Historical overview of spinal deformities in ancient Greece
© Vasiliadis et al; licensee BioMed Central Ltd. 2009
Received: 26 January 2009
Accepted: 25 February 2009
Published: 25 February 2009
Little is known about the history of spinal deformities in ancient Greece. The present study summarizes what we know today for diagnosis and management of spinal deformities in ancient Greece, mainly from the medical treatises of Hippocrates and Galen. Hippocrates, through accurate observation and logical reasoning was led to accurate conclusions firstly for the structure of the spine and secondly for its diseases. He introduced the terms kyphosis and scoliosis and wrote in depth about diagnosis and treatment of kyphosis and less about scoliosis. The innovation of the board, the application of axial traction and even the principle of trans-abdominal correction for correction of spinal deformities have their origin in Hippocrates. Galen, who lived nearly five centuries later impressively described scoliosis, lordosis and kyphosis, provided aetiologic implications and used the same principles with Hippocrates for their management, while his studies influenced medical practice on spinal deformities for more than 1500 years.
Physicians in ancient Greece had a remarkable knowledge of anatomy, although dissection of human bodies was prohibited. They derived their knowledge from cadavers in battlefields, from observations of athletes exercising in the gymnasiums, and from dissections of animals.
Spinal deformities in ancient Greece
Spinal Deformities in the work of Hippocrates and Galen
Anatomy and biomechanics of the spine
Hippocrates considered knowledge of the spinal anatomy essential to physicians: "One should first get a knowledge of the structure of the spine; for this is also requisite for many diseases" . According to legend, the "great" Hippocrates used his knowledge of human anatomy to create a copper copy of the skeleton, which he offered to the oracle at Delphi.
In his book On Nature of Bones, Hippocrates describes that the function of the bones and particularly of the spine is to maintain the erect position of man and to form the shape of the human body . He describes the anatomy and the diseases of the spine and suggests treatments for patients with spinal deformities. This is the first systematic presentation of anatomy and pathology of the spine in medical history. He realized that the spine was held together by means of intervertebral discs, ligaments, and muscles, permitting him to describe the normal curvatures of the spine . This remarkable knowledge of anatomy derived from cadavers in battlefields, from observations of athletes exercising in the gymnasiums, and from dissections of animals, because dissection of human bodies was prohibited. These were first performed many years later by Herophilus of Chalcedon (335-280 BC) .
Galen agreed with Hippocrates' principle that a good knowledge of spinal anatomy is an absolute prerequisite for its treatment and provides a comprehensive description of the muscles, vertebrae, discs, ligaments, meninges, and spinal cord as well as a detailed description of the normal spinal curvatures . Galen studied anatomy in Alexandria of Egypt, the most important center for anatomical studies in antiquity, thanks to the Herophilus who carried out human dissections.
In Galen's book On the Usefulness of the Parts of the Body  there is a description of the anatomy of the spine which has few differences from those found in contemporary medical texts . His anatomic doctrines affected medicine for more than 1200 years, until the studies of Vesalius altered knowledge. In the same book he pledges that nature's wisdom formed the structure of the spine and wrote: "Nature creates nothing without a purpose". He wrote that the vertebrae are safely bound together in their anterior surface and articulated in the back. The ventral part of the spine provides for the harmony in spinal motion, while the dorsal section ensures stability and safeness and continues: "Nature, tends to keep everything in motion and at the same time aims at the security of its components. The vertebral column exemplifies how these two more or less opposite trends can keep in balance. If the spine was a single, rigid bone, then it would be invulnerable but also inflexible like a statue. In that case man would have been deprived of motion, which is the vital feature of life. On the other hand, a spine consisting of many small parts would be more flexible, but the unavoidable consequence of this flexibility would have been its vulnerability. The number of the existing vertebrae is the ideal as it allows the spine to bend in a circular rather than in an angular manner thus avoiding the injury of the spinal cord".
Description of normal and abnormal spinal curves
In Hippocrates' treatise On Articulations, one of the most important surgical texts of the entire Hippocratic Collection, Hippocrates classifies diseases of the spine in five groups and presents the etiology, the clinical manifestations, and the management of these diseases. The five groups of spinal diseases which introduced by Hippocrates are, a) kyphosis as a result of either a disease (non traumatic) or spinal injury (traumatic), b) scoliosis, c) concussion ("seisis") which means burst fractures, d) dislocations of the vertebrae and e) fractures of the spinous processes.
Galen described four types of spinal deformities, namely kyphosis when they spinal column moves backward, lordosis when it moves forward, scoliosis when it moves to the side and succussion, where there is no spinal deformity but the intervertebral articulations still have moved. He comments that Hippocrates used the term scoliosis to describe all spinal deformities . He agreed with Hippocrates that these deformities can be caused by the presence of tuberculous nodes in the lung which usually leads to kyphosis, but also lordosis or scoliosis, by a spinal injury due to a fall either on the hips or on the shoulders, as a result of aging and fatigue of the spine and because of painful conditions. The mechanism of the deformity, according to Galen, is the formation of tuberculous nodes next to the vertebrae as well as intervertebral ligament shrinkage and pulling of the vertebrae toward the nodes. Depending on the number and location of the nodes, all three types of deformities can be produced .
Description of spinal injuries is beyond the aim of the present study. In the following paragraphs, only the pathology and treatment of spinal deformities is discussed.
Description of Spinal Deformities
Non traumatic Kyphosis
Hippocrates described four different causes of nontraumatic kyphosis, namely tuberculous spondylitis, epilepsy (the sacred disease), congenital or aquired bilateral dislocation of the hip, but it may also appear in healthy people. In his treatise On articulations he writes "Curvature of the spine occurs even in healthy persons in many ways, for such a condition is connected with its nature and use; and besides, there is a giving way in old age and on account of pain".
In his book On Places in Man, Hippocrates divided tuberculous spondylitis into two categories. Galen endorses the Hippocratic division of the disease in these two categories. In the first category, the curvature of the spine is formed above the attachment of the diaphragm and are thought to be incurable, while in the second, the hump is situated below this level. The skeletal changes concern the hips and the spine: "The hips are still more attenuated in such cases than where the hump is high up; yet the spine as a whole is longer in these than in high curvatures" .
He describes spinal and thoracic deformity in a remarkable way: "the ribs do not enlarge in breadth, but forwards, and the chest becomes pointed instead of broad; the patients also get short of breath and hoarse, for the cavities which receive and send out the breath have smaller capacity. Besides, they are also obliged to hold the neck concave at the great vertebra that the head may not be thrown forwards" and continuous "...these patients have also, as a rule, hard and unripened tubercles in the lungs; for the curvature and contraction is in most cases due to such gatherings, in which the neighbouring ligaments take part" .
The deformity of the spine is more pronounced in patients who have not reached puberty, implicating the role of growth in development of the deformity: "When hump-back occurs in children before the body has completed its growth, the legs and arms attain full size, but the body will not grow correspondingly at the spine; these parts are arrested in their development" . In adults, the disease has a more benign course, because the growth of the body already has been completed: "When curvature comes on in persons whose bodily growth is complete, its occurrence produces an apparent crisis in the disease then present. In time, however, some of the same symptoms found in the younger patients show themselves to a greater or lesser degree; but in general they are all less malignant" .
Twenty-three centuries after Hippocrates described tuberculus spondylitis, Percivall Pott (1714–1788), a famous British surgeon, described spinal tuberculosis in his work Remarks on the Kind of Palsy of the Lower Limbs Which is Frequently Found to Accompany a Curvature of Spine. Today, tuberculous spondylitis is known as "Pott's disease" .
Hippocrates describes the pathology of post-traumatic kyphosis, commonly caused by falling on the shoulder or buttock in his book On Articulations and explains why the spinal cord usually is not injured:
"...in the curvature, one of the vertebrae necessarily appears to stand out more prominently, and those on either side less so. It is not that one has sprung out to a distance from the rest; but each gives way a little, and the displacement taken altogether seems great. This is why the spinal marrow does not suffer from such distortion, because the distortion affecting it is curved and not angular",  and concludes that this condition has low mortality: "(Deviations) in the form of a hump are not as a rule injuries which cause death, retention of urine, or loss of sensation ... for external curvature does not stretch the ducts which pass down the body cavity, nor does it hinder free flow" .
In the Hippocratic works, the term "scoliosis" has a general meaning and applies to almost every kind of spinal curvature, including those spinal deformities resulting from injuries of the vertebrae with or without dislocation of the vertebral bodies. When the term is restricted to its contemporary meaning, then little information can be derived from the Hippocratic texts . Hippocrates mentions two possible causes of the diseases: "due to 'gatherings' (probably tuberculous abscesses) on the inner side of the spine and postural – while in some cases the positions the patients are accustomed to take in bed are accessory to the malady". Although Hippocrates promises to discuss the issue of scoliosis together with chronic diseases of the lung in On Articulations, this commitment was never fulfilled, at least in the Hippocratic texts preserved until today. Galen believes that this may be the result of a loss of some of the Hippocratic treatises, in which there might have been references to this disease. He describes a strange case of scoliosis of the cervical spine, which is related to severe sore throat in the second book of Epidemics (Επιδημίαι, "Epidimiae"). 
Treatment of Spinal Deformities
When Hippocrates refers to management of the spinal deformities he makes no distinction between the various types; thus, the methods presented in his books apply to almost every kind of spinal curvature.
Hippocrates recommended diet and extension for the treatment of scoliosis. Spinal manipulation as a treatment for spinal deformities was widely practiced at the time of Hippocrates.
He was the first who invented devices based on principles of axial traction and three points correction for correction of curvatures of the spine and the management of spinal diseases. The devices used by Hippocrates for treatment of spinal deformities were the Hippocratic ladder, the Hippocratic board and the Hippocratic bench. Although Hippocratic books do not contain illustrations, these are provided by Apollonius of Kitium (1st century BC), who commented on the techniques presented by Hippocrates in On Articulations. These fine illustrations are preserved in a Florentine surgical manuscript (Laurentianus 74. 7, 9th century AD) .
"If one desires to do succussion, the following is the proper arrangement. One should cover the ladder with transverse leather or linen pillows, well tied on, to a rather greater length and breadth than the patient's body will occupy. Next, the patient should be laid on his back upon the ladder; and then his feet should be tied at the ankles to the ladder, without being separated, with a strong but soft band. Fasten besides a band above and below each of the knees, and also at the hips; but the flanks and chest should have bandages passed loosely round them, so as not to interfere with the succussion. Tie also the hands, extended along the sides, to the body itself, and not to the ladder. When you have arranged things thus, lift the ladder against some high tower or house-gable. The ground where you do the succussion should be solid, and the assistants who lift well trained, that they may let it down smoothly, neatly, vertically, and at once, so that neither the ladder shall come to the ground unevenly, nor they themselves be pulled forwards. When it is let down from a tower, or from a mast fixed in the ground and provided with a truck, it is a still better arrangement to have lowering tackle from a pulley or wheel and axle .
Paulus of Aegina (625–690 AD), although lived in the Byzantine period, he is considered the last physician of Greek antiquity. He collected doctrines of the antique period in his seven-volume encyclopedia. In his medical practise, he used the Hippocratic board for management of spinal deformities and also emphasized in the use of orthoses in spinal trauma and deformities .
Other treatment methods
Hippocrates often experimented with new methods. One of his unsuccessful attempts being described in On Articulations. An advanced treatment method involve placing the patient supine on the Hippocratic board and trying to fill with air a leather sack positioned under the patient's spine, which, when attempted by Hippocrates, it proved to be unsuccessful. Hippocrates in On Articulations, conceived the idea of transabdominal correction of spinal deformities, although he was reluctant to perform such an operation on a living patient .
Ethics in management of spinal deformities
Hippocrates refers to the ethical issues arising from the use of methods of reduction. He warns patients against charlatans and incompetent practitioners who not only demonstrate treatment methods to impress their audience but also use such forcible maneuvers for harm and not for healing: "Wherefore succussion on a ladder has never straightened anybody, as far as I know, but it is principally practiced by those physicians who seek to astonish the mob- for to such persons these things appears wonderful. For example, if they see a man suspended or thrown down, or the like; and they always extol such practices, and never give themselves any concern whatever may result from the experiment, whether bad or good. But the physicians who follow such practices, as far as I have known them, are all stupid" .
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