Historical VignettePaul of Aegina (625–690): His Work and His Contribution to Neurologic Surgery: Trephinations and Laminectomies in the Dark Ages
Introduction
The purpose of this historical review is to summarize the work of Paul of Aegina (625–690) (Figure 1), especially his contribution to the treatment of neurosurgical disorders and trauma. A major review of the available literature in PubMed and Google Scholar and additionally of books and library material was undertaken. An effort was made to find the most significant parts of his contribution to surgery and medicine, with a special interest in neurologic surgery for both brain and spine diseases.
Therefore, this review focuses on the role of Paul of Aegina in the history of surgery and his influence in the subsequent medicine and surgery of the Islam, proving that he was not only a carrier of the knowledge discovered by his predecessors (Hippocrates, Galen, etc.) but that 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. This review will focus especially in the use of laminectomy and trepanation in his practice, his methods, and the conditions in which he applied such treatment options.
Section snippets
Paul's Early Life and Studies
Paul was born on the island of Aegina in the 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 he was highly influenced by the Arabic medicine, which, at the time,
The Medical Practice and Writings of Paul
Paul of Aegina describes all his knowledge, the basis of his practice, and his experience and innovations in his opus magnum, Epitome of Medicine. This multivolume text comprises 7 books and 519 chapters (Figure 2).3 The first book treats subjects of hygiene, nutrition issues, and patient-specific dietary needs. In the second, the different kinds of fever and conditions related to them are presented as etiologic factors or coexistent conditions like body fluid discharges, critical days, and
Paul on Head Injuries and Disorders
In his work, Paul gives a detailed description of skull fractures and their treatment. He categorizes them as fissure, incisional, expression, depression, arched fracture, and capillary. This categorization has to do with the eventuality that they are linear, with a gap, depression, comminuted, displaced inwards or outwards, and if they are across the hairline. He recognizes the danger that small fractures can cause significant hematoma and contusion with brain injury and consequent death.1, 2
Paul and Spine Surgery
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 to the Hippocratic and Galenic tradition, he recognizes 3 types of spine dislocations and subluxations: anterior, posterior, and sideways.1, 2, 8, 9, 10, 11
In addition, he warns against the violent reduction of such subluxations upon a ladder, just like his predecessors. He attributes the detrimental results of such an action to
Discussion
As far as the work of Paul in the classification, description, and surgical management of skull fractures and head trauma is concerned, one can say that it is heavily based on previous work dating back in ancient Egyptian and Greek medical and surgical concepts; trephinations for the drainage of subdural hematoma, debridement of head fractures, and partial craniotomies were widely used surgical practices of surgery from early antiquity. Trephination is first described in the Edwin Smith
Conclusions
In summary, one can easily identify the surgical talent and boldness of Paul of Aegina compared with the medical and surgical trends of his era. In his work, he uses methods and techniques that would not be used effectively until after the Renaissance in Western Europe. However, our knowledge of his full work is at least incomplete. He established laminectomy and spinal decompression as a sound treatment method for spinal process fractures, and he boldly supported its use as a safe method for
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.