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ACCP Critical Care Medicine Board Review 20th Edition
Joshua O. Benditt Digital Instant Download
Author(s): Joshua O. Benditt, et al. American College of Chest Physicians
ISBN(s): 9783805593663, 380559366X
Edition: 20
File Details: PDF, 18.59 MB
Year: 2009
Language: english
Contents
Solid Organ Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Joshua O. Benditt, MD, FCCP

Infections in AIDS Patients and Other Immunocompromised Hosts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

George H. Karam, MD, FCCP

Nervous System Infections and Catheter Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

George H. Karam, MD, FCCP

Bradycardias: Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

James A. Roth, MD

Upper and Lower GI Bleeding in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Gregory T. Everson, MD

Tachycardias: Diagnosis and Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

James A. Roth, MD

Heart Failure and Cardiac Pulmonary Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Steven M. Hollenberg, MD, FCCP

Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Steven M. Hollenberg, MD, FCCP

Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
John P. Kress, MD, FCCP

Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Gregory A. Schmidt, MD, FCCP

Hypertensive Emergencies and Urgencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

R. Phillip Dellinger, MD, FCCP

Critical Illness in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Mary E. Strek, MD, FCCP

Venous Thromboembolic Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

R. Phillip Dellinger, MD, FCCP

Weaning From Ventilatory Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Scott K. Epstein, MD, FCCP

Trauma and Thermal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

David J. Dries, MD, MSE, FCCP

Postoperative Critical Care Management and Selected Postoperative Crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

Jonathan S. Simmons, DO, MSc, FCCP

Acute Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

John P. Kress, MD, FCCP

Coma, Delirium, and Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Scott K. Epstein, MD, FCCP

Abdominal Problems in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

David J. Dries, MD, MSE, FCCP

ACCP Critical Care Medicine Board Review: 20th Edition iii

Hypothermia, Hyperthermia, and Rhabdomyolysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Janice L. Zimmerman, MD, FCCP

Ventilatory Crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

Gregory A. Schmidt, MD, FCCP

Poisonings and Overdoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

Janice L. Zimmerman, MD, FCCP

Anemia and RBC Transfusion in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Karl W. Thomas, MD, FCCP

Endocrine Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

James A. Kruse, MD

Coagulopathies, Bleeding Disorders, and Blood Component Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381

Karl W. Thomas, MD, FCCP

Hemodynamic Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

Jesse B. Hall, MD, FCCP

Nutritional Support in the Critically Ill Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

John W. Drover, MD

Acid-Base Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

Gregory A. Schmidt, MD, FCCP

Issues in Postoperative Management: Postoperative Pain Management and Intensive Glycemic Control . . . . . . 425
Michael A. Gropper, MD, PhD, FCCP

Seizures, Stroke, and Other Neurologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Thomas P. Bleck, MD, FCCP

Resuscitation: Cooling, Drugs, and Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Brian K. Gehlbach, MD

Issues in Sedation, Paralytic Agents, and Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Michael A. Gropper, MD, PhD, FCCP

Severe Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485

Michael S. Niederman, MD, FCCP

Acute Kidney Injury in the Critically Ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507

Richard S. Muther, MD

Antibiotic Therapy in Critical Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523

Michael S. Niederman, MD, FCCP

Electrolyte Disorders: Derangements of Serum Sodium, Calcium, Magnesium, and Potassium . . . . . . . . . . . . . . 539
Richard S. Muther, MD

iv Contents
 ACCP Critical Care
Medicine Board
Review: 20th Edition
The American Board of Internal Medicine (ABIM) is not affiliated with, nor does
it endorse, preparatory examination review programs or other continuing medical
education. The content of the ACCP Critical Care Medicine Board Review: 20th Edition
is developed independently by the American College of Chest Physicians (ACCP),
which has no knowledge of or access to ABIM examination material.

The views expressed herein are those of the authors and do not necessarily reflect the
views of the ACCP. Use of trade names or names of commercial sources is for information
only and does not imply endorsement by the ACCP. The authors and the publisher
have exercised great care to ensure that drug dosages, formulas, and other information
presented in this book are accurate and in accord with the professional standards in
effect at the time of publication. However, readers are advised to always check the
manufacturer’s product information sheet packaged with the respective products to
be fully informed of changes in recommended dosages, contraindications, etc., before
prescribing or administering any drug.
Copyright © 2009 by the AMERICAN COLLEGE OF CHEST PHYSICIANS.
Copyright not claimed on material authored by the US Government. All rights reserved.
No part of this book may be reproduced in any manner without permission of the publisher.

Published by the
American College of Chest Physicians
3300 Dundee Road
Northbrook, IL 60062-2348
Telephone: (847) 498-1400; Fax: (847) 498-5460
ACCP Web site: www.chestnet.org

Printed in the United States of America

First Printing
ISBN 978-0-916609-76-4
Authors
Joshua O. Benditt, MD, FCCP Brian K. Gehlbach, MD Michael S. Niederman, MD, FCCP
Director of Respiratory Care Services Assistant Professor of Medicine Chairman, Department of Medicine
Division of Pulmonary and Critical Care University of Chicago Professor of Medicine
Medicine Section of Pulmonary and Critical Care Winthrop University Hospital
University of Washington School of Medicine Chicago, IL Vice Chairman, Department of Medicine
Seattle, WA SUNY at Stony Brook
Michael A. Gropper, MD, PhD, FCCP Mineola, NY
Thomas P. Bleck, MD, FCCP Professor and Vice Chair
Chairman of Neurology, Evanston Department of Anesthesia and Perioperative James A. Roth, MD
Northwestern Healthcare and Care Director of Electrophysiology
Professor and Vice Chair for Academic Director, Critical Care Medicine Associate Professor of Cardiovascular
Programs University of California, San Francisco Medicine
Department of Neurology San Francisco, CA Medical College of Wisconsin
Northwestern University Feinberg School of Milwaukee, WI
Medicine Jesse B. Hall, MD, FCCP
Evanston, IL Professor of Medicine Gregory A. Schmidt, MD, FCCP
Anesthesia and Critical Care Professor, Division of Pulmonary,
R. Phillip Dellinger, MD, FCCP The University of Chicago Critical Care, and Occupational Medicine
Professor of Medicine The Pritzker School of Medicine Department of Internal Medicine
Robert Wood Johnson Medical School Chicago, IL University of Iowa
Director, Division of Critical Care Medicine Iowa City, IA
Director, Medical/Surgical Intensive Care Steven M. Hollenberg, MD, FCCP
Unit Professor of Medicine Jonathan S. Simmons, DO, MSc, FCCP
Cooper University Hospital Robert Wood Johnson Medical School Clinical Assistant Professor
Camden, NJ University of Medicine and Dentistry of New Co-Director, Critical Care Fellowship
Jersey Program
David J. Dries, MD, MSE, FCCP Director, Coronary Care Unit Chair, Disaster Preparedness and Emergency
Assistant Medical Director for Surgical Care Cooper University Hospital Management
HealthPartners Medical Group Camden, NJ Departments of Anesthesia and Emergency
John F. Perry, Jr., Professor of Surgery Medicine
University of Minnesota George H. Karam, MD, FCCP Surgical Intensive Care Unit
Regions Hospital Paula Garvey Manship University of Iowa Hospitals and Clinics
St. Paul, MN Professor of Medicine Iowa City, IA
Louisiana State University
John W. Drover, MD School of Medicine Mary E. Strek, MD, FCCP
Associate Professor New Orleans, LA Associate Professor of Medicine
Chair and Medical/Director Head, Department of Internal Medicine Section of Pulmonary and Critical Care
Critical Care Program Earl Long Medical Center University of Chicago
Queen’s University Baton Rouge, LA Chicago, IL
Kingston General Hospital
Kingston, ON Canada John P. Kress, MD, FCCP Karl W. Thomas, MD, FCCP
Assistant Professor of Medicine Assistant Professor
Scott K. Epstein, MD, FCCP Section of Pulmonary and Critical Care Division of Pulmonary Diseases
Dean for Educational Affairs and Professor University of Chicago Critical Care, and Occupational Medicine
of Medicine Chicago, IL University of Iowa
Tufts University School of Medicine Iowa City, IA
Pulmonary, Critical Care and Sleep Medicine James Kruse, MD
Division Chief, Critical Care Services Janice L. Zimmerman, MD, FCCP
Tufts Medical Center Bassett Healthcare Head, Division of Critical Care Medicine and
Boston, MA Cooperstown, NY Director, Medical Intensive Care Unit
Department of Medicine
Gregory T. Everson, MD Richard S. Muther, MD The Methodist Hospital
Professor of Medicine Medical Director Houston, TX
Director of Hepatology Division of Nephrology
University of Colorado School of Medicine Research Medical Center
Denver, CO Kidney Associates of Kansas City PC
Kansas City, MO

ACCP Critical Care Medicine Board Review: 20th Edition v

DISCLOSURE OF AUTHORS’ CONFLICTS OF INTEREST

The American College of Chest Physicians (ACCP) remains strongly committed to providing the best available evidence-
based clinical information to participants of this educational activity and requires an open disclosure of any potential
conflict of interest identified by our authors. It is not the intent of the ACCP to eliminate all situations of potential conflict of
interest, but rather to enable those who are working with the ACCP to recognize situations that may be subject to question
by others. All disclosed conflicts of interest are reviewed by the educational activity course director/chair, the Continuing
Education Committee, or the Conflict of Interest Review Committee to ensure that such situations are properly evaluated
and, if necessary, resolved. The ACCP educational standards pertaining to conflict of interest are intended to maintain the
professional autonomy of the clinical experts inherent in promoting a balanced presentation of science. Through our review
process, all ACCP CME activities are ensured of independent, objective, scientifically balanced presentations of information.
Disclosure of any or no relationships will be made available on-site during all educational activities.

The following authors of the Critical Care Medicine Board Review: 20th Edition have disclosed to the ACCP that a
relationship does exist with the respective company/organization as it relates to their presentation of material and should be
communicated to the participants of this educational activity:

Authors Relationship
Thomas P. Bleck, MD, FCCP Grant monies
(sources other than industry): NINDS, NIAD
Grant monies
(industry-related sources): ALSIUS,
NovoNordisk, Actelion
Consultant fee: USAMRICD
Speakers bureau: PDL BioPharma
Steven M. Hollenberg, MD, FCCP Speakers bureau: Novartis-Makers of Valsartan
Michael S. Niederman, MD, FCCP Consultant fee, speaker bureau, advisory committee, etc: Pfizer, Inc.,
Merck & Co., Inc., Schering-Plough, Ortho-McNeil, Nektar, Cerexa
Grant monies (from sources other than industry): Nektar to study
aerosolized amikacin in VAP therapy. Brahms to study procalcitonin
James A. Roth, MD Advisory committee: Medtronic Regional Advisory Board Member
Mary E. Strek, MD, FCCP Grant monies (industry-related sources): AstraZeneca LP,
GlaxoSmithKline

The following authors of the ACCP Critical Care Medicine Board Review: 20th Edition have disclosed to the ACCP that he or
she may be discussing information about a product/procedure/technique that is considered research and is not yet approved
for any purpose:

Thomas P. Bleck, MD, FCCP Nicardipine for subarachnoid hemorrhage; several drugs for status
epilepticus
John W. Drover, MD Parenteral glutamine
Michael S. Niederman, MD, FCCP Aerosolized amikacin

The following authors of the Critical Care Medicine Board Review: 20th Edition have indicated to the ACCP that no potential
conflict of interest exists with any respective company/organization, and this should be communicated to the participants of
this educational activity:

Joshua O. Benditt, MD, FCCP Brian K. Gehlbach, MD Richard S. Muther, MD

R. Phillip Dellinger, MD, FCCP Michael A. Gropper, MD, PhD, FCCP Gregory A. Schmidt, MD, FCCP
David J. Dries, MD, FCCP Jesse B. Hall, MD, FCCP Jonathan S. Simmons, DO, FCCP
John W. Drover, MD George H. Karam, MD, FCCP Karl W. Thomas, MD, FCCP
Scott K. Epstein, MD, FCCP John P. Kress, MD, FCCP Janice L. Zimmerman, MD, FCCP
Gregory T. Everson, MD James A. Kruse, MD

vi
Needs Assessment

Rely on the ACCP Critical Care Medicine Board Review 2009 to review the type of information you should know for the
Critical Care Subspecialty Board Examination of the American Board of Internal Medicine (ABIM). Designed as the best
preparation for anyone taking the exam, this comprehensive, exam-focused review will cover current critical care literature
and management strategies for critically ill patients.

The ABIM Critical Care Subspecialty Board Examination tests knowledge and clinical judgment in crucial areas of critical care
medicine. This premier course will review the information you should know for the exam. Course content mirrors the content
of the exam, as outlined by the ABIM, and includes the following topics:

Pulmonary disease 22.5%

Cardiovascular disorders 17.5%
Renal/Endocrine/Metabolism 15%
Infectious disease 12.5%
Neurologic disorders 7.5%
Surgical/Trauma/Transplantation 7.5%
Gastrointestinal disorders 5%
Hematologic/Oncologic disorders 5%
Pharmacology/Toxicology 5%
Research/Administration/Ethics 2.5%

Total 100%

Target Audience
Physicians in critical care and pulmonary medicine
Physicians in emergency departments
Physicians in anesthesiology
Physicians in surgery
Advanced critical care nurse practitioners
Advanced respiratory therapy practitioners
Physician assistants
Pharmacists

General Publications Disclaimer

The American College of Chest Physicians (“ACCP”) and its officers, regents, executive committee, members, and employees
are not responsible in any capacity for, do not warrant and expressly disclaim all liability for any content whatsoever in, and
in particular without limiting the foregoing, the accuracy, completeness, effectiveness, quality, appearance, ideas, or products,
as the case may be, of or resulting from any statements, references, articles, positions, claimed diagnosis, claimed possible
treatments, services, or advertising, express or implied, contained in any ACCP publication, all such responsibility being
solely that of the authors or the advertisers, as the case may be. All responsibility and liability for any of the foregoing for
any claimed injury or damages to any person or property alleged to have resulted from any of the foregoing, whether based
on warranty, contract, tort, or any other legal theory, and whether or not any claimant was advised of the possibility of such
damages, is expressly disclaimed and denied by ACCP, its officers, regents, executive committee, members, and employees.
For any possible specific medical condition whatsoever, all persons should consult a qualified health-care professional of their
own choice for advice.

ACCP Critical Care Medicine Board Review: 20th Edition vii

 ACCP Mem
So Many Reasons To Join.
Find Yours Today.

Communications Educational Resources

 CHEST, for specialists in pulmonology, critical care,  Discounted tuition for all CME courses and

sleep medicine, thoracic surgery, cardiorespiratory educational products

interactions, and related disciplines Board review courses and preparation materials
Hands-on clinical learning at the ACCP
journals over the last 100 years in medicine Simulation Center for Advanced Clinical
and biology. Education
Available at www.chestjournal.org Self-study tools, including ACCP-SEEK
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viii
 Point. Click. Access.
Link to the resources you need
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Education
 Calendar of upcoming courses, including

the annual CHEST meeting and hands-on

education opportunities in the ACCP
Participation Opportunities
Simulation Center for Advanced Clinical
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Education
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Full articles online
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ACCP Critical Care Medicine Board Review: 20th Edition ix

 Tobacco Prevention Education
 The 4th Edition CD-ROM: Make the Choice:

Tobacco or Health? Speaker’s Kit for presentations

The CHEST Foundation is the philanthropic to health professionals and patients
arm of the American College of Chest Physicians
 Lung Lessons SM curriculum teaches elementary
(ACCP), a 17,500-member international medical
specialty society.
smoking
The CHEST Foundation mission is to provide  Lung Lessons SM: A Presenter’s Guide DVD
resources to advance the prevention and treatment demonstrates how to teach the Lung Lessons SM
curriculum to children
to advance patient care in cardiopulmonary and
 Evils of Tobacco CD-ROM and video for children
critical care medicine, The CHEST Foundation has
and women in India
targeted the following four focus areas:

 Tobacco Prevention Critical Care and End-of-Life Care

 Humanitarian Service  The Critical Care Family Assistance Program and

 Clinical Research replication tool kit to improve coordination of

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and families
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members have when a family member is admitted
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support promising clinical research Cancer
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 Clinical research awards in asthma, COPD,

Donate online at
and women’s health
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 The American Lung Association and CHEST

Foundation Clinical Investigator Award
 The American Society of Transplantation and
The CHEST Foundation Clinical Research Award
in Lung Transplantation
 Association of Specialty Professors and The CHEST
Foundation of the ACCP Geriatric Development
Research Award

ACCP Critical Care Medicine Board Review: 20th Edition xi

Solid Organ Transplantation
Joshua O. Benditt, MD, FCCP

Objectives: organ rejection as well as the antirejection medi-

cations that are used to try to prevent this prob-
• Review the main principals of solid organ transplantation,
pertinent immunobiology and an approach to the major lem. A brief review of the rejection immunobiology
complications seen following the transplant procedure will be presented here. Reviews of this topic are
• Identify the usual clinical course and major complications referenced in the bibliography
of liver transplantations
• Identify the usual clinical course and major complications The immune system is composed of the fol-
of kidney and kidney-pancreas transplants lowing two parts: natural immunity and adaptive
• Identify the usual clinical course and major complications immunity. Natural immunity refers to the non-
of lung and heart transplantation
specific reaction whereby the recruitment of
Key words: heart transplantation; kidney transplantation; inflammatory cells such as macrophages, poly-
kidney-pancreas transplantation; liver transplantation; lung morphonuclear leukocytes, and lymphocytes are
transplantation recruited to areas of infection or tissue injury is
induced through nonspecific mechanisms of cel-
lular response. Adaptive immunity involves the
recognition of the presence of specific cell surface
proteins on infectious agents or transplanted
Overview of Solid Organ organs that results in the activation of T and B
Transplantation lymphocytes, which react to those foreign agents.
This form of immunity is specific and results in
Solid organ transplantation has increased in fre- the memory and specific recognition of foreign
quency dramatically over the past 2 decades tissues and infectious agents. Although there is
largely due to advances in the understanding and significant overlap and interaction between the
management of rejection immunobiology. Survival innate and the adaptive systems, it is the latter
following solid organ transplantation has also that is more involved in solid organ transplant
increased with better antirejection medications, rejection.
and an understanding that overimmunosuppres- The major response of the host to the trans-
sion results in its own complications and is to be planted organ is the activation of T-cell lympho-
avoided. Currently, one of the major limitations to cytes in the host that results in a cascade of
increasing the number of transplants performed reactions that are designed to destroy the trans-
is the imbalance between the limited supply of planted foreign body. Key to this process is the
donor organs and the large and growing number recognition of the transplanted organ as “foreign.”
of patients on organ-recipient waiting lists. This occurs through cell surface recognition mol-
The major issues that are likely to be seen in ecules known as the major histocompatibility
the critical care setting regarding solid organ complex (MHC) proteins on the cell surface of
transplantation are complications in the postop- cells in the transplanted organ. These MHC pro-
erative period related to mechanical surgical pro- teins are recognized by antigen-presenting cells
cedure complications, infection, rejection, and (APCs) that may be T cells or macrophages. A
complications related to the antirejection medicines portion of the MHC molecule is usually then
themselves. cleaved and processed by the APC, which then
“presents” this foreign antigen fragment on its
Rejection Immunobiology cell surface to T cells that are destined for activa-
tion. The APCs bind to the T cells through the for-
A basic understanding of the immune system eign antigen fragment as well as a second
is important to understand the process of solid costimulatory receptor on the T-cell surface. Once

ACCP Critical Care Medicine Board Review: 20th Edition 1

this binding of the two ligands occurs, activation Table 1. Drugs or Compounds That Affect Cyclosporine Levels
of the T cell occurs. This T-cell activation leads to
Increase Levels Decrease Levels
the rejection cascade that includes the following:
(1) clonal expansion of B cells that produce anti- Diltiazem Nafcillin
bodies to molecules on the transplanted organ cell Nicardipine Rifabutin
surfaces; (2) induction of CD8-positive T cells that Verapamil Rifampin
Fluconazole Carbamazepine
mediate cytotoxicity; and (3) help for macro- Itraconazole Phenobarbital
phages to induce delayed type hypersensitivity Ketoconazole Phenytoin
responses. It is these processes that lead to the Clarithromycin Octreotide
Erythromycin Ticlopidine
rejection and dysfunction of the transplanted
Lansoprazole Oristat
solid organ. Modern immunosuppression regi- Rabeprazole St. John’s wort
mens are designed to interfere with this process in Cimetidine
a number of ways. Methylprednisolone
Allopurinol
Several patterns of rejection have been de- Bromocriptine
scribed in solid organ transplantation. Hyper- Metoclopramide
acute rejection is seen within minutes to hours of Colchicine
Amiodarone
transplantation and is mediated by preformed
Danazol
antibodies that cause vascular injury. The kidney Grapefruit juice
and heart are particularly susceptible. There is no
specific treatment but this form of rejection
usually can be avoided by pretransplant cross-
matching. Accelerated rejection is an uncommon and monitoring of drug levels are essential. Cyclo-
form of antibody-mediated rejection that is seen sporine is metabolized by the hepatic cytochrome
several days after transplantation and is charac- p450 system and is subject to many drug interac-
terized by vascular necrosis. Acute rejection is the tions (Table 1). Important side effects include neph-
most common cause of graft failure and is medi- rotoxicity, hypertension, neurotoxicity (eg, tremors,
ated by T-cell-mediated cytotoxicity. Acute rejec- paresthesias, and seizures), gingival hyperplasia,
tion is defined as occurring between 1 week and hyperlipidemia, and hypertrichosis. Tacrolimus
3 months following transplantation. Chronic rejec- (FK506) is a macrolide that has essentially the same
tion generally appears ⬎3 months after the trans- mechanism of action as cyclosporine. In liver, kid-
plant procedure and is characterized by a slowly ney, and lung transplant recipients, tacrolimus is
progressive course associated with the presence more effective than cyclosporine in preventing
of fibrosis on histologic analysis of the trans- acute and chronic rejection, and is effective in the
planted organ. treatment of acute rejection. In comparison with
cyclosporine, tacrolimus is associated with more
Immunosuppression neurotoxicity, nephrotoxicity, and glucose intoler-
ance, but less hypertension, dyslipidemia, gingival
Immunosuppression is required to prevent the hyperplasia, or hirsutism. Sirolimus is a newer
rejection of the transplanted organ. The approaches agent that has effects similar to those of cyclospo-
to induction and maintenance immunosuppres- rine and tacrolimus and is used more commonly in
sion, as well as the treatment of established rejec- renal transplantation or in situations in which first-
tion, vary significantly from one institution to line immunosuppression protocols have not been
another. Most centers use a combination of agents entirely effective. Azathioprine is a purine analog
in low doses to minimize the toxicity of individual that inhibits lymphocyte proliferation. Leukope-
drugs. Cyclosporine is a fungal cyclic peptide that nia, hepatitis, and cholestasis are important toxici-
inhibits the transcription of interleukin (IL)-2 and ties. Mycophenolate mofetil is a more selective
the expression of IL-2 receptors, resulting in the inhibitor of purine synthesis that appears to be
blockade of T-cell activation. There are marked more effective than azathioprine at preventing
individual variations in the absorption and metab- acute rejection. Diarrhea, emesis, and leukopenia
olism of cyclosporine; the precise timing of dosages are the principal side effects of mycophenolate

2 Solid Organ Transplantation (Benditt)

mofetil. Corticosteroids are nonspecific antiinflam- varicella-zoster virus (VZV) also occurs in this
matory agents that inhibit cytokine production, time frame. Toxoplasmosis and Pneumocystis
antigen recognition, and T-cell proliferation. The carinii pneumonia may develop after the first
familiar side effects of corticosteroids include posttransplant month.
Cushing syndrome, hyperglycemia, hyperlipid- Pretransplant identification of latent infec-
emia, osteoporosis, myopathy, and cataracts. Poly- tions in the donor and recipient is essential in
clonal and monoclonal antibodies are used to defining risks. Routine testing includes serology
deplete the T cells that mediate acute rejection. testing for CMV; HSV; EBV; VZV; hepatitis A, B,
Antithymocyte and antilymphocyte globulin may and C; HIV, toxoplasmosis, and relevant endemic
cause serum sickness, thrombocytopenia, and leu- mycoses, such as histoplasmosis and coccidioido-
kopenia. Initial treatment with OKT3, a murine mycosis. A tuberculin test should be performed,
monoclonal antibody to the T-cell receptor, often and the chest radiograph evaluated for granulo-
elicits fever, chills, and a capillary leak syndrome matous disease. Indolent infection of the oral
resulting in hypotension and pulmonary edema. cavity and sinuses should be excluded, and immu-
OKT3 also increases the risks of cytomegalovirus nizations should be brought up to date. Prophy-
(CMV) infection and Epstein-Barr virus (EBV)- laxis is effective against many latent and some
related posttransplant lymphoproliferative dis- acquired infections. Routine surveillance is help-
order (PTLD). Newer mouse/human chimeric ful for the preemptive management of CMV infec-
monoclonal antibodies to IL-2 receptors (eg, basil- tions, and possibly others. Suspected infection
iximab and daclizumab) are associated with less should be approached with an assessment of risks
toxicity. and an aggressive effort at specific diagnosis.
CMV is the bane of transplantation. Primary infec-
Complications of Solid Organ Transplantation tion occurs when a seronegative patient receives
an organ from a seropositive donor; secondary or
The complications of solid organ transplanta- reactivation infection develops in seropositive
tion are most commonly divided into infectious recipients. Active infection (viral replication) will
and noninfectious complications. Each of these develop in most patients at risk, and is diagnosed
categories is then divided along temporal lines. by antigen detection, nucleic acid identification,
Infectious Complications: Infectious complica- or culture. Symptomatic disease develops in 40 to
tions are most often divided into early and late 60% of primary infections and approximately 20%
infections. Nosocomial infections are prominent of secondary infections. The manifestations of
in the early posttransplant course, followed by CMV disease vary with the organ transplanted.
the reactivation of latent infections in the graft or The risk of CMV disease is increased in patients
host, and new opportunistic infections related to who are treated with antithymocyte globulin or
the intensity and duration of immunosuppres- OKT3. CMV disease is treated with ganciclovir,
sion. Staphylococci and Gram-negative bacilli are with or without CMV Ig. CMV disease can be pre-
the most common early bacterial pathogens, fol- vented by the use of screened blood products, oral
lowed later by infections caused by Legionella, valganciclovir prophylaxis, and by prophylactic
Nocardia, Mycobacteria, and Listeria. Candidia- or preemptive treatment (at the earliest sign of
sis and aspergillosis are the major fungal infec- viral replication) with ganciclovir and hyper-Ig.
tions occurring in the first few months after The PTLD is caused by EBV infection, and
transplantation, but the reactivation of endemic occurs in 6 to 9% of lung transplants, 3 to 5% of
mycoses and cryptococcosis may present later. heart transplants, 2 to 4% of liver transplants, and
Herpes simplex virus (HSV) often reactivates in ⬍1% of kidney transplants. The risk of PTLD is
the initial weeks after transplantation, and her- increased by treatment with anti-T-cell antibod-
pesvirus-6 is increasingly recognized 2 to 4 weeks ies. PTLD presents 6 to 24 weeks after transplan-
posttransplant. CMV and hepatitis C infections tation with an infectious mononucleosis-like
typically present after the first month. The peak syndrome or diverse local manifestations that
incidence of EBV-related PTLD is 3 to 6 months may involve any lymphatic tissue, the GI tract,
after transplantation. Dermatomal reactivation of lungs, kidneys, or brain. The diagnosis is made by

ACCP Critical Care Medicine Board Review: 20th Edition 3

demonstrating the EBV genome in association Table 2. King’s College Hospital Criteria for Liver
Transplantation in Patients With Fulminant Hepatic Failure
with benign or malignant lymphatic proliferation.
Treatment strategies include reduced immuno- Conditions Criteria
suppression, interferon-α, and cytotoxic chemo-
therapy. Local resection may be helpful, and there Acetaminophen- Arterial pH ⬍7.3 (irrespective of
is an uncertain role for acyclovir or ganciclovir. induced the grade of encephalopathy)
disease or grade III or IV encephalopathy,
Noninfectious Complications: Noninfectious prothrombin time of ⬎100 s,
complications consist of complications related to and serum creatinine level of
the surgical procedure itself, rejection, and those ⬎ 3.4 mg/dL (301 μmol/L)
All other causes of Prothrombin time of ⬎ 100 s
related to the toxicities of the immunosuppressant
fulminant hepatic (irrespective of the grade of
drugs. They also can be divided into early and failure encephalopathy) or any three
late complications. Noninfectious problems in the of the following variables
first few weeks after solid organ transplantation (irrespective of the grade of
encephalopathy): (1) age ⬍ 10 yr
include (1) surgical complications; (2) graft dys- or ⬎ 40 yr; (2) etiology of non-A,
function related to ischemia, preservation, and non-B hepatitis, halothane
reperfusion; and (3) rejection. After the first few hepatitis, or idiosyncratic drug reac-
months, chronic rejection is a significant problem tions; (3) duration of jaundice before
onset of encephalopathy of ⬍7 d; (4)
as are the side effects of immunosuppressant prothrombin time of ⬎ 50 s; and (5)
medications, as noted above. These noninfectious serum bilirubin level of
complications will be discussed in more detail ⬎18 mg/dL (308 μmol/L)
with each of the specific transplant types.

Liver Transplantation bilirubin [in milligrams per deciliter]) ⫹ 11.2 (Ln

INR) ⫹ 9.6 (Ln serum creatinine [in milligrams
Background per deciliter]) ⫹ 6.4. A score of ⱖ10 is the usual
indication for referral to a liver transplant center.
Liver transplantation is a treatment for both A listing for liver transplantation usually occurs
acute and chronic liver failure. In the acute setting, at this point or with a higher score. The score is
liver transplantation is used in cases of fulminant also used for prioritization on the waiting list.
hepatic failure, which is defined as the onset of liver
failure with encephalopathy within a short period Typical Postoperative ICU Course
of time (weeks). Cases of fulminant hepatic failure
that may require transplant include acetamino- Liver transplant recipients require ICU care
phen toxicity, acute viral hepatitis, autoimmune for 1 to 4 days after surgery. The cardiac output is
hepatitis, and others. The criteria for transplan- generally high, and the systemic vascular resis-
tation have been difficult to evaluate as patients tance is low; circulatory instability is common
either survive to full recovery or die rapidly. The and usually volume-responsive. Myocardial
Kings College criteria (Table 2) are the most com- depression is a poor prognostic sign. Calcium
monly used prognostic criteria to decide on the may be depleted by the citrate in blood products.
suitability of a patient for liver transplantation. Hyperglycemia is common, and potassium levels
Chronic liver failure (cirrhosis) that is uncom- may be high or low. A mild metabolic acidosis
pensated is considered to be treatable by liver may be present initially, but metabolic alkalosis
transplantation. The decision to consider liver develops as the liver metabolizes citrate. Deficient
transplantation will depend on the severity of the clotting factor levels and thrombocytopenia con-
disease as well as the quality of life and the absence tribute to a significant bleeding diathesis. Blood
of contraindications. The system currently in products are usually replaced empirically (for
place to characterize the severity of liver disease evident bleeding and a fall in hematocrit),
appropriate for transplantation is known as the although many centers monitor coagulation with
Model for End-stage Liver Disease (or MELD) thromboelastography, which is a rapid measure
score. The score is calculated as 3.8 (Ln serum of the time to the onset of clotting, the rate of clot

4 Solid Organ Transplantation (Benditt)

formation, and maximum clot elasticity. Impor- or strictures. Biliary complications are diagnosed
tant signs of a functioning graft are the production by cholangiography and are managed with sur-
of golden-brown bile, the restoration of clotting, gical or endoscopic repair.
the absence of metabolic acidosis, and the resolu- Acute rejection is the most common cause of
tion of encephalopathy. Patients should be awake liver dysfunction after transplantation. Most
and alert within 12 h. The serum bilirubin level patients experience at least one episode, usually 4
may rise initially because of hemolysis, but liver to 14 days after transplantation. The clinical signs
enzyme levels should fall each day. The prothrom- (eg, fever, tenderness, and enlargement of graft)
bin time and partial thromboplastin time should and laboratory features (eg, elevated levels of
improve daily and should be normal within 72 h. hepatocellular enzymes and bilirubin) are nonspe-
Most patients can be extubated within 12 to 48 h. cific. The diagnosis is confirmed with a liver biopsy
finding that demonstrates mononuclear cell portal
Noninfectious Complications infiltration, ductal injury, and venulitis. Most
patients respond to therapy with pulse steroids or
Hemorrhage in the first 48 h usually is caused anti-T-cell antibodies. ICU readmission is rarely
by diffuse oozing in the setting of a coagulopathy required. Common noninfectious pulmonary
and is managed with blood products. Later, complications of liver transplantation include atel-
intraabdominal bleeding may be related to necro- ectasis, pleural effusions, and pulmonary edema.
sis of a vascular anastamosis. GI hemorrhage In most cases, preoperative shunting caused by
may result from stress ulceration or the develop- the hepatopulmonary syndrome improves over
ment of portal hypertension. Primary graft fail- days to months posttransplant. Respiratory mus-
ure occurs in 1 to 5% of patients receiving liver cle weakness, the abdominal wound, impaired
transplants and usually is a consequence of isch- mental status, and severe metabolic alkalosis may
emic injury. The signs of graft failure include contribute to delayed weaning. ARDS occurs in
poor bile formation, metabolic acidosis, and ⬍10% of liver graft recipients, usually as a conse-
failure to resolve encephalopathy and coagulop- quence of sepsis. Neurologic dysfunction after
athy. The treatment is retransplantation within liver transplantation may be caused by hepatic
48 h, before brainstem herniation from cerebral encephalopathy, hypoglycemia, intracranial hem-
edema occurs. Vascular complications include orrhage, air embolism, drug toxicity, or infection.
thromboses of the hepatic artery, hepatic vein, or
portal vein. Hepatic artery thrombosis occurs in Infection
about 5% of patients and presents in one of the
following four ways: massive liver necrosis (eg, Bacteria are the most important causes of
fever, rising enzymes, deterioration in mental infection after liver transplantation, particularly
status, renal insufficiency, and shock); a bile leak in the first 6 weeks after grafting. Gram-positive
with or without evidence of liver injury; recur- cocci and Gram-negative bacilli are the predomi-
rent bacteremia from hepatic abscesses; or as an nant pathogens, and the site of infection often
asymptomatic finding on a routine ultrasound. involves the transplanted liver or the recon-
The diagnosis is made by duplex ultrasonogra- structed biliary tree. Intraabdominal abscesses,
phy, and the treatment is operative repair or peritonitis, cholangitis, and surgical wound infec-
retransplantation. Portal vein thrombosis is less tions are the most common foci of bacterial infec-
common, and presents with ascites and variceal tion, followed by pneumonia, catheter sepsis, and
hemorrhage, with or without graft dysfunction. urinary tract infections.
Hepatic vein thrombosis is rare, and presents Prophylactic systemic and topical antibiotics
with liver failure and massive ascites. Biliary are commonly used but are of unproven value.
complications occur in up to 28% of patients. Bile CMV infection will be evident in approximately
leaks are caused by traumatic or ischemic injury 50% of liver transplant recipients, and half of these
to the common bile duct. Biliary obstruction may cases will be symptomatic. Seropositivity for
be caused by the kinking of the bile duct or drain- CMV is the most important risk factor for CMV
age tubes, dysfunction of the sphincter of Oddi, disease. The peak onset of CMV infection is

ACCP Critical Care Medicine Board Review: 20th Edition 5

28 days after transplantation. The most common Noninfectious Complications
manifestation is a mononucleosis-like syndrome
that is characterized by fever, malaise, myalgias, Serious noninfectious complications are
and neutropenia. Hepatitis is the most common uncommon after renal transplantation. Volume
involvement in the liver. Anecdotal reports have overload and graft dysfunction occasionally lead
suggested that the treatment of CMV disease with to pulmonary edema. Surgical complications such
ganciclovir is beneficial. CMV disease can be pre- as renal artery thrombosis, renal vein thrombosis,
vented in high-risk patients by long-term (100- urine leaks, and lymphoceles occur in ⬍5% of
day) ganciclovir prophylaxis or by preemptive patients. Hyperacute rejection from preformed anti-
treatment at the first sign of viral replication. HSV bodies causes immediate graft failure and is usually
mucositis reactivates in 40 to 50% of seropositive detected in the operating room. Acute rejection
patients and can be prevented or treated with occurs in 50 to 60% of patients within the first
acyclovir therapy. Fungal infections complicate 3 months and is suspected by a rise in creatinine level
10 to 40% of liver transplants, usually in the first that is not attributable to cyclosporine toxicity. Acute
2 months, and are more common in liver trans- rejection is empirically treated with corticosteroids;
plants than in the transplantation of other organs. refractory cases are confirmed by renal biopsy.
Candidemia, from an abdominal or vascular Chronic rejection develops in 8 to 10% of patients.
source, is the leading mycosis, followed by pul-
monary aspergillosis. Pneumocystis infections are Infectious Complications
rare in patients receiving prophylaxis.
Urinary tract infections are common soon after
Kidney Transplant renal transplantation and can be prevented with
prophylaxis using antibiotics. Bacterial infections
Background of the wound, IV catheter sites, and the respiratory
tract also may complicate the early postoperative
Kidney transplantation is the treatment of course. Opportunistic infections caused by Legio-
choice for patients with end-stage renal disease. A nella, Nocardia, and Listeria usually occur 1 to
successful kidney transplant improves the quality 6 months after transplantation. Fungal infections
of life and reduces the mortality risk for most are less common in renal graft recipients than in
patients, when compared with maintenance dial- other organ transplant patients. Primary CMV
ysis. Unfortunately, the number of patients await- infection develops in 70 to 90% of seronegative
ing transplant far outstrips the supply of donor recipients of a kidney from a seropositive donor,
organs available and has resulted in many patients and 50 to 60% of these patients will be symp-
requiring ongoing dialysis with its associated tomatic. CMV infection develops in 50 to 80% of
morbidities. Sources for renal allografts include seropositive recipients, and 20 to 40% of these
cadaveric donors, living related donors, and liv- patients will have clinical disease. The onset of
ing unrelated donors. Human leukocyte antigen infection is usually 1 to 6 months after transplant.
matching of the donor and the recipient is rou- The mononucleosis-like CMV syndrome is the
tinely performed, resulting in the high levels of most common manifestation of CMV disease in
graft survival that are seen. In the United States, renal transplant recipients; CMV pneumonia will
diabetes or hypertension is the cause of chronic develop in about 25% of symptomatic patients.
renal insufficiency in most recipients. Ganciclovir appears to be effective in treating CMV
disease in the setting of renal transplantation.
Typical Postoperative ICU Course
Kidney-Pancreas Transplant
Patients who have undergone renal transplan-
tation rarely, if ever, require ICU care in the imme- Background
diate postoperative period. They are generally
extubated in the recovery room and brought to a Kidney-pancreas transplant is considered for
non-ICU hospital floor. patients with renal failure and type I diabetes. The

6 Solid Organ Transplantation (Benditt)

major reported benefit is an improved quality of frequent in the first month after transplantation
life due to avoidance of the need for insulin and but may appear a year or more postoperatively.
dialytic therapy. Most procedures are performed Active CMV infection will develop in most
as simultaneous transplants, although sequential patients who are at risk, and the majority of these
kidney then pancreas transplantation or pancreas infections will be symptomatic with a viremic
transplantation alone is performed. For those syndrome; the liver is the most common site of
patients with type I diabetes mellitus undergoing tissue infection in the form of hepatitis.
cadaveric transplantation (but not living donor
transplantation), survival appears to be better Heart Transplant
with a simultaneous pancreas transplantation.
Background
Typical Postoperative ICU Course
Published recommendations for considering
Patients require ICU monitoring of fluids and transplantation in patients with cardiac condi-
electrolytes, and tight glucose control with an tions are for those with advanced disease (gener-
insulin drip to keep the pancreas at rest. Glucose ally, New York Heart Association class III or IV)
regulation may normalize within hours, but sev- that have not responded to maximal medical
eral days are often required for full graft function. management. Underlying coronary artery disease
Also, bicarbonate loss due to secretion by the pan- and nonischemic cardiomyopathy each account
creas into the bowel or bladder where the pan- for about 45% of cases, a distribution that has not
creas implant is placed can lead to metabolic changed appreciably in many years. Judging
acidosis. when in the course of chronic heart failure trans-
plantation should be considered is difficult. In
Noninfectious Complications general, the peak oxygen uptake measured on
cardiopulmonary exercise testing appears to pro-
Complications are more common after kidney- vide the most objective assessment of functional
pancreas transplantation than after kidney trans- capacity in patients with heart failure and may be
plantation alone. Surgical complications include the best predictor of when to list an individual
vascular thrombosis, hematuria, perforation of patient for cardiac transplantation. The 2002 task
the duodenal segment, and urethral stricture. Loss force of the American College of Cardiology and
of sodium bicarbonate in the urine may cause the American Heart association recommended
significant dehydration and metabolic acidosis. the use of exercise testing with ventilatory gas
Acute pancreatic rejection occurs in ⬎ 85% of cases, analysis for this purpose.
more commonly than kidney rejection, and is more
refractory to therapy with corticosteroids. Pancre- Usual Postoperative Course
atic rejection is diagnosed by an abrupt fall in
urinary amylase levels; some centers confirm rejec- Cardiac function is depressed for several days
tion histologically by cystoscopic biopsy. Most postoperatively, and the right ventricle recovers
cases of pancreatic rejection fail to respond to corti- more slowly than the left. Cardiac output is ini-
costeroids and require repeated courses of OKT3. tially rate-dependent in the denervated heart, and
treatment with low-dose isoproterenol or pacing
Infectious Complications is often required for 2 to 4 days. Patients are rou-
tinely extubated within 24 h and discharged from
Infections also are more common in patients the ICU within 48 h.
who receive kidney-pancreas transplants than in
recipients who receive kidney transplants alone Noninfectious Complications
because of the additional surgery and the need for
more immunosuppression. Wound infections, The early complications of heart transplanta-
urinary tract infections, and abdominal abscesses tion include those of cardiac surgery in general.
caused by bacteria or fungi are particularly The development of left lower-lobe atelectasis

ACCP Critical Care Medicine Board Review: 20th Edition 7

and mediastinal fluid collection is common in primary site of infection, but dissemination is
most patients, but hemorrhage is unusual. Pul- evident in half of the cases at diagnosis. Toxoplas-
monary edema is a frequent occurrence because mosis is an important consideration when a sero-
of pretransplant congestion, postoperative left negative recipient receives a heart from a
ventricular dysfunction, and volume overload; seropositive donor. Primary infection presents 4 to
heparin-protamine reactions and reperfusion 6 weeks after transplantation with fever and non-
injury may alter lung permeability. Persistent pul- specific signs involving the heart, brain, eyes,
monary hypertension is an important early prob- lungs, and/or liver; myocardial infection may
lem that may lead to right ventricular failure. mimic rejection. The diagnosis is supported by
Treatment with prostaglandin E1, nitric oxide, seroconversion and confirmed by the demonstra-
inotropes, and assist devices may be effective. tion of tachyzoites in tissue. Treatment with pyri-
Rejection may occur any time after heart trans- methamine and sulfadiazine is effective if instituted
plantation and is diagnosed histologically from promptly. Pyrimethamine also may be effective in
routine surveillance endomyocardial biopsies. preventing primary infection. Reactivation of latent
Clinical signs of rejection such as fever, heart fail- toxoplasmosis in seropositive recipients is not clin-
ure, arrhythmias, and pericardial friction rubs are ically significant. P carinii pneumonia develops in
unreliable. The severity of rejection is graded by 3% of cardiac transplant patients without prophy-
the degree of lymphocytic infiltration and myo- laxis but is now rare. Active CMV infection will
cyte necrosis. Mild cases may resolve spontane- develop in most seropositive patients and serone-
ously; about one third of patients require treatment gative recipients of hearts from seropositive donors.
for rejection. Most episodes respond to treatment One third of these infections will be symptomatic,
with pulse corticosteroids and/or increased doses usually with a mononucleosis-like syndrome.
of cyclosporine. Refractory patients usually CMV pneumonia develops in 10% of infected
respond to anti-T-cell treatment. Accelerated cor- patients. Serious morbidity and mortality are
onary atherosclerosis is the leading cause of death largely limited to patients with primary infection.
⬎1 year after heart transplantation. The cumula- Ganciclovir appears to be effective in the treatment
tive incidence is approximately 10% per year. Cal- of CMV disease in heart transplant patients. The
cium channel blockers and hydroxymethylglutaryl role of ganciclovir in prophylaxis is uncertain. The
coenzyme A reductase inhibitors may slow the reactivation of oral and genital HSV infection is
development of allograft vasculopathy. common in the first few months after heart trans-
plantation. VZV typically reactivates in a dermato-
Infectious Complications mal distribution 3 to 6 months after transplantation.
HSV and VZV infections usually remain localized
Nosocomial bacterial pneumonia, mediastini- and respond to treatment with acyclovir. PTLD
tis, empyema, and catheter-related infections are develops in 2 to 7% of heart transplant recipients,
common in the first month after transplantation. usually presenting 3 to 6 months after transplanta-
Gram-negative bacilli and Staphylococcus aureus are tion. PTLD is probably caused by EBV, and the risk
frequent pathogens. Legionella pneumonia and is markedly increased by treatment with OKT3.
wound infections are important in the first Any lymphatic tissue may be involved, as well as
3 months after heart transplantation, particularly the GI tract, lungs, kidneys, or brain. Most cases
in hospitals with contaminated water supplies. respond to a reduction in immunosuppressive
Nocardia infection of the lung may present at any therapy. The resection of localized tumors and
time after the first postoperative month and may treatment with acyclovir may be helpful.
disseminate to the brain or bone. Atypical myco-
bacterial infections have been reported in 3% of Lung Transplant
heart transplant recipients, usually involving the
lung, mediastinum, or soft tissues. Aspergillosis is Background
the most common fungal infection after heart
transplantation, developing in 5 to 10% of recipi- Lung transplantation is relatively infrequent
ents, usually in the first month. The lung is the compared to other transplants because of the

8 Solid Organ Transplantation (Benditt)

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girl, stands by giving directions; tools, lasts, strips of leather, and such like,
are hung round on the walls. Fig. 201, the counterpart to Fig. 200,
represents a smithy. Near the hearth, of which only a portion can be seen,
crouches a young workman, holding a piece of iron on the anvil with the
forceps in his right hand, while another workman, also without any
clothing, strikes the iron with a massive hammer, suspended above his head
by both hands. Two men wearing the himation, perhaps visitors to the
workshop, are seated on low stools. On the ground lie a hammer and
forceps; on the walls hang tools, such as hammers, chisels, drills, and
productions of the workshop, viz. a sword and a can.
Fig. 202 introduces us to the workshop of an artist and a metal founder.
In the presence of two men dressed in the himation, leaning on their sticks,
two workmen are occupied in chiselling or working over the colossal figure
of a warrior, represented in a posture of attack, which is placed under a
scaffolding. There is another colossal figure of a naked youth, who has
fallen to the ground, and is stretching out his arms as though praying for
help. Here the head has not yet been added, for as a rule the ancients
composed their large bronze figures in several pieces; the head lies on the
ground near the statue, at which a workman is doing something with his
hammer, perhaps trying to smooth away roughness produced in the casting.
This second figure seems to be connected with the first, and the whole to
represent a group of combatants. A little further is the furnace, behind
which stands an assistant looking round; a workman crouching on a low
stool wears the cap usually worn by labourers with fire, and consequently
represented in pictures of Hephaestus; he is stoking the coals in the
 Fig. 200.

furnace to a fresh glow with a long pole curved at the end, and a second
apprentice stands looking at him, leaning on his hammer. On the walls hang
a variety of tools—hammers, files, a saw, etc.; also models of feet and
heads, and little tablets representing sketches of whole men and animals.
No less interesting is the workshop of a vase painter, represented in Fig.
203. Here we see a youth seated in an armchair, with a large two-handled
cup on his knee, which he is painting with the brush held in his right hand;
near him stands a little low table, on which are several pots containing
paints or varnish. Behind him a young apprentice, who also has pots on the
ground near him, is painting a large amphora; on the right a second boy and
a girl are working at a cup and another amphora, while a jar and a large
drinking-cup (κάνθαρος) stand on the ground, and other vessels hang on the
wall. Athene, the patroness of the arts, and Nike are hasting to crown the
skilful labourers as the reward of industry.
It is difficult to determine the kind of work which the magnificent old
man in Fig. 204, a terra-cotta figure from Tanagra, is doing; in front of him
is a board with which he is occupied, and a little gridiron. Some have
pronounced him a baker, others a maker of plaster of Paris tablets, others a
tanner; perhaps he might be a cook, seated in the street, and frying some
quickly-cooked dish over the gridiron, in order to sell it to the common
people, who often procured their food in this way from travelling cooks.
 Even worse than the position of the artisans was that of the hired
workmen, that is, those labourers who, though free citizens, had not learnt
any technical art with which they could earn their living, and who were
therefore obliged to hire themselves out for

Fig. 202.

hard bodily labour. Not only citizens, but even their wives, were often
driven by need to perform such menial offices as day labourers in mills or
in the fields; many such workmen carried weights in the harbour, or helped
to load or unload the goods, to carry stones for building, etc. The pay was
very small, if only on account of the competition of slave labour; sometimes
a day’s wages was three or four obols, though higher amounts are
mentioned. The fleets, and in particular the rowing boats, were manned out
of this class, which was socially regarded as the lowest, and which bore the
name of “thetes.”

Fig. 202.

In the eyes of the Greeks, tradesmen stood on the same footing as

mechanical labourers. There was, of course, a distinction; if the cultured
Greek, who occupied himself only with higher intellectual pursuits,
despised the artisan because he regarded his bodily activity as unworthy of
a free man, the tradesman seemed to him contemptible because he was
influenced only by desire for gain, and all his striving was to get the
advantage over others. The

Fig. 203.

profit and wealth accruing to so many Greek states from trade was not
sufficient to decrease the prejudice against money-making occupations,
even the common people were not able to understand that the merchant, on
account of the risk of injury, or even loss of his goods, changing conditions
of price, and all his own trouble involved, was obliged to demand a higher
price for his wares than what had been originally paid by himself; and the
opinion that the merchant’s business was based on love of gain and deceit
was so common that even a philosophical intellect like Aristotle’s was
under the influence of this prejudice. It is possible that the Greek merchants
often deserved the reputation of dishonesty which they bore; their
predecessors, the Phoenicians, who had formerly carried on the whole trade
of Greece, had not unduly been reproached with deceit and even robbery
and piracy, and it is possible that there were traces of this still visible in the
Greek merchants. Still the contempt for the merchant class was not equally
directed at all; the wholesale dealer who imported his wares from a
distance, and had little personal contact with the public, was less affected by
it; in trading cities, such as Aegina and Athens, a great number of the rich
citizens belonged to this class. But the small trader was the more exposed to
the reproach of false weights and measures, adulteration of goods,
especially food, and all manner of deceitful tricks. Some complaints were
made that are still heard at the present day, that the wine dealers mixed
water with their wine, that the cloth-workers used artificial dressing to
make their materials look thicker, that the poulterers blew out the birds to
make them seem fatter, etc. Worst of all was the reputation of the corn
dealers. The division between

Fig. 204.

wholesale and retail traders seems to have been somewhat sharper in Greek
antiquity than at the present day, partly because the former were not only
merchants but also seafarers. The wholesale dealers as a rule were owners
of ships; they fetched their goods themselves on their journeys, or
commissioned responsible subordinates in their place. The ship was laden at
home with goods which were likely to find a good sale at the port to which
she journeyed; of course the owner made inquiries beforehand about the
best places for disposing of his goods, the private conditions, possible
competition, etc. It was, therefore, very important to hit the right moment,
and artificial manoeuvres for sending up the price of goods were not
unknown. Arrived at their destination, the wares were publicly sold, for
which purpose bazaars were erected in large harbours; then the goods were
either bought collectively by a wholesale dealer, or in small quantities by
smaller traders; there were also agents who undertook the mediation
between the buyer and seller in return for a commission. As a rule,
therefore, goods were purchased with the money, chiefly products of the
country which might be sold with advantage at home; it was almost
necessary to make fresh purchases, since the money of another state would
have no value at home, though Attic money could pass current anywhere. A
merchant did not always content himself with putting in at one single port;
he often visited a succession of neighbouring ports, calling at smaller
stations on the way, sometimes selling, sometimes buying, and often the
cargo of a ship changed three or four times during a journey. Probably these
wholesale dealers did not deal only with particular goods as at the present
day, but took anything which was likely to find a good sale, such as corn,
wine, oil, honey, skins, wool, clothes, textile ware, metal work, even statues
and books. Payment was made in coined money, and the calculation cannot
always have been an easy one, owing to the variety of money systems
prevailing in antiquity. In the Homeric age barter was usual, but afterwards
this ceased in civilised countries, though in some districts, as for instance
the neighbourhood of the Black Sea, it continued for some time longer.
Very different was the position and occupation of the retail dealer or
pedlar. He did not travel by sea, scarcely even by land, but usually carried
on his business at one place; he either bought his goods direct from the
producers or from the wholesale dealers, and offered them for sale in open
shops or in booths on the market-place; in large towns there were special
stands or markets for particular goods, but those who offered their wares at
these places were usually the producers themselves, thus at the Pot Market
at Athens, the wares were offered by real potters, who had doubtless made
them themselves. We must therefore distinguish between shopkeepers who
lived only by trade, and did not themselves produce, and producers, who
brought their own goods to market; the latter were regarded as merchants
by the ancients, and the hatred, where it existed, was chiefly directed at the
small shopkeepers, who sold their wares for as high prices as possible. In
small cities the circumstances may have been somewhat different, for it was
only the most important trades connected with food and clothing that were
carried on there, and many branches were not represented at all;
consequently many kinds of goods had to be imported for sale by the small
shopkeepers. No doubt the inhabitants of the small towns and even the
country people often went to the capital to satisfy their wants, especially to
the great markets held on fixed days of the month, usually on the first; the
national festivals too provided opportunities for many kinds of purchases,
since a sort of fair was usually connected with them.
 In the market-places of large towns there were usually covered arcades
in which the merchants and dealers set up their wares; in some places there
were market-halls of this kind for special goods, such as corn, oil,
ointments, etc. Besides these permanent places of sale, there were light
booths of a temporary nature, constructed in tent fashion of woven reeds
and linen. The life in the market-place probably resembled that of the
present day in the south; the custom of calling out and extolling goods
existed in ancient Greece as well, and so did the excessive demands of the
seller and the depreciation on the part of the purchaser, and even the
notorious rudeness of the fish-wives seems to have been known to the
Greeks. We find mention also of peddling, and carrying wares from house
to house, and this was chiefly the case with provisions.
Greek art supplies very few pictures from the trader’s life. Fig. 205,
taken from a vase-painting, though a caricature, has an especial interest on
account of its subject: a certain king Arcesilas of Cyrene (probably
mythical), is represented as a dealer in silphium; it is well known that the
silphium plant, so much valued by ancient epicures, came from Cyrene, and
was an important article of trade. Under a canopy, the curtains of which are
suspended by rings, stands a large pair of scales, at which five men are
weighing goods, some of which are heaped up on the scales and others
lying about on the ground.

Fig. 205.
 Most of the goods are as yet unpacked; these workmen, however, have
already filled large woollen sacks with them, and one of them is in the act
of tying his up, while another is carrying his away. The weighing and
packing are conducted under the superintendence of king Arcesilas, who is
seated close by, holding in his left hand his sceptre, and with his right
apparently giving directions to a workman standing before him. His
costume is very extraordinary. The panther under the prince’s seat, a lizard,
a stork (or crane), a monkey, and several pigeons, give life to the picture,
and partly indicate the place where the scene is laid. Below the main
picture, where we must suppose the cellar for the stores to be, workmen are
piling up finished packets, under the direction of a man in a cloak.
Occupations connected with money were largely developed in antiquity.
The merchants who dealt with such business—the bankers and money-
changers—were called by the Greeks “table-merchants” (τραπεζῖται), from
the table at which they originally carried on their occupations. Their duties
were of a double nature; besides the actual business of changing, they
undertook the investment of capital and the transaction of money business.
When the increased coinage of money and the augmentation of trade and
travel brought large sums into the hands of individuals, those who had not
invested their possessions in wares or property or slaves, naturally desired
to profit by it in some other way, and thus the loan business was gradually
developed, in which capitalists lent money to those who required it for any
mercantile undertaking, in return for a security and interest. In the bond
executed in the presence of witnesses, the amount of the capital, the interest
agreed upon, as well as the time for which the loan was arranged, had to be
entered. For greater safety, a third person usually became security for the
debtor, or else some possession was mortgaged, the value of which
corresponded to the sum lent. They distinguished between pledges in
movable objects, such as cattle, furniture, slaves, etc.; and mortgages given
partly on movable objects, such as factory slaves, and partly on immovable
property. Mortgages of this kind were very common in seafaring business.
The merchant who borrowed money from a rich citizen in order to carry on
a particular business with it, pledged his ship or the goods with which he
dealt, or perhaps both, to his creditor in a formal contract. They
endeavoured to obtain as much security as possible by very exact
arrangements concerning the object of the journey, the nature of the goods,
etc.; moreover, the interest in business of this kind was very high, because
the creditor ran the risk of losing his bargain entirely, or in part, by storms,
or pirates, or other misfortunes. Mortgages were also given on property in
land, and the creditor’s right of ownership was inscribed on stone tablets set
up on the property in question, with the name of the creditor and the amount
of the debt. In some places the State itself conducted books for mortgages,
in which all the property was entered, together with the amount of the
mortgages upon it. Here, as in other loans, interest was high, and this was
due to the insecurity of trade and the very incomplete development of
agricultural conditions. There were no laws against usury; from ten to
twenty per cent., or higher if it was for risk at sea, was common, but there
were even cases where thirty-six or forty-eight per cent. were taken. Of
course, in these circumstances complaints of extortion were made.
The arrangement of this money business was chiefly in the hands of the
bankers. Their original and chief occupation was the changing of money—
the various kinds of coinage which became current through foreign trade;
and here they got their profit from the rate of exchange. They also lent
money, both small sums and capital for trade and other business
undertakings, and this was their share in these monetary transactions. Rich
people often invested their money with these bankers, who paid them
interest and gave them security or pledges; they then themselves lent the
money to men of business, and on account of the risk naturally demanded
higher interest than they paid. But even when money was lent direct by a
capitalist to a merchant, the mediation of a banker was often resorted to in
concluding the contract; for these men were well known to the public on
account of their extensive business, and possessed considerable business
knowledge. As a rule, though some were known as usurers, and trickery and
bankruptcy occasionally occurred, they enjoyed so much confidence that
they were gladly engaged as witnesses in business contracts, and requested
to take charge of the documents. Money also was deposited with them, for
which no particular use appeared at the moment, and which would not be
safe if kept at home; of course, if this capital lay idle the banker could pay
no interest, but often demanded a sum for taking charge of the deposit.
Some of them left their money in the hands of money-changers to increase
the business capital, and the extent to which this was done is proved by the
fact that the banker Pasion, at the time of Demosthenes, in a business
capital of 50 talents (£11,700), had 11 talents (£2,593) lent by private
persons.
 C H A P T E R X V.

SLAVERY.
Slaves in Ancient Greece—Captives Taken in War—The Slave Trade—The Price of Slaves
—Native Serfs—The Helots—The Penestae and the Clarotae—The Status of the Slave—
Protection against Ill-treatment—The Slave’s Duties—Modes of Liberation.

All the social and economic conditions of antiquity are based on the
institution of slavery, and without it would have been impossible; in fact,
slavery is so closely interwoven with the whole life of antiquity that even
the political development of the ancient nations and their achievements in
the domain of art and industry would be inexplicable without the existence
of a large slave population. So great was the importance of slavery in
antiquity that any account of Greek life would be incomplete, which did not
give some slight sketch of these peculiar conditions.
The institution of slavery in Greece is very ancient; it is impossible to
trace its origin, and we find it even in the very earliest times regarded as a
necessity of nature, a point of view which even the following ages and the
most enlightened philosophers adopted. In later times voices were heard
from time to time protesting against the necessity of the institution, showing
some slight conception of the idea of human rights, but these were only
isolated opinions. From the very earliest times the right of the strongest had
established the custom that captives taken in war, if not killed or ransomed,
became the slaves of the conquerors, or were sold into slavery by them.
This custom, which was universal in the Homeric age, continued to exist in
the historic period also, so that not only was it adopted in contests between
Hellenes and barbarians, but even in the numerous feuds between Hellenes
and Hellenes they often condemned their own countrymen to the hard lot of
slavery; in later times, however, it was only in cases of special animosity
that they resorted to this expedient; as a rule, they exchanged or ransomed
captive Greeks. Besides the wars, piracy, originally regarded as by no
means dishonourable, supplied the slave markets; and though in later times
endeavours were made to set a limit to it, yet the trade in human beings
never ceased, since the need for slaves was considerable, not only in
Greece, but still more in Oriental countries.
In the historic period the slaves in Greece were for the most part
barbarians, chiefly from the districts north of the Balkan peninsula and Asia
Minor. The Greek dealers supplied themselves from the great slave markets
held in the towns on the Black Sea and on the Asiatic coast of the
Archipelago, not only by the barbarians themselves, but even by Greeks, in
particular the Chians, who carried on a considerable slave trade. These
slaves were then put up for sale at home; at Athens there were special
markets held for this purpose on the first of every month; the slaves were
arranged on platforms, so that the buyers might examine them on all sides,
for they sought chiefly to obtain physical perfection and strength of limb for
hard work, and therefore, if the purchasers desired it, the slaves had to be
undressed. Of course, those slaves who were bought merely for the sake of
their bodily strength were least valuable; a higher price was given for those
who had any special skill or were suited for posts of confidence, and
considerable prices were also given for pretty female slaves or handsome
boys. Consequently, there was great variety of price; at the time of
Xenophon the price for a common male slave, who was only suited for
rough work, was half a mina (about £2), else the ordinary average was two
minae (about £8); for slaves who possessed any technical skill or higher
education the price rose from five to ten minae (£20-£40), and even in
exceptional cases amounted to one talent (£240).
A large portion of the slave population consisted of those who were born
in slavery; that is, the children of slaves or of a free father and slave mother,
who as a rule also became slaves, unless the owner disposed otherwise. We
have no means of knowing whether the number of these slave children born
in the houses in Greece was large or small. At Rome they formed a large
proportion of the slave population, but the circumstances in Italy differed
greatly from those in Greece, and the Roman landowners took as much
thought for the increase of their slaves as of their cattle. Besides these two
classes of slave population, those who were taken in war or by piracy and
those who were born slaves, there was also a third, though not important,
class. In early times even free men might become slaves by legal methods;
for instance foreign residents, if they neglected their legal obligations, and
even Greeks, if they were insolvent, might be sold to slavery by their
creditors, a severe measure which was forbidden by Solon’s legislation at
Athens, but still prevailed in other Greek states. Children, when exposed,
became the property of those who found and educated them, and in this
manner many of the hetaerae and flute girls had become the property of
their owners.
Finally, we know that in some countries the Hellenic population
originally resident there were subdued by foreign tribes, and became the
slaves of their conquerors, and their position differed in but few respects
from that of the barbarian slaves purchased in the markets. Such native serfs
were the Helots at Sparta, the Penestae in Thessaly, the Clarotae in Crete,
etc. We have most information about the position and treatment of the
Helots; but here we must receive the statements of writers with great
caution, since they undoubtedly exaggerated a good deal in their accounts
of the cruelty with which the Spartans treated the Helots. Still, it is certain
that in many respects their lot was a sad one. The constant fear of general
insurrection on the part of the Helots entertained by the Spartans, whose
own numbers were far fewer, and the terrible severity with which they
punished, not only real insurrection, but even merely suspected revolution,
prove to us that the statements concerning the cruel treatment of the Helots
are not absolutely without foundation. But, as a rule, they did not perform
menial slave offices in the houses of the free citizens, but cultivated their
lands, and as they were only obliged to hand over a certain part of the profit
to the owners, they were able to keep the remainder for themselves, and
sometimes to accumulate fortunes and even to purchase their freedom. Nor
do we hear of cases in which individual Spartans treated the Helots who
were subordinate to them with especial severity—most of the cases of
cruelty towards Helots are those in which State reasons seemed to require
such proceedings, and were aimed, not at individuals, but at the whole mass
of slaves. This was due to a curious arrangement by which the Helots were
not, like other slaves, private property of the Individual citizens, but State
property and assigned to a particular piece of land, and along with it to the
owner for the time being, without enabling him to maintain right of
ownership over them. We must not therefore regard the Helots in the same
light as ordinary slaves; they were rather public serfs, and on this account
they were better off than those who belonged to individual owners. There
seems no doubt that besides the Helots there were also private slaves at
Sparta, who rendered personal services in the households.
 The position and treatment of the slaves varied in different periods, and
differed also in the different parts of Greece. Here, too, the conditions of the
heroic age were patriarchal, and the distinction between free men and slaves
was not so great as afterwards. Trustworthy slaves superintended extensive
farms and numerous herds; old female slaves had the whole direction of the
household; they were often intimately connected with the inmates of the
house, and showed touching fidelity and affection for their masters, with
whom they lived on a familiar footing. Similar conditions existed in later
times too, but only in remote pasture districts, such as Arcadia, where even
in the historic age the slaves were almost regarded as members of the
family, ate at the same table as their masters, and shared their labours and
recreations. Generally speaking, the Dorians were regarded as stern
masters, and the Athenians as kinder and more considerate; in fact, a
common reproach against the Athenians was that their kindness degenerated
into weakness, and that the slaves were nowhere so insolent as at Athens;
they expressed themselves freely, it was said, did not give way even to free
citizens in the street, they drank, they met together for common banquets,
carried on love affairs, etc., just like free men. These reproaches seem not to
have been altogether exaggerated, as is proved by the important part played
by slaves in the newer Attic comedy; they were usually insolent, cunning
fellows, who cared little for an occasional beating, and were always ready
to play their masters a trick, or to intrigue with the sons against their stern
fathers. Still it was not unusual in Attica for slaves to run away, and
therefore the slave-owners tried to prevent this by stern supervision, and
even by chaining and branding. It is natural that the temperament of the
Athenians, which changed quickly from extreme to extreme, should not
often succeed in finding the right mean between severity and kindness, and
therefore, in their sudden transitions from excessive consideration to
severest cruelty, a real feeling of attachment between slaves and masters
was very rare; still there were instances of devoted fidelity on the part of the
slaves, and many inscriptions still extant speak of such devotion continuing
even to the grave.
The rights assigned by law to the master over his slaves were very
considerable. He might throw them in chains, put them in the stocks,
condemn them to the hardest labour—for instance, in the mills—leave them
without food, brand them, punish them with stripes, and attain the utmost
limit of endurance; but, at any rate at Athens, he was forbidden to kill them.
These severe punishments were generally reserved for special cases of
obstinacy, theft, or such like; as a rule, the slaves were treated much as our
servants are. Their masters gave them the ordinary dress of artisans and
workmen—the exomis, or short garment with sleeves (compare the terra-
cotta figure, No. 206);
their food was simple but nutritious, chiefly barley
porridge and pulse, sometimes meat; their drink was the
cheap wine of the country; they had their own sleeping
apartments, usually those of the male slaves were
separated from those of the female, except when the
master allowed a slave to found a family and to live with
one of his fellow-slaves. Legal marriages between slaves
were not possible, since they possessed no personal rights;
the owner could at any moment separate a slave family
again, and sell separate members of it. On the other hand,
if the slaves were in a position to earn money, they could
acquire fortunes of their own; they then worked on their
own account, and only paid a certain proportion to their
owners, keeping the rest for themselves, and when they Fig. 206.
had saved the necessary amount they could purchase their
freedom, supposing the owner was willing to agree, for he was not
compelled. Generally speaking, the position of the public slaves was even
more favourable. There were certain occupations which free men were
unwilling to undertake, and for this purpose the State used slaves; thus, for
instance, at Athens the executioner, torturers, gaolers, and police were all
slaves; they had their own dwellings assigned them by the State, could
possess property, and received a small salary from the State out of which
they had to feed and clothe themselves; they could also earn money by
other kinds of work, and sometimes attained a position of fortune. Some of
them, as for instance the Athenian police, held a position which gave them
certain rights over the citizens, and, therefore, the position of these public
slaves must have been a very independent one, while the numerous temple
slaves also felt the hardness of their position much less than those whose
owners were private persons.
The protection given to slaves by the State was very small, but here
again there were differences in different states. It was only in cases of the
utmost emergency that the State interfered between master and slave. In the
oldest period the owner had power of life and death over his slave, but later
legislation put an end to this, and at Athens, in particular, the master might
not even kill a slave if he found him committing a crime, the penalty of
which was death; cases of necessary defence, or such where the crime could
only be prevented by killing the perpetrator, were, of course, excluded. If
any owner had killed his slave without being able to justify himself, he was
punished for so doing, not as severely as though he had murdered a free
man, but only as if it were a case of manslaughter. Further protection
against excessive ill-treatment from their masters was given by the right of
sanctuary, which permitted the slave to take refuge at the altar of some god,
where he found, at any rate, protection for the time being; they might even,
supposing they were too cruelly used by their masters, ask to be sold to
another master, and it even appears as if the owner could be legally
compelled to grant this request. In other respects the State took little notice
of slaves, except to forbid certain things, such as gymnastic exercises, love-
making with free citizens, participation in certain festivals and sacrifices.
Very curious and characteristic of the view they held of slaves, were the
arrangements when a slave had to give evidence in a court of law. So bad
was their opinion of the moral character of barbarians, and especially of
those who were not free, that they thought the slaves could only be induced
to speak the truth by direct physical compulsion, and consequently they
were always questioned under torture. If in a suit one party required the
testimony of his opponent’s slave, the latter could refuse it, but he did so at
the risk of losing the suit. Sometimes a master voluntarily offered his slave
as witness. If the torture, of which there were various grades, some of them
very severe, inflicted any lasting injury on his body or health, the owner
might demand compensation, supposing that he was not the loser in the
case.
The mode in which slaves were used varied a good deal, according as an
owner required his slaves for his own personal service or household, or
used them for work in the field or at some trade, or sent them out to work
for others. Among those in the personal service of their master were all who
were occupied with the duties of the household and service and attendance
on their master and his family. Their number was, of course, regulated by
the size of the household; a poor family had often to content itself with a
single slave, but very few were so poor as not to have any; in large houses a
whole army of slaves was kept, who all had their special duties, though
often very slight ones. There were the door-keeper, the slaves who attended
their master or his family in the street, the paidagogos, the lady’s maid, the
cook, the coachman, the stable boys, water carriers, wool workers, etc. This
whole army of servants was usually under the direct supervision of a
superintendent or steward, himself a slave, but a particularly trustworthy
one, who was often trusted so much by his master as to have charge of his
keys and his signet ring. The office of these stewards was of particular
importance on the country estates, where they had all the slaves required for
farming purposes immediately under them, and had to assign them
occupations and superintend their work, unless the master undertook this or
himself took up his dwelling on the estate. Slaves who could fill such posts
of confidence would, of course, fetch a very high price, and their position
can in no way be compared with that of ordinary slaves. The same may be
said of those who possessed some intellectual culture, and could serve their
masters as secretaries or readers, or even help them in scientific labours, by
making extracts, etc.; but this was far rarer among the barbarian slaves of
the Greeks than among the Greek slaves of the Romans. The slaves could
also render their masters important assistance by technical skill; thus, in a
rich household, there would be, besides the cook, a special baker for bread
and cakes, also weavers, fullers, embroiderers, whose duty it was to provide
the clothing. And as the slaves in the country had to work in field and
meadow, to attend the vineyards, and olive gardens, to guard and attend the
cattle, so the artisan set his slaves to work in his workshop, and either
instructed them himself in his art or bought such as were already trained for
the purpose. Even physicians often had slave assistants, and some of these
were so much trusted by their masters that they took their place by the sick
bed.
It was very common, too, for people who were not themselves artisans to
own a number of slaves who practised some particular trade, as in a factory.
Among the ancients slaves took the place of machinery, for they were
tolerably cheap to buy and maintain, and thus a factory of this kind, worked
by slaves, was a good investment for capital, especially if the owner
understood enough business to undertake the direction himself, or if he had
a good overseer. These factory owners also escaped the prejudices against
artisans; to own slaves who made money by the work of their hands was not
regarded as “mechanical” so long as they kept their own hands from the
work. Thus the father of Demosthenes possessed a knife factory, that of
Isocrates a flute factory, Lysias and his brother owned a shield factory of
one hundred and twenty workers. The slaves who worked in these were not
all necessarily the property of the owner. Very often a slave proprietor who
did not understand a business himself, let his house to someone who carried
it on at his own risk; or, supposing a master to possess among his slaves one
who understood some particular trade, he let him out for a certain time at a
fee (which was paid not to the slave, but to the master) to someone who
could make use of him, perhaps in a large factory. In this way slaves were
often let out for work in the mines, which required a great many hands; in
fact, they might be let out for a long or short period, even for days and half-
days, for work in the fields, domestic occupations, personal service, etc.
Many of the flute girls and hetaerae were slaves, and were hired out by their
owners by the hour, day, or month, an arrangement with which we are
familiar from ancient comedy.
Moreover, it sometimes happened that slaves who had learned some
profession made an agreement with their masters to pay them a certain
proportion of their earnings, and keep the rest for themselves; sometimes
these lived in their own houses and paid for their own food, and might
easily earn enough to purchase their freedom.
There were various ways of liberating slaves, and the proceedings were
different in different states; it was a matter of some importance too, whether
a slave was private property or owned by the State or by some sanctuary.
There was no definite legal formula for the manumission of private slaves
as at Rome; the State did not interfere in the matter, but only demanded a
certain tax from the liberated slave. As a rule, the act of manumission was
performed before witnesses or publicly in some large assembly, at the
Theatre, in courts of law, etc., in order to give the freed man a guarantee of
its validity. It often happened that an owner gave all or some of his slaves
their freedom in his will, either immediately upon his death or on the
condition that the slave should serve his heirs for a certain period, or pay a
certain sum to them out of his own earnings in return for his freedom. If a
slave purchased his freedom during the lifetime of his master there was a
curious arrangement for establishing the legality of the proceeding, since a
slave was not able to conclude a legally valid contract. We owe our
knowledge of this proceeding chiefly to documents at Delphi. A mock sale
had to be carried on; the master sold the slave for a sum mentioned in the
contract (which was paid by the slave himself, unless it was remitted by the
master) to some god, e.g. at Delphi to Apollo, under the condition that he
should be free as soon as he entered the possession of the god. The slave did
not then become a temple slave, but was set free by the god, probably in
return for some small payment to the sanctuary. As these contracts were
concluded in the presence of witnesses, usually priests of the divinity in
question, and deposited in the sanctuary, the freed slave had the security of
not being afterwards claimed by his former master or his heirs, and again
losing his freedom. Sometimes these contracts contained clauses which
pledged the slave to certain obligations towards his master as long as he
lived, or towards his heirs, or to care for the burial and grave of his former
master, etc. In most cases the freed slave did not immediately lose all
connection with his old master; he was not a citizen, and therefore his
former owner became his legal patron. It was not unusual for the contract to
specify that in case the slave should die without children, his property
should belong to his former master or his heirs, and sometimes this even
extended to the children of the slave, supposing they in turn died without
legal heirs. It may have often happened, as was also the case among some
of the Russian serfs in our own time, that the freed slave was richer than his
master, and we may thus explain such obligations as those already
mentioned, or the condition that the liberated slave should maintain his
master until his death. The right of citizenship was seldom conferred on
slaves when they were set free; supposing this was the case, of course, all
such obligations were omitted. This was usually done when a slave had
deserved especially well of his country; thus, for instance, all those who
fought at the battle of Arginusae received their freedom and the right of
citizenship. The conditions at Sparta were different; sometimes the Helots
received their freedom from the State, especially those children of Helots
who were educated and brought up together with the sons of citizens, but
the right of citizenship was never combined with this freedom. Still, it was
not unusual for children who were born of Spartan fathers and Helot
mothers to be both free men and citizens; the celebrated Spartan generals
Lysander, Gylippus and Callicratidas, were sons of Spartans and Helots.
It would be impossible to make a guess at the number of slaves in
Greece. Statements on the subject are extant, but these are insufficient to
give us any general idea. There can be no doubt that the number was a very
large one; it was a sign of the greatest poverty to own no slaves at all, and
Aeschines mentions, as a mark of a very modest household, that there were
only seven slaves to six persons. If we add to these domestic slaves the
many thousands working in the country, in the factories, and the mines, and
those who were the property of the State and the temples, there seems no
doubt that their number must have considerably exceeded that of the free
population. The injurious influence of this part of the population, who were
chiefly barbarians, was felt in many different ways; and though it is not as
evident in Greece as in Rome, where the disastrous results of slavery are
most marked, yet we cannot hesitate to affirm that the speedy fall of Greece
from her political and social height, and the sad picture she offered under
Roman dominion, was due, among other causes, in very great part to the
institution of slavery.

THE END.
 L I S T O F A U T H O R I T I E S C O N S U LT E D F O R
THIS BOOK.
I.—Works Bearing on the Subject Generally.
J. A. St. John. “The Hellenes.” London, 1844.
J. P. Mahaffy. “Social Life in Greece from Homer to Menander.”
London, 1875.
W. A. Becker. “Charikles neu bearbeitet von H. Goell.” Berlin, 1877.
C. F. Hermann. “Griechische Privataltertümer,” 3rd ed., edited by H.
Blümner. Freiburg and Tübingen, 1882.
Panofka. “Bilder antiken Lebens.” Berlin, 1843.
Panofka. “Griechen und Griechinnen.” Berlin, 1844.
Weiszer. “Lebensbilder aus dem Klassichen Altertum.” Stuttgart, 1862.
A. Baumeister. “Denkmäler des Klassichen Altertums.” Munich, 1884.
Th. Schreiber. “Kulturhistorischer Atlas des Altertums.” Leipzig, 1885.
H. Blümner. “Kunstgewerbe im Altertum.” Leipzig and Prague.

II.—Works Dealing with Special Subjects.

1. Costume.
W. Helbig. “Das homerische Epos aus den Denkmälern erläutert.”
Leipzig, 1884, pp. 115-180.
J. Boehlau. “Quaestiones de re vestiaria Graecorum.” Weimar, 1884.
Fr. Studniczka. “Beiträge zur Geschichte der altgriechischen Tracht.”
Vienna, 1886.
Th. Schreiber. “Mitteilungen des deutschen archaeologischen Instituts in
Athen.” Vol. VIII. (1883), pp. 246 f.; IX. (1884), pp. 232 f.

2. Birth and Early Childhood.

H. v. Swiecicki. “Die Pflege der Kinder bei den Griechen.” Breslau,
1877.
 Becq de Fouquières. “Les jeux des anciens.” Paris, 1869.
L. Grasberger. “Erziehung und Unterricht im Klassischen Altertum.”
Würzburg, 1864-1881.

3. Education.
L. Grasberger. (See 2.)
J. L. Ussing. “Erziehung und Jugendunterricht bei den Griechen und
Römern.” Berlin, 1885.

4. Marriage and Women.

No special books quoted.

5. Daily Life within and without the House.

G. Bilfinger. “Die Zeitmesser der antiken Völker.” Stuttgart, 1886.

6. Meals and Social Entertainments.

Anastasios Maltos. A modern Greek work on the symposia of the
Ancient Greeks. Athens, 1880.

7. Sickness and Physicians; Death and Burial.

Welcker. “Kleine Schriften.” III., pp. 1 f.

8. Gymnastics.
L. Grasberger. (See 2.)
J. H. Krause. “Die Gymnastik und Agonistik der Hellenen.” 2 vols.
Leipzig, 1841.
Ed. Pinder. “Ueber den Fünfkampf der Hellenen.” Berlin, 1867.
H. Marquardt. “Zum Pentathlon der Hellenen.” 1886.

9. Music and Dancing.

K. v. Jan. “Die Griechischen Saiteninstrumente. Programm des Lyceums
von Saargemünd.” Leipzig, 1882.
Gevaert. “Histoire et théorie de la musique dans l’antiquité.” Vol. II.
(1881), pp. 241 f.
 K. v. Jan. An article in “Baumeister’s Denkmäler des Klassischen
Altertums.” I., 553 f.

10. Religion.
K. F. Hermann. “Lehrbuch der gottesdienstlichen Altertümer der
Griechen.” Second edition. Revised by K. B. Stark. Heidelberg, 1858.
Metzger. An article entitled Divinatio in Pauly’s “Realencyklopädie.” II.,
pp. 1113 f.
Bouché-Leclerque. “Histoire de la divination dans l’antiquité.” Paris,
1880.
Büchsenschütz. “Traum und Traumdeutung im Altertum.” Berlin, 1882.

11. Games and Festivals.

J. H. Krause. “Ἑλληνικά.” Part I. Olympia. Vienna, 1838. Part II.,
Pythien, Nemien, und Isthmien. Leipzig, 1841.
E. Curtius. Olympia. Berlin, 1852.
Ad. Böttiger. Olympia. “Das Fest und seine Stätte.” Second Edition.
Berlin, 1886.
Holwerda. An article in the “Archæologische Zeitung” for 1880, pp. 169
f.
A. Mommsen. “Delphica.” Leipzig, 1878, pp. 149-214.
H. Guhrauer. “Der Pythische Nomos” in “Supplemente der neuen
Jahrbücher für Philologie und Pädagogie.” Vol. VIII., pp. 309 f.
A. Mommsen. “Heortologie. Antiquarische Untersuchungen über die
städtischen Feste der Athener.” Leipzig, 1864.
A. Michaelis. “Der Parthenon.” Leipzig, 1871.
Preller. An article in Pauly’s “Realencyklopädie.” Vol. III., pp. 83 f.
Preller. “Demeter und Persephone.” pp. 342 f.

12. The Theatre.

Wieseler. An article entitled “Griechisches Theater,” in Ersch. Gruber’s
“Encyklopädie.” First series. Vol. LXXXIII., pp. 243 f.
Wieseler. “Theatergebäude und Denkmäler des Bühnenwesens.”
Göttingen, 1851.
 Alb. Müller. “Lehrbuch der szenischen Altertümer.” Freiburg-im-Br.,
1886.
W. Donaldson. “Theatre of the Greeks.” Ninth edition, London, 1879.
Lüders. “Die Dionysischen Künstler.” Berlin, 1873.
Sommerbrodt. “Scaenica.” Berlin, 1876. pp. 199 f.
Arnold. An article in “Verhandlungen der 29ten Philologen
Versammlung,” 1875. pp. 16 f.
Wieseler. “Das Satyrspiel.” Göttingen, 1848.
O. Benndorf. “Beiträge zur Kenntnis des Attischen Theaters,” an article
in the “Zeitschrift für österreichische Gymnasien.” 1875.

13. War and Seafaring.

W. Rüstow and H. Köchly. “Geschichte des Griechischen
Kriegswesens.” Aarau, 1852.
Helbig. “Das Homerische Epos aus den Denkmälern erläutert.” pp. 195-
250.
Jähns. “Handbuch einer Geschichte des Kriegswesens von der Urzeit bis
zur Renaissance.” Leipzig, 1880.
A. Müller. An article in Baumeister’s “Denkmäler des Klassischen
Altertums.” Vol. I., pp. 525 f.
Boeckh. “Urkunden über das Seewesen des Attischen Staates.” Berlin,
1840.
Graser. “De veterum re navali.” Berlin, 1864.
A. Cartault. “La trière Athénienne.” Paris, 1880.
A. Breusing. “Die Nautik der Alten.” Bremen, 1886.
Raoul Lemaître. “Sur la disposition des rameurs sur la trière antique,” an
article in the Revue Archéologique for 1883. pp. 89 f.
14. Agriculture, Trade, and Commerce.
Büchsenschütz. “Besitz und Erwerb.” Halle, 1869.
Büchsenschütz. “Die Haupstätten des Gewerbfleiszes im klassischen
Altertum.” Leipzig, 1869.
W. Drumann. “Die Arbeiter und Kommunisten in Griechenland und
Rom.” Königsberg, 1860.
 Blümner. “Die gewerbliche Thätigkeit der Völker des klassischen
Altertums.” Leipzig, 1869.
Blümner. “Technologie und Terminologie der Gewerbe und Künste bei
Griechen und Römern.” 4 vols. Leipzig, 1875-1887.
15. Slaves.
Wallon. “Histoire de l’esclavage dans l’antiquité.” Second edition. Paris,
1879.
Büchsenschütz. “Besitz und Gewerb.” pp. 104—208.
 INDEX.
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z
Abacus, The, 111
Academy, The, at Athens, 119, 127
Acarnania, Javelin-throwers of, 478
“Achaeans, Curly-haired,” 64, 72
Achilles, Wail at the death of, 248;
bandaging the arm of Patroclus, 464
Acropolis, Buildings on the, 179
Actors, Dress of, 4, 46;
Gloves of, 56;
sometimes poets, 421;
selected by poets, and examined by the State, 421;
Division of parts to, 422;
Dumb, 423;
Payment of, 423;
Guilds and Schools of, 423;
Costumes and masks of, 422-444;
Prizes of, 449
Adonis, Festival of, 152
Aeschines, Figure of, 2;
his employment in boyhood, 104;
his allusion to slaves, 532
Aeschylus, The Trilogy of, 411;
his introduction of a second actor, 412;
Songs and Chorus of, 413;
his “Eumenides,” 428;
his contest with Sophocles, 449
Aesculapius, 234;
Sanctuaries of, 238;
Sacrificial offering of cocks to, 336
Aesop’s Fables, 88
Aetion exhibits his picture at Olympia of Alexander’s Marriage, 364
Aetolia, Javelin-throwers of, 478
Agesilaus, Dress of, 50;
Anecdote of, and the hobby-horse, 93
Agora, The, 128
Agrae, The lesser Eleusinia at, 378
Agricultural implements, 493
Agricultural pursuits, 176
Agriculture, in statistical relation to industry and trade, 489;
the chief occupation in the heroic period, 491;
at Sparta, 491;
at Athens, 491;
Irrigation in, 492;
in Arcadia, 493;
Allusion in Homer to, 493;
Implements of, 493
Alcibiades, Shoes named after, 55;
at a banquet, 216
Alcmene, her song to her children, 85
Alexander the Great and Roxana;
picture of their marriage, by Aetion, 364
Alexandria, School of, 128
Alexandria Troas, Ruins of Wrestling School at, 121
Alexandrine period, Varieties of female dress in the, 43
Altis, Grove of, 121, 304, 362, 365
Amazons, Chiton of, 39;
Battle-axe of, 475;
Shields of, 478
Ambrosia, Festival of, 385
Amorgos, Looms of, 48
Ampechonion, The, 43
Amphiaraus, Temple of, 243;
Oracle of, 346;
Figure of, 465;
Helmet of, 469
Amphictyons, The, 369
Amphidromia, The, 82, 83, 84
Amphoras, 373
Amulets for infants, 83, 84;
in curing disease, 243
Anacreon on Conversation, 219
Anaximander introduces methods of measuring time, 184
Anaximenes lecturing at Olympia, 364
Andromache, Head-dress of, 74, 145
Andromeda, Masks relating to, 430
Animals, Sacrifice of, 137, 138, 203, 336, 337
Animals, wild, Hunting, 196
Anthesterian Festival, The, 385
Antioch, School of, 128
Antiphon on spear-throwing, 278
Antisthenes, 127
Aphrodite Anadyomene, 172
Aphrodite bathing, 159
Aphrodite Pandemos, 134
Aphrodite Urania, 134, 151
Apollo, Figure of, 4;
The chlamys of, 19;
Head-dress of, 66;
invoked at weddings, 137, 144;
at the purification of Orestes, 330;
Sacrifice of asses to, 336;
Oracles of, 342;
Clarian Temple of, 344;
Sacrifice at Pythian Games to, 367;
Hecatomb to, 370;
A slave set free by, 531
Apollo-Coropaeus, Oracle of, 345
Apoxyomenos, The, of Lysippus, 285
Arcadians, The, 458
Arcesilas of Cyrene, 514
Archery, Skill of Cretans in, 300;
Instruction in, 124 (See, also, Bow and Arrows)
Archon Basileus, Dress of the, 4
Areopagus, The, 102
Arginusae, the battle of, Slaves at, 531
Argolis, 371
Argos, Prophecy at, 344
Ariadne, 444
Aristarchus, inventor of sun-dials, 185
Aristophanes, his allusions to chitons and mode of wearing the hair, 69;
allusions to nurseries, 85;
 allusion to the mother of Pheidippides, 98;
his descriptions of marriage, 134, 170;
“Birds” of, 140;
“Frogs” of, 200;
allusion to fidelity of citizens to judicial duties, 195;
The “Acharnians” of, 236, 383;
his account of the recovery of Plutus from blindness, 240;
Comedies of, 392;
Jokes of, 436
Aristotle, Shaven face of, 73;
his allusion to the flute, 112;
teaches in the Lyceum, 127;
his opinion of work, 490;
of tradesmen, 510
Arithmetic in Spartan education, 101;
in Attic education, 111, 127
“Armour-race,” The, 273, 274
Arms, Exposure of, 18
Arms, presented to ephebi, 118;
used in war, 452;
of Homeric soldiers, 460;
of later times, 462-480
Army of Sparta, 454-456;
of Athens, 456-460 (See, also, Soldiers)
Artemidorus, Dream-book of, 342
Artemis, Chiton of, 29;
Dolls offered to, 92;
invoked at weddings, 137, 144;
Sacrifice at Pythian Games to, 367
Artist, Profession of, 489, 500;
Workshop of an, 504
Askolia, Game of, 384
Aspasia, 172
Astragals (See Knuckle-bones)
Astronomy in Attic schools, 114, 127
Athene at her toilet, 159;
as a weaver, 498
Athene-Hygeia, 375
Athene Polias, 372, 375, 377
Athens, Dress at, 12;
Shoes worn at, 55;
Walking-sticks at, 64;
Mode of dressing the hair at, 68;
System of education at, 102-132;
Tribes and clans of, 143;
Daily life in, 179-201;
Streets and suburbs of, 179, 180;
Houses at, 179, 181;
Duties and voluntary services of citizens of, 194, 195;
Banquets in, 203-232;
Festivals of, 372-390;
Theatre of, 396;
Military service in, 456
Athletes, Hair of, 69;
Complexion of, 285;
Position and training of, 302-305;
useless to the State, 305;
at Olympia, 358
Auditorium of theatres, 398-402
Augustus, Obelisk of, in the Campus Martius, 185

Babylonians, their arrangements for measuring time, 184

Ball, Game of, 223, 299
Bankers, 190, 516, 517, 518
Banquets for men, 203;
Order of proceedings at, 205;
The various dishes served at, 206, 207;
Drinking at, 209;
at religious festivals, 349;
at Olympia, 363 (See, also, Symposium)
Barbers’ shops, 189, 190
Barbiton, The, 314
Barley-cake, 208
Barter, 515
Basilinna, 386, 387
Baskets for learning to walk, 86
Bathing children, 85
Baths for new-born infants, 80;
in gymnasia, 121;
for bride and bridegroom, 137;
of women, 159;
for men, 192-194;
Public and private, 192, 193;
connected with the gymnasia, 192
Battering-ram, 480
Battle-axe, The, 475
Beard, the, Modes of wearing, 71-74
Beer, 211
Bib, The, 24, 28, 32, 33, 35, 36, 39
Birds, Snaring, 197;
Sacrifice of, 336
Birds of Aristophanes, 140
Birth and Infancy, Period of, 78-98
Birthdays, 203
“Black broth,” 178
Blindness, Cures for, 240
Board of Inspection in Sparta, 99
Boating, 126
Boehlau on the woman’s chiton, 21
Boeotians, Food of, 206
Bogies, 88
Boots, 52, 53
Boule, The, 195
Bow and Arrows, Teaching the use of, 124;
Construction of, 300;
in war, 476, 477 (See, also, Archery)
“Bowl of Duris,” The, 307
Boxing, 116, 123, 291, 292;
subject to special rules, 292;
Injuries from, 293;
Methods of, 293-296;
 Thongs used in, 293, 296;
at Olympia, 353
Boys, Clothing of, 100, 118;
Education of, 99-132;
Gymnastic exercises of, 100, 115, 116, 119-124;
Oath taken by, 117;
period when classed as ephebeia, 117;
exercised in arms, 124;
horse-riding, swimming, boating, and marching, 124-126;
Advanced instruction of, 127, 128;
at quoit-throwing, 278;
as priests, 325, 326;
at the Olympic games, 353, 354;
at Pythian games, 368;
at theatres, 447;
as slaves, 521
Branchidae, The Sanctuary of, 344
Bread, 207, 208
Bridal dress, 138
Bridal presents, 135
Bridal procession, 139
Bridal song, 140
Bridal torches, 139
Brooches, 6
Brygos, vase painter, 30
Burning the dead, 250, 254, 255
Byzantium, Intemperance at, 197

Cakes, 207, 208;

for Cerberus, 245
Callirhoe, The sacred water of, 137
Calypso, 145
Camps, 455
Caps, Shape and material of, 59
Captives taken in war, 452
Carriages for infants, 90;
of the rich, 198
Caryatid, Dress of a, 37;
Head-dress of a, 75
Castanets, 320
Cattle rearing, 176, 496, 497
Cavalry, 452, 457, 479, 480
Cenotaphs, 264
Ceos, Burial ordinances of, 251
Cerberus, 245
Chairs, 202
Chariot races, 353, 354-357, 368, 373
Charioteers, Costume of, 4, 354
Chariots, Fighting from, 451
Charon, The pilos of, 59;
his fees, 245
Chemises, 43
Children, Customs at the birth of, 78-80;
Swaddlings for, 80;
Suckling, 81;
Legitimation of, 81;
Exposure of, 82;
Naming, 83;
Welcome and Dedication of, 82, 84;
Charms for, 84;
in the nursery, 85;
Bathing, 85;
Weaning, 85;
learning to walk, 87;
Clothing of, 88;
Threats for quieting, 88;
Stories for, 88;
Toys for, 89-92;
Games of, 92-97;
Chastisement of, 98;
Education of, 98;
Registration of new-born, 143;
bound to obedience, 148;
at meals, 178;
 at the Feast of Cans, 386;
as slaves, 521 (See, also, Boys and Girls)
Chionis, jumping feat of, 269
Chiton, The, long and short, and by whom worn, 3, 4;
Homeric descriptions of, 6;
Change in the cut of, 8;
of Hermes, 11;
of workmen and others, 12;
Modes of wearing the, 14, 15;
combined with the himation, 17;
worn at home, 19;
its resemblance to the peplos, 20;
worn by women, 21, 24-26;
Changes in, 30;
Construction of, 33;
Folds of, 33, 34;
Arrangement of, 37;
Varieties of, 39-41;
Colour of, 44, 45;
Patterns of, 46;
Material of, 47, 48;
on the stage, 438;
of soldiers, 465
Chlaina (Cloak), 3;
shape of, 7, 8;
material of, 15
Chlamys, The, 7;
place of its origin, 17;
shape and mode of wearing, 18;
of Hermes and Apollo, 18, 19
Choragia, The, 418
Choruses, 214, 350, 389, 392, 394, 413, 415;
Training of, 417, 419, 420;
Prizes to, 419;
The selection of, 420;
Dress of, 444
Circe, 145
Cirrha, 368
Cithara, The, taught in Attic schools, 112;
Construction of, 309-311;
Manner of playing, 311;
at Pythian games, 366
Cithara player, Dress of, 32;
at banquets, 133
Citizens, Daily life of, 188-201;
Judicial duties and voluntary services of, 195;
as soldiers, 456
Civic rights of young men, 133
Civil duties, 195
Clans at Athens, 143
Clarian Temple of Apollo, The, 344
Clarotae, The, 522
Cleisthenes, Reforms of, 457
Cleon, 428
Cloak, The, 7;
Mode of wearing, 15, 17, 19;
Coloured, 47
Clocks, Water, 185-187
Clothes, Washing, 156, 157
Club, The, 475
Club-rooms, 179, 192
Cnidus, Medical school of, 235, 239
Cock and quail fighting, 228
Coffins, Material and shapes of, 252, 253
Coins put into mouths of dead men, 245
Callicratidas, 532
Colours of dress, 44-47
Comedy, 414, 415, 436-442
Comus, The, 230
Concubinage, 145, 146
Condottiere, The, 459
Conjurers, 217
Conversations and discussions at symposia, 219
Cooking, 206
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