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THE HIPPOKRATIC SPIRIT
By
George K. Daikos
Professor Emeritus, School of Medicine
University of Athens, Greece
E-mail: daik@otenet.gr

Galen wrote of Hippocrates : We are indeed zealots of Hippocrates, for he has been an excellent physician (aristos iatros) and philosopher . He surpassed everyone and was the first to bring to light the perfect medicine (Iatriki) of Hellenes. He is the man who gave us all the good seeds.

Adamantios Koraes, an 18th century Greek physician and scholar, from the island of Chios, who lived in France and who edited many masterpieces of the Ancient Greek Literature, wrote : “The life of Hippocrates is one of few who can “hardly have a parallel. ?e resembles his contemporary Socrates. History and his writings testify that studying and practicing Medicine had no other purpose, but men’s benefit”

It was not just an isolated phenomenon, but the evolution and consequence of previous ideas and practices. It was ?nly natural for the scientific Medicine of Hippocrates to appear during the Golden Age of the Ancient Greece.

Hippocratic medicine replaced the theocratic medicine practiced by the priests, evolving from the Minoan Medicine of Crete mentioned in the Homeric poems, and by the prehippocratic philosophers. Before the Hippocratic School was formed, the great medical schools of Kyrene, Kroton, Rhodes, Elaia and Knidos already existed
Hippocratic Corpus:
A great debate is still going on among scholars (Littré being the first) about the books that constitute the so called Hippocratic corpus. There are three possibilities about their author: a) as genuine works of the great Teacher, b) as written by Hippocrates’ disciples, c) as written at a later time. The truth is that they represent a continuum, expressing the teachings of the Hippocratic School of Kos Hippocrates’ son in law, Polyvos is considered by some to have played an important role similar to that of Plato for Socrates.
Hippocratic Spirit:
It is hard to summarize what the main characteristics of Hippocratic spirit were.
However, we can emphasize the following main points:
a) Study and description of disease with scientific accuracy, based on detailed history , careful physical examination, inspection, palpation and auscultation.
b) The importance of the epidemiologic history completed with information about weather and local conditions prevailing at the time of the epidemic.
c) An effort to elucidate the pathophysiology of disease, as much as the preva?ling beliefs of the time , but also beyond them.
d) Emphasis on the importance of the “patient and his illness” and not the illness (nosos) itself.
e) Emphasis on prevention and healthy habits. The physician should be an instructor of the public for healthy lifestyle in the Hippocratic books we have the first introduction to the importance of lifestyle.
f) Stress on the significance of diet.(There are 4 books on Diet).
g) Contrary to the School of Knidos, the “whole” and not the “parts” is emphasized.
h) Practice of humane medicine with compassion towards the suffering person.

Hippocratic terms used to this day:
Some of the diseases and terms originating in Hippocratic books are persisting to our times, such as pneumonia, pleuritis, aphthes, amygdalitis, kynanche, diftheria, enteritis, ileos, empyema of thorax and abdomen , dysentery, lithiasis, nephrolithiasis, nephritis, cystitis, spondylitis, karkinos, hemeplegia, paraplegia, lethargic encephalitis, mania, melancholia, hysteria, opisthotonos, tetanos, epilepsy, typhos, asthma, echinococcus etc.
Methodology:
In the passage that follows, we can admire the exact requirements for investigating new areas, characteristic of the Hellenes of the Golden age: “But Medicine has long had all its means at hand, and has discovered both the principles and the methods, through which the discoveries made over a long period are many and excellent; full discovery will be made, if the inquirer is competent, conducts his researches with knowledge of the discoveries already made, and makes them his starting point. But anyone who, casting aside and rejecting all these means, attempts to conduct research in any other way or after another fashion, and asserts that he has found out anything , is and has been, the victim of deception” (Ancient Medicine ,21)
To help or at least do no harm: (Ofeleein I mi blaptein):
In all dangerous cases you should be on watch …Declare the past, diagnose the present, foretell the future, practice these acts. As to diseases, make a habit of two things – to help, or at least to do no harm.
The Art consists of three factors, the disease, the patient and the physician.
The physician is the servant of the Art. The patient must cooperate with the physician in combating the disease.” (Epidemics 1st, 11)
Some people say that medicine on those days was paternalistic. The last sentence speaks to the contrary.
The science of Medicine-Need for Lifestyle Changes:
“Turning now to what is generally admitted to be the science of medicine….
I do not believe anyone would ever have looked for such a science if the same diet (regimen) were equally good for the sick and the healthy. Even now some people, the barbarians and some Greeks,, who have no knowledge of medicine, go on behaving when they are ill, just as they do in health. They neither abstain from, nor moderate the use of the things they like”. ( On Ancient Medicine , 5)

The Importance of Knowing What is Man:
“There are some physicians and sophists who maintain that no one can understand the science of medicine unless he knows what man is. Anyone who proposes to treat men for their illnesses must first learn that”.
“I do not believe that any clear knowledge of Nature can be obtained from any source other than a study of medicine and then only through a thorough mastery of this science”.( On Ancient Medicine, 20)

Master Description of Diseases:
Parotitis
“There was much rain in Thassos about the time of the automnal equinox and during the season of the Pleiads…..The summer was for the most part cloudy but there was no rain. The etisiae (winds blowing yearly in the summer down to our days) were few and light and blew at scattered intervals…… Many people suffered from swellings near the ears, in some cases on one side only, in others both sides were involved. Usually there was no fever and the patient was not confined to bed. In a few cases there was slight fever. In all cases the swellings subsided without harm and none suppurated as do swellings caused by other disorders. The swellings were soft, large and spread widely. They were unaccompanied by inflammation nor pain and they disappeared leaving no trace. Boys, young men and male adults in the prime of life were chiefly affected and of these, those given to wrestling and gymnastics were specially liable. Few women took it. Many patients had dry, unproductive coughs and hoarse voices. Soon after the onset of the disease, but sometimes after an interval, one or both testicles became inflamed and painful. Some had fever, some not. These cases were serious enough to warrant attention, but for the rest, there were no illnesses requiring care.

Tetanos:
“The forman of the big ship hit his index finger with the anchor (ankyra)
Inflammation followed and necrosis and fever…….Later on he complained that he could not formulate words. The prognosis was that opisthotonos would follow.
Mandibles were immobilized…..All the back of his body was taken by spasms With sweats …..the third day he died’’ ( Epidemics the 5th, 74) “When Tetanos occurs, the mandibles are immobilized like wood, and the mouth cannot be opened, the eyes are full of tears ….the spine cannot bend, the lower extremities do not come together, the same for the hands …..and when the patient is about to die the fluids that he is trying to swallow flow from the nose , the same with the sputum”.
(About Diseases the 3d,12)

Cancer (karkinos):
“ It is better not to treat those who have internal cancers since, if treated, they die quickly, but if not treated they last a long time” (Aphorisms VI, 38)
“ In a woman in the town of Abdera, carcinoma developed in her breast, and bloody fluid flowed from the nipple” (Epidemics the 5th ,101)
Exercise –Resting:
“Diseases caused by over-eating are cured by fasting. Those caused by starvation are cured by feeding-up. Diseases caused by exertion are cured by rest. Those caused by indolence are cured by exertion”. ( Nature of Man , 9)
In the book On Diet 3 (Regimen III), there is a detailed program for exercises according to the season and in relation to the food.
“As for exercises (in summer), practice on the circular track and in the double stade should be infrequent and short, walking should be in the shade….
After dinner walking should be restricted to a short stroll, but in the early morning walks should be taken. One should, however, beware of the sun and of morning and evening chills, such as are given off by rivers, lakes, or snow”.
(Diets,3 (Regimen III), 140, , 14-150)

Medicine and Physicians practicing it.
Quality Control
“Although the art of healing is the most noble of all the arts, because of the ignorance both of those practicing it and of their rash critics, it has at this time fallen into the least repute of them all.
“The chief cause for this seems to me to be that it is the only science for which states( poleis) have laid down no penalties for malpractice. Ill repute is the only punishment and this does little harm to the quacks, who are compounded of nothing else.
“Such men resemble dumb characters on the stage who, bearing the dress and appearance of actors, yet are not so. It is the same with physicians. They are
many in name, few in fact”.
Medical errors:
“ Thus exactness is difficult to achieve and small errors are bound to occur.
I warmly commend the physician who makes the least errors. Infallibility is rarely to be seen. Most physicians seem to me to be in the position of ignorant captains?. In calm wheather they can conceal their mistakes, but when overtaken by a mighty storm or a violant gale, it is evident to all that it is their ignorance and error which is the ruin of the ship will ruin the ship.
“ So it is with the majority of doctors. They treat men who are only slightly ill…such diseases are many and more common than the serious ones. When physicians make mistakes over such cases, their errors are not perceived by the layman, but when they have to treat a serious case, a mistake or lack of skill is obvious to all, and vengence not long delayed”. (On Ancient Medicine, 9)

Prerequisites for Becoming a Physician
“For a man to be truly suited to the practice of medicine, he must be possessed by a natural disposition for it, undergo the necessary instruction, under favorable circumstances, have education, industry and time. The first prequisite is a natural disposition, for a reluctant student renders every effort vain”
“ The growth of plants forms an excellent parallel to the study of medicine. Our characters (?????) resembles the soil, our masters’ precepts the seed.
Learning from childhood is the sowing of the seed in season and the circumstances of teaching resemble the climatic conditions that control the growth of plants. Dilligence is the working of the soil. Time strengthens all these things, so that nurture is perfected” (Hippokrates,Law or Canon).

Evidence based Medicine:
“ But conclusions which are merely verbal cannot bear fruit; only those do which are based on demonstrated facts ( evidence, endeixis). For affirmation and talk are deceptive and treacherous. Wherefore one must hold fast to facts ….if one is to acquire that ready and infallible habit, which we call medicine (iatriki)”

Medical Fees:
“I urge you not to be unkind, but consider carefully your patient’s means.
Sometimes offer your services for nothing, calling to mind a previous benefaction or present satisfaction. And if there be an opportunity of serving one who is a stranger in financial straits, give full assistance to all such , for where there is love of man, there is also love of the Art” (Parangeliai 6, (Precepts VI).

The Oath:
The so called Hippocratic Oath is actually older than Hippocrates. How older though is not possible to define. The Hipoocratic School has accepted and perfected it.
It is remarkable that in a text of not more than a page long, a code of medical ethics
is presented that survived so many centuries, being accepted and valid to our days. Initially the first christian physicians did not want to recite the oath swearing by the idolatric gods, but eventually they ommitted the heading and kept the text, or changed it to swear by the Holy Trinity.
“I will use my power to help the sick to the best of my ability and judgement.
I will abstain from harming or wronging any man by it”
In this phrase the ethics of the practice of the medical profession are concentrated.
The physician pledges to use all his means, knowledge, and abilities to help the sick, to the best of his judgement. It is implied that he should keep abreast of the current knowledge and that he will decide to the best of his judgement.
This has served as the basis of the medical authority and responsibility.
“ I will not give a deadly (thanassimon) medicine ( pharmakon) to anyone , if I am asked,
nor will I suggest any such a thing. Neither will I give a woman means to procure an abortion”
It is surprising that such a statement is made against euthanasia and abortion,
showing respect for the beginning and the end of life.
“Whenever I go into a house, I will go to help the sick and never with the intention of doing harm or injury. I will not abuse my position to indulge in sexual contacts with the bodies of women or of men, whether they be freemen or slaves”
“ Whatever I see or hear, professionally or privately ,which ought not to be divulged, I will keep secret and tell no one”.
The confidentiality, which is so much stressed in the oath, nowadays becomes problematic with the type of medicine that is increasingly applied worldwide.
It is impossible to keep a medical secret anymore. The data bases are accessible to
non medical authorities
Humane Medicine:
As an extension of the principles of the Oath, there are passages describing humane medicine to be one of the main hippocratic heritages. We encounter concepts that have been propounded in the Christian era. The great Greek fathers of the Church have called such concepts the “thyrathen paedeia”, or the “Spermatic Logos”.
In the book of “Peri Physon” (About Breaths), one of the oldest books, which deals with the air and its influence on the disease, (Physa is the inner air, pneuma is the outer air and has been translated in latin as spirit), the reader is astonished to see the following passage, with which the book begins:
“There are some arts which to those who possess them are painful, but to those “who use them are helpful, a common good to laymen, but to those who practice them grievous. Of such arts there is one which Hellenes call Iatriki (Medicine)”.
“For the physician (iatros) sees terrible sights, touches unpleasant things, and the “misfortunes of others bring a harvest of sorrows that are peculiarly his “
“But the sick by means of the art rid themselves of the worst of evils, disease, “suffering, pain and death, for Medicine proves for all these evils a manifest cure”.

References for future reading:

- Hippocrates 1923-1995 Loeb Classical Library, Harvard University Press; vol I-VIII.
- Hippocratic Writings 1983 Penguin Classics, (ed) G.E.R. Loyd, London.
- Marketos SG 1997 The medical school of Kos, Hippocratic Medicine, Human Sciences, Forum, Trends in Experimental and Classical Medicine; vol 7, pp, 313-324.

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