Aristotle, godfather of evidence-based medicine (b)

(being continued from 7/06/17)


In 331, Alexander the great conquered Egypt and built the city of Alexandria at the site of the village of Rakotis (Ra-kedet in ancient Egyptian dialect, meaning “Ra builds”) (Sallam, 2001). After the death of Alexander, Egypt came under the rule of one of his generals, Ptolemy I (Soter), whose descendants, the Ptolemies, ruled Egypt until 32 BC, when Cleopatra VII joined by Mark Anthony, lost the war against Octavios and Egypt became a Roman dependency.

Under the Ptolemies, Alexandria grew in size and importance and became one of the largest and most influential cities of antiquities, second in size only to Rome. At the urging of Demetrius of Phalerum, Ptolemy I established the famous Library of Alexandria and a Museum. Both the Library and the Museum formed the rock stones of the first University in history, where knowledge from the whole universe was kept. At its acme, the Library of Alexandria held about 500.000 to 700.000 books in the form of scrolls (Fig. 6).

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Fig. 6,The Ancient Library of Alexandria.

From its beginnings, the school of Alexandria was based on the ideas of Aristotle carried over by the founders of Alexandria (Alexander) and its Library (Ptolemy I), both students of the great philosopher. The school of Alexandria (the Hellenistic or new Hellenic school) was therefore the first school of knowledge in history to be solely based on “logic” (i.e. philosophy). Every scientist in Alexandria was a philosopher, meaning that his conclusions were reached on the basis of logic and common sense (i.e. philosophy) rather than superstition or ideas that cannot be explained logically. This concept was later revived during the Middle Ages, where a student would become a “doctor in philosophy” if he reaches his conclusions on the basis of logic or a “doctor in theology” if he builds his theory on metaphysical givens which cannot be scientifically proven.

Famous scientists/philosophers of the ancient Alexandria University included Euclid father of geometry, Heron inventor of the first steam engine, Archimedes the greatest mathematician of antiquity, Erastothenes the astronomer who calculated the perimeter of the earth to the nearest 100 kilometers and Ptolemy father of geography credited with the drawing of the first map of the world (Pollard and Reid, 2007).

The old Alexandria school of medicine

With the establishment of the Library of Alexandria, Ptolemy I (Soter) and Ptolemy II (Philadelphus) invited numerous physicians from Greece and from all corners of the classical world (the eastern half of the Mediterranean Sea) to Alexandria where they studied, practiced and taught medicine. These great physicians brought with them the medical knowledge of the Greek world and supplemented it with many ancient Egyptian medical practices (Ghaliounghui, 1973; Nunn, 1996), but the real contribution of the old Alexandria school of medicine was to re-evaluate (critically appraise) the old medical knowledge, keeping only what conformed to the ideas of Aristotle and common sense and purify it from non-logical theories and practices (Saunders, 1963; Kudlien, 1964; Longrigg, 1992). The most famous physicians of the old Alexandria Medical School were Herophilus of Chalcedon, Erasistratus of Chios and Soranus of Ephesus (Vidal, 1985; Acar et al., 2005).

Herophilus was born at Chalcedon in Bithynia and was a grandson of Aristotle. He was a pupil of Praxagoras and Chrysippus, who were among the most renowned philosophers, scientists and physicians of their period. Herophilus was a great anatomist and surgeon, considered to have been the first to dissect the human body systematically and is largely considered as the father of anatomy (Dobson, 1925; Wiltse and Pait, 1998; Strkalj and Chorn, 2008). He discovered at least seven of the cranial nerves and paid particular attention to the fourth ventricle, lying between the cerebellum and the brain stem, which he correctly identified as the main controlling center of the brain (Martín-Araguz et al., 2002). He was the first to describe accurately the confluence of the brain venous sinuses at the occiput, called torcula Herophiliafter his name (Acar et al., 2005). He wrote extensively on all branches of medicine, including ophthalmology, cardiology and obstetrics. He described the thoracic duct, although he did not know its purpose. He wrote the most accurate descriptions of the male and female genitalia up to his time (Sallam, 2001).

Herophilus’ observations of the pulse are also outstanding. He observed the pulse and grasped its significance as a gauge for health and disease. He studied the pulse during systole and diastole and noted its rate, strength and regularity. From these measurements, he was able to make medical deductions. One of his classifications “the goat-leap pulse” still survives. Thus Herophilus, who gave a rational explanation of the pulse, may also be called the father of cardiology. Herophilus was the first to time the pulse with a portable klepsydra (water clock), calibrated for different ages of his patients. He is probably the first physician to bring measurements into clinical investigations (Potter, 1976; Sallam, 2001).

Erasistratus was born on the island of Ceos (Chios) and served at the court of Nicator Seleucus I, first king of Syria (c. 306 to 280 BC). He later went to Alexandria where he worked for many years. His name was linked to that of Herophilus as a co-developer of the school of anatomy in Alexandria (Sjöstrand, 2001). Erasistratus rejected the ancient Hippocratic humoral pathology of the four humours. He agreed with Herophilus that the origin of the nervous system was in the brain and that sensory and motor nerves were separate entities (Tomey et al., 2007). He correctly regarded the brain as the center of psychic functions. He described the liver, bile duct, spleen, kidneys and intestines, and named the trachea. From his study of the liver, he connected hardness of the liver with ascites. From post-mortem examinations, he learned the pathology of pleurisy. Erasistratus used the term “pathology” in reference to many varieties of fever, paralysis, abdominal disease, ascites and gout. He may therefore be considered the father of pathology (Christie, 1987; Wills, 1999).

Contrary to the custom of the time, Erasistratus did not advocate the treating of disease by bloodletting and disliked purgation. In haemorrhage of the limbs, he used compression bandages. He described the tricuspid and mitral valves, and came closer than anyone before Harvey to discovering the circulation of the blood. He is also said to have invented the catheter. In later years, Erasistratus settled at Samos, where he died between 250 and 240 BC (Sallam, 2001).

Soranus was born in Ephesus (near present day Izmir in Turkey) in 98 AD and practiced in Alexandria during the second century AD. Several of his writings still survive, most notably his four-volume treatise on “Gynaecology”, and a Latin translation of his “On Acute and Chronic Diseases”. He is credited with the first description of the human uterus and with writing “the Life of Hippocrates”. Later in his life, Soranus traveled to Rome were he practiced for few years before dying there in 138 AD (Drabkin, 1951; De Filippis Cappai, 1991; Todman, 2008).

Many other physicians worked and studied in Alexandria, before travelling to work in other parts of the Mediterranean. The most notable of them is probably Galen who travelled to Rome, achieved great fame and became the personal physician of Emperor Marcus Aurelius and his son Commodus (Nutton, 1993; Dunn, 2003; Tomey et al., 2007).

The fall of Alexandria

The medical school of Alexandria was still active until late in the 3rd century AD. However, with the spread of Christianity, the city became the site of numerous revolts, first against the pagan Roman rulers and later between the native Egyptians following their orthodox (Coptic) Christian doctrine and their local rulers following that of the Roman Emperors. At the same time, philosophy was loosing ground to the new religious “dogma” and being a philosopher became an unwelcome proposition. In 389 AD, Theophilus Patriarch of Alexandria extracted an edict from Emperor Flavius Theodosius (the Great) where all symbols of the ancient pagan world were to be destroyed. In 391 AD, the mobs attacked these symbols setting fire to most of them, including the Serapeum and the secondary library underneath it, where the great body of books had been transferred (the great fire of Alexandria, 391 AD). By the end of these calamities, much of the human knowledge accumulated throughout the previous centuries was eternally lost, to be rediscovered during the Renaissance (Pollard and Reid, 2007). In 415 AD, the last of the famous Alexandria philosophers, the great mathematician Hypatia was accused of heresy and attacked by the mobs. She was a follower of the school of the 3rd century thinker Plotinus discouraging empirical enquiry and encouraging logical and mathematical studies .
Following one of her public lecture, she was killed and dragged behind her chariot along the streets of Alexandria. Her tragic death marked the beginning of the so called “dark ages” (Dzielska, 1996).


Fig. 8,Islamic portrayal of Aristotle.


Hassan N. SALLAM
Professor in Obstetrics and Gynaecology, University of Alexandria, and Director of the Suzanne Mubarak Regional Center
for Women’s Health and Development, Alexandria, Egypt.


About sooteris kyritsis

Job title: (f)PHELLOW OF SOPHIA Profession: RESEARCHER Company: ANTHROOPISMOS Favorite quote: "ITS TIME FOR KOSMOPOLITANS(=HELLINES) TO FLY IN SPACE." Interested in: Activity Partners, Friends Fashion: Classic Humor: Friendly Places lived: EN THE HIGHLANDS OF KOSMOS THROUGH THE DARKNESS OF AMENTHE
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