Monday, July 31, 2017

Hippocratic Proctology?

Way too much medical-political news lately, from the taxation issues in Canada to the fiasco in the U.S. Senate. Thought I'd lighten the mood with some historical fiction. Ever wonder what teaching rounds might have looked like in the time of Hippocrates?

Author's note: the medical content (to the extent that it can be called medical at all), is derived from the Delphi Classics translation of the Hippocratic Corpus.

“Now this is something you won’t normally see on Kos,” said Hippocrates, motioning for his students to gather around the patient, lying naked and spread-eagle on a makeshift table of wood planks. “As I’ve discussed time and again, the diseases we treat derive from an imbalance of humors – phlegm, blood, black bile, yellow bile – brought on by changes in the air, in the water, what we eat and drink, or how much we exercise. Our job as physicians, as practitioners of the Art, is to understand these relationships and correct the imbalance – apply cold to the hot, moisture to the dry, and so on.

“Today we won’t worry about the cause of the patient’s condition, because we already know it. This morning’s lesson will be a surgical one: we are going to go over the proper treatment of a fistula. It’s a channel that develops between diseased skin around the anus into the rectum. Has anyone seen a fistula before?” The five students shrugged in silence. “Okay. Has anyone seen saddle sore before?” Silence again. “Hmm. Well, I suppose it’s been decades since the war with the Persians, so you just haven’t been exposed to battlefield medicine.

“Rowers and cavalrymen are by far the most likely to develop fistulae. The long hours on horseback or at sea cause a large volume of blood to pool around the anus, stretching and weakening the surrounding flesh – saddle sore, as a horseman might say. Nikomachos here is a rigger on a merchant ship that began its journey in the Ionian Sea to the northwest of the mainland. The wind wasn’t enough to propel the ship, so Nikomachos went from rigger to oarsman for a long stretch of the voyage. All that sitting and rowing weakened his anal flesh.  

“Once the flesh is weak and fragile, it only takes a slight injury – a fall, a sliver of wood – to create a pustule in the area. If your patient describes a pustule around the anus, or if you see one on exam, cut it open right away to let it drain. The last thing you want is the pustule to burst into the rectum and form a fistula. Unfortunately for Nikomachos, he didn’t notice the problem until too late. The fistula expanded to the point that he noticed the fetid smell from contamination with flatus and feces.”

And smell fetid it did, even in the open-air colonnade with a mid-morning breeze. Hippocrates had made a habit of mouth-breathing as much as possible around the sick, but his students had yet to discover the best ways of avoiding foul odors. One youth looked absolutely peaked, another ashen and on the brink of passing out. Hippocrates signaled the most senior student to take the poor juniors aside to regain their composure. “ Is that what minotaur shit smells like?!?” moaned the more alert of the two.

Hippocrates held up a garlic bulb. “The first step in the care of a fistula is measurement of its depth.” He stuffed the garlic in the opening by the patient’s anus, pushed it as deep as it would go, then plucked it out and held it up once more. A third student reeled from the blast of fetid air. “You can see by the fecal staining how big of a plug we’ll need to help the area heal.” He handed the garlic to a temple servant with directions to cut a patch of cotton. “We’ve already given Nikomachos some medication beforehand. He’s had three drinking cups of – can anyone recall the elixir?”

“Powdered fennel root, steeped for three days?” said the senior student.

“Four days,” said Hippocrates, “plus some honey. Not unpleasant to the taste, actually. The elixir is to be given on an empty stomach, after you’ve given a purgative. I don’t advise wine for pain relief, despite the patient’s discomfort.” He accepted the cut cotton cloth from the servant, and continued to demonstrate as he spoke. “You’ll need to bleach the area clean with chalk. Then moisten your cloth in the juice of a milkweed, and sprinkle it with grounds of roast orchid. Thread the cloth through the fistula until you can feel it on the inside the rectum…”

“That hurts!” screamed Nikomachus. “How soon can I have wine?!?”

“In due time,” said Hippocrates, turning back to his students. “The cloth needs to stay in the fistula for six days. We’ll fashion a small pessary from the horn of an offered animal and plug the rectum to keep the cloth in place. Nikomachus, you’ll be able to remove the pessary as needed to move your bowels. At the end of the six days, we’ll apply alum to the area to help dry it up and anoint it daily with myrrh until it’s fully healed. Any questions?”

Hippocrates took delight in teaching the finer points of proctology. The Art was gaining traction in the Greek world, with physicians increasingly trained to look past deference to the gods. His predecessors and contemporaries were enjoying popularity and wealth as they traveled. Proctology was a superb way to keep his students humble.

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