Hippocratic Corpus - Part 2

Urology

With many books incorporating different urology practices and observations and nearly 30 works in the Hippocratic book collection entitled Aphorism seemingly solely dedicated to urology in general, urology was one subject that was thoroughly investigated.^[49] Seemingly, the main and most problematic topic covered in urology was that of bladder disease in patients, especially when urinary tract stones (that is, stones within either the kidneys or the bladder) were present.^[49][50] Urinary tract stones, in general, have been seen within records all throughout history, even as far back as the ancient days of Egypt.^[50] Theorizing how these urinary tract stones formed, how to detect them and other bladder issues, and the controversy on how to treat them were all major investigating points to the authors of the Hippocratic Corpus.

Stone formation theories

Throughout the books of the Hippocratic Corpus, there are varying hypotheses as to reasons why and exactly how urinary tract stones actually formed. It is noted that these hypotheses were all based on the use of uroscopy and observation of patients by doctors of the time.^[49]

• Within the work On the Nature of Man, suggest that the bladder stones first form within or attached to the aorta, much like any other tumor-like object would. In this place, the stone will essentially form pus. Afterward, this stone formation is transported by the blood vessels and forced into the bladder where urine will also be transported.^[49]
• In another work, On Airs, Waters, Places, it is suggested that drinking water can attribute to urinary tract stones. If water consumed consists of a mixture of more than one water sources, the water is of impure quality. The different waters are in conflict with one another and therefore produce deposits of sediment. The accumulation of these deposits within the urinary tract due to drinking the waters can then result in urinary tract stones.^[49]
• Additionally in On Airs, Waters, Places, another passage describes that formation of urinary tract stones will occur when urine cannot flow through the system easily and causes the sediment in the urine to collect in one area and meld, forming a stone. This can occur when inflammation occurs within the part of the bladder leading to the urethra. When the stone forms at this point, it can block flow and, therefore, cause pain. In this scenario, it was hypothesized that males are more likely to form stones than females due to the anatomy of the bladder.^[49]

Detecting bladder disease/stones

The main mechanism of detecting bladder disease's symptoms, including inflammation and urinary tract stone formations, is through the appearance of the urine itself and the changes that occur with the urine over time.^[49] In Aphorism, it was simply stated that as the appearance of urine diverges more and more from the appearance of "healthy" urine, the more likely it is to be diseased and the worse the disease becomes.^[49]

In Aphorism works, it was noted that urine lacking color could indicate diseases of the brain – some today think that this author who made this statement was meaning to refer to chronic renal failure or even diabetes. It was also suggested that the appearance of blood within urine could indicate vessels of the kidney to have burst, potentially due to necrosis of blood arteries or vessels. Furthermore, doctors noted that if bubbles formed on top of urine, the kidneys were diseased and showed the potential of long-lasting disease.^[49]

Treatment of bladder disease/stones

When it comes to the treatment of urinary tract stones, many solutions were suggested, including drinking a lot of a water/wine mixture, taking strong medication, or trying different positions when trying to flush them out.^[49][50]

Extracting the urinary tract stones was another option; however, this method was not utilized very often due to its serious risks and possible complications of cutting into the bladder.^[51] Other than leakage of urine into the body cavity, another common complication was that of the cells of the testes dying due to the spermatic cord inadvertently being cut during the procedure.^[49][52]

In fact, due to these and other complications and the lack of antiseptics and pain medicines, the Hippocratic Oath opted for the avoidance of surgery – unless absolutely necessary – especially when concerning surgeries that dealt with the urinary tract and more so when stone removal was the intent.^[49][50][51] Although, the urinary tract stone removal was not a necessary surgery and it appeared to be avoided in most cases, some argue that the Hippocratic Oath only wards of these procedures if the doctor holding the knife is inexperienced in that area.^[49][52] This idea puts forth the development of medical specialties – that is, doctors focusing on one particular area of medicine versus studying the wide array of material that is medicine.^[49][50] The doctors whom have become experts in the urinary tract – whom we would call urologists today – are those that could perform the heightened risk procedure of stone removal.^[49][50][52] With this reliance on specialized doctors of the urinary tract, some believe that urology itself was the first definable expertise of medical history.^[50][52]

Greek ostrakon

Wine

References to wine can be found throughout Greek antiquity in both dramas and medical texts.^[43] The Hippocratic texts describe wine as a powerful substance, that when consumed in excess can cause physical disorders, today known as, intoxication. Although the negative effects of wine on the human body are documented within the Hippocratic Corpus, the author/authors maintain an objective attitude towards wine. During this time, those studying medicine were interested in the physical effects of wine, therefore no medical text condemned the use of wine in excess. According to the Hippocratic text, the consumption of wine significantly affects two regions of the body: the head and the lower body cavity.^[43] Excessive drinking can cause heaviness of the head and pain in the head, in addition to disturbances in thought. In the lower body cavity, excess wine ingestion can have a purging effect; it can be the source of stomach pain, diarrhea, and vomiting.^[43] This stomach pain was more common among athletes because of their intense diets composed mainly of meat and wine.^[53] An overall effect of wine that all Greek doctors of the time have observed and agree on is its warming property. Therefore, wine's properties are described as "hot and dry."^[43] As documented in the Hippocratic texts, extreme use of wine can result in death.

Physicians tried to study the human body with pure objectivity to give the most accurate explanation for the effects of external substances that could be given for the time. During this period, physicians believed not all wines were equally potent in producing a range of perilous symptoms. According to the Hippocratic texts, physicians carefully categorized wine by properties such as color, taste, viscosity, smell, and age. According to Hippocrates, a more concentrated wine leads to a heavy head and difficulty thinking, and a soft wine inflames the spleen and liver and produces wind in the intestine.^[43] Other observations of the ingestion of wine included the varying levels of tolerance within the population being observed. This observation led to the belief that the size of one's body and one's environment had an influence on ability to handle wine.^[43] Because of this, different people would require different concentrations and dilutions of wine for medicinal use.^[53] After observation, men with larger bodies were able to consume more than men with smaller bodies and the same effects could be observed between them.^[53] Physician's also hypothesized that gender contributed to the effects of wine on the body. Women were noted to have a cold and wet nature which encouraged Hippocratic doctors to prescribe them undiluted wine. This differed from men, who typically were hotter by nature.^[53] It was not common practice between physicians of the time to recommend the consumption of wine for children. Physicians collectively believed that there was no purpose for children to drink wine. However, in rare circumstances, there are records of some doctors recommending wine for children, only if heavily diluted with water, to warm the child or to ease hunger pains.^[43] Mostly, doctors prohibited wine consumption for people under eighteen.

Greek physicians were very interested in observing and recording the effects of wine and intoxication, the excessive use of wine was well known to be harmful, however, it was also documented as a useful remedy. Several of the Hippocratic texts list the properties and use of foods consumed during 5th century BC.^[43][54] Wine was first defined as a food by all doctors. Directions for consumption varied based on gender, season, and other events in daily life. Men were encouraged to consume dark, undiluted wine before copulation, not to the point of intoxication, however enough to provide power and guarantee strength to the fetus.^[43] Because of wine's visual similarity to blood, physicians had assumed a relationship between the two substances. For this reason, men with cardiac illness, lack of strength, or pale complexion were encouraged to consume dark, undiluted wine.^[43] Multiple texts within the Hippocratic Corpus advise the use of wine in accordance with the seasons. During the winter, wine must be undiluted, to counter the cold and wet, because wine's properties are dry and hot. During fall and spring, wine should be moderately diluted, and during the summer, wine should be diluted as much as possible with water, because of the hot temperatures. The practice of mixing wine and diluting wine is also seen in prescription form, however, the dosage and quantities are left to the doctor.^[43] The prescription of wine as a treatment was prohibited with diseases that affected the head, brain, and those accompanied by a fever.^[43] Wine could also be used as an external remedy by mixing it with other substances such as honey, milk, water, or oil to make salves or soaks.^[55] Patients with pneumonia like illnesses would soak in a wine mixture and breath in the vapors with the intent to expel the pus from their lungs.^[55] Wine was frequently prescribed as a topical remedy for sores because of its drying effect.^[54]

Epidemics 1

Text from the section Aphorisms in the Hippocratic Corpus

Epidemics 1 begins by describing each season's characteristics. It states that autumn has strong south winds and many rainy days. Winter had south winds with the occasional north wind and droughts. Spring was southerly and cold with slight rain. Summer was cloudy and did not rain.^[56]

It then described diseases associated with each season. For example, in spring many people began having mild fevers which, in some cases, caused hemorrhage. The hemorrhage was rarely fatal. Swelling next to both ears was also common. Coughs and sore throats accompanied the other symptoms.^[57] Based on modern knowledge, this disease was mumps, which causes salivary glands under the ears to swell. It is remarkable that this ancient work describes symptoms so vividly that modern doctors can diagnose the cause a thousand years later.^[58] This section of the Hippocratic Corpus assumes that when looking at human disease and the health of humans, you must look at the seasons, winds and orientation of places, the nature of the water, the nature of the soil and the lifestyle of the inhabitants of a particular city.^[59]

Epidemics 1 goes on to describe the climate on two occasions and the diseases associated with them, called constitutions. The symptoms described include more serious, sometimes lethal, fevers, eye infections, and dysentery.^[56]

On Diseases

Jaundice is a disease that is mentioned numerous times throughout and is described as occurring in five ways. Jaundice is when the skin or eyes turn yellow.^[60] The Greek physicians thought of Jaundice to be a disease itself rather than what medical professionals know now to be a symptom of various other diseases. The Greeks also believed that there were five kinds of jaundice that can occur and report the differences between them.^[61]

The first kind can quickly turn fatal. The skin appears to be green. The analogy made in the text is that the skin is greener than a green lizard.^[61] The patient will have fevers, shiver, and the skin becomes very sensitive. In the mornings, sharp pains occur in the abdominal region. If the patient survives more than two weeks, they have a chance of recovery. The treatments suggest drinking a mixture of milk and other nuts and plants in the morning and at night.^[61] The second form develops only during the summer because it was believed the heat of the sun causes bile, a dark green fluid produced by the liver, to rest underneath the skin. This causes a yellowish color to the skin, and pale eyes and urine. The scalp also develops a crusty substance. The treatment calls for several baths a day on top of the mixture mentioned in the first remedy. Surviving past two weeks with this form of jaundice was rare.^[61] In two other forms of this disease, occurring during the winter, set in due to drunkenness, chills, and the excess production of phlegm. The last form is the least fatal and most common. It is associated with eating and drinking too much. The symptoms include yellow eyes and skin, fever, headache, and weakness.^[61] The treatment however, it very different from the rest. The physician will draw blood from the elbows, and advise to take hot baths, drink cucumber juice, and induce vomiting to clear the bowels. If the treatment is followed, a full recovery is possible.^[62] The several forms of jaundice that the Greek physicians proclaimed might be because jaundice occurs due to varying sicknesses like hepatitis, gallstones and tumors. The diverse set of symptoms were probably the effects of the sicknesses rather than the jaundice itself.

Empyemas

An empyema is a Greek word derived from the word empyein which means "pus-producing".^[63] According to the Hippocratic Corpus, they can occur in the thorax, the uterus, the bladder, the ear, and other parts of the body.^[55] However, the writings indicate that the thorax was the most common and provided more description. Physicians at the time thought that the cause of an empyema was by orally ingesting some form of foreign body where it will enter the lungs. This could be done by inhaling or drinking the foreign body. The physicians also thought that empyemas could occur after parapneumonic infections or pleurisy because the chest has not recovered from those illnesses.^[55] Parapneumonic infections can be tied to modern pneumonia which can still be fatal.

There are many symptoms associated with an empyema ranging from mild to severe. The most common ones are fever, thoracic pain, sweating, heaviness in the chest, and a cough.^[55] Treating an empyema was primarily done using herbal remedies or non-invasive treatments. Mostly mixtures of plants and organic matter were drunk or bathed in. There are a few extreme cases in which invasive procedures were performed and mentioned in detail. One of these treatments included the patient behind held down in a chair while the physician cut between the ribs with a scalpel and inserted a drainage tube which would remove all of the pus.^[55] The research and descriptions that the Greek physicians performed were so accurate that they were the foundation of what we know about empyemas today.

Dermatology

The Hippocratic Corpus provides valuable guidance for dermatology and the diagnosis of skin diseases or infections. Hippocrates described multiple dermatologic diseases, specifically in neonatal and pediatrics. These diseases included intertrigo, lichenoid eruptions, vitiligo, furuncle, leprosy, papulosquamous disease, skin reactions to specific medications, skin reactions to mosquito bites, warts, scabies, and impetigo.^[64] Along with the variety of skin diseases described in the Hippocratic Corpus is the suggest treatment. These treatments stem from the belief that dermatologic diseases were a result of imbalance in body humors.

For relief from various dermatologic conditions, the Hippocratic text recommends spring water or seawater baths and topical application of a fatty substance as a form of treatment.^[64] For intertrigo, or infant chafing, myrrh oil and litharge were powerful astringent compounds that were recommended as a form of treatment.^[64] For lichenoid skin conditions, vinegar, steam baths, pumice stones, and manna (sugar substance derived from mica thuris plant) were recommended to treat this skin disease. The Hippocratic text also offers sulfur as a treatment for lichenoid, which has a strong antibacterial effect that is still prescribed in dermatologic medications today.^[64] For leprosy and vitiligo, lime water and concentrated vinegar are recommended by the Hippocratic Corpus to treat these conditions.^[64]

Many of these forms of treatment proposed in the Hippocratic Corpus are utilized today for dermatologic infections. Modern medicine makes use of sulfur as an antibacterial compound, spring water has shown effective benefits when treating skin diseases, and oil-based products such as myrrh oil and litharge are used as ointments to treat intertrigo, eczemas, and skin lesions.^[64] When reflecting on the treatments of skin diseases and infections in the Hippocratic Corpus, it is evident that some of the approaches when applied to modern dermatology are still valid.