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“I Will Not Cut, Even for the Stone”: Origins of Urology in the Hippocratic Collection ______

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“I Will Not Cut, Even for the Stone”: Origins of Urology in the Hippocratic Collection ______ REVIEW ARTICLE Vol. 41 (1): 26-29, January - February, 2015 doi: 10.1590/S1677-5538.IBJU.2015.01.05 “I will not cut, even for the stone”: origins of urology in the hippocratic collection _______________________________________________ E. Poulakou-Rebelakou1, A. Rempelakos2, C. Tsiamis3, C. Dimopoulos4 1Department of History of Medicine, Athens University Medical School, Athens, Greece; 2Urological Department, Hippocrateion Hospital, Athens, Greece; 3Department of Microbiology, Athens University Medical School, Athens, Greece; 4National Committee of Ethics and Deontology, Athens, Greece ABSTRACT ARTICLE INFO ______________________________________________________________ ______________________ The Hippocratic Collection, including the most of ancient Greek medicine, remains still Key words: interesting, despite the recent advances that transformed definitely the urological hea- Hippocratic Medicine; Renal ling methods. Considering the patient as a unique psycho-somatic entity and avoiding stone; Urology; Uroscopy high risk surgical manipulations were the leading principles dictating the everyday practice. Contemporary physicians can still learn from the clinical observations in Int Braz J Urol. 2015; 41: 26-9 times of complete absence of laboratory or imaging aid, from the prognostic thoughts, the ethics, and the philosophical concepts, represented by the Hippocratic writings, _____________________ tracing into them the roots of Rational Medicine in general and Urology in particular. Submitted for publication: December 17, 2014 _____________________ Accepted after revision: December 24, 2014 INTRODUCTION vements of this period, the Hippocratic medicine developed the main concepts of the medical spe- I will not cut, even for the stone, but I cialties. Some topics in Urology, such as uroscopy will leave such procedures to the practitioners of and stone disease, are presented here. The main that craft (1). references derived from the famous Hippocratic The roots of a rational approach to medi- treatise entitled Aphorisms, an anthology of seven cine, particularly to that of the objective observa- sections containing medical truths included in one tion by the bedside of the patient, are attributed to or two phrases, like epigrams. Hippocrates, a member of a family of well-known The most important healing methods are physicians on the island of Kos (2) (Figure-1). surgery (including the use of knife, lancet, and He lived and flourished in a very particular pe- cautery), blood-letting, baths, drugs, ointments riod in classical Greece, the golden age of Pericles and plasters, fomentations and control of lifestyle (5th century), when many dominant personalities (diet and exercise). There were no reliable anes- made too many significant contributions to Wes- thetics and antiseptic agents, making a surgical tern civilization (3). Among the scientific achie- operation quite adventurous and painful, while 26 IBJU | HIPPOCRATIC UROLOGYX Figure 1 - The famous plane tree in the island of Kos, native The urine must be observed to see how far it re- place of Hippocrates, under which the great physician of sembles that passed in health. The less it resembles classical era teached young medical students (Engraving healthy urine, the more diseased it is; the more by Comte de Choiseul-Gouffier, Voyage pittoresque de la it resembles it, the healthier it is. (Aphorisms VII, Gréce, 1782). 67). The analysis of the urinary system in those ti- mes, where anatomic dissections were not allowed was rare and coincidental. The holistic approach combining information clinical observations from all organs added to the urologic experience and concluded to interpretations accepted until today. Moreover, the reluctance of undertaking cutting of the stone by cystotomy seems as evidence of evaluating the dangers and preserving the prin- ciple primum non nocere (Epidemics I, 11). Hip- pocrates considered that the physician must have two special principles in mind, namely, to do good or to do not harm. Some operations on the kidney were not avoided; pyonephrosis and renal abscess were physicians and patients agreed on the avoidance considered as operable cases and drainage by deep of this procedure. Historians often comment that loin incision was recommended. For many centu- Hippocratic medicine delayed the development of ries, cystotomy tended to cause severe disability Urology by condemning the cutting of the bladder and even death. Some complications were also for a stone’s excision, but only the inexperience reported such as the leakage of urine, common was condemned. On the contrary, the performance also after incisions on other organs (bowel). The by the specialists was favored pre-announcing the most severe complication of cystotomy seemed to future urological surgeons (4). be gangrene and necrosis of the testis, due to the This paper intends to present the contri- cut of the spermatic cord (2). The Hippocratic ad- butions of the Hippocratic writings to two main vice to the physicians was to avoid this procedure branches of the urologic specialty: the uroscopy if possible, introducing the category of high risk (macroscopic urine observation) and the theory of operation, only for specialists, and attempting to the renal stone formation, both based on the study protect the patients from untrained healers. Hero- of the original Greek text. dotus mentioned some specialists he met during his visit to Egypt: doctors for eyes, teeth, the ab- Urological contributions of the hippocratic col- domen and for obscure internal diseases (7). lection One of the most typical examples refers A detailed study of Corpus Hippocraticum to the need for differentiating the upper from the reveals several disorders of the urinary tract (5). lower urinary tract infection: (8) Small fleshy ob- The observations concerning the anatomy and jects, the shape of hairs, in the urine which is thi- physiology of the related organs and the etiolo- ck, mean there is a discharge from the kidneys gy and treatment of various urological diseases (Aphorisms IV, 76) and When blood clots in the seem accurate. Furthermore, the theory of stone urine are accompanied by strangury, abdominal formation is still valid and the diagnostic inter- and perineal pain, it is the parts about the bladder pretations of the macroscopic urine examination which are affected (Aphorisms IV, 80). The astute- (uroscopy) are still respectful (6). It is emphasized ness of the objective clinical observations in times that no other system or organ of the human body of deteriorated anatomic knowledge is impressive gives us so much diagnostic or prognostic infor- (9). Most of the anatomic passages of the Corpus mation by its excretion as does the urinary tract: seem to have been based on animal dissection or 27 IBJU | HIPPOCRATIC UROLOGYX secret human dissection (3). It is noteworthy that and it is narrow as well. Moreover, girls drink Hippocrates baptized many of the urological ter- more than boys (On Airs, Waters, Places, 9). ms and diseases, such as lithiasis (=stone disease), The patient’s age plays a main role in stone cystitis, cystotomy, nephritis, orchitis, strangury formation: Sedimentation after urination is more and many others. However, it was possible to re- frequent in children. It is because they are warmer cognize the kidney and the bladder dysfunction (Epidemics VI, part 3, 7) and sandy urinary sedi- and their clinical manifestations in disease. ment shows that a stone is forming in the bladder (Aphorisms IV, 79). For the treatment of lithiasis, The theory of renal stone formation fluid intake is recommended (wine mixed with The Hippocratic concept of renal and bla- abundant water) or stronger drugs: By giving a dder stone formation were based on detailed cli- medication to a patient with a stone, they have nical observation and uroscopy (7). The possible propelled the stone into the urethra by the force ways of genesis of lithos (Greek word for stone) of medication so that it has passed with the urine are described in several treatises of the Corpus. (On Diseases I, 8). The presence of a sandy sediment or of stones in the urine means that originally tu- Hippocratic uroscopy observations mors grew in relation to the aorta and suppura- The contribution of the Corpus to the de- ted. Then stones were squeezed out through the velopment of uroscopy is priceless and his work blood-vessels together with urine into the blad- on this field of Urology reflects the function not der (On the Nature of Man, 14). exclusively of the urinary system but of the whole In one of the treatises attributed directly body. Hippocrates studied the acute diseases and to Hippocrates (10) On Airs, Waters, and Places, the evolution of urine during the stages of chronic a hygiene-oriented epidemiologic text, the qua- diseases and emphasized on the constant appea- lities of water were considered responsible for rance of certain elements in the urine. Colorless stone formation. Drinking water collected from urine is bad; it is especially common in those with many different sources may be dangerous for disease of the brain (Aphorisms IV, 72). The short stone disease, gravel and strangury: phrase indicates a reduced ability to concentrate When two sorts of water are mixed they the urine and may refer to chronic renal failure quarrel with one another and will leave sediment or to diabetes insipidus (the latter unknown in 5th of sand and it is by drinking this that the diseases century BC). mentioned above are cause. The sudden appearance of blood in the uri- The Hippocratic text offers more clinical ne indicates that a small renal vessel has burst observations: (Aphorisms IV, 78). It may signify necrotizing re- If the neck of the bladder becomes infla- nal papillitis due to ischemic necrosis. med and does not allow the urine to pass the Bubbles appearing on the surface of the densest and cloudiest part of urine is gathered urine indicate disease of the kidneys and a pro- together. The gravel formed coalesces to form a longed illness (Aphorisms VII, 34). It may refer stone, preventing the urine from being passed. to chronic inflammatory activity in the glomeruli Great pain is thus caused.
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