Aetius

The first great Christian physician whose works meant much for his own

time, and whose writings have become a classic in medicine, was Aetius

Amidenus, that is, Aetius of Amida, who was born in the town of that

name in Mesopotamia, on the upper Tigris (now Diarbekir), and who

flourished about the middle of the sixth century. His medical studies,

as he has told us himself, were made at Alexandria. After having

attracted attention by his medical learning and skill, he became

physician to one of the emperors at Byzantium, very probably Justinian,

(527-565). He seems to have been succeeded in the special post that was

created for him at court by Alexander of Tralles, the second of the

great Christian physicians. There is no doubt that Aetius was a

Christian, for he mentions Christian mysteries, and appeals to the name

of the Saviour and the martyrs. He was evidently a man of wide reading,

for he quotes from practically every important medical writer before his

time. Indeed, he is most valuable for the history of medicine, because

he gives us some idea of the mode of treatment of various subjects by

predecessors whose fame we know, but none of whose works have come to

us. His official career and the patronage of the Emperor, the breadth

of his scholarship, and the thoroughly practical character of his

teaching, show how medical science and medical art were being developed

and encouraged at this time.



Aetius' work that is preserved for us is known in medical literature as

his sixteen books on medical practice. In most of the manuscript it is

divided into four Tetrabibloi, or four book parts, each of which

consists of four sections called Logoi in Greek, Sermones in Latin. This

work embraces all the departments of medicine, and has a considerable

portion devoted to surgery, but most of the important operations and the

chapters on fractures and dislocations are lacking. Aetius himself

announces that he had prepared a special work on surgery, but this is

lost. Doubtless the important chapters that we have noted as lacking in

his work would be found in this. He is much richer in pathology than

most of the older writers, at least of the Christian era; for instance,

Gurlt says that he treats this feature of the subject much more

extensively even than Paulus AEginetus, but most of his work is devoted

to therapeutics.



At times those who read these old books from certain modern standpoints

are surprised to find such noteworthy differences between writers on

medicine, who are separated sometimes only by a generation, and

sometimes by not more than a century, in what regards the comparative

amount of space given to pathology, etiology, and therapeutics. Just

exactly the same differences exist in our own day, however. We all know

that for those who want pathology and etiology the work of one of our

great teachers is to be consulted, while for therapeutics it is better

to go to someone else. When we find such differences among the men of

the olden time we are not so apt to look at them with sympathetic

discrimination, as we do with regard to our contemporaries. We may even

set them down to ignorance rather than specialization of interest. These

differences depend on the attitude of mind of the physician, and are

largely the result of his own personal equation. They do not reflect in

any way either on his judgment or on the special knowledge of his time,

but are the index of his special receptivity and teaching habit.



Aetius' first and second books are taken up entirely with drugs. The

first book contains a list of drugs arranged according to the Greek

alphabet. In the third book other remedial measures, dietetic,

manipulative, and even operative, are suggested. In these are included

venesection, the opening of an artery, cupping, leeches, and the like.

The fourth and fifth books take up hygiene, special dietetics, and

general pathology. In the sixth book what the Germans call special

pathology and therapy begins with the diseases of the head. The first

chapter treats of hydrocephalus. In this same book rabies is treated.

What Aetius has consists mainly of quotations from previous authors,

many of whom he had evidently read with great care.



Concerning those bitten by a rabid dog or those who fear water, Gurlt

has quoted the following expression, with regard to which most people

will be quite ready to agree with him when he says that it contains a

great deal of truth, usually thought to be of much later origin: When,

therefore, any one has been bitten by a rabid dog the treatment of the

wound must be undertaken just as soon as possible, even though the bite

should be small and only superficial. One thing is certain, that none of

those who are not rightly treated escape the fatal effect. The first

thing to do is to make the wound larger, the mouth of it being divided

and dilated by the scalpel. Then every portion of it and the surrounding

tissues must be firmly pressed upon with the definite purpose of causing

a large efflux of blood from the part. Then the wound should be deeply

cauterized, etc.



There are special chapters devoted to eye and ear diseases, and to

various affections of the face. Under this the question of tattooing and

its removal comes in. It is surprising how much Aetius has with regard

to such nasal affections as polyps and ulcers and bleedings from the

nose. In this book, however, he treats only of their medicinal

treatment. What he has to say about affections of the teeth is so

interesting that it deserves a paragraph or two by itself.



He had much to say with regard to the nervous supply of the mucous

membranes of the gums, tongue, and mouth, and taught that the teeth

received nerves through the small hole existing at the end of every

root. For children cutting teeth he advised the chewing of hard objects,

and thought that the chewing of rather hard materials was good also for

the teeth of adults. For fistulas leading to the roots of teeth he

suggests various irritant treatments, and, if they do not succeed,

recommends the removal of the teeth. He seems to have known much about

affections of the gums and recognizes a benignant and malignant epulis.

He thought that one form of epulis was due to inflammation of a chronic

character, and suggests that if remedies do not succeed it should be

removed. His work is of interest mainly as showing that even at this

time, when the desire for information of this kind is usually supposed

to have been in abeyance, physicians were gathering information about

all sorts even of the minor ailments of mankind, gathering what had been

written about them, commenting on it, adding their own observations, and

in general trying to solve the problems as well as they could.



Aetius seems to have had a pretty good idea of diphtheria. He speaks of

it in connection with other throat manifestations under the heading of

crusty and pestilent ulcers of the tonsils. He divides the anginas

generally into four kinds. The first consists of inflammation of the

fauces with the classic symptoms, the second presents no inflammation of

the mouth nor of the fauces, but is complicated by a sense of

suffocation--apparently our croup. The third consists of external and

internal inflammation of the mouth and throat, extending towards the

chin. The fourth is an affection rather of the neck, due to an

inflammation of the vertebrae--retropharyngeal abscess--that may be

followed by luxation and is complicated by great difficulty of

respiration. All of these have as a common symptom difficulty of

swallowing. This is greater in one variety than in another at different

times. In certain affections even drinks when taken are returned

through the nose.



Hypertrophy of the tonsils--Aetius speaks of them as glands--is to be

treated by various astringent remedies, but if these fail the structures

should be excised. His description of the excision is rather clear and

detailed. The patient should be put in a good full light, and the mouth

should be held open and each gland pulled forward by a hook and excised.

The operator should be careful, however, only to excise those portions

that are beyond the natural size, for if any of the natural substance of

the gland is cut into, or if the incision is made beyond the projecting

portion of the tonsil, there is grave danger of serious hemorrhage.

After excision a mixture of water and vinegar should be kept in the

mouth for some time. This should be administered cold in order to

prevent the flow of blood. After this very cold water should be taken.



In this same book, Chapter L, he treats of foreign bodies in the

respiratory and upper digestive tracts. If there is anything in the

larynx or the bronchial tubes the attempt must be made to secure its

ejection by the production of coughing or sneezing. If the foreign body

can be seen it should be grasped with a pincers and removed. If it is in

the esophagus, Aetius suggests that the patient should be made to

swallow a sponge dipped in grease, or a piece of fat meat, to either of

which a string has been attached, in order that the foreign body may be

caught and drawn out. If it seems preferable to carry the body on into

the stomach, the swallowing of large mouthfuls of fresh bread or other

such material is recommended.



With regard to goitre, Aetius has some interesting details. He says

that all tumors occurring in the throat region are called bronchoceles,

for every tumor among the ancients was called a cele, and, though the

name is common to them, they differ very much from one another. Some of

them are fatty, some of them are pultaceous, some of them are cancerous,

and some of them he calls honey tumors, because of a honey-like humor

they contain. Sometimes they are due to a local dilatation of the blood

vessels, and this is most frequently connected with parturition,

apparently being due to the drawing of the breath being prevented or

repressed during the most violent pains of the patient. Such local

dilatation at this point of the veins is incurable, but there are also

hard tumors like scirrhus and malignant tumors, and those of great size.

With the exception of these last, all the tumors of this region are

easily cured, yielding either to surgery or to remedies. Surgery must

be adapted to the special tumor, whether it be honey-like or fatty, or

pultaceous. The prognosis of goitrous tumors is much better than might

be expected, but evidently Aetius saw a number of the functional

disturbances and enlargements of the thyroid gland, which are so

variable in character as apparently to be quite amenable to treatment.



Aetius' treatment of the subject of varicosities is quite complete in

its suggestions. The term varices, he says, is applied to dilated

veins, which occur sometimes in connection with the testes and sometimes

in the limbs. Operations on testicular varices patients do not readily

consent to; those on the limbs may be cured in several ways. First,

simple section of the skin lying above the dilated vessel is made, and

with the hook it is separated from the neighboring tissues and tied.

After this the dilated portion is removed and pressure applied by means

of a bandage. The patient is ordered to remain quiet, but with the legs

higher than the head. Some people prefer treatment by means of the

cautery. Gurlt, in his History of Surgery, calls attention to the

fact that two of our modern methods of treating varicose veins are thus

discussed in Aetius, that by ligation and that by the cautery. The

cautery was applied over a space the breadth of a finger at several

points along the dilated veins.



Aetius' chapters on obstetrics and gynaecology are of special interest,

because, while we are prone to think that gynaecology particularly is a

comparatively modern development of surgery, this surgical authority of

the early Middle Ages treats it rather exhaustively. His sixteenth book

is for the most part (one hundred and eleven chapters of it) devoted to

these two subjects. He has a number of interesting details in the first

thirty-six chapters with regard to conception, pregnancy, labor, and

lactation, which show how practical were the views of the physicians of

the time. Gurlt has given us some details of his chapters on diseases of

the breast. Aetius differentiates phagedenic and rodent ulcers and

cancer. All the ordinary forms of phagedenic ulcer yield to treatment,

while malignant growths are rendered worse by them. Where ulcers are

old, he suggests the removal of their thickened edges by the cautery,

for this hastens cure and prevents hemorrhage. With regard to cancer,

he quotes from Archigenes and Leonides. He says that these tumors are

very frequent in women, and quite rare in men. Even at this time cancer

had been observed and recognized in the male breast. He emphasizes the

fact that cancerous nodules become prominent and become attached to

surrounding tissues. There are two forms, those with ulcer, and those

without. He describes the enlargement of the veins that follows, the

actual varicosities, and the dusky or livid redness of the parts which

seem to be soft, but are really very hard. He says that they are often

complicated by very painful conditions, and that they cause enlargement

of the glands and of the arms. The pain may spread to the clavicle and

the scapula, and he seems to think that it is the pain that causes the

enlargement of the glands at a distance.



His description of ulcerative cancer of the breast is very striking. He

says that it erodes without cause, penetrating ever deeper and deeper,

and cannot be stopped until it emits a secretion worse than the poison

of wild beasts, copious and abominable to the smell. With these other

symptoms pains are present. This form of cancer is especially made worse

by drugs and by all manner of manipulation. The paragraph from Leonides

quoted by Aetius gives a description of operation for cancer of the

breast, in which he insists particularly on the extensive removal of

tissue and the free use of the cautery. The cautery is used at first in

order to prevent bleeding, but also because it helps to destroy the

remains of diseased tissues. When the burning is deep, prognosis is

much better. Even in cases where indurated tumors of the breast occur

that might be removed without danger of bleeding, it is better to use

the cautery freely, though the amputation of such a portion down to the

healthy parts may suffice. Aetius quotes this with approval.



Others before Aetius had suggested the connection between hypertrophy of

the clitoris and certain exaggerated manifestations of the sexual

instinct, and the development of vicious sexual habits. As might be

expected from this first great Christian physician and surgeon, he

emphasizes this etiology for certain cases, and outlines an operation

for it. This operation had been suggested before, but Aetius goes into

it in detail and describes just how the operation should be done, so as

to secure complete amputation of the enlarged organ, yet without injury.

He warns of the danger of removing more than just the structure itself,

because this may give rise to ugly and bothersome scars. After the

operation a sponge wet with astringent wine should be applied, or cold

water, especially if there is much tendency to bleeding, and afterwards

a sponge with manna or frankincense scattered over it should be bound

on. He treats of other pathological conditions of the female genitalia,

varicose veins, growths of various kinds, hypertrophy of the portio

vaginalis uteri, an operation for which is described, and of various

tumors. He describes epithelioma very clearly, enumerates its most

frequent locations in their order, lays down its bad prognosis, and

hence the necessity for early operation with entire removal of the new

growth whenever possible. He feared hemorrhage very much, however, and

warns with regard to it, and evidently had had some very unfortunate

experiences in the treatment of these conditions.



Aetius seems to have had as thoroughly scientific an interest in certain

phases of chemistry apart from medicine as any educated physician of the

modern time might have. Mr. A.P. Laurie, in his Materials of the

Printer's Craft,[2] calls attention to the fact that the earliest

reference to the use of drying oil for varnish is made by the physician

Aetius.



Aetius, or Aetios, to use for the nonce the Greek spelling of his name,

which sometimes occurs in medical literature, and should be known, has

been the subject of very varied estimation at different times. About the

time of the Renaissance he was one of the first of the early writers on

medicine accorded the honor of printing, and then was reprinted many

times, so that his estimation was very high. With the reawakening of

clinical medicine in the seventeenth century his reputation waxed again,

and Boerhaave declared that the works of Aetius had as much importance

for physicians as had the Pandects of Justinian for lawyers. This high

estimation had survived almost from the time of the Renaissance, when

Cornelius went so far as to say: Believe me, that whoever is deeply

desirous of studying things medical, if he would have the whole of Galen

abbreviated and the whole of Oribasius extended, and the whole of Paulus

(of AEgina) amplified, if he would have all the special remedies of the

old physicians as well in pharmacy as in surgery boiled down to a summa

for all affections, he will find it in Aetius. Naturally enough, this

exaggerated estimation was followed by a reaction, in which Aetius came

to be valued at much less than he deserved. After all is taken into

account in the vicissitudes of his fame, it is clear, however, that he

is one of the most important links in the chain of medical tradition,

and himself worthy to be classed among makers of medicine for his

personal observations and efforts to pass on the teachings of the old to

succeeding generations.