Friday, November 29, 2013

760-370 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 Physicians" 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. 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 teh 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 that succussion was also used to diagnose empyema (pus in the pleural space).  He said, "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 pleural 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 deethe inside like vinegar."  A pleuritic friction is well described... "A grinding may be heard which sounds as if it came from two leather straps."
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)
He paid attention to the prognosis more so than the diagnosis.  According to Neuburger, was "that the preservatoin of the organism be his goal."  He 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.

  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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