[665] It will be remarked that the characters of the urine throughout are favorable. Though darkish at first, this was reckoned not unfavorable, as being connected with the lochial discharge. (See Galen. Comment. 2, Epid. iii.) The sediments afterwards are all of good omen; but, as Galen remarks, its first characters indicated a prolonged fever.
[666] On the Critical Days, see Paulus Ægineta Book II., 7.
[667] On comparing the symptoms here enumerated with the Prognostics, it will be remarked that none of them are of fatal omen. But the white sediment, and afterwards the reddish color of the urine, while they indicated recovery, at the same time prognosticated a protracted attack of fever. See Prognost., 12. The reader will further remark that there is an absence of all the decidedly fatal symptoms, such as delirium, coldness of the extremities at the commencement, and so forth.
[668] The rapid recovery in this case would seem to be partly attributable to the decided plan of treatment, namely, the copious affusion of hot water on the head. Hippocrates probably had it in view when he wrote the forty-second Aphorism of the Seventh Book: “In fever not connected with bile, if a large quantity of hot water be poured over the head, it proves a resolution of the fever.” Galen points it out as a remarkable circumstance, that in this case the crisis took place without concoction of the urine, in consequence of the hemorrhage from the nose, and the sweating.
[669] In this case, as Galen remarks, the continued sweats, unfavorable condition of the hypochondriac region, and the black urine, precluded all hopes of recovery. He thinks our author related the case as an instance of sudden death in fever, this patient having died on the fourth day after the attack (the first not being counted). See his Commentary. He also makes reflections upon this case in his work On Difficulty of Breathing, where he points out the danger of meteorism of the hypochondriac region as being necessarily accompanied with dyspnœa, and connected with inflammation (2).
[670] This case, as Galen remarks, is interesting from the suddenness of the fatal result. We should not hesitate nowadays to set it down as a case of malignant erysipelas; the pain, swelling, and bullæ of the foot and ankle must have been of this nature. By the way, these bullæ, when not followed by suppuration, are represented in the Coacæ Prænotiones, as a fatal symptom. Galen thinks it strange that this patient was not bled, but accounts for it by supposing that Hippocrates had been called in too late. He remarks on this case in the Second Book of his work On Difficulty of Breathing.
[671] Galen looks upon this patient as an example or paradigm of general principles in Prognostics. Thus, with regard to the characters of the urine, it is stated that on the eleventh day the urine was thin, of a good color, and having many substances floating about in it, but without sediment. Thus matters remained until the sixteenth, when the urine became somewhat thicker, and had a slight sediment. Now Galen remarks (as the reader will find on turning to the Book of Prognostics) that these characters of the urine are indicative of recovery after a protracted disease. Galen further points out that no one of the fatal symptoms are mentioned, and that swellings of the parotid glands and the dysenteric affections of the bowels indicated that the crisis would be distant. He also calls attention to the case as confirmatory of the doctrines of Critical Days. In the Second Book of his work On Difficulty of Breathing, he makes some remarks, of no great importance however, on the meteorism of the hypochondriac region, as noticed in this case.
[672] In this case, as Galen remarks, the characters of the urine from the first were such as to indicate a fatal and speedy result. On the second day the urine was turbid, and without any sediment; on the third day the same, and consequently confirming the anticipation of the disease proving mortal; on the fourth, oily urine, with epistaxis, so that it was not to be wondered at that the patient died on the sixth. Indeed, when we further take into account the state of the breathing, the coldness of the extremities, the meteorism of the hypochondriac region, and the subsultus tendinum, it is difficult to imagine a more hopeless case of fever. Having mentioned “oily urine,” it may be well to state its characters, as fully given by one of the later authorities on urology, namely Theophilus. He says, when the urine in fevers assumes the color of oil, it indicates that the fat of the body is melting down; when the appearance of the urine still more resembles oil, it shows a still greater melting; and when the urine in consistence and color exactly resembles oil of a dark color, it prognosticates a fatal collapse. (De Urinis, 17; ed. Ideler.) On this subject, see further some very interesting observations by Foës, in his annotations on this passage (p. 988). With regard to the respiration in this case, see also the remarks of Galen in the Third Book of his work On Difficulty of Breathing (tom. vii., p. 932; ed. Kühn). As Galen here remarks, Hippocrates explains the meaning of this passage in one of his Aphorisms, where he writes thus: “In fevers, when the respiration stops, it is a bad symptom, for it prognosticates convulsion.”
[673] According to Galen, this case is an instructive example of the danger of neglecting the diet at the commencement of complaints which appear unimportant. This man, having taken supper at the beginning of a fever which appeared slight, suffered therefrom as the result showed; that is to say, vomiting ensued, followed by serious symptoms, among which Galen particularizes, as indicating a fatal result, urine at first thick and without sediment, and afterwards oily. So much importance did the ancient physicians attach to observations on the urine in fevers! Galen further calls attention to the fact, that the patient died on a critical day, that is to say, on the eleventh.
[674] Galen, in the commentary, makes a remark regarding this report, which appears more important to him than it will do to most modern readers, namely, that he wonders Hippocrates did not state the age of this patient. He adds, that it is very rare for a pregnant woman to have such a serious fever without parting with her child. He thinks the patient, in the present instance, owed her recovery to the strength of her constitution, as “urine white, and not of a good color,” in combination with the other bad symptoms, indicated an unfavorable result. By the way, upon reference to the Basle edition of Galen, and to Foës’s annotations on this case, it will be seen that there is a difference of reading in the words descriptive of the urine, that is to say, some read ἀχρόων, some εὑχρόων. Certainly it appears to me that Foës is right in preferring the latter. The decided crisis, it will be remarked, took place on a critical day, that is to say, the fourteenth, by a sweat.