Mostafa Abdel_Salam Mohamed, MD

Consultant of Nephrology

Twelve centuries of nephrologicalwritings in the Graeco-Romanworld of the Eastern Mediterranean(from Hippocrates to AetiusAmidanus)

A. Diamandopoulos Renal Department, St. Andrew’s Regional Hospital, Patras, Greece Nephrol Dial Transplant (1999) 14

[Suppl 2]: 2–9

The island of Crete is at the centre of the Eastern Mediterranean basin, the

birthplace of medical science.

The year 450 BC marks the emergence of ‘scientific medicine’,

650 AD marks the emergence of ‘Islamic medicine’, which continued to influence

medical practice until modern times.

In the Bronze Age, Mesopotamian, Egyptian and Minoan medicine was based on experience, a practice that

was fundamentally changed by the Greeks

Crombie AC. Styles of Scientific Thinking in the European Tradition. Volume 1. Duckworth and Co. Ltd, London:

1994: 188

The Greeks adopted a method used in the NearEast— they performed an examination andsubsequently made a diagnosis. However, theGreeks also searched for a logical explanationby asking questions and supplying answers.Their fundamental question was:

Is Medicine an Art or a Science?

Crombie AC. Styles of Scientific Thinking in the European Tradition. Volume 1. Duckworth and Co. Ltd, London: 1994:

342–345

Galen

Heal and not to Theorize.

Avicenna

Medicine was mainly an art

Medicine is a pure science

Aristotle

Averroes

Medicine is a Scientific Art

Hippocrates

• Forced a compromise between the two ideas on therole of medicine

• Suggesting that it was pure science, like mathematicsand the natural sciences

• Its manifestations diverted according to theparticular conditions of the patient and theenvironment.

Plato: for him, medicine was

• ‘one of those arts that lend their aid to nature, ...(in it) judgment and foresight, wisdom, art and law

Thus, the basic contribution of theHippocratic era to nephrology was achange in the general way of scientificthinking, which eventually led to theestablishment of the precise biomedicalmodel of modern nephrology.

However, Greek philosophers had two disadvantages.

• The first was that the naturaltheories of Greek Medicine werethe cause, among many correcttheses, of some naive hypotheses.

The theory of the Four Humours

All diseases resulted from an imbalance of the four humours of the body, i.e. black bile, blood, phlegm

and yellow bile

Although this theory was inaccurate inmany aspects, it was crucial inestablishing the doctrine thatmetabolic and idiosyncraticabnormalities are the basis of manydis-eases

Secondly, the lack of establishedinstitutions, such as universities, topromote research and to safe-guardthe rights of scientists later proved tobe disadvantageous to Greekmedicine, and science as a whole.

Hippocrates wrote extensivelyon renal diseases, and hence isjustifiably called the

‘Father of Clinical Nephrology’

Eknoyan G. Origins of nephrology: Hippocratic nephrology. Am J Nephrol 1988; 8: 498

Most of his writings have withstood the passage of time.

However, Hippocrates wrote in an era when little was known about the anatomy and physiology of the kidneys,

• Therefore

He did not understand their exact role, believing that urine was formed in the bladder.

His main nephrological contributions can be divided into four categories.

• 1- Description of four Renal Ailments. Severalauthors assign to Hippocrates the diatribeAbout Inner suffering, while others consider itto be a work from the neighboring School ofCnidus.

In this work, there are very good descriptions of

• Nephrolithiasis with colic

• Renal tuberculosis

• A syndrome compatible with renal vein thrombosis or papillary necrosis

• A suppurative chronic renal infection.

• In the same work, there is a passage on renal damage due to crush syndrome.

2- Thirty seven out of 423 ofHippocrates’ Aphorisms dealt withrenal problems.

• These included references to gout

• changes in micturition

• prognosis in elderly patients with renal ailments

3- Hippocrates advocated the use ofuroscopy in diagnosis but was not anenthusiastic supporter of the method.

• His observation that ‘Bubbles appearing on the surface of the urine indicate renal disease with a prolonged course

4- On Lithiasis:

• Hippocrates wrote about renal stones,which he linked to the use ofdrinking water rich in minerals. Healso differentiate between lithiasis ofthe kidneys and of the bladder

A dubious passage in the Oath prohibitsmedical doctors from performinglithotomy.

• Many explanations are given, including the ideathat Hippocrates wanted to protect doctors frombeing accused of malpractice (lithotomy wasperformed mainly by paramedics at that time).

With Hippocrates, as with many ancient writers:

• It is sometimes difficult to understandprecisely what is meant by the termsemployed. For example, Hippocrates used theword ‘ureter’ indiscriminately to denote theureter and the urethra

Another diffcultyis the widespread plagiarism that

occurred during the Middle Ages.

in the 11th century, Constantinus Africanus

translated into Latin Isaak Judeus’ book On Urines

The translation subsequently appeared as an original work

composed by Africanus himself

Later, Aristotle, in his work HistoriaAnimalium, describes his idea aboutthe kidneys. He too failed to realizetheir purpose, assigning to them agenetic and decorative role.Aristotle also theorized about thediuretic properties of several plants,in a typical archaic way of thinking

Hellenistic contributions to nephrology (4th–1st century BC)

Erasistratus, who livedduring the 3rd centuryBC, was the first todeclare that urine isformed in the kidneys

Ammonius, renowned for his technique for performing a lithotomy

The Alexandrian doctor Herophilus described the prostate gland, while Lycus was the first to describe the filtration of urine

Chrysippus is better remembered for his poultice with soothing and diuretic properties, which he applied over the kidneys

Praxogoras elegantly described a patient with a recto-cystic fissure, who was passing urine from his rectum, and who survived with this condition for at least 12 years

Philomelos suggested the application of pressure over the lower abdomen in order to facilitate the passage of urine in patients with urine retention

Roman contributions to nephrology (1st century BC to 4th century AD)

Celsus was a prolific medical writer, although he was not a doctor.

The subjects of his many writings included lithotomy

A bronze urethral catheter, to be used mainly in males but also in females

Pliny the Elder wrote about many subjects

of nephrological interest, and insisted

on the ritual significance of urine

Aretaeus Cappadoces He wrote about hydronephrosis from venereal diseases and nephritis, accurately describing the anaemiclook of renal patients, unhealthy skin and a tendency towards edema and/or vascular accidents

He also described diabetic nephropathy, and he is popularly believed to have coined the word ‘diabetes’, although it is now known that the term was first proposed by Demetrius of Apameia, three centuries before Aretaeus’s birth

Dioscorides: personal doctor to Emperor Nero

• His outstanding contribution to medicine in general, and to nephrology in particular, was the extensive Materia Medica.

• In this publication he described, among other drugs, 300 substances of vegetable, animal or mineral origin that had a nephrological effect.

• The work was monumental and, until the last century, served as the basis of all subsequent pharmacopoeias in Europe.

Galen was personal doctor to Emperor Marcus Aurelius

• He successfully showed, by ligating animal ureters, that urine flows from the kidneys to the bladder.

• He also experimented further on the anatomy and physiology of the urinary tract. Hence, Eknoyan has rightly called him

• The Father of Experimental Medicine’.

Galen also elaborated on several acute and chronic renal ailments. He was a real scientist and was one of the last great medical writers of antiquity.

He characterized the human body as ‘a sacred discourse that composed a true hymn to our Creator’, thus later becoming a favourite of the Christian Church.

خطاب مقدس يتكون من ترنيمه حقيقية لخالقنا

Cassiodorus, who wrote about renal problems, was favouredmainly in the Latin West. Rufus from Ephesus, according to Wellman, was ‘One of the few independent doctorsof the post-classical era’.

His treatise On the Diseases of theKidneys and the Bladder, written around the end of the 1st century, is the only ancient nephrologicaltreatise that has survived intact