Past exam of the medicine course of the University of Oxford / 1865 / Second examination / Medical translations (No. VI.)

Original volume: Examination papers for the Degree of Bachelor of Medicine by the University of Oxford (1864–1867). PDF volume pages 49–50; Oxford, December 1865, No. VI. Open the original paper in the scanned volume.

Original questions are transcribed from the public-domain edition. Credit: Wellcome Collection; original supplied by Royal College of Physicians, London. Source and public-domain rights statement.

The original paper is untitled. The two headings below identify its unnumbered medical translations in their source order.

Opus etiam esse cucurbitula potest in morbis longis, quamvis et iis jam spatium aliquod accessit ; sive corrupta materia, sive spiritu male habente : in acutis quoque quibusdam, si et levari corpus debet, et ex vena sanguinem mitti vires non patiuntur. Idque auxilium ut minus vehemens, ita magis tutum ; neque umquam periculosum est, etiamsi in medio febris impetu, etiamsi in cruditate adhibetur. Ideoque ubi sanguinem mitti opus est, si incisa vena praeceps periculum est, aut si in parte corporis etiam vitium est, huc potius confugiendum est : cum eo tamen, ut sciamus, hic ut nullum periculum, ita levius praesidium esse ; nec posse vehementi malo, nisi aeque vehemens auxilium succurrere.

Celsus. Lib. 2. § 11.

Instruction applying to both passages, printed after them: Translate these passages, and criticize them by the light of Modern Pathology and Practice. State in what cases you would endorse, and in what you would dissent from the treatment here recommended by Aretæus.

Translation. A cupping vessel may also be needed in chronic diseases, even when they have already continued for some time, whether because the bodily material is corrupted or because the wind is in a disordered condition; likewise in some acute diseases, if the body needs to be relieved but the patient's strength does not permit blood to be let from a vein. This remedy is less forceful and therefore safer; nor is it ever dangerous, even if used in the midst of an attack of fever, or while food remains undigested. Accordingly, where bloodletting is needed, if opening a vein presents an immediate danger, or if the disorder is also situated in a particular part of the body, one should resort to this instead. We must nevertheless understand that, just as there is no danger here, so the protection is weaker, and that a violent malady cannot be met except by an equally forceful remedy.

Critical interpretation. Celsus is comparing local cupping with general venesection, rather than distinguishing a scientifically established safe treatment from a dangerous one. His absolute claim of harmlessness and his rule that severe disease requires an equally forceful intervention need criticism, even though the concern for the patient's limited reserve is sensible.

The instrument and the historical explanation. Cucurbitula means a cupping vessel, not a vegetable prescribed as food. Earlier in the same chapter, Celsus describes bronze cups using burning material and horn cups from which air is withdrawn through an opening. Reduced internal pressure holds the cup against the skin. He distinguishes wet cupping, over incised skin, from dry cupping, over intact skin; the present comparison with bloodletting chiefly concerns the former, while the reference to disordered wind belongs to his broader account of cupping. Materia and spiritus are his explanatory categories: “corrupted material” and pathological wind in ancient medicine should not be silently relabelled as demonstrated bacterial infection or a modern measurement of gas. Cruditas means a state of incomplete digestion, not a specific modern disease. ^[ref]

Criticism available in 1865. A cautious practitioner could agree that the patient's condition limits the use of depletory measures, and that a local complaint does not automatically require general bloodletting. But neither premise proves that local bloodletting is needed. The important distinction is between comparing the burdens of two interventions and establishing a benefit from either. By 1864, John Hughes Bennett was arguing that venesection could not remove established inflammatory exudation and that routine depletion in pneumonia weakened the processes needed for recovery. His account supplies contemporary grounds for dissenting from the final maxim: a severe inflammatory disease might call for support rather than an equally violent intervention. This was an argument available before the examination, although his particular theory of inflammatory repair is itself historical. ^[ref]

Present-day assessment. The absolute statement “never dangerous” is false. Wet cupping can cause blood loss and anaemia, and both forms of cupping can cause burns, scars and infection. Current research does not establish cupping as an effective general remedy for fever or internal inflammatory disease. A skin mark or extracted blood is an observed local effect, not by itself evidence that the cause of an internal disease has been removed. The defensible part of the paragraph is the concern for the patient's reserve, not its assurance of harmlessness or its equation of severity with therapeutic violence. ^[ref]

Aretæus. Περὶ Θερ. Ὀξ. Παθ. Β. γ.

Instruction applying to both passages, printed after them: Translate these passages, and criticize them by the light of Modern Pathology and Practice. State in what cases you would endorse, and in what you would dissent from the treatment here recommended by Aretæus.

Translation. Open the hollow vein at the elbow, but withdraw the blood through a small opening, so that the patient's strength is not markedly affected: a sudden, large withdrawal puts the constitution to the test. Take away much less than for other indications. For, in a case of collapse, even a small mistake readily sends the patient to the realm of the dead. Give food immediately, therefore, to restore strength; for nature takes pleasure both in getting rid of the old material and in receiving the new.

If the patient's strength rules out venesection, but there are inflammations, apply a cupping vessel at that site well before the crisis of the disease. For collapse occurs on the critical days, since it is at the same periods that nature brings matters to a decision and diseases kill. Even if the patient reaches the point of needing wine, it is not altogether safe to drink wine while inflammations are present. Wine increases pain in those with inflammation, but strengthens the constitution in those without it.

One or two days before applying the cupping vessel, a poultice is needed both to relax the parts and to encourage a free flow of blood. In some patients, poulticing should also continue after cupping into the second day. Here too there must be restraint: with cupping, excessive loss of blood carries the same danger. Use enemas only for old, retained faeces, and spare the patient's strength.

Critical interpretation. Aretaeus of Cappadocia couples depletory interventions with concern for impending collapse. The assessment requires judging each measure and its indications, not simply approving or rejecting the whole paragraph. The detailed comparison below separates what could reasonably have been argued in 1865 from present-day pathology and practice.

What condition is being treated? The source is On the Treatment of Acute Diseases by Aretaeus of Cappadocia, II.3, concerning the cardiac affections of Aretaeus. The surrounding chapter describes a dangerous febrile illness with impending collapse; it argues that apparent weakness can arise either from deficiency or from what the author regards as excess. This explains his apparently paradoxical recommendation to bleed someone at risk of collapse. It does not establish that this patient category corresponds to one present-day heart disorder. In particular, the passage's συγκοπή must not automatically be identified with modern syncope, which denotes a brief loss of consciousness from inadequate cerebral perfusion, with spontaneous recovery. ^{[ref] [ref]}

The “hollow vein at the elbow” is an ancient designation used here for antecubital venesection; it cannot mean opening the deeply situated vena cava. Δύναμις means the patient's strength or reserve, rather than a measured numerical quantity. The κρίσις is the decisive turn of the illness, and the critical days in ancient medicine belong to the author's prognostic framework. No specific critical-day schedule or numerical volume of blood is supplied in this extract, and neither should be invented. The one- or two-day interval actually mentioned concerns preparation with a poultice.

What could be endorsed in 1865? The warning that rapid depletion or excessive blood loss could precipitate collapse is sound clinical caution, and it applies to wet cupping as well as venesection. The emphasis on preserving strength, providing suitable nutrition, and avoiding unnecessary evacuation could also be endorsed. Bennett's 1864 argument offers an especially clear contemporary comparison: supporting recovery was preferable to routine lowering measures, and limited bleeding that did not exhaust the patient should at most be considered palliative rather than assumed curative. A local reduction of vascular congestion could be considered as an exceptional palliative indication within that contemporary argument; it was not a reason to bleed every patient with inflammation. ^[ref]

Where the recommendation should be opposed. In an exhausted patient with a weak circulation after substantial blood loss, removing more blood would intensify the very danger being feared. The small incision changes the rate of removal, but does not by itself guarantee a tolerable total loss. Equally, pneumonia or another inflammatory disease does not establish an excess of removable blood merely because fever and a forceful pulse accompany it. These are grounds for dissenting from the indication, rather than merely demanding a smaller dose of the same intervention. The reservation is already intelligible from Aretaeus of Cappadocia's own warning, and the rejection of routine depletion is supported by the contemporary argument just cited.

Present-day examples clarify the distinction. In hypovolaemic shock, the relevant issue is insufficient circulating volume and inadequate perfusion; assessment, replacement of deficits and repeated reassessment are appropriate principles, rather than therapeutic bloodletting. Conversely, a patient with acute heart failure and pulmonary oedema may require removal of excess fluid, but current guidance uses carefully monitored diuretic therapy rather than routine loss of blood. These opposite clinical examples show why “collapse” alone cannot choose between depletion and support. Modern assessment follows blood pressure, the pulse, peripheral perfusion, fluid losses and signs of fluid overload; it does not wait for an ancient critical day. ^{[ref] [ref]}

Modern venesection nevertheless has specific indications, including haemochromatosis and polycythaemia vera. In the former it reduces excess iron; in the latter it can reduce an excessive red blood cell burden. These are defined abnormalities, not confirmation of the ancient rule about bleeding in inflammation or impending collapse. They are present-day qualifications, not diagnoses or knowledge attributed to the 1865 candidate. ^{[ref] [ref]}

Food, wine and local applications must be judged separately. Suitable food can help an alert, depleted convalescent who can swallow safely, so the restorative aim deserves qualified endorsement. Immediate oral feeding of someone who cannot protect the airway is different: the route must be appropriate, and oral food does not by itself reverse circulatory failure. Current nutritional guidance explicitly considers swallowing safety and alertness. The idea that removal of old material makes new food beneficial does not provide a modern mechanism for restoring lost blood. ^[ref]

The claim about wine also requires dissent in its universal form: absence of inflammation is not sufficient evidence that wine will restore the patient's circulation. An 1865 discussion could question indiscriminate stimulation as well as indiscriminate depletion; Bennett expressly distinguished nutritive support from overstimulation. Present-day resuscitation assesses the cause and circulatory state instead of treating wine as a general restorative. ^{[ref] [ref]}

A gentle warm local application may be considered for comfort, as warmth and relief of pain were also discussed in the 1864 contemporary argument. That is a palliative aim, distinct from preparing to extract supposedly harmful blood. There is no basis here for endorsing a poultice or wet cupping as a cure for deep internal inflammation; the caution about excessive bleeding remains applicable. ^{[ref] [ref]}

Finally, the restriction of enemas to retained faeces is preferable to routine purging of a weak patient. A concrete modern counterpart is a selected case of faecal impaction, for which an enema is one possible treatment after assessment. It does not follow that every older stool requires an enema, or that an enema treats the cause of a febrile collapse. Thus the defensible parts of the passage are conserving reserve and using a measure for a specific indication; the unsupported parts are universal depletion, harmlessness, and treatment timed by critical days in ancient medicine. ^[ref]