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Home , 285 BC, Erasistratus, Praxagoras

Hellenic J Cardiol 2013; 54: 15-17

Historical Perspective The Contribution of Alexandrian Physicians to Cardiology 1 1 2 George Androutsos , Marianna Karamanou , Christodoulos Stefanadis 1History of Department, 2First Cardiology Department, Hippokration Hospital, University of Athens, Medical School, Athens,

Key words: lexandria was an important Greek and pharmacology; physicians knowing , cultural and intellectual center theory enjoyed a reputation far surpassing Herophilus, and its famous library used to that of other practitioners.”2 , A cardiology, contain more than five hundred thousand This development could not have circulation. papyri. However, the medical school of reached its full extent without the medical Alexandria flourished as a result of the institutions founded in Alexandria by king progressive decline of Cos medical school. (367-282 BC). Medicine Its fame was founded on the ancient Egyp- left the medical families, in favor of state tians’ access to medical knowledge, and run institutions from which graduated a mainly the practice of human . class of medical practitioners freed from Prohibited by Greeks, human dissec- the constraints of usual medical practice.2 tion was authorized in Alexandria during the first half of the third century BC. This The protagonists of the golden age of parenthesis to history was closed after the Manuscript received: Alexandrian medicine August 22, 2011; renewed influence of religion opposed the Accepted: handling of human corpses.1 However, the That medical revolution had four protago- April 2, 2012. period during which human dissection was nists: two teachers, of Cos and authorized remains one of the most defin- of Cnidus, and their pupils, Address: itive moments in the development of med- Herophilus of Chalcedon and Erasistra- Marianna Karamanou ical thinking. tus of . According to these For the first time, Alexandrian phy- physicians, practicing and physi- 4 Themidos St. sicians applied the teachings of Aristo- 145 64 Kifissia ology, opened the “black box” of the hu- Athens, Greece tle (384-322 BC), seeking to establish a man body. e-mail: corpus of theoretical medical knowledge, Praxagoras of Cos (fourth century mariannakaramanou@ even though clinical practice (diagnosis BC), influenced by Aristotle, adhered to yahoo.com and therapeutics) continued to follow the cardiocentrism and considered the Hippocratic doctrines. Moreover, they ex- as the seat of the soul, of thought and psy- plored the constitution and the functions chic functions, a belief seen also in An- of the human body (anatomy and physiol- cient Egypt.3 In contrast to Aristotle, ogy), entities almost unknown to the Hip- Praxagoras distinguished the from pocratic followers. Polybius (fourth cen- the , not by the differences in their tury BC) writes that medicine was born wall, but by examining the fluids flowing in Alexandria, “medical theory became through them. According to Praxagoras, more important than dietetics, the veins contained blood and the arter-

(Hellenic Journal of Cardiology) HJC • 15 G. Androutsos et al ies, like the left ventricle, were filled with , vi- pulses, he studied the pulses’ intensity and rhythm, tal spirit (air). He believed that the air transported drawing conclusions about their clinical application in by the pulmonary veins of the to the heart was his treatise entitled Manual of pulses.4 transformed into vapor thanks to cardiac heat. It was Like his teacher Praxagoras, he believed that then sent through the arteries, explaining the phe- veins conducted the blood and the arteries the pneu- nomenon of pulse. In 330 BC, he presented the diag- ma, arguing that the heart did not pump the pneuma nostic value of the pulse, as a guide to illness.3 From into the arteries, but that the arteries attracted the the clinical and therapeutic point of view, Praxagoras pneuma by dilatation. In his masterpiece Manual of remained faithful to the Hippocratic tradition. pulses, Herophilus makes an extensive study of the ar- On the other hand, Chrysippus of Cnidus (fourth terial pulse, referring to it as a water clock (“clepsy- century BC) is less known. He distanced himself from dra”). However, some of his considerations regarding the Hippocratic method and became a follower of Ar- the pulses were already described in the papyrus of istotelian teachings. Around 350 BC, he attempted to Smith and were well known before the establishment reconcile the conceptions of Cos medical school and of Greek physicians in Egypt. those of Empedocles of Agrigento (490-430 BC).3 Herophilus rejected the “cardiocentric” system of Thanks to their pupils, Herophilus and Erasistra- Aristotle for the nervous one. He clearly differentiat- tus, anatomical knowledge made tremendous prog- ed the endings of small vessels and located the ress during the short period when dissection of hu- origin of the nervous system at the level of the cere- man corpses was allowed. However, their work is bellum and spinal cord.4 known through other writers, such as and Cel- Erasistratus of Chios (310-250 BC), like Herophi- sus. According to Celsus (42 BC-38 AD): “As pain lus an anatomist, was also a great physiologist. The and various diseases originate in the inner part of the contribution of Erasistratus to our knowledge of car- body, Herophilus and Erasistratus argue that no one diac anatomy is considerable. His conceptions were a can apply remedies to these parts if he ignores them. curious mixture of progress and remarkable premoni- For this reason, it is necessary to open human cadav- tions that approached very closely to the blood circu- ers and to examine the internal organs. Herophilus lation theory, together with gross errors that are diffi- and Erasistratus did it as by far the best: they used to cult to understand. He defended the idea that arteries open the corpses of alive men (criminals) and to ob- contained pneuma (air), and in order to explain the serve, while these men were still breathing, the hu- phenomenon of blood spurting from a torn , he man organs; their location, color, form, consistency, reasoned that venous blood forced its way to the ar- neighboring structures etc.”2 tery through tiny connections.5 Herophilus of Chalcedon (323-285 BC) was born According to Erasistratus, the auricles were not in the city of Chalcedon in Asia Minor and practiced part of the heart but were just a dilatation of the vena medicine in Alexandria. Herophilus was considered cava. He described the route of blood from the by Galen (130- c.201) as a reference in anatomy. He to the heart through the inferior vena cava and from was the first to practice in human corpses the heart to the lungs through the arterial (pul- and his research shocked his contemporaries. Public monary artery), and he was the first to report the role rumor accused him of practicing vivisection on those of the tricuspid and pulmonary valves.5 His principal awaiting the death penalty and he was described as a contribution to cardiology consists of recognizing the “butcher who dissected six hundred persons in order role of the heart valves, as he realized that they en- to examine the human body.” Celsus defends him and sured the unidirectional flow of blood. We owe to justifies his actions: “It is not cruel to seek, by tortur- him a great anatomical description of vessels, renal ing criminals, cures for the innocent.”2 arteries, mesenteric arteries, vena cava, pulmonary Herophilus was the first to use the term “venous artery and venous valves.5 artery” for the vessel that we call today the “pulmo- nary artery”. He described the carotid artery, the sub- Discussion clavian vein, the splanchnic vessels and the vessels of the genital apparatus. He also described the lymphat- Despite the significant progress made in anatomy, ic system. He recognized the presence of blood in ar- the works of the Alexandrian physicians contained a teries, denied the role of the heart in respiration and, lot of digression and errors concerning heart physi- arguing that the heart is involved in the generation of ology. They described the arteries and the veins, but

16 • HJC (Hellenic Journal of Cardiology) Alexandrian Physicians remained loyal to the ancient Greeks who believed 1500 years, until 1628, when (1578- that the veins contained blood and the arteries air. 1657) published his revolutionary discovery of the Although Erasistratus assumed “synastomoses” or blood circulation.7 communications between the arteries and veins, this was mainly to explain why an incised artery gave out blood. Willius and Dry recognize, on the other hand, References that Erasistratus was the first to described the venous valves.6 Galen, demonstrating the constant presence 1. Rullière R. La cardiologie jusqu’à la fin du 18e siècle. In: Histoire de la médecine, de la pharmacie, de l’art dentaire et of blood in the arteries, explains the erroneous ap- de l’art vétérinaire. Paris: Albin Michel/Laffont/Tchou; 1978. proach of Erasistratus. p. 281-289. Mistakenly, these Alexandrian physicians contin- 2. Vegetti M. Entre le savoir et la pratique, la médecine hellé- ued to believe that the liver was the place of blood nistique. In: Grmek MD. Histoire de la pensée médicale en Occident, vol. 1: Antiquité et Moyen Age. Paris: Editions du formation. From there, it was transported to different Seuil; 1995. p. 70-83. organs by the vena cava, whose lower part passed by 3. Bounhoure JP. Histoire de la cardiologie: des hommes, des the right heart in order to nourish the lungs through découvertes, des techniques. Toulouse: Privat; 2004. p. 30-31. the pulmonary arteries. For this reason, the role of 4. Boustani F. La circulation du sang. Entre Orient et Occi- dent, l’histoire d’une découverte. Paris: Philippe Rey; 2007. the lungs in blood oxygenation was completely un- p. 30-38. known. Even if they understood the simultaneity of 5. Bariéty M, Coury C. Histoire de la médecine. Paris: Fayard; the cardiac systole and arterial diastole, they did not 1963. p. 148-196. conceive of attributing the dilatation of the arteries to 6. Willius FA, Dry TJ. A history of the heart and the circulation. Philadelphia: Saunders; 1948. a passive phenomenon due to the cardiac pulse. 7. Androutsos G, Karamanou M, Stefanadis C. William Harvey Their mistakes would be largely repeated by Ga- (1578-1657): discoverer of blood circulation. Hellenic J Car- len, whose doctrines dominated medicine for almost diol. 2012; 53: 6-9.

(Hellenic Journal of Cardiology) HJC • 17