Home > Articles

  • Print
  • + Share This
This chapter is from the book

Milestone #2 It’s the patient, stupid: the creation of clinical medicine

  • “His symptoms were shivering, nausea, insomnia, and lack of thirst... He was delirious, but calm, well-behaved and silent.”
  • Hippocrates, Epidemics 3, 420-350 BC

The term “clinical medicine” embodies much of what we now like to think any good doctor practices. It includes everything from taking a detailed patient history, to performing a careful physical examination and recording of symptoms, to diagnosis, treatment, and an honest assessment of the patient’s response to that treatment. Prior to Hippocrates, the practitioners of medicine were not especially concerned with such details. Rather than focusing on the pains and woes of individual patients, early Greek physicians tended to take a one-size-fits-all approach, in which patients were subjected to ritualistic, predetermined, and highly non-individualized treatments. In changing that approach, Hippocrates founded the art and science of clinical medicine.

How does one invent “clinical” medicine? Some say that Hippocrates developed his clinical insights through exposure to a long and curious tradition in the Asklepieion of Kos. For many years, patients recovering from illness would inscribe in the temple an account of the help they had received so that it might be useful for other patients. According to this story, Hippocrates took on the task of writing out these inscriptions and, armed with this body of knowledge, established the practice of clinical medicine.

More likely, the clinical skills developed by Hippocrates and his followers were earned through hard work over the course of many years and many interactions with many patients. One vivid and typical example of these skills, recorded in the book Epidemics 3, involves a youth in Meliboea who apparently was no icon of Greek virtue. According to Hippocrates, the youth “had been feverish for a long time as a result of drunkenness and much sexual indulgence... His symptoms were shivering, nausea, insomnia, and lack of thirst.” Although not for the squeamish, the subsequent description of the youth’s demise demonstrates a skill of clinical observation that could stand as a model for any medical student today:

  • “First day: There passed from his bowels a large quantity of solid stools with much fluid. During the following days he passed a large quantity of watery, greenish excrement. His urine was thin, sparse, and of bad color. His respiration was at long intervals and deep after a time. There was a flabby tension of the upper part of the abdomen extending laterally to both sides. Cardiac palpitation was continuous throughout... Tenth day: He was delirious, but calm, well-behaved and silent. Skin dry and taut; stools either copious and thin or bilious and greasy. Fourteenth day: All symptoms exacerbated. Delirious with much rambling speech. Twentieth day: Out of his mind; much tossing about. No urine passed; small amounts of fluid retained. Twenty-fourth day: Died.”

Through such clinical observation—with its focus on individual patients and their symptoms—Hippocrates raised medicine from the dusky gloom of demons and rituals into the bright light of keen observation and thought. And it made perfect sense in the world view that Hippocrates had begun to shape: if diseases had natural cases, why not look more closely at symptoms for clues as to what those causes might be? What’s more, this new focus on individual patients paved the way for another component that we now regard as essential to good medicine: the “doctor-patient relationship.”

  • + Share This
  • 🔖 Save To Your Account