( Originally Published 1911 )
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 ins steries, and appeals to the name of the Saviour and the martyrs. He was evidently a man of wide reading, for lhe quotes from practically every important medical writer before his time. indeed, he is most valuable for the history of medicine, because he gives us seine 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, hut 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 veneseetion, 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, ete."
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. lie thought that one form of epulis was due to inflammation of a chronic character, and suggests that if remedies do not succeed it should he 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." lie divides the anginas generally into four kinds. The first consists of inflammation of the fauces with the classic. symptoms, the second presents no inflamation 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 lunation 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 he 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 sonic interesting details. He says that " all tumors occurring in the throat region are called bronehoceles, 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 hocal 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," lie 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 eautery was applied over a space the breadth of a finger at several points along the dilated veins.
Aetius' chapters on obstetrics and gynecology are of special interest, because, while we are prone to think that gynecology 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 he morrhage. 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 smehl. 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. lie 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," 1 calls attention to the fact that the earliest reference to the use of drying oil for varnish is made by the physician
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 subjeet 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.