THE DOCTOR'S BAG BY Keith Souter aka Clay More

2 – THE HIPPOCRATIC OATH

Welcome back to The Doctor's Bag, our monthly look at 19th century medicine, and how aspects of it compare to the profession today. This time we'll take a look at that famous oath that binds all doctors, and has done throughout the millennia - apart from when the actions of various unscrupulous or unethical doctors have demanded that it be updated.

THE OATH

‘I SWEAR by Apollo the physician, and Aesculapius, and Hygieia, and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation …….’

A code rather than an oath

Hanging on the office wall of countless frontier doctors, according to western movies and novels, would be a copy of the Hippocratic oath. It may even have been in Latin, for that was the language of medicine for centuries.  In reality, most frontier doctors probably had no such adornment to their surgery wall, on account of the fact that they were probably not medically qualified at all. And those that were may have merely held a diploma qualification that certified that they had attended a series of lectures at some sort of medical college.

No formal educational qualifications were needed to enter a medical school. Indeed,  even the famous Harvard Medical School in 1870 had no written examinations, because apparently most of the students at that time could not write well enough.

But that is not to say that these early doctors did not serve their communities well. Some were superb, while others were at the most, better than nothing.  Still others didn’t stay around too long. Yet all of them would have had an awareness of a code of practice, the Hippocratic code. Basically, it was to do the best for your patient through hell and high water, and not to betray a confidence. That would have been the code that governed their professional life.

The Hippocratic oath

Everyone associates the Hippocratic oath with medicine. It is one of the most popular selections of ancient literature, even though the original Oath is now rarely read or recited. Hippocrates himself almost certainly did not write the original oath, but the work is traditionally included in the Corpus Hippocratum, a collection of medical writings attributed to him, written between the fifth and fourth century, BC.

Aesculapius was the Greek god of healing, and Hygieia and Panacea were his two daughters. Hygieia was the goddess of cleanliness and sanitation, while Panacea was the goddess of Universal remedy. It is said that of the two, he preferred Hygieia.

Nowadays we would agree with that, since ‘hygiene’ is probably one of the most important measures that benefits the health of a community.  And of course, there is no such thing as a panacea – a cure-all!

Hippocrates of Kos (460-370 BC) was an ancient Greek physician, who really brought medicine out of the religio-magical practice of his forefathers and who laid the foundations for the practice of clinical medicine.

Aphorisms

It is generally accepted that we must thank the Classical Greeks for the aphorism, as we know it, that short segment of distilled wisdom that is designed to express a general truth. They are like proverbs and adages; essentially they are rules of thumb. Sometimes they will be discrete packets of wisdom; at other times they are building blocks, which link up with other aphorisms to make a greater whole.

In the Aphorisms of Hippocrates, one of the books of the Hippocratic Corpus that is regarded by philologists as having been genuinely written by Hippocrates himself, the aphorism is seen as an ideal vehicle for passing on the wisdom of experience. In reading these today one can almost imagine the father of western medicine sitting under the famed plane tree on Kos and delivering his nuggets of wisdom to his eager pupils. Indeed, they were an ideal way of handing on the oral tradition of medicine.

 The plane tree on Cos, under which Hippocrates reputedly sat and taught his pupils

The first aphorism of Hippocrates

In this first aphorism, which is often abbreviated to ‘Life is short, the Art is long,’ we see a remarkable piece of advice, which is highly relevant to the practice of any form of medicine.

‘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.’

Hippocrates is telling us that it takes a lifetime to truly learn the art or practice of medicine, and that no one can truly master it. The crisis or opportunities for learning are quickly over, so must be grasped. Experience is not always reliable, so it is important not to base knowledge exclusively upon experience. And finally, judgement is always difficult, because of the complexities of the discipline.

Know a few aphorisms

Doctors in Britain, before the time of any sort of regulation of their practice, could impress by trotting out the odd aphorism in Latin or Greek.  About ninety-five per cent of all medical terms are based on Latin or Greek or a mixture of the two. In general, anatomical terms and the names of micro-oragnisms (which of course were not discovered or known about back in the days of the Civil War and the decade or so after) were derived from Latin. The names of conditions and pathological states, on the other hand, come from the Greek.

            

Most doctors would know this Latin aphorism:

Ubi pus, ibi evacua. Which means, ‘where there is pus, let it out.’ It is a great surgical maxim, especially in pre-antibiotic days.

And, this one:

Res in cardine est. Which means, ‘the next 24hours will tell.’ Again, without modern drugs, often 24 hours could be critical.

Taking the oath

The swearing of the Hippocratic oath is something that is done when you graduate from a university or a medical school. I remember taking my oath, many moons ago, along with my fellow students in our class of 100. It was a proud moment that made one conscious of the long history of oath-taking in our profession.

For several centuries now, doctors upon qualification have taken modified versions of the oath containing the essence of its message.  It is the code by which doctors agree to live by and the fact that doctors take it,  is essential in allowing patients to put their trust in the individual doctor.

There are four main variations:

The Oath of Maimonides written by Moses Maimonides (1135-1204 AD), a rabbi, philosopher and physician in the 12^th century. He was the court physician to Sultan Saladin. Apparently he had declined an invitation to become personal physician to King Richard the Lionheart.

The Declaration of Geneva adopted by the World Medical Association at Geneva in 1948. This arose from the Nuremberg Code formulated in 1949, after the trials in which 23 Nazi doctors were found guilty of breaching the medical code by performing horrific operations on prisoners in concentration camps.

There were other amendments to the Declaration in 1968, 1984, 2005 and 2006, to deal with various issues as they have arisen, including euthanasia, torture of prisoners and so on.

The Oath of Lasagna was written in 1964 by Louis Lasanga, the Dean of Tufts Medical School. It stresses the importance of dealing with patients as human beings, not just as medical cases.  

The Restatement of the Hippocratic oath in 1995. Again, slight variation, which was drawn up by 35 eminent US physicians, the ‘Value of Life Committee. This is the commonest one taken in medical schools today. 

The Oath today

In 1989 a survey was done of 126 US medical schools. It was found that three still used the original Hippocratic oath, 33 used the Declaration of Geneva, 65 used the restatement and 4 used the Oath of Maimonides.

Dr Logan Munro of Wolf Creek

The town doctor of Wolf Creek graduated from Edinburgh University in Scotland in 1853 and took his Hippocratic oath at the graduation ceremony. To him it is a solemn principle that guides him in both his professional and his personal life. And nothing will make him break it! You will find out in the forthcoming Wolf Creek novels 4 and 6.

As is customary, I will be giving away a hardback copy of my book Doctors' Latin - A miscellany of Latin and Greek Medical phrases, to one commenter. It may be useful if you want to decipher his or her handwritten scrawl.