Summary
Hippocrates is traditionally considered the father of modern medicine, still influencing, 25 centuries after his time, various aspects of medical practice and ethics. His collected works include various references to infectious diseases that range from general observations on the nature of infection, hygiene, epidemiology, and the immune response, to detailed descriptions of syndromes such as tuberculous spondylitis, malaria, and tetanus. We sought to evaluate the extent to which this historical information has influenced the modern relevant literature. Associating disease to the disequilibrium of body fluids may seem an ancient and outdated notion nowadays, but many of the clinical descriptions presented in the Corpus Hippocraticum (Hippocratic Collection) are still the archetypes of the natural history of certain infectious diseases and their collective interplay with the environment, climate, and society. For this reason, modern clinicians and researchers continue to be attracted to these ‘lessons’ from the past – lessons that remain extremely valuable.
Keywords
Introduction
Although infectious agents have been in existence since long before humanity, and despite the rapid advances characterizing the previous century in terms of the recognition and treatment of the diseases induced by these agents, infection remains a major cause of human morbidity and mortality, and an ever-present threat. The latter fact has often led specialists to look back in order to either underline a specific pathogen's importance to humanity or to seek ideas regarding pathophysiology and treatment. In looking into the past for options for the future, the heritage of Hippocrates is of great significance.
“Ωφɛλɛɛιν μɛ βλάπτɛιν” (primum non nocere) was Hippocrates’ advice, meaning “first do no harm”. Hippocrates (Figure 1), considered by many as the father of Western medicine, was born in 460 BC on the island of Cos where he created the famous medical school around 430 BC. He is credited with the writing of the Corpus Hippocraticum (Hippocratic Collection), although many have speculated that this represents a collective work of Hippocrates and his heirs. He was the first to regard disease as a natural, rather than a supernatural phenomenon, encouraging doctors to look at physical causes of illness and to use objective observation and critical deductive reasoning. Hippocrates believed that the causes of disease could be understood only through empirical study. For more than 2000 years, Hippocrates’ ethical code, known as the Hippocratic Oath, has guided the practice of Western medicine.
We sought to investigate the effects that the Hippocratic works and observations still impose on modern infectious diseases practice.
Data sources
We reviewed various texts of Hippocrates’ writings; these were studied in their original (ancient Greek) language. Readers wishing for English translations may find those freely available on the web from the Massachusetts Institute of Technology Internet Classics Archive useful (http://classics.mit.edu/Browse/browse-Hippocrates.html). We also performed a search of PubMed and Web of Knowledge/Science databases of the Institute of Scientific Research (ISI) for articles on Hippocrates and infectious diseases, using the key terms ‘Hippocrates and infectious diseases’, ‘Hippocrates and hygiene’, ‘Hippocrates and contagion’, and ‘Hippocrates and epidemics’. General search engines were also used, with the terms ‘Hippocrates’ and individual infectious disease names.
Hippocrates and infection
Several infectious diseases were first described by Hippocrates or a Hippocratic doctor, who no longer believed in magical miasmata that pollute whole populations, but rather in the concept of contagion, thus separating medicine from superstition.
Infectious diseases are prominent throughout the Hippocratic works; however, the Hippocratic approach, based on the general view of disease as a fluid dysregulation, means that most descriptions of clinical cases are vague and could be attributed to a wide variety of pathogens. Further confusion to the modern reader may emerge from the use in these works of terms such as cholera, leprosy, and typhus in a different manner: in fact, one of the typhus types described by Hippocrates represents the typical natural history of rheumatoid arthritis (43rd vignette of Internal affections). However, one cannot deny certain important aspects of the infectious diseases and immune responses recognized, such as the characterization of fever and swelling as part of the immune response, the seasonal emergence of various types of infection (hence the detailed description of climate evolution in the Epidemics books), the immune compromise related to excess alcohol intake, the relationship of certain diarrheal diseases to consumption of inadequately cooked meat and seafood, and foremost, the systematic approach to the progression of the various clinical syndromes.
Many infectious syndromes are present in the Corpus Hippocraticum: meningitis with a typical description of nuchal rigidity, intracranial abscesses, and cranial osteitis in Diseases II,
1
tonsillitis and peritonsillar abscess formation, lower respiratory tract infections including pneumonia and empyema, puerperal infections, cellulitis and fasciitis, erysipelas and its suppurative complications, post-abortion septicemia, various infectious disorders of the gastrointestinal tract even including descriptions of cases similar to pseudomembranous colitis, and intra-abdominal infections,2
are all present. Of interest though is the absence of extended reports on sexually transmitted diseases, apart from random notes on genital ulcerations.Various specific infectious diseases are described in more detail, most notably tuberculosis, the term ‘phthisis’, subject of vignettes 10–12 of Internal affections, surviving to our times: tubercular enteritis (with reference to the ominous prognosis conferred in tuberculosis in general) and spondylitis (typically in vignette 10 of Places in man and the 41st part of On the articulations) are accurately and comprehensively described,
3
as is the presence of digital clubbing in these patients.4
The beneficial effect of humid climates for patients with consumption is also mentioned. Brucellosis is often described as originally depicted by Hippocrates:5
in the 7th part of the Aphorisms (vignette 64), Hippocrates mentions that protracted fevers can be accompanied by ‘tumors’ and joint aches, something that might be consistent with the disease; osteoarticular complications of brucellosis have been extensively recognized in antiquity.6
Tetanus is described accurately and extensively, and in some vignettes of the fifth (74, 95) and seventh (36) books of Epidemics, Hippocrates was the first to describe the adverse outcome of a phenomenally minor morbid condition. Numerous case descriptions may be reminiscent of bubonic plague, a disease possibly responsible for the Great Plague of Athens (430–428 BC),7
or rickettsioses (relapsing fevers), although any remarks on the potential relationship of the latter with arthropod bites are suspiciously (for an astute observer like Hippocrates) absent. It has also been suggested that a vignette of rapidly fatal sepsis in a food critic in the first book of Epidemics is descriptive of Vibrio vulnificus infection.8
, 9
The earliest detailed accounts of the periodic fevers of malaria are present in the Corpus Hippocraticum,
10
a disease accounting for the decline of many of the city-state populations, referenced by an increasing number of subsequent Greek and Roman authors.11
Hippocrates was the first to describe the disease's manifestations (for example the prominence of splenomegaly), to classify fevers as tertian and quartian (typically in chapter 18 of Affections), and to relate the disease to the time of year and proximity to stagnant waters (classically relating stagnant waters and enlarged spleens in On airs, waters and places); he has also been acknowledged as the first to describe the mechanism of action of antimalarial agents.12
A wide variety of parasitoses are also recognized: references to enteric worms and ascarides, but also classical descriptions of pulmonary hydatid disease (for example in the 23rd vignette of Internal affections) and cases of hepatic lesions following protracted diarrhea reminiscent of amebiasis.
11
Cases with pallor and geophagia may refer to hookworm disease.11
It has also been suggested that dracunculiasis was prevalent from the time of Hippocrates. Some scholars13
suggest that the Rod of Asclepius represents the small stick around which the female worm, Dracunculus medinensis (known to most as the Asclepian or Aesculapian snake), was slowly wound. In indigenous areas this worm is still extracted from subcutaneous tissues by winding it around a small stick, twisting it slightly each day until the entire worm is removed.Descriptions reminiscent of gas gangrene, glanders, and poliomyelitis (cases of acquired clubfoot) are also present. Destructive ulceronecrotic lesions of the mouth, face, and airways, reminiscent of noma, a disease of potentially infectious origin, also exist.
14
Parotitis is one of the most accurately described syndromes in Hippocrates’ Epidemics.Certain forms of jaundice, the subject of analysis in vignettes 26–29 and 35–38 of Places in man, are typical of viral hepatitis; of interest here is one of Hippocrates’ Aphorisms, citing that jaundice accompanied by diarrhea (as would be the case with hepatitis A virus infection) is usually more benign than other forms. In a similar vein, a comment on the severity of a certain type of dysentery in the childhood population might guide towards a potential diagnosis of shigellosis. Descriptions of other diarrheal syndromes may be typical of cholera.
A recent article indicates that Hippocrates may also have described spongiform encephalopathy in goats and cattle.
15
The most notorious episode related to infectious diseases in the Corpus Hippocraticum is the epidemic ‘Cough of Perinthus’, a winter epidemic of an upper respiratory tract infection and its consequences, extensively narrated in the seventh chapter of the sixth book of Epidemics. It is often cited as the first influenza epidemic of human history. However, there are many aspects of the disease that point to a different etiology, for example the relatively scarce reports of post-influenza pneumonia in an otherwise detailed history of the outbreak, and the presence of peripheral nervous system complications, also mentioned in the second and fourth books of Epidemics; in fact an outbreak of diphtheria would be a more satisfying explanation of the Cough of Perinthus. An alternative etiology would be the simultaneous emergence of two or three infectious disorders.
The Hippocratic On airs, waters and places can be considered the first textbook of travel medicine, a book for traveling practitioners focusing on infectious disease geography, citing as one of the most frequent causes of disease the bad quality of air and water.
16
In the same vein, Hippocrates conceived hygiene as “an influence of atmosphere, soil, and water on human health”,17
, 18
citing that “every disease has its own nature and arises from external causes”, and giving more importance to the expected outcome or prognosis of a disease than its identification or diagnosis.An everlasting influence
Hippocrates developed a naturalistic approach to medicine, including the field of infectious diseases, introducing the concept of clinical observation to Western medicine.
Why do modern day researchers keep going back to Hippocrates? We are living in an era of rapid scientific advances in all aspects of infectious diseases, and information drawn from ancient observations may not significantly alter our current perceptions. Yet, we keep returning: an ancient bug that has contributed to the shaping of history receives a certain respect; the disease is not something new but something that has been around for ages and should demand our attention. One might simply notice the continuing debate over the Plague of Athens or the cause of death of Alexander the Great: following the US West Nile virus epidemics of recent years, an article has emerged in support of this virus as the cause of Alexander's death.
19
Another more scientific reason has to do with the understanding of the evolution of pathogen ecology through the ages, an understanding that may prove fruitful in terms of basic research. Furthermore, although ancient, some notions expressed in the Hippocratic works are still applicable today. What is more important though, is a reason easily recognized to anyone familiar with Hippocratic descriptions of infection: the clarity of presentation of the clinical course and the astute inclusion of infection in a broader environmental and social context are still unparalleled by modern thinking.Delving into the past may not always provide the answers; undoubtedly, those unfamiliar with the Hippocratic heritage may feel disappointed by the absence of definite descriptions of more infectious syndromes. On the other hand, the hundreds of patient vignettes in the works of Hippocrates would serve as discussion matter for endless clinicopathological rounds. Finally, exploring the past will almost definitely provide a more progressive way of thinking, and this is nowhere more pronounced than in the field of infectious diseases – the Hippocratic heritage and the various ways it is still perceived today.
Conflict of interest: No conflict of interest to declare.
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Article info
Publication history
Published online: January 07, 2008
Accepted:
November 14,
2007
Received in revised form:
November 6,
2007
Received:
July 10,
2007
Corresponding Editor: William Cameron, Ottawa, CanadaIdentification
Copyright
© 2007 International Society for Infectious Diseases. Published by Elsevier Inc.
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