Aretaeus of Cappadocia

Roman physician

• Born: fl. probably second century
• Birthplace: Cappadocia, Roman Empire (now in Turkey)

Considered by many the greatest ancient physician after Hippocrates, Aretaeus wrote the best and most accurate descriptions of many diseases and made landmark studies of diabetes and neurological and mental disorders.

Early Life

Not even the exact century of Aretaeus (ar-uh-TEE-uhs) of Cappadocia’s birth is known; most scholars agree on the second century c.e., although a few offer the first or third century. Aretaeus’s epithet is “Cappadocian,” implying that he was born in that most eastern of Roman provinces. No other information about his life is certain. Scholars conjecture, however, that he studied in Egypt at Alexandria, founded in 331 b.c.e. as the major center for medical study, research, and teaching. Aretaeus mentions Egypt in his works and describes its geography and some diseases and therapeutics unique to that country. Some scholars believe that Aretaeus also practiced medicine in Rome; he prescribed wines known to second century Rome—namely, Falernian, Fundian, Sequine, and Surrentine.

Aretaeus was an Eclectic by practice and a Pneumatist by training. After Hippocrates in the fifth century b.c.e. there was little advance in the knowledge of disease and its treatment, although there were significant gains at Alexandria in the area of anatomy because of the dissections of human bodies. Instead, post-Hippocratic physicians tended to theorize about medicine as a philosophy and to develop various schools of medicine. Dogmatism and Empiricism were the first schools. The Dogmatists employed theoretical principles; they believed that reason and systematic studies of anatomy and physiology were necessary for the physician. The Empiricists, on the other hand, rejected theory and anatomy; they stressed experience and observation. The “tripod” of the Empiricists’ knowledge was personal observation, researched historical observation, and use of analogy in analyzing unknown cases.

Two schools developed in reaction to the Dogmatists and Empiricists. Methodism, founded in the late first century b.c.e., rejected the theory of the humors so prevalent in Hippocratic medicine and advocated an atomic stance. The Methodists considered disease an interference of the normal position and motion of the atoms in the human body; treatments were prescribed to restore the proper order of the atoms—relaxants to counteract excessive tension, astringents to counteract excessive looseness.

The Pneumatic school, established around 50 c.e. by Athenaeus of Attaleia, stressed pneuma, meaning “vital air” or “breath.” The beliefs of the Pneumatists were a combination of the Stoic philosophy, with its emphasis on primordial matter, the pneuma, from which all life comes, and Hippocratic pathology. Disease occurs when an imbalance of the four humors (blood, phlegm, black bile, and yellow bile) disturbs the pneuma in the human body.

Each of these various schools had both strengths and glaring weaknesses in its theories and practices. The knowledge of these weaknesses, coupled with Roman common sense, which rejected the Greek love of theory, led most Roman physicians, beginning with Archigenes (fl. c. 100 c.e.), to pick and choose among the various doctrines and ideas of the four schools. Such physicians were called Eclectics. That Aretaeus was an Eclectic is obvious from his work: For example, although he followed Pneumatism in its concept of the vital breath and its relation to the four humors, Aretaeus pursued anatomy and physiology avidly, as the Dogmatists did, yet he also relied heavily on observation and experience in the manner of an Empiricist. His emphasis on simple regimens and treatments recalls the Methodist school as well as Hippocrates.

Life’s Work

Aretaeus refused to be dogmatic and speculative. He attempted to describe diseases in clear, scientific, and rational terms, and his writings bear the marks of careful thought and extensive clinical experience. Aretaeus wrote seven works, two of which survive: Peri aition kai semeion oxeon kai chronion pathon (On the Causes and Symptoms of Acute and Chronic Diseases, 1856) and Oxeon kai chronion nouson therapeutikon biblion (Book on the Treatment of Acute and Chronic Diseases, 1856). The lost works discussed fevers, surgery, pharmacology, gynecology, and prophylaxis. Aretaeus wrote in Ionic Greek, a dialect that had not been in use for centuries; he chose the Ionic style to imitate Hippocrates, who also wrote in that dialect.

Aretaeus followed the Methodist classification of diseases into chronic and acute; the distinction was made on the course of the disease, that is, whether the disease lasted over a long period of time or was of a short duration and reached a “crisis” (the point in the progress of the disease when the patient recovered or died). Chronic diseases include paralysis, migraine headaches, and insanity, while examples of acute diseases are pneumonia, pleurisy, tetanus, and diphtheria. Aretaeus’s descriptions of these and other diseases show him to be an accurate observer who was concerned more for the patient than for theory itself. His accounts, so important in the history of medicine, may be summarized in the following categories: anatomy and physiology, symptomatology (physical description of diseases such as diabetes, leprosy, and ulcers), neurology and psychiatry, surgery, and therapeutics.

Aretaeus devoted more attention to anatomy and physiology than most ancient physicians. As stated earlier, Aretaeus followed the Pneumatist doctrine: He believed that the body is composed of the four humors and of spirit (pneuma), and the proper mixture and interplay of these elements constitutes health. Blood is formed in the liver from food; phlegm is secreted by the brain into the other organs; and yellow bile comes from the liver, black bile from the spleen. The most important organ is the heart, because the heart is the site of heat and pneuma. The heart draws the pneuma from the lungs, which are stimulated by it. Respiration itself depends on the movement of the thorax and diaphragm and also on the lungs’ contraction and expansion. Regarding the nervous system, nerves originate in the brain; this idea was based on the perception that the spinal cord was a prolongation of the brain. All nerves cross between their origin in the brain and their final termination in the body; Aretaeus based this belief on his startling observation that a cerebral lesion caused paralysis on the opposite side of the body.

Aretaeus knew much about circulation. The aorta, he stated, comes from the heart and is located to the left of the vena cava; the aorta carries the pneuma to the other organs. The veins, which originate in the liver, bring the blood to all the body. Aretaeus asserted that the content of the arteries was light-colored, that of the veins dark. The liver itself is composed mostly of blood and produces blood and bile; if it becomes inflamed, jaundice results. Aretaeus wrote remarkable accounts of the kidneys and the bile ducts. He thought of the kidneys as cavities that acted like sieves for collecting urine and were connected to the bladder by two tubes, one from each kidney. Digestion of food occurs not only in the stomach but also in the intestines. The portal vein takes the food after digestion to the liver, where it is taken out as blood by the vena cava to the heart. This scheme shows that Aretaeus was aware of nearly all circulatory processes and the direction of blood flow in the veins.

One of Aretaeus’s greatest accomplishments was his practice of physical diagnosis. He used anatomical inspection, distinguishing the appearances of ulcers in the small and large bowels, for example. Also, before he discussed a disease, Aretaeus prefixed an anatomical and physiological introduction concerning the part(s) of the body afflicted by the disease (this is the method used in many modern medical textbooks). In his physical examinations, Aretaeus employed auscultation of the heart, palpitation of the body (to check for enlargement of the liver and spleen), and percussion of the abdomen. Aretaeus always noted carefully the patient’s symptoms: temperature, breathing, pulse, secretions, color of skin, and condition of the pupils. In the tradition of Hippocrates, Aretaeus related diseases to foods eaten by the patient and to climate, time of year, and environment.

Aretaeus’s symptomatology is considered excellent by medical historians and, in some instances, not improved on even by contemporary medicine. Especially praiseworthy are Aretaeus’s accounts of hematemesis, jaundice, dropsy, tuberculosis, tetanus, epilepsy, and cardiac syncope. Aretaeus distinguished between pneumonia and pleurisy and is credited with the initial descriptions of diphtheria and asthma. He was the first European to write a symptomatic account of diabetes, and he gave the disease its name. Aretaeus correctly thought of diabetes as a progressive form of dropsy with polyuria and excessive thirst that results in emaciation of flesh. Finally, Aretaeus’s accounts of leprosy are invaluable. He offered useful distinctions between the types of leprosy: elephantiasis (the tuberous form of leprosy) and the maculo-anesthetic form, which involves mutilation of the body; he also provided the first recorded instance of isolating lepers and distinguished between conveyance of disease by actual contact (contagion) and transmission of disease at a distance (infection).

Aretaeus’s discussions of neurological and mental diseases are important. He divided such illnesses into acute and chronic classes. The acute diseases, as he described them, are phrenitis (a febrile delirium or, at times, meningitis), lethargy (a comatose state, or encephalitis), marasmus (atrophy), apoplexy (an acute form of paralysis), tetanus, and epileptic paroxysm. Chronic diseases include cephalaea (migraine headache), vertigo (chronic paralysis), and all forms of insanity. Especially important are Aretaeus’s astute distinctions between apoplexy, paraplegia, paresis, and paralysis; the basis of division was the extent of loss of movement and sensation. Aretaeus was the first to distinguish between spinal and cerebral paralysis: When the paralysis is spinal, it occurs on the same side as the lesion; when cerebral, the paralysis occurs on the opposite side (crossed paralysis).

Aretaeus’s clear and full discussion of the different kinds of insanity has remained unsurpassed. He noted the stages by which intermittent insanity (manic depression) can become a senile melancholia that does not remit. While the former may be treated by phlebotomy, wormwood, and black hellebore (a plant that produces violent shocks to the nervous system similar to those in modern electric shock treatment), senile melancholia is incurable.

Aretaeus’s book on surgery has been lost; he did, however, refer to surgery throughout his extant writings. Aretaeus recommended craniotomy (trepanning) for epilepsy and for cephalalgia and cephalaea (acute and chronic headache, respectively). He used catheters for urological diseases and mentioned surgery to remove kidney stones. It should be noted that surgery was not commonly practiced in antiquity, but when it was deemed necessary, the practicing physician usually performed it.

Aretaeus’s treatments of disease are conservative. As in his discussions of the causes and forms of diseases, Aretaeus relied on experience and common sense, not abstract theory. He rejected tracheotomy and pleaded for extreme caution in the application of phlebotomy, venesection, cupping, and leeches: Aretaeus argued that only in severe cases should much blood be removed. Instead, he used purgatives, emetics, suppositories, laxatives, ointments, and poultices. Aretaeus also stressed exercise, massages, baths, temperate lifestyles, and a healthy diet including milk, fruits, vegetables, and foods without starch and fat. He also prescribed opium for people afflicted with feverish delirium.

Significance

No ancient medical writer, except perhaps Hippocrates, surpassed Aretaeus of Cappadocia for vividness and clarity in the description of diseases. Aretaeus’s descriptions of diabetes, tetanus, diphtheria, leprosy, asthma, and mental and neurological disorders are especially valuable and are landmarks in medical history. Aretaeus tried his best to put his symptomatology on a sound anatomical basis; for every disease, he supplied splendid accounts of anatomy. He gave therapeutics and cures for every disease, acute and chronic; his treatments are simple and rational. In his writings, Aretaeus was perhaps the most unbiased physician in antiquity, rejecting dogmatic thought, theory, and superstition. Finally, Aretaeus was unique in refusing to abandon the patient who was incurable; while even Hippocrates recommended turning away hopeless cases, Aretaeus ordered all measures to be taken, and, when those failed, he offered support and sympathy.

Bibliography

Allbutt, Sir Thomas. Greek Medicine in Rome. 1921. Reprint. New York: B. Blom, 1970. Still one of the best textbooks on the medical schools and the practice of medicine in the Roman Empire. The chapter “Some Pneumatist and Eclectic Physicians” discusses Aretaeus and is superb in providing background information to the Eclectic and his writings.

Aretaeus of Cappadocia. The Extant Works of Aretaeus the Cappadocian. Edited and translated by Francis Adams. 1856. Reprint. Boston: Milford House, 1972. Aretaeus’s work translated into English. The introduction to Aretaeus, his background, and his work is somewhat difficult for the nonspecialist, and the antiquated English of the translation is forbidding.

King, Helen. Greek and Roman Medicine. London: Bristol Classical Press, 2001. An overview of medicine in the Greek and Roman world.

Lloyd, Geoffrey, and Nathan Sirin. The Way and the Word: Science and Medicine in Early China and Greece. New Haven, Conn.: Yale University Press, 2002. A study of science and medicine in two early cultures.