Thomas Sydenham The English Hippocrates

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 medicine 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 clinical 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 apparently 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 established 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 prestigious 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 knowledge was a paramount religious duty, guided Sydenham's approach to medicine. Studying cadavers was useless, because death was an admission of defeat, or proof of inadequate care. Medical education, according 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 microscopy and pathological anatomy, which he dismissed as frivolous and irrelevant.

Although Sydenham ridiculed attempts to study the ravages of disease through postmortems, he considered close study of the natural history 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 moderation 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 generated 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 symptoms, 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 maturation 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 allowance 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 physicians, 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. Frustrated 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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