thirty-six hippocratic aphorisms of nephrologic interest
TRANSCRIPT
WORLD KIDNEY FORUM
Thirty-six Hippocratic Aphorisms of Nephrologic Interest
Athanasios Diamandopoulos, MD, PhD,1 Pavlos Goudas, MD,1 andDimitrios Oreopoulos, MD, PhD2
by th
World Kidney ForumAdvisory Board
Rashad S. BarsoumCairo, Egypt
Christopher R. BlaggMercer Island, Washington
John BoletisAthens, Greece
Garabed EknoyanHouston, Texas
John T. HarringtonBoston, Massachusetts
HIPPOCRATES IN CONTEXT
I t is said that the beginning ofeducation is the understand-
ing of terminology. Thus, webegin this article by discussingthe word “aphorism.” It derivesfrom the Greek aphorizein (apo� horizein [horizon, bound-ary]), meaning to delimit, markoff, divide, define. In form, apho-risms are always terse and tren-chant, facilitating maximumcomprehension in minimum ex-pression. The Hippocratic apho-risms are just that: concise, of-ten pithy, and memorablestatements of literal truths andfrequently obvious wisdoms. Ifwe can use an aphorism to de-fine what aphorism is, the mostappropriate one would be: “Thefinest thoughts in the fewestwords.”1 The term aphorismitself originally was coined to
refer to the aphorisms of Hip-American Journal of Kidney Diseases, Vol
pocrates that are included inthe Corpus Hippocraticum,which is the full collection ofHippocratic writings. Themost famous of the Hippo-cratic aphorisms is the firstand remains familiar: “Life isshort, and Art [of medicine]long; the crisis fleeting; expe-rience perilous, and decisiondifficult. The physician mustnot only be prepared to dowhat is right himself, but alsoto make the patient, the atten-dants and the externals coop-erate.” 2[Section 1, Alphorism 1]
To best understand the apho-risms, it is important to placethem into the context of boththe medical knowledge and cul-tural practices of the times. Inthe era of Hippocrates, knowl-edge of anatomy was reason-ably thorough, reflecting alengthy history of battlefieldmedicine. The Corpus Hippo-craticum is composed of somewritings by Hippocrates him-self, some by students of Hip-pocrates, and some insertedinto the collection at a laterdate. The corpus contains scat-tered many correct observa-tions: it defines the aorta asoriginating in the heart and de-scribes the development of the
In this article, we discuss the nephrisms. Although similar attempts habelieve that in each era new insightsrisms through the prism of current methe Hippocratic text, we discuss the 3nephrology. We conclude that thesepocrates as the “Father of Clinical NeAm J Kidney Dis 54:143-153. © 2009
kidneys at the end of renal ar-
54, No 1 (July), 2009: pp 143-153
teries, the branches of the ab-dominal aorta, and the paralleldirection of the nerves. Theanatomical connection of sper-matic arteries with the kidneysis observed, a fact that led tothe notion that sperm is createdinitially inside the kidneys andthen delivered through the sper-matic vessels to the testiclesbefore finally exiting the body.The similar shape of both kid-neys and their apple-like coloralso is described. A descriptionof the granular and viscous tex-ture of the kidneys and theexcess of humidity in their in-terior is given, and it is notedthat the ureters descend fromthe kidneys and end in the blad-der. It is written that renal ves-sels transfer blood with liquidwaste products of metabolic re-actions to the kidneys and the
From the 1Renal Department, StAndrew’s State Hospital, Patras,Greece; and 2University Health Net-work and University of Toronto, To-ronto, Canada.
Address correspondence to Athana-sios Diamandopoulos, MD, PhD, Cho-rio Romanou, Patras, 26500, Greece.E-mail: [email protected]
© 2009 by the National KidneyFoundation, Inc.
0272-6386/09/5401-0021$36.00/0
ic content within Hippocrates’ Apho-ken place ever since antiquity, webe gained by examining the apho-
knowledge. Of the 400 aphorisms int we consider to be most relevant toorisms support the concept of Hip-ogy.”e National Kidney Foundation, Inc.
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doi:10.1053/j.ajkd.2009.01.275
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Diamandopoulos, Goudas, and Oreopoulos144
blood returns, purified, to theentire body. Hesitantly, the au-thor allows that the kidneys are“not alien to the excretion ofurine.” Observations of patho-physiological characteristics,diagnosis, and prognosis of re-nal diseases are spread through-out these works, in which vari-ous urologic symptoms areconnected with their correct di-agnosis and prognosis. Theterm “nephritic” (���������) isused to describe patients with avariety of renal ailments, such asstrangury, anuria, and hematuria.
THE APHORISMS
The Hippocratic aphorismswere probably written circa 400BCE and contain 400 entriesdealing with all aspects of prac-tical medicine. Although au-thorship of much of the Cor-pus Hippocratum is debated,the aphorisms are consideredone of the few works in theCorpus most likely penned byHippocrates himself. This be-lief was held as far back asGalen and the Byzantines andis echoed by more recent writ-ers, including Paul-Émile Lit-tré (1801-1811) in the 19th cen-tury, although several scholarsstill express reservations abouttheir authenticity.3,4 The bookof aphorisms was very influen-tial because of its clarity andbrevity. Numerous writers ex-tensively commented on it;from the Greek-speaking worldalone, these included Soranus,Rufus, Galen, Paladius, Stepha-nus of Athens,5 TheophilusProtospatharius, Damascius,and Johannes Actuarius.
The Islamic world also hasbeen heavily influenced by the
Hippocratic aphorisms. No-table Arabic translations of itinclude versions by Ibn al-Quff (d 1286) and Ibn Abı�Sa�diq (d �1068). Because thelatter composed a popular com-mentary on the aphorisms ofHippocrates, he was known insome circles as “the secondHippocrates” (Buqra� al-tha�nı�).In mimicking Hippocrates,other influential Arab scholarscomposed their own “apho-risms,” which in reality wereedited copies of the original.One example is al-Ra�zı�’s Kita�bal-Murshid ([The Guide]; Fig 1).The Hippocratic aphorisms also
Figure 1. The opening of the treaKita�b al-Murshid [The Guide]. In the inmisunderstanding and confusion regarcomposed new medical aphorisms, wmedical art and a guide for students. C
influenced the Jewish doctors.7
One of Maimonides’ medicalwritings is the Commentary onthe Aphorisms of Hippocrates.In this work, Maimonides occa-sionally criticizes both Hip-pocrates and Galen when ei-ther of these Greeks differsfrom his own views. Follow-ing the fashion, he also wrotehis own aphorisms, calledPirkei Moshe (Medical Apho-risms of Moses).8
As would be expected, theaphorisms were translated intoLatin at an early stage, facilitat-ing dissemination in Westernmedical thought. Early transla-
n medical aphorisms by al-Ra�zı� titledtion, al-Ra�zı� explains that because of
the aphorisms of Hippocrates, he hascould serve as an introduction to they of the National Library of Medicine.6
tise otroducding
tions were undertaken by Bur-
eref
World Kidney Forum 145
gundio of Pisa (from Greek inthe 12th century), Gerard ofCremona (in Toledo, fromGreek in the 12th century), andWilliam of Moerbeke and oth-ers (from Arabic after 1260).9
As early as 1145, the aphorismshad reached then-remote En-gland (Fig 2). Rabelais in Francegained his reputation as a seri-ous scholar with a translation ofthe aphorisms, which appearedin a 1532 edition from the Gry-phius publishing house.11 Char-acteristic of the high esteem thework had in the Renaissance,Theophrastus Paracelsus, onJune 24, 1527, surrounded by acrowd of cheering students,
Figure 2. A page of Hippocratic aoriginated in England, perhaps in HNational Library of Medicine.10
publicly burned the works of
Avicenna and Galen andshowed respect only to theaphorisms of Hippocrates.12
HIPPOCRATIC APHORISMSOF NEPHROLOGIC INTEREST
Here, we analyze the Hippo-cratic aphorisms of nephro-logic interest, interpreting andspeculating on their relevanceto our contemporary knowl-edge. Although there are othersimilar works on various dis-eases, they rarely include somany aphorisms referring to asingle specialty. We used thetranslation of the Scottishmedical doctor Francis Ad-
sms from a treatise on medicine thatord, around 1145. Courtesy of the
ams2 (1796 to 1861) and the
edition of Hippocrates’ Textsby the French medical doctorand lexicographer, Littre13, vol-umes that have the same cita-tion indexing, ie, in sectionsand aphorisms. When we be-lieved that some aphorismscould have a different meaningthan that given by Adams’stranslation, we have added thealternative meaning in brack-ets, leaving the text unaltered.We also compared our com-ments with those of previousancient and Byzantine writers.We used Kühn’s14,15 1965 edi-tion of Galen’s In HippocratisAphorismos Commentarii anda 1966 edition (Hakkert pub-lishing house) of the treatiseCommentarii in HippocratisAphorismo from the Byzantinemedical writers Theophilus,Stephanus, and Damascius.16
(Theophilus Protospatharius,circa 7th century CE, was aphysician in the court of theByzantine Emperor Heraclius;Stephanus of Athens was aByzantine physician of the 6thcentury; and Damascius was aByzantine physician of the 9thcentury CE, not to be confusedwith the neoplatonic philoso-pher.) Although they wrotecomments for all aphorisms,we included only those that, inour opinion, further elucidateeach aphorism’s meaning. Be-cause some aphorisms spanmore than one category, theyhave been classified arbitrarilyby major topic, independent oftheir sequence in the originaltext.
OnUroscopy (without specificdiagnosisorprognosis)
[Section 4. Aphorism 69]When the urine is thick, gru-
phori
moss, and scanty in cases not
Diamandopoulos, Goudas, and Oreopoulos146
free from fever, a copious dis-charge of thinner urine provesbeneficial. Such a dischargemore commonly takes placewhen the urine has had a sedi-ment from the beginning, orsoon after the commencement.
This could very well be adescription of oliguric renalfailure complicating a febriledisease. The scanty amount ofurine that is thick and “gru-moss” (“thrombodea,” ie, likea thrombus, dark red, curdled)may very well be the result ofan acute tubular necrosis,whereas the large amount ofthin urine that follows couldrepresent the lysis of the fail-ure with its polyuric phase.
[4.70] When in fevers the urineis turbid, like that of a beastof burden, in such a case thereeither is or will be headache.
The urine of horses, don-keys, and cattle is turbid, prob-ably because of the high con-centration of phosphates thatthey consume through theirvegetative feeding. Ancientshad noticed this as a differencecompared with human urine,which is clear even whenhighly concentrated. This ob-servation had been reported ini-tially in Mesopotamian writ-ings, then in ancient Greekwritings, and later in the Ara-bic medical writings.17 Themost probable explanation forthe turbid urine Hippocrates de-scribes is either pyuria or over-excretion of organic or inor-ganic salts. Such a conditioneventually will lead to an ab-normal internal milieu and thuspossibly headache. In the caseof macroscopic pyuria, one cansuggest pyelonephritis; hence,the headaches. In the case of
turbid urine caused by protein-uria (“macroscopic” protein-uria if one can coin such aterm), this implies massive ne-phrotic-range proteinuria. Sucha condition will almost cer-tainly be accompanied by ac-tivation of the renin-angioten-sin system with salt retention,generalized edema, and hyper-tension. Thus, the “either is orwill be headache” predictionalso could be a sign of hyper-tension.
[4.71] In cases which come toa crisis on the seventh day,the urine has a red nubeculaon the fourth day, and theother symptoms accordingly.
This is a prognostic apho-rism. The hematuria that pre-sents on the fourth day afterthe outbreak of the disease is asign of the severity of the dis-ease, and the aphorism pre-dicts that there will follow acrisis on the seventh day. Bycrisis, it is meant the end of thedisease, not worsening. Al-though it is not unusual fortransient hematuria to cease af-ter a few days, we cannot giveany significance to the num-bers 4 or 7 of the correspond-ing days. This numbering is aremnant of the pre-Socratic andPythagorean teachings on thesignificance of numbers inmedicine. It was based on theMesopotamian and Babylonianline of thought to connectearthly phenomena with thephases of the moon.17
[4.72] When the urine is trans-parent and white, it is bad; itappears principally in casesof phrenitis.
This could describe a patientwith advanced renal failure.Transparent white urine could
be a description of the isosthe-nuria of chronic renal failure.Galen14(p759line17) andDamascius16(p430line11) com-mented that the “phrenitis” wascaused by retention of toxicsubstances (yellow bile) thatwere not properly excretedthrough urine, instead accumu-lating in the brain and causingthe symptom. We suggest thatthis aphorism is applicableeven today because if we re-place “yellow bile” with “ure-mic toxins,” we have a descrip-tion of neurological signs ofsevere renal failure, ie, uremicencephalopathy.
[4.76] When small fleshy sub-stances like hairs are dis-charged along with thickurine, these substances comefrom the kidneys.
This could be one of theearliest descriptions of bloodcasts. What is most impressiveis Hippocrates’ certainty thatsuch substances come from thekidneys. Hippocrates was wellaware of the complicated anat-omy of the kidneys, althoughhe could not explain their func-tion. He clearly distinguishedblood in the urine as a sign ofhemorrhage, ie, a ruptured ves-sel from the bladder or kid-neys, and the “fleshy sub-stances” as originating from thekidneys.
[4.77] In those cases wherethere are furfuraceous par-ticles discharged along withthick urine, then the bladderhas scabies [is “scabious”].
Thick urine with “furfura-ceous” particles probably de-scribes cystitis with excretionof squamous cells from the epi-thelium of the bladder. It couldalso be a case of cystitis with
white blood cell aggregates.
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The term “scabious” is descrip-tive rather than diagnostic.
[7.31] When there is a farina-ceous sediment in the urineduring fever, it indicates a pro-tracted illness.
This is a description of casesof fevers that are complicatedby either massive discharge ofepithelial cells or pyuria. Ineither case, the renal involve-ment, an acute inflammatorycondition or pyelonephritis, isindeed a case that would havepersisted, considering the Hip-pocratic means of treatment.
[7.32] In those cases in whichthe urine is thin at first, andthe sediments become bilious,an acute disease is indicated.
Galen in his com-ment15(p132line11) clarified thatHippocrates meant black, notyellow, bile. He then ex-plained that this aphorism re-fers to time only, not to lo-cum, ie, the aphorism predictsthe course of disease, not theaffected organ.
Is this a description of acutetubular necrosis or postinfec-tious glomerulonephritis? Ifthis aphorism is connected tothe previous one, ie, it refers topatients with fever, it probablyis an exacerbation of somechronic renal disease. The“thin” urine could be a descrip-tion of the isosthenuria of achronic disease. Although “bil-ious” in modern English wouldmean green, Hippocrates re-fers to bilious as either yellowor black (ie, very dark red). Ifwe assume he means black bile,as Galen states, this aphorismdescribes an acute exacerba-
tion of a chronic condition.[7.33] In those cases in whichthe urine becomes dividedthere is great disorder in thebody.
This aphorism refers to urinewith a large quantity of sedi-ment, making it appear “di-vided” into 2 parts, sedimentand suspension. The largeamount of sediment, whateverthe cause may be, predisposesto a very severe condition.
[7.34] When bubbles settle onthe surface of the urine, theyindicate disease of the kid-neys, and that the complaintwill be protracted.
Galen elaborated on thisaphorism: “Bubbles are cre-ated when the liquids arestretched by air. And usuallythis happens when the liquidcontains something sticky. Inwhich case the bubbles don’tbreak easily and becomepermanent . . . .”15(p134line12)
This is the most frequentlyquoted “renal” Hippocraticaphorism and it could be oneof the earliest descriptions ofproteinuria. It is the increase inthe surface tension of the urinecaused by the proteins that pro-duces this phenomenon. Unfor-tunately, the aphorism does notgive any detail concerning thepatient’s condition, ie, edema,weakness, headaches (hyper-tension), and so on.
[7.35] When the scum on thesurface is fatty and copious, itindicates acute diseases of thekidneys.
Regarding this aphorism,previous commentators havestated that the presence of grossquantities of fat on the surfaceof urine indicates decomposi-tion of the fat in the body in
acute generalized diseases orthe perinephric fat in diseasesof the kidneys. They also con-nected this case with cases offatty stools as having the samecause.18 The notion persistedthrough the 19th century withthe term lipurie.19 Althoughthis aphorism provides inad-equate detail to be certain, itcould be a description of ne-phrotic-range nonspecific pro-teinuria with a variety of pro-teins excreted, thus the “fatty”(lipoproteins) and “copious” (ingross quantity).
[7.67] We must look to the uri-nary evacuations, whether theyresemble those of persons inhealth; if not at all so, they areparticularly morbid, but if theyare like those of healthy persons,they are not at all morbid.
This aphorism is a reminderto all physicians (and knownby all nephrologists): Alwayslook at the patient’s urine. Itreminds one of another apho-rism by Sir Robert Hutchisonat the beginning of the 20thcentury: “The ghosts of deadpatients do not ask why we didnot employ the latest fad ofclinical investigation; they ask‘why did you not test myurine?’ ”20 Hippocrates somuch believed that examina-tion of urine was fundamentalfor diagnosis and prognosis thathe declared that if the urine ofa sick person is normal, theprognosis is favorable.
OnDiagnosis
[4.75] Blood or pus in theurine indicates ulceration ei-ther of the kidneys or of thebladder.
The English translator paidno attention to the grammar of
this aphorism, not heeding the
Diamandopoulos, Goudas, and Oreopoulos148
distinction between “����”(“ureei”; “is urinating”), whichsuggests continuity, and“�����” (“ourese”; “uri-nates”), which implies only aninstant. A more precise transla-tion of this aphorism is: “If [apatient] is urinating [����/ureei] blood or pus, this indi-cates ulceration of the kidneysor the bladder.” On the basis ofthe use of a continuous tense,Theophilus argued that theaphorism does not refer to rup-ture of an abscess from anotherorgan, such as the liver, intothe urinary system, in whichcase the blood and pus uri-nated would not last long, per-haps 2 or 3 days. Asking rhe-torically “And why did he notmention the ureters?” Theophi-lus further explains that “bymentioning the two ends heincluded the middle.” Damas-cius added: “Urinating impliesmany days . . . . For urinatingand urinate are not thesame.”16(p432line28) It is interest-ing to notice the detail in whichthese commentators analyzedthis aphorism, and its impor-tant message is the chronicityof the disease.
[4.41] A copious sweat aftersleep occurring without anymanifest cause indicates thatthe body is using too muchfood. But if it occurs whenone is not taking food, it indi-cates that evacuation isrequired.
In this case, the skin is usedas an alternative route for fluidelimination in cases of over-consumption of food. How-ever, in cases in which there isprofuse sweating without over-indulgence, Hippocrates statesthat it is a sign of excess fluids
that need to be eliminatedthrough some kind of treat-ment. That is, the natural elimi-nating organs, kidneys and/orgastrointestinal tract, are mal-functioning, unable to offerproper catharsis, and thereforesome other kind of provokedcatharsis must be applied.21
[4.74] When there is reason toexpect that an abscess willform in joints, the abscess iscarried off by a copious dis-charge of urine, which is thick,and becomes white, like whatbegins to form in certain casesof [exhaustive] quartan fever.It is also speedily carried offby a haemorrhage from thenose. [If a nosebleed also oc-curs as well, lysis will comevery fast.]
Here, Galen14(p764line8) andthe Byzantine commentat-ors16(p431line25) state that thesubstance accumulated in thejoints can be removed byurine and thus the patient becured.
What would be the trigger-ing factor “to expect that anabscess will form in joints”? Inan adult man, the driver is prob-ably overconsumption of foodand wine in cases of hyperuri-cemia. Hyperuricemia couldform tophi, which resemble ab-scesses (gout), whereas poly-uria with urine full of a whitematerial (phosphates or amor-phous urate salts, although thelatter usually are reddishbrown) will gradually lead tothe lysis of arthritis. However,the aphorism does not indicatewhether the polyuria was spon-taneous or was to be achievedby some medical intervention,such as water consumption orsome medication.19
[4.78] In those cases wherethere is a spontaneous dis-
charge of bloody urine[� where they are urinatingbloody urine], it indicates rup-ture of a small vein in thekidneys.
The key word in this apho-rism is “spontaneous.” Hip-pocrates had obviously no-ticed some cases of hematuriathat had no apparent cause. Inother aphorisms, he refers tohematuria as the result ofsome known or at least sus-pected cause, such as the pass-ing of a stone or trauma, asystemic disease with fever,or cancer. However, he real-ized that spontaneous hematu-ria could occur with no appar-ent cause in an otherwisehealthy person, and that is thereason he attributed this con-dition to a “rupture of a smallvein.” Galen elaborates cor-rectly that “spontaneous” maymean either without apparent ex-ternal cause (ie, trauma) or with-out preliminary symptoms (eg,bladder ulceration).14(p774line1)
Theophilus again reminds thereader of the grammar of theaphorism, using the verb “uri-nating,” not “urinate,” imply-ing a long duration of thesign.16(p434line22) According toEknoyan,22 aphorisms 4.75 to4.78 probably describe papil-lary necrosis, whereas wespeculate that it may well be acase of bladder tuberculosis.With our present knowledge,we cannot exclude immuno-globulin A nephropathy as analternative diagnosis.
[4.79] In those cases wherethere is a sandy sediment inthe urine, there is calculus inthe bladder.
The “sandy” sediment in theurine could be calcium or urate
salts. In either case, the exis-
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tence of calculi in the bladderand/or kidneys of such a pa-tient is highly probable.
[4.80] If a patient pass bloodand clots in his urine, andhave strangury, and if a painseizes the hypogastric regionand perineum, the parts aboutthe bladder are affected.
[7.39] When a patient passesblood and clots, and is seizedwith strangury and pain in theperineum and pubes, diseaseabout the bladder is indicated.
These 2 diagnostic apho-risms are almost identical, withaphorism 7.39 probably beingadded at a later date. The topo-graphic localization and asso-ciation with anatomic struc-tures gives a good idea ofHippocratic knowledge of anat-omy.
[4.81] If a patient pass blood,pus, and scales, in the urine,and if it has a heavy smell,ulceration of the bladder isindicated.
Theophilus commented exten-sively on this aphorism, writingthat it “gives three facts, locus,constitution and malignity of theaffection. Because by scales,which mean petaloid, indicatesbladder affection, by pus andblood, indicates abrasion; for therecannot be pus in the urine withoutulcer;And by heavy smell, mean-ing malodourous, indicates malig-nity; for the malodorous is a signof sepsis and sepsis indicatesmalignity.”16(p436line13) Thisaphorism probably describes asevere case of unattended in-fection of the genitourinarysystem. It also could be tuber-culosis or cancer complicatedby a common infection. Theinfection probably is in thebladder because the aphorism
refers to “scales,” which maymean discharge of bladder epi-thelial cells.
OnPrognosis
[4.83] When much urine ispassed during the night, it in-dicates a slight retreat of thedisease.
This appears to be a de-scription of heart failure orkidney failure, in which theextravascular fluids are mobi-lized during the night, reflect-ing homeostatic changes asso-ciated with supine positioning(eg, mobilization of periph-eral edema) and subsequentlyare eliminated through thekidneys with a deceptive im-provement in symptoms.Galen14(p779line10) and Dama-scius16(p437line8) suggestedthat the condition was causedby reduced excretion of thefluids that were supposed tobe excreted by the gastrointes-tinal system during nighttimeand thus had to be excretedby the kidneys.
[6.6] Diseases about the kid-neys and bladder are curedwith difficulty in old men.
Galen15(p17line8) states thatthe reason the elderly are curedwith difficulty when they havediseases of the genitourinarytract is because they also haveother diseases. In a contempo-rary medical “aphorism,” it isacknowledged that in older in-dividuals, there often is morethan 1 disease that explainssymptoms, whereas youngerindividuals usually have 1 uni-fying cause.23 The originalaphorism recognized this andnoted that the urogenital sys-tem often was affected. Diabe-tes, hypertension, heart failure,
already deteriorated renal func-tion, prostate hypertrophy (inmen), and mild immunodefi-ciency make the cure of renaldiseases far more difficult inthe elderly than the young.Hence, this aphorism is cor-rect.
[6.11] Hemorrhoids appear-ing in melancholic [those withincreased “black bile”] andnephritic affections arefavourable.
This is another aphorism thathighlights the Hippocratic be-lief that some diseases re-quire a kind of catharsis to becured. The appearance ofhemorrhoids with probablerupture and bleeding wouldprovide some means of spon-taneous catharsis. Needless tosay, it would also decreaseblood pressure.
[6.28] Eunuchs do not takethe gout, nor become bald.
[6.29] A woman does not takethe gout, unless her mensesbe stopped.
[6.30] A young man [boy]does not take the gout until heindulges in coition.
Aphorisms 6.28, 6.29, and6.30 deal with the same sub-ject: the relationship betweensexual hormones and gout. Wenow know that testosterone lev-els increase the likelihood ofboth gout (and baldness) andthat estrogens decrease the risk.The male-female ratio of goutin premenopausal women andsimilar-age-group men variesfrom 7:1 to 9:1 and becomes3:1 in those older than 65years.24 Even more impressiveare Galen’s comments. Galenadded that not only the ab-sence, but also the irregularity,
of menses was connected with
ey [FNatio
Diamandopoulos, Goudas, and Oreopoulos150
gout in women and even re-ported the rarity of cases ofgout in women with normalcycles,15(p43line15) in accor-dance with modern statistics.25
These 3 aphorisms are indeedthe triumph of personal experi-ence. They succeeded in cor-rectly connecting signs reflect-ing sex hormone levels withgout.
[7.36] Whenever the afore-mentioned symptoms occur innephritic diseases, and alongwith them acute pains aboutthe muscles of the back, pro-vided these be seated aboutthe external parts, you mayexpect that there will be anabscess; but if the pains berather about the internalparts, you may also ratherexpect that the abscess will beseated internally.
Unfortunately, the aphorismdoes not mention which ex-actly are the “aforementionedsymptoms.” However, it isprobable that it refers to anabscess that causes pain radiat-ing either internally or exter-nally, in accordance to its loca-tion. Eknoyan22 considersaphorisms 7.31 to 7.36 mostlikely as descriptions of postin-fectious glomerulonephritis.
[7.47] If a dropsical patientbe seized with hiccup [cough]the case is hopeless.
For an unknown reason, theEnglish translator Adams trans-lated the word “cough” as “hic-cup.” It is not impossible thatthe text Adams had in his handshad the word “lygx,” not “vyx,”ie, hiccups, not cough. Supportfor use of “cough” in this apho-rism comes from comments byGalen,15(p153line4) as well as inLittre’s translation of the apho-
risms, in which a word for“cough” is used. If the aphorismrefers to hiccups, it may be acase of end-stage renal failure ormore probably describes casesof chronic or tension ascites thatcause pressure on the phrenicnerve. In such cases of noncom-pensating nonretractable ascites,either from heart or liver failure,the emergence of hiccups couldbe a grave sign.
[7.81] In the discharges bythe bladder, the belly, and theflesh [the skin?] if the bodyhas departed slightly from itsnatural condition, the diseaseis slight; if much, it is great; ifvery much, it is mortal.
This simple aphorism con-nects the severity of the signwith the course of the disease.
Figure 3. An illustration showingcorrelate with internal organ patholGersdorff’s Feldbuch der Wundartznhann Ulrich Wechtlin. Courtesy of the
The abnormal urine, feces, and
sweat become prognostic toolswhen compared with the nor-mal excrements.26 The morethe aberration from the nor-mal, the worse the prognosis.
OnTherapy
[6.36] Venesection cures dys-uria; open the internal veinsof the arm.
This aphorism is based onthe ancient belief that certainveins correspond to certain or-gans (Fig 3).27,28 By cutting acertain vein, the correspondingorgan would be relieved by theexcretion of extra or toxic flu-ids that had accumulated in it.This theory was erroneous andhad led to horrific cases of
ts for venesection that supposedlyFrom a 1528 edition of Hans vonieldbook of Surgery], illustrator Jo-nal Library of Medicine.28
poinogy.
bloodletting, especially during
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the Middle Ages. However, wemust not forget that until themiddle of the 20th century,bloodletting with leeches andbloodletting with cupping overthe lumbar region were com-mon therapeutic interven-tions.19 It is still used in someparts of the world. The correctprinciple behind this erroneouspractice was the elimination ofinflammatory toxins from theblood. In Hippocrates’ time,this was sought through blood-letting, whereas nowadays, itis attempted through dialysis.
[7.29] When strong diarrhoeasupervenes in a case of leuco-phlegmatia, it removes thedisease.
By the term “leucophlegma-tia,” Hippocrates states the over-abundance of white phlegm, 1of the 4 humors. In contempo-rary English, this could beinterpreted as water overloadand generalized edema. Theterm was coined because ofthe white color of the skin insuch patients. The strong diar-rhea removes the excess wa-ter, thus providing lysis of thedisease. In this case, the gutbecomes the apparatus ofclearance.
[7.48] Strangury and dysuriaare cured by drinking purewine [drunkenness], and vene-section; open the vein on theinside.
The drinking of pure wineprobably has a slight analge-sic, diuretic, and antidepres-sant effect (the original Greektext uses the word “drunken-ness”). As for bloodletting, thathas to be done from a specificvein, we have already men-tioned this in commenting on
aphorism 6.36.[4.82] When tubercles form inthe urethra, if these suppurateand burst, there is relief.
The “tubercles” are prob-ably tuberculous granulomatafrom genitourinary tuberculo-sis or any other chronic infec-tion. Their location inside theurethra would cause pain, dys-uria, and difficulties voiding.Undoubtedly their evacuationrelieves the patient.
OfGeneral Interest
[2.10] Bodies not properlycleansed, the more you feedthem the more you injure.
This aphorism may well ap-ply to renal failure, as well asto the failure of other organs,such as the liver or heart. Inthe case of renal failure, alow-protein diet is the mostbeneficial and it is interestingto note that the diets de-scribed for patients withchronic diseases in the Hippo-cratic writings were low-pro-tein diets. Consequently, if thepatient in renal failure is not“cleansed” of its uremic tox-ins, the more we nourish themthe more we injure them.
[4.2] In purging we shouldbring away such matters fromthe body as it would be advan-tageous had they come awayspontaneously; but those ofan opposite character shouldbe stopped.
We believe that this apho-rism is similar to the theoreti-cal basis of dialysis. Perfectdialysis will remove substancesthat would have been removedhad the kidneys not been dam-aged and prevent the loss ofsubstances that the kidneys
would have spared.[4.3] If the matters which arepurged be such as should bepurged, it is beneficial andwell done; but if the contrary,with difficulty.
In this statement, which fol-lows the previous aphorism de-scribed, Hippocrates judges thenecessity of the cure by itsresult. If we removed unneces-sary substances, the patient willimprove and be comfortablewith the treatment, but if weremoved the necessary ones,the patient would hardly toler-ate it.
These 3 aphorisms on purga-tion as a means for eliminatingmetabolic toxins may not be asalien to modern nephrology asthey look. We still try to ex-crete some toxins in renal fail-ure through the gut. Currentexamples include the use ofcation-exchange resins in pa-tients with hyperkalemia or theuse of phosphate binders in pa-tients with hyperphosphatemia.
CONCLUSIONS
Having reviewed the majorHippocratic aphorisms appli-cable to nephrology, we areleft with the impression thatthese are fine examples of thepower of empiricism at itsbest. The knowledge dis-played reflects the personalopinion formed by astute ob-servation of a competent phy-sician. Because of that, Hip-pocrates (Fig 4) has beenrightly referred to by some asthe “Father of Clinical Ne-phrology.”22 It is evident thatHippocrates, in the aphorisms,shows in the briefest possibleway his ability for astute clini-cal observation and his scien-tific desire to explain every-
thing logically, using the
Rube
Diamandopoulos, Goudas, and Oreopoulos152
limited knowledge available.Very few modern nephrolo-gists trained in the latest evi-dence-based medicine couldaspire to such a successfulunderstanding of the kidneydiseases with such limitedmeans. However, it requires alot of good will and someimagination to connect hisideas with today’s knowledgein this field. In recording thehistory of medicine, we face2 risks: the first is claimingthat one scientist was the firstto discover a disease, a symp-tom, a treatment (the well-known “I told it first” syn-drome30), whereas the secondis to conclude that everythinghas already been told before andtrying to support this conclusion
Figure 4. Hippocrates Hiraclidaeengraving by Paulus Pontius afterLibrary of Medicine.29
with biased arguments “prov-
ing” the excellence of our medi-cal predecessors.
Although it is considered anew specialty, the field of ne-phrology has reached itspresent level of knowledge asthe result of a long process ofdiscovery that should be stud-ied and understood not as aquestionable tradition worthyonly of “after dinner talk,” butas a very scientific way ofthinking. We believe that theevolution of this understand-ing is appreciated better by ex-ploring the history of bothmedicine in general and ne-phrology in particular.
ACKNOWLEDGEMENTS
vs., drawing by Peter Paul Rubens,ns, 1638. Courtesy of the National
Financial Disclosure: None.
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