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“I will not cut, even for the stone”: origins of urology in the
hippocratic collection
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E. Poulakou-Rebelakou1, A. Rempelakos2, C. Tsiamis3, C. Dimopoulos4
1
Department 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
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Accepted after revision:
December 24, 2014
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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
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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. and may be identified with the term chronic glo-
A special mention for stone disease in merulonephritis (11).
childhood is notable, as it was unusual to fo- It is impossible in a short article like this to
cus on pediatric problems and, furthermore, to include all the urologic knowledge of the Hippo-
distinguish male and female children urological cratic physicians, acquainted through long expe-
problems, based on the anatomic differences of rience. However, the symptoms of bladder disease
the urethra. (ulcer, tumor, psoriasis, lithiasis and inflammation)
Female children are less liable to stone are all recognized by the urine appearance and the
because the urethra is short and wide and the changes of this appearance. In the Aphorisms Hip-
urine is passed easily in males it is not straight pocrates sums up much of what is of relevance to
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