A recent essay on this blog, “Navigating the complexity of ‘first do no harm’ in modern medicine,” provided an excellent review of this principle. However, as is so often the case, it misattributed the statement to the Hippocratic Oath.
Certainly, this does contain elements of this sentiment, more fully expressed in another work of Hippocrates called “Of the Epidemics.” But the term does not originate with this Greek physician.
Scholars have investigated the use of this admonition in the history of Western medicine, and most attribute its origin to Thomas Sydenham, someone who eventually became known as the “English Hippocrates” for his revival of Hippocratic methods.
Sydenham is truly one of the “greats” of medicine and is considered by many to be the founder of clinical medicine. For those interested, there are several books available, some straightforward biographies, and others containing his actual writings on the subject of medicine. A brief summary will suffice here.
Sydenham was born in 1624 and became a protégé of Oliver Cromwell during the English Civil War, a time when England briefly ceased to be a Constitutional Monarchy and became a Republic.
Readers may recognize his name from the chorea that sometimes complicates streptococcal pharyngitis; he was the first to differentiate scarlet fever from measles. He gave the name pertussis to whooping cough, was key in promoting the use of quinine for malaria, and the first to link fleas to Typhus. He also wrote extensively on mental disorders.
As a physician, Sydenham relied upon observation and experience in assessing proper treatments and was distrustful of scientific theories and experimentation. He was generally disliked by his contemporaries, as he had little respect for their methods and approach to healing.
Sydenham’s medicine leaned heavily on bedside observation and clinical case histories, just like Hippocrates, and he came to understand that different diseases had their own natural histories, which was one of his major contributions to the field of medicine. His study of epidemics led him to be recognized as one of the founders of epidemiology.
Sydenham’s major contributions to medicine are mostly contained in his book Observationes Medicae, published in 1676. It includes his studies of London epidemics and the first attempt to classify diseases systematically. It became a standard textbook for more than two centuries.
Sydenham’s personal affliction with gout (something later shared with Osler) led him to become an expert on this topic, publishing a masterly treatise on it in 1683. He was the first to use laudanum (tincture of opium) for pain relief in gout.
When I graduated from medical school in England in 1979, my father presented me with an engraved copper plaque bearing the Hippocratic Oath written in both the original Greek and English. Yet paradoxically, my school did not require us to take the oath. It is my understanding that currently, some medical schools in the US do, and some do not.
Many have pointed out that the original Oath is unsuited to today. Modifications and alternatives have been proposed more in line with current medicine and today’s sensibilities. Some of these do include the admonition. A good review of the topic can be found in a 2022 paper published in the Journal of Medical Internet Research.
Perhaps more importantly, the concept of “do no harm” has come under scrutiny, and some have argued that the prefix of “first” is inappropriate and at odds with current practice. Some aspects of this are usefully discussed in the essay I first mentioned.
While the concept of avoiding injury to the patient was well recognized by Hippocrates, the pithy admonition “first, do no harm” belongs to Sydenham, the father of clinical medicine. It is not included in the original Oath, a document that may not have actually been written by Hippocrates at all.
Let us give credit where it is due to one of the greats of medicine, Thomas Sydenham.
Martin C. Young is a pediatric endocrinologist.
