THOMAS SYDENHAM, THE ENGLISH HIPPOCRATES | Kickoff

THOMAS SYDENHAM, THE ENGLISH HIPPOCRATES

12 May

Thomas Sydenham (1624–1689) epitomized the reaction  of the clinician to abstract  and speculative medicine and the pretensions  of physicians who  behaved  as if their  scientific research  was more  significant  than medicine practiced  at the bedside of the patient.  When scientific medi- cine was generally carried out in the autopsy  room,  patients  with long, lingering  illnesses  might  well  frustrate   a  physician  who  was  overly devoted to his research.

Like Hippocrates, Sydenham  believed that  it was the task  of the

physician  to  assist the body’s natural healing  processes,  while finding patterns  in symptoms and searching for the cause of disease. Since clini- cal medicine was an art  that  demanded  acute observation, experience, and  balanced  judgment,  the true  physician  should  dedicate  himself to useful  techniques,  common  sense, and  the  principles  of Hippocrates. Revered  as the English Hippocrates, Sydenham  was eulogized as ‘‘the great  representative  of  the  practical  medicine  of  practical  England’’ and  the man  who recognized  ‘‘the priority  of direct  observation, and its paramount supremacy  to everything else.’’

Politically, as well as professionally,  Sydenham  might be regarded as the antithesis of William Harvey. Indeed, Sydenham’s goals and achievements have been ascribed  to the events that  made him a highly politicized person; that  is, his attempts  to reform medicine were appar- ently inseparable  from his political  stance. Sydenham  and his brothers fought  as soldiers in the Parliamentary Army; their mother  was killed in a Royalist  raid.  Several close encounters  with death  during  the war convinced Sydenham  that  a special providence  had spared  his life.

After the Royalists  were defeated,  Sydenham  resumed  his studies

at  Oxford  and,  in  less than  two  years,  he  was  granted  a  bachelor’s degree in medicine.  When  hostilities  began  again,  Sydenham  rejoined the army. In 1655, Sydenham resigned his Oxford fellowship and estab- lished a private  practice in an aristocratic London  neighborhood close to the malarial marshes that generated a steady supply of fever patients. He also attended  the sick poor  at various  London  hospitals.  Although Sydenham  became  a Licentiate  of the Royal  College of Physicians  in

1663, he was never granted the honor of becoming a Fellow of that pres- tigious  association.  His  enemies even tried  to  rescind  his license and banish  him  from  the  College  of  Physicians  for  medical  heresy  and irregular  practice. In an age where personal abuse was a common  form of professional  discourse,  Sydenham  was always  ready  to  return  real or imagined insults. Defensive about the deficiencies in his formal education,   Sydenham  boasted   of  his  ability  to  ‘‘think  where  others read.’’

Puritan  principles, especially the idea that increasing useful knowl-

edge was a paramount religious duty, guided Sydenham’s approach to

medicine. Studying  cadavers  was useless, because death  was an admis- sion of defeat, or proof of inadequate care. Medical education,  accord- ing to Sydenham,  could take place only at the bedside of the sick, not in the classroom,  library,  or anatomy  theater.  Despite  his admiration for Hippocrates, Sydenham  insisted that  experience had  been his only teacher.  Many  of  the  anecdotes  treasured   by  Sydenham’s  followers reflect this attitude.  For  example, when Dr.  Richard  Blackmore  asked Sydenham   to   recommend   the   best   books   for   learning   medicine, he replied: ‘‘Read ‘Don Quixote’; it is a very good book; I read it myself still.’’ Perhaps  this  retort  reflected  his opinion  of both  young  doctor Blackmore  and  the medical  literature  of his time, along  with  micros- copy and  pathological  anatomy,  which he dismissed as frivolous  and irrelevant.

Although  Sydenham ridiculed attempts  to study the ravages of dis- ease through  postmortems, he considered close study of the natural his- tory of disease among hospital  patients  valuable training.  According  to Dr. Robert  Pitt, by carefully studying the course of disease in a hospital for  the  ‘‘meaner class’’ of patients,  Sydenham  was able  to  determine whether  a  fever  could  be  cured  by  ‘‘Natural  Power,’’ or  whether  it required  ‘‘Bleeding, Vomiting,  Purgatives .. . before  risking  the  lives of people of quality.’’ When accused of diminishing  the dignity of the healing  art  by recommending  plain  and  simple medicines,  Sydenham countered  that  wise men understood that  ‘‘whatever is useful is good.’’ Not only were simple remedies useful, they were safer than ‘‘superfluous and  over-learned  medicines’’ that  were likely to aggravate  the disease until the tormented patient  ‘‘dies of his doctor.’’ Recommending mod- eration  in  all  things,  Sydenham  prescribed  appropriate diets,  drugs, exercise, and  opium,  the drug  God  had  created  for the relief of pain. Even a simple remedy,  like a rag  dipped  in rosewater  and  applied  to the forehead,  often did more good than  any narcotic.

In 1665, the year of the Great  Plague,  Sydenham  and  his family fled from  London. While living in the countryside,  he found  the time to complete his Medical Observations Concerning the History  and Cure of Acute Diseases. As an admirer  of the rapidly  developing  science of taxonomy,  Sydenham  prescribed  analogous  methods  for  the study  of the natural history  of disease. Because Nature  produced  uniform  and consistent  species of diseases, Sydenham  assumed  that  close attention to  a  small  number  of cases would  produce  information that  applied to all similar cases. Combining  direct observations and Robert  Boyle’s chemical theories,  Sydenham  suggested that  subterranean effluvia gen- erated disease-causing miasmata  when they came in contact with certain corpuscles in the air. As the atmosphere became ‘‘stuffed full of particles which  are  hostile  to  the  economy  of the  human  body,’’ each  breath became saturated with ‘‘noxious and unnatural miasmata’’ that  mixed with the blood  and engendered  acute epidemic diseases.

In his attempt to extend scientific taxonomy to medicine, Sydenham envisioned  disease  as  an  entity  existing  independently   of  the  person who might become its victim. Acute diseases caused by changes in the atmosphere that affected great numbers of people at the same time were called epidemics; other  acute diseases attacked  only a few people at a time and could be called intercurrent or sporadic.  Physicians had long been content with vague designations of diseases in terms of major symp- toms, but Sydenham believed that the physician must learn to distinguish between different  diseases with similar symptoms.  For  example, fevers were vaguely classified as continued,  intermittent, and eruptive. Typhus was the most common  of the continued  fevers, malaria  was the prime example of an intermittent fever, and  smallpox  was the most  dreaded eruptive fever.

Smallpox,  which  Sydenham  carefully  distinguished  from  scarlet

fever and measles, was so common  in the seventeenth century that,  like Rhazes,  Sydenham  regarded  it as essentially part  of the normal  matu- ration  process. Physicians generally kept smallpox patients  confined to bed under  a great  weight of blankets  and  prescribed  heating  cordials to drive out  diseased matter.  Sydenham  contended  that  the orthodox

‘‘heating regimen’’ caused excessive ebullition  of the blood,  which led to  improper  fermentation, confluent  pustules,  brain  fever, and  death. To assist nature,  Sydenham  prescribed  a simple and moderate  ‘‘cooling regimen’’ featuring light covers, moderate  bleeding, and a liberal allow- ance of fluids.

Sydenham’s  short  treatise  on  mental  illness has  been  called  the

most important seventeenth-century work on psychological disorders and their treatment. According  to Sydenham,  psychological  disorders  were as  common   as  physical  complaints.   Moreover,   hysteria,   a  disorder the ancients  attributed to  the wanderings  of the uterus,  seemed to be the most common of all chronic diseases. Perhaps it was no surprise that hardly any women were wholly free of this disorder,  but it was certainly remarkable to learn that men were also subject to hysterical complaints. Faced  with  the  challenge  of  determining  a  new  etiology,  Sydenham ascribed hysteria to disordered  animal spirits. Time, the prince of physi- cians, healed many of these patients,  but Sydenham  also recommended

‘‘steel syrup’’ (iron  filings steeped  in wine) and  horseback  riding.  For both  mental  and  physical  complaints,  Sydenham  was as enthusiastic about  horseback  riding  as modern  health  activists  are  about  jogging. Some  patients  had  to  be tricked  into  health-restoring exercise. Frus- trated  by one  patient  who  stubbornly  refused  to  get well, Sydenham suggested  a  consultation with  the  wonder-working Dr.  Robinson at Inverness. The patient made the long trip on horseback  only to find that there was no such doctor, but, as Sydenham expected, anticipation, exercise, and anger effected a cure.

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