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Thirty-six Hippocratic Aphorisms of Nephrologic Interest

2009; Elsevier BV; Volume: 54; Issue: 1 Linguagem: Inglês

10.1053/j.ajkd.2009.01.275

1523-6838

Athanasios Diamandopoulos, Pavlos Goudas, Dimitrios G. Oreopoulos,

Medical and Biological Sciences

In 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.” In 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.” 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.”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: 245-269Crossref Scopus (38) Google Scholar 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.” 2Hippocrates: Aphorisms. Adams F, transhttp://classics.mit.edu/Hippocrates/aphorisms.htmlGoogle Scholar[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 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.3Lloyd G. The Hippocratic Question, The Classical Quarterly, New Series, vol. 25, no. 2.in: Cambridge University Press, 1975: 171Google Scholar, 4Jouanna J. Hippocrate. Fayard, Paris, France1992Google Scholar 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,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: 701-703Crossref Google Scholar 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.7Geller J. Hippocrates, Galen and the Jews: Renal medicine in the Talmud.Am J Nephrol. 2002; 22: 101-106Crossref PubMed Scopus (7) Google Scholar 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).8Roster F. The life of Moses Maimonides, a prominent medieval physician, Einstein Quart.J Biol Med. 2002; 19: 125-128Google Scholar 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).9Bieber J. The Principal Sources of Ancient Science in Western Christendom Between A.D. 500 and A.D. 1300.http://www.scribd.com/doc/12922665/Sources-of-Greek-and-Arab-Sciences-in-the-Middle-AgesGoogle Scholar 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.11Bolgar R. Rabelais's Edition of the “Aphorisms” of Hippocrates.Modern Lang Rev. 1940; 35: 62-66Crossref Google Scholar 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.12Senfelder L. History of Medicine, The Catholic Encyclopedia. Appleton, New York, NY1911http://www.newadvent.org/cathen/10122a.htmDate: 2008Google Scholar 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 Adams2Hippocrates: Aphorisms. Adams F, transhttp://classics.mit.edu/Hippocrates/aphorisms.htmlGoogle Scholar (1796 to 1861) and the edition of Hippocrates' Texts by the French medical doctor and lexicographer, Littre13Hippocrates: Aphorisms.in: Littre E. Oeuvres completes d'Hippocrate. vol 4. Hakkert, Amsterdam, The Netherlands1962: 458-608Google Scholar, 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's14Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 17. Olms, Hildesheim, Germany1965: 345-887Google Scholar, 15Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 18.1. Olms, Hildesheim, Germany1965: 1-195Google Scholar 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.16Theophilus Protospatharius, Stephanus, Damascius: Commentarii in Hippocratis aphorismos.in: Dietz R. Scholia in Hippocratem et Galenum. vol 2. Hakkert, Amsterdam, The Netherlands1966: 244-544Google Scholar (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. [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.17Prioreschi P. Supernatural elements in Hippocratic medicine.J History Med Allied Sci. 1992; 47: 389-404Crossref PubMed Scopus (4) Google Scholar 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.17Prioreschi P. Supernatural elements in Hippocratic medicine.J History Med Allied Sci. 1992; 47: 389-404Crossref PubMed Scopus (4) Google Scholar[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. Galen14Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 17. Olms, Hildesheim, Germany1965: 345-887Google Scholar(p759line17) and Damascius16Theophilus Protospatharius, Stephanus, Damascius: Commentarii in Hippocratis aphorismos.in: Dietz R. Scholia in Hippocratem et Galenum. vol 2. Hakkert, Amsterdam, The Netherlands1966: 244-544Google Scholar(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 comment15Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 18.1. Olms, Hildesheim, Germany1965: 1-195Google Scholar(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 . . . .”15Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 18.1. Olms, Hildesheim, Germany1965: 1-195Google Scholar(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.18Diamandopoulos A. Comments on the treatise “On Urines”: by the wisest Nicephorous Vlemmydes, An excellent medical work in the iambic manner: by the wisest Psellus. Musical Uroscopy, Patras, Greece, Achaean1995Google Scholar The notion persisted through the 19th century with the term lipurie.19Widal F. Pathologie des reins, chapter: Lipurie.in: Roger G. Widal F. Teissier P. Nouveau Traite de Medecine, Fascicule XVII. Mason et Cie, Paris1929: 951-953Google Scholar 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?’ ”20Swash M. Mason S. Hutchison's Clinical Methods.in: Bailliere Tindall, London, England1984: 133Google Scholar 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. [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.”16Theophilus Protospatharius, Stephanus, Damascius: Commentarii in Hippocratis aphorismos.in: Dietz R. Scholia in Hippocratem et Galenum. vol 2. Hakkert, Amsterdam, The Netherlands1966: 244-544Google Scholar(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.21Diamandopoulos A. Goudas P. The substitution of renal function through skin catharsis: A clinicohistorical review.Kidney Int. 2003; 59: 1580-1589Crossref Scopus (7) Google Scholar[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, Galen14Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 17. Olms, Hildesheim, Germany1965: 345-887Google Scholar(p764line8) and the Byzantine commentators16Theophilus Protospatharius, Stephanus, Damascius: Commentarii in Hippocratis aphorismos.in: Dietz R. Scholia in Hippocratem et Galenum. vol 2. Hakkert, Amsterdam, The Netherlands1966: 244-544Google Scholar(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.19Widal F. Pathologie des reins, chapter: Lipurie.in: Roger G. Widal F. Teissier P. Nouveau Traite de Medecine, Fascicule XVII. Mason et Cie, Paris1929: 951-953Google Scholar[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).14Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 17. Olms, Hildesheim, Germany1965: 345-887Google Scholar(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.16Theophilus Protospatharius, Stephanus, Damascius: Commentarii in Hippocratis aphorismos.in: Dietz R. Scholia in Hippocratem et Galenum. vol 2. Hakkert, Amsterdam, The Netherlands1966: 244-544Google Scholar(p434line22) According to Eknoyan,22Eknoyan G. Origins of nephrology: Hippocrates, the father of clinical nephrology.Am J Nephrol. 1988; 8: 498-507Crossref PubMed Scopus (22) Google Scholar 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.”16Theophilus Protospatharius, Stephanus, Damascius: Commentarii in Hippocratis aphorismos.in: Dietz R. Scholia in Hippocratem et Galenum. vol 2. Hakkert, Amsterdam, The Netherlands1966: 244-544Google Scholar(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. [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. Galen14Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 17. Olms, Hildesheim, Germany1965: 345-887Google Scholar(p779line10) and Damascius16Theophilus Protospatharius, Stephanus, Damascius: Commentarii in Hippocratis aphorismos.in: Dietz R. Scholia in Hippocratem et Galenum. vol 2. Hakkert, Amsterdam, The Netherlands1966: 244-544Google Scholar(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. Galen15Galen In Hippocratis aphorismos commentarii.in: Kuhn G. Claudii Galeni opera omnia. vol 18.1. Olms, Hildesheim, Germany1965: 1-195Google Scholar(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.2