INT J TUBERC LUNG DIS 19(4):373–374 Q 2015 The Union http://dx.doi.org/10.5588/ijtld.14.0736

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Hippocrates and tuberculosis T. M. Daniel,* P. A. Iversen† *Department of Medicine, School of Medicine, †Department of Classics, Case Western Reserve University, Cleveland, Ohio, USA

THE PHYSICIAN HIPPOCRATES (c. 460–370 BCE), after whom the famous Hippocratic Oath is named, is widely credited with being the founder of patient-oriented medicine. There are few definite facts known of his life, but tradition states that he was a native of the island of Cos (off the west coast of Turkey opposite Halicarnassus, modern Bodrum), where the earliest and most important Asclepieion (temple-medical complex in honor of the Greek god of healing, Asclepius) was located. He is also said to have traveled and taught (Plato notes, disapprovingly, for a fee) throughout the ancient Greek world, and to have left behind an extensive corpus of medical writings that were later assembled by scribes and scholars. Several of the works and anecdotes that have been attributed to him are now widely believed to be spurious. It is for this reason that many modern scholars cautiously refer to the writings attributed to Hippocrates as the ‘Hippocratic corpus’. Although Hippocrates lived in an era when diseases were attributed to an imbalance in the four humors rather than being distinguished by their etiologies, he nevertheless observed his patients carefully, identifying distinct disease entities in them, and writing about these diseases in terms of clinical features that characterized them. This is nowhere more evident than in his references to tuberculosis, which he doubtless recognized in those patients under his care, often at the late stages in its fatal course. The Ancient Greek words most commonly used by Hippocrates for tuberculosis are the noun uh´iri1 and ´ its related adjectival forms uhimxde1/uhim xdee1 (the ˜ former of which can be turned into a noun that is virtually equivalent to uh´iri1 by adding the definite article so´ in front of it, i.e., so` uhimxde1). The ˜ primary meaning of this root word is to waste away, perish, decay, or wane. As such, this root was commonly applied to the waning of the moon or any wasting disease. Hippocrates, however, used it most often in contexts in which a modern medical reader can be confident that the term refers to KEY WORDS: phthisis; consumption; Asclepius

tuberculosis. We have limited this discussion to instances of this use of uh´iri1 and its related forms. The Aphorisms of Hippocrates are among the bestknown of his writings, and in them one recognizes clear references to clinical features of tuberculosis. For example, he states, ‘uh´iri1 occurs most commonly between the age of eighteen and thirty-five years’ (Aphorism 5.9). It is thus clear that Hippocrates recognized the predilection of tuberculosis for young adults, a characteristic that distinguishes it from many other chronic respiratory infections. Elsewhere Hippocrates distinguishes tuberculosis from other respiratory infections by noting that it occurs in the summer and autumn rather than in the winter, when acute respiratory infections are commonest. In one noteworthy passage in Epidemics (1.1.2, lines 1–3) he states, ‘Beginning early in the summer, throughout the summer and in winter, many of those who had been ailing a long time took to their ´ beds in a state of consumption (uhimxdee1). . .. Some showed the symptoms now for the first time; these were those whose constitution inclined to be con1 Hippocrates thus clearly sumptive (uhimxde1).’ ˜ distinguished the respiratory infections of winter seasons from the non-seasonal tuberculosis. Hippocrates describes yet another clinical feature typical of tuberculosis. ‘Most of them were affected . . . in the following manner: . . . constant sweats, but not diffused over the whole body’ (Epidemics 1.1.2, lines 13–15).1 Modern clinicians know that the sweats that so characterize tuberculosis are limited to the upper trunk. Elsewhere Hippocrates discusses fevers (those of malaria are easy to recognize). Most fevers peak at night, he notes. In contrast, ‘Diurnal [fever] is still more protracted and in some cases passes into uh´iri1’ (Epidemics 1.4.24).1 Astute modern clinicians know that a diurnal fever spike in addition to nocturnal fever is sometimes seen in tuberculosis and may be an important clue to its diagnosis. In this same passage, Hippocrates goes on to note that fever in persons with uh´iri1 carries an unfavorable prognosis. Persistent fever often denotes disseminated tuberculosis.

Correspondence to: Thomas M. Daniel, 43 Laurel Lake Drive, Hudson, OH 44236, USA. e-mail: [email protected].

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that in women ‘of a hard constitution’ living in cities facing cold winds, ‘cases of uh´iri1 are frequent after parturition’ (Airs, Waters, and Places 4).1 The fact that tuberculosis may arise in the postpartum period is well known to modern tuberculosis clinicians. Diarrhea as a pre-terminal event in disseminated tuberculosis is also noted in Aphorisms 5.12 and 5.14. Gastrointestinal tuberculosis is rarely seen today, yet it occurs as a pre-terminal event in some patients dying of untreated tuberculosis. Finally, Hippocrates notes that tuberculosis frequently terminated with the death of the patient. Typical is a passage from the Epidemics: ‘For consumption (so` uhimxde1) was the worst of the ˜ diseases that occurred, and alone was responsible for the great mortality.’ (Epidemics 1.1.2). The poor prognosis of consumption (so` uhimxde1) is noted ˜ twice more in this work (Epidemics 1.1.3 and 3.2.13).1 In summary, the descriptions of uh´iri1 and its related forms in the writings attributed to Hippocrates give evidence that he recognized tuberculosis as a distinct entity at a time when medical thought was oriented towards imbalance of humors rather than specific diseases. Figure Hippocrates. Pencil drawing by Clarissa Daniel.

Reference Elsewhere, in discussing the prevalence of disease related to geography and weather, Hippocrates notes

1 Jones W H S, translator. Hippocrates, Vol. I. Cambridge, MA: Harvard University Press, 1923.

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