Recently, I was asked to give a medical opinion on a patient who had been stuck with the label of hypochondriac for more than 1,800 years. As an internist, I frequently must decide if a patient is truly sick or merely imagining various symptoms.
This patient, Aelius Aristides, was a public speaker and man of letters born in 117 A.D. in Greece. He wrote a great number of excruciatingly boring speeches, plus one remarkable work, "Sacred Tales," in which he chronicled his numerous ailments and the treatments he received at the direction of Asclepius, the god of medicine.
According to my friend, Lynn Kraynak, a classicist specializing in ancient Greece, scholars through the centuries have written off the old philosopher as a "whining hypochondriac."
Amazingly," Kraynak observed, "we scholars have never gotten a medical opinion."
She wondered if a modern physician -- meaning me -- would be willing to examine Aristides' medical history and assess whether this patient was merely a complainer or really sick. She sent me a translation of "Sacred Tales," and thus I had that most important aid to a diagnostician: a detailed medical history. Presentation of a Case
A.A., a 72-year-old Caucasian male Sophist, complains of recurrent choking sensations, malaise, cough, chills and fever since age 26.
He apparently felt well until January of 144 A.D., when at age 26 he developed nasal congestion and a mild sore throat after taking a warm springs bath in midwinter. He then set out in freezing temperatures from his estate north of Pergamum to Rome -- a journey that, because of his illness, took 100 days instead of the customary 30. En route, he developed discomfort in his ears, chills, high fever, loss of appetite and shortness of breath. The patient also suffered from pain in his gums and was observed cupping his hands as if to catch falling teeth.
Arriving finally in Rome, he began complaining of abdominal bloating and a sensation of respiratory blockage in his throat. His Roman doctors prescribed a 48-hour purgation achieved by his drinking elaterium, a concoction whose active ingredient is squirting cucumber. He continued to ingest elaterium until he developed bloody diarrhea.
After this pharmacologic approach had failed, surgeons recommended a blood-letting procedure. Without anesthesia, they made a superficial incision of the skin beginning from the patient's chest down to his bladder. Cupping instruments were applied to the profusely bleeding incision, at which time the patient reported that he again suffered a severe blockage of breathing. He recalls that "everything was smeared with blood." Another violent purge was prescribed. Afterward, he stated that he felt as if "my intestines were cold and hanging out."
In the autumn of 144 A.D., still ailing, the patient decided to return to his home in Asia Minor. He ruled out going by land from Rome, because "my body could not bear the shaking." Sailing from Rome, he suffered severe sea sickness, but his dominant symptom continued to be intermittent upper respiratory blockage with choking sensations.
"With much effort I would draw a rasping and shallow breath," he wrote. "A constant constriction in my throat followed, and I had fits of shivering . . ." His doctors "were at a loss . . . There was nothing which did not trouble me."
By November of 144 A.D., he had been almost continuously symptomatic for 10 months. Despite the strenuous efforts of physicians and "gymnastic trainers" -- physical therapists? -- his maladies remained undiagnosed. "My disease formed and grew, ever progressing as time went on," he wrote.
Aristides was to suffer the rest of his life -- about 46 more years -- with symptoms arising from a succession of illnesses contracted in this period between January and November 144 A.D.
His hopes of a great public career were dashed by his voice-impairing symptoms. He spent much of the remainder of his life as a patient at the Asclepieum of Pergamum, by all accounts the Mayo Clinic of its day. His personal physician was none other than Asclepius himself, the god of medicine. Since Asclepius appeared only in his patients' dreams and thus issued his prescriptions while his patients slept, bedrest was the dominant activity, or inactivity, of temple medicine.
A patient admitted for treatment to a medical temple in the second century was required to perform sacrifices and purification rituals before the heaven-sent doctor would appear. (In the same manner, a modern surgical patient must first sacrifice his health insurance card and then submit to meticulous scrubbing of his skin before the ethereally gowned surgeon floats into view.)
Aristides, like his fellow patients, was instructed by priests to lie down and allow Asclepius, the god of medicine, to appear in his dreams. In the morning, the patient would recount his dreams to a priest, who would interpret them and dispense what the doctor (Asclepius) ordered, in the form of medications, diet and exercise.
For his first treatment, Asclepius ordered his dreaming patient to go barefoot and to bathe in the river during a strong north wind in December. A regimen of sleeping alternating with bathing brought little relief over the next year. In the winter of 145 A.D., Aristides wrote, "Body remarkably weak; bedridden a long time. Three baths in river: rainy and stormy during baths. Undressed and dove into river in which rocks churned and timber was being carried along by wind and current."
After enduring this primitive version of a Jacuzzi bath, the patient was ordered to bathe in the harbor during a cold north wind and after emerging, to stand uncovered in the wind. The patient obeyed.
Despite these ministrations, or because of them, the patient's condition worsened. He reported in the winter of 145: "Flow from head . . . turmoil in chest . . . breath caught in throat, causing inflammation . . . constant expectation of death." He stated that whenever food touched his palate, the air passage would close, causing a choking sensation and a fiery pain that felt as if it were penetrating his brain. The medical priests kept him wrapped in wool in a dark room "so that day was equal to night and the nights were sleepless instead of the days."
Also in 145, his doctor prescribed bathing with a soap mixed with raisins. But the patient continued to suffer. He reported that his stomach troubles were at their peak. "Everything was swollen and inflamed," he complained. He underwent many blood-lettings -- in one case the blood was drained from a vein in his forehead.
With the nagging persistence of his complaints, his doctor told him, in effect, to jump in the lake, or at least bathe in the river. The blood-lettings and the bathing eventually seemed to produce temporary comfort and relaxation. At one point, Asclepius commanded the patient to smear mud on his body before bathing and run around the temple three times. Then he bathed in the Sacred Well (presumably surrounded by well wishers).
But by the spring of 146, Aristides could take no nourishment nor retain what he did take. He complained of profound exhaustion. On the advice of his physician, he rode a horse at dawn at full speed, during which time he felt somewhat better, only to relapse when he dismounted. Subsequently, he received a narcotic prescription: wormwood. He drank this mixed with vinegar and felt much better -- but then suffered severe withdrawal symptoms when the addicting drug was discontinued.
In the summer of 148 A.D., he noted one thing that helped: writing a poem. He observed that while engaged in creative work, he became oblivious to pain.
That fall, at age 30, he developed a very painful swelling in the groin that grew to extraordinary size. The enlarging mass was accompanied by fever. Asclepius advised a conservative approach, resisting the temptation to have the mass incised and drained. The tumor persisted for four months.
When the inflammation was at its height, Asclepius prescribed a medication that when applied to the tumor, caused most of the swelling to disappear quickly, leaving the overlying skin in folds. Unfortunately, the patient failed to record the ingredients of this prescription. The tumor presumably drained, leaving an inflamed opening in the skin. The drainage site rapidly healed after the patient obediently smeared on an egg.
His health remained poor during 149 and was not improved by two shipwrecks he survived that year. He went on to 16 more years of recurrent respiratory and abdominal symptoms, culminating in his contracting symptoms and signs of "the plague" -- smallpox -- in the summer of 165 A.D., at age 47.
Throughout this period, Aristides kept voluminous notes. He suffered severe, burning abdominal pains and was unable to take nourishment. During one bout of nausea, he received an enema of honey and was instructed to swallow a goose liver sausage. On Feb. 11, 166, the patient spent a routine day of "bathing in the morning and vomiting at night." On Feb. 13, he merely vomited.
Work on his speeches, poems and the recording of his dreams afforded him some relief from his continued symptoms. In 171 A.D., at age 53, he hinted that he might be feeling better by noting that he had not bathed in five years, except rarely in the sea, river or in a sacred well as prescribed by his divine doctor. He continued to receive purges, enemas and phlebotomies uncountable. On doctor's orders, he went barefoot in winter, slept in the open air and wore no undershirt under his tunic. Yet he continued to write, speak and edit and worked each day at least until midnight.
The circumstances of his death, at age 72, in 189 A.D. are unknown. Physician's Diagnosis
Thanks to the careful recording of his symptoms in his "Sacred Tales," this patient has provided the physician of 1990 A.D. some insight into his actual diagnoses.
Until now, Aristides has been written off as a hypochondriac, commonly defined as a person who has "an excessive preoccupation with one's health." Implied in the definition is the suspicion that the symptoms a hypochondriac suffers are largely imaginary or at least exaggerated.
In my opinion, however, he was not a hypochondriac.
As a diagnostician, I am, of course, deprived of the opportunity to examine Aristides and order appropriate lab tests on him (may he rest in peace). On the other hand, I have a treasure trove of clinical information written down by the patient himself.
His repeated references to a blockage of his upper airway passages, his choking sensations and the burning pain in his throat clearly point to a chronic inflammatory disease of the oropharyngeal cavity -- the mouth and throat. He had apparently been in good health until about age 26, when he developed symptoms of a common cold.
Still sniffling, he set out on an arduous journey to Rome. The persistence of his viral infection and the exhaustion from traveling in freezing temperatures most likely lowered his resistance to more destructive micro-organisms.
Shortly after setting out, he developed symptoms highly suggestive of complicating bacterial infections: acute otitis media -- earaches -- and gingivitis -- a gum infection that probably accounted for his worrying that his teeth would fall out. More ominously, he developed a high fever and shortness of breath, indicative of a lung infection.
He then made the mistake, still committed to this day, of seeking medical advice. Faithful to the standard practice of the time (and therefore immune to charges of malpractice), his Roman physicians recommended purgation with a powerful drug called elaterium, derived from the squirting cucumber, which causes profuse watery diarrhea. This drug is considered too dangerous for practical use today.
Aristides, who would prove to be a most compliant patient, took elaterium for two days before achieving the desired result of bloody diarrhea. Undoubtedly, this massive purgation caused serious dehydration and a profound loss of vital minerals, leading to the infliction on the patient of another common treatment of the day: blood-letting. Toxic Treatments
To add medical insult to surgical injury, he received another course of powerful intestinal purgatives, plus other unspecified drugs and antidotes. Often, what drug therapists of Aristides' day called desired results we now term "toxic side effects." In effect, his various treatments further lowered his resistance to a major bacterial invasion.
It is no surprise that his respiratory difficulty increased. His cough, chills, fever and choking sensations can best be explained by the diagnosis of pulmonary tuberculosis that spread to the epiglottis: a thin valve-like structure near the base of the tongue. The epiglottis covers the upper airway during swallowing, preventing the entrance of food and drink into the larynx. A tuberculous epiglottitis would easily account for his chronic recurrent throat pain and choking when he swallowed food and drink.
It is known that tuberculosis was prevalent at the time in the regions where the patient lived and traveled. In someone with Artistides' hardy constitution, which he clearly demonstrated by surviving his midwinter baths and other debilitating therapies, tuberculosis can remain a dormant disease until the host's resistance is compromised.
In my opinion, the rigors of his initial 100-day, midwinter journey to Rome, compounded by his enervating blood and intestinal purges significantly lowered his resistance to the spread of the tubercle bacillus through his lungs, up into his epiglottis and pharynx and eventually into the lymph nodes in his abdomen and groin.
The patient's graphic description, in the fall and winter of 148 A.D., of an enlarging mass in his groin and its subsequent rapid disappearance following local applications are consistent with a diagnosis of swollen lymph nodes that drained on their own without surgical incision.
If my diagnosis of tuberculosis is correct, then Aristides' vigorous horseback riding on his doctor's orders is history's first recorded case of galloping consumption.
In addition to TB, Aristides probably suffered from gastritis and irritable colon due to the numerous caustic medications, such as squirting cucumber, that he obligingly ingested. As the result of his countless blood-lettings, he undoubtedly developed chronic iron-deficiency anemia. His repeated intestinal purgation most likely caused dehydration, potassium deficiency and malnutrition.
At the same time, his resulting low-fat diet probably helped prevent an untimely demise from heart disease or stroke. After all, he lived to the dignified age of 72.
The innumerable symptoms that Aristides recorded make clinical sense today. The preoccupation with his health that he evinced in the "Sacred Tales" speaks more strongly for his having suffered from serious physical diseases than from hypochondria. As an internist, I recognize the presence of real physical disease in this long-suffering Sophist.
Aristides' relationship to his spectral physician, Asclepius, I believe, is relevant to an appraisal of the modern doctor-patient relationship. Aristides was in some respects a model patient in that he ascribed god-like attributes to his doctor and slavishly complied with Asclepius' sometimes punishing prescriptions. Nowadays, it is just such a model patient who often turns into a model corpse. I encourage my patients to challenge me -- or get a second opinion -- if they don't agree with my recommendations. (Although, God knows, a little devotion now and then doesn't hurt.)
Dr. Asclepius faithfully called on his patients each night as they lay dreaming. By contrast, when a modern physician makes a house call in the middle of the night, the patient only thinks he is dreaming.
None of the drugs that Artistides reported taking is known by modern pharmacologists to cure anything. At best, these medications caused relief of symptoms largely due to their placebo effect; at worst, they caused new symptoms. (Placebo is Latin for "I shall please.")
In the long run, old Aristides probably benefited from the bedrest and placebo therapy prescribed by a trusted and worshipped physician.
Of great interest is the relief of symptoms Aristides experienced while doing creative work -- a function presumably of the pain-deadening effects of chemicals called endorphins released from his central nervous system while he was happily absorbed in his writing. Aristides' experience inspires me to encourage my patients to lose themselves, and their symptoms, in creative pursuits.
It is easy for the modern physician to be condescending toward ancient temple medicine. And yet, until the discovery of the antibiotic streptomycin in 1943, the treatment of tuberculosis remained essentially the same as that in Aristides' day: strictly enforced regimens of bedrest, bathing and prolonged exposure to the elements.
I predict that 200 years from now, physicians will look back at doctors like me and our ancient gadgets -- CT scans, sonograms, colonoscopes -- and our primitive therapies -- antibiotics, open-heart surgery -- and have a fine dry chuckle.
The doctor of 2190 A.D. will preside over a genetically engineered population conceived in petri dishes and programmed to be disease-free and eternally youthful after age 28. (Perhaps the doctor's role will be to encourage high-fat diets, smoking, sedentary behavior and the unbuckling of seat belts in order to make room for the next, more perfect batch.)
But to return to the second century A.D.: Before the advent of a specific cure for diseases like tuberculosis, some patients got better; most did not.
Many of those patients who were able to achieve remission of their tuberculosis before the antibiotic age undoubtedly benefited from the placebo effects of their medication and from a nurturing relationship with their physician.
A prime example is Aelius Aristides and the doctor of his dreams, Asclepius.
Oscar London is the pseudonym of Arlan Cohn, a Berkeley, Calif., internist who is the author of "Kill as Few Patients as Possible" and "Take One as Needed" (Ten Speed Press.)