| | Thirty-six Hippocratic Aphorisms of Nephrologic InterestIn this article, we discuss the nephrologic content within Hippocrates' Aphorisms. Although similar attempts have taken place ever since antiquity, we believe that in each era new insights may be gained by examining the aphorisms through the prism of current medical knowledge. Of the 400 aphorisms in the Hippocratic text, we discuss the 36 that we consider to be most relevant to nephrology. We conclude that these aphorisms support the concept of Hippocrates as the “Father of Clinical Nephrology.” Hippocrates in Context  It is said that the beginning of education is the understanding of terminology. Thus, we begin this article by discussing the word “aphorism.” It derives from the Greek aphorizein (apo + horizein [horizon, boundary]), meaning to delimit, mark off, divide, define. In form, aphorisms are always terse and trenchant, facilitating maximum comprehension in minimum expression. The Hippocratic aphorisms are just that: concise, often pithy, and memorable statements of literal truths and frequently obvious wisdoms. If we can use an aphorism to define what aphorism is, the most appropriate one would be: “The finest thoughts in the fewest words.”1 The term aphorism itself originally was coined to refer to the aphorisms of Hippocrates that are included in the Corpus Hippocraticum, which is the full collection of Hippocratic writings. The most famous of the Hippocratic aphorisms is the first and remains familiar: “Life is short, and Art [of medicine] 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 the externals cooperate.” 2[Section 1, Alphorism 1] To best understand the aphorisms, it is important to place them into the context of both the medical knowledge and cultural practices of the times. In the era of Hippocrates, knowledge of anatomy was reasonably thorough, reflecting a lengthy history of battlefield medicine. The Corpus Hippocraticum is composed of some writings by Hippocrates himself, some by students of Hippocrates, and some inserted into the collection at a later date. The corpus contains scattered many correct observations: it defines the aorta as originating in the heart and describes the development of the kidneys at the end of renal arteries, the branches of the abdominal aorta, and the parallel direction of the nerves. The anatomical connection of spermatic arteries with the kidneys is observed, a fact that led to the notion that sperm is created initially inside the kidneys and then delivered through the spermatic vessels to the testicles before finally exiting the body. The similar shape of both kidneys and their apple-like color also is described. A description of the granular and viscous texture of the kidneys and the excess of humidity in their interior is given, and it is noted that the ureters descend from the kidneys and end in the bladder. It is written that renal vessels transfer blood with liquid waste products of metabolic reactions to the kidneys and the blood returns, purified, to the entire body. Hesitantly, the author allows that the kidneys are “not alien to the excretion of urine.” Observations of pathophysiological characteristics, diagnosis, and prognosis of renal diseases are spread throughout these works, in which various urologic symptoms are connected with their correct diagnosis and prognosis. The term “nephritic” (νεϕριτικος) is used to describe patients with a variety of renal ailments, such as strangury, anuria, and hematuria. The Aphorisms The Hippocratic aphorisms were probably written circa 400 bce and contain 400 entries dealing with all aspects of practical medicine. Although authorship of much of the Corpus Hippocratum is debated, the aphorisms are considered one of the few works in the Corpus most likely penned by Hippocrates himself. This belief was held as far back as Galen and the Byzantines and is echoed by more recent writers, including Paul-Émile Littré (1801-1811) in the 19th century, although several scholars still express reservations about their authenticity.3, 4 The book of aphorisms was very influential because of its clarity and brevity. Numerous writers extensively commented on it; from the Greek-speaking world alone, these included Soranus, Rufus, Galen, Paladius, Stephanus of Athens,5 Theophilus Protospatharius, Damascius, and Johannes Actuarius. The Islamic world also has been heavily influenced by the Hippocratic aphorisms. Notable Arabic translations of it include versions by Ibn al-Quff (d 1286) and Ibn Abī Sādiq (d ∼1068). Because the latter composed a popular commentary on the aphorisms of Hippocrates, he was known in some circles as “the second Hippocrates” (Buqrā al-thānī). In mimicking Hippocrates, other influential Arab scholars composed their own “aphorisms,” which in reality were edited copies of the original. One example is al-Rāzī's Kitāb al-Murshid ([The Guide]; Fig 1). The Hippocratic aphorisms also influenced the Jewish doctors.7 One of Maimonides' medical writings is the Commentary on the Aphorisms of Hippocrates. In this work, Maimonides occasionally criticizes both Hippocrates and Galen when either of these Greeks differs from his own views. Following the fashion, he also wrote his own aphorisms, called Pirkei Moshe (Medical Aphorisms of Moses).8 As would be expected, the aphorisms were translated into Latin at an early stage, facilitating dissemination in Western medical thought. Early translations were undertaken by Burgundio of Pisa (from Greek in the 12th century), Gerard of Cremona (in Toledo, from Greek in the 12th century), and William of Moerbeke and others (from Arabic after 1260).9 As early as 1145, the aphorisms had reached then-remote England (Fig 2). Rabelais in France gained his reputation as a serious scholar with a translation of the aphorisms, which appeared in a 1532 edition from the Gryphius publishing house.11 Characteristic of the high esteem the work had in the Renaissance, Theophrastus Paracelsus, on June 24, 1527, surrounded by a crowd of cheering students, publicly burned the works of Avicenna and Galen and showed respect only to the aphorisms of Hippocrates.12 Hippocratic Aphorisms of Nephrologic Interest Here, we analyze the Hippocratic aphorisms of nephrologic interest, interpreting and speculating on their relevance to our contemporary knowledge. Although there are other similar works on various diseases, they rarely include so many aphorisms referring to a single specialty. We used the translation of the Scottish medical doctor Francis Adams2 (1796 to 1861) and the edition of Hippocrates' Texts by the French medical doctor and lexicographer, Littre13, volumes that have the same citation indexing, ie, in sections and aphorisms. When we believed that some aphorisms could have a different meaning than that given by Adams's translation, we have added the alternative meaning in brackets, leaving the text unaltered. We also compared our comments with those of previous ancient and Byzantine writers. We used Kühn's14, 15 1965 edition of Galen's In Hippocratis Aphorismos Commentarii and a 1966 edition (Hakkert publishing house) of the treatise Commentarii in Hippocratis Aphorismo from the Byzantine medical writers Theophilus, Stephanus, and Damascius.16 (Theophilus Protospatharius, circa 7th century ce, was a physician in the court of the Byzantine Emperor Heraclius; Stephanus of Athens was a Byzantine physician of the 6th century; and Damascius was a Byzantine physician of the 9th century ce, not to be confused with the neoplatonic philosopher.) Although they wrote comments for all aphorisms, we included only those that, in our opinion, further elucidate each aphorism's meaning. Because some aphorisms span more than one category, they have been classified arbitrarily by major topic, independent of their sequence in the original text. On Uroscopy (without specific diagnosis or prognosis) [Section 4. Aphorism 69] When the urine is thick, grumoss, and scanty in cases not free from fever, a copious discharge of thinner urine proves beneficial. Such a discharge more commonly takes place when the urine has had a sediment from the beginning, or soon after the commencement. This could very well be a description of oliguric renal failure complicating a febrile disease. The scanty amount of urine that is thick and “grumoss” (“thrombodea,” ie, like a thrombus, dark red, curdled) may very well be the result of an acute tubular necrosis, whereas the large amount of thin urine that follows could represent the lysis of the failure with its polyuric phase. [4.70] When in fevers the urine is turbid, like that of a beast of burden, in such a case there either is or will be headache. The urine of horses, donkeys, and cattle is turbid, probably because of the high concentration of phosphates that they consume through their vegetative feeding. Ancients had noticed this as a difference compared with human urine, which is clear even when highly concentrated. This observation had been reported initially in Mesopotamian writings, then in ancient Greek writings, and later in the Arabic medical writings.17 The most probable explanation for the turbid urine Hippocrates describes is either pyuria or overexcretion of organic or inorganic salts. Such a condition eventually will lead to an abnormal internal milieu and thus possibly headache. In the case of macroscopic pyuria, one can suggest pyelonephritis; hence, the headaches. In the case of turbid urine caused by proteinuria (“macroscopic” proteinuria if one can coin such a term), this implies massive nephrotic-range proteinuria. Such a condition will almost certainly be accompanied by activation of the renin-angiotensin system with salt retention, generalized edema, and hypertension. Thus, the “either is or will be headache” prediction also could be a sign of hypertension. [4.71] In cases which come to a crisis on the seventh day, the urine has a red nubecula on the fourth day, and the other symptoms accordingly. This is a prognostic aphorism. The hematuria that presents on the fourth day after the outbreak of the disease is a sign of the severity of the disease, and the aphorism predicts that there will follow a crisis on the seventh day. By crisis, it is meant the end of the disease, not worsening. Although it is not unusual for transient hematuria to cease after a few days, we cannot give any significance to the numbers 4 or 7 of the corresponding days. This numbering is a remnant of the pre-Socratic and Pythagorean teachings on the significance of numbers in medicine. It was based on the Mesopotamian and Babylonian line of thought to connect earthly phenomena with the phases of the moon.17 [4.72] When the urine is transparent and white, it is bad; it appears principally in cases of phrenitis. This could describe a patient with advanced renal failure. Transparent white urine could be a description of the isosthenuria of chronic renal failure. Galen14(p759line17) and Damascius16(p430line11) commented that the “phrenitis” was caused by retention of toxic substances (yellow bile) that were not properly excreted through urine, instead accumulating in the brain and causing the symptom. We suggest that this aphorism is applicable even today because if we replace “yellow bile” with “uremic toxins,” we have a description of neurological signs of severe renal failure, ie, uremic encephalopathy. [4.76] When small fleshy substances like hairs are discharged along with thick urine, these substances come from the kidneys. This could be one of the earliest descriptions of blood casts. What is most impressive is Hippocrates' certainty that such substances come from the kidneys. Hippocrates was well aware of the complicated anatomy of the kidneys, although he could not explain their function. He clearly distinguished blood in the urine as a sign of hemorrhage, ie, a ruptured vessel from the bladder or kidneys, and the “fleshy substances” as originating from the kidneys. [4.77] In those cases where there are furfuraceous particles discharged along with thick urine, then the bladder has scabies [is “scabious”]. Thick urine with “furfuraceous” particles probably describes cystitis with excretion of squamous cells from the epithelium of the bladder. It could also be a case of cystitis with white blood cell aggregates. The term “scabious” is descriptive rather than diagnostic. [7.31] When there is a farinaceous sediment in the urine during fever, it indicates a protracted illness. This is a description of cases of fevers that are complicated by either massive discharge of epithelial cells or pyuria. In either case, the renal involvement, an acute inflammatory condition or pyelonephritis, is indeed a case that would have persisted, considering the Hippocratic means of treatment. [7.32] In those cases in which the urine is thin at first, and the sediments become bilious, an acute disease is indicated. Galen in his comment15(p132line11) clarified that Hippocrates meant black, not yellow, bile. He then explained that this aphorism refers to time only, not to locum, ie, the aphorism predicts the course of disease, not the affected organ. Is this a description of acute tubular necrosis or postinfectious glomerulonephritis? If this aphorism is connected to the previous one, ie, it refers to patients with fever, it probably is an exacerbation of some chronic renal disease. The “thin” urine could be a description of the isosthenuria of a chronic disease. Although “bilious” in modern English would mean green, Hippocrates refers to bilious as either yellow or black (ie, very dark red). If we assume he means black bile, as Galen states, this aphorism describes an acute exacerbation of a chronic condition. [7.33] In those cases in which the urine becomes divided there is great disorder in the body. This aphorism refers to urine with a large quantity of sediment, making it appear “divided” into 2 parts, sediment and suspension. The large amount of sediment, whatever the cause may be, predisposes to a very severe condition. [7.34] When bubbles settle on the surface of the urine, they indicate disease of the kidneys, and that the complaint will be protracted. Galen elaborated on this aphorism: “Bubbles are created when the liquids are stretched by air. And usually this happens when the liquid contains something sticky. In which case the bubbles don't break easily and become permanent ....”15(p134line12) This is the most frequently quoted “renal” Hippocratic aphorism and it could be one of the earliest descriptions of proteinuria. It is the increase in the surface tension of the urine caused by the proteins that produces this phenomenon. Unfortunately, the aphorism does not give any detail concerning the patient's condition, ie, edema, weakness, headaches (hypertension), and so on. [7.35] When the scum on the surface is fatty and copious, it indicates acute diseases of the kidneys. Regarding this aphorism, previous commentators have stated that the presence of gross quantities of fat on the surface of urine indicates decomposition of the fat in the body in acute generalized diseases or the perinephric fat in diseases of the kidneys. They also connected this case with cases of fatty stools as having the same cause.18 The notion persisted through the 19th century with the term lipurie.19 Although this aphorism provides inadequate detail to be certain, it could be a description of nephrotic-range nonspecific proteinuria with a variety of proteins excreted, thus the “fatty” (lipoproteins) and “copious” (in gross quantity). [7.67] We must look to the urinary evacuations, whether they resemble those of persons in health; if not at all so, they are particularly morbid, but if they are like those of healthy persons, they are not at all morbid. This aphorism is a reminder to all physicians (and known by all nephrologists): Always look at the patient's urine. It reminds one of another aphorism by Sir Robert Hutchison at the beginning of the 20th century: “The ghosts of dead patients do not ask why we did not employ the latest fad of clinical investigation; they ask ‘why did you not test my urine?’”20 Hippocrates so much believed that examination of urine was fundamental for diagnosis and prognosis that he declared that if the urine of a sick person is normal, the prognosis is favorable. On Diagnosis [4.75] Blood or pus in the urine indicates ulceration either of the kidneys or of the bladder. The English translator paid no attention to the grammar of this aphorism, not heeding the distinction between “ουρεη” (“ureei”; “is urinating”), which suggests continuity, and “ουρηση” (“ourese”; “urinates”), which implies only an instant. A more precise translation of this aphorism is: “If [a patient] is urinating [ουρεη/ureei] blood or pus, this indicates ulceration of the kidneys or the bladder.” On the basis of the use of a continuous tense, Theophilus argued that the aphorism does not refer to rupture of an abscess from another organ, such as the liver, into the urinary system, in which case the blood and pus urinated would not last long, perhaps 2 or 3 days. Asking rhetorically “And why did he not mention the ureters?” Theophilus further explains that “by mentioning the two ends he included the middle.” Damascius added: “Urinating implies many days.... For urinating and urinate are not the same.”16(p432line28) It is interesting to notice the detail in which these commentators analyzed this aphorism, and its important message is the chronicity of the disease. [4.41] A copious sweat after sleep occurring without any manifest cause indicates that the body is using too much food. But if it occurs when one is not taking food, it indicates that evacuation is required. In this case, the skin is used as an alternative route for fluid elimination in cases of overconsumption of food. However, in cases in which there is profuse sweating without overindulgence, Hippocrates states that it is a sign of excess fluids that need to be eliminated through some kind of treatment. That is, the natural eliminating organs, kidneys and/or gastrointestinal tract, are malfunctioning, unable to offer proper catharsis, and therefore some other kind of provoked catharsis must be applied.21 [4.74] When there is reason to expect that an abscess will form in joints, the abscess is carried off by a copious discharge of urine, which is thick, and becomes white, like what begins to form in certain cases of [exhaustive] quartan fever. It is also speedily carried off by a haemorrhage from the nose. [If a nosebleed also occurs as well, lysis will come very fast.] Here, Galen14(p764line8) and the Byzantine commentators16(p431line25) state that the substance accumulated in the joints can be removed by urine and thus the patient be cured. What would be the triggering factor “to expect that an abscess will form in joints”? In an adult man, the driver is probably overconsumption of food and wine in cases of hyperuricemia. Hyperuricemia could form tophi, which resemble abscesses (gout), whereas polyuria with urine full of a white material (phosphates or amorphous urate salts, although the latter usually are reddish brown) will gradually lead to the lysis of arthritis. However, the aphorism does not indicate whether the polyuria was spontaneous or was to be achieved by some medical intervention, such as water consumption or some medication.19 [4.78] In those cases where there is a spontaneous discharge of bloody urine […where they are urinating bloody urine], it indicates rupture of a small vein in the kidneys. The key word in this aphorism is “spontaneous.” Hippocrates had obviously noticed some cases of hematuria that had no apparent cause. In other aphorisms, he refers to hematuria as the result of some known or at least suspected cause, such as the passing of a stone or trauma, a systemic disease with fever, or cancer. However, he realized that spontaneous hematuria could occur with no apparent cause in an otherwise healthy person, and that is the reason he attributed this condition to a “rupture of a small vein.” Galen elaborates correctly that “spontaneous” may mean either without apparent external cause (ie, trauma) or without preliminary symptoms (eg, bladder ulceration).14(p774line1) Theophilus again reminds the reader of the grammar of the aphorism, using the verb “urinating,” not “urinate,” implying a long duration of the sign.16(p434line22) According to Eknoyan,22 aphorisms 4.75 to 4.78 probably describe papillary necrosis, whereas we speculate that it may well be a case of bladder tuberculosis. With our present knowledge, we cannot exclude immunoglobulin A nephropathy as an alternative diagnosis. [4.79] In those cases where there is a sandy sediment in the urine, there is calculus in the bladder. The “sandy” sediment in the urine could be calcium or urate salts. In either case, the existence of calculi in the bladder and/or kidneys of such a patient is highly probable. [4.80] If a patient pass blood and clots in his urine, and have strangury, and if a pain seizes the hypogastric region and perineum, the parts about the bladder are affected. [7.39] When a patient passes blood and clots, and is seized with strangury and pain in the perineum and pubes, disease about the bladder is indicated. These 2 diagnostic aphorisms are almost identical, with aphorism 7.39 probably being added at a later date. The topographic localization and association with anatomic structures gives a good idea of Hippocratic knowledge of anatomy. [4.81] If a patient pass blood, pus, and scales, in the urine, and if it has a heavy smell, ulceration of the bladder is indicated. Theophilus commented extensively on this aphorism, writing that it “gives three facts, locus, constitution and malignity of the affection. Because by scales, which mean petaloid, indicates bladder affection, by pus and blood, indicates abrasion; for there cannot be pus in the urine without ulcer; And by heavy smell, meaning malodourous, indicates malignity; for the malodorous is a sign of sepsis and sepsis indicates malignity.”16(p436line13) This aphorism probably describes a severe case of unattended infection of the genitourinary system. It also could be tuberculosis or cancer complicated by a common infection. The infection probably is in the bladder because the aphorism refers to “scales,” which may mean discharge of bladder epithelial cells. On Prognosis [4.83] When much urine is passed during the night, it indicates a slight retreat of the disease. This appears to be a description of heart failure or kidney failure, in which the extravascular fluids are mobilized during the night, reflecting homeostatic changes associated with supine positioning (eg, mobilization of peripheral edema) and subsequently are eliminated through the kidneys with a deceptive improvement in symptoms. Galen14(p779line10) and Damascius16(p437line8) suggested that the condition was caused by reduced excretion of the fluids that were supposed to be excreted by the gastrointestinal system during nighttime and thus had to be excreted by the kidneys. [6.6] Diseases about the kidneys and bladder are cured with difficulty in old men. Galen15(p17line8) states that the reason the elderly are cured with difficulty when they have diseases of the genitourinary tract is because they also have other diseases. In a contemporary medical “aphorism,” it is acknowledged that in older individuals, there often is more than 1 disease that explains symptoms, whereas younger individuals usually have 1 unifying cause.23 The original aphorism recognized this and noted that the urogenital system often was affected. Diabetes, hypertension, heart failure, already deteriorated renal function, prostate hypertrophy (in men), and mild immunodeficiency make the cure of renal diseases far more difficult in the elderly than the young. Hence, this aphorism is correct. [6.11] Hemorrhoids appearing in melancholic [those with increased “black bile”] and nephritic affections are favourable. This is another aphorism that highlights the Hippocratic belief that some diseases require a kind of catharsis to be cured. The appearance of hemorrhoids with probable rupture and bleeding would provide some means of spontaneous catharsis. Needless to say, it would also decrease blood pressure. [6.28] Eunuchs do not take the gout, nor become bald. [6.29] A woman does not take the gout, unless her menses be stopped. [6.30] A young man [boy] does not take the gout until he indulges in coition. Aphorisms 6.28, 6.29, and 6.30 deal with the same subject: the relationship between sexual hormones and gout. We now know that testosterone levels increase the likelihood of both gout (and baldness) and that estrogens decrease the risk. The male-female ratio of gout in premenopausal women and similar-age-group men varies from 7:1 to 9:1 and becomes 3:1 in those older than 65 years.24 Even more impressive are Galen's comments. Galen added that not only the absence, but also the irregularity, of menses was connected with gout in women and even reported the rarity of cases of gout in women with normal cycles,15(p43line15) in accordance with modern statistics.25 These 3 aphorisms are indeed the triumph of personal experience. They succeeded in correctly connecting signs reflecting sex hormone levels with gout. [7.36] Whenever the aforementioned symptoms occur in nephritic diseases, and along with them acute pains about the muscles of the back, provided these be seated about the external parts, you may expect that there will be an abscess; but if the pains be rather about the internal parts, you may also rather expect that the abscess will be seated internally. Unfortunately, the aphorism does not mention which exactly are the “aforementioned symptoms.” However, it is probable that it refers to an abscess that causes pain radiating either internally or externally, in accordance to its location. Eknoyan22 considers aphorisms 7.31 to 7.36 most likely as descriptions of postinfectious glomerulonephritis. [7.47] If a dropsical patient be seized with hiccup [cough] the case is hopeless. For an unknown reason, the English translator Adams translated the word “cough” as “hiccup.” It is not impossible that the text Adams had in his hands had the word “lygx,” not “vyx,” ie, hiccups, not cough. Support for use of “cough” in this aphorism comes from comments by Galen,15(p153line4) as well as in Littre's translation of the aphorisms, in which a word for “cough” is used. If the aphorism refers to hiccups, it may be a case of end-stage renal failure or more probably describes cases of chronic or tension ascites that cause pressure on the phrenic nerve. In such cases of noncompensating nonretractable ascites, either from heart or liver failure, the emergence of hiccups could be a grave sign. [7.81] In the discharges by the bladder, the belly, and the flesh [the skin?] if the body has departed slightly from its natural condition, the disease is slight; if much, it is great; if very much, it is mortal. This simple aphorism connects the severity of the sign with the course of the disease. The abnormal urine, feces, and sweat become prognostic tools when compared with the normal excrements.26 The more the aberration from the normal, the worse the prognosis. On Therapy [6.36] Venesection cures dysuria; open the internal veins of the arm. This aphorism is based on the ancient belief that certain veins correspond to certain organs (Fig 3).27, 28 By cutting a certain vein, the corresponding organ would be relieved by the excretion of extra or toxic fluids that had accumulated in it. This theory was erroneous and had led to horrific cases of bloodletting, especially during the Middle Ages. However, we must not forget that until the middle of the 20th century, bloodletting with leeches and bloodletting with cupping over the lumbar region were common therapeutic interventions.19 It is still used in some parts of the world. The correct principle behind this erroneous practice was the elimination of inflammatory toxins from the blood. In Hippocrates' time, this was sought through bloodletting, whereas nowadays, it is attempted through dialysis. [7.29] When strong diarrhoea supervenes in a case of leucophlegmatia, it removes the disease. By the term “leucophlegmatia,” Hippocrates states the overabundance of white phlegm, 1 of the 4 humors. In contemporary English, this could be interpreted as water overload and generalized edema. The term was coined because of the white color of the skin in such patients. The strong diarrhea removes the excess water, thus providing lysis of the disease. In this case, the gut becomes the apparatus of clearance. [7.48] Strangury and dysuria are cured by drinking pure wine [drunkenness], and venesection; open the vein on the inside. The drinking of pure wine probably has a slight analgesic, diuretic, and antidepressant effect (the original Greek text uses the word “drunkenness”). As for bloodletting, that has to be done from a specific vein, we have already mentioned this in commenting on aphorism 6.36. [4.82] When tubercles form in the urethra, if these suppurate and burst, there is relief. The “tubercles” are probably tuberculous granulomata from genitourinary tuberculosis or any other chronic infection. Their location inside the urethra would cause pain, dysuria, and difficulties voiding. Undoubtedly their evacuation relieves the patient. Of General Interest [2.10] Bodies not properly cleansed, the more you feed them the more you injure. This aphorism may well apply to renal failure, as well as to the failure of other organs, such as the liver or heart. In the case of renal failure, a low-protein diet is the most beneficial and it is interesting to note that the diets described for patients with chronic diseases in the Hippocratic writings were low-protein diets. Consequently, if the patient in renal failure is not “cleansed” of its uremic toxins, the more we nourish them the more we injure them. [4.2] In purging we should bring away such matters from the body as it would be advantageous had they come away spontaneously; but those of an opposite character should be stopped. We believe that this aphorism is similar to the theoretical basis of dialysis. Perfect dialysis will remove substances that would have been removed had the kidneys not been damaged and prevent the loss of substances that the kidneys would have spared. [4.3] If the matters which are purged be such as should be purged, it is beneficial and well done; but if the contrary, with difficulty. In this statement, which follows the previous aphorism described, Hippocrates judges the necessity of the cure by its result. If we removed unnecessary substances, the patient will improve and be comfortable with the treatment, but if we removed the necessary ones, the patient would hardly tolerate it. These 3 aphorisms on purgation as a means for eliminating metabolic toxins may not be as alien to modern nephrology as they look. We still try to excrete some toxins in renal failure through the gut. Current examples include the use of cation-exchange resins in patients with hyperkalemia or the use of phosphate binders in patients with hyperphosphatemia. Conclusions Having reviewed the major Hippocratic aphorisms applicable to nephrology, we are left with the impression that these are fine examples of the power of empiricism at its best. The knowledge displayed reflects the personal opinion formed by astute observation of a competent physician. Because of that, Hippocrates (Fig 4) has been rightly referred to by some as the “Father of Clinical Nephrology.”22 It is evident that Hippocrates, in the aphorisms, shows in the briefest possible way his ability for astute clinical observation and his scientific desire to explain everything logically, using the limited knowledge available. Very few modern nephrologists trained in the latest evidence-based medicine could aspire to such a successful understanding of the kidney diseases with such limited means. However, it requires a lot of good will and some imagination to connect his ideas with today's knowledge in this field. In recording the history of medicine, we face 2 risks: the first is claiming that one scientist was the first to discover a disease, a symptom, a treatment (the well-known “I told it first” syndrome30), whereas the second is to conclude that everything has already been told before and trying to support this conclusion with biased arguments “proving” the excellence of our medical predecessors. Although it is considered a new specialty, the field of nephrology has reached its present level of knowledge as the result of a long process of discovery that should be studied and understood not as a questionable tradition worthy only of “after dinner talk,” but as a very scientific way of thinking. We believe that the evolution of this understanding is appreciated better by exploring the history of both medicine in general and nephrology in particular. Acknowledgements Financial Disclosure: None. References 1. 1Murray D. Aphorisms and clichés: The generation and dissipation of conceptual charisma: The aphorism: The linguistic style of alluring knowledge. Annu Rev Sociol. 1999;25:245–269. 2. 2Hippocrates: Aphorisms. Adams F, trans. http://classics.mit.edu/Hippocrates/aphorisms.html. 3. 3Lloyd G. The Hippocratic Question, The Classical Quarterly, New Series, vol. 25, no. 2. In: Cambridge University Press; 1975;p. 171. 4. 4Jouanna J. Hippocrate. Paris, France: Fayard; 1992;. 5. 5Potter P. Stephanus of Athens: Commentary on Hippocrates' Aphorisms, Sections III-IV, and Stephanus of Athens: Commentary on Hippocrates' Aphorisms, Sections V-VI (review). Bull History Med. 1997;71:701–703. 6. 6National Library of Medicine: Islamic Medical Manuscripts. http://www.nlm.nih.gov/hmd/arabic/E2_E4.html#E3. 7. 7Geller J. Hippocrates, Galen and the Jews: Renal medicine in the Talmud. Am J Nephrol. 2002;22:101–106. MEDLINE |
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