It proves to be a mere compilation from the works of Avicenna.

SECT. XV.—ON THE INDICATIONS FROM THE SPUTA.

Such as are somewhat yellow, golden, frothy, and thin, indicate only want of concoction, but nothing positively bad. But such as are intensely yellow, golden, frothy, green, viscid, round, and still more the black, are bad. For, with the exception of the blood, whatever of the other humours is unmixed, indicates a bad diathesis, having its origin in an inflammatory heat. The bloody sputa are of an intermediate character, but those of yellow and black bile are unfavorable. The manner in which they are brought up ought also to be considered; for, if they are readily spit up, it is clear that such are good, whereas the contrary are bad. It is an indication of complete concoction that the expectoration is unctuous, white, and equable, and in consistence, neither fluid nor very thick; as it is of a complete failure of concoction that it is not spit up at all. If it is indeed spit up, but thin, it is a mark of feeble concoction. If it is of an unmixed yellow or golden colour, it is not good. But if it is livid, of a verdigris-green, or black, it is a most fatal symptom.

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COMMENTARY. Galen has treated fully of this subject in his work (de Crisibus, ii, 10.) See also Hippocrates (Prognost. and Coacæ), and Celsus (ii, 9.) Aëtius is somewhat fuller than our author (v, 52.) See Avicenna (iv, 2); Averrhoes (Cantic. i, 2); Haly Abbas (Theor. vii and x, 10); Rhases (ad Mansor. x, 24.)

We shall be content with giving a few of the observations of the Arabians, of whom Haly is the most full and accurate upon this head. The lungs and the other parts within the chest being the organs of life, when affected, they occasion inflammation of the heart. Expectoration indicates some affection of those parts. When the expectoration is thin and small in quantity, the disease is not concocted; when the sputa are of moderate consistence and equable, the disease is at its acme; when thick, it is certainly on the decline. Thinness indicates that the humour which occasions the complaint is of a subtle nature; thickness, the contrary. Blackness indicates vehement heat. Green sputa are indicative of the presence of green bile, white of phlegm, and redness of blood. When fetid, they proceed from putrefaction. Black sputa indicate great danger.

Prosper Alpinus makes many ingenious remarks on the characters of the sputa. (De Vita et Morte ægrot. vii, 19.)