áaaaaaaaaAlexander the Great conquered all of the

Mediterranean but, as often happens, such great expansion

ultimately brought about the collapse of Alexander's empire. He
left power in the hands of various generals, and so his Empire
was divided into numerous kingdoms. Among the most important
kingdoms was that of Pergamo and, above all, that of the
Ptolemies in Egypt. Here the Greek culture fused with the
Egyptian.

During the Ptolemies' empire, a cultural movement of vast

proportions developed at Alexandria in Egypt. The largest and
most famous library in ancient times was built, which contained
the sum of the epoch's knowledge, and which, unfortunately,
suffered several misfortunes in the following centuries. It was set
áddadsaaaddsaasdon fire by Caesar and by other Roman
emperors, and was definitively destroyed around 640 by an Arab
Caliph. This library was a true and real university in which
scientists trained in the Aristotlean school. However, they
dissected not only animXxZXXXxasDaals, but also humans.
Egypt was a land which, for millennia, had practised funerary, so
dissection had been performed as a preparation for
mummification. Therefore, the technique of postmortem
examination acquired importanadsaddasdasdsadassdce, not
only in terms of dissection, but as also occurred in the
Renaissance, as a fundamental part of a doctor's professional
activities.

Very important was the empirical school, widespread in

Alexandria, according to which a doctor's work consisted of three
fundamental activities: anamnesis (case history), autopsy
(visiting the ill, in the sense of inspecting the patient), and
diagnosis. Thus, the school had very interesting principles which
bring to mind those of today, but all the same it failed because
there was no concrete possibility of either making an accurate
diagnosis or consequently, due to their lack of knowledge,
providing an ad hoc therapy for the illness.
At the same time as the empirical school trained doctors, the
dogmatic school which was a continuation of the Hippocratic
school and the methodical school, which had a great success,
were flourishing in Alexandria.
Two outstanding scientists working outside the above-mentioned
schools also lived in Alexandria, namely Herophilus (330 B.C.)
(1) and Erasistratus (304 B.C.-250 B.C.) . The latter was a
great scientist, above all because he was the first to recognise
that the arteries are vessels, opposing Aristotle's belief that
arteries did not transport blood but pneuma (2). Moreover, he
placed great emphasis on the study of the pulse, on the concept
of body temperature etc., contributions which were lost in the
course of the following centuries (3).

As already mentioned, the most important school in Alexandria

was the methodical school. This did not no rest on the
philosophy of the four elements, but to the rival philosophy, the
atomistic theory of Democritos (who lived between the V and
the IV centuries B.C.). The Hippocratic conception was finalistic,
analogous to that of Aristotle, whereas the theory of Democritos
was based on the case. According to this school the pores had
great importance: so, according to whether the pores were open
or closed, the patient had a condition of looseness or tension
respectively. It was necessary to do everything to keep the pores
in their normal open mode, and attention had to be paid to how
one washed, to the water's temperature This concept, reported
by Galen, became the cause of extremely poor hygiene in
Medieval times because it was interpreted wrongly and taken to
mean that water was condemned for causing the pores to close.

In Ancient Greek and then, in Roman times, there were great

developments in hygiene. The body's physiological needs were
no longer carried out in the external environment or in communal
open places (streets, clearings...) but in appropriate buildings,
public lavatories equipped with a water supply and a sewage
system. Rome had an efficient sewage system in addition to an
extremely functional water supply system. This was not only for
the rich, but included everyone; in the insulae (tenanted houses
in ancient Rome), there was a fountain, with running water
brought to every house by aqueducts. These aqueducts were
constructed using lead pipes, a very malleable material, and
were blamed for the fall of the Roman Empire because of the
disease caused by lead compounds in the water resulting in lead
poisoning, also known as saturnism. In fact, it seems that it was
not so much polluted water that caused this illness, but wine.
Indeed, water came from mountainous areas and was rich in
calcium compounds which were deposited with the passage of
time on the inside of the lead pipes and so formed a protective
layer keeping the water from the lead which thus could no longer
enter into the running water. On the other hand, wine was rich in
soluble lead compounds because these were used to control the
wine's fermentation in the same way as disulphide is today.

Medicine was practiced in a family environment in Rome (the

family doctor was the pater familias who had absolute power
over the family) and although medicine was not based on any
true real theory, it was, however, a rationalised empirical science.
The herbalist was very important even if, he too, worked in an
empirical manner.

Medicine arrived in Rome with the conquest of Greece. To be a

doctor in Rome was considered disdainful, something that only a
foreigner would do. Since, after its conquest by the Romans,
Greece was poverty-stricken after numerous wars had wasted it,
there were a great many medics who sold themselves as slaves
so as to be able to go to Rome and exercise their profession.
Many of these became famous and bought their freedom,
becoming freedmen. The sect that enjoyed the best fortune was
the Metodic (4), with Asclepìades and his student Temison
influencing the Roman medical culture very strongly.
Furthermore, there were very important writers of treatises in
Rome, among whom was the founder of herbal medicine,
Dioscorides Pedanius (First Century A.D.) who published a
book entititled De materia medica, which remained the basis of
pharmacology until the early 1800s. Soranus of Ephesus (I/II
century) , a Greek doctor, published a gynaecological treatise,
and above all Aulus Cornelius Celsus (14 B.C.-37 A.D.) with
his treatise De Medicina, also were important. The latter textbook
was a kind of medical encyclopaedia that discussed arguments
of surgery and of medicine from a scholarly point of view rather
than that of an expert in the subject, simply compiling a great list
of common practices in Rome. This enables us to gain an idea of
the development of surgery at that time, above all in particular
fields such as dentistry (5).

However, the most characteristic element of Roman sanitation

was hygiene. The Romans washed a great deal, to which the
use and the number of thermal baths existing at that time bears
witness. Leaving an extremely important mark on western
culture, the most important doctor in Roman times was the
Pergamese Galen (129 A.D.-200 A.D.) (6). He was the son of
the kings' architect who thus came from a wealthy family and
after his apprenticeship at Alexandria went to Rome where he
was doctor to the gladiators, acquiring anatomical experience,
even though he followed Greek concepts, and he dissected
animals above all else. The most studied animal was the pig
("the animal most similar to man" said Galen) and the monkey
(7). Galen's instinct lead him to realise the fundamental
importance of the organs and their effective role. For example,
he understood that the urinary bladder did not produce urine but
that this came from the ureter (he demostrated this by joining the
ureters together) and for the first time described the recurrent
nerve and its role in fonation. He was very important as a
practicing physician: basing his treatment on medicinal plants, he
introduced several pharmaceutical drugs. For example, use of
willow bark, laudanum (an opium tincture) as anaesthetics.

However, together with these useful drugs, he used some

completely useless potions, amongst which were theriac (8), a
broth containing the strangest of things: goat dung, pieces of
mummy, adder's heads. The only good thing about this brew was
the fact that it was boiled for long time sterilising the material
contained in it. It was used until the end of the 18th century,
generally being produced once a year under the responsibility of
the magistrate in the various cities, and then sold in the
pharmacies. Notwithstanding his numerous intuitions, possibly
because the most accepted theory of the time was the
Hippocratic, Galen embraced the theory of the humours.
Furthermore, he emphasised the therapeutic aspect of the
materia peccans. Among the materia peccans was pus, which
was called "bonum et laudabile" by Galen because it was an
expression of materia peccans that had to be eliminated: he
understood that pus is a substance that does require elimination.
However, unfortunately and above all by Galen's followers, this
theory was exploited very narrowly: in fact, Galen's writings were
used to advocate the formation of pus in order to promote
healing of wounds. This concept continued to be considered
valid until the end of the 16th century.
Furthermore, Galen emphasised other therapeutic methods,
such as blood-letting. He also introduced the methodist concept
of the pores, but this was distorted into an invitation not to wash
oneself because water could obstruct the pores.

Galen elaborated a philosophical theory in order to understand

how our body functioned and how blood circulated. On the basis
of many of Aristotle's assertions (he was the first to consider
digestion as a method of processing ingested food in the
stomach), Galen maintained that the nutritious substances were
then brought to the liver (the principal organ for blood
distribution) via the mesenteric veins (the chyliferous vessels had
not been discovered at that time). This material became blood in
the liver and was enriched in spiritus naturalis (natural spirit).
Most of this blood went from the liver, through the veins, to all
parts of the body where it was consumed as a nutriment. On the
other hand, some blood went through the vena cava to the heart
in which burnt the living spiritus vitalis (vital spirit), which in turn
enriched the blood. In particular, the blood reached the heart on
its right-hand side and from here reached the left-hand side of
the heart through the pores of the septum. From here through
the arteries, as they were considered to be vessels, the blood
above all reached the brain. However, before reaching the brain
the blood passed through a special vascular network (the rete
mirabile) situated in the neck (9). The blood reaching the
encephalon, was enriched by another spirit, the spiritus animalis
(animal spirit), and through the nerves, which were considered to
be the third system of vessels, it reached the body's organs
where it gave life. This theory did not hypothesize that blood
circulates, only that it moves: in Galeno's opinion it moved
according to the sea's tides. Naturally, this theory could be easily
refuted. In reality, if this concepts were true, there would have to
be an enormous quantity of blood. If the blood consumed itself
as it reached the body's parts, it is logical that the body would
continuously consume a notable quantity of it. Slitting the throat
of an animal would be enough to demolish this theory, as Harvey
did 1500 years later. Furthermore, according to Galen's theory
the blood was filtered in the brain, so that its impurities could be
discharged through the cribriform plate (a lamina of the
ethmoidal bone so-called because it is akin to a sieve - cribrum
in Latin) giving rise to tears, saliva, mucus and sweat.

Although was a fascinating theory, it had no experimental basis,

but, because it fitted well with Christian doctrine, it then became
almost a dogma and was still considered to be valid in the 16th
century at the times of the great Vesal. In addition to that of the
blood, among the Galenic conceits thus rendered untouchable
was its anatomy mainly founded on animal studies.

As evidence of Galen's unassailable position is the fact that,

notwithstanding all the evidence presented by any skeleton seen
by any physician, for more than a millennium anatomists went on
to assert that the humerus is curved and that any straight ones
were nothing else than tricks played by nature.
After Galen there was a multitude of medics who worked in the
Western empire, but also in the Eastern empire with a
consequent diffusion of knowledge from the West to the East.
In the wake of the great importance placed on hygiene the first
true and real hospitals were built in Roman times. As reported by
Vitruvius, they had facilities such as waste disposal, a water
supply system, sewerage, and free circulation of air as
evidenced by the numerous windows with which these hospitals
were provided.

In parallel with the transfer of power to Byzantium, there was a

transfer of the medical culture and hygiene too. Baths and
hospitals were numerous, and social medicine made its
appearance. There were famous doctors such as Paul of Egina
in the city of Byzantium, but these did nothing else but repeat
what Galen had said. In Byzantium, a dispute arose between
Bishop Cyril and Bishop Nestorius. The latter lost and was
expelled from Constantinople. So he sought refuge in the Middle
East in areas found in present day Iraq and in Egypt. Nestorius
carried all his classical cultural baggage with him including that
of being a doctor, originating a medical concept very similar to
that found in Ancient Rome.

Great importance was given to hygiene: very advanced hospitals

were built in Baghdad, other Iraqi cities, and in Cairo along the
lines of those constructed by the Romans. In this Arab era no
importance was assigned to anatomy, but the concept of holistic
medicine continued. So the notion of washing oneself frequently
(10) remained firmly established. In Arab medicine, religion also
was very influential. One of the Koran's concepts was that the
human body should not be cut because, along with the blood,
the soul also would leave the body. This meant that surgery
could not be practised. Moreover, this belief, disallowed
dissection for 24 hours after death for fear of damaging the soul.
In order to prevent this happening, the Arabs invented
cauterization (which is still used today in order to block the
vessels temporarily during a surgical operation) (11). At that time
eschar had to be followed by suppuration in order to create pus,
bonum et laudabile, fully respecting the therapy of the time, even
it often led to the patient's death.

Furthermore, to their credit, the Arabs handed down the writings

of the Ancient Greeks, that had reached them through the
Nestorians or as gifts from various Western princes, by
scrupulously translating them into Arabic whilst leaving the
parallel Greek test. Great Physicians were Rhazes (864-925)
and Avicenna (980-1037) . Around the half of 1200 the Syrian
Ibn-Al-Nafis (1213-1288) described the pulmonary circulation. It
is unlikely, however, that his discovery did influence western
medicine since it surfaced only in 1924.

The Arab civilisation reached its zenith in Islamic Spain. At

Cordoba in particular there were great physicians as
Maimonides, Giuannizzius, Rhazes, Albucasis, and Averroes
(1126-1198) . The period of the Moorish civilisation (12) in
Europe was the apex of Arab civilisation. After the fall of the
Moors the Arab empire collapsed and their knowledge came
back to Europe, particularly to Montpellier and Salerno.
Although in the east the Arab developed an extremely advanced
society based on the ancient inheritance of the classic, and
sustained by the nascent Islamic conception that translated and
commented on the ancient texts, in the West it was a period of
obscurantism and return to theurgic medicine. The saints were
believed to be adjuvant and their relics were thought to have
miraculous powers. Wars were even fought over these relics
(13). The concept of the Cult of Saints was particularly
widespread in this period. The most famous among the adjuvant
saints were Saints Cosmas and Damian (14): they were the
patrons of the Medici family as well as of doctors, and were
called anargiri because they did not ask for fee. A posthumous
"miracle" was attributed to them: they attached a leg taken from
a black man's cadaver to the sacristan of their church, who had a
gangrenous leg.

There were protecting saints for every organ and against all
diseases: St. Lucy was protector of the eyes, St. Apollonia of the
teeth, St. Blaise for the throat, St. Fiacre protected against
haemorrhoids, St. Anthony against leprosy, and St. Roch against
plague, St. Anne parturition and St. Agatha against diseases of
breast.

As already mentioned, after the fall of the Arab kingdoms the

Spanish Muslim scientists settled above all in France, at
Montpelier, and in Italy in Salerno, where the so-called Salerno
school flourished and which, according to legend, was founded
by a Greek, by a Latin and by a Hebrew and by an Arab a little
before the year 1000. A plethora of Greek and Arab manuscripts
were to be found in this school. As a result, there was a return to
Greek and classical culture and Hippocratic medicine. In this
epoch great importance was placed on moderation in diet and in
wine. In addition, advice was given on what needed doing and
what, on the other hand, should be avoided. For example,
overdoing amorous activities was to be avoided, reading by
candlelight should also be avoided, as should forcing oneself
during defecation, and not overindulging in wine was essential.
The principles of hygiene returned, of washing one's hands
frequently, of wholesome healthy fresh air. Great importance was
given to the concept of temperament, four of which were
identified: the jovial temperament, the loving or amorous
temperament, the choleric and the phlegmatic.

So, above all, great importance was given to what one ate in
relation to the temperament. For example, if a person was very
choleric, it meant he had a great deal of bile and too much fire. It
was necessary to tone down and dampen such a temperament
by making the person eat fish from marshes, which is cold, or
otherwise the coot (which was considered to be a fish).
Emphasis was place on examining the ill and on examining the
urine. There was a degree of development in surgery, but not in
the condition of the surgeon, who was still considered to be a
sort of servant (as underlined by his raiment) and not a doctor.

The first universities were founded in this period. At first, there

were the Studia, which were institutes sponsored by the lay civil
community, whereas the university ("Universitas studiorum"),
was, at first, a spontaneous phenomenon, originated where
itinerant students chose a valid teacher by offering him a salary.
In this case power lay in the hands of students who could
change teacher when they wished if they were not satisfied. The
emperor, Frederick Barbarossa, was the first to finance these
students, giving them financial support if they remained and
settled in his city. Then, the Church entered into the situation and
the University could only become such through the issuing of a
Papal Bull. The first university in the western world given a Papal
Bull was the University of Bologna. The first Universities were
based on the liberal sciences of the trivium (rhetoric, dialectics
and grammar) and of the quadrivium (mathematics, geometry,
astronomy (15) and music (16)). Medicine only entered into
university disciplines about 150 years later: in Bologna the
physician Taddeo degli Alderotti (1223-1303) argued
medicine's cases with the rhetors, managing to elevate the
status of medicine into a position alongside the other university
disciplines.
--------------------------------------------------
(1) One recalls Herophilus's torcular.
(2) This was due to the fact that when an incision was made into
an animal, the veins were full of blood while the arteries were
not.
(3) One recalls the first attempt to classify the various vegetables
with particular attention being paid to their medicinal properties,
made by Theofrastos, a student of Aristotle.
(4) This is the sect which went back to the atomistic theory, to
that of pores.
(5) Dental surgery is of Etruscan origin as they were able
dentists: in fact, they used dental prosthetics and dental
implants.
(6) From Pergamos were the people who invented books. These
were made of sheepskins suitably treated, which could be written
on, and which were used as a substitiute for the much more
costly Egyptian papyrus.
(7) The first of these was quite diffuse in Europe and is still
present in Gibraltar nowadays where there is a colony of
monkeys on the Rock.
(8) It is believed that is was introducd by Mithradates, king of
Ponto.
(9) This system was described by Aristotle following his studies
on animals, which mainly concerned animals with long necks,
such as horses in whose neck exists a vascular system which
acts to keep the blood warm in the long passage towards the
encephalon.
(10) On the occasion of the first exchanges between eastern and
western, the former complained about the fact that the
westerners smelt, and not just a little! Indeed, in the 17th century
the King of France only washed once a year!
(11) An eschar forms in these which blocks the blood flow.
(12) An exquisite product of the Moorish civilisation is conserved
in Cagliari in the National Art Gallery: It is a jug taking the form of
a bird made of bronze which was offered to the guest so that he
or she could wash their hands before the meal (a ewer).
(13) Among other things the remains of one of the saints and one
of the church doctors were conserved for a good 500 years in
Cagliari: St. Augustine of African origin, who had been Bishop of
Hippo, in Numidia. When the Barbary pirates invaded Roman
Africa, the African Bishops of Hippo brought the remains of St.
Augustine to a safe place, namely Cagliari, where they remained
for about 500 years until the Lombard king Liutprandus acquired
the remains and those of St. Lussorius, Camerinus and Cesellus,
who were the latter's grooms, from the judge of Cagliari in order
to demonstrate that he was a truly Catholic king. St. Augustine
and the other saints were buried in Pavia. On the other hand, the
head of St. Lussorius ended up in Pisa, in the church of the
Cavalieri. A silver bust of him was also commissioned to the
famous Donatello. Demonstrating the strength of the cult of the
saints, the tenure of the President of the Italian Republic
(formerly of the King of Italy) was dedicated to St. Rossore (the
Pisan equivalent of St. Lussorius).
(14) Until recently, the church of St. Saturnin at Cagliari was
dedicated to Saints Cosmas and Damian since the two saints
were painted in a picture inside the church. Today this church
has been rededicated to its original saint.
(15) In reality it is astrology.
(16) It was considered to be an exact science in that it was
composed of the exact succession of the seven notes.