Hippocrates and rheumatology.

Giampiero Pasero, MD, Professor of Medicine, Director (retired), Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa; Piero Marson, MD, Blood Transfusion Service, Hospital of Padua, Padua, Italy. © Copyright CLINICALAND EXPERIMENTAL RHEUMATOLOGY 2004. The cover of Clinical and Experimental Rheumatology this year has been dedicated to Hippocrates, the "Father of Western Medicine". Therefore, in our last issue for this year we felt it would be appropriate to discuss Hippocrates' contributions to the history of rheumatology. Hippocrates, as is well known, embodied the transition from pre-history to the history of medicine and the dawn of what may be referred to as "rational" medicine (1). Still, although the practice of medicine was no longer reserved for priests, a lingering sentiment that physicians belonged to a privileged class remained. It is interesting to note that the Hippocrates oath included the vow to teach the art only "to one's sons and the sons of one's teacher", thus excluding all of those who did not belong to the profession "by right of birth". Furthermore, some of the Greek physician's teachings, such as his theory of the four bodily humours, reflected traditional dogmatic concepts rather than scientific fact. All the same, there is no doubt that under the influence of the philosophers of the Ionic school with their interest in the natural sciences, Hippocrates developed an approach based on direct observation of the symptoms displayed by the patient rather than on pre-conceived notions; he was in a sense the founder of what we consider today as the medical sciences. The Hippocratic texts represent, in fact, the first written accounts in which it is possible to identify specific illnesses known to modern physicians without resorting to complicated or imaginative interpretations. In many cases they illustrate the depth of understanding that may be reached solely on the basis of scrupulous observation and reasoning. The rheumatic diseases, because of their clear symptomology, offer particularly fascinating examples of Hippocrates' powers of observation and deduction. The rheumatic condition for which the pioneering nature of Hippocrates' scientific approach is best known is without a doubt gout. His three celebrated aphorisms (2) – that gout never develops in men before puberty or in women before menopause, and is never seen in eunuchs – are cited in every modern textbook that covers gout. It is remarkable that Hippocrates was able to deduce these facts solely on the basis of clinical observation when we consider that: (i) the existence of uric acid was unknown to him, having been discovered by Scheele in 1776 (3); (ii) the condition of hyperuricemia was not detectable before A.B. Garrod invented his famous "thread test" in 1848 (4); and (iii) the variations in uric acid levels as a function of age and sex, upon which the morbidity in gout depends, were conclusively demonstrated only during the well-known Tecumseh epidemiological study conducted in 19551960 (5). Today we know that Hippocrates' first two aphorisms are true only in the case of primary gout; other forms (such as secondary gout or gout associated with an enzyme deficit) may be observed, albeit rarely, in children (6,7) or in women of child-bearing age (7,8). Today it not possible to confirm the veracity of the third aphorism, although in 1965 a physician in Hong Kong reported a probable case of gout in one of the last eunuchs of the Chinese imperial court (9). In 1534 Dominicus Burgauer wrote an extensive – but incorrect – exegesis on these aphorisms, affirming that the disease was exacerbated by melancholy and by excessive indulgence in lovemaking after meals, and for this reason it was absent in eunuchs and those who did not engage in sexual activity (10), whereas today we know that these epidemiological factors are actually linked to the influence of the gonadal hormones on uric acid metabolism. Hippocrates' observations on the subject of gout are not limited to these three aphorisms. For example, he noted that the pain tended to become exacerbated in the spring and autumn months, and correctly affirmed with regard to its prognosis that elderly patients, patients with periarticular concretions (probably tophi, although not all historians of medicine agree that Hippocrates identified these correctly), and those who lead a sedentary life have little hope of recovering, whereas there is reason for optimism in the case of y o u n g e r, physically active patients withEDITORIAL Clinical and Experimental Rheumatology 2004; 22: 687-689.