In Defence of Ancient Bloodletting
Transcription
In Defence of Ancient Bloodletting
SA 28 Julie 1979 MEDIE I:: TYD KRIF 149 Histol'Y 01 Medicine In Defence of Ancient Bloodletting P. BRAIN SUMMARY The ancients used bloodletting extensively in infectious and other diseases. When recent work on iron and bacterial infection is taken into account, it is possible to argue that bloodletting, which reduced plasma iron and transferrin saturation, might have been of value in increasing resistance to infection by bacteria or plasmodia. Galen's bloodletting methods are summarized, and their probable effect on plasma iron is considered. The ancient physicians, who had no specific remedies for infection whatsoever, may well have been justified in making responsible use of bloodletting, both for the treatment and for the prophylax:s of infectious disease. S. Afr. med. J., 56. 149 (1979). The ancients used bloodletting extensively as a general therapeutic measure. a practice that began before Hippocrates and became extinct, except for a few special indications, within living memory. Until a few years ago it would probably have been impossible to put forward a rational justification of the ancient practice in the light of modern pathology. I believe, however. that when recent work on iron and bacterial infection is taken into account it is possible to argue that the general use of venesection in infectious disease, which prevailed in antiquity. may have been justified in the circumstances then obtaining. I attempt such an argument in this article. By far the most extensive account of bloodletting in antiquity is that of Galen. In addition to numerous references in other books, he has left 3 extensive works on venesection,' the first dating from his arrival in Rome for the first time in AD 162. when he was in his early thirties. and the third from the closing years of his life, some 30 years later. Since no English translations of any of them have ever been published. it is not surprising that they are little known today. They offer, however, much interesting information on Galen's personality and on medical practice in Rome in his time, in addition to his views on venesection. Galen used venesection both as an evacuant and as a revulsive or derivative remedy, but only its use as an evacuant is relevant to the present argument. The writers of the Hippocratic corpus in the 5th and 4th centuries BC, although Galen would like to think otherwise. generally used venesection only occasionally and in moderation; Galen, on the other hand, employed it in all the acute infectious diseases and in others. too. as long as the Natal Blood Transfusion Service, Durban P. BRAIN. :\1.A .. :\1.0 .. Medical Director D.lle received: I March 1979. patient's strength permitted and certain other conditions prevailed. He did not originate this practice. Celsus say that in his own time, the beginning of the Christian era. it was a new doctrine that venesection should be used in almost all diseases,' and this idea does not appear anywhere in the Hippocratic corpus except once in the Appendix to the work Regimen in Acute Diseases. This appendix is a lengthy collection of disjointed notes, generally regarded as spurious (if, indeed, anything in the Corpus can be regarded as genuine); hence part of it may well be late. The relevant pas age reads: 'In the acute diseases you will phlebotomise if the disease appears severe, and the patients are in the prime of life and in possession of strength',' and Galen remarks that it i worthy of Hippocrates and that he should have included it in the Aphorisms! He is less complimentary about other parts of the same Appendix,' which makes it clear that he does not attribute the whole of it to the father of medicine. Galen employed venesection in the acute diseases both when the disease was already severe and when it was expected to be so. 'The magnitude of the disease, therefore, together with the strength of the powers, are the chief indications for phlebotomy: the first a showing what one must do, the second as not forbidding it by what ome of the younger physicians call a contra-indication. For sometimes the patient's condition demands phlebotomy, while the weakness of the powers forbid it. When both of these indications require it, it is clearly catled for.'" This does not apply only when disease is already present. but also when it is incipient: 'For not only when severe disease is already pre ent is it the time for phlebotomy, but also whenever it is likely to occur. The doctrine that Hippocrates enunciated ha anticipated us by teaching that however much we may rightly do once diseases are already pre ent, it is nevertheless better for us to forestall them by acting at their beginnings or when they are about to begin. Thu it i possible to carry over the said indication to people in health. For you will phlebotomise these too when there is a likelihood that they will be eized with a evere disease. taking into consideration their age and their trength. For if someone is apt to fall into a severe di ea e, even if no sign exists anywhere in the body. we think it proper to perform phlebotomy. It is enough to con ider the patient's age. with his strength, 0 that the three thing comprising the decision are the magnitude of the disease. whether present or expected; the tage of life in the prime. and the strength of the power .'7 Prophylactic venesection of the kind mentioned above should take place at the beginning of spring;" we are told ature of Man that blood inin the Hippocratic work crea e in pring. Patient who had u tained injurie 150 SA MEDICAL thought likely to be followed by inflammation were al 0 venesected prophylactically. Even the empiricist physicians, ay Galen, who based their treatment on experience alone, used it in this way when some part of the body had been brui ed.9 Galen believed that in u ing venesection he was imitating nature. Even irrational brutes, he says, evacuate themselve by provoking vomiting and giving themselve enemas, as the ibis doe :'. 'Does nature not evacuate all women every month,' he a k , 'pouring forth the uperfluity of the blood? . . . Jf you could learn what great benefit the female sex enjoys from this evacuation, 1 don't know how you could delay further and not hasten by every mean to evacuate superfluous blood . . . A woman who is well cleansed is not eized with gouty or arthritic or pleuritic or peripneumonic diseases, and neither epilepsy nor apoplexy nor dyspnoea nor loss of speech ever come on at any time if she is well cleansed. Was a woman ever seized with phrenitis or lethargy or spasms or tremors or tetany while her periods were coming? or did you ever know a woman to suffer from melancholy or madness or haemoptysis or haematemesis, or headache, or suffocation from synanche, or from any of the major and severe diseases, if her menstrual secretions were well established? If they are suppressed again, she is certain to fall into every sort of evil, and when the evacuations return. they are healing remedies. But leave the women now and come to the men, and learn how a many as habitually evacuate the excess by means of a haemorrhoid, all pass their lives unaffected by diseases; while those in whom evacuations have been restrained have fallen into the gravest illnesses. Will you not evacuate even these of blood, not even if they should fall into a synanche, or into peripneumonia, but through refu ing to retract your erroneous opinions allow so many to perish? You, perhaps, will do this; 1, on the other hand. have often cured not only these diseases, but also spasm and dropsy, by evacuation of blood.'" Galen regarded a moderate evacuation as 3 cotyles (about 800 ml) of blood." He did not venesect children under the age of 14 years; in older children, I cotyle might be removed, followed by a further half cotyle later, if necessary." Even thin people, he said, could have too much blood; this was what was wrong with an anorexic girl who had not menstruated for 8 months, so he removed 3 Roman pounds (about I I) over 3 days, which cured her." Copious venesection, up to 6 pounds (2 I) in one operation, was in Galen's opinion a most effective means of extinguishing the flame of severe fevers; the amount, however, depended on the patient's strength, and some could not tolerate the removal of more than a pound and a haiL" During these heroic evacuations, which continued until the patient lost consciousne s, his trength, as indicated by the pulse, had to be carefully watched; Galen knew of three doctor who had killed patients by evacuating them in thi way." It wa not always necessary to take the full amount at one operation; sometime, particularly when there was an accumulation of crude humour, it might be spread over everal days. Thi was known a epaphairesis (repeated removal).'~ The Hippocratic belief in beneficial evacuations, whether by the menses, haemorrhoids, or phlebotomy, which Galen JOUR AL 28 July 1979 trongly upported, was no doubt current for many centurie thereafter; by 1946, however, most doctors would certainly have said that, except in a few special conditions, there wa no advantage in losing blood. In that year, however, Schade and Caroline'" described a plasma protein. tran ferrin, which has the property of binding iron. The iron in the plasma (as distinct from that in the haemoglobin) normally exists bound to transferrin rather than free, since there is more transferrin than is necessary to bind the amount of iron that enters the plasma. In normal ubject the transferrin is 30 - 40"{, aturated, and at this level the binding i extremely firm. As the transferrin saturation increases, however, the binding becomes looser, so that the transferrin is more easily deprived of some of its iron, for instance by invading bacteria. Bacteria require iron, and many species cannot grow in normal human plasma unless iron is added, the reason being that they cannot detach iron from the transferrin at its normal level of saturation; if, however, enough iron is added to saturate it fully, any excess will exist free in the plasma and bacterial growth will be greatly encouraged. Some bacteria have developed iron-binding compounds of their own (mycobactin in the case of Mycobacterium Illberculosis) which are efficient enough to compete with transferrin for iron. The higher the transferrin saturation, the easier it is for bacteria to grow; it is not surprising, therefore. that a natural mechanism exist by which, at the onset of bacterial infection, plasma iron, and hence also transferrin aturation, falls sharply." A normal adult has about 4 g of iron, of which about half is in the haemoglobin and the rest in the iron stores. principally in the liver. (Plasma iron makes up an insignificant proportion of the total.) When the body is depleted of iron by the removal of red cells, iron is mobilized from the stores, and red cell production is not much affected until these are almost exhausted. Only then does the haemoglobin fall to abnormally low levels.'" Plasma iron, similarly, does not fall to unusually low levels, de pite losses of blood, while any stores remain; never· theless it and the transferrin saturation are somewhat lower in people who are losing blood, such as women during the reproductive period, than in those who are not. It has recently become possible to estimate the total iron stores by the simple method of determining the serum ferritin level; I Jig ferritin per litre is an indication of about 8 mg storage iron, although this may not apply in all ab· normal conditions. Z1 It is thus possible to determine easily whether the subject is in iron balance, i.e. whether losses in the stools, through the skin and by bleeding are being made up by absorption of iron from food, so that the tore remain constant. If more is lost than is absorbed. the subject is in negative balance and stores decline; if more is absorbed than is lost, the balance is positive and stores increase, as they do in many Black men in South Africa because of the large amounts of iron in their traditional diet. Since, then, in plasma at least, it is more difficult for bacteria to grow if iron and transferrin saturation are at low levels, it might be argued that this would apply to all the body fluids and, hence, that in conditions where bacterial infections were prevalent, it might be to the subject' :2 Julic 1979 SA MEDIE advantage to be iron-deficient. The beneficial eva uations of the Hippocratic authors. in fact, might have been beneficial after all. Is there any evidence that this might be so? It might be thought that the physicians of the 19th century were still under the influence of the Hippocratic writers if they believed this. but the testimony of Trousseau, a most acute clinician, is nevertheless of interest. He wrote: 'When a very young physician, I was called to see the wife of an architect, suffering from neuralgia, a pale woman, presenting every appearance of chlorosis; I prescribed large doses of preparations of iron ... fn less than a fortnight there was a complete change: the young woman acquired a ravenous appetite and an unwonted vivacity; but her gratitude and my delight did not last long . . . A short cough supervened, and in less than a month from the commencement of the treatment, there appeared signs of phthisis which nothing could impede.' He wrote of another patient, 'a girl of fifteen, who after a mild attack of dothinenteria fell into a state of anaemia and prostration, which I considered chlorosis. I administered ferruginous remedies, which rapidly restored her to florid health; and although there was nothing in the family history to lead me to fear the coming calamity, she was simultaneously seized with haemoptysis and menorrhagia, and died two months afterwards with symptoms of phthisis_ which had advanced with giant strides. I do not blame the iron for having caused this calamity; but [ do blame myself for having cured the anaemia, a condition, perhaps, favourable to the maintenance of the tuberculous affection in a latent state.'''' Trousseau wrote that very few doctors shared his views, but that his conviction of their truth increased daily. In fact. von Niemeyer. the eminent] 9th century authority on tuberculosis, expressed the contrary view. which is the orthodox one today. to the effect that the better the nutrition the better the prognosis. There has recently_ however. appeared some evidence that suggests that Trousseau may have been right. When food shelters were provided for starving nomads in the Ogaden desert, bacterial and plasmodial infections, previously latent, were lighted up as soon as they were given a good diet." The same phenomenon had been observed by others in the treatment of kwashiorkor: there was a grave danger of overwhelming bacterial infection when a good diet was given to these children.'" apparently because the transferrin. in common with other plasma proteins. is reduced in consequence of malnutrition. and thus a small amount of iron will aturate it fully and permit free growth of bacteria. The same phenomenon has been observed in domestic cattle. which are free from outward signs of infection while they are short of food, but become clinically ill when the rains arrive and food becomes plentifuL'" The authors of the Ogaden studies have suggested, in fact, that some such mechanism is an ecological necessity, preventing, by an increased resistance to infection, the total annihilation of the specie in times of famine, and at the ame time the unbridled increase of numbers in time of plenty. through an increased susceptibility to infectious disease." There i a significant remark in the Hippocratic work E TYD KRIF 151 all/re of Mall, to the effect that in epidemic the body hould be kept as thin and weak as possible.'" The observation that the state of the highly trained athlete i a dangerous one also appear more than once in the Corpus.'" A study specifically implicating iron in the mechanism has recently been published by the Murrays.'" Somali nomad who were not malnourished were studied. The diet of these people i low in iron, and many of them are irondeficient. while otherwise not badly nourished. Of 94 nomads entering the camp, 64 were not iron-deficient according to the criteria adopted,31 and 26 were iron-deficient. ineteen of the non-deficient subjects, but none of the deficient ones. howed evidence of infection (malaria parasites in blood smears. tubercle bacilli in sputum, fever of unknown origin. pneumonia, hepatiti , eye infection. brucellosis, etc.). The authors then collected all the available iron-deficient subjects who showed no evidence of infection, and divided them into 2 groups. The first group of 71 subjects was treated with 900 mg of ferrou sulphate by mouth daily for 30 days; the control group, numbering 66, received tablets containing no iron. Haemoglobin. plasma iron. and transferrin saturation increased notably in the first group. The interesting finding, however, was that this group had far more epi~odes of infection during the period of treatment than the group receiving the inactvie tablets. Only ] of the placebo group, compared with 13 in the group receiving iron, had clinical evidence of malaria, while malaria parasites appeared in the blood of 21 of the treated group. but only in that of 2 of the controls. Tuberculosis was reactivated in 3 of the treated group_ but in none of the placebo group. In all, there were 46 episodes of clinical infections of various kinds in the treated group. as against 3 in those receiving the placebo. The authors suggest that iron deficiency probably play a part in suppressing certain infections, suggesting that in Somali nomads it may be part of an ecological corn promi e. Their diet i deficient in iron: 'The iron deficiency. debilitating in some but rarely fatal. prevent the more serious consequence of potentially fatal infections with malaria. tuberculosis. and brucellosis to which the nomad are constantly exposed . . . It may be unwise to attempt to correct iron deficiency in the face of quiescent infection. especially in isolated societies where the natural ecological balance is often a first line of iefence against severe infections.' [t is at lea t arguable. therefore. that in certain circumstances iron deficiency might be desirable. TO one would suggest that it should be encouraged in civilized countrie today. since we have better method of dealing with infection than the ancients possessed; but the physician of antiquity was not in this fortunate position. He had no specific remedie at all. If he could reduce plasma iron and transferrin saturation by bloodletting. or by omitting to treat beneficial natural evacuations. he could perhaps increa e his patients' resistance to infectiou di ease. H. in Galen's time, the woman who was well cleansed by her menses was. in fact. somewhat iron-deficient. she might well have been in the same po ition a the Murray' Somali nomads: the minor degree of debility from the anaemia was a small price to pay for very considerable immunity from the clinical manife tation of infection. 152 SA MEDICAL for which, once they had appeared, there wa no specific treatment whatever. And the problems of ancient medicine were, for practical purposes, all problems of infection. Malaria, remarks Jones," was undoubtedly the greatest medical problem of antiquity; together with bacterial diseases of the chest it provided the ancient physician with most of his work. The only question is how rich in iron the diet in antiquity was, and what the effects of bleeding, whether natural or therapeutic, were. These effects will be considered first. Fortunately, although bleeding as a therapeutic measure has been almost entirely abandoned, there is abundant information available from blood donors. A single donation of whole blood, say 400 ml, removes about 200 mg of iron in the form of haemoglobin; Galen would have regarded it as a small evacuation. Many donors, however, give blood repeatedly at intervals which may be as short as 2 months, and may thus lose more than 2 I of blood a year. It has been estimated that a daily loss of 6 - 8 ml, as a result, for example, of bleeding piles or hookworm infestation, may put a patient into negative iron balance even on a normal diet, since even with the increased absorption that prevails in iron deficiency, not enough can be absorbed from the diet to make up for it.'" This amount is about the same as that given by a donor who donates once every 2 months. Laurell'" has published some figures on the effects of giving blood on serum iron and transferrin saturation. Seventeen donors, most of whom had given one previous donation several months before, were tested before and 1 week after donating 400 ml of blo~d. The mean serum iron was 117 ,,ug/dl, and the mean transferrin saturation 37%, before the donations; a week later the figures were 79 .,ug/ dl and 23 ob respectively. This would be a temporary effect, but might none the less be significant when a patient was bled at the onset of infection, as was Galen's practice. A group of 17 donors who had given repeated donations, totalling between 1,5 and 3 I per donor in the preceding year, had a mean plasma iron level of 95 ,ug/ dJ, and mean transferrin saturation of 27%. These studies were conducted in Sweden immediately after World War n, and suggest that. at least in the dietary conditions then prevailing, the loss of even 400 ml of blood had some effect on plasma iron and transferrin saturation. while the loss of 2 I or thereabouts in the course of 1 year reduced both these levels considerably. Laure1J'" also stu· died 11 patients with haematological signs of iron deficiency. as a result of chronic bleeding from the gut or uterus. The mean haemoglobin level was nearly g/d\. JOUR 28 July 1979 AL the mean plasma iron level was 33 .ug/dl and the mean transferrin saturation was 8 %. These patients would no doubt correspond to some of those in antiquity who were enjoying beneficial evacuations from haemorrhoids or menorrhagia, which the doctors refrained from treating; this is clear from two observations of Galen's. He says that bleeding from haemorrhoids was sometimes so severe as to kill the patient, or to leave him grossly hydropic or cachectic;" such haemorrhoids would, of course, be treated. In the management of patients who had not reached this stage, however, doctors sometimes planned totally unnecessary treatment in an attempt to satisfy them, while leaving their evacuations unchecked.'" Further information can be obtained from a study of blood donors in South Africa. If Galen's methods were applied to this modern population, what might their effects be? His moderate evacuation of 3 cotyles removes about 400 mg of iron as haemoglobin, and a single such evacu· ation should thus precipitate a subject with a plasma ferritin of less than SO ,ug/I into iron deficiency anaemia. In Table I the serum ferritin levels for new donors (before any donations have been given) in Durban are shown. The population groups differ in dietary habits. The means for Whites are almost identical with those found in Washington State, USA." In Table I it is made clear that the majority of the women, and an appreciable proportion of the men, would be rendered anaemic, or brought to the verge of anaemia, by just one of Galen's moderate evacuations, and that few (except some of the siderotic Zulu men) could withstand his more heroic ministrations with haemoglobin levels intact. The iron content of ancient diets is crucial to the argument. If the diet of most of Galen's patients contained the same amount of iron as modern Western diets, his bloodlettings would have approximately the effects mentioned. If, on the other hand, there was as much iron in it as there is in the diet of the average middle-aged Black man, the effects would be far less_ Jacques Andn?' has published a fully documented study of Roman diet, from which some indications of iron content can be obtained. There is nothing to suggest that the staple diet of cereals. vegetables and oil was particularly rich in iron; this would have been obtained chiefly from meat and from wine. There is, again, no evidence that the consumption of animal flesh exceeded that of today; in the early centuries the Roman diet was in fact largely vegetarian, although more meat was eaten later. Unless we can discover some article of diet which contained large amounts of iron and TABLE I. SERUM FERRITIN LEVELS IN DURBAN BLOOD DONORS Population group White Black (Zulu) Indian Sex Male Female Male Female Male Number of subjects with serum ferritin level Number of donors examined Mean serum ferritin level (,ug/I) SD 96 100 99 100 100 93 36 223 32 65 27 275 41 43 64 <SO,ug/1 26 81 17 85 42 2 Julie 1979 SA EDIE was taken in very large quantitie like the traditional sorghum beer of the modern Black man, who may take in 150 mg iron a day in beer alone - it is unlikely that the average patient in Galen's time was in positive iron balance. Such an article of diet might have existed, however, in the wine of antiquity. ome red wine today contain twice a much iron as traditional African beeL" although they are admittedly usually drunk in smaller quantities; nevertheless, some French red wine drinker become siderotic. as do Black. It is possible, therefore, that the red wines of antiquity contained ubstantial amounts of iron: on the other hand, they were invariably drunk diluted with water. There is some evidence that the wine of poorer quality derived from later pressings of the grapes might have contained more iron; this is particularly so of the worst wine. made by macerating the exhausted skins in water and returning them to the press. From these the elder Cato prepared 'un horrible vin d'hiver' for his laves. diluting 260 parts of this pressing with 1 500 parts of a mixture of fresh and sea water, vinegar and heated wine. The ration for a slave engaged in the hardest labour was at most a litre a day." which, allowing 100 mg iron per litre in the original pressing. could scarcely, in view of the dilution, have provided more than 10 or 12 mg of iron, most of which in any case would not be absorbed. Slaves with lighter duties got only a quarter of this amount. How much the free man drank depended. of course, on the price. Under Diocletian, a century after Galen, half a litre of the best wine sold at the price of a kilogram of pork, while the same amount of vin ordinaire could be got for a quarter of that amount. The ratio i almost the same in South Africa today. Andre's conclusion is that the price of wine was not excessive at any tage of Roman history, but on the other hand was never so low that the poor could use it habitually. Athenaeus, who flourished at about the time of Galen's death, made the surprising observation that at that time neither women nor lave in Rome drank wine, and that the free man began doing so only at the age of 30." Although women were certainly forbidden wine in Rome up to 200 BC. Galen mentions it use to bring on the menses," and we have already seen that the elder Cato gave wine (if this mixture can be so described) to his laves. It therefore seems unl ikely that Athenaeus was reporting correctly the situation in the time of Galen. although it might well be that most women. through a combination of tradition and domestic circumstances (fewer parties!) still drank substantially less wine than men did. thus unwittingly rendering their beneficial evacuation even more beneficial because of an iron-deficient diet. It seems likely. therefore, that there was no more iron in the diet of the average Roman in Galen's time than there is in ordinary Western diets today, and that many women, if not men. were therefore in negative iron balance. That this was so in Galen's time. if my thesi is correct. would appear from Galen's observation that women who had copious menstrual evacuations were protected from many diseases. as were men who had bleeding haemorrhoids. Although there i now ome theoretical ground for believing that iron deficiency might have thi protective effect E TVD 153 KRIF and some evidence that it is 0 in pra tice, it mu t be made clear that the problem i not imple. Cau ation in medicine i always complex. the result of many factors which have different, and ometime oppo ite, effe t . There is evidence that cell-mediated immunity i defective in iron· deficient ubjects," uggesting that such ubject might be more rather than le . u ceptible to viru disease; and furthermore, there is no doubt that iron deficiency anaemia. by \ eakening the patient. might decrea e re i tan e to di ease. Galen was clearly aware of this, since he took into account the patient' trength when onsidering veneection, and stopped the evacuation at once if it eemed to be failing. Hi use of epaphaire i is interesting; by taking blood in repeated smaller amounts rather than in one large one he could reduce plasma iron and transferrin aturation without dangerously diminishing the blood volume and imperilling life. My the is i that. in the conditions prevailing in Galen's time. the good effect of moderate iron deficiency. in increasing resistance to certain infections, outweighed the bad effects of debilitating the patient. If, by removing blood. the physician of the time was able to prevent, or to keep latent, infections that, once established, he was powerle to cure. he wa right in using phlebotomy. This wa clearly the experience of most practitioners, since Galen tells u tliat the empiricist school. who abjured all theory and based their treatment purely on experience, all made use of it. Tt wa not. however. universally practised by competent phy icians: the great exception was Erasistratus'" That uch a man could acquire a distinguished reputation without ever employing vene· section show that its benefits were not so entirely obviou that no one could ignore them and make a uccess of practice. Erasistratus. however. like his master Chry ippu . wa an exception. Almost every other celebrated physician of antiquity. and for many centuries thereafter. made ome use of the remedy: is it conceivable that they were all completely wrong? REFERENCES C. G .. ed. (1964): Clalld,i Gale"i Opera Omnia, 20 vol,. Hildesheim: G. Olms. (Reprint of the 19th century edition.) Abbreviated to K. The 3 works are in K XI. pp. 147 - 316. Celsus: De Medici"a, H. 10.. I. littre, E., ed. (1962): Qellvres completes d'Hippocrate, 10 vol'. Amsterdam: A. Hakken. (Reprint of the 19th century edition) Abbreviated to L. The passage is in L 2. 39 . K XV, 763. e.g. K XV, 891. 893. K Xl, 289 - 90. K XI, 277 - 8. K XI, 27I. K X, 27. K X, 16. The ibis. according to one old auth.,r. . purges itsell I. Kiihn, 2. 3. 4. 5. 6. 7. 9. 10. at tbe fundament with its crooked beak.' I I. 12. 13. 14. IS. 16. 17. 1 . 19. 20. 11. 22. 23. K Xl, 165 - 6. K XI. 174. K XI, 290 - 91. K XVI lb. I. As she was of a prominent family. Galen sub· sequently received many such patients. whom he cured in the ~ame way. This is perhaps the first account of anorexia nervosa in the literature. and Galen's cure was presumably psychologica1. K XI. 294. K Xl, 2 - 9. K Xl, 2 6. Schade, A. L. and Caroline. L. (I 46): ience, 104. 340. For reviews of the topic ee Weinbers. E. D. (1974): Science, 184, 952: Kochan. I. (1973): Curr. Top. Microbiol. Immunol.. 60. I' Bullen. J. J.• Rogers. H. J. and Grifliths. E. (197 ): Ibid .• 80. I. Bothwell. T. H. and Finch. C. A. (1962): Iron Metabo/lsm. p. 2 I London: Churchill Livingstone. Jacobs. A. (1977): Semin. Haemat.. 14. 89. Trousseau, A. () 6 - 72): l.eClures 0" Clinical AIel/idOl!. vol V, D. 9. London: ew Sydenham Society. Von Niemeyer. F. (I 70): Clinical Lec/urn 011 Plllmollary Con· sumption. London: lew ydenham iety A 154 MEDICAL 24. t\1urray. J .. i\1urray. 1\1. B.. 1urrJ.Y. A. B. et al. (1976) : L1.ncet, I. 12 3. t\.1cFarlane. H .. Reddy. S.. Adcock. K. J. et 0/. (1970) : Brit. med. J .. 4. 26 . ciety of Medicine (1937) : Proc. roy. 26. Royal oc. I\led .. 30. 1039 and 1O~9. 27. Murray. M. J. and Murray. A. B. (1977) : Lancet. I. 123. 2 . L 6. 56. 29. e.g. L 9, 110. 30. Murray, M. J .. M Lirray. A. B.. Murray. M. B. et al. (197 ): Bnt. med. J .. 2, 1113. 31. Haemoglobin less than 11 g/dl. serllnl iron less than 25 !'g/dl. transferrin saturation less than 15%. with hypochromia and micro· cYlosis in the meaT. 32. Jones, W. H. S. (trans.) (1923): HipPOCTlllf!..'i. vol. I. pp. Ivi· Ivii. 2- 33. 34. 3 -. 36. 37. 38. 39. 40. 41. 42. 43. 44. 28 July 1979 JOUR TAL London and Cambridge. 1ass: Loeu ClaSSiC.l) Libr~r)'. BOlhwell and Finch. p. 315. LaureIl, C-B. 09:+7): Acta physiol. sc::md.. 1-1. <;juppl. ~6. S2. K Xl, 307. K XI. 170. Worwood. M. (1977): Semin. Haemat.. 1·1. 21. Andre, J. (1961): L'A{imemQtioll et la CUOllle f; Rome. Parl~ Klincksieck. Jacobs. pp. 9 ·9. Andr';. pp. 164· 5. Andr';. pp. 170· I. K XL 205. Joynson. D. H. M .. Jacobs. A .. Walker. D. M. et al. (1972): Lancet. 2. 1058. Galc:l's first work on venesection is a polemic against Ensistralll"_ Curiosa Paediatrica n THEODORE lAMES SUMMARY A small series of a dermal curiosity occurring in children is described. It appears not to have been presented heretofore in medical writings and certainly not in our South African medical literature. The constancy of its presentation suggests strongly a genetic localization for its origin (if not a fanciful one!) and the name foveae scapularum cutaneae bilaterales congenitae in true dermatological fashion is wholly descriptive, ponderous though it be for such light 'residua pennarum'! S. A/,.. med. l., 56. 154 (1979). During recent years I have collected a small series of 6 children, ranging in age from I to 6 years, with a curious dermal anomaly. The presenting complaints of the children were entirely unrelated. One of the 6 children was brought to me by a colleague to whom I had demonstrated the feature with its striking constancy. owhere in the nume· rous departments of our medical literature have I seen a mention of the curiosity, which deserves recording if only for its surely genetic origination. Fig. 1 shows scapular dimples which occur over the acromions of the spines of the scapulas. In 5 instances the symmetry and sameness of the dimples were remarkable; in the 6th child the right dimple was less in Pinelands, CP TflEODORE J:\\IE·. Date received: 24 Octoher ~I.Ll. 197 (,I LB. Fig. 1. Scapular dimples. depth than its twin on the left, but distinct, nonetheless. That the dimples are congenital I have no doubt. although the youngest exhibitor was only a little less than I year old. The oldest in the series had turned 5 years. All were Coloured children, and therefore of mixed blood. but there is no contributory evidence that the anomaly is necessarily genetically connected with pigmentation of the skin and no famili()l relationship among the children could be determined. I cannot even venture to guess at the dermato-ana· tomical significance of the genetic nature implicit in its constancy other than a whimsical 'residua pennarum·. but a suitable name for it would be foveae scapularum cutaneae bilaterales congenitae. satisfactory for a dermal curiosity of unknown origin.