The theory which prevails the most universally in the Hippocratic works, is that of coction and crisis. It is met with at every step, sometimes isolated, sometimes combined with others ; but especially is it united to the system of four elements and four humors. It forms an integral part and is the most characteristic trait of the ancient Dogmatism, and it is retained even in our time, while all its cotemporaneous doctrines have been abandoned.

 

The Asclepiadae, of the isle of Cos, regarded disease as an association of phenomena, resulting from the efforts made by the conservative principle of life to effect a coction of the morbific matter in the economy. They thought that it could not be advantageously expelled until it was properly prepared, that is, until after its elements were separated and united with the natural humors of the body, so as to form an excrementitious material.

The vital principle that effected this preparatory work, as well as sustained all other physiological functions, has received various names among ancient authors, according to their notions of its particular attributes. Some called it nature, (j'oac^, when they wished to indicate the totality of forces and phenomena over which it presided ; motor, euopfia)i<, impetum faciens, to signify the prompt impulse which it gave to the whole machine; soul, spirit, (f'oyjj, to signify its immaterial essence, and the noblest of its faculties - the intellect. The word Tweoaa , breath, designated, more particularly, the way in which the vital principle sustained itself, the substance from which it drew its nourishment: and the word dzptiov,, heat, expressed one of the most immediate effects, and the most indispensable to life.

When the morbid substance approaches the period of maturity, nature seems to redouble her efforts ; the fever augments, the patient is overwhelmed, or delirious, all the symptoms are aggravated and announce the approach of a revolution ; this was the moment of the crisis, or judgment of the disease. The day on which it was accomplished, the signs which preceded or accompanied it were termed critical, and required the special observation and attention of the physician. He must be able to discern whether these signs were good or bad, and predict, on seeing them, what will be the fate of the patient. He must respect the critical labor of nature, if it proceed properly, nor disturb it by violent remedies, and in no case attempt to aid the vital principle, unless in urgent necessity.

When the coction was effected, which might be known by the amendment of the symptoms, it only remained to evacuate the heterogeneous material. Nature often accomplishes this last effort, herself, and the disease terminates by a critical sweat, urination, or stools. But it also frequently happens, that the vital principle, fatigued and broken down by the efforts of the crisis, requires aid, and then the physician must come to its relief. To accomplish this, say the authors, he must push the material toward the emunctory. to which it naturally tends ; that is, he must give sudorifics, or purgatives, or diuretics, according to the indications of nature, whose faithful minister he must show himself to he, in all things. In this way diseases terminated, in the most favorable cases. (Oeuvres d'Hippocrate, par M. Littre, T. V. Traite des humeurs, § 3, et ale)

But it might happen, that the coction could not be effected, or only imperfectly. In such cases, one of two things must occur : either the vital principle, overcome by the morbid element, succumbs, and the patient dies, or the struggle between the vital element and the morbid goes on, and a new effort at coction commences, and is continued for a limited number of days, in the same manner as at first. This second effort may have a termination, complete or incomplete, and so on successively.

The number of days necessary for the coction, or the elaboration of the morbigenous matter, was termed the critical period. The most perfect period was supposed to be the quaternary, or that of four days ; next, the third ; finally, in addition to these two, was the septenary, which had a high consideration.

In the treatise on Prognostics, section 20, we read as follows : " the same number of days which brings about the cure, or death of the sick, regulates the crises of fevers. The most benign, those which are accompanied with the most encouraging signs, terminate in four days, or sooner ; the most malignant, or those accompanied with the most menacing signs, destroy life in four days, or less : such is the limit of the first period. The second period reaches the seventh day ; the third, the eleventh day ; the fourth, the fourteenth day ; the fifth, the seventeenth day; the sixth, the twentieth day. Thus, these periods, in the most acute diseases, go from the first, in four days, to the sixth in twenty days. But none of these periods, they say, can be calculated, rigorously, by entire days, for neither the year, nor the months, are counted by entire days. Still farther, by the same calculation, and same progression, we have a first period of thirty-four days, a second of forty, and a third of sixty days. The most difficult part of the diagnosis is, to determine from the beginning the favorable, or unfavorable termination of those cases in which the crises are slowest ; for, in the beginning, all protracted diseases are very similar. It is necessary to make observations from the first day, and then examine the state of things, after each quaternary is passed ; in this way, mistakes in regard to the termination of diseases are avoided. The nature of the quartan fever is submitted to a similar course. The good or bad termination of a case, when the crisis is reached in the shortest time, is more easily known, for the accessions are extremely dissimilar. The patients who will recover, have easy respiration, not much suffering, sleep at night, and offer otherwise encouraging symptoms : on the other hand, those that are to die, have dyspnoea, delirium, sleeplessness, and all the most alarming signs. Since these affections thus act, it is necessary to establish conjectures according to the time, and according to each additional period, in proportion as the diseases proceed toward the crisis. With women, the crisis, after accouchement, follows the same rule.(Oeuvres d' Hippoc, translated by E. Littre, Paris, 1840, T. II, p. 169)

In the above scale of critical days, it may be observed that each period is formed by adding the r umber four or three to the preceding one. To properly conceive of the origin of this progression, we must recur to the system of Pythagoras, already described, ( See page 83) The number four, it may be remembered, represents in that system all substances endowed with proper faculties, having an existence distinct from other beings, as God. man, a plant, or a mineral ; hence it follows that the Asclepiadae, inheritors of the doctrines and symbolical language of the Egyptians, were naturally led to designate by the number four the morbid entity come to its complete development. For the same reason, the number three,, which represented the whole of the essential properties of all beings, might also indicate to them the plenitude of the faculties of the morbid entity.

If any doubt yet remains on the connection that exists between the system of Pythagoras and the theory of critical days, the following passage will remove them: - "A physician, says one, who neglects nothing that may contribute to the establishment of his patient's health, must observe carefully what passes each day. Among those days of even numbers, the most important are the fourteenth, the twenty-eighth, and the forty-second. This is supposed to arise from the perfection of those numbers, and the manner in which they are composed of other whole numbers. It would take up too much time to give their reasons : it will be sufficient to say that they refer to the ternary and quarternary."( See the Traite de la Grossesse a sept mois, § 3 ; translation of Gardeil)

As nature is not subjected to our arbitrary limitations, it often happens that the duration of diseases does not respond exactly to an exact number of ternary or quarternary periods ; they were therefore obliged to change more than once the manner of counting critical days. Opinions varied very much in that respect, even in ancient times. The author of the treatise on Diseases developed in his fourth book a physiological and pathological theory, according to which all the odd days are assumed to be critical days. But this rule was found in many cases to be at fault, so that they were forced to admit that the rule of odd days was exceptional in numerous cases. Hippocrates himself points out several. In the third book on Epidemics, section third, it is said that " all diseases offer, it is true, difficulties in crises, the absence of crisis, and a long duration, which was especially remarkable in those to which I refer : in some, the crisis was retarded for eighty days ; in most of them the disease ceased without a distinct crisis."

Notwithstanding the vagueness that existed in the determination of critical days, the doctrine of crisis is maintained in our times. Pinel, one of the most philosophic spirits of our epoch, wrote at the end of the last century : " I suppose that no one is so little enlightened, as to think he can suspend, by the aid of remedies, the course of an acute disease, such as an essential fever, or a phlegmasia. On the contrary, he must commence by counting the days, from the beginning, so as to recognize what their actual period is. It is known that inflammatory fevers, as well as gastric, continue, in general, to the end of the first, second, and sometimes, third septenary ; but the gastric remitting fevers continue to the sixth or seventh week, whatever method of treatment may be employed, and may continue many months, if exasperated by a too active treatment.(Nosogr. Philos. Introduction, p. 35) "

Landre" Beauvais, author of a treatise on semiotics, expresses himself as follows: "Hippocrates, excellent observer and reliable historian, has established the doctrine of crisis. Asclepiades and the methodists, guided by prejudice, denied the crisis and critical days. They accused Hippocrates of being led by the dogmas of Pythagoras, or numbers, and they attacked Galen, who remained faithful to the principles contained in the writings of the father of medicine. Asclepiades had many imitators in succeeding ages ; Celsus was the most illustrious ; but can one adopt the sentiments of those who refuse to admit the crisis, when it has been so successfully sustained by Galen, Duret, Baillou, Fernel, Sydenham, Forestus, Stahl, Baglivi, Van Swiften, Stohl and Pinel, and when every day, clinical observations confirm the views of these great masters."Diction, des Scienc. Medicales, the word Crisis, T. II, p. 376)

A medical opinion which has traversed so many ages, and come down to us supported by such respectable names, merits a profound examination. We must conclude, until the contrary is established, that it is not a pure play of the imagination, but that it has some foundation in the observation of the natural progress of diseases.

I will remark, in the first place, that the connection that exists between the doctrine of crisis and the dogmas of Pythagoras - a connection that it is vain to deny - proves nothing for or against this doctrine. The real question is, are there diseases which proceed, or seem to proceed from some solid, liquid, er gaseous, deleterious substance, introduced into the economy, exciting there a reaction, which is manifested by a succession of nearly constant symptoms ? Now it is not doubtful that there are diseases of this kind. We cite, in the first place, fevers caused by vegetable emanations - formerly so common, and so destructive, which assume usually, a periodic form, as a quotidian, tertian or quartan. I will also cite the eruptive fevers, such as variola, rubeola, vaccinia, miliary, etc., which have well marked phases of incubation, eruption and desquemation. It is true, that certain authors pretend that these last diseases are of modern origin - I had almost said invention ; but that is a controverted, and a very controvertible opinion, as I shall prove at a proper time. But admitting they are so, it cannot be denied that if new periodic diseases have arisen since Hippocrates, the old ones could become extinct, and in this hypothesis, there would be, therefore, a compensation.

Thus, then, there has existed, and there still exists a very numerous class of diseases, of nearly constant periods, and it is in a great measure, upon the observation of this remarkable phenomenon, that the doctrine of coction and crisis has been founded. Recall now a remark that I have already made, namely, that the attention of the Asclepiadae was especially directed to acute diseases, and amongst these, principally to epidemics. The greater number of the clinical relations that have been transmitted to us, relate to epidemics. Now febrile affections, of regular periods, generally prevail as epidemics.

What then is the reproach that can be legitimately applied to Hippocrates and those who have adopted his theory of crisis ? It is that of extending to all diseases that which is true only of a certain number ; in a word, for having generalized too much an idea ; and this is the most common defect of all systems, as has been already remarked. 

 From History of Medicine by P.V. Renouard M.D.

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