Saturday, November 30, 2013

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 his 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 as a vague symptoms: 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.

  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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