Paul of Aegina

Byzantine physician and writer

• Born: c. 625
• Birthplace: Aegina, Greece
• Died: c. 690
• Place of death: Unknown

Paul of Aegina was a celebrated Byzantine physician, surgeon, and medical writer. His Epitome summarized nearly all medical knowledge of his time and had a profound influence on Western European, Arabic, and Persian medicine. His treatment of surgery is the best summary of ancient surgery that has survived.

Early Life

Little is known of the life and career of Paul of Aegina (ih-JI-nuh). He was born on the Greek island of Aegina in the Saronic Gulf near Athens in the early seventh century. As a young man, he studied at Alexandria in Egypt. At this time, the eastern Mediterranean world was dominated by the Byzantine Empire, which came into existence in 395, when the Roman Empire was divided in two. Centered in the great city of Constantinople, named after the emperor Constantine in 330, the Eastern Roman Empire gradually developed a separate identity. Enjoying geographic and economic advantages over the Western Roman Empire, it survived after the fall of Rome in the west. No one thought of it as a new empire but rather as a continuation of the Roman Empire on a reduced scale.

Alexandria had long enjoyed a reputation as one of the chief centers of learning in the Mediterranean. It was renowned as a center of medical study, particularly the study of anatomy. Late antiquity witnessed a gradual decline in the quality of learning in all fields, but the schools of medicine continued to function at Alexandria well into the Byzantine period, even if their finest days were past. Hence Alexandria continued to attract young medical students, as it had for centuries. Paul seems to have practiced medicine in Alexandria, where he may even have taught, but how long he remained is not known. In 640, the city fell to the Muslims, ending, for all intents and purposes, Alexandria’s prominence as a center of science and medicine. Whether Paul remained there after the conquest, and if so how long, are unknown.

According to a later Arab source, Paul had special experience in women’s diseases and enjoyed considerable success in their treatment. Midwives are said often to have sought his aid regarding difficult cases and to have received from him much useful advice. For that reason he was given the title of alqawabeli, or “the birth-helper.” He wrote on pediatrics and obstetrics and in fact summarized nearly everything that was known at the end of antiquity on these subjects. He does not, however, seem to have specialized in these areas to the exclusion of others, for his writings reveal wide experience in medicine and surgery generally.

Life’s Work

Byzantine medicine fell heir to nearly a thousand years of Greek medical development. Greek medicine, after reaching its zenith in the work of Galen in the second century, began a long period of decline and ossification. In late antiquity, medical writers increasingly abandoned firsthand medical investigation in favor of compiling encyclopedic compendia of medical knowledge in which the great medical writers of the past, whose works were regarded as too extensive to be manageable, were summarized and abridged. Hence much of the earlier Greek medical heritage was passed down to subsequent generations in the form of medical encyclopedias. In the fourth century, Oribasius, the court physician to Emperor Julian, compiled a large medical encyclopedia in seventy books. This practice of systematic compilation was continued by Byzantine physicians such as Aëtius of Amida and Alexander of Tralles in the sixth century. Paul of Aegina, who had Oribasius’s work at his disposal, believed that it was too long to be used by most ordinary physicians and so compiled his own abridgment of it, Epitome medicae libri septum (The Seven Books of Paulus Aegineta, 1844-1877, commonly known as the Epitome).

In the preface to his Epitome, Paul disclaims originality, saying that he has compiled the work from previous authors except for a few things that he has employed of his own. He includes material chiefly from Oribasius, but also information from other distinguished medical writers. His statement that earlier writers had said all that there was to say on medicine has been taken to indicate Paul’s recognition of the low state of medicine in his own day. In fact, however, it is probably no more than a conventional expression of piety to the great medical writers of the past.

Book 1 of the Epitome deals with hygiene and regimen. Paul accepts Greek humoral pathology, discusses the temperaments, and recommends dietary therapeutics for different seasons and ages. Book 2 is devoted to fevers, which are symptomatic of acute or chronic diseases, and to the discussion of the value of the pulse (of which Paul classifies sixty-two varieties), urine, and sputum as indications of disease. In book 3, Paul deals with topical afflictions. He begins at the top of the head (with afflictions of the hair) and proceeds downward to the toenails. Included are discussions of diseases of the kidneys, liver, and uterus. Book 4 treats diseases of the skin (such as leprosy and cancer) as well as intestinal worms. Book 5 deals with toxicology and describes the treatment of stings and bites of venomous animals. Book 6 is devoted to general surgery and book 7 to simple and compound medicines (Paul includes some six hundred plants and ninety minerals).

In the Epitome, there are 242 sections that deal with virtually every aspect of medicine and represent a summary of medical knowledge in Paul’s day. While relying heavily on Oribasius, Paul also drew on Galen, Soranus, Aëtius, and Dioscorides, sometimes reproducing them word for word. Yet Paul was no mere copyist. He was critical, providing correctives where necessary. On one occasion, having given the Hippocratic opinion on a particular condition, he added the warning, “Time, however, has demonstrated that this procedure is inadvisable.”

Book 6 of the Epitome contains the best short treatment of ancient surgery that survives. The book is divided into two sections that deal respectively with manual operations and the treatment of fractures and dislocations. Altogether, Paul provides detailed descriptions of more than 120 operations. In general, he describes surgery only on the surface of the body or in its orifices (such as nasal or genital passages), where surgical instruments can be easily inserted. Paul describes lithotomy (surgical removal of bladder stones), trephination (removal of a bone disc from the skull), removal of tonsils, and amputation of the breast. Also included are surgical techniques for tracheotomies, catheterization, and removal of hemorrhoids. The method that he recommends for excision of tonsils remained virtually unchanged in practice for centuries. Paul describes as well venesection, cupping, and the use of ligation for bleeding vessels. Book 6 also contains one of the most detailed treatments of ancient ophthalmic surgery extant. Paul records procedures for removal of cataracts, and his treatment of trachoma is especially good for the age in which it was written. His account of military surgery is similarly comprehensive. Paul’s treatment of surgery shows him to have been probably the greatest surgeon of his day. Although his accounts of surgical procedures were for the most part derived from the works of earlier medical writers, he reproduced them with clarity and precision. He did not hesitate to reject established procedures when he thought it necessary. Thus, in his treatment of fractures, he sometimes contradicts Hippocratic teaching in favor of what he regards as sounder procedures (for example, he recommends the immediate reduction of dislocations).

Among other aspects of medicine treated by Paul are pediatrics (he includes discussion of dentition, convulsions, and constipation), lung diseases, and difficult labor. He provides one of the earliest descriptions in medical literature of lead poisoning. There are also descriptions of encephalitis, apoplexy, and epilepsy. In his discussion of insanity, there are excellent clinical observations as well as sound recommendations for treatment. Paul also gives the first description of hygienic rules for travelers, which became very popular in the Middle Ages.

Significance

Paul was the last great physician and surgeon of the early Byzantine period. Following his death near the end of the seventh century, there was little original work done in medicine; few influential Byzantine physicians are known until the eleventh century. Although Paul reflects the tendency of late Roman and Byzantine physicians to substitute the collected wisdom of earlier Greek writers for experimentation and independent judgment, he rose above his contemporaries in rejecting traditional procedures and therapeutics where they conflicted with his personal experience. Since the time of Aulus Cornelius Celsus (c. 25 b.c.e.-c. 50 c.e.), it appears that in technical skill Roman and Byzantine surgeons had made considerable advancement. Paul’s treatment of surgery represents the culmination of advances made by Greek surgeons. The progress, however, ended with him: There was no one after Paul who equaled him. Hence, he became the authoritative writer on surgery for later Byzantine physicians which had negative as well as positive ramifications. In describing the operation for hernia, for example, Paul recommended that the testicle be removed; as a result of his authority, this unfortunate procedure continued to be practiced until the sixteenth century. His treatment of surgery was long used as a textbook at the University of Paris. In the sixteenth century, his works were translated into Latin and quoted extensively by medical writers. His discussion of surgery was extracted by Hieronymus Fabricius ab Aquapendente (the teacher of William Harvey) in his work on surgery published in 1592.

Paul’s reputation was at least as great among Muslim physicians as it was among European Christians. Arab and Persian physicians quoted him frequently and regarded him as an authoritative Greek writer on medicine. The famous Persian physician al-Rāzī borrowed heavily from Paul’s surgery. Abū al-Qāsim (1013-1106), the great Muslim surgeon, based his well-known treatise, al-Taṣrīf liman ՙajaz ՙan al-Ta՚ālīf, on the surgical writings of Paul. Inasmuch as Abū al-Qasim remained the leading authority on surgery until the thirteenth century, Paul of Aegina continued to influence surgery in the Muslim world nearly as long as he did in the West.

Bibliography

Biller, Peter, and Joseph Ziegler, eds. Religion and Medicine in the Middle Ages. Rochester, N.Y.: York Medieval Press, 2001. An examination of medicine in medieval times with an emphasis on religion and the Catholic Church’s influence. Bibliography and index.

French, R. K. Medicine Before Science: The Rational and Learned Doctor from the Middle Ages to the Enlightenment. New York: Cambridge University Press, 2003. An examination of the role of physicians in the Middle Ages. Bibliography and index.

Garcia Ballester, Luis. Galen and Galenism: Theory and Medical Practice from Antiquity to the European Renaissance. Burlington, Vt.: Ashgate, 2002. A study of Galen and how his beliefs on medicine affected later physicians such as Paul of Aegina.

McVaugh, Michael R., and Nancy G. Siraisi, eds. Renaissance Medical Learning: Evolution of a Tradition. Philadelphia: History of Science Society, 1991. A look at how medicine was learned during the early Renaissance. Bibliography and index.

Paul of Aegina. The Seven Books of Paulus Aegineta. Translated by Francis Adams. 3 vols. London: Sydenham Society, 1844-1847. An excellent translation into English of the Epitome prefaced by a good introduction on Paul of Aegina and his influence on later medicine.

Scarborough, John, ed. Symposium on Byzantine Medicine. Washington, D.C.: Dumbarton Oaks, 1984. A collection of papers by specialists that deal with virtually every aspect of Byzantine medicine.