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Another extremely important writer in these early medieval times, whose opportunities for study in medicine and for the practice of it, were afforded him by Christian schools and Christian hospitals, was Paul of Ægina. He was born on the island of Ægina, hence the name Æginetus, by which he is commonly known. There used to be considerable doubt as to just when Paul lived, and dates for his career were placed as widely apart as the fifth and the seventh centuries. We know that he was educated at the University of Alexandria. As that institution was broken up at the time of the capture of the city by the Arabs, he cannot have been there later than during the first half of the seventh century. An Arabian writer, Abul Farag, in "The Story of the Reign of the Emperor Heraclius," who died 641, says that "among the celebrated physicians who flourished at this time was Paulus Æginetus." In his works Paul quotes from Alexander of Tralles, so that there seems to be no doubt now that his life must be placed in the seventh century.

The most important portion of Paul's work for the modern time is contained in his sixth book on surgery. In this his personal observations are especially accumulated. Gurlt has reviewed it at considerable length, devoting altogether nearly thirty pages to it, and it well deserves this lengthy abstract. Paul quotes a great many of the writers on surgery before his time, and then adds the results of his own observation and experience. In it one finds careful detailed descriptions of many operations that are usually supposed to be modern. Very probably the description quoted by Gurlt of the method of treating fishbones that have become caught in the throat will give the best idea of how thoroughly practical Paul is in his directions. He says: "It will often happen in eating that fishbones or other objects may be swallowed and get caught in some part of the throat. If they can be seen they should be removed with the forceps designed for that purpose. Where they are deeper, some recommend that the patient should swallow large mouthfuls of bread or other such food. Others recommend that a clean soft sponge of small circumference to which a string is attached be swallowed, and then drawn out by means of the string. This should be repeated until the bone or other object gets caught in the sponge and is drawn out. If the patient is seen immediately after eating, and the swallowed object is not visible, vomiting should be brought on by means of a finger in the throat or irritation with the feather, and then not infrequently the swallowed object will be brought up with the vomit."

In the chapter immediately following this, XXXIII, there is a description of the method of opening the larynx or the trachea, with the indications for this operation. The surgeon will know that he has opened the trachea when the air streams out of the wound with some force, and the voice is lost. As soon as the danger of suffocation is over, the edges of the wound should be freshened and the skin surfaces brought together with sutures. Only the skin without the cartilage should be sutured, and general treatment for encouraging union should be employed. If the wound fails to heal immediately, a treatment calculated to encourage granulations should be undertaken. This same method of treatment will be of service whenever we happen to have a patient who, in order to commit suicide, has cut his throat. Paul's exact term is, perhaps, best translated by the expression, slashed his larynx.

One of the features of Paul's "Treatise on Surgery" is his description of a radical operation for hernia. He describes scrotal hernia under the name enterocele, and says that it is due either to a tearing or a stretching of the peritoneum. It may be the consequence either of injury or of violent efforts made during crying. When the scrotum contains only omentum, he calls the condition epiplocele; when it also contains intestine, an epiplo-enterocele. Hernia that does not descend into the scrotum he calls bubonocele. For operation the patient should be placed on the back, and, the skin of the inguinal region being stretched by an assistant, an oblique incision in the direction in which the blood vessels run should be made. The incision should then be stretched by means of retractors, until the contents of the sac can be lifted out. All adhesions should be broken up and the fat be removed, and the hernia replaced within the abdomen. Care should be taken that no loop of intestine is allowed to remain. Then a large needle with double thread made of ten strands should be run through the middle of the incision in the end of the peritoneum, and tied firmly in cross sutures. The outer structures should be brought together with a second ligature, and the lower end of the incision should have a wick placed in it for drainage, and the site of operation should be covered with an oil bandage.

The Arab writer, Abul Farag, to whose references we owe the definite placing of the time when Paul lived, said that "he had special experience in women's diseases, and had devoted himself to them with great industry and success. The midwives of the time were accustomed to go to him and ask his counsel with regard to accidents that happen during and after parturition. He willingly imparted his information, and told them what they should do. For this reason he came to be known as the Obstetrician." Perhaps the term should be translated the man-midwife, for it was rather unusual for men to have much knowledge of this subject. His knowledge of the phenomena of menstruation was as wide and definite. He knew a great deal of how to treat its disturbances. He seems to have been the first one to suggest that in metrorrhagia, with severe hemorrhage from the uterus, the bleeding might be stopped by putting ligatures around the limbs. This same method has been suggested for severe hemorrhage from the lungs as well as from the uterus in our own time. In hysteria he also suggested ligature of the limbs, and it is easy to understand that this might be a very strongly suggestive treatment for the severer forms of hysteria. It is possible, too, that the modification of the circulation to the nervous system induced by the shutting off of the circulation in large areas of the body might very well have a favorable physical effect in this affection. Paul's description of the use of the speculum is as complete as that in any modern text-book of gynæcology.