The Power of Prognosis

     The ancient Greeks, and also the Romans, were great believers in the unseen power of destiny and fate.  They frequently consulted oracles like the one at Delphi to seek guidance from the gods and augur the probabilities for success or failure in an important endeavor.  They were always trying to read signs and omens in their everyday lives.
     This general attitude carried over into the practice of medicine.  Particularly esteemed was the physician who could read the signs and omens in the patient's condition to tell what his prospects were for survival and recovery.
     It has often been said of Hippocrates and the physicians of his Coan school that they placed a special emphasis on prognosis; many attribute this to Egyptian influence.  But, writing in his Canon of Medicine almost 1500 years later, Avicenna asserts that nothing lends more credibility and esteem to a physician than his powers of prognosis, and his ability to tell the past, present and future course of an illness.
     Greek Medicine is a system of natural healing that believes in the healing power of Nature; and so, many diseases are seen as self-limiting.  However, many diseases are not, and can have grave, serious or even fatal consequences if allowed to run their course. 
     The ultimate  yardstick for measuring the value of any medical treatment or intervention is how much it will improve the outcome of the disease or disorder  over the negative option of doing nothing, and allowing the disease to naturally run its course.  The physician's knowledge and powers of prognosis must be such that he is able to intelligently discuss with his patient the merits, pros and cons, and probable outcomes of the various treatment options under consideration.
     Every disease, as a phenomenon of Nature, has its own particular progression, life cycle and developmental rhythms.  Knowing the natural cycles and rhythms of disease progression will enable the astute physician to intervene in the most timely and effective manner.
     Greek Medicine, as a holistic healing system, recognizes that the life, health and wellbeing of the patient is intimately connected with the larger, universal life cycles of Nature and the cosmos.  Celestial, climactic and environmental factors all exert their influence on the course and outcome of the patient's illness or disease.

The Doctrine of Critical Days

     The Doctrine of Critical Days maintains that certain days in the course or progression of an illness or disease tend to be critical.  On these days, the physician must be especially vigilant, as they can mark decisive turning points in the patient's condition, for better or worse, depending on how they are managed.
     Notions of critical days aren't exclusive to Greek Medicine, but were also part of the Egyptian and Sumerian / Babylonian medical systems.  In Greek Medicine, the Doctrine of Critical Days predates Hippocrates; Pythagoras, with his predilection for numbers, is generally considered to be the doctrine's originator.
     The first critical day in the progression of any disease is, of course, the day of onset, which is taken to be the first day of the disease.  The following days are numbered sequentially from the day of onset as day one. 
     In Greek Medicine, there are two main sources, or traditions, for determining critical days.  The first, and perhaps the easiest to learn, is the astrological method of  determining critical days, which is based on the Moon's weekly phases, or quarters.  The second source, or tradition, derives from the Aphorisms and other writings in the Hippocratic corpus which discuss the Doctrine of Critical Days.

Critical Days and the Lunar Phases

     Greek Medicine, as a holistic healing system, regards the health of the individual as being intimately connected with, and influenced by, the Universal Life Forces and cycles of Nature and the Cosmos.  As above, so below; and so, the vital cycles of the world below are influenced by celestial cycles in the heavens above. 
     Of these celestial cycles, the most important one involves the monthly cycle of the two luminaries, the Sun and the Moon.  These determine the monthly waxing and waning flow of our emissive (solar) and receptive (lunar) vital energies, and influence the overall vitality and immunity of the organism.
     This monthly soli-lunar cycle has four critical turning points, at which the Sun and Moon form hard angles to each other.  These are the lunar quarters, which divide the lunar month into four phases, lasting about one week each. 
     The lunar quarters - New Moon (conjunction), First Quarter (waxing square), Full Moon (opposition), and Last Quarter (waning square) - are the critical turning points in the monthly flow of vital energies.  It is at these critical turning points that critical developments and milestones in the progression of an illness naturally and most frequently tend to occur, either for better or worse.
     The astrological conception or schema of critical days is patterned after the weekly quarters, or phases, of the monthly lunar cycle:
     The first critical day is the day of onset, which often falls on a lunar quarter, but not always.  Subsequent critical cays in the course of the illness fall at weekly intervals thereafter.  If the illness had its onset on a Monday, for example, that initial Monday would be the first critical day, with the following Monday being the next critical day.  There can be up to four critical days in the progression of an acute illness, after which Greek Medicine classifies the disease as chronic. 
     On critical days, the illness makes its most decisive and important turns, or developments.  On the first critical day, the day of onset, the illness makes its initial appearance, presenting with its most salient or cardinal signs and symptoms.  Subsequent critical days can mark decisive turns for the better, or even remissions; or, they can mark decisive turns for the worse.
     The first judicial day comes on Day 3 of the illness, exactly two days after the first critical day, or day of onset.  The full nature and scope of the illness unfolds completely, enabling the physician to judge fully its implications for the life and health of the patient.
     Subsequent judicial days follow at weekly intervals thereafter, always two days after a critical day, for the entire course of the acute illness.  On these days, the physician can judge more fully the exact nature of the critical development that happened on the preceding critical day.
     The first intercedental day comes on Day 5 of the illness, exactly four days after the first critical day, or day of onset.  It presages what will happen on the following critical day.  If things are going well on an intercedental day, even if it be the first one, chances are that the following critical day will mark a decisive turn for the better, or even a remission of the illness.  Conversely, if things are going badly on an intercedental day, the following critical day does not bode well, and may mark a turn for the worse.
     In all illnesses, the astute physician takes careful note of the beginning, or day of onset, which is the most critical in determining the nature, course and duration of the disease.  Since subsequent critical days follow at one week intervals after the first, the Moon will always be in a sign of the same Modality as She was in at the day of onset, or the first critical day.
     If the Moon is in a Cardinal sign (Aries, Cancer, Libra, Capricorn) on the day of onset, the illness will most likely be acute, decisive and short term.
     If the Moon is in a Fixed sign (Taurus, Leo, Scorpio, Aquarius) on the day of onset, the illness will most likely be recalcitrant and entrenched, often going on to become chronic.
     If the Moon is in a Mutable sign (Gemini, Virgo, Sagittarius, Pisces) on the day of onset, the illness will tend to develop into something intermittent or recurring, that comes and goes.  Conditions of environmental or allergic sensitivity are also favored. 
     Greek Medicine defines acute illnesses as those whose duration is a lunar month (four weeks) or less.  Illnesses lasting longer than a month are defined as chronic.  Chronic illnesses are under the dominion of the Sun and His annual solar cycle, with the critical periods occurring at three month seasonal intervals after the day of onset. 

Critical Days in Hippocrates' Aphorisms

     Aphorisms has always been one of the best known and loved works of Hippocrates.  The aphorisms contained therein are short, concise, pithy sayings of healing wisdom drawn from clinical experience.
     In sections II and III of the Aphorisms, we can find aphorisms most directly relating to disease prognosis and critical days.  Consider the following:

     Acute disease comes to a crisis in fourteen days.
          -  Hippocrates,  Aphorisms  II:23

     I previously mentioned the one month limit on the definition of acute diseases, and their correlation to the monthly lunar cycle.  It just so happens that fourteen days is the length of the waxing half of the lunar cycle, from New Moon to Full Moon.  After the initial fourteen days of an acute disease, the lunar aspects are reversed, and whatever has caused the growth of the disease comes to a climax, and starts to wane.
     I'm sure that there are plenty of acute diseases that come to their climax in less than fourteen days.  But when Hippocrates wrote this aphorism, he was probably considering the natural limit, or maximum time span, within which acute diseases may come to their climax.  Although some acute diseases may come to their climax sooner, as a general rule, none come to their climax later.

     The following aphorism also relates clearly to the Doctrine of Critical Days:

     The fourth day is indicative of the seventh; the eighth is the commencement of the second week; and hence, the eleventh, being the fourth of the second week, is also indicative; and again, the seventeenth is indicative, as being the fourth from the fourteenth, and the seventh from the eleventh.
     -  Hippocrates,  Aphorisms  II: 24

     In fact, unless one understood something of the Doctrine of Critical Days, this aphorism of Hippocrates would seem to be nothing more than numerical nonsense, or mathematical jibberish. 
     Instead of the more complex schema of critical days I presented earlier, Hippocrates presents here a more simplified version.  He dispenses with the judicial days altogether, and puts the intercedental days, which are indicative or presaging of the following critical days, at roughly mid-week.

Disease Signs, Good and Bad

     Sections II and III of Hippocrates'   Aphorisms are the ones that deal most centrally with signs and symptoms in disease prognosis.  I will present a few of my favorite aphorisms from these sections here.
     Although the original translator, Francis Adams, has used the word "symptom" exclusively, I have taken liberties with his translation and used the word "sign" when an objective sign was being discussed, and not a subjective symptom.  Although some of these aphorisms are self explanatory, I have added commentary of my own where I deemed it necessary and appropriate:

     In whatever disease sleep is laborious, it is a deadly sign; but if sleep does good, it is not deadly.
     -  Hippocrates,  Aphorisms  II : 1

     This is fairly self explanatory.  If sleep isn't performing its normal restorative function, then the fundamental homeostatic and regenerative mechanisms of the body are seriously out of order.

     When sleep puts an end to delirium, it is a good sign.
     -  Hippocrates,  Aphorisms  II : 2

     This is in the same vein, and shows that sleep is having a healing and restorative function.

     Both sleep and insomnolency, when immoderate, are bad.
     -  Hippocrates,  Aphorisms  II : 3

     What is needed is a healthy balance between sleep and wakefulness.  See the relevant page in the Hygiene section for more details.

     Spontaneous lassitude indicates disease.
     -  Hippocrates,  Aphorisms  II : 5

     Lassitude and fatigue for no apparent reason indicates that something is drastically wrong with the normal vital principles and functions of the organism.

     Those bodies which have been slowly emaciated should be slowly recruited; and those which have been quickly emaciated should be quickly recruited.
     -  Hippocrates,  Aphorisms  II : 7

     The word, "recruited" here means , "rebuilt" or "restored".  This is one of Nature's laws; one can't take any shortcuts in restoring the health and nutritional status of someone who has slowly atrophied and lost it.  In such cases, only restoration done gradually, bit by bit, will be of any quality, lasting and permanent.
     Conversely, nutritive losses incurred quickly by the body will be felt more urgently and acutely.  Therefore, they need to be restored as quickly and urgently as possible to return the organism to homeostasis.

     What remains in diseases after the crisis is apt to produce relapses.
     -  Hippocrates,  Aphorisms  II : 12

     Ideally, the acute crisis of a disease should be a complete catharsis that eliminates all pathogenic matter from the organism.  Any pathogenic matter that remains will go on to create further illness and disturbances of a similar nature. 

     When a person who is recovering from a disease has a good appetite, but his body does not improve in condition, it is a bad sign.
     -  Hippocrates,  Aphorisms II : 31

     This shows that there is something drastically and fundamentally wrong with the person's pepsis, or digestion, assimilation and metabolism.

     In diseases, there is less danger when the disease is one to which the patient's constitution, habit, age, and the season are allied, then when it is one to which they are not allied.
     -  Hippocrates,  Aphorisms  II : 34

     The normal homeostatic mechanisms of the body are more accustomed to handling pathogenic factors and processes that are allied in nature and temperament to the individual's constitutional makeup, habits, age and life stage, as well as climactic and environmental factors that are similarly allied.  Conversely, these same homeostatic mechanisms are more likely to be severely upset or deranged by pathogenic factors that run contrary in nature to that to which they are accustomed to handling.

     Persons who are naturally very fat are apt to die earlier than those who are slender.
     -  Hippocrates,  Aphorisms  II : 44

     If this isn't an all-out endorsement for weight loss and proper weight management, I don't know what is.  Modern medicine has confirmed that obesity poses great risks to the life and health of the individual.

Diseases of the Seasons and Stages of Life

     Section III of the Aphorisms goes on to discuss seasonal and environmental influences in health and disease, as well as the particular diseases that are predominant in the various stages of life.
     According to Hippocrates, here are the diseases that prevail in the four seasons of the year:
     Spring:  maniacal, melancholic and epileptic disorders; bloody flux, quinsy, coryza, hoarseness, cough, ulcerations, tuberculosis, arthritic disorders.
     Summer:  ardent and tertian fevers, vomiting, diarrhea, opthalmies, pains of the ears, ulcerations of the mouth, infections and mortifications of the private parts.
     Autumn:  quatrain and intermittent fevers, enlarged spleen, dropsy (edema), phthisis, strangury, lientery, dysentery, sciatica, quinsy, asthma, epilepsy, maniacal and melancholic disorders.
     Winter:  pleurisy, pneumonia, coryza, hoarseness, cough, chest pains, pains of the ribs and loins, headache, vertigo, apoplexy.
     The most dangerous times, when the onset of disease is most likely, is, of course, when the seasons change, especially from hot to cold, and vice-versa.  Of all the seasons, Hippocrates affirms that spring is the most conducive to health, and autumn the most problematic for disease.
     Hippocrates also goes on to discuss which diseases are prevalent in the various stages of life.  Here is his analysis:
     Infants:  apthae (cold sores), vomiting, coughs, sleeplessness, frights, inflammation of the navel, watery discharges from the ears. 
     Dentition (Teething):  pruritis of the gums, fevers, convulsions, diarrhea - especially in those who are cutting their canine teeth; constipated bowels - especially in those who are chubby or fat. 
     Childhood:  tonsil problems, cervical spine disorders, asthma, calculus, round worms, various parasites, tubercles and phymata.
     Adolescence:  most of the foregoing disorders, plus more chronic fevers and epistaxis (nosebleed).
     Hippocrates goes on to explain that youths and adolescents generally suffer a definite crisis in their complaints, which can happen to some in forty days, and to others in seven months, seven years, or at the onset of puberty, or menstruation in women.  Those complaints and disorders that do not pass away at around the time of puberty or menarche usually go on to become chronic.
     Young Adults:  hemoptysis, phthisis, acute fevers, epilepsy, etc...
     Middle Age:  asthma, pleurisy, pneumonia, lethargy, phrenitis (inflammation of the brain), ardent fevers, chronic diarrhea, cholera, dysentery, lientery, hemorrhoids.
     Old Age:  dyspnea, catarrhs with cough, dysuria, joint pains, nephritis, vertigo, apoplexy, cachexia (a sickly complexion), pruritis of the whole body, insomnia; fluxes of the bowels, eyes and nose; dimness of vision, cataracts, glaucoma, and hardness of hearing.
     Of course, the world has changed a lot since Hippocrates' day, and with it our system of healthcare and the diseases people suffer from.  Certain diseases like cholera and leprosy have largely been eliminated, although some on the above list are still common and familiar.  Although there has been a dramatic decline in infectious diseases, degenerative diseases like cancer have reached near epidemic proportions.  Times change, and so do diseases.