Paul of Aegina; the first routine laminectomy in recorded History

This review emphasizes the role of Paul of Aegina in the history of surgery and his influence on the subsequent medicine and surgery of Islam, proving that he was not only a carrier of the knowledge discovered by his predecessors (Hippocrates, Galen, etc.), but also he expanded the horizons of surgery of his time, using his talent to perform very complicated surgery with favorite outcomes in a variety of diseases in many fields of medicine.

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Paul was born on the island of Aegina in Saronic Gulf, just outside Athens. Little is known of his early life. He studied medicine in Alexandria, Egypt. There, he acquired a deep knowledge of Greek medicine as depicted by the work of Hippocrates, Galen and their successors and the discipline and innovative ideas of the whole Alexandrian School of thought. He traveled extensively in the Middle East. He came in contact and was highly influenced by the Arabic medicine, which, at the time, was very advanced. Paul’s most significant talent was an unusual skill in surgery combined with an acute power of observation and recording of his medical experience.

His most significant medical and surgical work was the Epitome of Medicine, which comprised seven books on a variety of treatises on medical and surgical subjects. This work was heavily based on the Hippocratic medical tradition with many influences and personal innovations.

Paul of Aegina had a great knowledge of the ancient writers, referring to them in his work widely while enriching their teachings with his own findings and observations especially as far as the surgical techniques part is concerned. His work was translated into Arabic in the 9th century and it represents a connection between Greek Hippocratic traditions and Islamic medicine.

Paul of Aegina describes all his knowledge, the basis of his practice, his experience and innovations in a compendium “Epitome of Medicine”. This compendium is divided into 7 books and 519 chapters.

The first book treats subjects of Hygiene and the preservation from nutrition issues for specific patient categories and their dietary needs.

In the Second part, he explained the whole doctrine of different kinds of fever and conditions related to them as aetiological factors or co-existent conditions like excrementious discharges, critical days and concluding with certain symptoms which are sometimes the consequences of fever.

The third book deals with “topical affections from the crown of the head to the nails of the feet” and discusses conditions of general pathology from brain infections and epilepsy to ileus, pleurisy and gonorrhea.

The fourth book discusses dermatological conditions such as herpes, gangrene, ulcers and leprosy, all related to dermatological manifestations as
well as parasitic worms.

The fifth book is a compendium of toxicology discussing treatment for poisons such as hemlock, poppy, mandrake and wolfsbane, and bites of venomous animals such as wasps, spiders, scorpions and vipers for human. Among other things, it treats deleterious substances and the preservatives from them.

The Sixth book is a real monument to the surgery of the era. It contains literally every significant surgical knowledge related to inner organs, soft tissue, skin and bones of early and medieval practitioners. It contains a number of ophthalmological, neurosurgical, general and orthopedic procedures.

Finally, the seventh book is devoted to pharmacology reciting ointments, antidotes, emetics and purgatives.

In his work, Paul presented innovative techniques of tracheotomy, tonsillectomy, catheterization of the bladder, lithotomy, inguinal hernia repair, abdominal paracentesis for ascites and many other surgical procedures including reduction of breast size. In addition, he presented novel techniques for the surgical reconstruction of the preternatural fingers, the early correction of pediatric strabismus, the treatment of perianal fistulae, plastic surgery, the management of humeral fractures, the management of uterine cancer and penile tumors. Furthermore, he made a devoted effort to teach surgery to others, to treat traumatic injuries and perform post-mortem cesarean sections and embryotomies.

His work is a bridge between medicine of ancient times and that of the Middle Ages. He influenced subsequent authors of medical and surgical texts like Rhazes, Haly Abbas, Albucasis, Avicenna and Fabricius.

Spine Surgery and Laminectomies Performed by Paul of Aegina

Paul gives a detailed account of the dislocations of the spine. He identifies the severity of such injuries and their high morbidity and mortality rate. In accordance with the Hippocratic and Galenic traditions, he recognizes three types of spine dislocations and subluxations: anterior, posterior and sideways.

In addition, he warns against the violent reduction of such subluxations e.g. upon a ladder, just like his predecessors. He attributes the detrimental results of such an action to nerve injury provoked by such a dislocation. As a result, he describes the complication of nerve injury with urine retention, coldness of the body, involuntary discharge of excrements and death if the injury occurs in the cervical spine.

Furthermore, he distinguishes spinal deformities of traumatic aetiology from those occurring during adolescence and development.

As far as Paul’s surgical technique and method are concerned, from his earliest surviving manuscript one can find samples and descriptions of numerous instruments which he designed and used for spine operations. A number of different elevators, raspatories and bone bitters are described.

Most significant are his views in the treatment of spine lamina fractures. Paul uses information that he attributes to Celsus in order to describe burst fractures with high morbidity and mortality if they involve the cervical spine. In these cases, he recommends the extraction of the broken part of the cervical vertebra which compresses the chord by the use of an incision which is pretty unspecific as far as the landmarks and surgical anatomy are concerned.

For the diagnosis of fractures of the spinal processes, he uses simple observation and palpation with the finger of the deformed spine after injury. He describes the use of an incision and extraction of the fragment followed by the closure of the wound with sutures. Therefore, in lamina fractures, Paul recommended early decompression through a laminectomy to secure the spinal cord, and he was the first surgeon in history to perform such an operation on a routine basis, apparently satisfied with its results.

He used similar diagnosis and treatment to fractures of the Os sacrum, especially of coccygeal fractures. The diagnosis was made with rectal palpation, and he recommended extraction of the bonny part through an incision and compressive application of bandages.

In addition, Paul had an improved sense of the requirements for a surgical technique such as the above. He mentions the use of wine to lavish the operating trauma; although the notion of antisepsis did not yet exist, he used compression during trauma dressing to prevent bleeding.

(Source: “Paul of Aegina (ca 625-690 AD), His Work and His Contribution to the Treatment of Spine Disorders: The First Routine Laminectomy in the Recorded History”, by Konstantinos Markatos et al.)

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Research-Selection for NovoScriptorium: Maximus E. Niles

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