Surgery on Aneurysms in Byzantine Times

Here we present selected parts of the very interesting paper “Surgery on Aneurysms in Byzantine Times (324-1453 A.D.)“, Eur J Vasc Endovasc Surg 15, 110-114 (1998), by J. Lascaratos, C. Liapis and C. Ionidis.

The practice of surgery developed greatly during the Byzantine period. Byzantine surgeons based their knowledge on that of the physicians of antiquity but improved on their techniques through personal contribution and experience. Byzantine surgery was so improved that surgeons dared to perform successful lithotripsy in the bladder (9th cent.) and to undertake the separation of Siamese twins (10th cent.).

oribasi.jpg

The first eminent Byzantine physician who dealt with surgery on aneurysms was Oribasius from Pergamum (325-403 A.D.), who studied medicine in the famous School of Alexandria. In 355 he was appointed to the position of palace physician and was later personal physician of the Emperor Julian the Apostate (361-363 A.D.), whom he accompanied on his voyages until the latter’s death. On Julian’s command he compiled the most important medical written material in an anthology, the famous “Synagogae Medicae’, a complete medical encyclopaedia of his era, consisting of more than 70 volumes. Unfortunately a considerable part of this ambitious work has been lost; but what remains affords us a surprising insight into the richness of ancient medicine. The surgical sections are the most complete technical treatises of antiquity and allow a reconstruction of the astonishingly developed surgical techniques of the Roman-
Alexandrian epoch.

Oribasius occupies himself with aneurysms in two chapters of his book. He defines aneurysm as a disease derived from the inosculation of the arteries or injury to the arteries so that the covering skin becomes scarred while the injury to the artery does not heal and the wound remains open underneath. The diagnosis of aneurysms is possible because they beat with the same rhythm as the pulse, and with pressure the tumour
disappears because its contents return to the artery. If the aneurysm is pricked, the blood spurts out and cannot easily be stopped, and if a thrombus is created in the aneurysm a necrosis results. The second chapter originates, as the writer himself declares, from the
great surgeon of antiquity, Antyllus (2nd cent. A.D.). According to this text, two forms of aneurysm exist: the first is caused by dilation of the arteries (from this mechanism the term aneurysm derives; aneurysm, “aneurysma” in Greek=an area being dilated); the
second form is caused by the rupture of an artery so that the blood escapes into the tissues. When aneurysms originate from dilation of the arteries they have a cylindrical form, while those that come from lesions of the vessels are rounded. On the walls of the
first, more foreign bodies are deposited (perhaps this refers to calcium deposits) and, when pressed by the fingers, no sound is heard. On the contrary, in traumatic
aneurysm an indistinct sound (“psophos” in Greek) is heard.

(…) From the 4th century Oribasius was able to describe two surgical techniques on traumatic and non-traumatic aneurysms, which had originated from Antyllus, the great surgeon of antiquity (2nd cent. A.D.) . The latter obviously learned them from his teachers, the surgeons of the Pneumatic School of Alexandria (1st cent. A.D.). Antyllus, therefore, is the first in the history of vascular surgery who described detailed techniques in this field.

aetius

(…) A second eminent Byzantine physician who dealt with surgery of aneurysms was Aetius Amidenus (6th cent.). He also studied in Alexandria and practised medicine in the Byzantine Empire during the reign of Justinian. He wrote a medical compendium of 16 books (“logi” in Greek), constituting the famous Tetrabiblus. Chapter 10 of his 15th book has the title “Concerning Aneurysms”. Aetius notes that aneurysms occur all over the body and especially in the area of the throat (especially in women during difficult
delivery in childbirth), in the head or in the inner elbow when the physicians undertake a phlebotomy and, due to medical error, prick together with the vein, the artery below, so that the blood and pneuma contained in the artery escape. Other reasons for formation of aneurysms are the inosculation of the artery or automatic rupture of it. The signs which cause us to suspect existence of an aneurysm are: painless tumours of various dimensions, very soft, homogeneous in colour and spongy, which subside and
almost disappear during finger pressure, soon to reappear after removal of pressure. This latter sign occurs mainly in non-traumatic aneurysms, because the traumatic form is less soft due to clotting of the blood in it. Many surgeons, Aetius adds, avoid operating on aneurysms located in the throat or on the head because, when opened, an unstemmable and strong flow of blood follows and the patient is at risk of dying during
the operation “under the surgeon’s knife”. Aetius adds information about a special technique for aneurysms in the inner elbow.

paul-of-aegina-physician-surgeon

(…) A third celebrated physician of Byzantium dealing with the same topics was Paul of Aegina (7th cent.), who studied and practised medicine in Alexandria. In his sixth book, the most noteworthy of his seven books, constituting his work “On Medicine”, is included a special chapter (37) with the title “Concerning Aneurysms’, where he follows the two techniques of Oribasius.

john actuarius

(…) Finally, in the fourteenth century the operations on aneurysms appear to have progressed. The greatest Byzantine physician of this century, John Actuarius, in his most important work “Therapeutic Method” described a new technique – simultaneous incision of the vessels and haemostasis with a special instrument which both lanced and cauterised. The same physician, when dealing with aneurysms, applied caustic materials which caused their shrivelling. John Actuarius stresses the danger of automatic rupture of the aneurysm, which manifests itself with acute pain and abundant haemorrhagia.

The research of the texts of Byzantine physicians proves that, from the early Byzantine period, they knew techniques for operating on aneurysms.

(…) Perhaps the extracts relevant to aneurysms, as with other topics on surgery ascribed to Antyllus, might have been inspired by previous great surgeons, such as those of the Pneumatic school: Archigenes (48-117 A.D.), Heliodorus (1st cent. A.D.) and Leonidas (1st cent. A.D.). Oribasius, however, was not only a simple compiler but had great personal surgical experience which is revealed in his works.

(…) The techniques of Paul of Aegina follow and interpret those of Oribasius, while Aetius adds his own technique for the iatrogenic aneurysm of the elbow, obviously very common due to the widespread practice of phlebotomies as a routine treatment. Finally, the contribution of Byzantine surgeons to operations for aneurysms is completed by John Actuarius who used an instrument simultaneously acting as a lancet and cautery (the use of cauteries was known from Hippocratic times and was widespread in Byzantium from early times, while the use of cautery knives is well known from the 7th cent.).

(…) it must be stressed that the techniques on aneurysms described by Paul of Aegina were adopted by the great surgeons of the West and were unchanged until the 16th century.

Research-Selection: Anastasius Philoponus

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