Saturday, February 28, 2015

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 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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Rare Disease Day: Severe Asthma

Today is rare disease day.  Does Severe Asthma qualify as a rare disease.  This is a relatively new sub-group of asthma, and some champion for it to be a disease entity of it's own, with it's own treatment guidelines.

Asthma affects about 10 percent of the world's population, and severe asthma affects about 10 percent of asthmatics.  So that should make it pretty rare.

Typical asthma presents with chronically inflamed airways that are oversensitive to environmental triggers. Asthma attacks are completely reversible with time or treatment.  It responds well to corticosteroid therapy, and therefore asthma attacks can be prevented and controlled. Between attacks breathing is normal.

Severe asthma, on the other hand, presents with airway remodelling, mainly the thickening of the smooth muscles lining airways.  This makes the walls of airways abnormally thick, creating chronically narrowed airways.  It responds poorly to corticosteroid therapy, and therefore asthma attacks are more frequent and severe.  Between attacks there is always some degree of dyspnea.

While steroids don't seem to work for sufferers of severe asthma, some evidence seems to point to Gallopamil as a future treatment option.  This is a calcium channel blocker generally used to treat cardiac arrhythmias. Studies show that it may may lesson the mass of airway smooth muscles, making their airway walls less thick. This makes it so the airways are not so obstructed, thus making breathing easier.

Further reading:









Friday, February 27, 2015

400 B.C.: The Hippocratic Oath

Wall plaque of Hippocratic Oath
What good is a physician who cannot be trusted.  If you were wounded in battle and had access to a physician, then you could get a soothing salve to allay your pain and speed your recovery.  Yet amid rumors your doctor took a bribe to poison a friend of yours, you wonder if you should avoid your doctor at all costs.

It was such poor ethics among the medical community around 400 B.C. that enticed the writers of the Corpus Hippocraticum to write an oath.  The goal was to improve ethics among physicians, and increase respect for the profession among the peoples.  The original oath was as follows:
I swear by Apollo the Physician and Asclepius and Hygieia and Panaceia and all the gods, and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken the oath according to medical law, but to no one else.

I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep myself holding such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
Like many ancient oaths it begins with an acknowledgement of the gods. Considering Apollo, Asclepius, Hygieia and Panaceia were the gods of health and healing, it's only fitting they were the gods noted.  Every person seeking good health would worship and make sacrifices to one of these gods.

This oath appears in the Corpus Hippocraticum, and is generally attributed to Hippocrates or one of his students.  Although, some historians place it's origin after the death of Hippocrates, and it's these historians who think it was written by some other physician and later added to the Corpus. Although the true origin may never be known.

Dr. Ron Paul, in his 2011 book "Liberty Defined," said the oath became so famous that one version of it or another was cited by all medical students until the 1960s. He said this was when the issue of physicians performing abortions was raised.   Rather than face the issue, medical schools stopped requiring graduating students from citing the pledge.

Today, however, a modified version is optional.
I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not", nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, be respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
The integrity of the medical profession has grown exponentially since the time of the Hippocratic writings, in part due to the ethical standards set forth by this oath. Some of the most respected people in any community are your doctors.

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Wednesday, February 25, 2015

Believers tend to be better patients

He was dying and he knew it.  Yet still he continued to read his history book.  I entered his room, and he smiled at me.  He told me stories of his past.  He enlightened me about what he was reading about.  He was a very smart man.  He was a good man.

I got to know him quite well over the course of a few days.  Then one day I sat down in a chair, and he said, "You know that I'm dying and it doesn't bother me. You want to know why?"

I nodded and watched as he picked up his Bible.  "This is the reason I don't worry about death.  I know that death is not the end but the beginning."  He smiled.

I truly believe that people who believe in God die better than those who don't believe.  Believers are happy all the way to the end because they know death is not the end.  They know that what they learn in this life can be used in the next, and so they continue to produce and to show joy.

I used to wonder why it was that someone who knew he was going to die would be reading a book.  What's the point? But the more I learn, the more I realize that most folks who know, and are reading, have a Bible on their side table.

I'm not saying that all people who know they are dying and don't believe are bad patients, nor that all believers are pleasant.  Yet I am saying that, based on my own observations, that believers tend to be more pleasant.

Monday, February 23, 2015

7 Incentives for Living Healthy with Asthma

The following post was originally published at healthcentral.com/asthma on January 22, 2014.

7 Incentives for Asthmatics to Maintain a Healthy Body

As each new year comes around, many among us make a New Year's resolution, the most common of which is to eat a healthy diet, exercise, and get in shape. This is a resolution that is especially important for asthmatics, one that should not be broken as the year progresses. What follows are seven incentives for asthmatics to maintain a healthy body.

1. Exercise increases stamina: Perhaps there really is no study necessary to prove that the more you work out the stronger your heart and lungs will become, and the more tolerant they will be to exertion. However, many studies have confirmed this nonetheless. The simple fact is that asthmatics tend to have an increased risk for getting short of breath with exertion and, therefore, this is an added incentive for asthmatics to stay physically active.

2. Obesity linked to worsening asthma: Various studies have confirmed a link between obesity and worsening asthma. The main reason for this is because fat cells seem to increase the release of inflammatory markers that may cause inflammation, or make chronic inflammation in asthmatic lungs worse. Obviously you should accept who you are as a person regardless of your weight, but if you have asthma you have an additional incentive here to lower your calorie intake and shed some pounds.

3. Exercise may reduce anxiety: Many studies have linked asthma and anxiety. Many others have confirmed that exercise reduces anxiety. Put these two together and you have yourself yet another incentive to keep your body physically active.

4. Exercise improves immune system: With a stronger immune system your body will be better capable of fighting off the germs that are spread from person to person. Plus, when your body becomes infected with a respiratory virus (the no. 1 asthma trigger), your body will be better capable of fighting it off. So this is yet another incentive for you hop on the treadmill or exercise bike.

5. High-fat foods trigger and cause asthma: Studies have confirmed the link between Burger King, McDonalds and KFC with worsening asthma control. This means that the more high-fat foods you put into your body the greater your risk of worsening asthma control. One theory suggests that your asthmatic immune system might recognize saturated fat as an enemy and promptly acts to rid it from your system. So this is yet another incentive to avoid those high-fat foods you know you should avoid anyway.

6. Healthy foods boost immune system: Studies have found that asthmatics who eat foods with higher levels of folic acid had better asthma control. The reason for this may be because folic acids somehow lower IgE antibodies, or antibodies responsible for the asthma allergy response in the lungs. Folic acid is found in many foods, such as beans, peas, nuts, whole grain breads, potatoes, spinach, cabbage, broccoli, bananas and berries. So this is a nice incentive for eating these healthier food options.

7. Most doctors recommend a healthy diet and exercise: Most asthma doctors recommend you take time off if your asthma is acting up. At the same time, most doctors also recommend that all asthmatics exercise no matter how severe their asthma is. If you can run on the treadmill, great. But if all you can do is a walk through the park, that’s great too. The important thing is that you do something. The same is true for eating healthy foods. Doctors see the evidence every day by their training and practice. So if they say you should eat healthy and exercise, that should be a good incentive right there.

Getting yourself in shape, eating healthy foods, and exercising can all help you obtain better asthma control. No one is saying you have to be perfect, but we recommend you choose a healthy diet and workout program that works best for you and get started today. You now have seven incentives to do just that.

For tips on how to exercise with asthma check out my post “14 Tips for Exercising with Asthma.”

Sunday, February 22, 2015

400 B.C.: Hippocrates and the four humors

Humors are the fluids of the body, and Hippocrates, around 400 B.C., believed there were four humors: blood, phlegm (pituita), black bile and yellow bile. When these were in balance throughout the boy good health resulted.  Therefore, an imbalance resulted in disease.

The entire theme of Hippocratic medicine is based on creating a balance, or homeostasis (balance), of these four humors, or re-establishing a balance that has been broken.

The basic idea of the four humors is explained by Hippocrates in his book "On Disease: Book IV." He said that the humors are formed by the food or drink taken in.  There are five places in the body where humors are made: stomach, head, heart, spleen and galbladd.  Each of these organs "attracts is congenerous humour to itself." (1, page 269, 270, 271)

Phlegm comes from pituitous food and drinks, and is attracted to the head. When phlegm is in abundance it causes headache. (1, page 269)

In his book "On the Different Parts of Man," he explains that when too much phlegm is produced or attracted to the brain, so much so that the brain cannot contain it, the fluid flows down one of seven pathways to cause disease.  It could flow to the nose and cause catarrh and coryza.  It could flow to the lungs and cause pulmonary disease. It could flow to the spine and cause spinal tuberculosis, or Pott's disease.  (1, page 228-235)

Other pathways are the eyes and ears, where the various diseases of these organs are formed, including deafness an blindness. It could also flow to the muscles where it causes dropsy, the joins where it causes gout, sciatica and edema. (1, page 227)

He explains that yellow bile is produced by bilious food and drinks, and is attracted to the gallbladder. When "retarded" it results in pain. (1, page 269)

Black bile is also produced by bilious food and drinks, and is attracted to the spleen.  When in excess diseases such as melancholia and hypochondria may result. (1, page 269)

Blood is attracted to the heart, and its excess results in many diseases, such as dropsy, hydropsy, and fever.  (1, page 269)

A common way to resolve problems of excessive blood is to perform an operation with a blade called venesection or bleeding. However, Hippocrates rarely recommended the procedure.

Regardless of the what humor is in excess, a common way to re-establish homeostasis is by evacuating fluids from the body, such as in purging.  This allowed for any impurities to exit the system in order to cleanse the body.  There are essentially four pathways for this to occur: mouth, nose, rectum and urethra. (1, page 269, 271)

The way to produce purging, therefore, is to cause vomiting, expectoration, bowel movement, and urination.  Another method of evacuation was to cause diaphoresis, or sweating.

The best way to cause purging in cases where a disease is caused by excessive phlegm was to cause vomiting.  (1, page 282)

Causes of too much or too little of any of the humors was sometimes the result of the organ attracting too much to it, although most often it is the result of the food or drink consumed. Diseases may also arise from the air, atmosphere and season. They also arise from excessive temperatures:  too hot or too cold.   (1, page 226)(1, page 270, 271)

Hippocrates believed he best way to maintain homeostasis of the humors was to pay close attention to diet. He also recommended exercise and bathing.  He also recommended these in ill health, and only when these simple methods didn't work did he recommend other remedies, such as purging and bleeding.

References:
  1. Coxe, John Redman, 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 Blakisto
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Saturday, February 21, 2015

760-370 B.C.: Hippocrates redefines medicine


What did Hippocrates really look like. Some historians speculate
most busts of him were made after his lifetime. Prioreschi said:
"It is highly probable that physicians of the Periclean Age wore
their hair and beards as much like the figures of Jove or
Aesculapius as possible, and were otherwise not lacking in the
self sufficiency which characterized the Greeks of the period.
We may therefore infer that the supposed portraits of Hippocrates
are only variants of the busts of Aesculapius. (1, page 92)

There are only a few people in our history whose contributions were so significant they end up being deified. One such man was the great physician Hippocrates.

While he may not have done all the work himself, his name is on one of the first and most significant medical treaties of all time: the Hippocratic Corpus. It would mold the image of Hippocrates, establishing him as the greatest physician of his time and of all time.

The Hipporcratic Corpus, often simply referred to as the Corpus, is a compilation of over 60 medical treaties which are essentially compilations of all the knowledge learned by Hippocrates from his "immediate ancestors," said medical historian Edward Meryon in his 1861 book "A history of medicine." (6, page 22)

The name Hippocrates is a reflection of all the great physicians that formed Greek medicine.  The Corpus is a reflection on the era he was born into.

Pericles (495-429) was in charge of the Athenian
Military during the Pelopannesian War, and
became a leading statesman and orator for Athens. 
Hippocrates was born on the island of Cos, near modern day Turkey, around 460 B.C., during the peek of Athenian democracy, an age when Pericles (495-429) walked the earth as a famous Greek general, statesman, and orator.   (1, page 21-22) (2, page 86)

It was an era of ancient Greece where the citizens of Rome had little work to do, and therefore had plenty of time to read, learn, and think.  This was made possible because most citizens had many slaves who did all the work for them.  This, it is said, gave rise to the Age of Philosophers in ancient Greece.

Of this time in our history, medical historian Fielding Hudson Garrison, in his 1922 book "An introduction to the history of medicine," said:
Never before, or since, had so many men of genius appeared in the same narrow limits of space and time. (2, page 86)
Medical historian Edward Meryon, in his 1861 history of medicine, said:
He lived at the most remarkable epoch of intellectual development, having as contemporaries the philosophers Socrates, Plato, and Xenophon; the statesman Pericles; the historians Herodotus and Thucydides; the poets Pindar, AEschylus, Euripides, Sophocles, and Aristophanes; and last, though not least, the sculptor Phidias. (1 page 22) (also see 8, page 126)
Garrison said Hippocrates was born into an era where the primary role of the physician was "either an associate of priests in times of peace, or a surgeon in times of war."  (9, page 87)

He was also born into an era where medicine was a blend of superstition and mythology, and was esoteric wisdom known only to the priest/ physicians at the Asclepions.  Those who were sick would spend time among the priest/physicians there, and the remedy would be revealed, and often involved magical elements such as incantations and amulets.  Yet these Asclepioins were not hospitals per se, merely places where the sick could learn the healing wisdom from the god Asclepius.

Those who were sick might also summon for a physician, men who, like the priest/physicians, were trained at the Asclepions. Yet these physicians were free from the bonds of the Asclepions, and were able to reach out to the general population, most often visiting their patients at their homes.

Medical historian Max Neuburger said:
From Homer's time (about 800 B.C.) and onward poets and historians make mention of lay physicians who freely exercised their profession untrammeled by temple medicine. In very early times the custom arose for communities to appoint official physicians whose duty it was, for a fixed salary, to to attend the poor gratis, to make the necessary sanitary arrangements in the presence of epidemics, and as experts to give evidence in court: it is equally certain that a medical corp accompanied armies and fleets... and that Greek physicians accepted posts as court and personal medical advisers to foreign princes. (8, page 97)
Natural medicine made it's way into the priesthood at the temple of Cos at an early date, and such medicine was learned by physicians who would then take their medicine outside the temple.  So this provided more options for the sick.  For those who were perplexed by the puerile medicine at the temples, they could summon a physician who practiced natural medicine.

Neuburger said that over time, particularly at Cnidos and Cos, there was a complete separation at the Asclepiades of all temple magic. So the priests and their magic ultimately gave way to physicians and their natural remedies. In the meantime there was a mixture of both types of medicine. (8, page 99)

Once summoned, the physician would then pack his bag of medical supplies and travel to the sick person's home.  Of these medical bags, Neuburger said:
On medical journeys a portable case was taken with indispensable instruments, bandages, ointments, plasters, emetics and purgatives. Such cases have been discovered (8, page 98)
Neuburger said there were also medical homes with sick rooms where the sick could see a physician for temporary treatment, although these homes were mostly reserved for people who required surgical intervention, such as for fractures and open wounds.  (8, pages 97-98)

Since there were no medical treaties at the time, there were no regulations and no standards as to how a physician was instructed. For this reason medical studies varied from one school to the next.

The result was often physicians who were ignorant of their trade, rough with their patients, and painful by their remedies. Many Greeks eventually recovered from their ailments without the guidance of a physician, and therefore it was often suspected that when a physician cured he was merely lucky.

As Hippocrates would later describe, this situation was exacerbated...
...under the pretext that physicians never undertake the care of those, who are already overpowered by disease. They say, that he cheerfully attends on such as would recover without him—but not a step will he take in behalf of those who are most in need of his assistance. If there was an art of medicine, they moreover say, it ought to cure these as well as the former. (3)
So it was no wonder that the sick would prefer to travel long distances to an Asclepion, or stay at home, tucked in their cozy beds, waiting their fate, as opposed to risking a call for any random physician.

Meryon said that most of what is known of the school of Cos, and later about Hippocrates himself, comes from biographies written after the death of Hippocrates.  From these we learn he was the "scion" of a family of physicians at the school of Cos "which had followed the pursuit of medicine at least 300 years." (1, page 21-22)

These physicians were well aware of the poor image of physicians.  They believed this poor image was due to the practice of physicians who graduated from the school of Cnidron.  This school was about 20 miles from Cos, and these physicians didn't care about the poor image, and did little if nothing to improve it.

Medical historian Edward Withington, in his 1894 book "Medical history from its earliest times," said physicians at the school of Cnidron were aggressive with their treatment. He said this is exemplified by the their motto: (4 ,page 52)
"Accurate diagnosis and vigorous treatment."  (4 ,page 52)
Medical historian Max Neuburger said Cnidian physicians focused on diagnosis, and then finding cures for these. He said: (8, page 114)
Their therapeutic methods, in accordance with their ideas upon localisation, appear to have been mostly topical, more radical than expectant and individualising. With knife and cautery to hand they were nothing loth to perform excision of a rib in empyema or nephrotomy in renal abcess and did not hesitate to order excessive purgation, dietetic cures or exhaustive walking exercise. (8, page 115)
Some of their therapeutic methods included: (8, page 115)
  • Injection of fluids in the air passages to produce coughing
  • Inhalations to promote the expulsion of mucus or pus from the lungs
  • Application of leather bags for the purpose of fomentation, swinging movements, etc. (8, page 115)
He wrote about a case described by Caelius Aurelianu in which a prominent physician named Euryphon at the school of Cnidus (a contemporary of Hippocrates) "tries to show that pleurisy is an affection of the substance of the lung."  (4 ,page 52)

Withington said Aurenlianu described the patient as being "thin as a skeleton, his legs like reeds, his chest still full of pus, and his ribs covered with scars from the cautery irons of Euryphon." (4, page 52) 


Neuburger said the writings of Euryphon, all of which have been lost, are believed to have influenced some Hippocratic writings. (8, page 115)

Physicians of Cnidron were also known to take bribes and use poisons to kill the enemies of their patients. To the physicians at Cos, this must have been the culmination of what was wrong with the profession, and what their potential patients must have feared the most.  So their aim was to change this image.  

The physicians at Cos frowned upon the act of using medicine to kill.  They frowned upon the act of being rough with their patients, and using aggressive treatment that was painful, and sometimes killed.  They were very concerned about the image of the profession and they aimed to improve upon it.  They aimed to create a kinder, gentler approach to medicine. This approach is later exemplified by the Hippocratic Treaties "On the Art of Medicine." (3)  

Hippocrates described a family of physicians who impressed upon their students that good bedside manner was essential.  They encouraged the use of gentle hands and gentle remedies. They were encouraged to assess their patient and their surroundings, and to "compare his disease with such as he had previously seen, either the same, or approaching thereto, and which he has cured by the admission of the patient himself." (3)

Like the Cnidian physicians, Con physicians performed accurate assessments, and even accurately described diseases and their treatments.  But the Con were more interested in prognosis than diagnosis, with their cures being based on this prognosis. (8, page 117)

Born into the Con family of physicians was Hippocrates II, a man history knows as the great Hippocrates.

Hippocrates II was the son of Heraclides, and the grandson of Hippocrates. Some historians said he was a direct descendant of Asclepius, and perhaps it was for this reason that Galen (2nd century A.D.) would later say of Hippocrates that "his writings should be reverenced as the voice of a deity." (6, page 21)(also see 5, page 23)(also see 6, page 203-204)

John Watson, in his 1856 book "Medical history from the earliest times," said it was from his father that Hippocrates learned much of his skill, technique and work ethic.  As a child he also had access to the "ablest masters in science and philosophy," and all the best physicians in the world. (5, page 46)(6, page 204)

Watson said that after the death of his father, he traveled to many countries before pursuing his profession in Macedonia, Thrase and other parts of Greece before settling in Thesally where he spent the later portion of his career.  He probably also taught at the School of Cos. In fact, some accounts have him starting the school.  (7, page 46)(8, page 86)

Neuburger said religion prohibited the examination of the internal organs of the human body for the purpose of science.  The only time a person's insides could be examined would be by the wounds obtained during fights in the gymnasium or on the battle field, or during the rare surgery that was performed.  For this reason, Hippocrates must have spent some time in the gymnasia, either as a student or as an observer.  (8, page 150, 156)

Physicians also spent time examining the naked bodies of the men, and so they would have learned, by observation and palpation, what was normal and what was abnormal.  By palpating abdomen's they would have learned what what normal and abnormal abdominal organs, such as the liver and spleen, felt like.  (8, pages 146, 150)

The only other means a physicaians might have learned anatomical knowledge was by dissecting animals, or spending time in slaughter houses or watching sacrifices. (8, page 150)

So, that in mind, it was unlikely Hippocrates observed an autopsy, although highly likely, perhaps with the guidance of his father, that he spent time at slaughtering houses, or observing sacrifices, or observing surgical cases, in order to obtain anatomical knowledge.  It's also highly probable that he spent time in the gymnasium at Cos to observe his father at work, but also to learn about the human body.

Neuburger said:
With regard to the respiratory tract, the Hippocratists knew the trachea, epiglottis and bronchi, and described the lungs as having five lobes... The circulatory system is described in the various writings in a most confused manner.  The starting-point was at first supposed to be the head, later the aorta and vena cave, which were thought to spring from the spleen and liver; according to the book De morbo sacro, all arteries enter the heart.  
He would have learned that the trachea, bronchi, and arteries were hollow and contained air.  He would have learned various bones, joints, bone marrow, and sutures of the skull.  Knowledge of the viscera (heart, liver, stomach, esophagus, intestines, liver, bladder, spleen, and kidney) was "scanty," said Neurburger, although he would have learned what was known about them. (8, page 151)

He would have learned of the nervous system, but sometimes nerves were confused with tendons, said Neuburger.  He would have learned about the four humours, the four qualities, and the four elements, and that their balance was what maintained health, and their imbalance what caused maladies.  (8, page 152)(9, pages 268-270)

He would have learned about a vital principle that was inhaled by the pneuma (breath), and that the "fundamental principle of life is the 'inherent' warmth of the body which has its seat in the left heart. Under the influence of this inherent warmth elementary fluids of the body are formed from food, and from variable admixture of these fluids solid parts of the body are formed." (8, page 152-153)

Organs are "built up" by nutrients obtained from the blood, which was created in the liver, warmed in the left ventricle, and circulated by means of the beating heart through the veins.  Cool air was taken in by the lungs to cool the heart.  (8, page 153)

He learned that the pneuma originated in the heart, or brain, and circulated through the body from one of these organs.  This pneuma would have been responsible for sensation and movement.  The brain may have been responsible for many of the ailments of the body, including diseases of the lungs, colds, catarrh (inflammation), etc. (8, page 153)

Of this, Neuburger wrote:
The brain is, for the most part, looked upon only as a gland, as the seat of cold and phlegm, entrusted with the task of attracting to itself the superfluous water of the body.  (If, in the functions, a disturbance sets in, abnormal accumulations of phlegm occur in other organs, i.e. catarrh.)
When an imbalance of the functions of the body occurs, such as an imbalance of the humours, the brain loses its ability to control the flow of fluids to it, and excessive phlegm flows to one or another organ of the body. For instance, excessive phlegm flowing to the lungs causes asthma, pneumonia, pleurisy, empyema, and phthisis. The same to the nose causes catarrh and coryza.

So through his studies he would have learned the basic anatomical structures of the body, and how they worked together in unity to create life, maintain health, and restore health.  He would have learned how nature assisted in this process.

Thomas Bradford, in his 1898 book "Quiz questions on the history of medicine," said that, at the school of Cos, Hippocrates would have learned from the theories and cures recorded on the stone tablets, or votives, that were stored there.  (5, page 23)

Bradford said he participated in...
"...careful study of the medical records found in the votive offerings that hung in great profusion about the walls of the Aesclepiads.  He soon began to have a reputation as a physician, and his name was known not only in Greece, but in foreign courts also. (5, page 23)
He used the wisdom he learned from his father, at the school of Cos, and from the sages during his travels abroad, to become a very gentle and skillful physician. He would win the hearts of both his patients and his fellow physicians, thus improving the image of the profession, said Withington (4, page 50)

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. Withington, Edward Theodore, "Medical History from the Earliest Times: A Popular History of the Art of Healing," 1894, London, The Scientific Press. (3)  (7)
  5. Prioreschi, Plinio, "A history of medicine: Primitive and ancient medicine," v (1)
  6. 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)
  7. Sigerist, Henry, "A History of Medicine," volume 2, 1961, Oxford University Press  (2)
  8. Neuburger, Max, writer, "History of Medicine," 1910, translated by Ernest Playfair, Volume I, London, Oxford University Press
  9. Coxe, John Redman, 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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