Are the Ancient Lessons of Hippocrates Still Relevant Today?

Author:
Richard Colgan, MD

Citation:
Colgan R. Are the ancient lessons of Hippocrates still relevant today? Consultant. 2018;58(2):80-82.

To cure sometimes, to relieve often, to comfort always.

                                                     Hippocrates (circa 460-370 bce)

Some of the most important tenets of good doctoring and ethical practice can be traced back to Hippocrates. Although he is highly recognized as the Father of Medicine, little is known about Hippocrates of Kos, also known as Hippocrates the Great (circa 460-370 bce).

“All we know about Hippocrates is legend,” notes Roy Porter in his book, The Greatest Benefit to Mankind.¹ Two hundred years after Hippocrates’ death, the Greeks founded the Library of Alexandria with the aim of compiling and organizing thousands of medical writings provided by many medical, religious, and spiritual philosophers. Works attributed to Hippocrates stood out for the detailed nature in which the author described those suffering from diseases. All writings that seemed to follow this unique style were thereafter noted as having been written by Hippocrates and represent the Corpus Hippocraticum—the bodies of work that followed his distinguished theories about health and humanity.

One of the most frequently cited English translations of Hippocratic texts was translated from the Greek in 1849 by the Scottish surgeon Francis Adams.² The reader is referred to this text to learn more about the veracity of different treatises ascribed to Hippocrates.

I have never met a medical student who did not know Hippocrates’ most famous quote, “Primum non nocere,” or “First, do no harm.” If you had to remember only one line attributed to Hippocrates, this is undoubtedly the most important one. It is a theme that spans the entirety of medical practice, yet there is so much more that is learned from Hippocrates as one explores his life, personal experiences, and teachings.

NEXT: Hippocrates and the Power of Observation

Hippocrates and the Power of Observation

Hippocrates was renowned for his power of observation, thought by many to be his greatest skill. His followers were known for practicing bedside medicine. A collection of his writings entitled Aphorisms³ contains more than 200 observations of medical practice, disease process, and pathologic theory. Many of these are still relevant today, and those that are not as applicable to modern medical practice are of great interest in that they provide insight into the evolution of medicine. Furthermore, although some of his conclusions have been shown to be made without current standards of scientific validation, it is important to recognize the value Hippocrates placed on the physician’s skill of observation and its application to the patient. This is as important today as it was more than 2 millennia ago.

Yogi Berra once said, “You can observe a lot by just watching.” All healers do this; some do it better than others. A few of Hippocrates’ observations from Aphorisms follow³:

• Life is short, and art long, the crisis fleeting, experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.
• For extreme diseases, extreme methods of cure, as to restriction, are most suitable.
• Spontaneous lassitude indicates disease.
• Persons who are naturally very fat are apt to die earlier than those who are slender.
• And in whatever part of the body heat or cold is seated, there is disease.
• If erysipelas of the womb seize a woman with child, it will probably prove fatal.
• Pneumonia coming on pleurisy is bad.
• Delirium upon division of the cranium, if it penetrate into the cavity of the head, is bad.
• When bubbles settle on the surface of urine, they indicate disease of the kidneys, and that the complaint will be protracted.
• Sleep and watchfulness, both of them, when immoderate, constitute disease.

Some of Hippocrates’ aphorisms may make you laugh, such as the following:

• Drinking strong wine cures hunger.
• If you wish to stop the menses in a woman, apply as large a cupping instrument as possible to the breasts.
• A woman does not become ambidextrous.
• Eunuchs do not take the gout, nor become bald.

Some simple but critical observations you do not want to miss include such details as the pack of cigarettes in your patient’s pocket, how your patient just crossed her arms as you gave advice she disagrees with and how this may negatively affect her adherence, and the atypical skin lesion that catches your eye as you listen to your patient’s posterior thorax. Another subtle observation not to be missed might include the slight change in mental status of an elderly patient, potentially denoting an early sign of sepsis or dementia. When I was a third-year medical student, one professor explained to me, “The organs of the aged do not cry out in pain.” I have remembered this throughout my years of clinical practice, and it has served me well. Observe all.

NEXT: The Hippocratic Oath

The Hippocratic Oath

Hippocrates cautioned that we evaluate honestly. The fact that the physicians of Hippocrates’ time were observed as being less than honest speaks of the human frailties to which we are all susceptible. We have all heard stories about or perhaps have been witness to physicians who do not evaluate honestly. The Hippocratic Oath, recited by medical students prior to graduation, urges physicians to act in a professional manner and not to provide therapy for our patients for personal financial gain.

“I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work,” Hippocrates wrote in the oath. Many occupations refer to themselves as “professional,” but this term takes on a very complex meaning when it is used to denote a physician, dentist, nurse, or other health care provider.

In the Hippocratic Oath, we are urged to practice beneficently and do what is best for our patients. This is a recurring theme in medicine and society throughout the ages. This concept is certainly not contentious, but as we will see it is felt by several teachers in the current century to be in need of reiteration. Euthanasia and abortion were clearly concepts about which Hippocrates felt strongly. Throughout the centuries, these topics evoke strong emotions from both patients and health care providers and continue to polarize many people in medicine, politics, religion, and society. It is up to physicians to sort through their own values on these controversial subjects and decide their practices accordingly.

This is followed in the oath by a declaration that as healers we should live a life of purity and holiness. From this interpretation, it almost sounds like we are entering a religious order, yet the fact that the healer’s examining room is often likened to a confessional strengthens this notion. It may be a stretch to compare physicians to priests; however, in both instances, those seeking service divulge the innermost secrets about their bodies and personal lives to a trustworthy advisor. Both physicians and religious figures are healers of people, and like priests, rabbis, and teachers, we share a common vocation to serve society.

Passion follows next in the Hippocratic Oath. While it is important to show compassion for our patients, Hippocrates notes it is not appropriate to be passionate with our patients. Unfortunately, throughout the United States and the world of medicine, there continues to be reports of physicians who engage in inappropriate relationships with their patients.

Perhaps one of the most important notions emphasized in the oath is that of physician-patient confidentiality. The Hippocratic Oath reminds us that we should not divulge what we have learned from our patients. Our communications and patient interactions must be kept secret in order to maintain the trust, safety, and dignity of our patients, and to uphold the protocol established by past professionals. Physician-patient confidentiality was felt to be important even before the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the HIPAA Privacy Rule were created.

Porter notes, “The art of diagnosis involved creating a profile of the patient’s way of life, habitation, work, and dietary habits.”¹ Hippocrates urged that when it comes to therapeutics, we should “assist nature.” He strongly advocated the encouragement of patients to take better care of themselves by changing their lifestyles, particularly when it came to following a prescribed diet: “A slender and restricted diet is always dangerous in chronic diseases.” Likewise, Hippocrates advocated exercise or activity for certain ailments: “It should be kept in mind that exercise strengthens, and inactivity weakens.”

Although many of his prescriptions would now be viewed as ludicrous by today’s standards, Hippocrates’ concern for well-being is parallel to current medical practice’s mindfulness of the importance of diet, exercise, and activity with regard to patients’ health. In recent years, this concept has become more applicable with the overwhelming surge of diagnoses of metabolic syndrome, childhood and adult-onset diabetes, obesity, coronary artery disease, hypertension, and many other preventable health problems currently plaguing our country.

NEXT: The Art of Prognostication

The Art of Prognostication

According to Hippocrates in The Book of Prognostics,⁴ one of the important qualities for a physician to cultivate is the ability to prognosticate: “[B]y foreseeing and foretelling, in the presence of the sick, the present, the past, and the future, and explaining the omissions which patients have been guilty of, he will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician. And he will manage the cure best who has foreseen what is to happen from the present state of matters.”

In The Book of Prognostics, we also learn one way in which Hippocrates avoided the malpractice of his day—censure. This implies that by being aware of the natural history of a disease and whether or not medical intervention will indeed improve a condition, the physician would best be able to counsel a patient about what to expect in the course and outcome of his or her illness. In the age of Hippocrates, it was recognized that effective communication between physician and patient was one of the best ways to avoid censure, particularly in matters when the prognosis was poor. Honest information about what the patient should or should not expect regarding his or her illness was as important then as it is now. Not only does it base the patient’s apprehensions in reality, but it also allows for informed decision making of both parties involved. Furthermore, it strengthens the physician-patient relationship as the patient’s trust in his or her doctor is reaffirmed.

In acute diseases, the physician should first observe the “countenance” of the patient. Hippocrates compiled some prognostic indications of a poor patient outcome, which are still recognized as valid⁴:

• Hollow eyes
• Collapsed temples
• Cold ears
• A black, green, livid (black and blue; deathly colored), or lead-colored face (The above 4 are part of the facies Hippocratica, or the facial look of the dying.)
• Seeing the whites of patients’ eyes when they are sleeping
• Cold sweats to the head, face, or neck (these in acute fever prognosticate death)
• A swelling in the hypochondria (the area just underneath the anterior rib cage, to the left and right of the epigastrium bilaterally) that is hard or painful
• Dropsies (diseases with drops, or water, or edema—eg, congestive heart failure) arising from acute diseases
• When the head, hands, and feet are cold while the belly and sides are hot
• Strong and continued headaches with fever, if any of the deadly symptoms be joined to them, are very fatal.
• Others of his prognostics are not as applicable to medical practice today and may be categorized as just plain funny, such as, “It is best when wind passes without noise, but it is better that flatulence should pass even thus than it should be retained.”

The Modern Lessons of Hippocrates

Hippocrates’ teachings have withstood centuries of scrutiny and are perhaps as relevant today as they were back then. This article only briefly reviews a few of his lessons. Some of the most important of Hippocrates’ lessons are first, do no harm, observe all, evaluate honestly, prognosticate when you can, and when it comes to therapeutics, assist nature.

Additionally, healers of any era should recognize that we are not in the practice of medicine for money but to serve our fellow man, and that we would be wise to learn from our predecessors in medicine and by carefully studying our patients. Lastly, it is ideal that we should live our life with purity and holiness as we practice our art. 

Richard Colgan, MD, is a professor and the vice chair for medical student education and clinical operations in the Department of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore. For more, visit his website, www.advicetotheyoungphysician.com.

References:

1. Porter R. The Greatest Benefit to Mankind: A Medical History of Humanity. New York, NY: WW Norton & Co; 1998.
2. The Genuine Works of Hippocrates. Adams F, trans. London, England: Sydenham Society; 1939.
3. Hippocrates. Aphorisms. Adams F, trans. http://classics.mit.edu/Hippocrates/aphorisms.html. Accessed January 31, 2018.
4. Hippocrates. The Book of Prognostics. Adams F, trans. http://classics.mit.edu/Hippocrates/prognost.html. Accessed January 31, 2018.