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Textbook of Critical Care 1st Edition Yatin Mehta Digital
Instant Download
Author(s): Yatin Mehta
ISBN(s): 9782031708919, 9351529681
Edition: 1
File Details: PDF, 90.98 MB
Year: 2015
Language: english
 Textbook of
CRITICAL CARE
 Textbook of
CRITICAL CARE
Including Trauma and Emergency Care

Editor-in-Chief
Yatin Mehta
MD MNAMS FRCA FAMS FICCM FIACTA FTEE
Chairman
Medanta Institute of Critical Care and Anesthesiology
Medanta–The Medicity
Gurgaon, Haryana, India
Editors
Jeetendra Sharma MD IFCCM
Head, Critical Care, Artemis Hospital
Gurgaon, Haryana, India
Mukesh Kumar Gupta MD (Int Med) FNB (Crit Care Med)
Senior Consultant, Critical Care Medicine
Institute of Critical Care and Anesthesiology
Artemis Hospital
Gurgaon, Haryana, India

Forewords
Jean-Louis Vincent
Naresh Trehan
Shirish Prayag

The Health Sciences Publisher

New Delhi | London | Philadelphia | Panama
 Jaypee Brothers Medical Publishers (P) Ltd

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Textbook of Critical Care Including Trauma and Emergency Care
First Edition: 2016
ISBN 978-93-5152-968-2
Printed at
 Dedicated to
This book is dedicated to all those intensivists—young and old, qualified or under training—who are
toiling day and night, unsung, behind the scene, sometimes under major resource constraints or hostile
environment, to make a difference to the sickest of patients in the critical care
Contributors

Abhijit Bhattacharya MBBS DA MD DAcp Amit Bedi MB ChB MD FRCA FFICM

Ex Professor and Head Consultant Anesthetist
Anesthesiology, Intensive Care and Pain Medicine Regional Intensive Care Unit
University College of Medical Sciences, Delhi University Royal Victoria Hospital
Advisor/Consultant, Delhi State Cancer Institute Belfast, Northern Ireland, United Kingdom
Advisor/Consultant, Hamdard Institute of Medical Amol Kothekar MD IDCC
Sciences and Research Assistant Professor
New Delhi, India Department of Anesthesia, Critical Care and Pain
Abhinav Gupta MD DNB FNB EDIC Tata Memorial Hospital
Additional Medical Superintendent Mumbai, Maharashtra, India
Head, Critical Care and Emergency Anil Arora MD (Med) DM (Gastro)
Sharda School of Medical Sciences and Research Chairman
Sharda University Department of Gastroenterology
Noida, Uttar Pradesh, India Sir Ganga Ram Hospital
New Delhi, India
Adarsh Chaudhary MS FRCS
Chairman Anil Bhan MBBS MS (Gen Surg) MCh (CTVS)
Division of GI Surgery, GI Oncology and Bariatric Surgery Senior Director, Cardiac Surgery
Medanta–The Medicity Medanta Heart Institute
Gurgaon, Haryana, India Medanta–The Medicity
Gurgaon, Haryana, India
Ajay Kumar MD DM MAMS FRCP (Glasg)
Director, Executive and Chief Anil Gurnani DA DNB FICCM
Fortis Escorts Liver and Digestive Disease Institute Group Director
Fortis Escorts Heart Institute Department of Anesthesiology and Intensive Care
Kailash Hospital and Heart Institute
New Delhi, India
Noida, Uttar Pradesh, India
Ajaya Nand Jha MS FRCS (Surg Neurol)
Anjan Trikha DA MD FICA
Chairman
Professor, Department of Anesthesiology and
Medanta Institute of Neurosciences
Intensive Care
Medanta–The Medicity All India Institute of Medical Sciences (AIIMS)
Gurgaon, Haryana, India New Delhi, India
Ajeet Singh MD Ankit Sharma MD
Senior Resident Senior Consultant, Critical Care Medicine
Medanta Institute of Critical Care and Anesthesiology Medanta Institute of Critical Care and Anesthesiology
Medanta–The Medicity Medanta–The Medicity
Gurgaon, Haryana, India Gurgaon, Haryana, India
Ali Zamir Khan MS FRCS (CTH) FRCS (Glasg) Anshul Bhatia MBBS MD PDCC (Neuroanesth)
Associate Director Consultant, Neuroanesthesia
Minimal Invasive and Robotic Thoracic Surgery Medanta Institute of Critical Care and Anesthesiology
Medanta–The Medicity Medanta–The Medicity
Gurgaon, Haryana, India Gurgaon, Haryana, India
Ambrish Mithal MD DM Anurag Sharma MD DM
Chairman Associate Consultant
Division of Endocrinology and Diabetes Medanta Institute of Neurosciences
Medanta–The Medicity Medanta–The Medicity
Gurgaon, Haryana, India Gurgaon, Haryana
viii Textbook of Critical Care

Archana Shrivastava MBBS DA IDCCM IFCCM EDIC Ashok Seth FRCP (Lond, Edin, Irel) FACC FESC FSCAI
Associate Consultant (USA) FCSI DSc (Honoris Causa) D Litt (Honoris Causa)
Department of Critical Care Chairman, Fortis Escorts Heart Institute
PD Hinduja National Hospital New Delhi, India
Mumbai, Maharashtra, India Ashok Vaid MD DM
Armin Ahmed MD (Anesth) Chairman
Pool Officer Division of Medical Oncology and Hematology
Department of Critical Care Medicine Medanta–The Medicity
Sanjay Gandhi Post Graduate Institute of Medical Medanta Cancer Institute
Sciences (SGPGIMS) Gurgaon, Haryana, India
Lucknow, Uttar Pradesh, India Atma Ram Bansal MD DM
Arun Garg MD (Gen Med) DM (Neuro) Certified Fellow in Epilepsy, Neurologist and Epileptologist
Associate Director Consultant
Medanta Institute of Neurosciences Medanta–The Medicity
Medanta–The Medicity Gurgaon, Haryana, India
Gurgaon, Haryana, India Balakrishnan Ashokka MD FANZCA MHPE
Arvind Kumar Baronia MD (Anesth) Clinical Lecturer
Professor and Head Department of Anesthesia
Department of Critical Care Medicine National University Health System
Sanjay Gandhi Post Graduate Institute of Medical Singapore
Sciences (SGPGIMS) Bala Venkatesh MBBS MD (Int Med) FRCA FFARCSI MD
Lucknow, Uttar Pradesh, India (UK) FCICM
Ashish Bindra MD DM Pre-eminent Specialist, Princess Alexandra Hospital
Assistant Professor Deputy Director, Intensive Care, Wesley Hospital
Department of Anesthesia Professor, Intensive Care, University of QLD
All India Institute of Medical Sciences Honorary Professor, University of Sydney
and Jai Prakash Narayan Apex Trauma Center St Lucia, Australia
New Delhi, India Balbir Singh MD DM FACC
Ashish Kumar MBBS MD Chairman
Consultant Division of Electrophysiology
Medanta Institute of Critical Care and Anesthesiology Medanta Heart Institute
Medanta–The Medicity Medanta–The Medicity
Gurgaon, Haryana, India Gurgaon, Haryana, India
Ashish Nandwani MD DNB (Nephro) MNAMS Balvinder Rana MBBS MS (Ortho)
Associate Consultant Associate Director
Division of Nephrology and Renal Transplant Medicine Medanta Bone and Joint Institute
Medanta Kidney and Urology Institute Medanta–The Medicity
Medanta–The Medicity Gurgaon, Haryana, India
Gurgaon, Haryana, India Banambar Ray MD (Anesth)
Ashit Hegde MD MRCP Chief Consultant, Critical Care and Anesthesia
Consultant in Medicine and Critical Care Apollo Hospitals
PD Hinduja National Hospital Bhubaneswar, Odisha, India
Mumbai, Maharashtra, India Beena Bansal MD DM (Endocrinology)
Ashok Rajgopal MBBS MS (Ortho) FRCS MCh Associate Director
Chairman, Medanta Bone and Joint Institute Division of Endocrinology and Diabetes
Medanta–The Medicity Medanta–The Medicity
Gurgaon, Haryana, India Gurgaon, Haryana, India
 Contributors ix

Biswajit Paul MD DNB (Cardio) Davy Cheng MD MSc FRCPC FCAHS CCPE
Consultant Cardiologist Distinguished University Professor and Chair/Chief
Non-invasive Cardiology Department of Anesthesia and Perioperative Medicine
Fortis Escorts Heart Institute Professor, Division of Critical Care Medicine
New Delhi, India Department of Medicine
Bharathram Vasudevan MBBS University of Western Ontario
Junior Resident, Department of Anesthesiology and London, Ontario, Canada
Intensive Care Debasish Pradhan MD (Anesth)
All India Institute of Medical Sciences (AIIMS) Senior Resident
New Delhi, India Department of Anesthesiology and Critical Care
Camilla Rodrigues MD North Eastern Indira Gandhi Regional Institute of Health
Consultant, Department of Microbiology and Medical Sciences (NEIGRIHMS)
PD Hinduja National Hospital and MRC Shillong, Meghalaya, India
Mumbai, Maharashtra, India Deepak Govil MD EDIC FCCM
Celina D Cepeda MD Associate Director
Resident Physician Medanta Institute of Critical Care and Anesthesiology
Department of Medicine Medanta–The Medicity
University of California – San Diego Medical Centre Gurgaon, Haryana, India
San Diego, California, USA Devender Sharma MD PGDCR
Charlie Lan MD Fellowship in Pain and Palliative Medicine
Assistant Professor Associate Consultant
Pulmonary, Critical Care and Sleep Medicine Section Division of Medical Oncology and Hematology
Department of Medicine Medanta Cancer Institute
Baylor College of Medicine Medanta–The Medicity
Houston, Texas, USA Gurgaon, Haryana, India
Chitra Mehta MBBS DNB (Resp Med) FNB (Crit Care Med) Deven Juneja MD
Senior Consultant Senior Intensivist
Medanta Institute of Critical Care and Anesthesiology Department of Critical Care and
Medanta–The Medicity Emergency Medicine
Gurgaon, Haryana, India Sri Balaji Action Medical Institute
Delhi, India
Christopher Howard MD
Fellow Dhruba Lahkar MBBS DNB (Anesth)
Pulmonary, Critical Care and Sleep Medicine Section Associate Consultant
Department of Medicine Medanta Institute of Critical Care and Anesthesia
Baylor College of Medicine Medanta–The Medicity
Houston, Texas, USA Gurgaon, Haryana, India
CR Das MBBS MD (Anesth) Dhruva Chaudhry MD (Med) DNB (Med) DM
Head (Pulm and Crit Care Med) FICCM FICP
Department of Anesthesiology and Critical Care Senior Professor and Head
Nobel Medical College and Teaching Hospital Department of Pulmonary Medicine and Critical Care
Kanchanbari, Morang, Nepal Pt BD Sharma PGIMS and
Daniel De Backer MD PhD University of Health Sciences
Professor Rohtak, Haryana, India
Intensive Care Department Dilip R Karnad MD FACP FRCP (Glasg)
Chirec Hospitals Senior Consultant, Department of Critical Care
Université Libre de Bruxelles Jupiter Hospital
Brussels, Belgium Thane, Maharashtra, India
x Textbook of Critical Care

Dipak Bhattacharya DTCD MD Ghulam Saydain MD FCCP

Senior Consultant Chest Physician Assistant Professor, Internal Medicine
Department of Pulmonary Critical Care and Pulmonary Critical Care and Sleep Division
Sleep Medicine Director, Pulmonary Hypertension Program
Vardhman Mahavir Medical College and Wayne State University
Safdarjung Hospital Detroit, Michigan, USA
New Delhi, India Ghulam Yasin Naroo
DK Singh MD FICCM MBBS FRCP (Glasg) FRCP (Ire) MRCS A & E (Ed)
Professor-in-Charge Consultant, Emergency Medicine
Trauma Centre and Intensive Care Unit Rashid Trauma Center
Institute of Medical Sciences Dubai, UAE
Banaras Hindu University Gopal Taori MBBS MD (Med) EDIC FCICM
Varanasi, Uttar Pradesh, India Intensive Care Specialist
Donald R Lazarus MD Monash Health
Assistant Professor Melbourne, Australia
Pulmonary, Critical Care and Sleep Medicine Gopi C Khilnani MD FCCP FICCM FICP FNCCP MNAMS
Department of Medicine Professor, Department of Pulmonary Medicine and
Baylor College of Medicine Sleep Disorders
Houston, Texas, USA All India Institute of Medical Sciences
Elavarasi A MD New Delhi, India
Senior Resident
Goutham Dronavalli MD
Department of Medicine
Assistant Professor
All India Institute of Medical Sciences
Pulmonary, Critical Care Medicine and
New Delhi, India
Sleep Disorders Section
E Wesley Ely MD MPH Baylor College of Medicine
Professor of Medicine Houston, Texas, USA
Pulmonary and Critical Care Medicine and Health
Harsh Sapra MBBS DA
Services Research
Fellowship in Neuroanesthesia and Critical Care
Associate Director, Aging Research for the Veteran’s Affairs
Belfast, UK
Tennessee Valley Geriatric Research Education and
Associate Director, Neuroanesthesia
Clinical Center (GRECC)
Medanta Institute of Critical Care and Anesthesiology
Vanderbilt University School of Medicine
Medanta–The Medicity
Nashville, Tennessee, USA
Gurgaon, Haryana, India
Farokh Udwadia MD FRCP (London & Edinburgh)
FCCP FAMS FCPS DSc HH Dash MD (Anesth)
Emeritus Professor of Medicine Director, Department of Anesthesiology and
Grant Medical College and JJ Group of Hospitals Pain Medicine
Consultant Physician and Director-in-Charge of ICU Fortis Memorial Research Institute
Breach Candy Hospital Gurgaon, Haryana, India
Consultant Physician, Parsee General Hospital Himanshu Khurana MBBS MD
Mumbai, Maharashtra, India Consultant, Medanta Institute of
Gaurang Vaghani MS MCh Critical Care and Anesthesiology
Senior Resident Medanta–The Medicity
All India Institute of Medical Sciences and Gurgaon, Haryana, India
JPNA Trauma Center Himanshu Verma MBBS FEVS
New Delhi, India Consultant
Gauri Saroj MD IDCCM Medanta Division of Peripheral Vascular and
Senior Consultant Endovascular Sciences
Department of Critical Care, Jupiter Hospital Medanta–The Medicity
Thane, Maharashtra, India Gurgaon, Haryana, India
 Contributors xi

Hironori Matsumoto MD Jonathan Borger MD FRCPC

Assistant Professor Assistant Professor
Department of Emergency and Department of Anesthesia and Perioperative Medicine
Critical Care Medicine University of Western Ontario
Graduate School of Medicine London, Ontario, Canada
Ehime University, Japan Joseph Thachuthara MD
Jagdish Chander Suri MD DTCD DNB FNCCP Fellow, Pulmonary, Critical Care and Sleep Medicine
Consultant, Professor and Head Department of Medicine
Department of Pulmonary Critical Care and Baylor College of Medicine
Sleep Medicine Houston, Texas, USA
Vardhman Mahavir Medical College and JP Sharma MD (Anesth)
Safdarjung Hospital Assistant Professor
New Delhi, India Department of Anesthesiology
Jai Mulchandani MBBS DNB All India Institute of Medical Sciences (AIIMS)
Chief Resident Bhopal, Madhya Pradesh, India
Department of Medicine Jun Takeba MD PhD
Deenanath Mangeshkar Hospital and Research Center Lecturer
Pune, Maharashtra, India Department of Emergency and Critical Care Medicine
Jamshed Nayer MD Graduate School of Medicine
Assistant Professor Ehime University, Japan
Department of Emergency Medicine JV Divatia MD FICCM FCCM
All India Institute of Medical Sciences (AIIMS) Professor and Head
New Delhi, India Department of Anesthesia, Critical Care and Pain
Janarthanan S MD Tata Memorial Hospital
Fellow in Onco-Critical Care Mumbai, Maharashtra, India
Department of Anesthesia, Critical Care and Pain Kalpalatha K Guntupalli MD
Tata Memorial Hospital Professor and Chief
Mumbai, Maharashtra, India Pulmonary, Critical Care and Sleep Medicine Section
Janet Martin Pharm D MSc (HTA) Department of Medicine
Assistant Professor Baylor College of Medicine
Department of Anesthesia and Perioperative Medicine Houston, Texas, USA
Department of Epidemiology and Biostatistics Kapil Zirpe MD FICCM
University of Western Ontario Head and Director
London, Ontario, Canada Neurotrauma Unit
Jason Chui MD FANZCA Grant Medical Foundation
Assistant Professor Ruby Hall Clinic
Department of Anesthesia and Perioperative Medicine Pune, Maharashtra, India
University of Western Ontario Karanjit Singh Narang MS MCh
London, Ontario, Canada Senior Consultant
Jeetendra Sharma MD IFCCM Medanta Institute of Neurosciences
Head, Critical Care Medicine Medanta–The Medicity
Artemis Hospital Gurgaon, Haryana, India
Gurgaon, Haryana, India Kaushal Madan MBBS MD DNB DM (Gastro)
Jignesh Shah MD DNB (Anesth) IFCCM EDIC Director of Excellence for Digestive and Liver Diseases
Associate Professor Incharge, Clinical and Transplant Hepatology and
Department of Critical Care Hepatobiliary Diesease
Bharati Vidyapeeth University Medical College Artemis Hospital
Pune, Maharashtra, India Gurgaon, Haryana, India
xii Textbook of Critical Care

Kavita Khandelwal MD Manish Bansal MD (Med) DNB (Cardio) MNAMS

Junior Consultant Senior Consultant
Department of Anesthesiology and Intensive Care Division of Clinical and Preventive Cardiology
Kailash Hospital and Heart Institute Medanta Heart Institute
Noida, Uttar Pradesh, India Medanta–The Medicity
Kensuke Umakoshi MD Gurgaon, Haryana, India
Assistant Professor Manish Munjal MD (Anesth)
Department of Emergency Medicine Senior Anesthetist and Intensivist Specialist
Graduate School of Medicine Jeevan Rekha Critical Care and Trauma Hospital and
Ehime University, Ehime, Japan Research and Training Institute
Khusrav Bajan MBBS MD EDIC Jaipur, Rajasthan, India
Critical Care Consultant and Head Manish Patel MD
Department of Emergency Medicine Senior Fellow
PD Hinduja National Hospital and Pulmonary Critical Care and Sleep Division
Medical Research Center Wayne State University/Detroit Medical Center
Mumbai, Maharashtra, India Detroit, Michigan, USA
KN Jagadeesh MBBS Manjri Garg MD (Med)
Associate Consultant Critical Care Senior Resident, General Medicine
Medanta Institute of Critical Care Vardhman Mahavir Medical College
Medanta–the Medicity Safdarjung Hospital, New Delhi, India
Gurgaon, Haryana, India Mansi Kaushik MBBS PGDCC FNIC
Lakshmi Mudambi MD Attending Consultant
Fellow, Pulmonary, Critical Care Medicine and Division of Clinical and Preventive Cardiology
Sleep Disorders Section Medanta Heart Institute
Baylor College of Medicine Medanta–The Medicity
Houston, Texas, USA Gurgaon, Haryana, India
Lata Bhattacharya MBBS MD Manvendra Singh MS MCh (CTVS)
Head, Department of Anesthesia Associate Consultant
Jawaharlal Nehru Cancer Hospital Medanta Heart Institute
Bhopal, Madhya Pradesh, India Medanta–The Medicity
Madhavi Desai DNB Gurgaon, Haryana, India
Associate Professor Marcus Ong MBBS MPH FAMS
Department of Anesthesia, Critical Care and Pain Associate Professor
Tata Memorial Hospital Department of Emergency Medicine
Mumbai, Maharashtra, India Singapore General Hospital
Madhu Nair MD Duke-NUS Graduate Medical School, Singapore
Senior Fellow Mayuki Aibiki MD PhD
Pulmonary, Critical Care and Sleep Medicine Section Chair of the Department of Emergency and
Baylor College of Medicine Critical Care Medicine
Houston, Texas, USA Ehime University Graduate School of Medicine
Maitree Pande MD Vice-President, Ehime University Hospital
Professor Ehime, Japan
Department of Anesthesia MC Mishra MBBS MS FRCS (Glasg) FACS FAMS
Lady Hardinge Medical College Director
New Delhi, India AIIMS Trauma Centre, New Delhi, India
Manal M Khan MS MCh (Plast Surg) Mrinal Sircar MBBS MD (Resp Med) DTCD DNB EDIC EDRM
Assistant Professor Director
Department of Burns and Plastic Surgery Department of Pulmonology and Critical Care
All India Institute of Medical Sciences (AIIMS) Fortis Hospital
Bhopal, Madhya Pradesh, India Noida, Uttar Pradesh, India
 Contributors xiii

Mukesh Kumar Gupta MD (Int Med) FNB (Crit Care Med) Nicole R Hall MD
Senior Consultant, Critical Care Medicine Assistant Professor
Artemis Hospital Department of Obstetrics and Gynecology
Gurgaon, Haryana, India Baylor College of Medicine
Munish Chauhan MD FNB EDIC Houston, Texas, USA
Associate Consultant Nidhi Gupta DM (Neuroanesth)
Department of Critical Care Medicine Consultant, Neuroanesthesia
Fortis Memorial Research Institute Indraprastha Apollo Hospitals
Gurgaon, Haryana, India New Delhi, India
Narendra Rungta MD FISCCM FCCM FICCM Nitin Sood
President, Jeevan Rekha Critical Care and Trauma Hospital MBBS MD (Med) DNB MRCP (UK) FRCPath (UK) CCT
Research and Training Institute, Jaipur, Rajasthan, India (Hemato-oncology)
Senior Consultant, Division of Medical Oncology
Naresh Bansal MD (Med) DNB (Gastro) Medanta Cancer Institute
Consultant Medanta–The Medicity
Department of Gastroenterology Gurgaon, Haryana, India
Sir Ganga Ram Hospital
New Delhi, India Palepu B Gopal MD FRCA CCST FICCM FCCM
Senior Consultant
Naresh Trehan Critical Care Medicine, Care Hospitals
Diplomate American Board of Cardiothoracic Surgery Hyderabad, Andhra Pradesh, India
Chairman, Medanta Heart Institute
CMD, Medanta–The Medicity Pamela Eakin MB BCh BAO (Hons) FRCA
Gurgaon, Haryana, India Specialist Registrar, Anesthesia/Intensive Care Medicine
Royal Victoria Hospital
Nayana Amin MD (Anesth) Belfast, Northern Ireland, United Kingdom
Professor, Department of Anesthesiology
Critical Care and Pain Pankaj Sonar MS (Gen Surg) DNB (GI Surg)
Tata Memorial Hospital Senior Resident
Division of GI Surgery, GI Oncology and Bariatric Surgery
Mumbai, Maharashtra, India
Medanta–The Medicity
Neena Rungta MD (Anesth) Gurgaon, Haryana, India
Ex-Professor
Sawai Man Singh Medical College
Parvesh Jain MD DM
Associate Professor and Head
Jaipur, Rajasthan, India
Department of Medical Gastroenterology
Neeraj Bharti MBBS ME FNIC Bangalore Medical College and Research Institute
Senior Consultant, Department of Internal Medicine Bengaluru, Karnataka, India
Kurji Holy Family Hospital
Peter Farling MB BCh BAO FFARCSI FRCA
Patna, Bihar, India
Consultant Anesthetist
Neeru Sharma DA IDCCM Royal Victoria Hospital
Jeevan Rekha Critical Care and Belfast, Northern Ireland, United Kingdom
Trauma Hospital Research and Training Institute
Philip Ong MD
Jaipur, Rajasthan, India
Assistant Professor
Neetu Jain DNB FCCP (USA) Pulmonary, Critical Care and Sleep Medicine Section
Assistant Professor Department of Medicine
Department of Pulmonary Medicine and Critical Care Baylor College of Medicine
Post Graduate Institute of Medical Sciences (PGIMS) Houston, Texas, USA
Rohtak, Haryana, India Poonam Malhotra Kapoor MD DNB MNAMS FIACTA FTEE
Neha Gupta MD (Int Med) FNB (Inf Dis) Professor
Infectious Diseases Physician Department of Cardiac Anesthesia
Associate Consultant Cardio-Thoracic Center
Medanta–The Medicity All India Institute of Medical Sciences (AIIMS)
Gurgaon, Haryana, India New Delhi, India
xiv Textbook of Critical Care

Pradeep Kumar Verma MBBS MD Prithwis Bhattacharya MBBS MD PDCC

Consultant and Incharge, ICU Professor and Head
Department of Anesthesia and Intensive Care Department of Anesthesiology and Critical Care
VM Medical College and Safdarjung Hospital North Eastern Indira Gandhi Regional Institute of Health
New Delhi, India and Medical Sciences (NEIGRIHMS)
Pradip Kumar Bhattacharya MD FICCM FCCM Shillong, Meghalaya, India
Director, Emergency Critical Care Services Priya Priyadarshini Nayak MBBS MD DNB
Chirayu Medical College and Hospital Resident
Bhopal, Madhya Pradesh, India Division of Medical Oncology, Medanta Cancer Institute
Prakash Shastri MD FRCA FICCM Medanta–The Medicity
Vice-Chairman and Senior Consultant Gurgaon, Haryana, India
Sir Gangaram Hospital Poulomi Chatterjee
New Delhi, India MBBS MD DNB (Resp Med) FISDA NCCP
Attending Consultant
Prasad Rao P Voleti MD FRCP (Glasg)
Department of Respiratory and Sleep Medicine
Director, Internal Medicine
Medanta–The Medicity
Medanta–The Medicity
Gurgaon, Haryana, India
Gurgaon, Haryana, India
Prashant Kumar MD IDCCM FNB EDIC Pushkar Chawla MBBS MS (Ortho)
Consultant, Orthopedics
Senior Consultant
Indian Spinal Injuries Center
Medanta Institute of Critical Care and Anesthesiology
New Delhi, India
Medanta–The Medicity
Gurgaon, Haryana, India Rahul Mehrotra MD (Med) DNB (Cardio)
Senior Consultant
Prashant Nasa MD FNB (Crit Care)
Medanta Heart Institute
Specialist Critical Care Medicine
Department of Critical Care Medanta–The Medicity
NMC Specialty Hospital Gurgaon, Haryana, India
Dubai, UAE Rahul Pandit FCICM FJFICM EDICM FCCP MD DA
Prashant Ranjan MD (Anesth) IDCCM Senior Consultant
Department of Pulmonology and Critical Care Medanta Heart Institute
Fortis Hospital, Noida, Uttar Pradesh, India Medanta–The Medicity
Gurgaon, Haryana, India
Prashant Saxena MDFCCP EDIC
Senior Consultant, Department of Pulmonology Rajeev Shandil DNB (Med) DNB (Gastro)
Critical Care and Sleep Medicine Consultant and Coordinator
Saket City Hospital Gastrointestinal Physiology Services
New Delhi, India Fortis Escorts Liver and Digestive Disease Institute
Fortis Escorts Heart Institute
Praveen Aggarwal MD DNB New Delhi, India
Professor, Department of Emergency Medicine
All India Institute of Medical Sciences (AIIMS) Rajesh Chawla MD FCCM
New Delhi, India Senior Consultant
Respiratory Medicine and Critical Care
Praveen Chandra MD DM FACC FESC FSCAI FAPSIC
Indraprastha Apollo Hospitals
Chairman, National Interventional Council (NIC)
New Delhi, India
Cardiological Society of India
Chairman, Division of Interventional Cardiology Rajesh Mishra MBBS MD FNB EDIC FCCP
Medanta–The Medicity Consultant Intensivist
Gurgaon, Haryana, India Ahmedabad, Gujarat, India
Pravin Amin MD FCCM Rajesh Pande MD PDCC FICCM FCCM
Physician and Intensivist Director, BLK Centre for Critical Care
Bombay Hospital BLK Superspecialty Hospital
Mumbai, Maharashtra, India New Delhi, India
 Contributors xv

Rajesh Puri MBBS MD (Med) DNB (Gastro) MNAMS Ravi P Mahajan

Associate Director, Gastroenterologist and Hepatologist MBBS DA MD (PGIMER) DM (Nottingham) FCAI (Hon) FRCA
Institute of Digestive and Hepatobiliary Sciences Professor and Head
Medanta–The Medicity Anesthesia and Intensive Care
Gurgaon, Haryana, India Queen’s Medical Centre
Nottingham, England, UK
Rajiva Gupta
MD DNB MRCP (UK) FACR (US) FRCP (Glasg) FRCP (Edn) Renuka Agarwal MBBS DNB (Anesth)
Director and Head Senior Resident
Rheumatology and Clinical Immunology Department of Pulmonology and Critical Care
Medanta–The Medicity Fortis Hospital
Gurgaon, Haryana, India Noida, Uttar Pradesh, India
Rajiv Parakh MBBS MS FRCS Richa Bhargava MD MSc RRA DGO
Chairman, Medanta Division of Peripheral Vascular and Attending Consultant
Endovascular Sciences Artemis Hospital
Medanta–The Medicity Gurgaon, Haryana, India
Gurgaon, Haryana, India Richie Jain MD FIACTA
Rakesh Kumar Khazanchi MBBS MS MCh (Plast Surg) Associate Consultant
Director, Division of Plastic Medanta Institute of Critical Care and Anesthesiology
Aesthetic and Reconstructive Surgery Medanta–The Medicity
Medanta–The Medicity Gurgaon, Haryana, India
Gurgaon, Haryana, India Rishabh Kedia MD MCh (Neurosurg)
Rakesh V Sondekoppam MD Fellow in Department of Image Guided Neurosurgery
Assistant Professor Medanta Institute of Neurosciences
Department of Anesthesia and Perioperative Medicine Medanta–The Medicity
Schulich School of Medicine and Dentistry Gurgaon, Haryana, India
Western University Ritabh Kumar MBBS MS (Ortho)
London, Ontario, Canada Senior Consultant, Orthopedics
Ramavath Devendra Naik MBBS Indian Spinal Injuries Center
Junior Resident New Delhi, India
Department of Medicine RK Mani MD MRCP (UK) FCCP FICCM
All India Institute of Medical Sciences (AIIMS) CEO, Medical Services
New Delhi, India Chairman, Pulmonology Critical Care and
Randeep Guleria MD DM (Pulm & Crit Care) Sleep Medicine
Professor and Head Nayati Healthcare and Research (P) Ltd
Department of Pulmonary Medicine and Sleep Disorders Gurgaon, Haryana, India
All India Institute of Medical Sciences (AIIMS) Roop Kishen MD FRCA
New Delhi, India Ex Consultant, Anesthesia and Intensive Care Medicine
Randhir Sud MD DM FIAMS Salford Royal NHS Foundation Trust
Chairman Salford, Manchester, UK
Institute of Digestive and Hepatobiliary Sciences RR Kasliwal MBBS MD DM
Medanta–The Medicity Chairman, Clinical and Preventive Cardiology
Gurgaon, Haryana, India Medanta Heart Institute
Ravichand Siddachari MD DNB MCh (Ire) FRCS (Ed) Medanta–The Medicity
Senior Consultant Gurgaon, Haryana, India
ANG Center for Liver and Biliary Sciences Ruchika Rajan MS FRCS
Indraprastha Apollo Hospitals, New Delhi, India Associate Consultant
Ravindra L Mehta MD FACP FASN FRCP Department of Plastic Reconstructive and
Professor, Clinical Medicine Aesthetic Surgery
Associate Chair for Clinical Research Medanta–The Medicity
Department of Medicine, San Diego, California, USA Gurgaon, Haryana, India
xvi Textbook of Critical Care

Ruchira Misra DCh DNB (Pediatr) Satoshi Kikuchi MD PhD

Consultant Assistant Professor
Medical and Pediatric Oncology Department of Emergency and Critical Care Medicine
Division of Medical Oncology and Hematology Graduate School of Medicine
Medanta Cancer Institute Ehime University
Medanta–The Medicity Ehime, Japan
Gurgaon, Haryana, India Saurabh Taneja MD FNB
Rupak Bhattarai MBBS MD (Anesth) Associate Consultant
Lecturer, Department of Anesthesiology and Critical Care Department of Critical Care and Emergency Medicine
Nobel Medical College and Teaching Hospital Sir Gangaram Hospital, New Delhi, India
Birat Nagar, Nepal Sauren Panja MD (Int Med) FNB (Crit Care) EDIC
Sachin Gupta MD IDCCM IFCCM EDIC Consultant, Critical Care
Consultant, Critical Care Medicine Head, Internal Medicine, Medica Superspecialty Hospital
Medanta Institute of Critical Care and Anesthesiology Kolkata, West Bengal, India
Medanta–The Medicity Shalimar MD DM
Gurgaon, Haryana, India Assistant Professor
Saketh R Guntupalli MD Department of Gastroenterology
All India Institute of Medical Sciences (AIIMS)
Assistant Professor
New Delhi, India
Department of Obstetrics and Gynecology
University of Colorado, USA Sharmishtha Shukla DA
DNB Student, Banglore Baptist Hospital
Saket Junagade MBBS MD MRCP (UK)
Bengaluru, Karnataka, India
Senior Consultant
Lotus Hospital Sheila Nainan Myatra MD FCCM FICCM
Nashik, Maharashtra, India Professor, Department of Anesthesia
Critical Care and Pain
Sameer Jog MD (Int Med) EDIC IDCCM Tata Memorial Hospital
Consultant Intensivist Chairman, Indian Society of Critical Care Medicine
Department of Intensive Care Medicine (ISCCM), Mumbai Branch
Deenanath Mangeshkar Hospital and Research Center Mumbai, Maharashtra, India
Pune, Maharashtra, India
Shivakumar Iyer MD DNB EDIC FICCM
Sameer Shrivastav MD DM Professor
Director and Head Department of Critical Care
Department of Noninvasive Cardiology Bharati Vidyapeeth University Medical College
Fortis Escorts Heart Institute President, ISCCM
New Delhi, India Pune, Maharashtra, India
Sandeep Dewan DA DNB IDCCM Shrikanth Srinivasan MD DNB FNB EDIC
Associate Director and Head Consultant
Department of Critical Care Medicine Medanta Institute of Critical Care and Anesthesiology
Fortis Memorial Research Institute Medanta–The Medicity
Gurgaon, Haryana, India Gurgaon, Haryana, India
Sanjay Mahendru Shruti Bajad MD
MBBS MS MCh (Plast Surg) DNB (Plast Surg) Senior Resident
Senior Consultant Division of Rheumatology and Clinical Immunology
Division of Plastic, Aesthetic and Reconstructive Surgery Medanta–The Medicity
Medanta–The Medicity Gurgaon, Haryana, India
Gurgaon, Haryana, India
Smruti Ranjan Mishra MBBS MD DM (Gastro)
Santosh Bhaskar MD (Anesth) IDCCM Senior Consultant
Associate Professor, Anesthesiology and Critical Care Institute of Digestive and Hepatobiliary Sciences
Chirayu Medical College and Hospital Medanta–The Medicity
Bhopal, Madhya Pradesh, India Gurgaon, Haryana, India
 Contributors xvii

S Saigal MD PDCC EDIC Supradip Ghosh MBBS DNB (Int Med) MNAMS EDIC
Assistant Professor Senior Consultant and Head
Department of Trauma and Emergency Department of Critical Care Medicine
All India Institute of Medical Sciences (AIIMS) Fortis-Escorts Hospital
Bhopal, Madhya Pradesh, India Faridabad, Haryana, India
Subhash Arora Suresh Ramasubban MBBS FACP FCCP
MBBS MD (Med) FRCP (Glasg) FRACP FCICM Director, Intensive Care
Deputy Director, Intensive Care AB-Pulmonary and Critical Care Medicine
Dandenong Hospital Apollo Gleneagles Hospital
Melbourne, Australia Kolkata, West Bengal, India
Subhash Gupta MS FRCS (Ed) FRCS (Glas) Susant Bhuyan DM (Neuro)
Senior Consultant Associate Consultant
ANG Center for Liver and Biliary Sciences Institute of Neurosciences
Indraprastha Apollo Hospitals Medanta–The Medicity
New Delhi, India Gurgaon, Haryana, India
Subhash Todi MD MRCP FICCM Sushma Patil DNB (Anesth) IDCCM
Consultant Intensivist Consultant, Neuro Trauma Unit
Advanced Medicare Research Institute Grant Medical Foundation
Kolkata, West Bengal, India Ruby Hall Clinic
Subrat K Acharya MD DM FNA FNASc Pune, Maharashtra, India
Professor and Head Sweta J Patel DA IDCCM
Department of Gastroenterology Consultant, Critical Care Medicine
All India Institute of Medical Sciences (AIIMS) Medanta Institute of Critical Care and Anesthesiology
New Delhi, India Medanta–The Medicity
Sudakshina Mullick Gurgaon, Haryana, India
MD (Gen Med) IDCCM FNB (Crit Care) EDIC Tajinder Kaur Bedi MD
Associate Consultant and Incharge, ICU Consultant
Tata Medical Center Department of Anesthesiology and Intensive Care
Kolkata, West Bengal, India Kailash Hospital and Heart Institute
Sumit Ray FCCM MD Noida, Uttar Pradesh, India
Senior Consultant and Vice-Chairman Tanveer A Yadgir
Department of Critical Care and Emergency Medicine PhD (Pub Health) Scholar BUMS MBA (Healthcare Services)
Sir Gangaram Hospital PGDEMS, NQEMT (Ireland)
New Delhi, India Medical Researcher
Sumit Singh MBBS MD DM Dubai Corporation for Ambulance Services, Dubai, UAE
Additional Director of Neurology Uday Aditya Gupta MBBS DTCD DNB IDCCM FCCP
Institute of Neurosciences Attending Consultant
Medanta–The Medicity Medanta Institute of Critical Care and Anesthesiology
Gurgaon, Haryana, India Medanta–The Medicity
Sumit Sinha MS MCh Gurgaon, Haryana, India
Additional Professor, Department of Neurosurgery Uma Munnur MD
All India Institute of Medical Sciences and Associate Professor
JPNA Trauma Center, New Delhi, India Department of Anesthesiology
Sunny Virdi MD (Med) DM Baylor College of Medicine
Fellow Houston, Texas, USA
Department of Pulmonary Critical Care Medicine Vijaya Patil MD (Anesth) DHA
(PCCM) Professor, Department of Anesthesiology
Pt Bhagwat Dayal Sharma Critical Care and Pain
Post Graduate Institute of Medical Sciences Tata Memorial Hospital
Rohtak, Haryana, India Mumbai, Maharashtra, India
xviii Textbook of Critical Care

Vijay Hadda MD Yatin Mehta MD MNAMS FRCA FAMS FICCM FIACTA FTEE
Assistant Professor Chairman, Medanta Institute of Critical Care
Department of Pulmonary Medicine and Sleep Disorders and Anesthesiology
All India Institute of Medical Sciences (AIIMS) Medanta–The Medicity
New Delhi, India Gurgaon, Haryana, India
Vijay Kher MD (Med) DM (Nephro) FAMS FRCPE YK Batra MD MNAMS FAMS
Chairman Professor and Head
Division of Nephrology Department of Anesthesia and Intensive Care
Medanta Kidney and Urology Institute Postgraduate Institute of
Medanta–The Medicity Medical Education and Research
Gurgaon, Haryana, India Chandigarh, Punjab, India
Vijay Kumar MD DNB (Cardio) Zafar M Khan MBBS FCPS DHA
Senior Consultant, Fortis Escorts Heart Institute Senior Specialist and Registrar
New Delhi, India Rashid Trauma Center
Wajahat Zafar Khan MBBS DHA Dubai, UAE
Resident, Department of Emergency Medicine Zubin Dev Sharma DNB
Rashid Trauma Center, Dubai, UAE Senior Resident
Wasir JS MBBS MD Institute of Digestive and Hepatobiliary Sciences
Senior Consultant Medanta–The Medicity
Division of Endocrinology and Diabetes Gurgaon, Haryana, India
Center for Advance Diabetes Technology and
Therapeutics
Medanta–The Medicity
Gurgaon, Haryana, India
Foreword

The field of critical care medicine has grown enormously since its very early beginning in the late 1950s
and intensive care beds and units have an increasingly important role to play in hospitals around the globe
as patients survive conditions to which, in the past, they would have succumbed. Advances in technology,
improved understanding of normal physiology and disease pathogenesis, and better general processes
of care at all levels of the medical system, have all played a role in this progress. This growth has fuelled
research and further development to such an extent that it is, sometimes, difficult to keep up-to-date with
the latest best practice for our patients.
The Textbook of Critical Care, edited by Dr Yatin Mehta, Dr Jeetendra Sharma and Dr Mukesh Kumar
Gupta, is clearly a very welcome update, providing intensivists and all involved in the management of critically-ill patients
with the latest guidance from experts on a broad range of relevant topics. Starting with the global concepts like scoring
systems and patient transport, the book moves through general physiological aspects of electrolyte and fluid balance,
glycemic control and mechanical ventilation, to consider each organ system in more detail. Specific patient groups are
also covered, for example, pregnant, post-transplant, or trauma patients. And finally, the topical issues of ICU organization
and ethics are addressed.
In spite of the internet revolution, books remain a vital source of information and a means of imparting knowledge
and expertise. I am honored to have been asked to write the Foreword for this comprehensive book on critical care and
congratulate Dr Mehta for a job well done!

Jean-Louis Vincent MD PhD

Professor of Intensive Care Medicine
Université Libre de Bruxelles
Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
President, World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM)
Foreword

The tremendous improvement in critical care over the last two decades is due to better understanding of
pathophysiology and management of multiorgan dysfunction syndrome by the intensivists. Patients, who
were considered terminally-ill or non-salvageable, are being sent home with good quality of life and this
is supported by the technological advances in organ support. As the longevity increases, older patients
also come for major surgical procedures such as coronary artery bypass surgery and are discharged home
due to joint efforts by the cardiac surgeons and cardiac critical care specialists using all their expertise,
knowledge and perseverance ably supported by technology.
This is also applicable to all other surgical specialties, as can be seen in the section in this textbook on surgical critical
care.
Dr Yatin Mehta has been with me for over the last 28 years and I have seen him grow from a cardiac anesthesiologist
to a full-fledged intensivist and this comprehensive textbook of critical care is a proof of that.
Generally, Indians tend to extrapolate Western literature to Indian context, which may not be completely correct.
Environment, genetic and racial factors along with availability of resources may seriously affect the incidence and outcome.
This excellent book can fill in that void. Masters of their respective fields, from all over the world, have contributed to this
book. I congratulate Yatin and his colleagues for this commendable effort.

Naresh Trehan
Diplomate American Board of Cardiothoracic Surgery
Chairman, Medanta Heart Institute
CMD, Medanta – The Medicity
Gurgaon, Haryana, India
Foreword

A new book on critical care medicine always comes with an inherent excitement. This book is no exception.
The field of critical care has grown enormously over the last four decades since the Society of Critical
Care Medicine was established in the early 1970s. From a humble beginning, the field of this practice has
moved at a very rapid pace.
In India, there were initial isolated attempts in the early 1980s, but the real thrust came after the
evolution of the Indian Society of Critical Care Medicine in 1993. From then on, the specialty has been
galloping to its current uniquely privileged position.
Along with the growth in number of ICUs and the equipment and the number of trained and qualified specialists
practicing critical care, there has been a constant atmosphere of academics and science. This has disseminated to all
parts of the country and has been a major achievement of any body of professionals in the field of medicine.
It is, therefore, no surprising that we are now getting a full-fledged textbook of critical care. Dr Yatin Mehta has been a
strong pillar and a significant contributor to the ethical, academic, vibrant and modern face of the field of critical care in
India. Under his able leadership, this textbook is seeing the light of the day. This is indeed a proud moment for all of us in
this field. Along with the contributions in the field of education and practice of this specialty, this has been an additional
feather in the cap of Dr Yatin Mehta.
The list of contributors to this textbook, both Indian and International, has been significant. Almost everyone who
is in ‘Who’s Who in this field, has contributed, and this is very remarkable. Excellent International contributors have
complemented this in a balanced way. This retains the flavor of the book and, at the same time, has the weight of
International level of contributions. Besides this, the list of topics is also exhaustive. Almost all topics have been covered
in detail and one will find most of the academic material here.
With the publication of this textbook, Dr Yatin Mehta and his team have made a significant and important contribution
for which they deserve all the compliments. I am sure, all of us will find this textbook very useful and interesting.

Shirish Prayag MD FICCM

Managing Director and Chief Consultant
Critical Care Medicine, Prayag Hospital
Pune, Maharashtra, India
Another Random Scribd Document
with Unrelated Content
that the indigenous population whose social structure was
matrilinear was not Indo-European at all but belonged to the same
race as the Hittites of Asia Minor and that the memory of them
survives in the mythological Amazons. To this question I hope to
return on another occasion. The subject has been already discussed
in Dr Walther Leonhard’s Hittites und Amazonen, 1911. 2 For a full
discussion of this question we may look to Mr Cook’s forthcoming
Zeus,
 492 ον ἔτ Themis AO ohh [cH. Now in Homer, once alive to
the fact of an earlier background against which is set the Northern
patrilinear family, traces of primaeval sanctities are not hard to find.
When Themis summons the Olympian agora, we remember? that
she not only summons the Olympian family, but she has to ‘range
round’ to find the earlier nature-potencies, the gods of spring and
stream. Hastily they do on their human shapes; we catch them at
the very moment of hurried, uneasy metamorphosis. But, though
they do on human shapes, they are no part of the great human,
patrilinear, family. Again, ritual is always conservative. In the archaic
ritual of the oath we see the contrast between new and old. When
Menelaos is about to engage with Paris, he says? to the Trojans
Bring ye two lambs, one white ram and one black ewe for Earth and
Sun, and we will bring one for Zeus. The Trojans, Southerners of
Asia Minor, use the old sympathetic ritual of the Horkos. The
primitive Horkos or barrier or division is between Earth and Sky, and
Earth the Mother is, as we shall presently see, before Sky, the
Father. The Achaeans, the Northerners, have no Horkos proper, but
they bring a ram for the anthropomorphic Zeus. If then we would
understand the contrast between the Olympians and their
predecessors we must get back to the earlier Themis, to the social
structure that was before the patriarchal family, to the matrilinear
system, to the Mother and the Tribe, the Mother and the Child and
the Initiated young men, the Kouretes. MATRILINEAR STRUCTURE.
We are back where we began. It may be well to recall what has
been so long out of sight. The relief in Fig. 143 from the Capitoline
altar? sets the old matrilinear social structure very clearly before us.
To the left the Mother is seated. Her child has been taken away from
her. Seated on a rock in the middle of the picture he 1 Supra, p. 482.
2 Hom. Jl. 111. 104, 5 Overbeck, Kunstmythologie, Atlas m1. 24.
 4 The Matrilinear Group 493 is suckled by the goat
Amaltheia. Over him, dominating the whole scene, two Kouretes
clash their shields. Mother, Child, Initiated youths, these are the
factors of the old social group. The father, Kronos, is... nowhere. We
hear the words of the Hymn: ‘For here the shielded Nurturers took
thee, a child immortal, from Rhea, and, with noise of beating feet,
hid thee away.’ From art-representations Kronos the father is
singularly, saliently, absent. We remember the detailed
representation of the birth of the child, on the Milan relief*; the
mother giving birth to the child, the child set on the throne, the child
on the ᾿ back of the prancing goat; always the mother and child, and
the animal form of the mother with its totemistic remembrance, but
never the father. The conclusion is very clear. The myth is a
presentation, a projection of the days when, at first, the facts of
fatherhood were unknown, and later, but little emphasized; when the
Themis of the group was the mother, as mother of the initiate youth
to be. Themis as abstract Right, or as statutory Law, sanctioned by
force, would surely never have taken shape as a 1 Supra, p. 7. ὅ 2
Supra, p. 60. Fig. 9.
 494 Themis | [on. woman; but Themis as the Mother, the
supreme social fact and focus, she is intelligible. sfG It may seem
strange that woman, always the weaker, should be thus dominant
and central. But it must always be observed that this primitive form
of society is matrilinear not matriarchal. Woman is the social centre
not the dominant force. So long as force is supreme, physical force
of the individual, society is impossible, because society is by
cooperation, by mutual concession, not by antagonism. —— . --
-...ὦὁ Fig. 144. Moreover, there is another point of supreme
importance. In primitive matrilinear societies woman is the great
social force or rather central focus, not as woman, or at least not as
sex, but as mother, the mother of tribesmen to be. This social fact
finds its projection in the first of divine figures, in Kourotrophos—
Rearer of Sons.’ The male child nursed by the mother is potentially ‘a
kouros, hence her great value and his. When Agamemnon bids
Menelaos slay all his foes root and branch, he says ‘Let not one
escape sheer destruction, spare not even that which a mother bears
in her womb, for it is a kowros!? 1 Hom. Il, νι. 58 ὅν τινα γαστέρι
μήτηρ κοῦρον ἐόντα φέροι. Prof. Murray kindly drew my attention to
this passage. Hence the custom, common to many lands, of placing
a male child in the bride’s lap that she may become Kourotrophos.
See D. 8. Stuart, The Prenuptial Rite in the New Callimachos, Journal
of Classical Philology, νι. 1911.
 ἱ xi] Kronos as Matrilinear King 495 Kronos the Father
emerges into prominence when patriarchy becomes dominant. He
then is figured as a sort of elder Zeus. He appears on another face
of the Capitoline altar! reproduced in Fig. 144. Like Zeus he is seated
on a chair with arms. Unlike Zeus he is veiled. Rhea approaches
bearing the swaddled stone. It is a strange, almost grotesque, blend
of old and new. Kronos as a father is respectable, even venerable.
But patriarchy, once fully established, would fain dominate all things,
would invade even the ancient prerogative of the mother, the right
to rear the child she bore. Standing before the Hermes of Praxiteles
I have often wondered why a figure so beautiful should leave the
imagination unsatisfied, even irritated. It is not merely that the
execution is late and touched with an over facility; it is, I think, that
the whole conception, the motive, is false. Hermes, the young male,
usurps the function of the mother, he poses as Brephotrophos. He is
really Kourotrophos. The man doing woman’s work has all the
inherent futility and something of the ugly dissonance of the man
masquerading in woman’s clothes. Kronos stands always for the old
order, before Zeus and the Olympians; he hates his father Ouranos
but reverences and takes counsel with Earth his mother. Another
trait links him with the earlier pre-patriarchal order. Unlike Zeus,
Kronos is not addressed as father. He is not father but ‘king, king
upon earth in the older Golden Age. O king Kronos and Zeus the
Father?. It is not a heavenly kingdom imagined, it is a definite reign
upon earth. Kronos is never, never could be, translated to the skies.
The reason is, I think, clear: Kronos is the king, he is the projection
of the old medicine king. He is like Picus, like Salmoneus. He reigns
as τύραννος in an ancient fortress, a τύρσις", not as Father in the
open δώματ᾽ Ὀλύμπου. It is as king that he is constantly confused
with Moloch who is Melek, the King‘. Kronos the king represents the
old matrilinear days and is 1 Overbeck, Kunstmythologie, Atlas 111.
24. 2 Julian, Conviv. 317d, ᾧ βασιλεῦ Kpove καὶ Ζεῦ πάτερ. 3 Pind.
Ol. τι. 124 ἔτειλαν Διὸς ὁδὸν παρὰ Κρόνου τύρσιν. For turris, τύρσις
and τύραννος and their possibly Mongolian origin see Rev. Arch.
1904, p. 414, 4 This illuminating suggestion, which immediately
commends itself, was made to Dr Frazer by Professor Kennett. See
Adonis, Attis and Osiris, Appendix, p. 401.
 496 Themis ity [ CH. therefore closely linked with Gaia. It
has been already’ shown how on the slopes of the hill Kronion at
Olympia was the sanctuary of the Mother and Child, Sosipolis and
Eileithyia. The same conjunction obtains at Athens. When the cult of
Olympian Zeus was brought by Peisistratos to Athens, with him came
Kronos and Rhea, and with him came Gaia’, for Rhea is but the
Mountain Mother, the Asia Minor wilder form of Gaia. As king, Kronos
is also daimon of the year. He stands for the cycle of reincarnation.
Plato, in the Politicus*, makes a most instructive comparison
between the Age of Kronos and his own age, the Age of Zeus. His
account of the Age of Kronos seems haunted by reminiscences not
only of totemism but of matrilinear social structure. Above all things,
it is the age of the Earth-Men, sown and re-sown‘. ‘ There were
divine daimones who were the shepherds of the various species and
herds of animals, and each was entirely sufficient for those whom he
shepherded. So that there was no wildness nor eating of each other,
nor any war, nor revolt amongst them....In those days God himself
was their shepherd....Under him there were no governments nor
separate possessions of women and children. For all men rose again
from the earth remembering nothing of their past. And such things
as private property and families did not exist, but Earth herself gave
them abundance of fruits from trees and other green things,
spontaneously, and not through husbandry. And they dwelt naked in
the open air, for the temperature of the seasons was mild. And they
had no beds, but lay on soft couches of herb which grew abundantly
out of the earth. Such, Socrates, was the life of men in the days of
Kronos.’ ἢ Plato seems conscious that, in the days of Kronos, the
ruler of each department was more herdsman or shepherd than
king. The ancient Basileus was indeed, as already has been hinted, a
person half daimon, half man, essentially a functionary, and almost
wholly alien to our modern, individualistic notion of king. Given that
Kronos was such a daimon king, it is clear that he rules over the
early earth-born race, that his kingdom is in quite a special way of
this earth. He stands for the Earth and her seasonal year rather than
for any cycle of Sun and Moon. The etymology of his name is not
quite certain, but the ancient guess which connects it with the verb
xpaivw is probably right. 1 Supra, p. 240. 2 Paus. 1. 18. 7. 3 971 π,
272 A. 4 Plato, op. cit. 272 EB καὶ τὸ γήινον ἤδη πᾶν ἀνήλωτο γένος,
πάσας ἑκάστης τῆς ψυχῆς τὰς γενέσεις ἀποδεδωκυίας, ὅσα ἦν
ἑκάστῃ προσταχθέντα;, τοσαῦτα εἰς γῆν σπέρματα πεσούσης...» and
see also Timaeus 42 p, 88 "Ὁ. The whole thought is that expressed
in ritual by the Anthesteria. Supra, p. 292.
 ΧΙ] Kronos as Year-G'od 497 Kronos is the Fulfiller, the
Accomplisher. In what sense he is the Accomplisher is clear from the
words of the Chorus in the Trachiniae’ : ἀνάλγητα yap οὐδ᾽ ὁ πάντα
κραίνων βασιλεὺς ἐπέβαλε θνατοῖς Kpovidas: ϊ ἀλλ᾽ ἐπὶ πῆμα καὶ
χαρὰ πᾶσι κυκλοῦσιν οἷον "Αρκτου στροφάδες κέλευθοι. Kronos is
the Accomplisher of the full circle of the year. His nature and his
name alike make easy his identification with Chronos2. He is not the
Sun or the Moon, but the circle of the Heavens, of Ouranos, husband
of Ge; of Ouranos, in whose great dancing-place the planets move,
And God leads round his starry Bear’. Kronos indeed, so far as he is
a Year-god, marks and expresses that earlier calendar of Hesiod, in
which Works and Days are governed by the rising and setting of
certain stars and constellations, Sirius, Orion, the Pleiades, and by
the comings and goings of migratory birds, the swallow, the cuckoo,
and the crane*. But though man looks to these heavenly and
atmospheric terata to guide his sowings and reapings, his real focus
of attention is still earth. And inasmuch as his social structure is
matrilinear, she is Mother-Earth; Father-Heaven takes as yet but a
subordinate place. When, nowadays, we speak of God as ‘Father’ we
mean of course no irreverence, but we strangely delimit the sources
of life. The Roman Church, with her wider humanity, though she
cherishes the monastic ideal, yet feels instinctively that a male
Trinity is non-natural, and keeps always the figure of the divine
Mother. 1, 126. 2 Thus Proklos on Plato, Kratylos, 61 νοῦς γάρ ἐστιν
ὁ βασιλεὺς ΚΚρόνος.. αὐτὸς εἰς ἑαυτὸν ἐπεστραμμένος, ὅς γε καὶ
τοὺς ἀπ’ αὐτοῦ προκύψαντας εἰς ἑαυτὸν αὖθις ἐπέστρεψεν καὶ
ἐνεκολπίσατο καὶ ἐν ἑαυτῷ σταθερῶς ἵδρυσεν, and the fragment of
Kritias (Diels, Ε.Υ..5.3, p. 618. 21) ἢ , ἀκάμας τε Χρόνος περί τ᾽
ἀενάῳ ῥεύματι πλήρης φοιτᾷ τίκτων αὐτὸς éavrév. Kronos and
Chronos were of course in meaning, as in form, entirely distinct to
begin with. Chronos is an Orphiec figure derived from the Iranian
Time-God Zrvan. His figure cannot be discussed here. See R. Hisler,
Weltenmantel und Himmelszelt, 1910, index s.v. Kronos, Chronos,
and Zrvan, and also for Kronos and Eniautos, W. Schultz,”Aiiros in
Memnon, 1910, p. 47. 3 W. Raleigh. 4 Supra, p.97. Since I wrote the
chapter on bird magic and the τείρεα there has appeared an
interesting paper dealing in part with the association of
constellations and birds by Dr M. P. Nilsson, Die dlteste
Zeitrechnung. Apollo und der Orient in Archiv f. Religionswiss., 1911,
x1v. p. 423. H. 32
 498 Themis [CH. The particular forms taken by a people’s
mythology or theology can, as before said, only be understood in the
lght of its social structure. The matrilinear stage had long been
buried and forgotten, and hence the figures of Dionysos and his
mother Semele, and his attendant Satyrs, the figures of Rhea with
her effaced husband Kronos and the band of the Kouretes, had. lost
their real significance. To the mythologist it is sufficient evidence of a
matrilinear state of society in Greece, with its attendant tribal
initiations, that such a social structure is seen thus clearly reflected
in mythology. But, to a mind trained rather in historical than
mythological method, such evidence may seem less convincing. We
have therefore now to ask: what evidence is there, apart from
mythological representations, of the existence of a social structure in
which the mother, the male-child, and the tribe were the main
factors ? We turn, of course, first and foremost to the Apatouria, the
festival of enrolment in the phratriai, but we turn only to be at the
outset disappointed. The name itself is manifestly patriarchal.
Apatouria is Homopatoria’, the festival of those who have the same
fathers. It is celebrated κατὰ τὰ πάτρια, according to paternal usage.
On the third day was celebrated the- festival of the κουρεῶτις, of the
shearing of the hair, the significance of which has been already?
noted in connection with Herakles and Apellaios. But here again we
can detect no special relation to the Mother. A chance biographical
notice in one of the ‘Lives*’ of Homer gives us the needful clue, and
makes us suspect and indeed feel practically certain that the festival
of The Same Fathers originally belonged to the Mothers‘. When
Homer was sailing to Greece, he put in at Samos. And the people
there chanced at the moment to be celebrating the Apatouria. And
one of the Samians, who had seen him before in Chios, when they
beheld Homer 1 So definitely the scholiast to Aristoph. Acharn. 146
οἱ δέ φασιν ὅτι τῶν πατέρων ὑμοῦ συνερχομένων διὰ Tas τῶν
παίδων ἔγγραφὰς οἷον ὁμοπατόρα λέγεσθαι τὴν ἑορτήν ~ ὁποίῳ
τρόπῳ λέγομεν ἄλοχον τὴν ὁμολέκτρον καὶ ἄκοιτιν τὴν ὁμόκοιτιν
οὕτω καὶ Ὅμοπατόρια ᾿Απατόρια. 2 Supra, pp. 378 and 441; for hair
shearing in general see Dr Frazer, Pausanias, vol. m1. p. 279. 3
Westermann, ps.-Herod. Biogr. 29, p. 15. 4 The connection of Athena
with the ἐφῆβοι, her κοῦροι, and their relation to initiation
ceremonies have been ably examined by Miss Dorothy Lamb, of
Newnham College, in an essay as yet unpublished. See also
Addenda.
 ΧΙ] The Apatouria and the Tritopatores 499 arriving at
Samos, went and told the clansmen, and made a panegyric about
Homer. And the clansmen ordered him to bring Homer. And the man
who had met him said to Homer—‘Stranger, the city is celebrating
the Apatouria, and the clansmen bid you come and feast with them.’
And Homer said he would, and he went along with his host. And, as
he went, he lighted on the women who were sacrificing at the
crossways to Kourotrophos. And the priestess looked at him in anger,
and said to him, ‘ Man, begone from the sanctities!.’ The festival has
become that of the ‘Same Fathers, but the sacrifice is by women and
to the Mother, the Rearer of Children. It is by the Crossways, for the
Mother has taken on her MoonAspect, as Eileithyia, as Hekate. It is
strange indeed, at the sacrifice for the ‘Same Fathers, that no man
might be present, but if the festival were once of the Same Mothers
all is clear. The Apatouria, the festival of the ‘Same Fathers,’ is late
and patriarchal. It is interesting to find that, late though it is, the
Apatouria finds—as in early days all social structure must—its
mythological reflection and representation in a myth, that of the
Tritopatores*; figures the interpretation of which, because they
neglect to examine social structure, has caused mythologists much
trouble and perplexity. Of the Tritopatores Suidas*, quoting
Phanodemos, says : The Athenians only both sacrifice and pray to
them for the birth of children when they are about to marry. The
scholiast*, commenting on the word 7'ritogeneva, recalls a phrase
that sounds like an echo of this prayer, and throws new light on it:
‘May my child be τριτογενής." The father prays to the Tritopatores
that his child may be 1 ἐἄνερ, ἀπὸ τῶν ἱερῶν.᾽ 5.1 follow the
explanation of Dr G. Lippold in his Tritopatreis, A. Mitt. χχχνι. 1911,
p. 105. Dr Lippold scarcely seems to see the great importance in
relation to Athenian social structure of his own convincing
interpretation. 3 s.v. Tprromdropes. For the older explanation of
Tritopatores see Prolegomena, p. 179: 4 Schol. BT ad Hom. Il. vit. 39
καὶ παροίμια παῖς μοι τριτογενὴς εἴη, μὴ τριτογένεια. It is very likely,
as Dr Lippold points out, that the two concluding words are not
original, but have been added, as often in similar cases, to make up
a desired hexameter. 32—2
 500 Themis. [cH. τριτογενής. Tritogeneia, we remember,
was the Athena who sprang from her father’s head: Tritogeneia, the
daughter of Zeus the Counsellor, Born from his sacred head, in
battle-array ready dight, Golden all glistering!. Tritogeneia is not ‘she
who is born on the third day,’ nor yet ‘she who was born from the
head of her father, nor yet ‘she who was born of the water of the
brook Triton’ ; she is she who was true born, and [to be true born is
in patrilinear days to be born in wedlock of your lawful father. |
Hesychius’, defining the word Τριτοκούρη, says: She for whom
everything has been accomplished as to marriage. Some define it as
‘a true virgin.’ The outrageous myth of the birth of Athena from the
head of Zeus is but the religious representation, the emphasis, and
over emphasis, οἰ patrilinear social structure) When an Athenian
prayed to the Tritopatores, it was not for children merely, but for
true born children, children born with him for their father. The
Apatouria, then, is the festival of those who have the . same father,
and of these the Tritopatores and Tritogeneia are the mythical
expression. Now we realize why the god and goddess, who presided
over the Apatouria, were Zeus and Athena, Father and Father-born
daughter. As, in the old matrilinear days, Kronos the father was
ignored, so, by the turn of the wheel, the motherhood of the mother
is obscured, even denied; but with far less justice, for the facts of
motherhood have been always patent. Athena is the real
Kourotrophos, but for patrilinear purposes she is turned into a
diagram of motherless birth. gy ( As patrons of the Apatouria, Zeus
and Athena bear the titles Phratrios and Phratria. The phratria is the
brotherhood of those who have the same father. It has nothing to do
with the ἀδελφοί, those who have the same mother, the
ὁμογάστριοι"; it is of the 1 Hom. Hym. xxvii. 4 Τριτογενῆ, τὴν αὐτὸς
ἐγείνατο μητίετα Ζεὺς σεμνῆς ἐκ κεφαλῆς πολεμήϊα τεύχε᾽ ἔχουσαν.
s.v. Τριτοκούρη: ἣ πάντα συν(τε)τέλεσται τὰ εἰς τοὺς γάμους" τινὲς
δὲ γνησία παρθένος. The origin of the stem τρῖτο is not known; all
that is clear is that it must mean ‘true,’ ‘genuine,’ 3 Gaius (Inst. 111.
10), in true patrilinear fashion, thus defines agnatus and
consanguineus: ‘legitima cognatio est ea quae per virilis sexus
personas coniungitur. 2
 ΧΙ] Zeus, Apollo, and Athena 501 patrilinear, not the
matrilinear structure. When, in the Eumenides', the Erinyes ask of
Orestes, slayer of his mother, What brotherhood will give him holy
water ? Apollo is ready with his answer: This too I tell you, mark
how plain my speech, The mother is no parent of her ‘child,’ Only the
nurse of the young seed within her. The male is parent, she as
outside friend Cherishes the plant, if fate allows its bloom. Proof will
I bring of this mine argument. A father needs no mother’s help. She
stands, Child of Olympian Zeus, to be my witness, Reared never in
the darkness of the womb, Yet fairer plant than any heaven begot.
This alliance of the three Olympians of the Humenides, Zeus, Apollo,
Athena, brings us to a curious point. The bond, we feel, is non-
natural; the three gods stand together not because there is any
primitive link, any common cultus, but as projections,
representations of patriarchy, pushed to the utmost. They are a
trinity of Phratriot, Patréoi. Where else, we ask, are these three
disparate divinities thus unequally yoked together? The answer is
clear and brings immediate light; in Homer and in Homer only. .
Achilles, sending forth Patroklos in his armour, prays* Would, O
father Zeus and Athene, and Apollo, would that not one of all the
Trojans might escape death, nor one of the Argives. Hector names
Apollo and Athene as linked together for special adoration? : Would
that I were immortal and ageless all my days, and honoured, like as
Athene is honoured and Apollo ; Itaque eodem patre nati fratres
agnati sibi sunt, qui etiam consanguinei vocantur, nec requiritur an
etiam matrem eandem habuerint.’ So subtle and persistent is the
suggestion of name that there are persons even to-day who think
that in some mysterious way they are more descended from their
father than their mother. For the whole question see P. Kretschmer,
Die Griechische Benennung des Bruders, Glotta τι. p. 210. 1559 ποία
δὲ χέρνιψ φρατέρων προσδέξεται; and see also Eur. Or. 552, and
Frg. 1048. 2 As long ago remarked by Mr Gladstone, who brought
together all the evidence in a book too little read now-a-days, his
Juventus Mundi, 1869, p. 266 (Section viii. Athene and Apollo). We
cannot of course adopt Mr Gladstone’s solution. He held that Apollo
and Athene were each in a special way the Logos of Zeus. The
question is also raised by Prof. Murray, Rise of the Greek Epic”, p. 69,
note 3. 3 Hom. 1]. xvi. 97. 4 Hom. Jl, viii. 540.
 502 Themis [ OH. and again}, even more significantly, he
links Zeus, Athene, and Apollo together as the typical happy family :
Would that indeed I were for ever as surely the son of aegis-bearing
Zeus, ard that my mother were lady Hera, and that I were held in
such honour as Apollo and Athene, as verily this day is to bring utter
evil on all the Argives! Apollo and Athena then are linked together as
Phratriot and this conjunction is found in the patrilinear Homer and
in the Eumenides where all the emphasis is patriarchal. Elsewhere
Apollo is linked with quite another goddess, with Artemis, and in this
conjunction we see a survival, though altered and disfigured, of
matriarchal structure. In Homer a great effort is made to affiliate
Artemis as one of the patriarchal family, but, in her ancient aspect as
Πότνια θηρῶν, she is manifestly but a form of the Great Mother: at
Delphi, where Apollo reigns supreme, his ‘sister’ Artemis is strangely,
significantly absent. What has happened is fairly obvious. Artemis, as
Mother, had a male-god as son or subordinate consort, just as
Aphrodite had Adonis. When patriarchy ousted matriarchy, the
relationship between the pair is first spiritualized as we find it in
Artemis and Hippolytos; next the pair are conceived of in the barren
relation of sister and brother. Finally the female figure dwindles
altogether and the male-consort emerges as merely son of his father
or utterer of his father’s will—Avos προφήτης. This is curiously and
instructively shown in the history of the Eiresione. Originally of
course the Eiresione was, as we have seen’, a sanctity per se, a
branch carried magically to promote fertility. In historical times, in
the Thargelia, Daphnephoria, ete. it was associated with the worship
of, it was ‘sacred to, Apollo*. This is natural enough for Apollo, as
Aguieus and as Kouros, was the young male divinity, the source of
fertility. In the Thargeha 1 Hom. Il. x11. 827. 2 Supra, p. 220. 3 Also
at the Eiresione of Samos, which was associated with the primitive
swallow song. See (Hdt.), Vit. Hom. p.17 f. ap. Suidam, 5.ν.
Ὅμηρος... ἤδετο δὲ τὰ ἔπεα τάδε (ἃ καλεῖται Εἰρεσιώνη) ἐν τῇ Σάμῳ
ἐπὶ πολὺν χρόνον ὑπὸ τῶν παίδων, ὅτ᾽ ἀγείροιεν ἐν TH ἑορτῇ τοῦ
᾿Απόλλωνος. In the song given by Suidas occur the lines νεῦμαί τοι
νεῦμαι ἐνιαύσιος ὥστε χελιδών ἕστηκ᾽ ἐν προθύροις ψιλὴ πόδας:
ἀλλὰ φέρ᾽ αἶψα Ἰπέρσαι τῷ ᾿Απόλλωνος γυιατιδος εἰ μέν τι δώσεις"
but the ceremony was really to Kourotrophos. See Suidas, loc. cit. ..
εἶτα ἀφίκετο (Ὅμηρος) εἰς Σᾶμον καὶ εὗρε γυναῖκα Κουροτρόφῳ
θύουσαν k.T.X.
 ΧΙ] The Korythalia 503 and the Daphnephoria the figure of
the Mother is effaced, though _ it may be that im the two
pharmakoi, female as well as male, __as in the two Oschophoroi'
and the Daphnephoroi, her figure really _ survives. But in another
service of the Eiresione the Mother holds her own, even to the
exclusion of the Son, the ceremony of the Korythalia. Hesychius?
defining Korythalia says, A laurel wreathed : some call it Hiresione.
The Etymologicum Magnum? gives further and most instructive
particulars. It thus defines the word Korythale: The laurel-bough
placed before the doors. Because branches which the call korot
blossom. So too Chrysippos : Let some one from within give me
lighted torches and woven foroz unmixed with myrtle. For poets call
branches, diversely, shoots and saplings and korot. And others when
their sons and daughters come to maturity, place laurel-boughs
before the doors in ceremonies of puberty and marriage. The
Korythalia, ‘Youth Bloom, expresses just that oneness of man and
nature that is so beautiful and so characteristic of primitive
totemistic thinking. For them it was expressed in ceremonial, in the
carrying of branches, for us it survives in ‘ poetry.’ Thy wife shall be
as the fruitful vine, upon the walls of thine house. Thy children like
the olive-branches, round about thy table+. And at Athens in prose,
for Demades’, the orator, is reported to have said | The epheboi are
the spring of the demos. But the Korythalia tells us more, it is the
matriarchal form of the Kiresione. We know the divinity projected,
represented by the Korythalia. She was no Kouros, she was Artemis
Korythala. Supra, p. 324. 5.0. κορυθαλία" δάφνη ἐστεμμένη τινὲς
τὴν εἰρεσιώνην. 3 s.v. κορυθάλη" ἡ πρὸ τῶν θυρῶν τιθεμένη δάφνη"
ὅτι οἱ κλάδοι (ods κόρους καλοῦσι) θάλλουσιν ὡς καὶ Χρύσιππος"
᾿Αλλὰ δᾷδας ἡμμένας μοι δότω τὶς ἔνδοθεν, καὶ κόρους πλεκτοὺς
ἀκραιφνεῖς μυῤῥίνης---οἱ γὰρ ποιηταὶ ἀνάπαλιν τοὺς κλάδους καὶ
ὄξους καὶ ὅρπηκας λέγουσι. τινὲς δὲ ὅτι ἡβησάντων τῶν νέων καὶ
θυγατέρων, δάφνας προετίθουν ἐφηβίοις καὶ γάμοις εἰς τὸ δίκρον. 4
Psalm exxviii. 3, 4. > ap. Athen. ur. 55. 99 καὶ Δημάδης dé ὁ ῥήτωρ
ἔλεγε... ἔαρ δὲ τοῦ δήμου τοὺς ἐφήβους ; cf. the ver sacrum of the
Latins. 1 2
 504 Themis [cH. And, if as to her nature there was any
doubt, she had another festival which marks her function, the
Tithenidia, the festival of nurses and nurslings. Call her Orthia?, or
Korythalia, or Hyakinthotrophos?, or Philomeirax?, it is all one; she is
Kouro- — trophos, the Rearing Mother, nurse of the Kouroi to be‘.
Kourotrophos and the Lady of the Wild Things are but the forms of
the ancient mother served by the Kouretes and she survives in the
figure of Artemis, the Huntress sister of Apollo. Of this we have
curious ritual evidence. At Messene, near to a temple of Eileithyia,
Pausanias® saw a hall of the Kouretes, where they sacrifice without
distinction all animals, beginning with oxen and goats and ending
with birds: they throw them all into the fire. Why this singular
service to the Kouretes ? Why indeed, unless we remember that they
were the ministrants, the correlatives of the Great Mother, the ‘Lady
of the Wild Things. To her the sacrifice of all living things is
manifestly, if hideously, appropriate. And to her it was offered.
Lucian*, in his account of the Syrian goddess at Hieropolis—
manifestly but a form of the Great Mother—tells how, in the court of
the sanctuary, were kept all manner of beasts and birds.
Consecrated oxen, horses, eagles, bears and lions, who never hurt
anyone, but are holy and tame to handle. But of these tame beasts
and birds in one day in the year there is a holocaust. | ‘Of all the
festivals,’ Lucian? says, ‘the greatest that I know of they hold in the
beginning of the spring. Some call it the Pyre, some the Torch. At
this festival they do as follows. They cut down great trees and set
them up in the courtyard. Then they bring in goats and sheep and
other live beasts, and hang them up on the trees. They also bring
birds and clothes and vessels of gold and silver. When they have
made all ready, they carry the victims round the trees and set fire to
them and straightway they are all burned,’ By a fortunate chance we
know that this sacrifice of all living things, so appropriate to the
Mother, was also made to Artemis 1 The etymology of Orthia is still
uncertain, but the scholiast on Pindar, Ol. m1. 54, is probably right in
his guess as to the meaning: ὅτι ὀρθοῖ εἰς σωτηρίαν ἢ ὀρθοῖ τοὺς
γεννωμένους. 2 For ὑακινθοτρόφος see Collitz-Bechtel, Samm. Gr.
Dialekt. 3501, 3502, 3512; the title occurs in Knidos. For Hyakinthos
as juvencus=adulescentulus, see Dr 5. Wide, Lakonische Kulte, p.
290. Ὁ Paus. v1. 23. 8. 4 Supra, p. 494. 5. χγ;.82. 9, δ De Syria Dea,
41. 7 Op. cit. 49.
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