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"HIPPOCRATIC MEDICAL ROUNDS"

By Donald Bockler



Type of Entry:

  • lesson/class activity

Type of Activity:

  • group role-play simulation
  • historical perspective

Target Audience:

  • Biology
  • Anatomy-Physiology
  • "Medicine in Society"

Notes to Teacher:

Background information necessary for performing this activity best comes from reading the primary texts of Hippocrates (Loeb Classical Library texts are available in most libraries). The best case studies come from his writings on the "Epidemics". A "medical bag" of Hippocratic herbs, liquids, emetics, bandages, and basic surgical equipment can be gathered and simulated before the class performance. The person role playing Hippocrates should wear a "sheet" and sandals.

Student requirements:

Students are to be given cards with roles and/or symptoms the day before the performance. Students can, but they need not dress in "Greek garb".

Preparation time needed:

Preparation time is needed to research background information on Hippocrates and humoral medicine. Materials for the Hippocratic "medicine bag" must be gathered and prepared before the performance. Colorful bottles should be gathered for "hydromel" (water and honey), "oxymel" (vinegar and honey), "gruel" (boiled cereal), "barley water", dilute "wines", and herbs. An "enema bag" can be fashioned out of "ancient" materials.

Class time needed: Prior to the performance, at least one class should be spent discussing "humoral medicine" as it contrasts with modern medicine based on the germ theory of disease. The performance in Hippocrates' workshop should take one class period.


Abstract

Biology teachers and students can role play such figures as Mendel, Darwin, Leeuwenhoek, and Harvey to compare worldviews and to illustrate how ideas have changed at key times throughout the history of science. This activity is used as an "attention grabber" at the beginning of the school year. It also serves as an ice-breaker that allows the teacher and students to know each other a little bit better. Lastly, although this activity is not directly evaluated after its completion, it gives reference to content and concepts to be covered later in the year. During my introduction to the ways of Science discussion in September, I contrast the germ theory of modern medicine with the humoral theory of medicine as different, yet valid, ways of knowing biology. I spend one day describing the basic ways of ancient Greek humoral medicine. Near the end of that class I suggest that we assume roles of Greeks in a Hippocratic medical workshop. I will role play an Hippocratic physician who will use humoral medicine to treat a variety of ailing student patients. These patients will be accompanied by family members, friends, rival physicians, herbalists, my apprentice, future patients, future physicians, as well as followers of the physician (aka, "medical groupies"). Index cards with information on various roles and patient symptoms are distributed before the class ends.


Background

("Part 1: Activity Description and Submission" section of Lesson Format)

What question does this activity help students to answer?

"Hippocratic Medical Rounds" illustrates how and why explanations of causes of disease have (and haven't) changed as medical knowledge has increased over the millenia.


Project

HUMORAL THEORY BACKGROUND

The humoral theory of medicine was developed by Hippocrates, expanded by Galen, and used throughout the Middle Ages. It was considered medical dogma in Western civilization until just over a hundred years ago. Chinese and other Eastern cultures still use humoral concepts in their medicine today, and some modern alternative health techniques of the West are finding renewed value in these "old" ideas.

Hippocrates (460~377 BC) believed that health and disease were natural phenomena, under human control, and explained by reason. He concentrated on the daily regimen of the patient rather than on possible supernatural influences thought to cause disease. Even though Hippocrates shunned mystical explanations for the existence of the universe and man, he still accepted the idea that human health and disease were due to the balance of four basic humors. It was the duty of the Hippocratic physician to bring unbalanced humors of disease back into harmony.

Hippocrates believed that man was composed of the four humors: blood, yellow bile, black bile and phlegm. These were related to the four basic elements of air, fire, earth, and water and were associated with the heart, liver, spleen and brain, respectively. Each humor was associated with a particular season and with two of its primary opposite qualities. The humors were derived from ingested foods which underwent a "cooking and ripening" process in the left ventricle. The resulting humors were then set in motion by "inner air" and "innate heat", and sent through veins to their respective organs. Hippocrates believed that blood vessels carried air, foodstuffs, and humors instead of the tissue that we now call blood. If the crude or morbid foodstuffs did not undergo complete ripening, or if the "inner air" became blocked at a specific organ, humors became unbalanced and disease resulted. Fevers developed when the body had a surplus of digested food due to lack of evacuation, and the new food had no place to go. Emetics were given to dissolve blocked humors, and heat was applied to activate the "inner airs". In most cases he allowed the body to take care of itself.

The balance of humors depended not only on the diet, but also on proper "modes of living" and on diseases of violence such as wounds, falls, or fatigue. The atmosphere and changes in heat and moisture caused the balance of humors to change with the seasons. For example, hot and dry summers set yellow bile in motion, producing bilious vomit, stool, and fever with yellowish skin. An early cold spell would increase "melaina-chole" (black bile) resulting in emotional instability. Balance was restored using theraputic "contraries" of heat and moisture in the diet or in hygiene.

CHARACTERISTICS OF THE HIPPOCRATIC PHYSICIAN

The Hippocratic physician often made house calls, but more often set up a booth or shop in the center of town. He might employ a crier to draw interest from passersby. In either case there was a more communal atmosphere to his workplace than one would find in a doctor's office today. The physician's workshop served as a meeting place for the patients and their families as well as acquaintances and people who came to watch the physician. This provided a chance for the physician to assert his authority and to discuss his prognosis with all who were interested, including assisting apprentices and, perhaps, rival physicians from other schools. He would explain his prognosis to all in his shop to persuade not only his patients, but also the bystanders that he was a good physician who knew his craft. The successful physician was skilled in medical diagnosis and prognosis as well as in oration and theatre.

The physician used his five senses to study all of the patient's secretions and excretions to determine the balance of the humors. The prognosis of a disease from these signs and symptoms aided the proper treatment to restore the humoral balance. Bleeding, venesection, was often used to remove morbid humors or air from the "blood vessels", and the body cavities were purged with herbal emetics. Regulation of the diet prevented further humoral malformation. The physician's main task in treating disease was to determine the prognosis by examining the patient's past. Little emphasis was placed on the diagnosis of symptoms to identify the present cause of the disease. Prognosis of disease was made using information about the environment and individual symptoms of the patient. The Hippocratic physicians believed that diseases were either "epidemic" diseases which affected all men at the same time in one area due to air breathed in common, or "sporatic" diseases that affected individuals in an area due to idiosyncrasies of diet and lifestyle.

PATIENT TREATMENT IN THE WORKSHOP

The Hippocratic physician would reassure his patient and ask about any changes in his/her recent past in travels, mode of work, interactions with others, diet, and body eliminations.

As he asked questions of the patient, he noted the position of the patient in bed. He observed the movement of the hands, and he scrutinized the nails and hair. examined the features and expression of the face, including the eyes, ears, tongue and nose. He may have placed his ear on the patient's chest or back to listen for rumbling or "gurgling like boiling vinegar", or he may have shaken the patient to listen for the splashing of pleuritic fluid. He used touch to take temperatures of the hand and the belly. Sometimes he used his senses of smell and taste to test the body eliminations of blood, urine, expectorant, or stool, especially in cases of general fever. But oddly, Hippocratic physicians were not interested in taking the pulse.

SAMPLE PATIENT: Asthma

This patient is having difficulty breathing and is producing much phlegm and sputum. This condition has affected the patient for several years, but it seems be most severe during late summer. Fees are discussed. (Some information provided on index card.)

Environment - This town has been undergoing a hot, dry spell for the past month. The winds have been gentle, from the south. The patient is visiting this area from a place to the south.

Individual - There is no paralysis of the tongue, but the patient's hands spontaneously move out of control as he tries to catch his breath. His voice appears difficult and weak. I hear no sounds of boiling vinegar or loose waters in the chest.

Prognosis - Sometimes an overflow of phlegm accompanies winds that change direction from the north to the south. This condition also seems to be long lasting for this patient. Therefore the disease seems to be of the sporatic, individual type rather than an epidemic disease due to "airs". Also, not many others in this town suffer from this disease. Nevertheless, it appears that the brain has softened and relaxed creating an overflow of phlegm. When the cold, moist phlegm reaches the lungs and heart, the blood is chilled causing blood vessels to palpitate making it difficult to inspire air and to pass fluids through the vessels. Hands then become powerless and move around in an uncontrolled manner. Blocked blood vessels result in asthma until the phlegm that flowed downward is warmed and dissipated. Excess phlegm may overflow the veins resulting in a loss of voice and wits. I prescribe hot compresses on the chest and bathing the chest with the contrary warm water and "smegma" (soap of olive oil and alkaline) to dissolve phlegm and bring up sputum easing respiration. A diet of "oxymel" (vinegar and honey) will dissolve the moisture and dog flesh will dry and heat as well as giving strength, but avoid puppy, however, because of its moist character. If speech does not return, I promise to open a vein on the inner portion of the right arm and perform venesection to remove the blocked humors. Lastly I recommend that the patient move his living quarters to face southwest to receive more warm and dry winds.

Addendum: Summary of Alternative Methods of Treating Asthma

  1. Hippocratic Medicine:

    Cause: An imbalance of the winter humor, phlegm, cools the heart and lungs making it difficult to inspire air. Blocked blood vessels result in difficult breathing, loss of voice, and uncontrolled movements. The imbalance is due to changes in the individual's diet, local environment, occupation or habits.

    Treatment: The four humors are rebalanced using diets involving specific foods and herbs along with warm bathes and compresses. Changes in local environment are suggested. Venesection is used in chronic cases when simpler methods fail.

  2. Modern Western Medicine:

    Cause: Asthma may be triggered by allergens, exercise, cold air, or environmental irritants. Typically, an acute attack of asthma first involves an allergen attaching to an IgE antibody on a mast cell causing the cell to release chemical mediators such as histamine. These cause the contraction of smooth muscles surrounding the bronchi, narrowing the airways within 30 minutes to exposure to the allergen. A second phase involving bronchial obstruction follows 4 to 12 hours later. This late response is due to an increase in eosinophils and chemical mediators creating inflammation, tissue damage, and bronchoconstriction. This results in mucus, wheezing, and respiratory distress.

    Treatment: Drugs are given to reverse the inflammatory response and to prevent further release of mediators from mast cells. No single drug is available to counter the effects of all of the mediators, so several drugs are used together, each acting in a different way, to reverse the symptoms. These drugs include epinephrine, ephedrine, atropine, and beta-2 adrenergics to relax smooth muscles and prevent bronchospasm; theophyllines to relax smooth muscle and prevent the release of mediators from mast cells; corticosteroids to reduce swelling and inflammation; and/or cromolyn to prevent both early and late phases of the asthma attack. Modern doctors would also take a medical history, a physical exam, and make suggestions regarding changes in the patient's environment and behavior to minimize future attacks.

  3. Chinese Medicine:

    Cause: A blockage of the flow of the life force, "chi" along the meridian to the lungs results in an imbalance between yin and yang in the organs. Tissues become stagnant, and waste toxins build up creating an environment for disease. The lungs and large intestine form the "Metal Element" in the Chinese Five Element Theory. (Other elements include Fire, Earth, Water, and Wood.) The lungs are considered recipients of "chi". The rhythm of breathing shapes chi, and ulimately, health and personality. The health of the lungs depends directly on the health of the intestines through the Metal Element, so poor intestinal health can contribute to asthma. Excess cold prevents the circulation of heat through the "superficial region" of the body, resulting in a build-up of internal heat contributing to asthma with coughing. This can also be caused by stress, or "emotions transformed into fire." Excessive worry and sadness are also harmful to the lungs, blocking the chi, causing asthma.

    Treatment: Chinese use specific foods, herbs and other therapeutics to restore balance and harmony to the body. Asthma can be treated by using specific classes of herbs: 1) to counteract rheumatism (for example, mistletoe and Chinese clematis); 2) to reduce excessive heat inside the body (for example, cork tree and purslane); and 3) to induce perspiration (for example, Chinese ephedra and purple perilla). Foods considered healing to the Metal Element include, brown rice, leafy, green vegetables, fish, ginger and garlic, and pears. Dairy foods, eggs, and high-fat meats should be eliminated from the diet. Massage to the acupunture point "Lung 1" (about two inches above your sternum) can stimulate lung energy to treat asthma.

  4. Homeopathy:

    Cause: Homeopaths believe that a "chemical memory", an "energy pattern" or an "imprint of essence" is left behind after a person has encountered a disease such as asthma. The asthma is an indidual expression of an imbalance of energy in the body. The symptoms result from a disharmony and in the person's attempt to restore order. Chronic diseases such as asthma can exist and vary due to genetic predispositions, allegic tendencies, infections, toxic exposures, or unhealthy habits.

    Treatment: Homeopathic remedies for asthma include: breathing exercises (similar to yoga) to strengthen the lungs; relaxation exercises; drinking plenty of fluids; and microdoses of Arsenicum (mineral white arsenic), Pulsatilla (windflower), Ipecac (Brazil root), or Spongia (toasted sea sponge). According to the homeopathic "Law of Similars", drugs related to or causing the symptoms of the disease that are toxic at high concentrations are given to the patient in "infinitesmally small" dilutions. These chemical memories stimulate the body's defenses to eliminate the illness. The symptoms are not the illness, but part of the curative process. Thus the microdoses of the toxins potentialize the underlying "vital force" of the body, allowing it to recover.


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