Nephrol Dial Transplant (1999) 14 [Suppl 2]: 2–9
Nephrology
Dialysis
Transplantation
Plenary Lecture
Twelve centuries of nephrological writings in the Graeco-Roman world
of the Eastern Mediterranean (from Hippocrates to Aetius Amidanus)
A. Diamandopoulos
Renal Department, St. Andrew’s Regional Hospital, Patras, Greece
Introduction
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’, while 650 AD marks the emergence of
‘Islamic medicine’, which continued to influence medical practice until modern times. This article reviews
12 centuries of nephrological writings in the GraecoRoman world of the Eastern Mediterranean, from 450
BC to 650 AD.
Scientific thinking and medicine in ancient Greece
In the Bronze Age, Mesopotamian, Egyptian and
Minoan medicine was based on experience, a practice
that was fundamentally changed by the Greeks [1].
The Greeks adopted a method used in the Near East—
they performed an examination and subsequently made
a diagnosis. However, the Greeks also searched for a
logical explanation by asking questions and supplying
answers. Their fundamental question was: Is Medicine
an Art or a Science? [2].
Greek philosophers were divided on this matter. In
the 2nd century AD, Galen thought that medicine was
mainly an art, the aim of which was to heal and not
to theorize. Later, the Arab, Avicenna, was of the
same opinion. Aristotle suggested that medicine is a
pure science, and in this opinion was followed in the
Middle Ages by the Arab, Averroës. Hippocrates
forced a compromise between the two ideas on the
role of medicine, suggesting that it was pure science,
like mathematics and the natural sciences, but that its
manifestations differed according to the particular conditions of the patient and the environment. Hence,
medicine was more accurately thought of as a Scientific
Art [3]. This represented enormous progress from
previous Eastern practices. Plato promoted an enduring tradition. For him, medicine was ‘one of those arts
that lend their aid to nature, ...(in it) judgement and
Correspondence
and
offprint
requests
to:
Athanasios
Diamandopoulos, MD, PhD, Nephrologist-Consultant in Charge,
Renal Department, St. Andrew’s Regional Hospital, Patras, Greece.
foresight, wisdom, art and law must be prior to hard
and soft, heavy and light...For art takes over the primary
works from the hands of nature, already formed and
then models and fashions the artificial ’ [4]. Could a
more apt description of the idea behind the creation
of the artificial kidney could ever be made?
Thus, the basic contribution of the Hippocratic era
to nephrology was a change in the general way of
scientific thinking, which eventually led to the establishment of the precise biomedical model of modern
nephrology. However, Greek philosophers had two
disadvantages. The first was that the natural theories
of Greek Medicine were the cause, among many correct
theses, of some naive hypotheses. A well-known
example was the theory of the Four Humours [3],
which proposed that all diseases resulted from an
imbalance of the four humours of the body, i.e. the
phlegm, the bile, the blood and the pneuma. Although
this theory was inaccurate in many aspects, it was
crucial in establishing the doctrine that metabolic and
idiosyncratic abnormalities are the basis of many diseases. Secondly, the lack of established institutions,
such as universities, to promote research and to safeguard the rights of scientists later proved to be disadvantageous to Greek medicine, and science as a whole.
Classical writers on renal diseases
Hippocrates (Figure 1) [5] wrote extensively on renal
diseases, and hence is justifiably called the ‘Father of
Clinical Nephrology’ [6 ]. 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, and he
therefore did not understand their exact role, believing
that urine was formed in the bladder. His main
nephrological contributions can be divided into four
categories.
(i) Description of four Renal Ailments. Several
authors assign to Hippocrates the diatribe About Inner
Sufferings, while others consider it to be a work from
the neighbouring School of Cnidus. In this work, there
are very good descriptions of nephrolithiasis with colic,
renal tuberculosis, a syndrome compatible with renal
© 1999 European Renal Association–European Dialysis and Transplant Association
Nephrological writings in the Graeco-Roman world
3
Fig. 1. A Hellenistic marble bust of Hippocrates, Kos Museum, Island of Kos, Greece. (Reproduced with permission from [5]).
vein thrombosis or papillary necrosis, and a suppurative chronic renal infection. In the same work, there is
a passage on renal damage due to crush syndrome
[7–9].
(ii) Thirty seven out of 423 of Hippocrates’
Aphorisms (4: 69–72; 5: 74–83; 6: 6, 11, 14, 21, 27,
29–31, 35–36, 49; 7: 29, 31–35, 37, 47–48, 70, 71) dealt
with renal problems. These included references to gout,
changes in micturition and prognosis in elderly patients
with renal ailments.
(iii) Hippocrates advocated the use of uroscopy in
diagnosis but was not an enthusiastic supporter of the
method. His observation that ‘Bubbles appearing on
the surface of the urine indicate renal disease with a
prolonged course’ [10] is a classic one, and probably
refers to albuminuria due to chronic glomerulonephritis.
(iv) On Lithiasis. Hippocrates wrote about renal
stones, which he linked to the use of drinking
water rich in minerals [11]. He also differentiated
between lithiasis of the kidneys and of the bladder
[12].
A dubious passage in the Oath prohibits medical
doctors from performing lithotomy. Many explanations are given, including the idea that Hippocrates
wanted to protect doctors from being accused of
malpractice ( lithotomy was performed mainly by
paramedics at that time). With Hippocrates, as with
many ancient writers, it is sometimes difficult to
understand precisely what is meant by the terms
employed. For example, Hippocrates used the word
‘ureter’ indiscriminately to denote the ureter and the
urethra [13]. Another difficulty is the widespread
plagiarism that occurred during the Middle Ages,
when many copyists were themselves labelled as the
original writers. For example, in the 11th century,
Constantinus Africanus in the Montecassino translated into Latin Isaak Judeus’ book On Urines, which
4
A. Diamandopoulos
Fig. 2. Asphodelus ramosous. A wild bulbous plant, recommended by Dioscorides as a diuretic and spasmolytic drug. Codex Vindobonensis
Med. Gr. 1, Nationalbibliothek, Wien, fol. 26r. (Reproduced with permission from [23]).
was written in the 9th century. The translation
subsequently appeared as an original work composed
by Africanus himself [14].
Later, Aristotle, in his work Historia Animalium,
describes his idea about the kidneys [15]. He too failed
to realize their purpose, assigning to them a genetic
and decorative role. Aristotle also theorized about the
diuretic properties of several plants, in a typical archaic
way of thinking [16 ].
Hellenistic contributions to nephrology
(4th–1st century BC )
In the following discussions about the nephrological
writings of the Hellenistic and Roman eras, it should
be noted that these two terms are used conventionally
to refer to a historical period, and not as an indication
of the nationality of the authors. For example, the
majority of medical writers from Roman times were
of Greek extraction but they are discussed in the
section on Roman contributions to nephrology.
Erasistratus, who lived during the 3rd century BC,
was the first to declare that urine is formed in the
kidneys. However, his idea was challenged by Galen
and by later authors, who attributed the discovery to
other writers. Ammonius, renowned for his technique
for performing a lithotomy, lived during the same
period. The Alexandrian doctor Herophilus described
the prostate gland, while Lycus was the first to
describe the filtration of urine.
Chrysippus, Praxagoras, Euryodes, Kleophantos
and Philomelos, all minor medical writers of the
Hellenistic period, are referred to by Rufus of
Ephesus, the excellent writer of the 2nd century AD
[17]. 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
Nephrological writings in the Graeco-Roman world
5
Fig. 3. Bramble bush. A wild bush, also recommended by Dioscorides as a diuretic and spasmolytic drug. Codex Vindobonensis Med. Gr.
1, Nationalbibliothek, Wien, fol. 83r. (Reproduced with permission from [23]).
with this condition for at least 12 years. Euryodes
reputedly operated on patients with renal problems,
following the tradition of Hippocrates. Kleophantos
likened the crust that stands on the surface of thick
urine with a medusa, while 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, purification from renal diseases, and a
bronze urethral catheter, to be used mainly in males
but also in females [18]. Pliny the Elder wrote about
many subjects of nephrological interest, and insisted
on the ritual significance of urine [19].
Aretaeus Cappadoces lived during the same century
as Celsus and Dioscorides, and is an excellent link
between the better-known Hippocrates and Galen. His
works were neglected around the 7th century AD and
were rediscovered in the 16th century. He wrote about
hydronephrosis from venereal diseases and nephritis,
accurately describing the anaemic look of renal
patients. His observations were written 18 centuries
before the publications of Richard Bright of London,
Robert Christison of Edinburgh and Pierre Rayer of
Paris, who are conventionally acknowledged as the
first to describe the characteristic. Aretaeus also
recorded other symptoms of renal patients, such as
unhealthy skin and a tendency towards oedema and/or
vascular accidents [20]. 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 [21].
Dioscorides lived during the 1st century AD. He
was a Greek doctor from Asia Minor practising later
in Rome, who may have been 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 veget-
6
A. Diamandopoulos
Fig. 4. Front cover of the book Musical Uroscopy. It depicts the well-known Byzantine uroscopist Theophilus Protospastharius and his
pupil Plossos. From the 15th century Byzantine manuscript, MS. Gr. 3632, fol. 51r, Bibl. Univ., Bologna. (Reproduced with permission
from [31]).
able, animal or mineral origin [22] (Figures 2 and 3
[23]) that had a nephrological effect. The work was
monumental and, until the last century, served as the
basis of all subsequent pharmacopoeias in Europe.
Even today, several of the drugs recommended by
Dioscorides are still used, or have been reintroduced
for the treatment of renal diseases.
Galen was personal doctor to Emperor Marcus
Aurelius, and the most prolific medical writer to date.
It is said that the surviving volumes of his works alone
are more extensive than the whole of Shakespeare’s
writings. 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.
During the Middle Ages, religious faith favoured a
bias towards humanistic values of medicine at the
expense, in several cases, of scientific and experimental
clarity. Galen, however, survived the change of intellectual climate because he, too, was a deeply religious
person. He characterized the human body as ‘a sacred
discourse that composed a true hymn to our Creator’
[24], thus later becoming a favourite of the Christian
Church.
Cassiodorus, who wrote about renal problems, was
favoured mainly in the Latin West. Rufus from
Ephesus, according to Wellman, was ‘One of the few
independent doctors of the post-classical era’. His treatise On the Diseases of the Kidneys and the Bladder,
written around the end of the 1st century, is the only
Nephrological writings in the Graeco-Roman world
7
Fig. 5. A cruciform text with the Hippocratic Oath, from the 12th century Byzantine codex Vat. Urbinas gr. 64. (Reproduced with
permission from [5]).
ancient nephrological treatise that has survived intact.
Rufus was not merely a compiler of texts. When he
used other writers’ work, he methodically reported his
sources. Rufus admired Hippocrates, and several of
his passages on renal diseases are quoted verbatim in
Rufus’s treatise [25]. In the treatise he correctly
describes the signs and symptoms of many renal problems, such as chronic renal failure, abscesses of the
kidneys and paresis of the bladder [26 ]. Rufus studied
some specific diseases, such as tuberculosis of the
urogenital tract, psoriasis of the bladder and the causes
of renal calculi (including diet and quality of drinking
water), and recommended flushing the kidneys with
huge amounts of water [27,28]. Among his treatments
were many accepted plant and mineral substances but
also some strange remedies. For example, a poultice
of grilled cicadas as a diuretic, and advising the patient
to urinate in a hot bath, measures which both increase
the renal blood flow [29]. His description of the role
of the healthy kidneys as ‘The filtration of clean urine
without blood or thickness’ is a very early and elegant
equivalent of the modern definition of a healthy urine
sample without haematuria or proteinuria.
Early Byzantine contributions to nephrology
(4th–7th century AD)
The Byzantine era began when Constantine the Great
moved the capital of the Roman Empire from Rome
to Constantinople, and ended with the conquest of
Alexandria by the Arabs in 642 AD. During this
period, the centre of medical knowledge was still
Alexandria. For a short time after the Byzantine era,
8
A. Diamandopoulos
Fig. 6. Imaginary scene, with Hippocrates flanked by Plato ( left), and Dioscorides (right), at the upper zone of the illustration. From the
codex ‘Medicina Antiqua’ fol. 3r., Wellcome Institute for the History of Medicine, London. (Reprinted with permission from [23]).
Arab and Jewish medicine took the lead, but
Constantinople was later established as a medical
centre par excellence. In the period under discussion,
Stephanus of Athens and Theophilus Protospatharius,
leaders in the art of uroscopy, were the two most
prominent writers who explored scientific diagnosis via
a urine sample. Their work, which has been discussed
previously [30] ( Figure 4) [31], remained basically
unchanged until the time of John Actuarius in the
13th–14th centuries. The bulk of their observations
passed intact into medical manuscripts both in the
East and the West. Oreibasius wrote extensively on
renal diseases, and in particular on diabetic nephropathy and gout. Aetius Amidanus compiled a large
treatise with many nephrological entries, based mainly
on Galen, Hippocrates and Rufus. He was copied
extensively by the eminent Arab doctors, Avicenna,
Averroës and others. Generally, Byzantine doctors of
the period studied acute and chronic renal failure, and
in their treatises ‘vulgarized’ traditional Galenism, in
order to be functional and homogenous [32].
Jewish contributions to nephrology (4th–7th
century AD)
Although Jewish physicians contributed extensively to
the understanding of renal diseases, their influence was
not evident until a later stage. Asaph Judeus is thought
to have lived during the 6th century, although this is
disputed. He was heavily influenced by Dioscorides
and Galen. His main contribution is the differential
diagnosis between renal and intestinal diseases. He
Nephrological writings in the Graeco-Roman world
also proposed an Oath similar to the Hippocratic
Oath [14].
Conclusions
In conclusion, the main contribution of the ancient
writers is not so much the many references to nephrology listed here but their philosophical thinking. For
example, Plato, in his work Phaedrus, cites the following dialogue: ‘If Hippocrates the Asclepiad is to be
trusted one cannot know the nature of the body except
by such a method.’ To which Socrates, the famous
philosopher answered: ‘He is right, my friend; but we
must not just rely on the authority of Hippocrates, but
must see also if our reason agrees with him on examination...’ [33].
Figures 5 [5] and 6 [23] show ancient Greek medical
thinking as being revered and, to some extent, almost
static and sanctified. In real life, ancient medical thinking was vivid, challenging and inquiring. Those characteristics are evident in the juxtaposition of two theses
by the most eminent ancient Greek writers.
Hippocrates, in a famous axiom, rightly condemns the
tendency of many doctors to pursue any novelty in
order to impress and to commercialize their trade: ‘Not
to look after patients with incurable diseases, as it is
well known that Medicine isn’t empowered to treat
everything’ [34]. His greatest admirer, Galen, did not
hesitate to challenge him and to wonder: ‘Would it ever
be possible to empty a human body from the corrupted
blood and to re-infuse a pure one, hence to treat the
most serious diseases?’ [35], a question to which modern
haemodialysis gave an affirmative answer. Thus, the
idea of blood purification and extra renal clearance
was born by the inquiring spirit of our ancestors in
the Eastern Mediterranean basin.
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