Tuesday, June 30, 2015

400 B.C.: The Hippocratic Inhaler

The first inhaler was probably invented long before Hippocrates walked the earth in the 5th century B.C.  Yet the first time it was ever recorded was by Hippocrates, or at least by one of the writers of the Hippocratic Corpus.  

The inventor is unknown to history, although one might suspect that a young Greek priest learned about it on one of his journeys, and it appeared to him in a vision at the Aesclepion at Cos.  He provided it as a remedy and it worked for what he was told it would work for.  It was then recorded in the votive tablets.

Many years later, while making his own effort to record the wisdom of the ancients, Hippocrates would have learned of this inhaler.  He wrote about it in his Hippocratic Corpus.  

Of course he didn't refer to it as an inhaler, of course not, as the term wasn't coined yet.  Also, chances are pretty good the inhaler he learned about was not used for asthma, or even asthma-like symptoms, but some other unknown malady.  Yet it may have been used for asthma at some point.

So, in the Corpus Hippocrates mentions this inhaler-like device.  The model basically consisted of a jar with a hole in the lid for the insertion of a hollow reed for inhaling the contents. The mouth was saved from burns by use of a soft sponge or egg shells between the mouth and reed.  (1, page 461)

Boiling water would be inserted into the jar, perhaps a recipe of medicines, the lid placed atop the jar, the reed stick inserted through the hole.  The patient would inhale by placing his mouth on the reed stick.  It was a simple design and must have worked quite well, because it was the design used by physicians for many years.

Hippocrates also described fumigations, which probably would have been of smoke or steam.  This treatment might have been more readily available than the inhaler.  (2, page 241)

However, it should be noted that the most common use of fumigations and the inhaler was probably not for respiratory ailments.

For instance, he recommended fumigation to induce menstuation in virgins. He
recommended fumigation, among other treatments, as a option when a female had pituitous (mucousy) menstruation, or when female hysteria results form displacement of her uterus, which might cause sterility. It was also recommended when a female could not feel her infant moving in the uterus at four or five months. He also recommended it for severe ulcers, among other similar non-respiratory ailments. (2, page 300, 304)

He did, however, recommend fumigations for certain types of phthisis, although mainly for spinal tuberculosis and not the pulmonary type. (2, page 281)

He also recommended inhalation for quinsy, or the various diseases that causes swelling of the throat. He also recommended inhalation for angina. (2, page 281, 260-262)

Getting back to the inhaler, many believe it was the Hippocratic Inhaler that was fine tuned during the 19th century when the first two inhalers were manufactured and placed on the market.

References: 
  1. Glasgow Medical Journal, Volume 14 By Glasgow and West of Scotland Medical Association, Royal Medico-Chirurgical Society of Glasgow
  2. Hippocrates, Claudius Galen, writers,  John Redman Coxe, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846, http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston
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Monday, June 29, 2015

370 B.C.: The dogmatic school of medicine

While Hippocrates is credited with creating the humoral hypothesis, it was his sons, Thessalus and Draco, who are credited with creating the first school, or sect, of medicine: the Dogmatic School of Medicine. (1, page)

There were various names for this school, depending on the era it was being described, and who was describing it.

Since it was based on the writings of the Hippocratic writers and Hippocrates himself, it was sometimes called the Hippocratic school, and physicians called Hippocratici. 

Since it was based on philosophers who believed it was necessary to rationalize about medicine, it was sometimes called the Rationalist school, and physicians called rationalists.

Since it was based on the belief that health was determined by a balance of the four humors (blood, phlegm, black bile and yellow bile) of Hippocrates, and diseases caused by an imbalance thereof, it was often called the Humoral school, and physicians called humoralists.

And, finally, since it was based on the dogma of Hippocrates, it was also called the Dogmatic school, and physicians called dogmatists or dogmatici. 

Regardless of the name, the general idea here is best explained by medical historian Edward Withington in 1894:  (3, page 57)
The ancient Greeks loved talking; his mind was more philosophical than scientific, and he preferred to speculate on things in general rather than to investigate particular facts... A Hippocratic writer had said, 'The physician who is also a philosopher is godlike.' This became the motto of the dogmatic school, was made the excuse for an immense amount of useless speculation, and was finally taken as the text of a special treaties by Galen himself. (3, page 57)
The dogmatic school of medicine was generally taught at the School of Cos, and was based on the opinions of Hippocrates, yet it was also based on the Stoic philosophy. This led to much "useless speculation," (3, page 57)

Part of this "useless" speculation was that diseases were caused by imbalances of the four elements and humors, and remedies were a means to re-establish the balance.  Remedies may be as simple as a lifestyle change, and as harsh as bleeding and purging.  Any particular remedy did not require any specific evidence that it worked.

You can  also learn more about Hippocratic medicine by reading about the medical wisdom of Hippocrates.

Followers of this school believed in the importance of studying anatomy, and often performed autopsies on animals such as pigs, monkeys and apes.  They performed autopsies on humans if possible, although this was frowned upon and illegal in the ancient world.  Human autopsies were performed when permission was granted, and in such cases was usually performed upon stolen corpses or, worse, live prisoners.

They had a basic understanding of human anatomy: the layout of the main organs, the vessels that line the body.  They understood the importance of correlating medicine with physiology.  The obvious problem with their school was the reliance on opinions as opposed to observation, experience and science.  Of course when the school was formed there was no knowledge of any of those things.  (3, page 60)

By about 50 A.D., when most referred to it as the Humoral or Rational School, it was under fierce competition by four other schools that also formed in Greece. Despite this competition, the basic tenants of this school would be followed by physicians all the way to the middle of the 18th century.

References:
  1. "Rationalism (philosophy), Encyclopedia Britannica.com, http://www.britannica.com/EBchecked/topic/492034/rationalism
  2. Withington, Edward Theodore, "Medical History from the Earliest Times," 1894, London
  3. Watson, John, "Medical Profession in Ancient Times, "
  4. Magill, Frank N., editor, "Dictionary of World Biography," Volume I: The Ancient World, 1998, Salem Press Inc., California
  5. Meryon, Edward, "History of Medicine: comprising a narrative of its progress from the earliest ages to the present and of the delusions incidental to its advance from empericism to the dignity of a science," volume I, London, 1861,
  6. Adams, Charles, Kendall, editor, "Johnson's Universal Cyclopedia: A new edition," volume V, A. Johnson Company, New York, 1894
  7. Garrison, Fielding Hudson, "An introduction to the history of medicine: with medical chronology, Bibliographic data and test questions," 1913, Philadelphia and London, W.B. Saunders company
  8. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press

Sunday, June 28, 2015

400 B.C.: Did Hippocrates recognize allergies?

While hay fever was not mentioned until the 19th century, and allergies not defined until the 20th century, the signs and symptoms of allergies were well known to physicians of the ancient world.  Perhaps the first allusion to this was by Hippocrates during the 5th century.

Claude Lenfantt, in his introduction to the book "The Immunological Basis of Asthma, quotes Hippocrates as saying: 
Cheese does not harm all men alike, some can eat their fill of it without the slightest hurt, nay, those it agrees with are wonderfully strengthened thereby.  Others come off badly.  So the constitution of these men differ, and the difference lies in the constituent of the body which is hostile to cheese, and is roused and stirred to action under its influence. (1, page introduction)
Since Hippocrates probably obtained his medical wisdom from his ancestors, who were probably teachers at the Asclepion at Cos, we can probably surmise that physicians going back to the early ancient world observed the symptoms of allergies.

Surely allergies caused grief and suffering for those afflicted with it, this would have been minor compared to all the diseases that plagued the ancient world.  So allergies, even more so than asthma, was essentially ignored by the medical community.  The symptoms were probably recognized and brushed aside as catarrh, or the common cold.

References:
  1. Lenfant, Claude, author of introduction, Bart Lambrecht, Henk Hoogsteden, Zuzana Diamant, editors, "The Immunological Basis of Asthma," Lung Biology of Health and Disease, Volume 174, Claude Lenfant, executive editor, 2003, New York, Marcel Dekker, Inc. 

Saturday, June 27, 2015

400 B.C.: What did Hippocrates think about asthma?

Hippocrates is given credit as the author of the Corpus,
and therefore as the father of medicine.  The truth is,
however, that the figure in the bust here is probably
 a composite of what a typical physician would look like
around 400 B.C. The name Hippocrates has become
synonymous with the transformation of medicine that
occurred during this era of history.
As we peruse ancient writings we find many references to asthma, or at least asthma-like symptoms. The ancient Egyptians, Greeks, Chinese and even Japanese all recorded asthma-like events and the remedies to go along with them.  Yet it was Hippocrates,  particularly in his Corpus Hippocraticum, who made asthma a household name.

Please note here that Hippocrates was an actual physician, although his name is generally attributed to the medical wisdom of this era.  So as historians contribute the birth of medicine to Hippocrates, they are actually referring to the accumulated wisdom of Hippocrates and all of his immediate ancestors.

As far as we know, the first known person to use the term was Homer in his epic poem the Iliad, which was written about 800 B.C. Homer used it to denote gasping or air hunger that occurred after physical exertion or during the process of dying.

As was typical of the ere of philosophers in ancient Greece, Hippocrates had questions and he yearned for answers.  He wanted to know about all diseases, their causes and cures.  With limited ability to inspect the insides of the human body, his anatomical wisdom was limited.

He had no means of associating symptom seen outside the body with changes that occurred inside.  He therefore was forced to use reason to answer his questions about diseases such as epilepsy, dropsy, colds, catarrh, and asthma.  These answers were called theories.  They may seem quite spurious to the modern reader, although to the ancient Greeks they were quite logical.

So when Plato, and then Hippocrates, used the term asthma, they were pretty much denoting a symptom rather than a disease.  Plato used the term to denote short, gasping breaths by those wounded in battle or those who were exhausted after running from an enemy. Hippocrates used it in a similar way, although his definition was a bit more refined.

For example, Hippocrates defined the various forms of shortness of breath:
  1. Dyspnea: Shortness of breath
  2. Asthma (asthmata): Severe shortness of breath
  3. Orthopnea: So short of breath you have to sit up to breathe (a bad sign)
  4. Tachypnea: Rapid respiratory rate
He was the first to define asthma as a medical term. Since he didn't understand anatomy, asthma became a rubric term, an umbrella term, for severe breathing difficulty.  So from this point on if you were short of breath you had asthma, regardless of the natural cause.

To Hippocrates, like headache and fever, asthma was merely a symptom.

While this was a very vague definition, it was a start.  Later, as new wisdom was learned, the definition evolved.  Diseases that did not fit under the newer definition were extricated from under the umbrella term asthma to become disease entities of their own.

The first two examples were probably peripneumonia and phthisis, two diseases we now refer to as pneumonia and tuberculosis.  Diseases extricated after the death of Hippocrates were scoliosis, cardiac asthma (heart failure), kidney asthma (kidney failure), bronchitis and emphysema.

It's also interesting to note that diseases that caused curvature of the spine, such as scoliosis, were also considered as asthma.  They caused dyspnea because they resulted in less space for the lungs in the chest.  As these people age it can lead to dyspnea and even an early death.  In fact, Hippocrates mentioned this in one of his Aphorisms:
Such persons as become hump-backed from asthma or cough before puberty, die. (17, page 141
Hippocrates also observed redness and inflammation inside the nose, mouth and eyes of some patients, and he referred to this as catarrh.  By this he observed signs of the common cold, bronchitis, and allergies.

He wrote a treaties "Of Epilepsy."  Prior to his time the condition was referred to as the sacred disease because it originated from the anger of the gods, most likely Cybele, Neptune, Proserpine, Apollo, Mars, and Hecate.  Hippocrates tried to explain that epilepsy was "nothing more sacred or divine than an other." (11, pages 201-203)

Hippocrates believed that instead of being a divine disease, epilepsy was caused had a natural cause, which started by an increase of phlegm in the brain that ultimately made it's way to the veins and impeded flow of pneuma to the brain. He said:
This malady, then, affects phlegmatic people, but not bilious. It begins to be formed while the foedtus is still in utero. For the brain, like the other organs, is depurated and grows before birth. If, then, in this purgation it be properly and moderately depurated, and neither more nor less than what is proper be secreted from it, the head is thus in the most healthy condition. If the secretion (melting) from the whole brain be greater than natural, the person, when he grows up, will have his head diseased, and full of noises, and will neither be able to endure the sun nor cold. (14)
Hippocrates, like Greek physicians before him, believed asthma was epilepsy of the lungs.  He believed that air (with pneuma) was inhaled and flowed through the body by means of the veins.  It flowed to the heart and brain and other organs in order to keep them functioning.

Hippocrates said:
By these veins we draw in much breath, since they are the spiracles of our bodies inhaling air to themselves and distributing it to the rest of the body, and to the smaller veins, and they and afterwards exhale it. For the breath cannot be stationary, but it passes upward and downward, for if stopped and intercepted, the part where it is stopped becomes powerless. In proof of this, when, in sitting or lying, the small veins are compressed, so that the breath from the larger vein does not pass into them, the part is immediately seized with numbness; and it is so likewise with regard to the other veins. (19)
He also believed that the humor phlegm was made in the brain.  When it was in excess it could flow to the heart and lungs, thus causing asthma. (9, page 61-62) (10, pages 14-15)

He said:
But should the defluxion (flow of humors) make its way to the heart, the person is seized with palpitation and asthma, the chest becomes diseased, and some also have curvature of the spine. For when a defluxion of cold phlegm takes place on the lungs and heart, the blood is chilled, and the veins, being violently chilled, palpitate in the lungs and heart, and the heart palpitates, so that from this necessity asthma and orthopnoea supervene. For it does not receive the spirits as much breath as he needs until the defluxion of phlegm be mastered, and being heated is distributed to the veins, then it ceases from its palpitation and difficulty of breathing, and this takes place as soon as it obtains an abundant supply; and this will be more slowly, provided the defluxion be more abundant, or if it be less, more quickly. And if the defluxions be more condensed, the epileptic attacks will be more frequent, but otherwise if it be rarer. Such are the symptoms when the defluxion is upon the lungs and heart; but if it be upon the bowels, the person is attacked with diarrhoea.  (14)
Mervyn J. Eadie and Peter F. Bladin, when writing about the sacred disease of Hippocrates, explained the thinking of Hippocrates regarding the cause of epilepsy and asthma.  They said:
He (Hippcrates or the Hippocratic writer) considered the disorder (epilepsy) in the following way:  during normal prenatal development the brain underwent a process of purification as it grew in the womb.  If this purification process did not occur, the sufferer was likely to grow up with a diseased head.  Purification of the brain might still occur after birth.  If so, phlegm would then be secreted into the upper respiratory tract or lost from the body in discharged from ulcers.  If such purification, which should have got rid of phlegm from the brain, did not occur at some state, the sufferer would be prone to experience epileptic seizures. When a 'defluction' of the retained phlegm from the brain occurred, the phlegm might go to the heart and chest to cause palpations, asthma, chest disorders and possibly spinal deformity. If it went to the abdoment it caused diarrhoea.  (18, page 94)
If the cold phlegm was not able to make it into the lungs or abdomen, it entered the veins where it obstructed the flow of pneuma.  When the pneuma was obstructed this could result in seizures, but it could also result in "interruption of inspiration."  (18, page 94)

When the pneuma was unable to make it back to the brain this caused "interruption of speech and intellectual functions, and loss of power in the hands.  The palpating veins affected the lungs to cause froth to emerge from the mouth.  The violent suffocation might cause involuntary defaecation, as the liver and stomach ascended to the diaphragm and the mouth of the stomach closed. (18, page 94)

So asthma was basically a symptom of a greater problem which ultimately originated from too much phlegm being created by the brain.

In his "Airs, Waters, and Places," he said:
...infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy). (14)
Hippocrates said:
Infants are subject to attacks of convulsions and asthma, which they consider to be connected with infancy, and hold to be a sacred disease (epilepsy) (13, pages 9, 11)
From these two passages many experts speculate Hippocrates observed that epilepsy and asthma were common in infants.

He also alluded to asthma as being "convulsive" or spasmotic in nature.  In other words, he alluded to what would later be referred to as the spasmotic theory of asthma, or that asthma was caused by "convulsions" or spasms in the lungs.

Paul Ryan, in his 1793 book "Observations on the history and cure of asthma," said:
It appears extremely probable that Hippocrates, in placing asthma... in contradistinction with pleurisy and peripneumony (pneumonia), must have had in view the spasmotic kind... he says that old men are very subject to difficult breathing, cough, and catarrhs and defluxion on the lungs. (9, pages 59-60)
After Hippocrates wrote about the disease as spasmotic in nature, later physicians suspected asthma was a nervous disorder.  It wouldn't be until the early 19th century that it was proved that Hippocrates was right all along, at least about asthma being spasmotic in nature.

Although others speculate that since asthma was associated with epilepsy, and that it was caused by defluxion of humors from the brain, that it was indeed a mental illness, or a nervous disorder.

Bernardino Ramazzini said Hippocrates was probably the first to describe asthma as a hazard of certain occupations.  Although the idea was scrapped until Ramazzini picked it up in the 17th century, and then scrapped again until the middle of the 20th century.

Hippocrates also accurately described asthma as a disease inherited along the family line, and while this was supported by an occasional physician along the historical timeline,  it wasn't proved until hundreds of years after the fall of Greece and Rome.

Despite his possible association of asthma with spasms in the lungs, he did not, as a general rule, associate diseases with specific organs.  This would be the accomplishment of a great physicians born into the 2nd century after the birth of Christ by the name of Galen.

Hippocrates speculated that diseases were caused by certain changes in the winds, changes in temperature, or by the ingestion of certain foods. These caused a disunity within the body of the four qualities and humors, thus causing disease.

For example, some aphorisms describe asthma as occurring commonly in the middle ages, when the body functions start to slow down and cool, and in the fall season, when the temperatures start to cool.

Image of Hippocrates (12, title page)
Hippocrates said:
In autumn many maladies which occur in summer prevail, besides quartan and erratic fevers, affections of the spleen, . dropsy, consumption, strangury, dysentery, sciatica, quinsey, asthma, volvulus, epilepsy, mania, and melancholy. (12, page 59)
He added:
To persons somewhat older, affections of the tonsils, incurvation of the spine at the ver- tebra next the occiput, asthma, calculus, round worms, ascarides, acrochordon, satyriasmus, struma, and other tubercles (phymata)^ but es- pecially the aforesaid. (16, page 134)
Ryan added:
...that the asthma mentioned by him was of the spasmotic kind, and that he considered cold and moisture its principle causes.  At least it must be allowed that this was his opinion with regard to the disorder in children. (10, page 62)
In review, he believed the following was true of asthma:
  • It was related to the epileptic resonse
  • It was hereditary
  • It was convulsive or spasmotic in nature
  • It was caused by an abundance of cold phlegm flowing from brain to lungs
  • It was common in infants
  • It was common in the elderly
  • It was caused by changes in seasons, such as from summer to fall (cooler air)
  • It was caused by some occupations
  • It is common in phlegmatic persons
It is generally believed that Hippocrates redefined the mode of assessing and diagnosing patients.  He made a thorough examination of the patient and his surroundings.  He assessed the patient's breathing both by observation with his eyes and with his ears.

He listened to his patient's breathing, took his respiratory rate, felt for a pulse, felt his skin for fever, observed perspiration and sweating, inspected his urine, inspected his sputum, among other things.

He may even have shook his patient in order so that he could hear if he had increased phlegm in his chest, a procedure called succussion.

He would ask the patient questions:
  • Have you been around anything new lately?
  • Is there a history of this in your family?
  • Is anyone else sick in your family? In your city-state?
  • Has there been a change in winds recently?
  • What is your job?
If the patient was unable to answer these questions, he would ask friends and family members.  The answers to these questions may determine what changes occurred to the humors inside the patients body.  This would then determine the cause and the cure.

If the patient was diagnosed with asthma, the cures were the same as for any basic ailment, and were generally meant to assist nature in the healing process.  Such remedies included:
  • Bathing
  • Breathing purified air
  • Getting plenty of sleep
  • Eating a specific and healthy diet
  • Getting exercise
He also believed asthmatics should avoid whatever was thought to exacerbate it, and this may have been the best remedy of them all.  

If asthma did not improve with the basic remedies, only then would Hippocrates recommend other remedies, such as:
  • Massage
  • Glass of wine or Mandragora as a sedative
  • Draught of white hellabore to induce a good purging to cleanse the system. 
  • Bleeding (rarely)
  • Inhaling herbs
Asthma historian Mark Sanders said that another remedy he might have prescribed was inhaling the fumes of various herbs "boiled with venegar and oil" through a tube.  (7)

He provided medicine with the first viable description of asthma and the first simple remedies.  His remedies were mainly palliative in nature, offering the patient hope as he waits for the asthma episode to dissipate.

Click here for more asthma history.

References
  1. Prioreschi, Plinio, "A history of medicine," vol II: Greek Medicine, chapter five, "Hippocrates," 2nd ed., 1996, NE, Horatius Press, 201-5
  2. Sigerist, Henry E "A History of Medicine," vol I, "Primitive and Archaic Medicine," 1951, New York, Oxford university Press
  3. Withington, Edward E, "Medical history from the earliest times: a popular history of the healing art," 1894, London, Aberdeen University Press
  4. Watson, John, "The Medical Profession in Ancient Times," 1856, New York,
  5. Fourgeaud, V.J, "Historical Sketches:  Galen," Pacific Medical and Surjical Journals, ed. Fourgeaud and J.F. Morse, Vol VII, San Franskisco, J Thompson and Co, 1864, page 22-29
  6. Meryon, Edward, "The History of Medicine," 1861, Chapter II, "The Greek System of Medicine, From the Time of Hippocrates to the Christian Era."
  7. Sanders, Mark, "Inhalation Therapy: An Historical Review," Primary Care Respiratory Journal, 2007, 16 (2), pages 71-81
  8. Cotto, Bob, "Who Discovered Asthma: Hippocrates or Galen?" ezinearticles.com, http://ezinearticles.com/?Who-Discovered-Asthma-Hippocrates-Or-Galen?&id=1381520, accessed 11/1/13
  9. Ryan, Michael, "Observations on the history and cure of the asthma:; in which the propriety of using the cold bath in that disorder is fully considered," 1793, London, Paternoster - Row
  10. Jackson, Mark, "Asthma: The Biography," 2009, London, Oxford University Press
  11. Hippocrates, "On Epilepsy," epitomised from the original Latin text by John Redman Coxe, 1846, "The Writings of Hippocrates and Galen," Philadelphia: Lindsay and Blakiston
  12. Hippocrates, "The aphorisms of Hippocrates," translated by Thomas Coar, 1822, London, Printed by A.J. Valpy, Red Lion Court, Fleet Street
  13. Hippocrates, "Airs, Waters and Places," translated by eminent scholars, 1881, London, Messrs Wyman and Sons 
  14. Hippocrates, "The Sacred Disease," translated by Robert Maynard Hutchins, "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952,; also see Hippocrates, "On the Sacred Disease," translated by Francis Adams
  15. Hippocrates, "Aphorism," section III, #22, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
  16. Hippocrates, "Aphorism," section III, #26, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
  17. Hippocrates, "Aphorism," section VI, #46, translated by Robert Maynard Hutchins, " "Great Books of the Western World: Hippocratic Writings on the Natural Faculties, 1952, 
  18. Eadie, Mervyn J., Peter F. Bladin, A disease once sacred: a history of the medical understanding of epilepsy," 2001, England, John Libby & Company Ltd.
  19. Hippocrates, "On the Sacred Disease," translated by Francis Adams

Friday, June 26, 2015

400 B.C.: Why was Hippocrates dubbed 'the father of medicine?'


A depiction of Hippocrates writing. 
Hippocrates might possibly be the most important figure in the history of medicine, and our history of asthma and respiratory therapy. His Hippocratic Corpus became the most essential medical document of all time. But, did he work alone, and did he deserve such an honor?

In the ancient world only a few people, called scribes, had the ability to write.  To garnish credibility for a document, the person given credit for writing it was usually a king. The reason for this was that most kings were believed to have the ability to communicate with the all-knowing gods. The document, therefore, contained the wisdom of the gods.  

This changed somewhat in ancient Greece, particularly in Athens. The Greeks liked to give credit for any important works. Still, in many cases, the author was some person who would garnish respect for the document. For instance, a document written by a group of unknown physicians at Cos may not garnish the respect as a document written by Hippocrates, the most famous physician in Greece.  

For this reason, and because many of the writings in the Hippocratic documents are suspected of being written by some hand other than that of Hippocrates, it is believed the Corpus Hippocraticum was a collaborative effort between various physicians of ancient Greece.  However, for posterity purposes, Hippocrates is most often given credit for the medical information it contains. Most medical writers after Hippocrates credit the document to Hippocrates.

Who actually wrote the Corpus Hippocraticum may probably never be known, although most modern experts on the subject would attest to the fact that most of the writings do not appear to be written by one person.  In fact, some experts suspect some were written prior to his birth, some during his lifetime, and some after his death.  So, chances are, he did not write the whole thing.

Max Neuburger, in his 1910 history of medicine, said: 
The wide range of opinion is shown by the fact that the number of "authentic writings (of which the commentator Erotianus at the time of Nero's time recognized thirty one and Galen thirteen) has sunk to two or even to nil, whilst modern criticism admits no more than six." (8, page 122)
So now we must ask: if Hippocrates did not write the whole thing, then who helped him out? Considering most of what we know about Hippocrates was written after his lifetime, we have no choice but to refer to speculation from the various experts on the subject.

In the ancient world there were a variety of diseases that plagued mankind, or that made their way through the cities killing hundreds, if not thousands, of people along its path.  Ancient physicians did not have knowledge of germs, so they simply referred to such epidemics as plagues.

Supposedly, sometime during the life of Hippocrates word got out that there was a plague in nearby city-states, and the people were, perhaps, in an all out panic. The leaders of the city-state must have approached the physician to see if he was privy to wisdom that might stop the plague from reaching the city.

Perhaps based on what he learned from his father, or from his teachings at the school of Cos, or by his travels to the school of Alexandria, he believed that strong winds could bring about disease, Hippocrates came up with an ingenious idea.

Of this, medical historian Edward Meryon wrote in 1861: (1, page 25-26)
Thucydides informs us that he kindled fires to neutralize the infection of a pestilence which broke out on two successive occasions in Attica, when the skill of the physicians could do nothing else to mitigate it."  (1, page 25-26)
Medical historian Thomas Bradford wrote in 1898:
He rendered a great service in stopping a plague which broke out in Athens in the time of Pericles, for which he was given a golden crown and the privilege of Athenian citizenship. (2, page 23)
So maybe such an act of heroism made him worthy of such fame.  

Medical historian Plinio Prioreschi said said in 1995 that there were many medical schools when Hippocrates walked the earth, the two most relevant to our history being the school of Cos and the school of Cnidian, which were near each other (about 20 miles apart) and were competing "in knowledge and effectiveness in curing disease." (3, page 28) 

Prioreschi mentions one theory where each school was stuck in it's own paradigm about diseases and its treatment. The Corpus Hippocraticum was the result of a koinon, or an association between the two schools.  It is thus Treaties whereby the two schools compromised on how to treat medical conditions.  (3, page 208-209)

Medical historian John Watson wrote in 1855 of Mercuriali, who suggested:
"Not more than fourteen treaties out of the whole collection were published by Hippocrates himself.  Five others... may have been left by him unfinished to be completed either by his son in law and successor, Polybius, by his sons Thessalus and Draco, by his grandson Hippocrates, or by other members of his family." (4, page 49)
Watson also noted the following:
"A third portion, including about 22 treaties, though perhaps not even begun by Hippocrates, is in strict accordance with his doctrines, and is believed by Mercuriali to have emanated from the immediate descendants of Hippocrates or other disciples of the school of Cos.  The remaining portion of the collection, according to the same authority, consists of spurious writings, and as such as contains opinions not in accordance with the doctrines of Hippocrates, though published as his."
(4, page 49)
Another theory is that as many as seven Hippocrates worked on the documents. We know that his grandfather was named Hippocrates. In additionNeuburger said:
In addition to his two sons Thessalos and Dracos, who also undertook journeys, his son in law Polybos, with Apollonios and Dexipos of Cos, probably also Praxagoras of Cos, ranked as his most famous pupils. It has been shown that Polybos took part in the formation of the Collection and acted as deputy in the school. Amongst the successors, there were five who bore the name of Hippocrates and represented themselves as medical authors. (8, page 125)
Prioreschi said that some parts of the Corpus may even have been written by physicians from the school of Cnidron. He said this may be evident in some of the passages that do not use theory to describe medicine.  He said  physicians of Cnidron tended to be more rational in their approach to medicine, compared to the speculative approach by the Con. (3, page 209-210, 214)

Whether or not parts of the corpus were written by Cnidron physicians may never be known. What is known is that, according to Neuburger:
"...the Hippocratic collection was brought together and edited in the beginning of the third century B.C. by a commission of Alexandrian scholars under order from the book loving Ptolomy. Even at that time doubt existed as to which of the writings could with certainty be ascribed to the great Hippocrates, and hardly one of the books had remained free from alterations and additions." (8, page 121)
So while they had the documents, they had no proof Hippocrates wrote them all. It's possible they attributed it to the great physician named Hippocrates.  However, it is also possible they ascribed the document to Hippocrates because this was a common name among the family of physicians at the School of Cos.

Medical historian Henry E. Sigerist suggested the entire treaties may be credited to Hippocrates because of his hard work, method of teaching, and skillful medical technique. It may have had nothing to do with Hippocrates being the superior physician at all, and mainly because later historians sought to credit someone for such important documents. (2, page 266)

Some historians speculate that Greek medicine had reached a point where a significant figure was needed to lift medicine to the next level, and the man born into, or raised into, this job was Hippocrates II.

It was, thus, his job to free medicine from the "fetters of oriental dogmatism... the leading-strings of the priestly caste... to rational science and moral dignity... (to) transition from the guild of the Asclepiads into the free profession of medicine." (8, pages 128-129)

Sigerist mentions another theory which postulates that Hippocrates was not superior to, but respected equally among his fellow physicians, with Hippocrates being the most senior.  With later Alexandrian physicians viewing these anonymously written medical texts as extremely important, they sought to give someone credit, and Hippocrates seemed the most logical choice.  (5, page 266)

Meryon goes as far to suggest that perhaps Hippocrates himself stole the best ideas of Cnidron. He said:
It has been stated, that having extracted all the information which the records contained in the temple of Cnidros could yield him, he set fire to it, in order that he alone might enjoy a monopoly of knowledge. (1, page 25)
Regarding this, Meryon stated in his notes:
The above calumy is attributed to Andreas, but Tzetstates said that it was the library of Cos, and not that of Cnidos, that was burnt. (1, page 25)
So was Hippocrates so selfish to earn credit for the documents that he was willing to destroy the information used in creating it?  Once again, there is no evidence to support this claim, so it is left to us as just another theory.

Meryon suggests Hippocrates was simply the benefactor of the era he was born into.  He was, after all, the son of a family of physicians who were all taught at the School of Cos.  Meryon said:
Much of the information contained in his writings, and which has been transmitted to us, appears to have been the accumulated knowledge of his immediate ancestors; and it is supposed by competent judges in the matter, that many, if not most, of the numerous treaties which are commonly attributed to him, were simply collected and written by him; for he had the great advantage, which can scarcely be appreciated, since the introduction of printing, of acquiring a thorough knowledge of the observations of his predecessors; and having, moreover, access to all the records and votive tablets in the temple of Cos, he had peculiar facilities to achieve the honour which is universally accorded to him. (1, page 22)
Watson, likewise, credited the era he was born into for his fame. He said:
"He lived in an age of progress, and while other arts and sciences were thus springing into life, and rising at once to maturity, it is not surprising that some man of genius should appear in the ranks of medicine, to give to it's principles from the utterance. This man was Hippocrates." (4, page 47)
So it appears that Hippocrates probably didn't work alone in creating the Hippocratic Corpus.  What will never be known with any certainty is who helped him.  

Another question one might ask is: does Hippocrates deserve credit for the Corpus?  

Considering that the document attributed to Hippocrates became the most significant document in Greek medicine, and that Greek medicine became the key to all medical wisdom, then I think we're fine with giving Hippocrates credit for the whole thing.

Considering how dogmatic people can be when considering new ideas, it must have been many years in the workings to transform medicine from the primitive mindset to the ancient mindset.  The fact that it eventually happened at all can be considered a revolution of sorts.

What matters most is that Hippocrates, or the Hippocratic writers, helped transform medicine away from the primitive world to the ancient world. Or, as Meryon put it, Hippocrates helped transform medicine from a profession of superstition to one of speculation by 'vague hypothesis.'  (6, page 21)

Of this, Watson said: 
"According to Celsus (a physician of the 2nd century), his (Hippocrates) principle credit is removing the teaching of medicine from the schools of philosophy, where it had always received some attention, and treating it as a distinct department of practical knowledge.  Pliny the elder supposes he was the first to institute clinical instruction."  (4, page 46, also see 3 page 42)
Withington said: 
It has been well said that great men illuminate the world by gathering into a focus the rays emanating from itself, and this is well seen in Hippocrates' third great service to medicine -- his rejection of supernatural heroes of disease.  The age was one of transition, and the simple faith in the old mythology was giving way in all direction."  (6, page 50)
Garison said:
Instead of attributing disease to the gods or other fantastic imaginations, like his predecessors, Hippocrates virtually founded that bedside method which was afterword employed with such signal ability by (later physicians).  (7, page 87)
Bradford said:
So great was his influence on medicine that it was no longer called the art of Aesculapius, but the science of Hippocrates." (2, page 23)
Chances are, however, that he did not work alone.  If it were possible to jump into a time machine and travel back to the age of Hippocrates, we'd probably find him, along with many other physicians, writing the passages that would end up in the Corpus.

Regardless, Hippocrates was referred by his contemporaries, including Plato, as "The Great." (6, page 48) He was also referred to as "the Great" when Aristotle walked the earth. The great second century Greco-Roman physician Galen referred to him as "the divine." The rest of history knows him as the father of medicine, and medicine as the "Hippocratic art." (8, page 125)

Max Neurburger, in his 1910 history of medicine, said:
The achievements of Hippocrates' family, of the Coan (Con) school, of many of his predecessors and immediate successors, all these were placed to the credit of the one man, whilst the historic personality was more and more veiled by the nimbus of homage. (8, page 126)
Yet through most accounts of the historians he earned this honor by his hard work and gentle approach. While he may not have written the Corpus, his name made it famous.  Perhaps for that reason alone he is deserving of honor as the father of medicine.

Over time, said Neurburger:
The mysticism of the Asclepiads diminished on the one hand in proportion to the admission of strangers into their fraternity, whereby the preservation of professional secrets were relaxed, on the other through intercourse with physicians (particularly Pythagorean), who had derived a more extended outlook from the schools of philosophy or who by empirical capacity had earned the confidence of the people." (8, page 100)
Neuburger also said that physicians like...
...Pythagoras, Empedocles, and their pupils, who were not without medical knowledge and dexterity, proved that healing was to be found even remote from the Asclepion shrines. Philosophically educated physicians aroused by their speculative and theoretical writings -- and considerable medical literature was in existence long before Hippocrates -- general scientific interest. (8, pages 100-101)
Hippocrates expounded upon this literature, setting up a system of medicine that made medical wisdom available to all who wished to become physicians.

This was all made possible by the physician of Cos, and, more particularly, by the the Hippocratic writers.  Although, through it all, it was made possible by the greatest physicians of all time: Hippocrates.

Legend has it he died in Thesally at the ripe old age of 80 or 85 or 90 or 105, depending on the source of reference.  Perhaps the longevity of his life was due to his mythical legacy; the fact he was essentially deified by later physicians.

References:
  1. Meryon, Edward, "The History of Medicine," Volume I, 1861, London, (6)
  2. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey (7)
  3. Prioreschi, Plinio, "A history of medicine: Primitive and ancient medicine," volume 1, 1995, NE, Horatius Press, (1)
  4. Watson, John, "The Medical Profession from the Earliest Times: an anniversary discourse delivered before the New York Academy of Medicine November 7, 1855," 1856, New York, Baker & Godwin (4)
  5. Sigerist, Henry, "A History of Medicine," volume 2, 1961, Oxford University Press  (2)
  6. Withington, Edward Theodore, "Medical History from the Earliest Times: A Popular History of the Art of Healing," 1894, London, The Scientific Press. (3)
  7. Garrison, Fielding Hudson, "An introduction to the history of medicine, 1922, (9)
  8. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press
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Thursday, June 25, 2015

400: What remedies did Hippocrates prefer?

Hippocrates treating a child. 
Once the diagnosis and prognosis was made, only then was it time for Hippocrates to prescribe the remedy.  
Hippocrates once wrote that he wasn't sure what remedies would provide heat, cold, moist or dry properties, so he preferred to leave this to nature.  This might explain why his most common remedy was to "assist nature" in the healing process with simple remedies such as: (1, page 28)(2, page 90)(3)
  • Fresh air  (1, page 28) 
  • Good diet: to excite natural heat and discharge it (1, page 28) (3)
  • Exercise  (1, page 28)(3)
  • Massage  (1, page 28)(4, page 148)
  • Cleanliness: Such as soaking in hot or cold water at a bath house (1, page 28)(1, page 90)
  • Sweating (by warm bath) (3)
  • Acrid drinks: to excite natural heat and discharge it (3)
  • Appropriate food or drinks: to aide the humors in their discharge (3)
  • Withholding of food, particularly in acute affections (4, page 147)
  • Drinking lots of fluid, especially for wounds (4, page 147)
  • Bodily works (like sawing wood) (4, page 148
  • Reading aloud
  • Singing (4, page 148)
Only when these simple remedies failed did he resort to his stash of medicinal remedies, which mainly consisted of sedatives to relax the body and purging to cleanse the body.  (1, page 28)(2, page 90)  

Examples of Hippocratic remedies include (in parenthesis is the expected response of the remedy):  (1, page 27)(2,page 90)
  • Hemlock (sedative
  • Henbane (sedative)
  • The juice of poppy or opium (sedative)
  • Mandragora from the family of nightshades (eases breathing, sedative) 
  • Hyssop (emetic)
  • Black Hellebore (emetic, universal purge)
  • White Hellebore (universal emetic)
  • Elaterium (laxative)
  • Scammony (laxative)
  • Spurge (laxative)
  • Mercurialis perennis (laxative) 
  • Barley water
  • Wine (2, pages 90-91)(4, page 147)
  • Hydrotherapy (pain) (1, page 27)(2, page 90)
  • A decoction of barley for a variety of ailments (4, page 147)
  • Unstrained broth
  • Honey water
  • Sour honey
  • Broths from millet, meal and wheat (4, page 147)
  • Cooling demulcent drinks (facilitate elimination of the morbid humours) (4, page 148)
  • Purgatives (causes a bowel movement to facilitate elimination of morbid humours (4, page 148)
  • Emetics (causes vomiting to facilitate elimination of morbid humours) (4, page 148)
  • Diruretics (causes urination to assist with incomplete elimination of humours)(4, page 148)
  • Diaphoretics (causes sweating to assist with incomplete elimination of humours)(4, page 148)
  • Blood letting (assisting incomplete elimination, particularly for inflammation) (4, page 148-149)
  • Cupping (rarely) (4, page 148)
  • Cauterization (rarely) (4, page 148)
  • Scarification (rarely) (4, page 148)
The last four on this list are the invasive remedies.  He rarely resorted to these to treat internal diseases. Although, occasionally, they were necessary. For instance, Neuburger said blood letting (venesection) was sometimes necessary, and was...
...carried out mostly on the arm, foot, popliteal space, tongue, etc., and pushed as far as possible, even to the production of faintness, for, "in the treatment of advanced disease extreme remedies, employed with care, are the best."  Similar but far less efficacy was ascribed to cupping or scarification; the use of leeches was not yet known.  Blood-letting and cauterization were intended for the relief of pain as well as for the derivation of the humours.  (4, page 149)
He resorted to surgery only to treat external diseases, such as cuts, fractures, etc.  This, perhaps, was due to the effort of the Cos, and Hippocrates, to show the gentle side of medicine.

Neuburger said that "Hipocratists were far from establishing the principle of which later was enunciated, of 'Contraria contrariis.'  This meant that opposites were treated with opposites.  Hippocrates would sometimes treat opposites with opposites, and sometimes similar with similar.  An example of treating contraries with contraries would be blood letting to decrease blood in a person with inflammation. 

Remedies for some common respiratory ailments: (4, page 155)
  • Pneumonia and Pleurisy:  
    • Remedies that could be given immediately:
      • Warm lotions,
      • Poultices
      • Innunctions with oil
      • Warm baths
      • Diet
      • Infusions
    • Remedies that couldn't be given until the seventh day:
      • Sternutatories to get rid of mucus
      • Expectorants to get rid of mucus (fat and salt articles of food, sour wine)
      • Injection of fluid into the windpipe to provoke cough 
  • Empyema:  
    • Cauterizing the back
    • Thorococentesis (aspirating a needle into chest to draw out pus)
  • Other respiratory ailments, of which the remedies may be same as above:
    • Haemoptysis (coughing up blood)
    • Hydrothorax (fluid in lungs)
    • Erysipelas of lung (cellulitis)
    • Phthisis (tuberculosis, consumption) (4, page 155)
Neurburger also said that "disease only comes to an end through removal of its cause."  So the ultimate goal of remedies was not just to treat the symptoms, but to completely cure the malady that plagued the person.  It is for this reason that Hippocratists were concerned with cures more so than remedies.  (4, page 149)

References:
  1. Meryon, Edward, "The History of Medicine," Volume I, 1861, London,  (6)
  2. Garrison, Fielding Hudson, "An introduction to the history of medicine, 1922, (9)
  3. Hippocrates, "The Art of Medicine," Section I, Treaties III, translated by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia, Lindsay and Blakiston (10)
  4. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press
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Wednesday, June 24, 2015

760-370 B.C.: How did Hippocrates determine diagnosis and prognosis?


Statue of Hippocrates
After a thorough examination of his patient and surroundings, Hippocrates was able to come to a diagnosis and prognosis. It was only from this diagnosis and prognosis that he was able to come up with a remedy that would assist nature in re-establishing a balance of the qualities and humors of the body.

The assessment of the patient was very thorough, and was essential to the later diagnosis, prognosis, and treatment.  Of this, medical historian Max Neuburger said:
Eyes and ears, indeed every means, sensory and intellectual, were employed in order to arrive at the opinion based upon experience as to the general condition of the patient. Without neglecting subjective symptomatology, the objective examination from head to foot was undertaken with the care and thoroughness which constitute so salient a feature of Hippocratism. The painfully minute observation and examination served, however, the additional purpose of explaining, by the combined action upon a particular case of external influences and individual peculiarities, those details in the course of an illness which might diverge from the disease-type. Hence the clinical history, as such, constitutes one of the most noteworthy characteristics of Hippocratic, in contrast with the rigid scheme of oriental medicine; the clinical history takes individuality into account. (4, page 144
Hippocrates wrote that there were two classes of disease: (1)
  1. External
  2. Internal (1)
External diseases would have been easy to see, as these were on the external surface of the body, such as inflammation (redness and swelling) of the skin.  By the time of Hippocrates the medical profession had been well acquainted with these types of diseases and how to treat them.

Neuburger said:
External localized affections were most minutely examined by sight and touch from the point of view of position, size, shape, consistence, painfulness, temperature (taken by laying a hand on the chest), colour, etc.  (4, page 144-145)
Internal diseases, on the other hand, were a bit more complicated, as the scars inside the body were less readily seen.  Although, Hippocrates did describe that some internal diseases provided scars that:
...are apparent both to sight and to the touch, by tumours, redness, &c.; and evince themselves by hardness, coldness, moisture, heat, &c.,—and thus enable us to recognise the presence or absence of such or such qualities as may or may not belong to them. There ought to be no mistake as to these,—not that they are easy to be comprehended, but because they are readily discovered, at least by those who are qualified to seek for them, by industry and natural attainments. Our art abounds in resources for visible diseases,—nor are they less abundant for those of a hidden character, or which attack the cavities or bones. (1)
Neuburger said:
internal (invisible) maladies (were examined) by a number of methods both sensory and intellectual... The following had to be noticed: -- age, temperament, mental state (memory, delirium, picking at the bed clothes), facial expression, tongue, voice, attitude in standing or in bed, condition as to nourishment or strength, power of movement, sensibility to pain, behavior during sleep, sensation of hunger or thirst, temperature, abnormal pulsation (was it abnormally strong or weak?), breathing, exhalations, condition of the skin, hair and nails, state of the sense organs, particularly of the eyes, possible abnormalities of the hypochondrium (enlargement of liver or spleen), abdominal swellings, possible tumours, abscesses, amount, color, consistence, smell, taste of blood and excretions, exceptional symptoms, such as gnashing the teeth, yawning, hiccough, sneezing, epistaxis, flatulence, itching, shivering, twitching, etc. (4, page 144-145)
There were certainly internal diseases that did not readily show their scars, such as hypochondria, hysteria, epilepsy and asthma.  Even upon the rare inspection, no scars were found on asthmatic lungs.  For this reason, Hippocrates created theories to help him understand these diseases.

After his thorough assessment he would make a diagnosis based on his education and experience.

Of diagnosing, Hippocrates wrote:
The possibility of this depends very much, nevertheless, on the accuracy of the report by the patient of his complaint, and the tact of the physician in his interrogatories. Sometimes this seems to be attained as by intuition, although more time and labour are required than in the case of external diseases. (1)
This was the basis of Hippocratic medicine. Asthma was more likely described by vague symptoms, such as shortness of breath.  Catarrh was another vague symptoms, which designated inflammation, or an accumulation of phlegm (fluid) from the brain.  Pleurisy was pain caused by inflammation of the pleura due to a swollen lung rubbing up against it.  Catarrh might have been your common cold, which may occur as inflammation of the nose or lungs. Hydropsy would have been fluid in the lungs. (5, pages 154-155)

A more specific diagnosis of lung diseases might be empyema (pus in lungs or pleura), pleuritis (inflammation on one side of lung), peripneumonia (inflammation on both sides of lung), phthsis (tuberculosis, consumption) or tumours. (5, pages 154-155)

All of these symptoms or diseases would be caused by an accumulation of phlegm from the brain to the lungs. Tumors, however, were caused by by an accumulation of blood or salt phlegm. (5, page 155)

Meryon said that upon assessing his patient, by observing his symptoms and his surroundings, he came to a prognosis, and this determined the cause and then the cure. Thus, determining the prognosis was the key to Hippocratic medicine.

Of this, Neuburger said:
The method of arriving at a prognosis is an inductive one, taking its starting-point from the clinical history, the importance of which is to be estimated by former individual experience and external evidence, taking into consideration the age, sex, habits of life and residence of the patient, the climate and epidemic conditions. (4, page 143)
Hippocrates said that each disease had "different symptoms... through which the physician becomes enabled to estimate the treatment he ought to pursue." (1)

For instance, if the physician observed a recent change in weather from hot to cold, and the patient presented with sneezes, inflamed nasal passages, runny nose, and maybe shortness of breath, he may be diagnosed with catarrh, or a cold in the head, or asthma.  Regardless, it was caused because the patient was exposed "to the kind of humour (phlegm) coming from the brain."   (2)

Palsy and epilepsy were also caused by too much phlegm, only in this case it was contained in the head.  The cause was the same as for catarrh, a cold, and asthma, and therefore the cure for all these ailments was the same.  (2)

Since he believed nature worked to maintain, or re-establish, a balance of the qualities and humors within a patient, his cure was therefore meant to assist nature. His most common remedies were the same for all diseases, and included a bath, sleep, diet, and exercise. Yet as the disease became stubborn to these simple remedies he resorted to more complex remedies such as purging or bleeding.

So he assessed the constitution of the patient, he assessed the surroundings of the patient, which included an assessment of the weather, of the city he lived in, and of the diseases that were prevalent for that city.  All of these would have bearing on his diagnosis. (2)

Once the diagnosis was made, the cause was known, and the cure was likewise known.

Hippocrates said:
It is then by no means surprising, that the physician should be slow in forming his judgment of diseases, before he undertakes their cure; since he has, as it were, to negotiate with them, by the agency of an interpreter. It appears, then, from all I have said, that medicine has an appropriate means of discovering the mode of cure, or at least of assuaging the sufferings of disease. (1)
Garrison said prognosis was based on one of the four categories of diseases that were created by Hippocrates: (3, page 90)
  • Acute (it's happening now)
  • Chronic (it's always present)
  • Endemic (found among certain people)
  • Epidemic (rapidly spreading) (3, page 90)
These, too, would have a bearing on the cure prescribed.

References:
  1. Hippocrates, "The Art of Medicine," Section I, Treaties III, translated by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia, Lindsay and Blakiston (10)
  2. Hippocrates, On Airs, Waters, and Localities, Section III, translated by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia, Lindsay and Blakiston (11)
  3. Garrison, Fielding Hudson, "An introduction to the history of medicine, 1922, (9)
  4. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press
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Tuesday, June 23, 2015

400 B.C.: How did Hippocrates assess his patients


Hippocrates examining a child, a painting by Robert Thom, 1950's.
Hippocrates became the most famous physicians of ancient Greece during the Age of Pericles by his skill and gentle approach as a physician. His approach to medicine was highly regarded not just by his patients, but by his peers. By his example, and through his writings, he would almost single handily improve the image of medicine.

In order to help future physicians develop the skills and technique needed to become a respected physician, and to create a good image of the profession, he compiled all the medical wisdom from the school of Cos into a series of 60 medical treaties called The Hippocratic Corpus.  

Most historians now believe that he did not write all of the Corpus by himself, although most would agree that he was, for whatever reason, the most significant and respected physician of his era, and for this reason his name is attributed to the treaties.  It would go on to become the cornerstone of Greek medicine, and all of medicine for the next 2,000 plus years.  

In this way, Hippocrates became the most famous physicians of his era and all time.  Not only was he referred to as "The Great Physician" during his time by the philosopher Plato, but he is referred to by most historians as "The Father of Medicine." 

By resorting to simple or natural remedies first, Hippocrates, like other physicians at the school of Cos, preferred the medical philosophy of looking out for the best interest of the patient, and to avoid risky treatment.  Such may be evident by the motto "first do no harm."

When Hippocrates was called to help a patient, he would pack his bags and travel to the patient's home.  As he was taught by his predecessors at the school of Cos, he would consider the patient as a whole.  As noted by 18th century physicians Bernardino Ramazzini, Hippocrates encouraged the following: 
'When you come to a patient's house, you should ask him what sort of pain he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats.' (1, page 15)
Of the assessment of the patient, Garrison said:
Hippocrates instituted, for the first time, a careful, systemic, and thorough-going examination of the patient's condition, including the facial appearance, pulse, temperature, respiration, excreta, sputum, localized pains, and movements of the body. (2, page 89-90) 
Medical historian Max Neuburger said the following were also assessed:
Odour of the sweat, of the sputum, of the vomit, the urine, the faeces, of the discharge from wounds; the taste of skin secretions, of wax from the ear, of nasal mucus, of the tears and sputum (sweet or the contrary) and of diverse other body fluids had to be investigated, partly by the physician, partly by the patient himself.  (5, page 145)
The color, consistency, and smell of phlegm was also assessed.  The assessment was useful in helping the physician come up with a diagnosis and prognosis, which would help determine if the patient was curable.  If the patient was curable, the prognosis was used to determine the eventual remedy or cure. 

For instance, as noted by Neuburger:
Yellow sputum, mixed with a little blood, occurring at the beginning of the illness in a patient suffering from inflammation of the lungs is a sign that he will recover, and is beneficial, occurring for the first time about the seventh day it is a somewhat surer sign.  (5, page 145)
Hippocrates himself wrote the following of his assessment:
Thus, it considers the voice, as to its clearness or hoarseness. It examines the discharges from certain regular channels; and drawing consequences from their odour, colour, consistence or fluidity,—he judges of the character of the disorders, and the existing state of the patient; and by the same means, medicine is even enabled, not only to ascertain the past, but likewise his future state. After having thus become acquainted with diseases, by their symptoms, if nature is unable to effect a cure, art then teaches how to excite those salutary movements, by which, without danger, the system may discharge itself of what is injurious to it. (3)
Regarding the movements of the body, Hippocrates was known to listen to a patient's heart and lung sounds by placing his ear upon his patient's chest, although if he wanted a more thorough examination of the humours inside the patient's chest, he would shake the patient, gently perhaps. This allowed him to hear secretions, if they were present, in the patient's chest.  (2, page 90)(5, page 146)

The procedure was called succussion, and was mainly used to recognize the presence of pus in the lungs to diagnose the presence of an empyema (pus in the pleural cavity, or the cavity surrounding the lungs. In fact, if a physician performed the procedure and failed to diagnose empyema when it was present, this was considered a "sign of lack of surgical dexterity," said Neuburger. (5, page 157)

According to Neuburger:
This shaking was supposed to effect the outflow of pus from the parenchyma of the lung by way of the bronchi... Recognition during this process of the splashing sound which occasionally occurred (in pyo- and hydropneumothorax, but also in bronchiectasis and cavities) resulted in the employment of succussion (known now as Hippocratic succussion) as a diagnostic method in order to determine whether and where pus were situated in the pleural cavity, also the most suitable spot for incision in thoracocentesis (a procedure involveing placing a needle into the chest and drawing up the excessive pus in the pleural space, or the cavity surrounding the lungs). (5, page 146)
Neuburger said succussion, "If it, and the pouring of fluid into the throat to excite coughing and expulsion of the pus, fail, then the operation of thoracocentesis is called for." (5, page 146)

Sounds other that the rare secretions heard upon succussion were also listened for by auscultation.  Some conditions caused a rattling sound in the trachea.  Diseases such as pneumothorax might cause crepitations, which is air bubbles under the surface of the skin, particularly on the upper chest area.  Pleuritic frictions, or what is now called a pleural rub, was also listened for.  This might indicate a collapsed lung (pneumothorax) or other such malady.

Certain noises in the chest may indicate hydrops of the lungs, or what would now be considered pulmonary edema caused by heart failure, kidney failure, or sometimes pneumonia.  Hydrops is an old term for water in the lungs.  Of this, Neuburger wrote:
Of the diagnosis of "Hydrops of the lung" it is stated: "When the ear is held to the side and one listens for some time, it may be heard to seethe inside like vinegar."  A pleuritic friction is well described... "A grinding may be heard which sounds as if it came from two leather straps." (5, page 147)
The Hippocratic concept also took into consideration the desires of the patient. As noted by Withington:
The wishes, and even the whims of the patient are to be indulged as far as possible, and a physician should rather lose his fee than trouble a sick person about it, for the memory of a good deed is better than a temporary advantage. He should also neglect no opportunity of serving the poor and the stranger, for "where the love of the art is, there is the love of man. "  This last quotation, indeed, is from a work of very doubtful authorship, but it expresses the spirit, if not the words of Hippocrates. (4, page 51)
Hippocrates paid attention to the prognosis more so than the diagnosis. Neuburger said this was so "that the preservation of the organism be his goal." (5, page 147)

He said Hippocrates was well aware of the "limitations and of the potentialities of his art."

And he made sure he "occupied himself only with those diseases in which a cure might be anticipated and approached the sick-bed inspired by the principle: 'Do good, or at least do no harm.'" (5, page 147)

He spared no effort to ease the mind of the suffering, even when he knew there was no chance that his remedies would cure the patient's disease.

References:
  1. Ramazzini, Bernardino, writer, "Disease of Workers," Wilmer Cave Wright, translator, 1964, New York, Hafner,  (8)
  2. Garrison, Fielding Hudson, "An introduction to the history of medicine, 1922, (9)
  3. Hippocrates, "The Art of Medicine," Section I, Treaties III, translated by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia, Lindsay and Blakiston (10)
  4. Withington, Edward Theodore, "Medical History from the Earliest Times: A Popular History of the Art of Healing," 1894, London, The Scientific Press.  (3)
  5. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume 1, London, Oxford University Press
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