46th Hist Med Lisboa 2018 XXVI SPECIAL ISSUE E-Supplement Final

ISSN 1373-4857
Vesalius
SOCIETAS INTERNATIONALIS HISTORIAE MEDICINAE
Journal of the International Society for the History of Medicine
Vol. XXVI, JUNE 2020, e-supplement

"Aesculapius in Lisbon", selected papers from Lisbon
46th ISHM Congress, 3-7 September 2018
Editors: Robrecht van Hee – Maria do Sameiro Barroso –
Francesco Maria Galassi
Vol.XXVI, No. 1, June 2020 e-supplement
Contents
EDITORIAL – p.5
Robrecht van Hee
OPENING CEREMONY SPEECH – p.6

Germano de Sousa
THE 46TH ISHM CONGRESS - LISBON: ISLANDS OF VIVID MEMORIES – p.8

Maria do Sameiro Barroso
A MEDICINAL DIALOGUE BETWEEN EAST AND WEST INDIES: THE

CONTRIBUTION OF GARCIA DE ORTA, NICOLAS MONARDES AND CRISTÓBAL
ACOSTA – p.12
Carlos A. Viesca T., Mariablanca Ramos de Viesca
THE GOA STONE: MYTHS, EMPIRICISM AND INSIGHTS ON CHEMISTRY – p.36

Maria do Sameiro Barroso
ASPARAGUS THE DIURETIC, A RENAL AMBASSADOR FROM GREECE TO

IBERIA – p.61
Athanasios Diamandopoulos
ORIGINS AND EVOLUTION OF SURGICAL INSTRUMENTS IN THE COLLECTION

AND RELATED DOCUMENTATION CONTAINED IN FMUP'S MUSEUM OF
MEDICAL HISTORY – p.74
Amélia Ricon Ferraz
JEWISH PHYSICIANS AND THE PORTUGUESE MEDICAL DIASPORA – p.91

Kenneth Collins
CHRISTUS ANATOMICUS, FROM VESALIUS DRAWINGS TO WAX MODELS –

p.107
Laura Musajo-Somma, Alfredo Musajo-Somma
THE APPEARANCE OF BUBONIC PLAGUE IN OPORTO, 1899 – p.121

João Martins e Silva
Cover image - Statue of Aesculapius, Roman period, 1st/2nd century AD, marble, Lisbon National Museum
of Archaeology Inv. 994.7.1. DGPC Photo credit: José Pessoa, 1994.
Courtesy of the Lisbon National Museum of Archaeology.
© www.vesalius.org.uk – ISSN 1373-4857 2

PORTUGUESE AND SPANISH CONTRIBUTIONS TO THE DISCOVERY OF RENAL

AND OCULAR FINDINGS IN PRIMARY HYPEROXALURIA – p.142
Davide Viggiano, Giovambattista Capasso, Francesca Simonelli, Valentina di Iorio,
Natale G De Santo
TH
EXOTIC PLANTS IN THE ITALIAN PHARMACOPOEIA OF THE 18 CENTURY –
p.152
Federica Rotelli
“HE WHO WANTS TO TRAVEL SHOULD …” – TRAVEL REGIMENS IN MEDIEVAL

ISLAMIC MEDICINE – p.167
Zsuzsanna Csorba
POISON, PROOF, AND FORENSIC MEDICINE IN NINETEENTH-CENTURY

FRANCE – p.175
Claire Cage
REPRESENTATION OF SPINAL TUBERCULOSIS IN A PTOLEMAIC DWARF

STATUETTE – p.188
Veronica Papa, Francesco Maria Galassi, Elena Varotto
SOFIA IONESCU-OGREZEANU (1920-2008), FIRST FEMALE NEUROSURGEON

IN ROMANIA AND FIRST FEMALE NEUROSURGEON IN SOUTH-EASTERN
EUROPE – p.196
Sinziana Ionescu, Eugen Bratucu, Mirela Renta
ANTÓNIO DE SOUSA PEREIRA (1904-1986) THE NOBEL PRIZE NOMINATION

– p.206
Catarina Janeiro, Amélia Ricon Ferraz
WALTER B CANNON: A HISTORY OF COMMITMENT – p.218

Carmen Pérez-Aguado, Alberto de Leiva-Hidalgo, Alejandra de Leiva-Pérez, Eulalia
Brugués
THE ROLE OF RELIGIOUS ORGANIZATIONS IN THE PROVISION OF HEALTH

CARE FOR NEGLECTED POPULATIONS: THE CASE OF CASA HOSPITAL SAN
JUAN DE DIOS OF RAMOS MEJÍA (ARGENTINA, 1942) – p.232
Jaime Elías Bortz, Nadia Gonzalez, Marisa Emilia Cetra, María Dolores Martigani
PORTUGUESE TROPICAL MEDICINE AND INTERNATIONAL NETWORKS: A

GLOBAL HEALTH GOVERNANCE PROJECT IN THE 20TH CENTURY – p.247
Isabel Amaral
DR CUNHA BELLEM AND THE OPERATIONAL MILITARY MEDICINE REFORM IN

19TH CENTURY – p.263
Rui Carvalho, Hugo Rodrigues
FRAGMENTS OF THE CONSTRUCTION OF THE MEDICAL ASSISTANCE MEMORY

IN THE HOSPITAL DOS CLÉRIGOS DO PORTO BETWEEN THE LAST QUARTER
OF THE EIGHTEENTH AND THE SECOND HALF OF THE NINETEENTH CENTURY
– p.271
António Miguel Santos
TEACHING AND LEARNING OF THE HISTORY OF MEDICINE AT PEOPLES’

FRIENDSHIP UNIVERSITY OF RUSSIA (RUDN UNIVERSITY) – p.286
Tatiana Sorokina
HISTORY OF MEDICINE AND BIOLOGICAL ANTHROPOLOGY

INTERCONNECTED IN A POSTGRADUATE PROGRAMME: THE FIRST YEAR OF
OPERATION – p.298
Niki Papavramidou, Rania Kalogeridou, Christina Papageorgopoulou

INTRODUCTION
R. VAN HEE
VESALIUS EDITOR-IN CHIEF
It is with great pleasure that I welcome the online publication of this Special Issue of
‘Vesalius. Acta Internationalia Historiae Medicinae’.
The Congress Vice-President, Maria do Sameiro Barroso, has done an enormous job in
collecting some of the best papers of the Congress into a volume, which touches on
various aspects of the history of Portuguese and World medicine.
The result is an icon for Portuguese medical health practitioners, and for the medical-
historical community at large.
The reader will find subjects ranging from diagnoses of diseases to medical or surgical
treatment along with medical assistance, patient care in the hospital context, bringing
up the diaspora of health practitioners and travel advice. Moreover, interesting
aspects of medical-historical education and medical art are discussed. Not the least do
important Portuguese physicians and surgeons attract particular attention.
The result is a widespread but coherent overview of subjects, covering not only
Portuguese but also international medical care.
As editor of Vesalius, I am proud that this volume will be distributed to all members
of the International Society for the History of Medicine and will be available for other
historians with interest in Portugal-related medicine.

OPEN CEREMONY SPEECH
GERMANO DE SOUSA
PRESIDENT OF THE 46TH ISHM CONGRESS
- Your Excellency the President of the Portuguese Republic

- Distinguished Minister of Health
- Distinguished President of the Portuguese Medical Association
- Distinguished Chairman of the Scientific Board of this Medical School
- Dear Colleague Dr. Carlos Viesca, Illustrious President of the ISHM
- Distinguished guests
- Dears Colleagues
- Ladies and Gentlemen
In the name of the Organizing Committee of this Congress and as his President, I
sincerely thank the high patronage and presence of His Excel lency the President of
the Portuguese Republic, Professor Marcelo Rebelo de Sousa, at the opening session
of this Congress, which honours this act in a special and superior way, and represents
a fundamental stimulus to us.
As a man of culture, no one better than you, Sir, understands the importance of these
historical matters to the present and future of Medicine and health care professions. I
am confident Sir, that your presence means support, allow me to say, in drawing due
attention to the historians of Medicine and related health professions whose functions
and importance are so often poorly understood.
Thank you so much.
I thank the presence of our Minister of Health, Professor Adalberto Fernandes. His
keen interest in the History of Medicine and Health, in general, has recently been well
demonstrated by the fundamental support he gave to the National Health Museum
with his kind help and will, surpassing the various vicissitudes that always impeded its
development.
Thank you, Minister.
I also thank the presence of my colleague Dr Miguel Guimarães in his capacity as
President of all Portuguese Doctors. His support honours this Congress.
Professor Miguel Xavier, President of the Scientific Board of this Faculty of Medical
Sciences, thank you for hosting us in this School and this space, one and another so
full of references to World History of Medicine.
Dear Dr Carlos Viesca, illustrious President of the International Society for the History
of Medicine, I thank you for choosing our country for this 46th ISHM Congress.

I hope this meeting fulfils the high quality of the previous Congresses of the Society over
which you preside.
Distinguished Guests, thank you for your kind presence.

Dear fellows
Ladies and Gentlemen
This Congress is an affirmation of a moral and cultural obligation: to preserve the

History of Medicine and health professions, the history of the art of healing and
preventing health, this "Ars Longa" made profession by Hippocrates 2500 years ago.
Furthermore, it is an honour for the Organizing Committee and me, that the 46th
Congress of the International Society for the History of Medicine takes place in
Portugal, precisely the country where five centuries ago, in giving new Worlds to the
World, the Discoveries came up with news of never known phenomena, American or
Asian flora and fauna and diseases never known before.
The Discoveries allowed Garcia de Orta, a great physician of the Renaissance who
practised medicine in Portuguese India to write the Colloquium of the Simple, a
treatise on Botany and Medical Matter in which he corrected inaccurate information
conveyed by classic authors of antiquity who wrote about the subject, facing the
errors that were copied and perpetuated blindly by doctors and medical school across
Europe up to that time.
"Do not frighten me with Dioscorides or Galen, for I will say no more than truth and
what I know," wrote Orta, reporting what he saw and experienced, unequivocally
affirming the primacy of experimentalism for the first time in medical history. After
Orta the spirit of experimentalism was gradually imposed throughout Europe, and was
followed by many of the most renowned and enlightened Portuguese Jewish
physicians who had to face religious persecutions which led them into European exile.
However, as all of you will see in your free time, Portugal is not only or even
principally history. It is a modern and progressive country, with warm and kind
people, worth to be known better.
So, on my behalf and of the Organizing Committee, I warmly welcome all the
colleagues and other attendants of this Congress, especially those who came from
other countries, hoping that you much enjoy this Congress, wishing all of you a
wonderful stay in Portugal and this beautiful town of Lisbon.
Thank you.

THE 46TH ISHM CONGRESS - LISBON: ISLANDS OF VIVID

MEMORIES
MARIA DO SAMEIRO BARROSO

VICE-PRESIDENT OF THE 46th ISHM CONGRESS
From 3-7 September 2018, the Lisbon Nova Medica School was on the top of the
world of History of Medicine, welcoming prominent researchers for a unique exchange
of ideas, knowledge and experience.
Lisbon, founded and named by Ulysses as Ulissipo or Olissipo, according to an ancient
legend, still carries traces from both indigenous and Roman healing cults and from
the appeasing and healing hand of Aesculapius, among vestiges of Jewish and Arabic
settlements. Still exhaling its glory as capital of a great maritime empire, leading the
trade of Eastern products and exotic materia medica at the Age of Discoveries, Lisbon
shared its emblematic places and warm hospitality with the bountiful supplies of
lecturers and delegates from all over the world.
Delegates from the following 35 countries conveyed their fruitful insights, diversity
and expertise: Argentina, Austria, Australia, Belgium, Bolivia, Brazil, Canada, China,
Croatia, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Israel, Italy,
Japan, Latvia, Marocco, Mexico, Nigeria, Poland, Portugal, Republic of Korea,
Romania, Russian Federation, Slovakia, Spain, Switzerland, Turkey, Ukraine, UK and
USA, bringing together a multi-string dialogue of innovative research assessing and
revitalizing forgotten or still vivid and inspiring memories of outstanding people and
themes in the History of Portuguese and worldwide Medicine.
In the first part of his speech delivered in Portuguese, the President of the Congress
put forward the founding lines and framework of this noteworthy international
meeting:
“The deepening of the so-called “small history”, meaning the history of everyday life,
the history of a science or of a particular sector of society makes the great History more
noticeable and clarified. As Auguste Comte stated in his Cours de Philosophie Positive,
“you do not get into knowing a science completely until you come up to its history”.
These are some of the reasons for this 46th Congress of the International Society for the
History of Medicine, which aims to deepen and reinforce knowledge in all areas comprising the
history of medicine, health and related professions.
Therefore, in the programme plenary and keynote lectures, free communications and posters
do figure covering the most varied aspects concerning numerous countries and continents
with particular emphasis to themes in the History of Portuguese Medicine and Health. So, as
you can see, from Garcia da Orta to Egas Moniz, many and several are the Portuguese
themes and figures covered in the vast program that will be filling the five days of our

meeting, which I hope you will appreciate with interest.

The Congress included a Round Table on History of Nephrology, a joint organization
with the International Society of the History Nephrology (ISHN) coordinated by
Athanasius Diamandopoulos, past President of the ISHM, and a Round Table on
Portuguese Tropical Medicine, coordinated by Isabel Amaral.
The selection of presentations for these Proceedings was not an easy task, which we
tried to resolve by inviting the authors from plenary, keynote lectures and requesting
chairpersons of round tables, oral presentations and posters to evaluate the quality of
the presentations.
From 249 received abstracts, 189 in total were presented, and from the selected, 21
have been accepted to this volume.
The topics range from Materia medica, History of Surgical Instruments, Portuguese
Jewish medicine, Epidemics, Medicine, Art and Religion, Medical Assistance,
Toxicology, Great Medical Personalities, Arabic Medicine, History of Nephrology,
Portuguese Tropical Medicine and Teaching of History of Medicine.
The first essay by Carlos Viesca and Mariablanca Ramos de Viesca goes straight to
one of the most relevant topics raised by a Congress taking place in Lisbon. Putting
forward the two physicians that mediated the first contact with the materia medica
brought from the East and Western Indies, brought together the discovery of new
worlds and the commerce set forward by Portugal and Spain, the two great maritime
powers of the time: Garcia de Orta (c.1501-1568) and Nicholas Monardes (1515-
1594), curiously noting that both physicians had also dedicated to the commerce of
exotic medical substances.
Moving to the end of the Age of Discovery, Maria do Sameiro Barroso presented the
most emblematic creation of Jesuit Portuguese exotic pharmacy: the Goa Stone.
Going deep into the myths surrounding the most respectful and expensive medical
therapeutic mirabilia, Barroso brought up a new view. By analyzing the ingredients in
the light of current chemical knowledge, thus shedding an accurate light on their
composition and possible therapeutic effects, she contextualized the creation of this
marvellous artificial stone in the framework of the mythic, magical, empirical
knowledge of the time.
Asparagus the diuretic, a renal ambassador from Greece to Iberia, also attractively
framed in travelling and materia medica, was presented by Athanasius
Diamandopoulos, focusing on its use as food and medicine, bringing up Iberian traits,
thoroughly analysing mythical, historical, therapeutic and artistic aspects.
The history of surgical instruments highlighted by the Portuguese tools and ancient
books from the library of the Museum of History of Medicine Maximiano Lemos in
Oporto was delivered by the Museum Director, Amelia Ricon Ferraz, honouring
prominent figures of Portuguese History of Medicine, such as the medical historian
Maximiano Lemos, the patron of the Museum.
From a different perspective regarding the Portuguese medical historians when
viewing the Jewish medical diaspora, Kenneth Collins presented a thorough overview
of the persecution of the Portuguese Jew physicians compelled to fly to Goa and
European cities after the establishment of the Inquisition in 1479, and the flourishing
of Portuguese medical culture out in Salonica, Amsterdam and London.Art and
anatomy, closely intertwined, mainly since Vesalius, was a fascinating topic presented
by Laura and Alfredo Musajo-Somma. By bringing together innovative material, a
Christ anatomical wax model, the authors framed ceroplastica (wax model) tradition
in Italy and religious relics, overviewing a whole set of models used as devotional
bodies, fortifying faith.
Martins e Silva brought up a prominent figure of Portuguese Public Health, Ricardo
Jorge (1858-1939), Municipal doctor in Oporto dealing with an outbreak of bubonic
plague. He diagnosed the condition and isolated Yersinia pestis in the lab but he had
to face public misunderstanding of the correct public health measures he
implemented. The inhabitants, and in particular, the trade and industry associations
of Oporto were more concerned with the economic consequences of the blockade than
with the course and spread of the epidemic. Ricardo Jorge had to flee to Lisbon where
his name figures in the most important Portuguese Public Health institution, the
National Health Institute Doutor Ricardo Jorge.
Challenging diagnosis were also attractive topics, presented at the Lisbon Congress.
Davide Viggiano et al. brought up the history of the discovery of primary oxaluria, a
rare hereditary condition of the metabolism, characterized by damage of the kidneys
(kidney stones) and the eyes (retinal oxalosis), identified after the discovery of oxalic
acid in the 17th century to which Portuguese and Spanish researchers contributed.
Federica Rotelli fully overviewed the importance of exotic plants in European botany
in Italian pharmacological collections from the eighteenth century related to the
University of Bologna, a leading medical school since the Middle Ages. She also
focused on the dangers and challenges when using new and unknown substances
requiring new expertise, challenging the Hippocratic-Galenic model of humourism.
Travelling has inspired an interesting approach. Zsuzsanna Csorba presented a little-
known facet of health guides for travellers in the medieval Islamic, putting forward
relevant information from the time in the advice given to travellers.
The emergency of Toxicology and Forensic Science along with the incapability to
provide accurate laboratory methods of identifying poisons was pointed out by Claire
Cage. Poisons, such as arsenic, cause symptoms that may resemble natural diseases,
as was the case. That was the reason why arsenic was largely employed.
Identification of diseases in art is a form of retrospective diagnosis, enabling the
perception of diseases when unknown to doctors, which was the case of a dwarf from
ancient Egypt displaying signs of Pott disease, presented by Veronica Papa et al.
To rescue Professor António da Silva Pereira from oblivion, Catarina Janeiro presented
the master of neurovascular diseases, nominated to the Nobel Prize, and creator of
the current portography method, calling the attention to his remarkable contribution
to the first angiograms.

Sinziana Ionescu brought up Dr Sophia Ionescu, the first neurosurgeon in Romania,
famous from her skill, bringing innovations especially in the fields of spine and brain
surgery.
Medical doctors committed to political and social causes are not infrequent. Carmen
Perez Aguado et al. presented the remarkable case of Walter B. Cannon, eminent
Professor of Physiology, living in the USA, who supported the Spanish Democracy
during the Spanish Civil War and after.
In Spanish colonial Argentina, the role of medical assistance provided by religious
institutions was the choice of Jaime Elías Bortz et al., surveying the Hospitable
Brothers of Saint John of God who also lead hospitals in Portugal and Spain but made
invisible in Argentina in colonial time.
Tropical medicine as an emerging field during the Portuguese colonial empire was
presented by Isabel Amaral, closely surveying the history and internationalization of
the School of Tropical Medicine created in Lisbon, pointing to the contribution of
generations of prestigious researchers.
The last four chapters present interesting reports on Portuguese History of Medicine
and Teaching of History of Medicine. Disclosing prominent medical personalities was
the choice of Rui Carvalho and Hugo Rodrigues, bringing forward an overview of Dr
Cunha Bellem, Army Chief Surgeon in the final 19th-century, establishing Tactical
Medic Training and Simulation, as adopted in other European countries.
Medical assistance in the context of religious institutions was the subject chosen by
António Miguel Santos by studying the archive of the Brotherhood dos Clérigos in
Oporto, underlining its charitable traits and providing medical care, hiring the best
physicians of the time, held in great esteem and honour.
Finally, Tatiana Sorokina presented the implementation of Teaching of History of
Medicine in Moscow, creating a fruitful interchange with other European universities
and writing guide books, and N. Papavramidou et al. presented the creation of a first
joint programme of History of Medicine in an initial cooperative programme with
students of Anthropology.
We hope these essays are inspiring, leaving insights for further studies, and that the
last two chapters boost the implementation of the Teaching of History of Medicine in
Medical Faculties all over the world. Such topics will be particularly welcome in
upcoming congresses.

A MEDICINAL DIALOGUE BETWEEN EAST AND WEST INDIES: THE

CONTRIBUTIONS OF GARCIA DE ORTA, NICOLAS MONARDES AND
CRISTÓBAL ACOSTA
Carlos A. Viesca T., Mariablanca Ramos de Viesca1
Abstract
In the second half of the 16th century, the communication between Europe and the Far East
countries was reasonably reestablished, but the New World also constituted an accessible
realm. Spain and Portugal had a crucial role in exploration travels, but also in commerce and
introduction of oriental and American products to different aspects of daily life, among which,
in medicine. Three authors, Garcia de Orta (c. 1501-1568), Nicolas Monardes (1493- 1588)
and Cristóbal Acosta (1515-1594) were of great eminence in the study, knowledge and
diffusion of medicinal plants, animal substances and minerals arriving in Europe, imported
from the East and West Indies. In the following pages, we will present a brief register of their
biographical data, some commentaries on their books and a recapitulation about the influence
of these new drugs on Renaissance therapeutics.
Keywords
Age of Discovery; Garcia de Orta; Nicholas Monardes; Cristóbal Acosta; materia medica
Résumé
Dans la seconde moitié du XVIe siècle, la communication entre l'Europe et les pays d'Extrême-
Orient était raisonnablement rétablie, mais le Nouveau Monde constituait également un
domaine accessible. L'Espagne et le Portugal ont joué un rôle crucial dans les voyages
d'exploration, mais aussi dans le commerce et l'introduction de produits orientaux et
américains dans différents aspects de la vie quotidienne, notamment en médecine. Trois
auteurs, Garcia de Orta (c. 1501-1568), Nicolás Monardes (1493-1588) et Cristóbal Acosta
(1515-1594), ont joué un rôle d'une grande importance dans l'étude, la connaissance et la
diffusion des plantes médicinales, des substances animales et des minéraux importés en
Europe des Indes orientales et occidentales. Dans les pages suivantes, nous présenterons de
brefs éléments biographiques, quelques commentaires sur leurs livres et une synthèse sur
l'influence de ces nouveaux médicaments sur les thérapies de la Renaissance.
1 Corresponding author: Carlos Viesca Treviño. Contact: cviesca@frontstage.org;

International Society for the History of Medicine, Department of History and Philosophy of Medicine, Faculty
of Medicine, National University Autonomous of Mexico (UNAM).

Mots clés
Âge des découvertes; Garcia de Orta; Nicholas Monardes; Cristóbal Acosta; materia medica
Introduction
The last years of the 15th century and the first decades of the 16th century opened
new ways to reach out India and China and, following the idea that it was possible to
arrive in India through a route towards the West, Christopher Columbus (1451-1506)
discovered the Caribbean Islands and the American Continent, called the West Indies.
Bartolomeu Dias (1450-1500) initiated the discoveries arriving in the Cape of Boa
Esperança, and shortly later, Vasco da Gama (1469-1524) opened the route to India.
Goa soon became a central place to Portuguese presence in the East. The discoveries
by Christopher Columbus were followed by the establishment of Spain in Mexico,
creating there the Viceroyalty of New Spain, expanding its territories from the North
American prairies to the Strait of Magellan at the Southern end of the American
Continent. At midway in his circumnavigation travel, Ferdinand Magellan (1480-
1521), arrived in the Philippine Archipelago and left the way open to India through
the Pacific Ocean.
All these discoveries and conquests enabled a new spherical worldview permitting
navigation in all directions, especially to places unknown by European people until
that time. The dream to get access to species and exotic products from the Orient
increased through the possibility of also reaching similarly exotic items from the West
Indies.
The activity of Portuguese and Spanish navigators and explorers was essential to the
exchange of medicinal products, taking classical European medicaments, particularly
products derived from medicinal plants, to Indies and returning with the newly
discovered products.
All the explorers, navigators and conquerors consigned under different forms their
perceptions and, frequently, praise the exotic nature encountered in the recently
opened spaces. An excellent example is a book by Gonzalo Fernández de Oviedo
(1478-1557), Historia general y natural de Indias, the first part being published in
1535, and the other two respectively in 1551 and 1559. It was an extensive work
including narratives on the conquest of the islands, mainly Santo Domingo and Cuba,
Mexico and Peru, along with beautiful descriptions of the geography of these new
lands and landscapes, plants and animals, following the model of Pliny the Elder (23-
79 AD).
th
We studied the works of three relevant 16 century authors, Garcia de Orta, Cristóbal
Acosta and Nicolás Monardes for this essay. All were physicians genuinely interested
in Natural History, and in diffusing acquired knowledge specifically focused on
medicaments found in the East and West Indies, which, through their works, they

made available to European physicians who introduced them into European
therapeutics.
Garcia de Orta
Garcia de Orta was a Portuguese physician descending from a Spanish Jew family
established from some generations in Valencia de Alcântara, seeking refuge in
Portugal after the edict expelling the Jews from Spain, ordered by Isabel and
Fernando, the Catholic Kings, in 1492. He was born in Castelo de Vide in 1501, being
the son of a merchant whose family lived as “marranos”, Jews converted to
Christianity. The family seems to have attained an unburdened economic status,
affording his son to study as a bachelor in Arts and Medicine in Alcalá de Henares and
Salamanca (in Spain), where he finished his studies in 1523.
In 1530, he became professor of Medicine at Lisbon University, and in 1534, he sailed
to Goa as personal phycisian of Viceroy Martin Afonso de Sousa (1490-1564). Some
years after travelling in the Viceroy’s expeditions, he settled in Goa in 1538, working
out a well renowned medical practice until he died in 15681.
Figure 1- Bronze sculpture of Garcia de Orta by Sculptor Martins Correia at the Instituto de Higiene e
Medicina Tropical, Lisbon. Photo courtesy: Elsa Martins Correia.

He and his family were affected by the persecution of the Jews after the
establishment of an Inquisition Court in Goa in 1565, but they did not seem to have
serious problems until Orta’s death. A year later, one of his sisters was burned alive
under the accusation of the occult practice of Jewish cult. He was sentenced
postmortem for the same reason2.
His medical practice and a genuine interest in the study of Materia medica, keeping
the main Spanish tendencies towards a revival of classical herbaria, following the
work of Pedanius Dioscorides (40-90 AD), led him to resume the medicaments known
and recommended by the authors of the Graeco-Roman antiquity, which had provided
him with a fruitful knowledge of the medical arsenal, extended to the inclusion of the
Indian medicinal plants. He explored carefully the items recommended by indigenous
people, identifying those already figuring in old European herbaria, and including the
unknown or not well-documented items in his repertory. He always gave the reason
for the botanical characteristics and medicinal properties, which he described,
following the indications contained in the works of the Islamic physicians, like Rhazes
(854-935) and Avicenna (980-1037).
All this material was integrated into his only known work Coloquios dos simples e
drogas he cousas medicinais da India, e assi dalgunas frutas achadas nella onde se
tratam algunas cousas tocantes a medicina, published in Goa in 15633.
The book soon attracted the attention of European scholars, first of all of Nicolas
Monardes, a Sevillian physician also committed to the study, analysis, employment
and commercialization of medicinal items. The contact with Orta’s Coloquios caused a
particular and crucial turning point in his work. Another eminent fact was the interest
of Carolus Clusius (1526-1609) in Orta’s book. Clusius was the absolute authority of
the Western world on medicinal plants and materia medica of the time, and a most
active diffuser of the discoveries through his works, particularly editions with
commentaries on the selected books4.
Cristóbal Acosta
Cristóbal Acosta (Cristóvão da Costa) was also a Portuguese born in San

Buenaventura at Cabo Verde Islands around 1525. He belonged to a Jew convert
family, like Orta. Acosta studied medicine maybe at Salamanca. In the fifties, loving
travels and adventure, he sailed to India and participated in some campaigns as a
soldier with Luis de Ataide (1516-1580), later Viceroy of Goa who brought Acosta,
appointed as his private physician from 1568 to 1572.
After that, he returned to Spain, settling down in Burgos where he published a book,
Tratado de las drogas y medicinas de las Indias Orientales in 15785. In this book, he
remembered Orta’s work, to which he possibly came across in his first voyage to
India. He glossed a considerable part of his data, drawing some of the plants with
great perfection.

Figure 2- Portrait of Cristóvão da Costa, bust directed to the left, glancing at the viewer, bearded,
wearing a ruff and fur-trimmed coat. 17th century, British Museum. Credit: Wiki Commons.
Figure 3 - Title page of the Spanish edition of "Tractado de las drogas y medicinas de las Índias
Orientales", 1578 by Cristóbal Acosta.
Clusius was the chief promoter of this treatise, like as of Orta’s work. In 1582, Clusius
published a summarized text in a Latin translation, and in the following years, four
reprints of the original book and Italian and French translations were published,
almost all with Clusius’ commentaries6. After his wife’s demise, Acosta retired from
the world and led a solitary monastic life in Nuestra Señora de la Peña near Tharsis, a
small village in Huelva, where he died sometime after 1592. This was the last year of
which we have a record since it is the date of publication of two volumes on moral
and religious themes he authored. He left a significant amount of materials on all
classes of plants and aquatic and terrestrial animals from India, China and Persia
unpublished, intending to complete the information of the items to include in his
treatise7.
Nicolas Monardes
Following the exploring scholars committed to the knowledge of the medicines sailing
from India and the West Indies to Europe, the third author attracting our interest is
Nicolas Monardes, a major figure for the study and introduction of American, mainly
Mexican and Peruvian medicinal plants into the current therapies in many European
countries such as Spain, Italy, France, Germany and England. Monardes was born in
Seville in a date which his biographers leave between 14938 and 15089; the first
according to a statement of his relatives, the second after his own information.10 He
acquired an excellent formation and was graduated as a bachelor in Arts in 1530 and
as a bachelor in Medicine in 1533, both at the Alcalá de Henares University 11 .
Just in 1547, enjoying a good reputation after some years of medical practice, he
obtained his Doctoral degree in medicine by the Colegio de Santa María de Sevilla
(Seville St. Mary’s College), the founding precursor of the Sevillian university12.
Figure 4 – Title page of Nicholas Monardes. Dos libros: El uno que trata de todas las cosas que traen
de nuestras Indias Occidentales, que sirven al uso de la medicina, y el otro que trata de la piedra
Bezaar [...] 1569. Biblioteca Digital Real Academia Nacional de Medicina, Madrid.
In the early thirties, he returned to Seville, working with a renowned physician,

Gaspar Pérez de Morales, who had published a book concerning the medicinal
utilization of the American balsam, in 153013. In 1537, he married Catalina Morales,
daughter of his professional guide. A year before, in 1536, Monardes had published
his first book, Dialogue called pharmacodylosis14. This work is fascinating because it
portraits the young physician expressing his deep assimilation of the teachings of his
masters from Alcalá, rejecting the “modern” innovations brought by the Arabic
medical and medieval tradition, coming back to the “ancients”, i.e. Graeco – Latin
sources. Contrary to the opinion of some early biographers of Monardes, commented
on his rejection of new West Indies medicaments highlighting that, in this work, he
just defended the priority of the medical classical authors, particularly Dioscorides,

in the field of pharmacopoeia, expressing his doubts on the quality and preservation
of the medicinal plants from the New World arriving in Sevilla15.
In the course of his medical practice in Seville, he not only witnessed the arrival of
some medicines from the New World but also questioned their usefulness, such as the
balsam prescribed and defended by his father-in-law, and tobacco or guaiacum, as
the most outstanding produts. Another more common but not less important plant
was the Michoacan Root, marking its entrance into the extensive list of medicinal
products from New Spain at that time.
This story begins in 1540, when a Genovese sailor, Pascual Cataño, asked Monardes
to purge him with this medicament he had brought with him. After many
supplications, Monardes finally agreed, obtaining a very good recuperation. 16 Years
after some interest and scientific and commercial inquietude, in 1552, Monardes
received the visit of Francisco de Mendoza (1547-1623), son of the first New Spain
Viceroy who owned a considerable number of Mexican plants. By that time, he also
had acquired a beautiful book, currently known as Codex de la Cruz – Badianus
redacted and painted by an Aztec physician, Martín de la Cruz, translated into Latin
by another indigenous working as a teacher of noble Indian children at the Imperial
College of Santa Cruz de Tlatelolco, Juan Badiano (1484-1560). The purpose of
Mendoza’s travel was to offer the plants and book to the Spanish and German
Emperor Charles V (1500-1558). He also intended to ask for the establishment of a
monopoly market on the distribution of sarsaparilla in Europe. The results were the
creation of a commercial company, and everything indicates that Monardes was the
medical promoter and commercial partner of Mendoza. The company was founded in
1553. One of its main imported products was sarsaparilla, the root that the monarch
allowed Mendoza to introduce and distribute in Europe17.
After that, Monardes negotiated intensely sending manufactured products and slaves
to Nombre de Dios, currently in Panama and Mexico, and sometime later, to Peru,
importing high quantities of medicinal items. He included numerous medicines
imported in his company’s cargos to Sevilla in his medical practice.
In 1565, after exchanging correspondence with physicians in several European
countries for some years, explaining the medicinal virtues of sarsaparilla and
Michoacan root, he published his first book on these themes: Dos libros, el uno que
trata de todas las cosas medicinales que traen de nuestras Indias Occidentales, que
sirven al uso de Medicina y como se ha de usar la rayz de Mechoacán, purge
excelentísima. El otro libro trata de las dos medicinas maravillosas que son contra
todo Veneno, la piedra Bezoar y la yerva Escuerzonera 18. He did not write and publish
a book, called after the medicines from the West Indies immediately after the
publication of Orta’s book on the same theme by chance, but concerning the East
Indies. The dialogue was open.
A second edition of the first book by Monardes was published in 1569, including a
second part in 1571. Finally, in 1574, the complete work on West Indies medicaments

in three parts was printed in Seville as Primera y Segunda y Tercera partes de la
Historia Medicinal de las Cosas que se traen de nuestras Indias Occidentales que
sirven en Medicina. Tratado de la piedra Bezoar y de la yerva Escuerzonera. Diálogo
de las grandezas del Hierro y de sus virtudes medicinales. Tratado de la Nieve y del
bever frío…19 The book had a very good acceptance, and was a new Sevillian edition in
1580 followed, being translated into Latin, and Italian, English and French in the late
years of the century and first decades of the next20.
Figure 5 – Italian edition of Orta’s and Monardes’ books, Venice, 1597. Author’s foto.
A remarkable fact was the interest in the work by Carolus Clusius, who incidentally
also worked with the Függer family, the bankers of Charles V who held the monopoly
market of the distribution of guaiacum since they were the commercial adversaries of
Monardes and the Mendoza family. Clusius translated into Latin, annotated and
published the works by Orta and Monardes in Antwerp, and also reunited both in a
volume translated into Italian, published in Venice in 1575, 1582 and 159721.
The dialogue had started with Monardes’ notice and reading of Orta’s book. He came
across Coloquios dos simples shortly after its publication. In 1565, he published his

book. Besides giving the first account of medicaments imported from the New World,
he gave a proper place to Bezoar stones, Opium and Bangue, which is nothing but
cannabis, to which we will return later. However, before that, Monardes, as we have
seen, established a commercial company, imported medicinal plants from America
that he started employing in his prescriptions, providing its distribution to other
physicians in different countries. The first item was Michoacan Root.
Michoacán root (Ipomea purga)
As the name indicates1, the Michoacán root was carried from Mexico to Seville and to
the European countries. Its relation to other purgatives from India and China was
evident. The history of how it came into the Spaniards’ knowledge is anecdotic.
Monardes related it in detail, recounting how a Franciscan chief-friar in the Michoacán
province fell seriously ill, and the local cacique sent him his physician who
administered him a powdered root, Michoacán Root, curing him. Later, the remedy
was given to other sick Franciscan friars, also with excellent results. Michoacán Root,
mentioned as rhubarb of Michoacán, was the purgative that Monardes had prescribed
to Pascual Cataño, the Genovese sailor who had begged him to use it after the failure
of the usual purgatives.
This episode around 1540 marked the entrance of the new medicines in Monardes’
classical pharmacopoeia22. These facts happened at least a quarter of a century
before coming across Orta’s book. Monardes obtained the root directly from the
Franciscan friars at Michoacán. Later, he could also see the flower of the plant and
cultivate it in his Sevillian garden23.
In 1565, Monardes, had some good clinical experience with the Michoacán Root,
declaring explicitly in his book that it did not have any harmful effect and could be
prescribed to people of all ages, adding that, if taken with wine, it would result in a
better effect. However, when mixed with another liquor, it provoked vomiting. It was
his drug of choice for poxes, all kinds of fevers, mainly malarial and chronic, acting by
purging phlegm and any retained and accumulated humours24.
In the last paragraph of the Michoacan (sic) Root chapter, Monardes claimed the
advantages of the available medicaments imported from the West Indies, praising the
excellence of this root as the most recommendable purgative. We should remember
that this long chapter proceeded directly from the private letters Monardes had sent
to numerous physicians and apothecaries in many places of Europe, later included in
a prominent work on the New World, highly praising these medicinal substances.
Not by chance, the chapter followed a series of small chapters dedicated to other
purgatives: purgative nits, purgative pinions (Jatropha curcas purgas Adanson) and
beans (Delichos pruriens) and pinipinichi (Euphorbia centuneuloides), this last being
one of the strongest. The precedent chapters were a short report since his central
theme was the Michoacan root.
1
Michoacán is located in Western Mexico.

Rhubarb
The primary purgative in European pharmacies was rhubarb. The introduction of

Michoacan Root represented another option in medical terms and competence from a
commercial point of view. In the third book of his Historia Medicinal…, published in
1574, and not included in the Frampton English translation, Monardes resumed
purgatives, dedicating a chapter to Indies Rhubarb.
This time, he compared rhubarb brought from Tierra Firme, the continental American
lands, specifically Panama, with a specimen from the Levant, affirming that it was
similar to the Oriental, presenting the same black colour cortex, red in its interior, like
a species rhubarb described by Dioscorides and the item from East Indies. He exalted
its medicinal virtues, not mentioning Orta. He claimed that it was a new and
accessible product and safe medicament.
Orta included Rhubarb in the first part of his book, clarifying that it was not necessary
to describe it because it was a well-known medicament to all physicians. He
emphasized that the plant sent from India to Europe would arrive in poor conditions
because of damp, and recommended the transport in drylands such as Persia and
Tartaria. The most useful should be collected and sent between June and September.
He also recommended that it should be prepared as in Cochin, cooked and diluted in
infusion or distilled in water because it would arrive in better conditions25.
Based on Orta’s text, Cristóbal Acosta made more commentaries, stating that no one
could know more about that plant than “el Doctor Orta”, repeating that all rhubarb
came from China, more specifically from Canton where the Portuguese merchants
carried it to Goa and then to Europe or to Tartaria and, from there, to Ormuz in
Persia, Arabia and Alexandria in Egypt. He also remarked that the maritime way, with
its humidity, provoked corruption in a great part, repeting the same recommendation
about distillation26.
When reading these texts carefully, it is easy to infer that two different rhubarbs were
in circulating: the classic, oriental, always coming from China through various ways
and known in Europe at least since Roman times; the other, discovered in New Spain,
belonging to the same genera, owning the same medicinal properties. As expected,
Monardes intended to exalt the rhubarb he knew and distributed. On the other side,
Acosta exalted the Oriental product.
Anti-syphilitic products
Syphilis was a major health problem in the 16th century. According to some, already
existent in the Old World, the contact with New World natives brought up another
treponema stock, provoking devastating epidemic, causing deaths and leaving many
people with bone and joint articulation affections, skin lesions and internal ailments.
In India and China, syphilis also appeared as a plague.

The sailors coming from Europe, arriving mainly to Portuguese ports as Goa and
Macao, had spread it. Garcia de Orta, in the chapter referring to the China Root, gave
notice on the high number of affected people in Goa and Japan, registering the
Persians’ for the disease, Bedefrangi, corresponding to Morbo gallico, by its
supposedly French origin27. For the Spaniards, the first epidemic burst of syphilis
appeared in 1493, after de second travel of Christopher Columbus to the West Indies,
and his return to Barcelona. Soon, the illness spread to Italy and France and, aside
bubonic plague, constituted the main epidemic disease in the 16th century.
Monardes began his book by enumerating the immense wealth in gold and silver
brought by the explorers, but also that they “brought unto us new Medicines and new
Remedies, wherewith they cure and provoke many infirmities….incurable and with no
remedy…”28 Some pages later, in the chapter on Guaiacum, he thanked God for
sending it from the same place where the illness, Poxe in Frampton 16th century
translation, syphilis or “mal de bubas” arrived. “Bubas” were the inflamed inguinal
lymph nodes characteristic of the early stage of the condition for which there was a
remedy in the New World.
Guaiacum
The first medicine originated in a tree, the guaiacum (Guaiacum Sanctum), also called
Holy Wood (Palo Santo), found in Santo Domingo and San Juan de Puerto Rico.
Monardes referred to the anecdotic way which brought it into the Spaniards’
knowledge: a Spaniard was suffering terrible pain due to the pox (bubas), inflamed
glands, “which he had got by the company of an Indian woman” was cured. The next
steps were easy to guess: the remedy was soon carried by many other Spaniards and
collected for exportation to Seville29.
Monardes described how to prepare the medicament and the details of the treatment,
but in the next two chapters he proceeded talking about China Root and Sarsaparilla,
also anti-syphilitic medicaments, more attractive to him because he was their leading
importer and distributor in Europe. Obviously, neither Orta neither nor Acosta
included guaiacum and sarsaparilla in their texts, just praising the virtues of the
China Root.
China root (Smilax China L., Smilax Pseudochina L.)
The introduction of China Root into medical practice in Europe was carried out by the
Portuguese, bringing it from Goa around 1540, according to Monardes. With the
support of Martin Alonso de Sousa, the Viceroy found it in Malacca and obtained large
quantities, shifting the old guaiacum treatment, expensive and difficult to find, to the
new one. In subsequent years, China Root became an essential product to export to
Lisbon.

Figure 6 – China root. Drawing by Acosta, Tratado de las Drogas, y Medicinas de las Indias Orientales,
1578.
The other treatment, consisting of mercury ointments, was highly toxic, supporting
Orta’s interest in a less hazardous treatment. The importance of obtaining the fresh
root was an overall concern of all physicians and merchants, being a recurrent theme
in the medical works of the 16th century. After a twenty-day treatment, Orta stated
that the sick people were throughout cured, no collateral effects being observed. He
recommended adding rosemary when headache or pain in nervous trajectory was
reported, or celery in hepatic concomitant affection30. Cristóbal Acosta, who also
wrote a chapter on China Root, followed Orta’s text closely. He mentioned the anti-
syphilitic properties of the China root in the last paragraph of the chapter, not
referring to Orta’s recommendations, just mentioning a notice on the books by
Amatus Lusitanus (1511-1568) and Andreas Mathiolus (1501-1577), commenting
Dioscorides, and Vesalius’ notice on it. Notwithstanding, he highlighted that they had
limited access to the authentic China Root31. In 1564, Andreas Vesalius (1514-1564)
wrote and published a small but relevant text on the use of the China Root in the
treatment of syphilis.
A decade later, Monardes took Vesalius’ study seriously and helped in introducing the
plant among physicians in Spain, recommending a shift from guaiacum to varieties of
the China root.
Now, let us read Monardes’ text on the China Root. Guaiacum being the first anti-
syphilitic medicament arriving in Europe, it was attractive to Monardes just as a
useful drug. Later, when he developed commercial interests, his attention derived
casually to China Root from New Spain.
He started his report on the virtues of the China Root, explaining that it would be
equivocal since the China Root had been initially a Chinese product, introduced by
Portuguese in the late 1530’s into Europe. However, he emphasized that some China
Root arrived in Seville directly from New Spain. Don Francisco de Mendoza, son of the
first New Spain Viceroy, Don Antonio de Mendoza, had seen it in Seville in 1552.
Mendoza’s travel to Spain had the purpose of offering medicinal plants and species
grown by his father and him in New Spain to Emperor Charles V. Mendoza had in
mind obtaining the monopoly market on the importation and distribution as a
counterpart to the Mendoza family, most outstanding in politics. Concerning the
monopoly market on guaiacum conceded two decades before to Anton Fugger, the
banker had sponsored the campaign of Charles of Habsburg to become German
Emperor.
Among these plants, Mendoza counted China Root cultivated in New Spain and
sarsaparilla. After that, Monardes established a commercial company importing his
cherished medicines from the New World, New Spain, Antilles, Tierra Firme and Peru.
Therefore, we have an explanation to why Acosta noted the medicinal effects of China
Root outside its anti-syphilitic action and also why he stated that European authors
might have used a spurious China Root, not the authentic arriving in Europe via Goa
and Portugal, and also why he never referred to Monardes.
Besides celebrating a second possible beneficial drug to treat syphilis, Monardes
offered a list of its usefulness in the treatment of other ailments: “It maketh a good
colour in the face, drives Jaundice away, and all evil complexion of the Liver32.”
However, later, the most significant product commercialized and utilized by Monardes
in his professional practice was Sarsaparilla he obtained and imported through
Francisco de Mendoza. The species was Smilax sarsaparilla L., almost identical with
European sarsaparilla, Smilax aspera L. Later. He also imported a species of
sarsaparilla from Honduras and Guayaquil33.
The quantity of imported sarsaparilla arriving in Seville was enormous. The
specifications of the different treatment schemes were given in detail by Monardes,
focusing on the capacity of sarsaparilla to “purge” humours, phlegmatic humours
predominant in syphilis, remembering the original Mexican indigenous way to produce
temperature elevation and hard sweating in temazcal baths (although not known to
Monardes) recommending to put the purged patients in warm chambers. In all these
commentaries, he constantly referred to his own experience as Orta did in his work34.

Opium and bangue
Other groups of medicines which hardly drew the attention of physicians and people
in the 16th century were the psychotropics, held as medicaments for many ailments.
Opium and bangue (cannabis) were available to the physicians working at Goa.
To Monardes, tobacco was the only one in his time, since he did not have the
possibility of coming across other psychotropic plants such as peyote (Lophophora
wiliamsii) or teonanácatl, the sacred mushrooms, (Psylocibe sp).
Orta dedicated a small chapter, the fourth of the first book of his Coloquios, to opium,
identifying it with the latex of the black papaver, pointing out that when used for a
time and discontinued, it would lead to deadly danger. He called especially the
attention that those taking it in small doses became somnolent. Others took it to fight
fatigue and excite sexual impulse. For these, Orta recalled the danger, confirmed in
some of his Portuguese patients, of becoming sterile and sometimes impotent35.
Acosta offered an ampler description starting by saying that it was profusely
consumed in India, many people taking it every day, not to be affected by tiredness
and fatigue. “This is the most ordinary and familiar remedy of the vile sons of
Venus36.” Acosta related an anecdote concerning opium addiction. Travelling towards
Buena Esperanza Cape, some captives, Turkish, Arabians and Persians, asked him for
opium saying that, as they were used to its daily intake, they would die if they did not
have it. In the impossibility to have it, they asked him to give them, as a physician,
increasingly daily dose of pure wine. This therapy stands as one of the first, if not the
first suppressive management mentioned. Acosta gave credit to Orta about the data
on the use of opium37.
Figure 7 – Bangue. Drawing by Acosta, Tratado de las Drogas, y Medicinas de las Indias Orientales,
1578.

Also, Orta and Acosta spoke of Bangue, a plant identified with the Indian hemp. The
first said that it produced drunkenness and brain-disturb with a state of pleasure
being at the origin of the necessity of soldiers to sleep when anguish and worries
tormented them in the campaign38.
Acosta reiterated than Indian people ate the seeds and leaves to increasing venereal
enhancement and stimulating the appetite; others took it to sleep without any
thought, to forget their work and suffering, dreaming illusions or simply to get
drunk39.
Monardes had no access to opium imported from the Orient. Nevertheless, in the first
chapter of his second part of his Historia Medicinal, when evaluating the virtues of
tobacco, Nicotiana rustica, which proved to have a high number of alkaloids producing
somnolence and impaired states of consciousness, especially when treated with lime
or chalk, he compared its actions with those of Opium and Bangue.
He recounted that in West Indies, the natives smoked tobacco after their heavy
dances to “take away weariness”, staying like dead after smoking, recovering
completely only some hours or days later. He observed the same effects in blacks
taken to the West Indies, inferring that it was not a cultural but a biological effect.
He proceeded comparing his observations with those reported from India, giving
details on the uses. He referred to wealthy people who took the best bangue and
aphion, opium, for leisure while ordinary people took it to keep the fatigue away.
Monardes praised much the multiple therapeutic actions of tobacco, acting as
coadjuvant in scarring wounds and chronic sores, also helpful in the treatment of
headaches, asthma, colds stomach pain, and womb ailments, in what concerned
hysterical disorders, abscesses and other conditions40.
Datura
Datura species were also recorded by Garcia de Orta, Acosta, and those who wrote
about medicinal and toxic plants in the Ancient and New World. Dioscorides and Pliny
described them, as well as Serapion (died around 1070), Amatus Lusitanus (1511-
1569), Leonhart Fuchs (1501-1566), Francisco Hernández (1514-1587), Fray
Bernardino de Sahagún (c. 1499-1590), Alonso López de Hinojosos (1535-1597) and
Agustín Farfán (c. 1532-1604). The role of datura in love magic was relevant and its
most common use registered in Classic times, Pre-hispanic America and in the Far
East. Curiously, Monardes did not mention it, maybe because the importation into
Spain was not a lucrative affair since such plants existed in Europe. However, the
leading cause was the relation of the plant to witchery.
The medical literature of New Spain registered toloatzin and tlapatl, datura meteloides
and datura stramonium respectively strongly pointing out to their anticholinergic
effects. Sahagún41 and Hernández42 left testimonies on their magic utilization, which
later would be one of the principal concerns of the Inquisition.

Figure 8 – Datura. Drawing by Acosta, Tratado de las Drogas, y Medicinas de las Indias Orientales,
1578.
Garcia de Orta wrote only about the use of the datura flowers mixed with food in
order to derange the people who ate it, provoking “loss of the brain”, followed by a
great laugh and “liberality” - sexual desire, accurately stating that the effects

lasted for twenty-four hours. After that, the intoxicated people came gradually to
normality. In the meantime, he said the person would happily let himself being
robbed. As a consequence, the primary utilization of the plant was not for medicinal
purpose but for bad deeds43.
Datura also appears as a chapter in Acosta book44. His description and considerations
go further than Orta. He described the plant, referring to Dioscorides’ text on
Stramonium, always bringing up their differences, giving the different names for the
plant in Malabar, Comorin, Arabia, Portugal, Turkey and India.
To Acosta, the most outstanding feature was the inadequate utilization, given by
women to alienating their lovers, ruling over them. He discussed the hallucinatory
effects and the treatments, mainly through emetics, clysters, ligatures and
bloodletting. Acosta’s main concern was to establish a clear difference between the
three species of datura, writing on the species with white flowers, common in Goa.
Balsams (Myroxylon pereirae, M. toluiferum, M. Peru)
Balsam was the base of popular treatments for surgical wounds and traumatisms,
applied locally to relieve pains and swellings. Administered orally, was recommended
in bladder conditions, to reestablish menstruation, and to treat different types of pain
in diverse localizations.
Recommended and employed since Classical Antiquity, the oriental balsam, imported
from Egypt and Arabia, was increasingly scarce, and, as Monardes would say, almost
exhausted. Henceforth, balsam, mainly from the West Indies and New Spain were a
fantastic improvement to the dreamed therapies, stating that if only balsam were the
result of the newly discovered lands, it would be worthy.
By this time, physicians discussed the classical tradition of the medical use of balsam
in a dialogue on the new possibilities opened by the discovering and importation of
balsam trees from the New World.
Three species of Myroxylon were discovered, the balsam tree (Myroxylon balsamum),
and the balsams of Tolu and Peru, the last used until the last quarter of the 20 th in
complicated surgical wounds to facilitate the intention scarring through its
regenerative and bacteriostatic properties45. Balsam tree was not mentioned in Orta
and Acosta’s works. To Monardes, this was a perfect example sustaining the capital
importance of the medicaments from the West Indies. Balsams were the ideal
substances because similar oriental products did not exist at all.
Cannafistola (Cassia fistula)
Garcia de Orta dedicated a chapter to Cassia solutiva, a common name, he said, for
Cassia fistula, criticizing the translation of Gerardo de Cremona (1114-1187). He
provided an extensive linguistic list of the different names of the plant in Arabic,
criticizing Avicenna (c. 980-1037 AD) for the corruption of Chiarsamdar instead of
Hiarxamber in the second book, chapter 197 of the Cannon.

In many places of India, other names were given to it, and, in Goa, it was known as
Bavasingua. Talking on the many places where it also grew, such as Malacca,
Cambodia, Siam and Egypt, he also corrected the description given by Andres Laguna
(1499- 1559), in his translation of Dioscorides’ Materia Medica. He mentioned that it
grew abundantly in America, where it had been cultivated and collected in abundance,
pointing out that it was much more expensive in Spain than in Portugal, where it
arrived from the authentic India46.
Nevertheless, Monardes took the offensive not mentioning his counterpart, talking
about the spurious conditions of this plant, when coming from the Orient, due to the
long travel from India to Venice, Genoa or to the Iberian Peninsula, arriving usually
totally corrupted. On the other side, the quality and virtues of the plant sent from
Santo Domingo and Puerto Rico were much better.
The purge of the choleric humour and phlegm was the primary medicinal effect of the
plant, beyond its utility in kidney diseases – passiones de riñones - and rheums
(humours accumulated in abnormal body parts), mainly permanent “evilles (sic) of
the breast.and griefes of the sides” 47.
Bezoar Stones
Maybe the original link between early Renaissance European physicians and India,
East India, was the possibility to access a bezoar stone, a precious medicament
reputed to be an infallible antidote against all kinds of venoms and also a marvellous
cure for all types of fainting, especially of ladies, and malignant fevers accompanied
by heavy somnolence or drowsiness.
The first publication of Monardes on medicinal plants, after his early work on
pharmacodilosis, was Dos libros. El uno que trata de todas las cosas que traen de las
Indias Occidentales, que sirven al uso de Medicina y como se ha de usar la rayz de
Mechoacán (sic), purga excelentísima. El otro libro trata de las dos medicinas
maravillosas que son contra todo veneno, la piedra bezoar y la yerva (sic)
escuerzonera48.
This work, published immediately after the Coloquios by Garcia de Orta, came into
Monardes hands who differentiated products coming from West Indies, the New
World, in one side, and two great reputed antidotes, the bezoar stone, from recent
incorporation to therapeutics after the closing of commerce with the Orient due to the
fall of Constantinople in Turkish hands, and escuerzonera, a herb growing in the north
of Spain and very difficult to obtain.
Monardes is clear when he says that, in his private practice, he strived to get bezoars
in Lisbon, always from Goa. He referred again to his difficult access to bezoars, in
Lisbon, to treat a Genovese woman living in Seville, María Cataño, and the Duchesse
of Béjar, to whom the book was dedicated.
Bezoar stone covers forty pages of the book, while the most noticeable among the
American plants take no more than five, except for the Michoacan Root, a

Figure 9 – Bezoar stones on display in the German Pharmacy Museum in Heidelberg Castle. Credit:
GNU Free Documentation License.
fundamental medicine to Monardes. He described the uses and forms of utilization of

the stone, scrupulously highlighting that it was not a mineral, and appealed to all
available classical, Arabian and modern references on its virtues and way of use,
making a vivid narrative of some anecdotic issues.
Garcia de Orta also wrote on the bezoar stone in his book. Nevertheless, his reference
is short, a brief chapter in the second book of his Coloquios49. The reason for this
ordering is straight: the chapter comes after the vegetal remedies and before the
other stones and minerals. He related how, after the habitual finding of bezoars
in the stomach of Persian and Himalayan known as Goats of the mountains, or Harts
in the languages of the mountaineers and Pazam in Persian, in Cape Comorin and
Goa, bezoars were found in the stomach of other ruminants related to wild goats.
He gave a piece of valuable advice: rich men in India should take bezoar powder
twice in a year, because not it would not only preserve them from being poisoned, but
it was also a marvellous cure and preservative from all kinds of melancholic
affections. This last use is the clue for the treatment of melancholic women and older
people, especially those who keep intellectual activity.
Cristóbal Acosta also dedicated a chapter, the twenty-first, to the Bezoar Stone. His
text is more and more detailed than Orta’s, but he followed him for the most part,
with two remarks. He asserted that in India – East Indies – there was a standard
criterion that noble and wealthy people should employ the bezoar stone because
giving it to ordinary people would be offensive to God. For these people, God had
created a more vulgar medicine, the Moringa Root.
Acosta specified the affections that should be treated with bezoars beyond
melancholic disorders; all the skinny people would have their condition enhanced, it
would facilitate childbirth and expel the placenta, blow out urinary stones and sands,
cure opened malignant abscesses, and be useful in the treatment of smallpox, leper,
and malarial fevers among others50.
Figure 10 - 'Engraving of a Llama' in Willem Piso, De Indiae Utriusque Re Naturali et Medica libri
quatuordecim..., Amstelaedami, Apud Mudovicum et Danielem, Elzevirios, 1658, Wellcome Images
Collection.
Monardes, obviously not mentioned by Acosta, looked for other source of bezoars. In
his second book, published in the 1671 edition of his Historia Medicinal51, he included a
letter, dated from October 1568, sent to him by Pedro de Osma, a noble living in Peru,
who described the Peruvian medicinal substances.
The first in his list were the bezoars, giving the notice of the existence of an animal in
Peru, the llama, producing bezoars in its stomach52. Three years later, now in the third
part, he included a chapter on Bezoars stones from Peru. By this time, Monardes took
advantage of the possibility of obtaining these stones through his agents in several
parts of these lands, bringing them to Seville for distribution to other Spanish cities
and other places in Europe.

He described the characteristics of the animal and its stones carefully, highlighting its
qualities, which he compared to the better products of East Indies, abounding in
references from his medical practice, pointing out the advantages in the treatment of
cardiac illnesses, failings, venoms. He curiously recommended it as a fantastic
medicine for people drinking putrid waters, infected with worms and poisonous
animals, considering bezoars useful in the treatment of pestilences and tavardetes
(typhus), and fundamentally in the illness called mirarchia by the Arabian classical
authors, which is the accumulation and retention of melancholic humours in the
mirach, which corresponds to mesentery of the intestines53.
Conclusions
The dialogue, often without expressed conscience of its interlocutors, remained open
for the next decades. Indies, East and West medicinal products flooded to European
countries and have had a priority presence in many aspects of medical treatments.
The intercourse between products coming through Portugal and those arrived in Spain
maintained a hard competivity, fighting not only for scientific priority but also for
commercial control.
An incontrovertible fact is that the works of Garcia da Orta, Monardes and Cristóbal
Acosta were milestones in the knowledge and introduction of new substances in
Western countries and the incipient modern medical science.
Many more products than those included in this paper permeate in the pages of the
cited books, many having counterparts in East or West Indies. Some species were
overall searched for preparation of sophisticated dishes like pepper and cinnamon
from India and tabasco from West Indies. We can also find exotic and magic items
fulfilling the most exciting imaginations such as the tree that showed who would live
or die. This legend was recorded by Monardes.
A plant from Peru would give an accurate prognosis. A bough on the patient’s hand
would show happiness or sadness that would be interpreted as infallible signs of life
or death.
On the other hand, the Sad Tree, presented in Acosta’s pages, every night developed
beautiful and odorous flowers which fell to the ground in the beginning the day; the
tree looked sad and faded, only recovering its beauty after the twilight. In this case,
the explanation is found in a legend recounting that a beautiful girl, after falling in
love for the sun, was left by him and committed suicide. From the funeral pyre, she
was transformed in this tree, which was a marvelous medicine for heart ailments,
physical and emotional.
These paradoxical data, reveal us secrets and marvels, both, from the immediate
physical reality and from the magical and imaginative world, opened towards new and
unknown lands that characterized human mentality awakened in the 16 th century. A
fruitful dialogue persisting until our days.

References
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que se traen de nuestras Indias Occidentales que sirven en Medicina, Sevilla, en casa de
Alonso Escribano, 1574, 1ª parte, fo. 30r.
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Monardes, Nicolás, Dos libros, el uno que trata de todas las cosas medicinales que traen de
nuestras Indias Occidentales, que sirven al uso de Medicina y como se ha de usar la rayz de
Mechoacán, purga excelentísima. El otro libro trata de las dos medicinas maravillosas que son
contra todo Veneno, la piedra Bezoar y la yerva Escuerzonera. Sevilla, en casa de Sebastián
Trugillo, 1565.

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Cosas que se traen de nuestras Indias Occidentales que sirven en Medicina. Tratado de la
piedra Bezoar y de la yerva Escuerzonera. Diálogo de las grandezas del Hierro y de sus
virtudes medicinales. Tratado de la Nieve y del bever frío… Sevilla, en casa de Alonso
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plantas medicinales mexicanas, y su Historia Medicinal de las Indias Occidentales,”, en
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The last one: Dell’Historia de i SempliceAroati et alter cosec he vengono portate dall’Indie
Orientali pertinent all’uso della Medicina, / di Don Garzia Da L’Orto, medico portughese…et
Due altri libri parimente di quella che si sono pórtate dall’ Indie Occidentali, con un Tratato
della Neve & del beber fresco, di Nicolo Monardes Medico di Seviglia, Venezia, Appreso
l’Heredi di Girolamo Scotto, 1597.
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plantas medicinales mexicanas, y su Historia Medicinal de las Indias Occidentales,”, ed. cit.
89-91.
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Cosas que se traen de nuestras Indias Occidentales…¸ed. cit. ff.28-37 and 83 ; Monardes /
Frampton, ed. cit. pp.58-67 and 154-155.
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Monardes / Frampton, ed. cit., 62.
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García da Orta, Della Historia dei Simplici e Aromatici…, ed cit. book 1, c. 37, 167 – 168.
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García da Orta, Della Historia dei Simplici e Aromatici…, ed cit., book 1, ch.38,168.
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Monardes / Frampton, ed. cit. p 10; Viesca, C. “la visión europea de las plantas medicinales del
Nuevo Mundo. la obra del doctor Nicholas Monardes. Gaceta medica de México. 1989, 9- 10:295-301.
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Monardes / Frampton, ed. cit., 28-29.
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García da Orta, Della Historia dei Simplici e Aromatici…, ed cit., book 1, ch.38, 168 – 175.
31
Acosta, Cristóbal, Tractado de las drogas…, ed. cit. c. X, 80.
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Monardes / Frampton, ed. cit. 34 – 37.
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López Piñero, José María, “Las nuevas medicinas” americanas en la obra (1565 – 1574) de
Nicolás Monardes”, Asclepeio, Vol. XLII, 1990,1:3 – 68, 32-33.
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Monardes / Frampton, ed. cit., 38 – 44.
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García da Orta, Della Historia dei Simplici e Aromatici…, ed cit., book 1, ch. IV, 23 – 25.
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Acosta, Cristóbal, Tractado de las drogas…, ed. cit. c.LXVIII, 412.
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García da Orta, Della Historia dei Simplici e Aromatici…, ed cit., book 2, ch.25, 249 – 250.
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Acosta, Cristóbal, Tractado de las drogas…, ed. cit. c. LXI, 360 – 361.
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91.
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Sahagún, Bernardino de, Códice Florentino, Libro XI, c. 7,1.
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Libro XII, c. 35 y Libro XVIII, c.63.
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44
Acosta, Cristóbal, Tractado de las drogas…, ed. cit. c. XI, 85 – 92.
45
Cosas que se traen de nuestras Indias Occidentales…¸ed. cit. ff.9 - 16; Monardes / Frampton,
ed. cit., 22 – 27

46
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47
Monardes, Nicolás, Primera y Segunda y Tercera partes de la Historia Medicinal de las Cosas
que se traen de nuestras Indias Occidentales…¸ed. cit. fo.25; Monardes / Frampton, ed. cit.,
49-50.
48
Monardes, Nicolás, Dos libros. El uno que trata de todas las cosas que traen de las Indias
Occidentales, que sirven al uso de Medicina y como se ha de usar la rayz de Mechoacán (sic),
purga excelentísima. El otro libro trata de las dos medicinas maravillosas que son contr todo
veneno, la piedra bezoar y la yerva (sic) escuerzonera, Sevilla, en casa de Sebastían Trugillo,
1565; Monardes / Frampton, ed. cit., 57 -101.
49
da Orta, Della Historia dei Simplici e Aromatici…, ed cit., book 2, ch. 45, 191 – 194.
50
Acosta, Cristóbal, Tractado de las drogas…, ed. cit. c.XXI, 153 – 160.
51
Monardes, Nicolás, Segunda arte del Libro de las cosas que se ttraen de nuestras Indias
Occidentales, que sirven al uso de la medicina. Do se trata del Tabaco, y de la Sassafras y del
Carlo Sancto y de otras muchas yerbas y Plantas, Simientes y Licores; que agora
nuevamente han venido de aquellas partes, de grandes virudes y maravillosos efectos…,
Sevilla, en casa de Alonso Escribano, 1571.
52
Monardes, Nicolás, Primera y Segunda y Tercera partes de la Historia Medicinal…, ed. cit.
fo.73.
53 Monardes, Nicolás, Primera y Segunda y Tercera partes de la Historia Medicinal…, ed. cit.
ff.110v – 113r.

THE GOA STONE: MYTHS, EMPIRICISM AND INSIGHTS

ON CHEMISTRY
Maria do Sameiro Barroso1
Abstract
The Goa Stone or Cordial Stone, an artificial bezoar created by the Jesuit Gaspar Antonio in
the mid-seventeenth century, was composed of precious animal ingredients, such as
scrapings of bezoar stones and unicorn horns, and vegetable and mineral ingredients,
bringing together respected, long-standing traditions, imported from the Oriental and Arabic
Medicine. Ancient myths built upon these substances and possible evidence of empirical
effectiveness sealed their path to glory. Although the composition of the Goa Stone was kept
in secrecy, it was reputed, or even more, as bezoars. Its splendour lasted for about 150 years
until the end of the eighteenth century when chemistry emerged and significant advances in
medicine put forward new diagnostic and therapeutic approaches which enabled more
accurate scientific theories that replaced myths.
Keywords
Goa Stone; bezoars; unicorn horns; medicinal use of gems; Company of Jesus; History of
Pharmacy
Résumé
La Pierre de Goa ou Pierre Cordiale est un bezoar artificiel, créé au milieu du XVIIe siècle par
le Jésuite Gaspar Antonio, et qui était composé d’ingrédients précieux animaux comme des
fragments de pierres de bezoar ou de cornes de licornes, etd’ ingrédients végétaux et
minéraux. La Pierre de Goa incarnait une tradition très ancienne, importée de la médecine
orientale et arabe. Des mythes anciens, relatifs à ces substances et leur efficacité empirique
potentielle avaient assuré leur gloire. Bien que la composition de la Pierre de Goa ait été
gardée secrète, elle était réputée, ou même plus, comme des bézoards. Sa splendeur a duré
approximativement 150 ans, jusqu’à la fin du XVIIIe siècle, alors que la chimie s’épanouissait
et que la Médecine progressait à grands pas vers des approches nouvelles en matière de
diagnostic et de traitement, en remplaçant les mythes par des théories scientifiques.
Mots-clés
Pierre de Goa; bézoars; cornes de licorne; usage medical de pierres précieuses; Compagnie
de Jésus; histoire pharmaceutique
1 Portuguese Medical Association: Department of History of Medicine, Lisbon, Portugal. CIAS — Centro
de Investigação em Antropologia e Saúde, Universidade de Coimbra, Portugal.
a orcid.org/0000-0002-2860-7387
Centre for History, Faculty of Letters, University of Lisbon. * Contact: msameirobarroso@gmail.com
Introduction
In the middle of the seventeenth century, the Jesuit Gaspar António created the
Cordial Stone or Goa Stone, an artificial bezoar, probably destined to be an affordable
good-quality product, providing an alternative to bezoar stones. Notwithstanding,
most of the ingredients of the Goa Stone were rare and costly, and the recipe
remained in secrecy. The Goa stone became as legendary as its most expensive
ingredients.
This article aims to disclose some myths and highlight some possible empirical
effectiveness. We consulted the recipes that had been kept at the Jesuit Archives in
Rome. The belief in mythic and magic healing power of the main ingredients was
focused by screening the possible pharmacological efficacy that could have validated
their use through insights on the chemical composition of their main compounds.
The Society of Jesus
The Society of Jesus, founded in 1540 by Ignatius of Loyola (1491-1556), played a

crucial role in the patient assistance, after arriving in Goa under the patronage of
Francis Xavier (1506-1552), a former Spanish noble, in 1542. Until 1601, the Goa
province comprised the Goa islands, certain areas in the North and the South of India,
Japan and China. At Goa, the College of St Paul was their most valuable possession
(1).
Medical assistance in the missions was poor since physicians and pharmacists were
hard to find. Therefore, although the Jesuits did not possess medical training, they
devoted themselves to the study of medicine and pharmacy, also getting knowledge
from local expertise. Later on, they founded pharmacies and launched new drugs that
were introduced in Europe (2). Living from small subsidies of the Portuguese Crown,
they had to work hard to survive. They bought lands, received donations and
endowments from pious lay people; they became slowly powerful landlords and
financiers (3).
Lisbon in the mid-seventeenth century
Lisbon continued to be the centre of knowledge on Eastern lands even though the
Dutch explorer Jan Huygen van Linschoten (1563-1611) had disclosed the secrets of
the Portuguese and opened maritime routes to the Oriental Indies to English and
Dutch sailors, traders and scholars.
Benefiting from the confidence that Vicente da Fonseca, the Dominican Archbishop of
Goa, had in Jan Huygen van Linschoten as his secretary, this explorer released top
secret information kept by the Portuguese, in his work Itinerario, published in 1596,
which had an immediate massive impact on geopolitical issues and economic trade
(4).
The German-born botanist Georg Eberhard Rumphius (1627-1702) was one of those
who benefited from Jan Huygen’s legacy and sailed to the East where he worked for
the renowned East India Company (Eastern Indonesia). However, before leaving,
Rumphius wrote in a letter from 1680 that, when he felt the urge to “know foreign
lands”, he “went first to Portugal” (5).
Figure 1 - Georg Eberhard Rumphius.

Portrait from Herbarium Amboinense, 1741.

The Goa stone
Rumphius gives the earliest account on the Goa Stone, approved by “the Inquisitors
and the representatives in the assembly of St Paul, the new order of the Jesuits in
Goa 1655”. Rumphius brings rave news about Gaspar António’s brainchild:
This is the stone made by the Portuguese in Goa, but that is now transported
throughout the Indies because of its beneficial powers; I do not know of what it is
made, except that from its appearance and taste, I would say its most important
ingredients are ground salt, Bezoar, Ambra and Musk. It has the size and shape of a
pigeon egg or small chicken egg, seems guilded on the outside, while inside it is dark
grey, glistening with small gold dots, soft to rub, and clearly smelling like Muscus and
Ambra (…) This Stone is the best and most effective Cordial that has been discovered
up till now, and there is no other like it: a Bezoar or other Cordial cannot compare to
this, and he who examines it, will acknowledge this himself, nay, will experience this
even more than what I say or indicate here (6).
He enumerated a long list of therapeutic indications of the Goa Stone taken from a
Portuguese manuscript. The indications included fevers and melancholy; scorpion
stings when drank and applied on the bites; preserving against venoms if drank with
water or wine every day while fasting; most useful to stop bleedings of chest or nose
by snuffing and drinking the dust of the stone; effective against tumours if taken with
water; also preserving sight and protecting against foul air. It would also protect
against four- and three-day fever, give a good memory and protect against
contagious leprosy if taken with wine.
Other indications included smallpox, improving the appetite, being useful against
stomach worms, clearing the reins of gravel, helping against bites from mad dogs
and poisoned weapons. It would also be helpful as a diuretic, laxative and against the
falling sickness. The Goa Stones were sold by weight in Goa, Cutschyn, and Ceylon
(7).
The English doctor John Freyer (c.1650-1733), Fellow of the Royal Society of
Medicine, described Gaspar António in his book relating his travel in Persia and East
India. He described the Paulistines as possessing the biggest of all monasteries of
Goa, which included a Library, a Hospital and an Apothecary’s shop:
well furnished with medicines where Gaspar Antonio, a Florentine, a lay-brother of the
Order, the Author of the Goa Stones, brings them in 50 000 Xerephins, by that
invention annually; he is an Old Man, and almost blind, being of great Esteem for his
long practice in Physick, and therefore apply to by the most Eminent of all Ranks and
Orders in this City (8).

Figure 2 - John Fryer, from the frontispiece to his New Account, 1698.
The income from the sale of Goa Stones was very high since the Royal Hospital managed by the Jesuits
received an annual sum of 14000 Xerephins (9).
The recipes of the Cordial Stones
Three recipes of Cordial Stone recipes figure on a manuscript currently kept at the
Jesuit Library of Rome, which include the instructions for preparation and posology.
The ingredients of the first recipe are as follows: seed pearl (aljôfar), musk
(almíscar), ambergris (âmbar griz), red coral (coral vermelho), white coral (coral
branco), emerald (esmeralda), fossil shark´s teeth (línguas de S. Paulo), topaz
(topázio), white Saint Paul’s earth (terra branca de S. Paulo), rubies (rubins),
Cananor stone (Pedra de Cananor), hyacinths (jacintos), deer horn tips (pontas de
veado queimadas), sapphires (safiras) and Oriental bezoar (pedra bezoar oriental).
The ingredients passed through a long and thoroughly elaborated preparation. After
being grounded and weighted, they were mixed with orange flower or other aromatic
water. Oriental bezoar, musk and ambergris were put aside. The paste was left
fermenting from six months up to a year. Then, Oriental bezoar, ambergris and musk
were added to some stones, and the paste was ground again with orange flower
water, making it softer. The balls were formed and kept in stone or ivory containers
until they were dry. The balls from the former paste were odourless and cheaper (10).
In the second recipe, called reformed stones of Gaspar Antonio, prepared in the
pharmacy of Goa, amber replaced ambergris, Malta earth replaced white St Paul’s

earth; fossil shark teeth were missing and unicorn horn (corno de cervo) being added
(11).
The third recipe was produced in the pharmacy of Macau. Comparing to the second
recipe, fossil shark teeth and Cananor stone are absent. Armenian earth (bolo
arménio) and terra sigillata replaced the earth of Malta. Spode (ispódio), garnet
(granadas), unicorn horn scrapings (raspas de unicórnio), ivory scrapings (raspas de
marfim), crab’s eyes (oculi cancrorum) and camphor were added (12).
The ingredients
They included the minerals, earths, animal and vegetable ingredients, listed in Table I
1st recipe 2nd recipe 3rd recipe

Minerals Emeralds Emeralds Emeralds
Topazes Topazes Topazes
Rubies Rubies Rubies
Hyacinths Hyacinths Hyacinths
Sapphires Sapphires Sapphires
Cananor
stone
Granats
Earths White St Earth of Armenian
Paul’s Malta earth
earth Terra
sigillata
Animal Seed pearl Seed pearl Seed pearl
ingredients
Oriental Oriental Oriental
bezoar bezoar bezoar
Musk Musk Musk
Ambergris
Amber Amber
Deerhorn Unicorn Unicorn
tips horn scrapings
St Paul’s
tongues
Ivory
scrapings
Spode
Vegetable Amber Amber
ingredients
Red and Red and Red and
white coral white coral white coral
Camphor

Medicinal use of the gems
Earlier in history, leading medieval Arabic authors on medicine and pharmacy had
used and traded gems as valuable magic, apotropaic and medicinal materials.
According to Cyril Elgood (1893-1970), a British medical historian of Persia:
The history of pharmacy of stones is by far the most exciting part of Persian
therapeutics. None of the ancient writers could resist the lure of ascribing marvellous
properties to the strange coloured stones which were occasionally discovered (13).
In the Middle East, gems were related to sacred and royal power since ancient times,
providing elevation of the spirit, carrying brilliance, light and happiness, and
mediating the relationship between the human and the divine as stated in an ancient
Assyrian charm:
Glänzende, prächtige Steine; Shiny, magnificent stones; shiny,

glänzende prächtige Steine magnificent stones
Steine der Freude und des Glucks Stones of joy and happiness Brilliant
Leuchtende Pracht für das Fleish der splendor for the flesh of the gods
Götter The Hulalini stone, the Sigurru stone
Der Hulalini Stein, der Sigurru Stein The Hulalu stone, the Sandu stone
Der Hulalu Stein, der Sandu Stein The Uknu stone, the Dushu stone,
Der Uknu Stein, der Dushu Stein, the precious Elmeshu stone, Perfect
der wertwolle Elmeshu Stein, in heavenly beauty
Vollendet in himmlischer Schönheit Put on the shiny breast of the king
Auf die glänzende Brust des Königs as an ornament
als Ornament gelegt Azagud, Azagud, High Priest of Bel, make
Höhepriester von Bel, bringe sie zum them shine,
Glänzen, Make them shine
Bringe sie zum Leuchten Ward this house from bad luck.
Bewahre dieses Haus vor dem Bösen
(14) Translated from the German by the author.
Abu Ray an Muhammad ibn Ahmad Al-Beruni (973-after 1050) had been one of the
most remarkable authors on this subject. He lived in India where he learned the
Hindu language and embraced their philosophical and pharmacological knowledge,
describing 1197 drugs.
He conveyed a catalogue of seventy recipes of comminuted gems, gold, silver,
mineral bezoar, unicorn and other organic, vegetable and mineral ingredients and
spices, taken in electuaries, moulded in pills or to be applied in

plasters or eye collieries, indicated as analeptics, invigorators, and in the treatment of

epilepsy and other conditions (15).
For Ahmad al Tīfāsi (1184-1253), a polymath born in Tifas, Tunisia, the hyacinth, a
golden gem, was, based on alchemical assumptions, at the origin of the other stones,
as gold was at the origin of metals (16).
The Arabic taste for compounds of comminuted gems taken orally comes up in the
early Middle Ages in Europe. One of the earliest recipes, he Confectio de Hyacinto, a
recipe from the Antidotario Napolitano, written by an unknown author of the medical
school of Salerno in the early Middle Ages (10th-12th century), is surprisingly similar to
the Goa Stone, including Oriental hyacinths, rubies, emeralds, sapphires, topazes,
pearls, red and white coral, spodium, ivory scrapings, unicorn horn, stag´s heart
bone and vegetable ingredients (17).
In the seventeenth century, the Gascoigne´s powder, figuring in a book by Elizabeth
Grey, Duchess of Kent (1581-1651), included comminuted bezoars:
Apothecaries Gaʃcon powder, with the uʃe. Take of Pearls, white Amber, Harts-horn,
eyes of Crabs, and white Corral, of each half an ounce, of black thighs of Crabs
calcined, two ounces, to every ounce of this powder put a dram [1/16 of an ounce] of
Oriental Bezar, reduce them all into very fine powder, and fierce them, and with Harts-
horn´s jelly with a little Saffron put therein, make it up into paʃt, and make therewith
Lozenges, or Trochifes for ' your uʃe. (18)
The Goa Stone is one of the last and most celebrated of these compounds that
flourished in the European medical literature until the end of the eighteenth century.
Grounded in rare and expensive ingredients of often unknown origin, its symbolic,
apotropaic and therapeutic properties were highly overstated.
The gems of the Goa Stone
The concept of a mineral as a chemically and physically uniform, natural constituent

of the solid earth crust, whose building blocks of rocks periodically arranged three-
dimensionally, was fully established at the beginning of the nineteenth century (19).
Minerals often come up with different names before that time, some of them
remaining obscure. Nevertheless, the gems of the Goa Stone have been identified,
and two main groups of minerals stand out: aluminium minerals, including corundum
like rubies and sapphires, and silicate minerals like emerald, topaz, hyacinth, garnet
and the Cananor stone.
Rubies, known as carbuncle in medieval lapidaries, had a significant symbolic and
medicinal meaning. In the Peterborough Lapidary, a late fifteenth-century treatise in
Middle English, the ruby, a red gem, was considered the lord of precious stones,
having virtues above all the other gems, helping people to get rid of sickness.
Beholding it would bring comfort to all distress, being a flood of paradise (20).

Rubies were used in cordials against poisons to absorb the humours, to strengthen
and rejoice the heart, restore weakness and to predict future diseases to those who
carrying them (21). Konrad von Megenberg (1309-1374), a German catholic scholar
who wrote the first German book on Nature (Das Buch der Natur), referred to
sapphire. The best sapphire came from India. It resembled the pure sky, and it was
the most effective to cure headaches, tongue palsy, poor sight. It was helpful against
unfaithfulness and fright; required chastity and brought peace of mind (22).
In the middle of the eighteenth century, this stone was credited for many virtues such
as fortifying the heart and other noble parts of the body and removing the poison
from pestilent carbuncle (or anthrax, skin ulcer caused by Bacillus anthracis) (23).
Figure 3 - Albarello from the royal monastery El Escorial, Spain, 1600-1625. Credit: Science Museum,
London. Figure 3a - 'Apothecary jar used for emerald fragments'. Credit: Wellcome Collection. Figure
3b - Earthenware jar for terra sigillata, Spain, 1601-1700. Credit: Science Museum, London. Figure 3c
-'Terra sigillata: seals Malta.'Credit: Wellcome Collection.
In 1800, the crystallographic analysis recognized the kinship between ruby and
sapphire. Ruby is a mineral corundum, aluminium oxide (Al 2O3). Sapphire is a variety
of corundum; its colour is due to the presence of iron and a small amount of titanium
(24).

It is difficult to assess the effectiveness of powdered rubies and sapphires taken

orally. Aluminium (Al), their main chemical component, stands as the most abundant
metal in the earth crust. Leading scientific consensus has not proved regular intake of
aluminium products as being harmful; instead, aluminium salts have been used to
improve the immune system’s response to vaccines (25).
Emerald, Beryllium aluminium silicate (Be3Al2Si6O18)), was credited as being
efficacious against poisonings, curing epilepsy, accelerating parturition, being
absorbent of acids and acrid humours, and also helpful against gastric pains,
intestinal colics and stopping haemorrhages (26). Topaz [Al2SiO4 (FOH)2] and
Hyacinths, a variety of zircon (zirconium silicate [ZrSiO4]), were credited as cordials,
absorbents, antacids, and useful against fever and melancholy (27).
Garnet [Orthosilicat X3Y2 (SiO4)3]. The X site is usually occupied by divalent cations
(Ca, Mg, Fe, Mn)2+ and the Y site by trivalent cations (Al, Fe, Cr)3. Garnet was
deemed as a cardiac tonic, calming palpitations, bringing a good mood and resisting
poison (28).
The Cananor Stone was a rare and costly stone. Engelbert Kaempfer (1651- 1716),
the German naturalist, physician and explorer, gave the following description:
The stone is so named from its source, the district of Cananoor in Malabar. The
Portuguese there call it Pedra frigue for its cooling effect. There are three kinds or
colours, to be sure: white, citrine, and dark blue, the last of which is very likely
nephritic stone in all respects but lightness (29).
The Cananor Stone was identified with the nephrite stone in the Pharmacopea
Tubalense. The best such stone came from Oriental Indy and was used as a diuretic in
renal colic and to help expelling calculus and urinary sand (30).
Nephrite, a variety of jade, calcium, magnesium and iron-rich amphibole,
Ca₂(Mg,Fe)₅Si₈O₂₂ (OH)₂, was known as the ‘Stone of Heaven’, highly valued by the
Chinese (31).
Earths
Terra sigillata is a thin, dry, friable earth, yellow or reddish and without flavour. It has
different names according to the place where it came from: Lemnian if it came from
the Turkish island of Lemnos; earth from Malta if it came from that island. St Paul’s
earth is the same earth of Malta, recording the stay of St Paul on the island after a
shipwreck. Samian earth came from the Greek island of Samos, and Chios earth from
Chios.
The earths were purified in water, moulded in troches and sealed according to their
origin, deemed as absorbent, astringent, good to treat intestinal colics,
haemorrhages, gonorrhoea, vaginal discharges, vomits, and also suitable against
poisons and pestilent fevers (32). Armenian earth is similar to terra sigillata (33).

The adsorbent clays used in Antiquity played a prominent role in toxicology, standing
as the precursors of activated charcoal (34). Silica is a natural compound from all
around the world in Nature, found in most rocks, clays and sands. When inhaled in its
crystalline form, it causes severe lung damage.
However, water-soluble forms found in plants such as horsetail, a herb traditionally
used to treat wounds, helps to strenghthen the connective tissue and improve the
renal function.
Wholegrains, green beans, rice, cucumber and tomatoes also contain water- soluble
silica. Although the role of silica in the human body is still not fully understood, it is
known to support bone formation, helping in the production of collagen, improving
the cardiac function and boosting the immune system (35).
Bezoar stones
Bezoar stones were certainly discovered by earlier hunter cultures and praised as
magic devices (36). Animal concretions were regarded with fear and awe in primitive
cultures, possibly because they penetrated the body without making a wound.
Bezoars were held in high esteem not only to counteract bites of poisonous animals,
but also to counteract the so-called poison of ‘malignant’ diseases, used to prevent
and cure the plague, smallpox, measles, and pestilences of all kinds (37).
According to Cyril Elgood:
The most famous of all and the most universal in its potency is surely the Bezoar-
stone, a native Persian stone, whose fame spread to Europe and whose very name is a
corruption of the Persian words bád-zuhr or antidote (38).
After the arrival of Vasco da Gama (1469- 1524) in India in 1498 and the Portuguese
taking over, bezoars were traded and studied by the Portuguese physicians Garcia de
Orta (1501-1568) and Amato Lusitano (1511-1568) (39).
Bezoars decorated with delicate Indo-Portuguese filigree or kept in silver and gold
containers are extant and evidence their high place of esteem in the past (40).
Chemically, the composition of bezoars is related to the animals from which they
originate, as well as to their diet.
In a study by Van Tassel, a Persian bezoar (from the Capra aegagrus), was composed
of calcium phosphate (whitlockite) (41).
A recent experiment of bezoars immersed in an arsenic-containing solution proved
that they were able to inactivate the poison: arsenate and arsenite, the two toxic
compounds of arsenic, being inactivated effectively, arsenate by phosphate, found in
the mineral brushite of the bezoar stones, arsenite by binding to Sulphur found in
degraded hair, a key component of bezoars (due to the ingestion of hair by the
animals licking themselves) (42).

Figure 4 - Bezoars from the Távora Sequeira Pinto Collection. (Oporto) From left to right: 4a-Oriental
bezoar from Ormuz mounted in Indo-Portuguese golden filigree pendant. 1580-1600. 2b-Oriental
bezoar mounted on a golden filigree stand, decorated with a coral branch on the top. 18 th century. 4c-
Oriental bezoar mounted on Indo-Portuguese golden filigree pendant in the form of a fruit. 17 th
century. Figure 4d- Spherical Oriental bezoar within a silver Indo-Portuguese filigree container. 17th
century (?). Figure 4e- Bezoar with silver mounts, probably German, 17th/18th century. Photo credits:
Pedro Lobo. Figure 4f- Oriental bezoar stone pendant, attached to a golden chain. 17 th century. Photo
credit: Chris Duffin.
Unicorns
Ctesias, the Cnidian, a physician and historian from the fifth century BC, introduced
the myth of unicorn in European medicine, art and literature (43). Aelius or Claudius
Aelianus (175 – c. 235 AD) summarized the belief in the existence of horned animals
in India:
India produces horses with one horn, they say, and some country fosters asses with a
single horn. And from these horns, they make drinking vessels, and if someone put
deadly poison in them and a man drinks, the plot will do him no harm. For it seems that
the horn both of the horse and the ass is an antidote to poison.2(44)
Aelian seems to describe the Indian rhinoceros. The belief in the alexipharmic virtue
of the rhinoceros horn, freeing from certain diseases and poisons those who drank
from beakers made out of it, is still current in the Orient (45). The myth of the unicorn
2 Translation by Scholfield 1958, 201 - Aelian, On Animals, Book III, Chapter 41.

flourished throughout the Middle Ages. Philippe de Thaon, the first known Anglo-
Norman poet from the 11th century, gives a full report of the unicorn associated with
Christianity:
Monoceros is an animal which has one horn on its head,

it is caught by means of a virgin, now hear in what manner.
When a man intends to hunt it and to take and ensnare it,
he goes to the forest where is its repair;
there he places a virgin, with her breast uncovered,
and by its smell the monoceros perceives it;
then it comes to the virgin, and kisses her breast,
falls asleep on her lap, and so comes to its death;
the man arrives immediately, and kills it in its sleep,
or takes it alive and does as he likes with it.
It signifies much, I will not omit to tell it you.
Monoceros is Greek, it means one horn in French:
a beast of such a description signifies Jesus Christ;
one God he is and shall be, and was and will continue so3(46).
Curiously enough, Thaon does not describe the Indian rhinoceros (Rhinoceros
unicornis), but the spiral twistings of a marine mammal corresponding to the teeth of
the whale from the North Sea Monodon Monoceros. In 1638, the Danish zoologist and
antiquarian Ole Worm (1588-1654) wrote a dissertation on the narwhal tusk, showing
the skull of the whale with the tusk. He concluded that all unicorns from Europe were
whale tusks and that the unicorn, the mythical animal, did not exist (47).
In the Pharmacopeia Tubalense, Coelho refers to the ancient myth of the unicorn, the
real unicorn, kept in the treasures of kings and nobles, its white horn looking like
ivory. The unicorn continued to be regarded as the most potent poison antidote, also
of great help in severe diseases like smallpox, plague, measles, epilepsy, and as a
blood purifier (48).
Narwhal and elephant tusks are mainly composed of ivory, a white and hard
substance consisting mainly of dentine, the primary component of teeth and tusks of
mammals, regardless of the origin of the species (mammoth, walrus, narwhal and
elephant).
Tusks are composed of inorganic substances such as calcium and phosphates (Ca 10
(PO4)6(CO3) H2O)(49). The main component of the horns of animals including the
Indian rhinoceros (Rhinoceros unicornis) is keratin, a protein, also the main
component of human and animal hair. Cups made of Indian rhinoceros horns were
worked in beautiful Indo-Portuguese jewelry.
3 Translation by Wright 1841, 81 – Philippe de Thaon, vv; 198-210.

Figure 5 - Narwhal tusk of an Arctic cetaceous (Monodon monoceros), 16th/17th century, European
silver mounts. 5a- Carved rhino cup. China, Goan filigree holder with vegetal decoration, late 16 th
century. 5b- Elephant tusk. Probably from Sierra Leone or Congo, 16th century. 5c- Fossil shark tooth
from a Dutch Kunstkammer. 17th century. Távora Sequeira Pinto Collection (OOporto) Photo credits:
Pedro Lobo.
From the biochemical point of view, animal tusks and horns are, like bezoars, rich in
phosphates and keratin of proven effect in inactivating arsenic (and possibly other
poisons).
Ivory scrapings
Ivory tusks from the African elephant (Elephas (Loxodonta) africanus A.) front
growing teeth were most prized in decorative arts. Ivory scrapings were employed in
medicine, in the treatment of intestinal colics, diarrhoea, epigastric pain, jaundice,
intestinal worms, epilepsy, melancholy, fevers and other conditions (50).
Saint Paul’s tongues
These tongues are fossils, glossopetra, petrified teeth from gigantic sharks,
Carcharodon megalodon, which once ruled the Tertiary seas. The best were found on
he island of Malta, and were used as amulets and credited as antidotes because they

were believed to originate in a mythic poisonous dragon (51). Like the earth of Malta,
St Paul’s tongues owe their name to the alluded stay of St Paul in the island of Malta.
Despite being fossils, they are possibly organically similar to narwhal and elephant
tusks.
Seed pearl
Pearls, organic concretions originating in marine bivalve mollusks of the family of

Unionidae and Margaritiferidae, are composed of aragonite (calcium carbonate) and
conchiolin, a protein, being perfected by Nature. They are amongst the most
celebrated gems. However, they are no minerals (52). The best pearls were said to
come from the East, where they were surrounded by legends and myths (53).
Oriental seed pearls were deemed as cordials, useful against poison, and efficacious
to restore strength and purify the blood. They would fight all acids better than any
other alkaline substance, and alleviate haemorrhages, diarrhoea and similar
gastrointestinal complaints (54).
Figure 6 - Encysted pearl in the shell from a Dutch ‘kunstkamer’ 17th century and 6a-Red coral branch
from a German ‘Kunstkammer’, 17 th century. Távora Sequeira Pinto Collection (OOporto). Photo
credit: Pedro Lobo. 6b- Crabs eyes, 2 pendants, one consisting of a group of three.'
Credit: Wellcome Collection.

Coral
Corals, skeletons secreted by small marine cnidarian animals, known as polyps, were
supposed to be a sea plant turned to stone hardened by the air. They were esteemed
as powerful amulets bringing heath to its wearers and averting the harmful results of
misfortune (55). Coelho recommended red coral to bring comfort and joy to the heart
because of its red colour, to purify the blood, to act as an antacid, being useful in the
treatment of dysentery, diarrhoea, helping in haemorrhoids and vaginal
haemorrhages because of its alkaline properties (56).
Calcium carbonate (CaCO3) is a common substance found in rocks such as the
minerals calcite, aragonite, limestone and calcite. It is currently used in medicine
mainly as antacid and as a source of calcium which plays a crucial role in the body,
being necessary for normal functioning of nerves, cells, muscles and bones (57). The
role played by calcium in the human organism provides insights into some medical
indications of substances mainly composed by calcium carbonate (58).
Crab’s eyes
Consisting of calcareous concretions, found in the stomach of the river Crawfish,

Astacus fluviatilis, crab’s eyes were very valued medicines. Calcium carbonate
(CaCO3) is their main chemical compound. They were absorbent of the acids,
employed in cordials, and in the treatment of gastric pain, urological pain provoked by
the obstructive kidney and bladder stones and locally applied in wounds, bruises and
haemorrhages (59).
Deerhorn tips and spodium
The ancients used to burn animal bones (spodium) and deer horn tips which turned it
into a white powder, rich in calcium, that they added to cordials and believed to be
effective against fevers, epilepsy paralysis and convulsions (60).
Musk
This valuable substance secreted by the male musk deer for scent marking is strong-
smelling reddish-brown, used in medicine and perfumery since ancient times. It
figures in Hippocratic gynaecological recipes and is a frequent ingredient of cordials. A
prominent constituent of its intense odour is the hydrocynamic acid. It is also rich in
salicylic acid and salicylaldehyde (the basic ingredients of aspirin), which the beaver
gets from its natural diet of willows. Its constituents are mainly amounts of benzoic
acid, benzyl alcohol, borneol, catechol and various phenols, giving castor a decidedly
acidic and ‘cleaning nature’ (61).

Ambergris
Ambergris is a rare product that occurs in around 1 per cent of sperm whales,
provoked by the fatal intestinal rupture due to curved like parrot squid beaks,
ingested by the sperm whale, passing from the stomach chafing and irritating the
intestinal lining. A growing mass is formed becoming a concretion that is expelled
floating on the sea until it comes ashore (62).
Coelho discusses the origin of ambergris, unknown at his time, describing white, grey
and black amber, ambergris being the best for medicine, as a fortifier for the brain
and heart, acting as anti-depressive. It was effective against melancholia, very useful
against poisons, and most helpful against pestilence and also an excellent
aphrodisiac. It should not be prescribed to women since it provokes hysteria (63).
Ambrein, a major constituent of ambergris, has proved to act as a male sexual
stimulant in rats by producing recurrent episodes of penile erection (64).
Amber
Amber, the Baltic fossil resin from Sciadopityaceae, was identified in the early
nineteenth century as a product of pine-like prehistoric trees, dated to the Tertiary
Period (65).
This fragrant and mysterious essence from the Baltic Sea has been regarded as an
amulet against evil external forces and as a medicine to facilitate fertility, cure fever,
and drive off evil spirits, among other indications. Amber acid (butanedioic acid,
ethane -1, 2- diccarboxilic acid), HOOC - CH₂ - CH₂ - COOH, participates in the
process of cell respiration and in the Krebs cycle.
This substance, known as ‘succinate’, a synonym of ‘amber acid’, strictly speaking
means the anion of succinic acid, and has stimulating properties as a bronchial
antispasmodic; it boosts biochemical and physiological reconstructive processes in
different organs, as recent studies have proven (66).
Camphor
Camphor is of widespread use in medicine. Cinnamomum camphora (L.) is a plant of

the Lauraceae family of Asiatic origin. Its oil, containing camphor and safrole, borneol,
heliotropin, vanillin and terpineol, as well as sesquiterpene alcohols, is used in the
preparation of expensive perfumes.
It is used in medicine due its mild antiseptic properties and mainly indicated in
respiratory conditions, also used for muscular strains and rheumatic conditions. In
small doses, it stimulates respiration, being employed against asthma, bronchitis,
emphysema, lung congestion, rhinitis, and also an analeptic in cardiac depression
(67).

Figure 7 - Albarello for Mesue's French Musked Lozenges of Aloeswood from Sicily, Italy.
Credit: Science Museum, London. 7a- Piece of grey amber, belonging to the Vigani Cabinet of Queens’s
College, University of Cambridge, early 18th century (compartment E17). Image reproduced with kind
permission of the President and Members of Queens' College. 7b- Baltic amber. Author’s collection.
The end of myths
When Gaspar Antonio created the Goa Stone, severe criticism on the medicinal
properties of precious stones had already been arising. The Irish natural philosopher,
chemist and inventor, Robert Boyle (1627-1691), known as the Father of Chemistry,
dismissed the therapeutic value of gems:
For my part, I never saw any great feats performed by those hard and costly Stones,
(as Diamonds, Rubies, Sapphires) that want to be worn in rings (68).
A similar dissatisfaction arises when we go through the ingredients of the Goa Stone.
When reading its indications in the work of Rumphius, a long repetition of the same
medicines with similar effects and some variations seems to emerge.
Some groups of different and costly ingredients currently prove to belong to the same
chemical substance, as summarized in Table 2.

Ruby Aluminium minerals

Sapphire
Emerald Silicat minerals
Topaz
Hyacinth
Granat
Cananor
Stone
(Nephrite)
Earths (Terra
Sigillata,
Malta Earth,
White St
Paul’s Earth)
Bezoar Calcium
stones Phosphates
Narwalh And Keratin
teeth, Ivory
scrapings,
Unicorn
scrapings,
Rhino horns
St Paul’s
tongues
(Glossopetra)
Deerhorn tips
Spodium
Seed pearls Calcium carbonate
Coral
Crabs eyes
Musk Benzoic acid, benzyl alcohol, borneol, catechol and
various phenols
Amber Amber acid
Ambergris Ambrein
Camphor Camphor and safrole, borneol, heliotropin, vanillin and
terpineol, and sesquiterpene alcohols
In the mid-17th century, William Heberden (1710-1801) one of the most reputed
doctors of the time, wrote Heberden completely ridiculed and disallowed the theriacs
and mithridatics that, like bezoars, were considered as alexipharmacs and all cure
diseases (69).
The English physician and chemist Frederick Slare (1647?-1727) carried out
experiments to test the efficacy of bezoar stones, the result being unsatisfying:
From the experiments we «My infer, that Bezoar ought not to be truʃted to, as an Alkali
to correct poiʃonous or other corrosive Salts or Humours, notwithstanding the great
Encomium given to it. (70)
As time went by, bezoars lost their credit. In the 19th century, they were no longer

decorated (71). Despite the reputation and prestige of the Goa Stone, wrapped in
gold foil and carefully kept in beautiful containers of Indo-Portuguese gold and silver
filigree, its therapeutic efficacy was also increasingly dismissed.
In a recent survey of the Goa Stone, very popular and esteemed in Great Britain at
the end of the 17th century, the British geologist and pharmaceutical historian
Christopher J. Duffin gives full account of the disbelief in the efficacy of the Goa Stone
in the treatment of severe conditions, being sometimes associated with the
Gascoigne’s powder or other alexipharmic compounds.
Controversy also came up because the secrecy of recipes was also being challenged
and doctors realized that they had been prescribing medicines of unknown
composition.
Figure 8, 8a - Mithridaticum and Theriac porcelain jars. 18th century. 8b-Bezoar stone with decorated
oval gold filigree container, 17th century 8c- Two bezoars. Open bezoar with slice removed and German
trichobezoar, 19th century. Courtesy of the Health and Pharmacy Museum, Lisbon.
The disbelief in the Goa Stones followed closely the decline of the belief in the
miraculous properties of the bezoars and other mythicized substances such as the
unicorn (72). Laterly, R. van Tassel studied the composition of bezoars from the
Collection of Henri van Heurck. Seven incomplete egg-shaped objects were Goa
Stones, the smooth outer surface coated with gold foil. The X-ray diffraction proved
that the coating was gold. The artificial nature of the specimen was apparent due to
the absence of any scaly or radiating structure.

The inner material looked homogeneous, granular and porous, and had a grey sandy,
white or light brown colour. It reacted strongly with effervescence in contact with
diluted acid. The X-ray diffraction powder data indicated calcite in addition to plenty
of quartz (73). Some bezoars of this collection are calcite concretions and calcite
‘Pebbles’ (74).
Figure 9 - Spherical Goa Stone with silver Indo-Portuguese filigree container, cup with stand and cover
decorated with arabesques. Late 17th century. Courtesy of the Lisbon Health and Pharmacy Museum.
9a - Oval Goa Stone, Europe, 1601-1800. Credit: Science Museum, London. 9b - Goa Stone and gold
and silver container. Indo-Portuguese filigree, end of the 17 th century. Távora Sequeira Pinto Collection
(OOporto). Credit: Pedro Lobo. 9c- Goa Stone and container of gold with cast legs and finials, late
17th- early 18th century. Metropolitan Museum of Art New York.
Conclusion
The Goa Stone shared the splendour of bezoars, unicorns and gems as the most
expensive medicines, endowed with mythical and magic powers of cure. It was
created in the mid-seventeenth century when Lisbon was still the centre of knowledge
of the Eastern lands; it took one hundred and a half years before the ancient
medicinal use of rarities came definitively to an end by the late 18th century, lasting
as the most remarkable pharmacological achievement of the Portuguese Jesuits.
Insights of modern chemistry shed some light on possible therapeutic effects of each
compound. When the compounds were put together, one does not know how they
would react. Some main groups of substances: aluminium, silicate minerals, calcium

carbonate and amber acid are essential to the human organism. However, high doses
of aluminium, silica and calcium carbonate are toxic. So far, no thorough studies have
been carried out on this issue. The only recent study on the composition of the Goa
Stones just showed gold (used to cover the costliest specimens), calcite and calcite
and quartz pebbles. From the only extent study, only calcium (from calcite) and
quartz (SiO2) (from the silica minerals employed) prevailed.
Acknowledgements
I would like to acknowledge Dr Álvaro Sequeira Pinto for the kind permission to
reproduce the images of the Távora Sequeira Pinto Collection, Dr João Neto, Director
of the Lisbon Health and Pharmacy Museum for the permission to reproduce the
images of the Bezoars and Goa Stone, and Professor João Martins e Silva for the
critical reading of the manuscript.
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ASPARAGUS THE DIURETIC, A RENAL AMBASSADOR FROM GREECE
TO IBERIA
Athanasios Diamandopoulos1
Abstract
Wild Asparagus is a green vegetable found in abundance in many parts of the world and
thriving in shadowy places. As the scope of this article is the immigration of the asparagus’
culture from the Eastern to the Western shores of the Mediterranean Sea and its perimeter,
we will just slightly touch its history in other places. Its first reported use comes from ancient
Egyptian sources, but the oldest trace of its use in Europe comes from the Minoan period in
Crete. Later, in the 3rd century AD, Atheneus in the Deipnosophistae refers to the plant’s
presence in Iberia. With the fall of the Roman Empire, it fell into disuse and was preserved
only in Monastic Gardens in Central Europe, although it was highly recommended as food and
medicament in the Eastern Roman Empire (Byzantium), till this fell to the Ottomans in the
15th century. However, it was gathered by peasants in 13th century Andalusia in Spain along
with other edible plants. Even now, it is a very popular delicacy both in Spain and in
Portugal's Alentejo Region. As a medicinal plant, it was first reported as Black Bryony by
Dioscurides in the 1st century AD, who noticed its diuretic action, and later by Pliny and Paulus
Aegineta. The notion persisted for centuries in the Greek iatrosophia. Wild asparagus
(Asparagus acutifolius) was reported by Riviera as a diuretic from Castilla-La Mancha in Spain
and similarly, in Granada. Asparagus racemosus showed diuretic activity at a 3200 mg/kg
dose- equal to 25mgr/kg BW of furosemide. From Europe, the use of Wild Asparagus passed
to the East, where it was used by the Chinese and Indian Medicine for centuries to treat
kidney disorders. Recently, Indian researchers proved its antiurolithiatic activity. A disturbing
side effect is the unpleasant scent of the eaters’ urine due to asparagusic acid. This article
discusses its historical and current use both as a culinary and as a healing agent.
Keywords
Asparagus; Dioscorides; Diuretic action; edible plant
Résumé
L’asperge est un légume vert, que l’on trouve en abondance dans nombre de pays du monde
entier, et qui croît dans des emplacements ombragés.
1 Nephrologist, Honorary Professor of the University of Athens, Past President of the International
Society for the History of Medicine, Vice-President of the Louros’ Foundation for History of Medicine,
Vice-President of the Pan-Hellenic Society for the Dissemination of the Hippocratic Spirit. Contact:
1453295@gmail.com

Comme cette étude se focalise sur la migration de la culture de l’asperge des côtes orientales
de la mer Méditerranée à son contour occidental et son périmètre, nous n’aborderons que
rapidement son histoire dans d’autres contrées. Son premier usage est rapporté dans des
sources de l’Egypte Ancienne; en Europe l’asperge est utilisée dès la période Minoenne en
Crète. Plus tard, au cours du IIIe siècle après J.C., Atheneus dans ses Deipnosophistae
mentionne la présence de cette plante en Ibérie. Vers la fin de l’Empire Romain, la plante
tombe en désuétude et n’est conservée que dans des jardins monastiques de l’Europe
Centrale, quoiqu’elle reste recommandée tant comme comestible que comme médicament
dans l’Empire Romain de l’Est (Byzance) jusqu’à ce que celui-ci soit conquis par les Ottomans
au XVe siècle. Cependant, elle restait cultivée au XIIIe siècle par les paysans andalous en
Espagne, avec d’autres plantes comestibles. De nos jours encore l’asperge reste une
délicatesse populaire en Espagne et dans la région de l’Alentejo au Portugal. Comme plante
médicinale, elle est nommée ‘Tamier Commun’ au Ier siècle après J.C. par Dioscoride, qui
avait déjà noté son action diurétique, ainsi que Pline et Paul d’Egine après lui. Cette notion a
persisté pendant des siècles dans l’iatrosophie Grecque. L’asperge sauvage (Asparagus
acutifolius) a été rapportée par Riviera comme diurétique dans la région de Castille-La
Mancha, et de la même façon à Grenade. L’ asparagus racemosus a montré une action
diurétique à une dose de 3200 mg/kg, égale à 25 mg/kg (de poids corporel) de furosémide.
De l’Europe, l’usage de l’asperge sauvage est passé en Orient, où elle a été utilisée par les
Chinois et en Inde pendant des siècles pour traiter les affections rénales. Récemment des
chercheurs en Inde ont prouvé son action anti-urolithiatique. Une réaction secondaire
désagréable est la mauvaise odeur de l’urine du consommateur, causée par l’acide
asparagusique. Cet article décrit l’usage historique et actuel de l’asperge comme comestible
et comme produit guérisseur.
Mots-clés
Asperge; Dioscoride; action diurétique; plante comestible
Introduction
This article discusses the history and current use of asparagus both as a culinary and
medical plant. Limiting the research to Europe, there is a notion that in prehistoric
times Minoan Greeks were eating asparagus in between other vegetables (1). A more
solid reference occurs in the myths about Theseus. Theseus killed Sinis, the Pine
Bender and Perigone; his daughter was hiding terrified in a forest of Asparagus (2).
Later, in the 3rd century AD, Athenaeus in the Deipnosophistae refers to the presence
of the plant in Iberia: “Polybius the Megalopolitas, speaking of the great happiness
which exists in Lusitania (and that is a district of Iberia, which the Romans now call
Hispania) where there are asparagus […]” (3).

Figure 1 - The wild asparagus’ established (r) cand young (l) shoots.
Figure 2 - Sinis, the Pine Bender’s daughter, hiding terrified in a forest of Asparagus. Images in Public
domain.
The price of the plant was excessive. In the Late Roman era, a Large Asparagus was
sold for 6d apiece, while the Ravenna Asparagus weighted 4 ounces a piece (4). The
love for this delicious food inspired works of art, like a mural from the Isis Temple, in
Pompeii circa 79 AD, now in the Archeological Museum, Naples.
The theme was copied innumerable times, and an example is an Antique Santana
ceramic tile depicting an Asparagus bunch from Lisbon, Portugal. With the fall of the
Roman Empire, it fell into disuse and was preserved only in Monastic Gardens in
Central Europe. Some sources claim that the Arabs learned to cultivate asparagus,
and brought it to Spain early in their conquest of Iberia.
That they did so ensured the science of cultivating asparagus, since the collapse of
the Roman Empire more or less doomed the practice in Europe. However, it was
gathered by peasants in the 13th century Andalusia in Spain along with other edible
plants, as referred by Spanish writers eight years ago (5,6).

Figure 3 - A mural from the Isis Temple, in Pompeii circa 79 AD, depicting a bunch of Aparagus.
Figure 4 - An Antique Santana ceramic tile depicting an Asparagus bunch from Lisbon, Portugal.
Images in public domain.
The same author elaborated on the mixed use of asparagus as a food and as a
medicinal, a permanent characteristic of many medicinal plants. Hence, later in this
article, we will discuss both uses, as people in the past – and even now – gather and
store the plant either to eat it fresh or as a therapeutic agent. There is a particular
notice of its alimentary and therapeutic use from the other Iberian country, Portugal,
where asparagus was thriving as reported in a 19th-century book (7). Even the place
where it mainly grows there, Corruda, is both an area and the Latin name for
Asparagus, while another centre for it is in Portugal's Alentejo Region. We will focus
firstly on the history of its effects on the kidneys and later on its alimentary one.
Asparagus’s renal effects
Asparagus contains saponins, and the active compound of it is Asparagine (8), which
had been isolated from asparagus juice for the first time in 1806 (9).
Figure 5 - (S)-Asparagine (left) and (R)-asparagine (right) in zwitterionic form at neutral pH.

As a medicinal plant, it was first reported as Black Bryony by Dioscorides (10) who
noticed its diuretic action and later elaborated on it. Galen, in the “Food and Diet”,
refuses to discuss on the spelling of the vegetable with a p or a ph as in the Attic
dialect; still, he described it in Alim Facult 6.641.4 as "heating, cleansing, and
desiccative. It relieves inflammation of the stomach, relaxes the bowels, makes urine,
and helps the weak. It removes obstruction of the liver and kidneys."
Other Ancient Greek and Latin authors, dealing with asparagus, include Hippocrates
R.5, who in the 5th century BC used asparagus to treat diarrhea and pains of the
urethra, describing it in the Regiment as dry and astringent; also Theophrastus in
Historia Plantarum 6.41- 2, Cato the Elder in De Agricultura 161, Pliny in Naturalis
Historia 19,145, Lucian Veris Historiis 1.16, Palladius Opus agriculturae 3, 24. But it
was the Byzantine Paulus Aegineta in the 7th century who accumulated the previous
knowledge when he wrote: “Asparagus, the Rock Asparagus or Myanthinus, is
detergent […] it is de-obstruent for the kidneys and liver, especially its roots and
seed” (11). Further on, he describes a kind of cocktail with asparagus and vinegar,
the Lithotriptic Posca (12). Interestingly, several modern asparagus cocktails which
are actually now à la mode are advertised for their refreshing and health-preserving
properties.
Simeon Seth (c-1035- c.1110), a Jewish Byzantine doctor, scholar, and grand
Chamberlain (protovestiarius) under Emperor Michael VII Doukas, revised Psellos'
ύνταγμα κατὰ στοιχείων περὶ τροφῶν δυνάμεων "On the Properties of Foods" (13)
which was devoted the Emperor Constantinos IX Monomachos with his work (14).
This work criticised Galen and emphasised eastern medical traditions and was
devoted to the next Emperor Michael VII Doukas. Seth held asparagus in great
esteem, saying that ‘[…] asparagus is a diuretic, removing obstructions from the liver
and kidneys, proof of which he says is the change in the odour of one's urine, […]’. He
goes on to say that it is good for settling intestinal colic and nephritis, kidney
problems to which people with a phlegmatic (cold and damp) constitution are prone
to. He also repeats Apicius’s advice (see further on in this article) that they are good
to eat with garum, a fish sauce.
This notion persisted for centuries in the Greek iatrosophia, i.e. semi-scientific books
on folk medicine. We indicatively refer to the 17th-century Geoponicon by the Monk
Agapios from Crete and several recipes from Cypriot Monasteries as presented by
Andreas Lardos in 2013 (15,16).
Returning to the cross-cultural importance of asparagus Lardos cites Rivera’s
statement that the plant was later transferred to Spain and was reportedly used as a
diuretic in Castilla-la-Mancha (17).
The Spaniards paid back their debt by sending early in their conquest of Mexico
asparagus sprouts for early planting with poor success (18). However, later, it
became fashionable both as a delicacy aspiring to the renowned Iberian varieties and
also as a medicament. We quote from the Journal of the Medical Association:

‘I have used a tincture of asparagus as a diuretic for sixteen or seventeen years, with
increasing confidence in its usefulness and efficacy […]. I use the following formula:
Take of dried tops of asparagus, five ounces; proof spirit, two pints. Take of fresh tops of
asparagus five pounds. Bruise and press out the juice; evaporate at a low temperature
till reduced to one pint, and strain. Lastly, add a pint of rectified spirit […]. The fallacy
and uselessness of such deductions is sufficiently apparent; upon generalisations so
vague, we might have discarded numerous of our best remedies as deleterious,
innocuous, or useless. […] Suffice it to say that, after some sixteen years’ experience, I
have found the tincture of asparagus a useful adjunct to our diuretic remedies. I have
found it most useful in promoting the diuretic properties of other drugs, as I conceive,
by directing them at once to the kidneys. I have repeatedly in my own practice, as also
in consultation, simply added from half a drachm to two drachms of tincture of
asparagus to each dose of an unsuccessful diuretic, and found that copious diuresis was
the result.’(19).
More recent studies demonstrate the validity of the old American Doctor’s statement.
We read that Asparagus roots have been used traditionally to support kidney function
and are listed in the Complete German Commission E Monographs for treatment of
urinary tract inflammation and kidney stones (20). The results demonstrate that
Asparagus-P was able to stimulate the metabolism of both kidney cell lines in a dose-
dependent manner (21). Moreover, Asparagus-P inhibited the metabolism of
inflammation-mediating cells (differentiated human promyelocytes). From Europe, the
use of Wild Asparagus also passed to the East, where it was used by the Chinese and
Indian Medicine for centuries to treat kidney disorders (22).
Recently, Indian researchers proved its diuretic activity equal to 25 mg/BW of
furosemide and its lack of toxicity (23). From the same subcontinent comes another
paper documenting the Asparagus’ lithotripsic powers. By microscopic examination
using polarised light of urolithiatic kidney sections, the authors showed intratubular
and interstitial crystal deposits in Group II rats. However, rats treated with ethanolic
extract of A. racemosus had far less kidney calcification (24).
Research on effects of asparagus on health is not limited only on renal issues (25).
Only 7 months ago, there was an article published in Nature implying some adverse
effects of asparagine on breast malignant metastases (26). Although the conclusions
were tenuis, they are counteracted by another article claiming a beneficial effect
against cancer on the asparagus eaters (27).
As usually, in medicine, you can prove what you like. A disturbing side effect is the
unpleasant scent of the eater´s urine and bowel gas, due to asparagusic acid. Even
Benjamin Franklin took note, stating in a 1789 draft for a letter to the Royal Academy
of Brussels that:
A few Stems of Asparagus eaten, shall give our Urine a disagreeable Odour” (he was
trying to convince the academy “To discover some Drug wholesome & not
disagreeable, to be mix’d with our common Food, or Sauces, that shall render the

natural Discharges of Wind from our Bodies, not only inoffensive, but agreeable as
Perfumes (28).
A goal that, alas, modern science has still not achieved! However, some people do not
smell anything different when urinating after they eat asparagus. Scientists have long
been divided into two camps in explaining this issue. Some believe that, for
physiological reasons, these people (which constitute anywhere from 20 to 40 per
cent of the population) do not produce the aroma in their urine when they digest
asparagus, while others think that they produce the exact same scent, but somehow
lack the ability to smell it. The most recent study, from 2010, found that differences
existed between individuals in both the production and detection of the scent (29).
In Swann’s Way, French novelist Marcel Proust penned something of a breathless love
letter to asparagus, offering the following reflection as he ponders a decked-out
dinner table:
What fascinated me would be the asparagus, tinged with ultramarine and rosy pink
which ran from their heads, finely stippled in mauve and azure, through a series of
imperceptible changes to their white feet, still stained a little by the soil of their
garden-bed: a rainbow loveliness that was not of this world. I felt that these celestial
hues indicated the presence of exquisite creatures who had been pleased to assume
vegetable form, who, through the disguise which covered their firm and edible flesh,
allowed me to discern in this radiance of earliest dawn, these hinted rainbows, these
blue evening shades, that precious quality which I should recognize again when, all
night long after a dinner at which I had partaken of them, they played (lyrical and
coarse in their jesting as the fairies in Shakespeare’s Dream) at transforming my
humble chamber into a bower of aromatic perfume. (30).
Apparently, he belonged to the other half of the population! Furthermore, by this

Proust’s letter, we reach the second part of this article that is Asparagus as Food.
Asparagus as Food
As it was stated earlier, people used to gather it along with many other herbs and
plants, both for eating and for curing. In the 1st century Apicius’ Book with Cooking
recipes we read, between others instructions, how to boil asparagus and also how to
make a “patina” with it, that is a kind of vegetable omelette (31).
We have seen the same ingredient to be repeated in Seth’s 9 th cent «On the
properties of foods» (32). Departing from the Imperial Rome’s elite cookery books we
read that in the 13th century poor peasants at Guadalquivir Valley (Spain) were
gathering at the huge free common lands various plants and herbs for food and
medicinal use, asparagi being between them (33). Thus, asparagus descanted as food
and medicament the social scale and was consumed by the hoi polloi.

Later this was reversed, and the lands were given as feudal estates to landlords and
asparagi became again not approachable to the peasants. On illustration 6 we see the
imaginary scene of peasants and/or courtiers gathering asparagus. It comes from the
Tacuinum Sanitatis 14th century medieval handbook of health, and it was based on
the Taqwīm as-siḥḥah ‫"( ةحصال ميوقت‬Maintenance of Health"), an eleventh-century Arab
medical treatise by Ibn Butlan of Bagdad. Four handsomely illustrated complete late
14th-century manuscripts of the Tacuinum survive in Vienna, Paris, Liège, and Rome.
In 2008, the first and only facsimile of the Tacuinum Sanitatis kept at the
Bibliothèque Nationale de France accompanied by a commentary volume by
Touwaide, König and García- C.M. was published (34). The text exists in several
variant Latin versions, the manuscripts of which are characteristically so profusely
illustrated that one student called the Tacuinum "a [300] picture book," only
"nominally a medical text" (35). All were produced in Lombardy initially for the court
of Visconti Count of Pavia and were not precisely herbals but rather the equivalent of
the modern “coffee-table” books aimed at a cultured lay audience to browse on (36).
Figure 6 - 14th century. Medieval book of health. MS nov. acq. Lat 1673, fol- 26, recto, Ca 138-
1390 depicting a couple uprooting asparagi. (Credit: Wiki Commons ).

In the next illustration 7 we see two “still life” 17th/18th cent paintings of foods with a
diuretic action in luxurious settings, amongst them asparagus.
Figure 7. I - Still life with Asparagus, Artichokes, Lemons and Cherries, 1602-14 by Blas de Ledesma.
Photograph: The Bowes Museum.
Figure 7. II -Nicholas-Henry Jeaurat de Beltry, Still Life of Asparagus, 18th century, oil on canvas.
Images in public domain.
Also, exquisite porcelain and silverware made in purpose for the serving of asparagi.
Figure 8. Images in public domain.

With the utilitarian modern society, all these vanity trimmings disappeared. Asparagus
is not collected any more by people dressed in court attire. Cultivation in an industrial
scale makes asparagus affordable to the many who could just go to a good restaurant,
or just visit the street market. The buying of asparagus in the streets is so much in the
popular culture that in Germany, the great consumer of it, a bronze statue was erected
depicting the Asparagus Wife selling a bunch of Asparagus to a girl.
Figure 9 - Schwetzinger Spargelfrau (The asparagus wife) statue at the homonymous German town,
where the famous “Asparagus Festival” takes place each Spring. Images in public domain.
This current availability of the food/diuretic asparagus recalls exactly what was meant
in the Pseudo-Galen, De remediis parabilibus, i.e. Remedies Easily Obtainable (37).
Approaching the end of this article, we may follow the steps of the famous French
botanist of the 17th century Joseph Pitton de Tournefort. Let us remember from his
meteoric carrier that he had visited Barcelona in 1681, had published a three volumes
botanical book, classifying 8846 plants, and visited Spain and Portugal, Greece, the
Archipelagos, Constantinople and Asia Minor.

There is a drawing in Tournefort’s botanical depicting asparagus (38).
Figure 10 - Asparagus, Creticus fruticosus, crassioribus et brevioribus acuteis, magno fructu Coroll Inst
Rei Herb 21 – de Tournefort Joseph Pitton. (Credit: Wiki Commons).

Conclusion
We conclude that Asparagus, as a characteristic culinary and healing ambassador

from the Eastern to Western shores of the Mediterranean Sea, represents a fluid
transnational exchange of knowledge, which is verified by current scientific research.
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ORIGINS AND EVOLUTION OF SURGICAL INSTRUMENTS IN THE

COLLECTION AND RELATED DOCUMENTATION CONTAINED IN
FMUP'S MUSEUM OF MEDICAL HISTORY
Amélia Ricon Ferraz1
Abstract
The history of surgical instruments has called the attention of researchers from a wide variety
of fields, but particularly of medical historians. It is a universal history of trial and error, as
well as successes, representing not only the history of Mankind itself but the scientific,
technical, technological and social transformations undergone throughout time. It is also an
unfinished history of an unpredictable outcome, as human needs and determination lead to a
constant search for adequate solutions to current problems. The collection and related
documentation found in the General Library and the "Maximiano Lemos" Museum of the
History of Medicine of the Medical School of the University of Oporto (FMUP) enables following
the history of surgical instruments by foregrounding the importance of medical documents
and artefacts. This article pays tribute to the museum's most prominent figures and to those
who have contributed to the safeguard, research and dissemination of the medical collection,
presenting this national heritage of great relevance to the medical field and the History of
Medicine.
Keywords
Medical museum; surgical instruments; medical collection; education
Résumé
L’histoire de l’instrumentation chirurgicale a inspiré pendant des siècles l’intérêt de divers

chercheurs, actifs dans de nombreux domaines, mais particulièrement des historiens de la
médecine.
C’est une histoire universelle avec des hauts et des bas, ainsi qu’avec des succès,
représentant ainsi non seulement l’histoire de l’humanité, mais aussi les transformations
scientifiques, techniques, technologiques et sociales durant des siècles.
1 PhD Director of the "Maximiano Lemos" Museum of the History of Medicine. Member of MEDCIDS –
Community Medicine, Health Information and Decision Making (FMUP). Member of CITCEM –
Transdisciplinary Research Centre «Cultura, Espaço e Memória» (FLUP). Portuguese Delegate to the
International Society for the History of Medicine. Contact: museuhm@med.up.pt

C’est également une histoire inachevée, parsemée de résultats imprévisibles, étant donné
que les besoins et la détermination humaine conduisent à une recherche continue de
solutions appropriées aux problèmes actuels. La collection et sa documentation associée, que
l’on trouve dans le Musée d’Histoire de la Médecine à la Faculté de médecine de l’Université
de Porto, permet d’étudier l’évolution de cette instrumentation chirurgicale à travers des
documents médicaux et des objets. Cet article rend hommage aux figures représentatives du
musée et aux personnages qui ont contribué à la préservation, à l'étude et la diffusion de
cette collection médicale, ainsi qu’à cet héritage national d’une importance particulière pour la
médecine et la pratique médicale actuelles.
Mots-clés
Musée de médecine; instruments chirurgicaux; collection médicale; education médicale
Introduction
The "Maximiano Lemos" Museum of Medical History of the University of Oporto

Medical Faculty (FMUP) was created on 16 October 1933 by the School Board,
following the initiative of Prof. Luís de Pina (1901-1972), PhD graduate on History of
Medicine who became the museum's first director. Maximiano Lemos had been the
first professor to hold the chair of History of Medicine [in the University].
All the artefacts, either on display or stored, are closely related to the History of
Medicine.
The museum contains a wide variety of collections, belonging to different fields and
domains, such as art, furniture design, clothing and jewellery. However, it is
particularly relevant due to the diversity and historical value of its diagnostic and
surgical instruments and devices. It also comprises a specialised library with a
comprehensive collection of monographs and journals dealing with the History of
Surgery, surgical instruments and their manufacturers, providing an inexhaustible
source of knowledge guiding us through our journey around this topic.
The museum is also part of the University facilities, where, in addition to research,
graduate and post-graduate teaching of the History of Medicine is held, several
activities taking place for the dissemination of the History of Medicine and studies on
medical museums.
Thus, using our documental archive and collection, we aim at highlighting the origin
and development of surgical instruments, provide information about this important
scientific heritage and pay tribute to all those who have contributed to its
preservation and dissemination (1, 2).

Figure 1 - Four tiles representing the first Portuguese surgical illustrations published in the
“Recopilaçam de Cirurgia” (1649) by António da Cruz. Our gift to the participants of the Museum’s 60th
Anniversary Meeting (1993).
Surgical use of natural human appendages
The term "surgery" derives from the Greek kheir (hand) and ourgos (work), meaning
"handwork". The etymology of the word has been pointed out countless times in
specialised literature, including the Hippocratic Corpus and the writings of Aulus
Cornelius Celsus (25 BC-50 AD), Ambroise Paré (1510-1590), Johannes Scultetus
(1595-1645), Lorenz Heister (1683-1758), and Joseph Lister (1827-1912), among
many other examples.
The first treatise on surgery ever printed in Portugal dates from 1649, and it was
written by António da Cruz (died 1626), who defined surgery as "the branch of
therapeutics dealing with the cutting, burning and fixing of bones, and with another
handwork that heals men" (3). In the following century, Feliciano de Almeida (1670-
1726) referred to surgery as a "manual art or science" (4).

Examples like these are abundant in Portuguese and international literature. The
hands of non-human primates are part of their locomotion systems. But bone
fragments from Homo habilis already show all the signs of bipedalism and vertical
posture. The hand was therefore no longer used exclusively for locomotion, but
gained new roles, allowing different tasks such as healing certain pathologies or
making tools. In the 1980s, John Robson Kirkup, a prestigious fellow of the
International Society for the History of Medicine2 established a relationship between
current surgical instruments and our natural appendages (5).
In ancient times, men examined a deep wound by using their forefingers as probes or
retractors or extracted a foreign body by curving their fingers like hooks. Body
cavities were examined by spreading both their edges. Lacerations of small blood
vessels were instinctively treated by finger pressure. The functional advantages of the
opposing thumb were fully used in order to solve diverse clinical situations.
My PhD dissertation, written in 1996, dealt with the analysis of the shape and
structure of surgical instruments, particularly in connection with the Portuguese
contributions since the 17th century (6).
I, therefore, reviewed all the Portuguese surgical literature in search of any
references to the use of natural human appendages and surgical instruments,
analysing their purposes and materials, in order to understand better Portuguese
surgical practices and knowledge.
Some examples of surgical applications of our natural appendages may be found in
the Portuguese surgical bibliography, such as the use of the finger as a probe in
António Ferreira's Luz Verdadeyra (1683) in the treatment of gunshot wounds (7),
limb fractures (8), skull trauma (9) or to diagnose gallbladder calculi (10).
The finger as a hook to remove of gum growths (11) appears in Feliciano de
Almeida's Cirurgia Reformada, or to treat frenulum conditions (12) in António de
Almeida's Tratado Completo de Medicina Operatória (1800); the fingers appear as
retractors in bronchotomies (13) and in the surgical treatment of hernia varicose
(14), as described by Feliciano de Almeida. The thumb or forefinger as haemostatic
(15) and tourniquet (16) in the treatment of aneurism as mentioned by António da
Cruz and António Ferreira. The thumb and fingers as tweezers to close face wounds
(17) and in the reduction of furcula fractures (18) in António Ferreira's treatise; the
thumb and fingers as pincers in the treatment of gunshot wounds (19) and cancer
(20), in Feliciano de Almeida's work.The fingernail as a retractor in skull trepanation
(21), and as a scalpel to relieve tumefaction (22) as described by Feliciano de
Almeida; the teeth to cut suture thread (Feliciano de Almeida) (23) and to close head
wounds by pressing the bone down (António Ferreira) (24). In fact, the hand has
always been a natural surgical instrument, as well as a precursor and design pattern
for surgical instruments. However, references on the use of fingernails and teeth are
scarce.
2
I had the privilege of having J. Kirkup as supervisor of my PhD dissertation and would like to express my appreciation for him.

Mineral and organic materials in Instruments
Instruments resulted from hominization and had several purposes. Sources about the
manufacture of tools at those times are very scarce. The debate about possible
explanations is extremely important as it may lead to new evidence. The study of
primitive communities in past centuries may shed light on this topic, but we should
bear in mind the hypothetical nature of any conclusions. A piece of evidence, for
example, may be found in a photograph showing the usage of wet cupping vessels
among Angola's Kwanyama tribe (25).
The instruments were originally made of mineral and organic materials. Pre-historic
tools made of lithic flakes are represented in the museum with a collection of stone
implements found in Castro de Vila Nova de S. Pedro, Azambuja, Portugal (26). There
is also a suction cup made from the upper end of a gourd used by primitive
communities of Western Africa, formerly under Portuguese control (27).
Biological and cultural maturity went hand in hand with the growing complexity of
tools. The earliest compound tools date back to the Epipaleolithic, though they had no
exclusive surgical purpose, and there no surgical instruments manufacturers were to
be found since the social organisation was undifferentiated.
First metal instruments
The use of metals in the manufacture of instruments was a revolution made possible
by increasing technological development. Those instruments incorporated small
amounts of pure gold, silver and copper, as well as melted copper, copper alloyed
with tin to produce the more resistant bronze, or containing a low percentage of zinc
to make brass. Copper extraction through smelting for surgical purposes seems to
date back to the 4th century BC, not long before the Hippocratic Era.
Copper extraction was easier than iron, which may explain the preference for the
former, but it was rarely used in its pure form (28). In the Hippocratic Corpus (29),
for instance, we find references to non-ferrous metals, such as lead and tin tubes and
probes for intrauterine and rectal medicine administration, gold threads for
mandibular fracture fixation, and uterine silver syringes.
There is a tendency to underestimate the quantity and quality of available iron.
Charcoal iron, i.e., wrought iron smelted by using charcoal, resulted in steelified iron,
whose surface was more suitable as a cutting blade. The first documented reference
to tempering steel by the Greeks may be found in the Hippocratic Corpus. Iron and
steel were widely used to make instruments, although bronze was usually the
material of choice. Due to its hardness and resistance, bronze has been better
preserved throughout the centuries, thus appearing to be the only or most widely
used material. Ore deposits in Austria and India yielded good quality iron, used by the
Romans to make cutting instruments and forceps.

References to the usage of organic materials are also extant. These materials and
ferrous metals have degraded through time, which explains why those artefacts are
so rare today. They were mostly instruments of plain design, combining two
instruments in one, little decoration and no inlays. Inlays became more frequent in
the 1st century. Gold- and silver-gilt instruments were rare, as well as representations
of health deities or their attributes.
The museum contains no items from the Graeco-Roman period. Research has been
based on the analysis of documental sources related to the main authors of the time,
such as Hippocrates (460-377 BC), Sushruta (6th century BC), Aulus Cornelius Celsus
(26 BC-50 AD), Soranus of Ephesus (1st/2nd century AD), Galen of Pergamon (130-
210 AD), Oribasius (320-400 AD), Aëtius of Amida (502-575), Pliny the Elder (23/24-
79 AD) and Paulus of Aegina (625-690), among others.
Two seminal works on this period are those written by John Stewart Milne (1907) who
illustrated instruments contained in European museums and private collections and
analysed classical works on the subject (30), and Ernst Künzl (1982), who examined
medical instruments and devices found in Roman physician´s tombs from Pompeii
and Herculaneum (31).
Medieval Instruments
In the Middle Ages, the Graeco-Roman medical tradition was preserved through the
practices of Monastic Medicine, Arabic Medicine and Byzantine Medicine. The work of
the already-mentioned Paul of Aegina, a 7th century Byzantine physician, describes,
particularly in Book 6, a wide variety of procedures and their necessary
armamentarium, though with hardly any reference to the materials used (32).
The study of these documental sources is an important contribution to the knowledge
of medieval surgical instruments. Peter Jones and Loren MacKinney have both
published comprehensive collections of illustrations of medieval surgical instruments
reproduced on wooden plates.
The interpretation of this iconography, however, is highly debatable, as the images
were not down to scale and resulted from a process of copying and translating (33,
34).
Surgical literature in Arabic is extensive. The museum contains a volume published by
the Wellcome Institute of the History of Medicine, written by M. S. Spink and G. L.
Lewis, entitled Albucasis on Surgery and Instruments (35). It is a lavishly illustrated,
bilingual edition of the Arabic source text and its respective English translation, with
comments by the authors. Albucasis (936-1013) was a rational, experienced surgeon,
who based his writings not only on his personal experience but on that of classical
authors, particularly Paul of Aegina.
The surgical procedures and instruments not mentioned in classical literature were
crafted by Albucasis himself or belonged to the Arabic medical tradition. Some of his
innovative surgical instruments included an Indian-iron tonsil guillotine; a silver,

bronze or copper paracentesis trocar; a silver and ivory syringe; an iron or Indian
steel lithotrite; the first pair of scissors with crossing blades controlled by a pivot
made of ferrous metal, and an obstetric forceps for embryotomy. A wide variety of
materials are mentioned in the book, from organic (wood and ivory) to non- ferrous
and ferrous metals. Albucasis favoured iron over gold cauteries, and, for the
manufacture of better quality instruments, he recommended the use of Indian or
Damascene steel, probably referring to early attempts at cast or crucible steel.
Late medieval surgeons did not illustrate their manuscripts, although images were
added to the texts later. Those drawings were often off the scale, made by people
with no medical knowledge.
There are references to ferrous and non-ferrous metals, such as silver and copper.
Organic materials were used to build the proximal ends of instruments like cautery
handles in order to reduce heat transfer. The difficulty in finding medieval surgical
instruments today, particularly those made of ferrous metals, has been analysed by
Ralph Jackson and Peter Jones.
According to these authors, the lack of extant instruments may be explained by a
number of combined events taking place in Western Europe: the fall of the Roman
Empire and its negative consequences for the tin and copper trade; iron-ore deposits
could be found in several different places, which favoured iron extraction; iron
production was cheaper than bronze production; ferrous instruments were recycled
for economic reasons, which caused the loss of many items; the decay of iron and
steel throughout time; and the difficulty in locating medieval findings in permanently
changing urban areas, as opposed to Roman archaeological sites - often military
camps in rural areas. Little information is available on the manufacture of new
instruments in this period.
16th to 19th century Instruments
The development of the printing press encouraged the advancement of surgery and
the manufacture of specific instruments, with the publication of a growing number of
treatises featuring images. Among them, it is worth pointing out some works
published in the period before the Louis Pasteur surgical revolution, such as those by
Hieronymus Brunschwig (1497), Hans von Gersdorff (1517), Ambroise Paré (1575),
Jacques Guillemeau (1594), John Woodall (1617), Johannes Scultetus (1655), Pierre
Dionis (1708), Lorenz Heister (1718), René-Jacques Garengeot (1727), Gian-
Alessandro Brambilla (1769), Bourgery and Jacob (1838-40), and Joseph Pancoast
(1844). Originals of these works or historical reviews are available in our library (36-
43).
In the 16th century, new instruments were introduced like the suture cannula, the
thumb lancet, the trepan brace, bullet extractors, spring scarificators and devices for
pivot forceps. In the 17th century, silversmiths, pewterers and cutlers became more
dedicated to the manufacture of instruments and decoration.

In the next century, the number of surgical instruments increased and got higher
complexity, manufactured by specific surgical instrument makers. In Portugal, the
first treatise on surgery was Recompilação de Cirurgia, by the already mentioned
António da Cruz, containing the first surgical illustration (44).
One century later, the Royal Surgeon António de Almeida published Tratado Completo
de Medicina Operatória (1800), four volumes including an extensive surgical
iconography resembling that found in the international literature (45).
Some catalogues of surgical instruments from the 18th century, particularly one of the
first produced by J. J. Perret (1772), a master cutler from Paris and expert surgical
instruments maker are specially noteworthy (46).
The combination of various circumstances may explain better the preservation of
surgical instruments from the Renaissance onwards: high quality and strength of
materials, a higher number of instruments to cater for the needs of a steadily growing
population, their interest for collectors and, as already pointed out, the development
of the printing press.
The evolution of surgical instruments goes hand in hand with scientific and
technological developments and medical advancements. The advent of gunshot
wounds, for example, demanded new surgical approaches, which in turn required the
design and manufacture of suitable instruments. The more luxurious their materials,
the higher the surgeon's social status would be. Communication between the surgeon
and the manufacturer was extremely important to identify needs, meet clinical
requirements and resulted in significant transformations of the armamentarium.
In addition, the analysis of catalogues of surgical instrument makers through time
shows their technical and technological concerns, as well as their strive for innovation
as a way of standing out among their peers.
Two examples are the take-apart of pivoting instrumentation or the rack catch to lock
pivot forceps by controlled compression, designed by prestigious French manufacturer
Joseph Frederic Charrière (1803-1876), and the introduction of asepsis and
antiseptics in surgery (47).
It is necessary to understand the development of steel production, a ferrous metal
and material of choice for many centuries. From the 7th to the 11th century, ferrous
metals replaced bronze almost completely. Until the 16th century, steel was of poor
quality.
After that, scientific and technological developments resulted in shear steel, a
homogeneous type of steel made up of juxtaposed layers, more suitable for cutting
instruments. Shear steel was brittle, hence the thickness of the instruments made
with it.
The museum collection houses an amputation case with knives of shear steel.
In the 1750s, Benjamin Huntsman, a clockmaker from Doncaster, invented and
manufactured cast or crucible steel with a higher content of carbon. But this type of
steel was only introduced by the turn of that century.

Figure 2 - 18th-century amputation case with knives made of shear steel.
Such innovation led to lighter and thinner instruments, and therefore to more
advanced surgical techniques and better clinical results.
In the museum’s collections, most of the 19thcentury armamentarium from the time
before the Louis Pasteur (1822-1895) revolution is made of crucible steel, such as a
19th century trephining and amputation case (48).
Entire surgical instruments or, more often, their handles could be made out of organic
materials. The international literature points out the use of wood and horn in the 17 th
century, and of ivory, tortoiseshell and ebony in the 18th and following century. These
materials are also mentioned in Portuguese surgical books (49, 50).
In tune with international findings, these two authors also mentioned a number of
non-ferrous metals used for instrument making, such as gold, silver, copper, tin and
lead, although they also highlighted the predominance of ferrous metals.

Figure 3 - 19th-century trephining and amputation case with instruments made of cast or crucible
steel. amputation case with instruments made of cast or crucible steel.amputation case with
instruments made of cast or crucible steel.amputation case with instruments made of cast or crucible
steel.
The collection itself may complement the documental sources found in our museum
library. Most surgical instruments date from the 18th century. We have been
cataloguing this estate according to the materials used, whether organic or ferrous
and non-ferrous metals, especially those made before the Louis Pasteur revolution by
the end of the 19th century.
We must bear in mind that the Age of Discoveries provided access to exotic materials,
which were soon used in instrument making.
Among animal materials, especially noteworthy were horsehair, bristles, the inner
lining of animal intestines, fish or mammalian skin, tortoiseshell, bone and ivory.

Figure 4 - Animal Materials – Ivory, Compact bone bistoury, scarificator, bladder trocar, trephining
saw, lithotome (from left to right).
Materials of vegetable source included different types of wood, especially ebony,

which could make up the entire instrument or, more often, its proximal end.
Laminaria sticks were used to dilate the cervix; the upper end of a gourd could be
turned into a suction cup.
Figure 5 - Vegetable materials – Wood vaginal speculum, vaginal valves, bladder gorgeret, trephining
saw, embryotomy hook (from left to right).
In addition to the already-mentioned stone implements, the museum houses a

number of mineral materials, such as several glass items - either surgical accessories
or pieces requiring specific instruments, such as ceramic prosthesis.

Figure 6 - Non-ferrous materials – Silver tracheotomy cannula, trocar, vaginal speculum, Holt’s dilator
(from left to right). Figure 6-Non-ferrous materials – Silver tracheotomy cannula, trocar, vaginal
speculum, Holt’s dilator (from left to right).
Non-ferrous metals include copper, gold, silver, lead, tin, brass and German silver. By
the turn of the 19th century, the use of these metals began to dwindle significantly.
19th century Instruments Revolution
An advocate of asepsis, Louis Pasteur (1922-1895) underlined the need for thermal
prophylaxis. On the other hand, Joseph Lister (1827-1912) widely used carbolic acid
as an antiseptic, which he applied on wounds, clothes and instruments, and sprayed
in the air. Both strategies led to dramatic changes in instrument making, in order to
reduce or avoid the corrosion of ferrous metals and the degradation of organic
materials.
Thorough sterilisation required dismountable instruments with straight lines and
smooth surfaces - the organic materials formerly used in the handles were therefore
replaced by more durable electroplated ferrous metals. Nickel electroplating
developed by Isaac Adams of Boston (1860) and Edward Weston's galvanic cell
(1870) boosted electrochemical processes. A number of surgical instruments kept in
the Maximiano Lemos Museum record these advancements (51).
New challenges arose by the turn of the century: the weight of the instrument, as its
metal content increased, and the quality of electroplating. Organic materials were
gradually eliminated or used only for instruments that needed no sterilisation.
Electroplated instruments were significantly more costly than those made of organic
materials.

Stainless Steel, Rubber and Plastic in Instrumentation
The first stainless steel surgical instruments were produced by Mayer & Co. in 1916
for Heath. After 1925, catalogues combined electroplated cast steel and the more
expensive stainless steel instruments. By the end of the 1930s, electroplated metals
had been almost completely replaced by stainless steel. It is possible to follow all
these changes through the evolution of a single instrument (52, 53).
Figure 7 - Ferrous Materials: shear steel, cast steel, electroplated steel, stainless steel (top-down).
Elastic gum and rubber are well represented in our collection. Around 1779, Theden of
Wurzburg and Bernard, in Paris, produced catheters by soaking a cloth cylinder with
tree sap, also used to make other tubular instruments. In 1791, Grossart made the
first tubular surgical instrument employing volatilised rubber. Sulphur vulcanisation,
developed by Goodyear in 1841, made rubber more resistant and led to a wide
variety of applications, such as gloves since 1900.
A vast collection of plastic items are on display (54). Plastic, a mixture of synthetic
resin polymers, started with the production of celluloid (1869) and bakelite (1907),
followed by many other composites after the 1930s, used to manufacture prosthetics,
suture thread, automatic suture devices, endoscopes and laparoscopes, scalpel
handles, trocars and several others.
Unsuitable for sterilization, plastic instruments had to be disposable. Plastic rapidly
began to replace stainless steel.

Figure 8 - The evolution of the bistoury.
The scientific and technological developments brought about new and more
comprehensive approaches and the consequent need for new armamentarium.
Hospitals began to change dramatically, from their facilities and fixtures to health
professionals' clothing and behaviour, which had a positive impact on public health.
Surgery treatises and surgical instrument catalogues record those paradigmatic
changes, as may be seen in their contents and a growing number of pages. Of
extraordinary relevance to understanding this instrument´s revolution are the works
of John Kirkup and James Edmonson (55, 56).
Figure 9 - James Edmonson, Amélia Ricon Ferraz and John Kirkup (from left to right) at the
“Maximiano Lemos” Museum of Medical History. University of Oporto, Medical Faculty.
In the second half of the 20th century, minimally invasive procedures and endoscopic
diagnostic techniques with inexhaustible surgical potential, represent the rise of a new
surgical framework. At the same time, surgical applications were found for new
sources of energy, like laser and ultrasound. Though often keeping the shape of
traditional surgical instruments, instrument extensions have moved the hand away
from the instrument's active end and from the operating field.
Conclusion
The origins and development of surgical instruments is a subject that has captured
the interest of professionals from many fields of knowledge, as it has always had a
multidisciplinary nature. It is an important chapter in the history of humankind and a
lesson in science, technology and technique, showing us the human ability to adapt to
changing social and environmental conditions.
Figure 10 - “ABC do Instrumento Cirúrgico” exhibition and catalogue.
Therefore, it is included in graduate and post-graduate programmes in our Medical

School, and the focus of significant research work. Through the analysis of a surgical
instrument, the student/ researcher learns to identify its dimension, shape, materials,
maker´s brand and other inscriptions and finds out more about its history.
Based on the information collected, s/he contextualises the object within its time and
field. Thus, they learn to value surgical instruments as an important legacy in the field
of surgery. They are also able to observe that, in spite of all their changes,
instruments have kept their basic patterns, as designed in the Graeco-Roman period.
In addition, they are able to see the influence of material technological developments
on surgical practices and clinical results, therefore getting a glimpse of future
possibilities.
They are required to identify the inscriptions found on the instrument to learn about
its historical context, particularly the maker's brand, which points to a specific
production period3 (57).
The museum's surgical collection has also inspired a number of temporary exhibitions,
scientific papers and art initiatives (58, 59).
Our students have always been keen supporters of all these activities, as they have
grown familiar with surgical instruments and, aware of their importance as heritage,
participate in their preservation and dissemination.
References
1. RICON FERRAZ, A. Catálogo Museu de História da Medicina Maximiano Lemos. Porto:

FMUP, 2000.
2. RICON FERRAZ, A. Inventário do Museu de História da Medicina "Maximiano Lemos".
Oporto: Faculdade de Medicina da Universidade do Porto, 2003.
3. CRUZ, A. Recopilaçam de Cirurgia. Lisboa: Officina de Miguel Deslandes, 1688, fo. 1.
4. ALMEIDA, F. Cirurgia Reformada….Lisboa: Officina Real Desladesiana, 1715, 2.
5. KIRKUP, J. A Historical Study of the Surgical armamentarium: Origins and materials.
Cambridge, 1995.
6. RICON FERRAZ, A. Uma análise da estrutura e forma dos instrumentos cirúrgicos: o
contributo português desde o Séc. XVII ao Séc. XX. Oporto: MEDISA, 1996.
7. FERREIRA, A. Luz verdadeyra, e recopilado exame de toda a cirurgia … Em Lisboa: na
Officina de Miguel Deslandes, 1683, 188.
8. Idem, 190.
9. Idem, 197.
10.Idem, 345.
11.ALMEIDA, F. 1715, 153.
12.ALMEIDA, A. Tratado Completo de Medicina Operatoria. Vol.3. Lisboa: Impressão
Regia, 1825, 48, note 1.
13.ALMEIDA, F. 1715, 176.
14.Idem, 270.
15.CRUZ, A. 1688, 110.
16.FERREIRA, A. 1683, 83.
17.Idem, 237.
18.Idem, 368.
19.ALMEIDA, F. 1715, 349.
20.Idem, 479.
21.Idem, 24.
22.Idem, 174.
23.Idem, 42.
24.FERREIRA, A. 1683, 209.
25.See references 1 & 2.
26.Ibidem.
27. Ibidem.
3 On this subject, see https://sigarra.up.pt/fmup/pt/ucurr_geral.ficha_uc_view?pv_ocorrencia_id=418187
accessed on 18 March
2020 and https://sigarra.up.pt/fmup/pt/ucurr_geral.ficha_uc_view?pv_ocorrencia_id=421381 accessed on
18 March 2020.

28. MCNEIL, I. Ed. An encyclopaedia of the History of Technology. London: Routledge,

1990.
29. ADAMS, F. The Genuine works of Hippocrates. 1, 2 vols. London: Sydenham Society,
1849.
30. MILNE, J. S. Surgical instruments in Greek and Roman times. London: Clarendon Press,
1907.
31. See reference 5.
32. ADAMS, F. The Seven books of Paulus Aegineta. 2 vols. London: Sydenham Society,
1846.
33. JONES, P. Medieval Medical Miniatures. London: British Library in with the Wellcome
Institute for the History of Medicine, 1984.
34. MACKINNEY, L. Medical Illustration in medieval Manuscripts. London: Wellcome
Historical Medical Library, 1965.
35. SPINK, M. S.; Lewis, G. L. Albucassis on Surgery and Instruments. London: The
Wellcome Institute for the History of Medicine, 1973.
36. CROOKE, H. An explanation of the fashion and use of three and fifty Instruments of
Chirurgery. Edimburgh: West port Books, 1982.
37. WOODAL, J. The surgions Mate. Ed. Fac-simil. Bath: John Kirkup, 1978.
38.SCULTETUS, J. Armamentarium Chirurgicum. Ulm: Kuhnen, 1655.
39. HEISTER, L. Chirurgie …. Nurnberg: Hoffman, 1718.
40. GARANGEOT, R. Nouveau Traité des Instruments de Chirurgie les plus utiles. Paris:
Huart, 1727.
41. BRAMBILLA, G. A. Instrumentarium Chirurgicum Militare Austriacum. Vienna: Schmidt,
1871.
42. PANCOAST, J. A Treatise on operative surgery… Philadelphia: Carey and Hart, 1844.
43.See reference 5.
44.CRUZ, A. Recopilaçam de Cirurgia. Lisboa: Officina de Miguel Deslandes, 1688.
45.ALMEIDA, A. Tratado Completo de Medicina Operatoria. Vol.4. Lisboa: Impressão
Regia, 1825.
46.PERRET, J.J. L’Art du Coutelier Expert en Instrument de Chirurgie …. Paris, 1772.
47.See reference 6.
48. See references 1 & 2.
50. FERREIRA, A. Luz verdadeyra, e recopilado exame de toda a cirurgia … Em Lisboa: na
Officina de Miguel Deslandes, 1683.
53. RICON FERRAZ, A. ABC do Instrumento Cirúrgico. Porto: U. Porto,
2010. 54. See reference 2.
56. EDMONDSON, J. American surgical Instruments an illustrated history of their
manufactures and a directory of instrument makers to 1900. San Francisco: Norman
Publishing, 1997.
57. RICON FERRAZ, A. The Portuguese Surgical Instruments of the “Maximiano Lemos”
History of Medicine Museum in Actes du 10e Colloques des conservateurs des musées
d’histoire des sciences médicales, Poto, 1993, 191-211.
58. RICON FERRAZ, A. Um olhar sobre o passado da gastrenterologia: catálogo da
exposição comemorativa dos 50 anos da Sociedade Portuguesa de Gastrenterologia.
2010. Porto: Sociedade Portuguesa de Gastrenterologia, 2010.
59. RICON FERRAZ, A. The Medical and Surgical Instruments in Urogynaecology. Lisboa:
FMUP, CHJ, IUGA, 20

JEWISH PHYSICIANS AND THE PORTUGUESE MEDICAL DIASPORA
Kenneth Collins1
Abstract
The expulsion of practising Jews from Portugal in 1497 produced effects which were to last for
several centuries. Many Jews chose to remain, observing their religion in secret but always
aware of the risks of betrayal to the Inquisition whose punishments could be severe, with
many practising their faith burnt at the stake. There was a tradition of medical studies among
many of these secret Jews who took advantage of their outward Catholic status to study at
medical schools which would not admit Jewish students. As persecutions intensified, Jews
managed to leave for cities where they could safely observe their religion openly. This paper
examines the experiences of Jewish physicians who escaped the Inquisition for Salonica
(Thessaloniki), Amsterdam and London.
Key Words
Jewish physicians; Portuguese Inquisition; Amatus Lusitanus; Jacob de Castro Sarmento
Résumé
L’expulsion des Juifs pratiquants du Portugal en 1497 a produit des effets qui ont duré
pendant plusieurs siècles. Beaucoup de Juifs choisissaient de rester et continuaient de
pratiquer leur religion en secret. Ils restaient cependant bien conscient des risques de
trahison et d’Inquisition. Les punitions pouvaient être très sévères et amenaient plusieurs
pratiquants au bûcher. Il existait une tradition d’études médicales parmi beaucoup de ces
Juifs pratiquant clandestinement, leur statut public catholique leur permettant de suivre des
études dans des écoles de médecine qui refusaient les étudiants Juifs. Suite à l’intensification
des représailles et persécutions, nombre de Juifs avaient réussi à fuir vers des villes où ils
pouvaient professer leur religion ouvertement. Cet article décrit les expériences des médecins
Juifs ayant fui l’Inquisition pour se rendre à Salonique (Thessaloniki), Amsterdam et Londres.
Mots-clés
Médecins Juifs; Inquisition Portuguaise; Amatus Lusitanus; Jacob de Castro Sarmento
1 Dr. Kenneth Collins, Senior Research Fellow, Centre for the History of Medicine, University of
Glasgow, Glasgow G12 8QQ. Currently Visiting Professor, History of Medicine, Hebrew University
of Jerusalem. Contact: Email: drkcollins@gmail.com

Introduction
The expulsion of Jews from the Iberian Peninsula during the 1490s, and the continued
migration of conversos, who initially took their Jewish beliefs and practices
underground, seeking a safe place to return openly to Judaism, brought many
thousands of Jews west, east and north. Many settled in the Ottoman Empire,
especially in the city of Salonica while others moved to the more northern mercantile
and cultural cities of Amsterdam and London. There had only been a small, but
relatively influential, Jewish community in Portugal during most of the 15th century
but the aftermath of the expulsion of the Jews from Spain was to have major
reverberations which continued for hundreds of years.
During the 15th century, medical care and training improved considerably under
Prince Henrique, Duke of Viseu and son of King Joao I. Prince Henrique, besides his
extensive maritime activities, was Protector of General Studies from 1418 until his
death in 1460 (1). His contacts with North Africa and his friendly relations with
Portugal’s Jews were elements in raising the quality of medical care in the country. He
encouraged the entry of Jewish physicians and surgeons into the country and among
Jewish practitioners was Master Nacim, a physician and oculist, who received a ‘Letter
of Privilege’ in 1434 entitling him to license all the other ophthalmologists in the
country.
This situation was to change dramatically during the 1490s. More than half of the
100,000 Jews expelled from Spain in 1492 tried to settle in Portugal. This was a
considerable number for a country of around one million inhabitants, and measures
were taken against the newcomers. Practising Jews were to leave Portugal in 1497
though in fact Jewish numbers were reduced by forced, if somewhat insincere,
conversions. Many decided to remain in Portugal and to act outwardly as Catholics but
keeping their Jewish practices in secret.
These Jews, known as New Christians or conversos, managed to preserve their Jewish
faith for more than two centuries and vestiges of this can still be found in isolated
places in Portugal, such as Belmonte, to the present day. In 1506 travel restrictions
on the New Christians were lifted and the flow of Portuguese Jews around Europe, and
to the New World began.
Here we shall look at the experiences of Jewish physicians of the Portuguese medical
diaspora who settled in the three cities, Thessaloniki (Salonica), Amsterdam and
London while drawing some general conclusions of the process of dispersal,
settlement and finally integration into the new lands and opportunities which became
open to them. For some, escaping the Inquisition to lands where it was possible to
practice Judaism openly meant a return to a faith which could only be practiced in
secrecy for many decades or even two or more centuries. Even Hebrew books were
banned, by an edict in 1524, though physicians and surgeons who did not know Latin
were permitted to keep a Hebrew medical library. Physicians were amongst the most

distrusted elements of the New Christian population, and medical schools were often
the most successful recruiting grounds for Judaising proselytisers (2).
Around 240 Jewish physicians received some form of punishment from the Portuguese
Inquisition and the procedures to establish the facts of Jewish secret practice could
extend beyond the individual’s lifetime.
Garcia da Orta was born in Portugal but studied in Salamanca and Alcala before
returning to Lisbon in 1525 where he practised medicine and was Professor of Logic.
In 1534 he settled in Goa, in Portuguese India, where he became a pioneer in Indian
medical botany and served as physician to the local Portuguese authorities. After his
death in 1568, there was suspicion that he had been a ‘secret’ Jew and when it was
confirmed that he had been actively involved in Jewish practices his body was
exhumed in 1580 and burned.
Among the emigres were significant numbers of physicians and other healers many of
whom had, because of their previous Christian status in Spain and Portugal, medical
qualifications from Iberian university medical schools. This gave them a major
advantage against their Jewish brethren who were unable to enter the medical
schools of Christian Europe. The only exception had been some of the Italian
universities, but especially the University of Padua which had permitted Jews to
graduate in medicine from early in the 15th century. Others had medical licenses from
city or other authorizing bodies while some were trained as apprentices with
recognized practitioners.
Secret Jews could be identified by appearing to observe the Jewish Sabbath or the
Passover, when the bread is not eaten, eating kosher meat and avoiding pork. They
would observe the Fast of Yom Kippur one day later than the mandated time as they
knew they would be observed the previous day. The Inquisition process and
punishment was highly intrusive and ruthless and punishments severe.
Medical victims of the Inquisition could be imprisoned, tortured, identified as ‘heretics’
and burned at the stake. Children could be taken from their parents and forcibly
baptised. The Inquisition also followed emigres to Portuguese colonies in the New
World and to Goa in India. False confessions were obtained during torture, and the
remaining Jews were ever more careful about hiding their religious practices. Garcia
Lopes (1520-1572) studied in Evora and practised in Portugal and was burned at the
stake in Evora in 1572. Isabella Mendes, from a prominent medical family, was
burned at the stake in Coimbra in 1718 and Francisco de Mesquita (1790-1873), the
uncle of Jacob de Castro Sarmento (1691-1762) whom we shall meet later, suffered
the same fate at Bragança in 1716.
The expulsion of Portuguese Jews occurred in 1497, but the long story of persecution
and inquisition was to continue for more than two centuries. Thus, we will find Jews
leaving Portugal and reverting to active Jewish practice through the eighteenth
century, several generations after the expulsion edict, skilled in their professions with
some maintaining or quickly mastering an impressive knowledge of Hebrew and

religious texts. For many others, however, long exposure to the freer religious
atmosphere, especially in Amsterdam and London led to an abandonment of faith
which the centuries of persecution could not achieve. The loss of generations of
talented physicians hampered medical progress in Portugal though, as we shall see,
many were able to maintain contacts with colleagues who remained in the country.
Salonica (Thessaloniki)
The arrival of Jews from Spain and Portugal transformed the city of Salonica both
culturally and economically, and the city was nicknamed la madre de Israel (mother
of Israel). The Ottoman Empire granted protection to Jews as dhimmis and
encouraged the newcomers to settle in its territories, and the large Jewish settlement
in Salonica prevented ethnic Greeks from dominating the city. Spanish Jews began
arriving in the 1490s, and the main migration from Portugal occurred mainly from the
middle of the 16th century following the establishment of the Inquisition in 1536.
There was another wave of emigration in 1577 as the Inquisition stepped up its
activities in identifying and punishing hidden Jews, following a temporary relaxation of
the Inquisition, related to economic problems. Many Jews from Iberia had settled in
Italy, but the introduction of the Inquisition to Italy in 1542 forced many of the new
arrivals to flee eastwards to the Ottoman lands.
By 1519, Jews represented more than half of the population of Salonica, and a
century later their proportion was around two-thirds, and their Ladino language,
based on mediaeval Castilian but also has elements from all the old Romance
languages of the Iberian Peninsula including Galician-Portuguese. Ladino, like Yiddish,
is written with Hebrew characters and contains a significant admixture of Hebrew. It
was widely spoken until modern times.
Salonica was well served by the Jewish physicians arriving from Iberia, France and
Italy, though we find no graduates of the University of Padua, uniquely open to Jews
from the fifteenth century. It was not possible to practise medicine in the Ottoman
territories without being licensed. The Ottoman medical schools, which were situated
in major centres, such as Istanbul, Damascus and Edirne, were mainly intended for,
and attended by, Muslim students although there may have been some Jewish
students in Istanbul in the last half of the fifteenth century. Jewish physicians were
prominent in the Ottoman world, serving a succession of Sultans.
The ibn Yahya family had a distinguished lineage in Portugal dating back to the 11 th
century including many rabbis, physicians and other scholars amongst its members,
most of whose descendants settled in the Ottoman Empire. The first physician we can
identify in the family was Gedaliah ibn Yaḥya ha-Zaḳen ben Solomon, who had been
physician to King Ferdinand (reigned 1367-1371) until 1370 when, falling from
favour, he became physician to Henrique of Castile.

His namesake Gedalya ibn Yahya ben Solomon was born in Lisbon in 1400 and before
he was thirty years old, he was appointed court astrologer to João I (reigned 1385-
1433).
Solomon ibn Yaḥya ben David, rabbi of the Lisbon community, held a prominent
position during the reign of King Afonso V of Portugal (reigned 1438-1481) as did
Joseph ibn Yaḥya benDavid. With the arrival of considerable numbers of Jews from
Spain, King João endeavoured to convert them to Christianity and when he chose
Joseph as the first to receive the baptism in 1495. Joseph then fled to Italy where he
was captured and died after being tortured on accusations of inducing secret Jews of
returning to Judaism included Judah who was born in Italy and graduated in Padua in
1557.
Settling in Salonica medical descendants of the ibn Yahya family include Gedalya, the
patriarch of a large medical family, who was the host of Amatus Lusitanus (1511-
1568) during his years in Salonica. His own descendants included Joseph ibn Yaḥya
bar Jacob Tam who had been born in Constantinople where he became body-
physician to Sultan Sulaiman, in constant attendance during the sultan's travels and
he met his death in battle in 1573 while accompanying the sultan. Other members of
his family included Moses and Tam who were also known for their charitable works
and Hebrew writings. By this time Jewish physicians formed a large and important
segment in Ottoman medicine.
They contributed to the medical care of the population of Salonica, providing hospital
facilities and even psychiatric care in the early modern period. There were dozens of
Jewish physicians in Salonica, and in following the careers of two prominent Jewish
physicians, we can observe their medical training and qualifications and consider their
cultural legacy and the transfer of medical traditions from Spain and Portugal to their
new home in a culturally diverse setting within the Ottoman Empire.
Amatus Lusitanus (João Rodrigues de Castelo Branco) was a justly celebrated
physician and philosopher, born in Portugal who lived there outwardly as a New
Christian but ended his days in Salonica as a Jew. After graduating with honours as
M.D. from the University of Salamanca, he returned home but left Portugal in fear of
the Inquisition. He went to Antwerp for a time and then travelled through Holland and
France, finally settling in Italy. His reputation as one of the most skilful physicians of
his time preceded him there, and during his short sojourn at Venice, he encountered
the physician and philosopher Jacob Mantino (1490-1549). And with his reputation as
a leading physician, he attended Pope Julius III and his sister and niece as well as
other distinguished personages.
Amatus was in Ferrara from 1546 to 1552, delivering lectures on anatomy, possibly
as a professor, conducting dissections, and describing medicinal plants. At one of his
lectures, he dissected twelve cadavers, a great innovation at that time, in the
presence of many scholars, including the anatomist Jean Baptiste Cananus (1515-
1579),

Figure 1- Amatus Lusitanus- Detail of the statue by Sculptor Martins Correia in Castelo Branco.
Photo courtesy of Elsa Martins Correia.
who discovered the function of the valves in the circulation of the blood. During this
time, he was invited by the King of Poland to practice there, but he declined,
preferring to settle in Ancona, where there was religious tolerance at the time.
With the accession of Pope Paul IV (Pope between 1555-1559), Ancona introduced
severe restrictions on both Jews and crypto-Jews, with the imposition of the
Inquisition. This led to arrests and tortures, and more than twenty Jews were burned
at the stake. Amatus fled to Pesaro, leaving behind several works in manuscript,
including his commentary on the Canon of Avicenna, and only one part of these
manuscripts was ever recovered. He moved again, from Pesaro to Dubrovnik
(Ragusa), in present-day Croatia, but after a couple of years, he left for Salonica in

1558, where, at last, he mainly within the Jewish community. His prolific writings
greatly enriched the contemporary medical literature.
Among the most important of these was his Centuriæ, a seven-volume work, in which
he published accounts of his cases and their treatment in editions in Italy, Holland,
France and Spain. His extensive writings on materia medica also met with much
favour. An important feature of the Centuriae is his medical oath, in the name of the
Biblical Ten Commandments, which emphasises the philanthropic aspects of medicine
and its requirement to care for the poor and needy. During his lifetime he published
several other volumes in Venice, Antwerp and Leiden. In many of these works, he
commends the Jewish values he was not yet able to profess openly illustrating the
profound emotional burden caused by the persecutions and exiles he experienced.
Today, his figure appears over the door of the Medical Faculty at the University of
Coimbra.
Daniel de Ávila Gallego was born into a family of conversos of Spanish or possibly
of Portuguese origin. His medical writings were composed in Ladino, rather than
Hebrew, Latin or Portuguese. This reflects the ubiquity of the language amongst
Salonica’s Jews, the recent return of the author to Jewish practice and a lack of
familiarity with Hebrew, then the predominant language of Jewish scholarly works.
Amatus Lusitanus published all his works in Latin to make his findings available to his
European colleagues but Gallego, half a century later, was writing for his
coreligionists. This decision has been said to reflect a turn from an earlier openness of
the ex-converso scholars who still cherished strong intellectual ties with Europe to a
more introverted outlook and focus on the community’s own concerns.
A few biographical details of Gallego appear in the introduction to his classic work
Diálogo del Colorado, published in Salonica in 1601. Only one copy exists today, in
the Ets Haim Library, in Amsterdam. The author describes himself as a Jew, a
philosopher and a doctor. He was a student of Juan Bravo and Rodrigo de Soria at the
University of Salamanca and was a young doctor living in Salonica when he wrote the
Diálogo having moved there to live openly as a Jew. The book describes the origin,
symptoms and appropriate remedies for what it calls a "new" disease that he always
refers to as mal colorado though the book’s subtitle makes it clear that the work is a
study of scarlet fever. The Diálogo del colorado is said to be the first monograph
devoted entirely to this disease as the distinctions between smallpox, measles and
scarlet fever had not been clearly established until the 16th Century.
Amsterdam
Many of the first Jewish physicians in the Netherlands had trained in Spain or Portugal
and only reverted openly to Judaism once they were established in Amsterdam from
the second half of the seventeenth century (3-5).
The newly independent and tolerant

Dutch provinces provided favourable conditions for observant Jews to establish a

community. They migrated most notably to Amsterdam, and as they established
themselves, collectively brought, besides medical experience, new trading expertise
and navigation knowledge to the city.
The newly arrived physicians could practice with their Portuguese or Spanish
qualifications or could obtain a simple licence to practice. From the middle of the
seventeenth century, Jews found their way into the Dutch universities, and especially
into Leiden where Jewish students and graduates begin to appear around 1650 and
which was developing a small but significant Jewish community infrastructure. Leiden
attained a high status amongst European institutions of higher learning, and its
medical school, led by such luminaries as Herman Boerhaave (1668–1738), probably
the greatest physician of his day, eventually ensured Leiden’s enviable reputation by
becoming possibly the leading European medical school during his lifetime.
Eighty-six Jewish physicians were identified practising in the Netherlands between
1610 and 1740. Not all found establishing medical practices simple given the numbers
of doctors and the size of the Jewish community. Place of study and graduation could
not be identified in about a quarter of the group, and a further dozen were licensed to
practise without medical degrees. About half were Dutch Jews, often children of
refugees from the Inquisition, while six were practising with degrees from Salamanca
and Seville in Spain and five from Evora and Coimbra in Portugal.
One of the most distinguished physicians to have settled in Amsterdam from Portugal
was Abraham Zacuth, known in Latin as Zacutus Lusitanus (1575–1642).
Figure 2 - Portrait of Zacutus Lusitanus. Unknown author. Photo taken by Sodabottle (Wiki Commons
license).

He was born in Lisbon as Manuel Alvares de Tavara into an illustrious family of secret
Jews and was the great-grandson of Abraham ben Samuel Zacuto (1450-1510) the
Royal Astronomer. After studying in Coimbra and Salamanca, he completed his
medical studies in 1596 in Sigüenza and from there returned to Portugal, attending
the Portuguese court as a practising physician. In 1625, at the age of fifty, he
reached Amsterdam with his wife and five children, where he openly returned to
Judaism and adopted the name Abraham Zacuth. He engaged in fruitful scientific
activity and published many medical books with expertise in his accurate clinical
descriptions of such illnesses as plague, diphtheria, malignant tumours and black
water fever an uncommon but serious complication of malaria.
His works were collected in two folio volumes, published posthumously in Lyon
(1642). They include De Medicorum Principum Historia, a systematic description of all
diseases, as investigated by physicians of preceding generations; Introitus Medici ad
Praxin containing 80 ethical principles for the physician in his behaviour at work:
Zacuti Pharmacopéa – a compendium of pharmacy, listing also the new drugs
imported from Latin America; Praxis Historarium – a survey of diseases in internal
medicine; Praxis Medica Admiranda – a collection of selected rare cases.
His observations reflected conditions only described in later literature such as
stomach disease accompanied by blood-stained vomiting, which he treated with
aluminium silicate which today we would know as peptic ulcer. Although his writings
were intended for a general readership, they included some autobiographical details
which emphasized his Jewish origin.
Balthazar (Isaac) Orobio de Castro was born in Bragança in 1617 and in addition
to his medicine he was a Jewish philosopher and religious apologist. While still a child,
he was taken to Seville by his parents, who were secret Jews.
He studied philosophy at Alcalá de Henares and became a teacher of metaphysics at
the University of Salamanca. Later he devoted himself to the study of medicine and
became a popular practitioner in Seville, and physician in ordinary to the Duke of
Medina-Celi and to a family with family links to the king.
When married and father of a family, he was, at the instigation of a servant whom he
had punished for theft, denounced to the Inquisition as an adherent of Judaism, and
incarcerated in a dungeon, where he remained for three years, subjected to repeated
tortures.
As he persistently denied the charge, he was finally released, but compelled to leave
Spain and to wear the sanbenito2, for two years. He thereupon went to Toulouse,
where he became Professor of Medicine at the university, at the same time receiving
from Louis XIV the title of Councilor;
_
2 Distinctive cap worn by suspected Jews.

but, weary at last of the hypocrisy and dissimulation of denying his religious beliefs,
he went to Amsterdam in about 1666, and there made a public confession of Judaism,
adopting the name Isaac.
In Amsterdam, he continued the practice of medicine, and soon became well- known,
within the Jewish community for his writings, on medicine, philosophy and on Biblical
themes. These included an ethical work critical of Baruch (Benedict) Spinoza, with
whom he maintained a friendly correspondence. His discussions on Christianity with
the Dutch preacher Philipp van Limborch were published by the latter in the work
entitled De Veritate Religionis Christianæ Amica Collatio cum Erudito Judæo, in
Amsterdam, 1687, the year of his death.
The physician, mathematician, astrologer, and poet Jacob Hebræus Rosales was born
Immanuel Bocarro Frances y Rosales around 1590 in Lisbon. He completed his
medical and mathematical studies at the University of Montpellier, returning to
Portugal, where he soon acquired a reputation as a physician, among his patients
being the Duke of Bragança and the Archbishop of Braga. Rosales openly avowed
Judaism in Amsterdam, taking the name of Jacob. Rosales was a prolific poet and
writer in Hebrew, Portuguese and Latin on mathematics and astronomy. His medical
output included two works published with Zacuto’s "De Medicorum Principum Historia"
(Amsterdam, 1629) and in Vol. II of Zacuto's collected works (Lyons, 1644).
London
The main Jewish exodus from Portugal to London occurred later than that of the
physicians we have described in Salonica and Amsterdam. Although Jews had been
expelled from England in 1290 and were not readmitted until 1656, some secret Jews
were present in England during the sixteenth century.
One of the most famous was Rodrigo Lopes (1525-1594) who was born in Crato,
Portugal and raised as a New Christian, but fled from the Portuguese Inquisition
settling in London in 1559 remaining a secret Jew though beyond the reach of the
Inquisition. He soon became a physician at St. Bartholomew's Hospital and developed
a large practice among powerful people including Robert Dudley and Francis
Walsingham.
In 1586, he was made physician-in-chief to Queen Elizabeth. Viewed outwardly, as
being a dutiful practising Protestant, Lopez was held in the Queen's favour. Around
1563, Lopez married Sarah Anes, and there is some evidence that both the Anes and
Lopez households secretly practised Judaism, which was then illegal in England.
In 1593, he was accused of conspiring with Spanish emissaries to poison the Queen
and was arrested, convicted and subsequently executed (hanged, drawn and
quartered). The Queen herself was uncertain of his guilt, and he maintained his
innocence and outward Christianity until his execution.

During the eighteenth-century, London was home to a group of highly talented Jewish
emigre physicians from Portugal, and some were able to maintain contacts with
Portugal. This may of course have been predicated on the special relationship existing
between Britain and Portugal. There was also a feeling amongst some of the emigres
that the Church in Portugal did not represent the whole nation and that as religious
refugees, Portuguese language and culture was worth cultivating and that there might
be the future prospect for the return of the New Christians who were now openly
Jewish.
Isaac Henrique Sequira (1738-1816), son and grandson of physicians, was born in
Lisbon but studied first at the University of Bordeaux and but completed his medical
studies at Leiden where he received his MD in 1758. Settling in London, he became a
Licentiate of the Royal College of Physicians in 1771 and was physician to the
Portuguese Embassy in London. He was described in Israel Zangwill’s 1891 novel of
London’s Jewish East End as “the great Dr. Sequira, pompous in white stockings,
physician extraordinary to the Portuguese Prince Regent”.
Figure 3 - Painting of Isaac Henrique Sequira (1738-1816) by Thomas Gainsborough (1727-1788), c.

1775. Museu do Prado Madrid. Wiki Commons license.
Other arrivals in London included Dr. Samuel Nunes Ribeiro and his nephew the
brilliant Dr. Antonio Ribeiro Nunes Sanches (1699-1783), who spent only two
years in London being afterwards recommended as physician to the Czarina of Russia,
Catherine the Great by his teacher in Leiden, Herman Boerhaave. Sanches had been
born in Penamacor, Portugal and studied first in Coimbra but moved to the University
of Salamanca where he graduated in 1724.
Though his subsequent departure from Portugal may have been connected to religious
persecution, he remained in good standing with Portuguese colleagues and
institutions during his travels around Europe, including his final years in Paris. At the
request of the Marquis de Pombal, he provided advice on health issues after the
Lisbon earthquake of 1755 and on Pombal-inspired changes in Portuguese medical
education in 1772.
Isaac de Sequeyra Samuda (1681-1729) graduated in Coimbra in 1720 but was

soon in London becoming a Licentiate of the Royal College of Physicians in 1721 and a
Fellow of the Royal Society in 1724. In 1728 he delivered the funeral oration for Dr.
David Nieto, Chief Rabbi of the Portuguese Jews in London at the Bevis Marks
Synagogue where the records were kept in Portuguese until the first years of the 19 th
century.
However, we shall focus on the life and career of one leading physician whose life
exemplified the risks of Jewish life in Portugal in the early 18 th century as well as the
trials of freedom in London.
Jacob de Castro Sarmento, known in Portugal as Henrique de Castro, was born in

Bragança in 1691 in the north of Portugal to New Christian parents Francisco de
Castro Almeida and Violante de Mesquita, both of whom were arrested by the
Inquisition in 1708 and his mother died, while under arrest in 1710 (6-8).
After school in Mértola, in southeast Portugal, he entered the University of Évora
where he studied the classics and the philosophy of Aristotle graduating MA in 1711.
From there he progressed to the University of Coimbra where he obtained his medical
degree in 1717, and he commenced work amongst the poor in Beja where he began
his lifelong fascination with the treatment of fevers.
It seems that he was involved in secret Jewish practices in Beja, and probably in
Lisbon also. From Lisbon, he fled to London concerned about arrest by the Inquisition
around 1720. By 1721 he was in London ‘ambitious to enrich his talents with scientific
knowledge’ and as Dr. Jacob de Castro he and his wife officially remarried in Bevis
Marks, the synagogue of the Spanish and Portuguese Jews.
Though close initially to the Rabbi David Nieto, he showed himself less concerned
about Nieto's attempts to encourage strict religious observance rather than his own
aims in promoting Jewish ethical values.
Thus, having been an outsider as a secret Jew in Portugal continued to be something
of an outsider in the synagogue in London. In 1724, now known as Sarmento, he was
cleared by the synagogue authorities of a charge of betraying fellow Jews in Beja to
the Inquisition, and he quickly published a detailed work expressing his own religious
beliefs, partly to vindicate himself after dismissal of the false charges.
The following year Sarmento became a licentiate of the Royal College of Physicians in
London and 1730 was elected a member of the Royal Society, the British national
science academy.
Figure 4 - Jacob de Castro Sarmento. Engraving by Richard Houston (1721-1775). (Wiki Commons
licence).
In association with Sir Hans Sloane (1660-1753), the President of the Royal College
of Surgeons and a founder of the British Museum, at whose home he was a frequent
visitor, he arranged for seedlings from Sloane’s Chelsea Physic Garden to be sent to
his old university in Coimbra. Indeed, the University archives in Coimbra have a letter
from Sarmento giving advice on establishing a botanical garden.
In 1737 and 1738, Sarmento translated works by Sir Isaac Newton (1643-1727) into
Portuguese. These works, like his translation of Bacon and the Portuguese-English
dictionary, was never printed manuscript copies survive in London and Lisbon.

Figure 5 - Frontispiece of Sarmento’s Portuguese translation of Isaac Newton’s Theory of the Tides
(1737).
With the devastating Lisbon earthquake in 1755, he wrote a detailed letter outlining
the measures needed for the control of infection. These initiatives were only part of
his ongoing connections with Portugal, and he maintained contacts with former
friends and teachers. He had been consulted by the Count of Ericeira, on behalf of
King Dom João V (reigned 1706-1750), about needed medical reforms. He was also
close to the Marquis of Pombal, Sebastião José de Carvalho e Melo (1699-1782), the
Portuguese Ambassador in London from 1738 to 1745 and later Portuguese Secretary
of State for Internal Affairs, the equivalent of a Prime Minister today, from 1750 to
1777. Some of Sarmento’s writings were in Portuguese, and indeed during the 1730s
he was in communication with the Royal Academy in Lisbon and in a foreword on a
book featuring material on the Inquisition, he dedicates the work to Dom João V the
King of Portugal, seeing himself as a Portuguese expatriate in London, exiled merely
on religious grounds.
The connection with Sir Hans Sloane was to prove of value for Sarmento in
obtaining a British medical degree, the first Jew to do so in the English-speaking
world, at Marischal College, Aberdeen University in 1739 (9). Sarmento may have
given lectures to medical students in Aberdeen from around 1736, and the connection
with Sloane, as well as Sarmento’s eminence, may have encouraged both the
invitation to lecture as well as the award of the degree. Sarmento was recommended
for the degree by Sloane, Dr. Alexander Stewart and by Dr. Cromwell Mortimer a
British physician, antiquary and second secretary of the Royal Society from 1730 to
1752. There were many Jewish graduates at the Scottish universities in the last
quarter of the eighteenth century and the beginning of the nineteenth century whose
origins were clearly Spanish or Portuguese. However, there were some others whose
Jewish connection cannot be established, possibly as the graduates planned to remain
within the Portuguese speaking world.
Sarmento was a polymath, writing poetry and composing other literary works outside
medicine. During the 1730s, his medical researches advanced with a comprehensive
work on materia medica. He was studying the effects of mineral substances, emetics,
hypnotics and the practice of venesection as part of a wider study of therapeutic
practices. He continued involvement in the care of the sick amongst the synagogue’s
poor helping to set up a hospital, the Bet Holim, to serve their needs. But, at the
same time, he was involved in ongoing disputes with the synagogue leadership.
Sarmento’s identification with the synagogue faded after the death of Rabbi Nieto and
was shaken by the hostility of his encounters with a leading, though also heterodox
figure, Dr Mayer Schomberg (1690-1761), an early Jewish medical graduate in
Germany. These were among the factors that eventually caused him to relinquish his
membership.
The hospital remains amongst his legacies, along with his support of inoculation
against smallpox and in developing quinine and commercializing it as Agoas de
Inglaterra (English Waters). Patent issues relating to the Waters began during his
lifetime and continued for many decades after his death. After the death of his second
wife, Sarmento removed himself from the synagogue, and the children of his third
wife were baptised. What the Inquisition could not achieve his decades in England
could.
The Jewish medical diaspora from Portugal could be found in many countries around
Europe, but this survey has just shown some of the lives of prominent physicians who
returned to outward profession of Judaism in the major centres of London,
Amsterdam and Salonica. We have shown how many of those forced to seek
sanctuary beyond the country of their birth regarded themselves as religious exiles.
Thus, especially in England where a long-standing alliance with Portugal was in force,
they tried to maintain cultural and professional links with Portugal through the
eighteenth century.

References
1.Moisao Cristina. Teaching Medicine in Mediaeval Portugal. Vesalius: Journal of the

International Society for the History of Medicine 2015, XXI (2): 56-60.
2.Swetschinski Daniel M. Reluctant Cosmopolitans, The Portuguese Jews of Seventeenth-
Century Amsterdam. London: Littman Library of Jewish Civilization, 2000.
3.Hes H.S. Jewish Physicians in the Netherlands, 1600– 1940. Assen (Netherlands): Van
Gorcum, 1980. Also available at NLI Stacks 81B 156.
4.Lindeboom G.A. Dutch Medical Biography: A Biographical Dictionary of Dutch Physicians and
Surgeons, 1475–1975. Amsterdam: Rodopi, 1984.
5.Modena A. & Morpurgo E. Medici e Chirurgi Ebrei dottorati e licenziati nell'Università di
Padova dal 1617-1816. Bologna (Italy): Forni Publication, 1967.
6.d’Esaguy Augusto. A Page from the Portuguese History of Medicine: Dr. Jacob (or Henrique)
de Castro Sarmento. Instituto de Coimbra, 1946.
7.Barnett Richard. Dr. Jacob de Castro Sarmento and Sephardim in Medical Practice in 18th
Century London. Transactions of the Jewish Historical Society of England. 1978-1980, 27: 84-
114.
8.Goldish Matt. Newtonian, Converso, and Deist: The Lives of Jacob (Henrique) de Castro
Sarmento. Science in Context 1997, 10: 651-675.
9.Collins Kennett. The International Story of Jews and Medicine in Scotland. Aberdeen:
Aberdeen University Press 1988, 33-37.

CHRISTUS ANATOMICUS, FROM VESALIUS DRAWINGS TO WAX

MODELS
Laura Musajo-Somma1, Alfredo Musajo-Somma2
Abstract
Christ’s body, a devotional object as a holy relic or material replica, also offers a way of faith-
building for laypeople. Through anatomical dissection and representation, it is possible to
visualize the holy flesh turning into the Holy Spirit to save human souls. The holy dissected
right forearm and hand, for example, is easily detectable in the Vesalius’ woodcut portrait in
his De Humani Corporis Fabrica (1543) and further broadsheets offer more views of
anatomical dissection. Wax has been the perfect material, not only as a flesh-like envelope,
to show to the devout public the internal anatomy, even if not correctly represented. It
happened for the holy anatomy too, even in its deepest layers. Wax models of Christus
anatomicus are indeed rare pieces in the ceroplastic tradition. These tridimensional models
are not useful as a self-learning medical tool, but as a device for the spiritual elevation of a
private and religious audience. An unknown anatomical wax model of the crucified body of
Christ of the XVIII century never recorded before is here studied, linking history, anatomy,
art and religion. Moreover, we record a synoptic table useful to identify the 14 wax models of
Christus anatomicus existing mainly in Europe up to now.
Keywords
Christ; anatomy; Vesalius; wooden sculptures; wax models; ceroplastics
Résumé
Le Corps du Christ, objet dévotionnel en tant que relique sainte ou réplique matérielle, a
donné lieu à une manière de promouvoir la foi parmi les personnes laïques. Par la dissection
anatomique du cadavre et la reproduction de planches anatomiques, il devenait possible de
visualiser le corps sacré se transformant en Saint Esprit, sauveur d’âmes humaines. La
dissection sacrée d’un avant-bras droit et d’une main droite par exemple, est facilement
reconnaissable dans le portrait de Vésale sur la gravure en bois de son De Humani Corporis
Fabrica (1543). D’autres planches et feuillets ont également montré des dissections
anatomiques. La cire a été un matériau parfait, non seulement comme enveloppe couleur de
chair, mais aussi pour montrer au public dévot l’anatomie interne, même si elle n’était pas
toujours correctement représentée.
1 Laura Musajo-Somma, MD, Ph.D. Centro Interuniversitario di Ricerca “Seminario di Storia della
Scienza”, University of Bari – Italy. e-mail: musajosomma@libero.it. Authors’ address: Via Calefati,
190 – 70122 Bari, Italy.
2Alfredo Musajo-Somma, MD. Centro Interuniversitario di Ricerca “Seminario di Storia della Scienza”,
University of Bari - Italy e-mail: musajosomma@libero.it. Authors’ address: Via Calefati, 190 – 70122
Bari, Italy.
Ceci était vrai également pour l’anatomie sacrée, même s’agissant de ses couches les plus
profondes. Les modèles de cire du Christus anatomicus sont toutefois des pièces très rares
dans la tradition céroplastique.
Ces modèles tridimensionnels n’étaient pas utilisables comme support d’apprentissage
médical, mais comme moyen de stimuler l’esprit religieux d’une assistance publique ou
privée. Un modèle en cire, jusqu'à présent inconnu et jamais décrit du corps du Christ crucifié
datant du XVIIIe siècle, est étudié dans ce travail, qui lie histoire, anatomie, art et religion.
De plus, nous décrivons dans un tableau synoptique les 14 modèles en cire du Christus
anatomicus répertoriés en Europe jusqu'à aujourd'hui.
Mots-clés
Christ; anatomie; Vésale; sculptures en bois; modèles de cire; céroplastique
Introduction
In the western world, anatomy and medical studies were never really independent
from theological assumptions, at least until the past century. The philosophical-
historical approach to medicine explains the needs of a global view about medical
humanities. The old “Cartesian dualism”, according to which man is linked to two
independent substances, namely the material body and the spiritual mind, offers the
best challenge to what is the true professional goal of the doctor’s duty: the struggle
in healing the patients and not their illness or their rotten bodies.
From a spiritual and older point of view, the spirit that becomes flesh - the
embodiment of God since the childbirth of Jesus to his resurrection - is a mystery
represented in several ways in the Christian tradition: the qualities of the employed
materials and the abilities of the artists are of primary importance for the believer
satisfaction and to reinforce the personal devotion. Indeed, the Five Holy Wounds
suffered by Jesus Christ during the crucifixion were the object of deep adoration
during the late Middle Ages.
It means that the study of Jesus Christ anatomy is linked to the historical truth of the
Passion, to the demonstration of the accuracy of the biblical prophecies and the
confirmation of the double nature of Jesus Christ (human and divine), finding the
beauty in his visualized inner body (1). Moreover, science scholars tried to give their
interpretation, interested in the modifications of the anatomy and physiology of the
human body that occur at the end of life, in violent circumstances and punishment,
during the crucifixion (2). The link between science and religion could be observed
from several perspectives, like conflict or harmony, but it is not always possible to
support only one of them. Several historical and theological studies reshape the
conflictual dimension among them, mainly rethinking about the possibility of human
dissection during the Middle Ages, when it was performed (3). In the medical area,

even if medieval anatomy textbooks usually contained no illustrations, few eminent
physicians were graphically able to represent the Christus anatomicus: the Italian
anatomist Mondino de’ Luzzi (c. 270-1362) offers a good example (4) to embrace
rationality and the Christian faith, as shown in his masterpiece.
Figure 1 - Mondino de’ Luzzi, Anatomia Mundini, per Joannem Dryandrum, 1541.
Vesalius’ legacy
Indeed, further progress will be achieved by the famous Belgian anatomist Andreas
Vesalius (1514-1564), who, soon after the graduation at Padua University in 1537,
was appointed Professor of Surgery at the same Italian university. Vesalius was lucky
enough because he “suffered from no religious persecution” (5) in his revolutionary
approach to anatomy while confuting the prevailing Galenism.
As a Renaissance man, Vesalius considered the human body as a microcosm of God
and, in this view as a Lutheran man because he considered medicine and religion
“closely connected” (6). The Vesalius’ printed masterpiece De humani corporis fabrica
offers an outstanding example of art as a manifestation of commitment towards
medicine and religion.
If we consider Vesalius’ woodcut image printed from the woodblock of his portrait (7)
at the start in folio 6 v of the De humani corporis fabrica, we recognise a way of ego-
showing. The author of the portrait probably is the Flemish artist Jan van Calcar.
Figure 2 - Portrait of Vesalius in the Fabrica, 1543.
Vesalius is not only dissecting a cadaver: he seems to embrace, like a Holy Cross, the
skinned right forearm and hand of a symbolic man, a manikin looking like Jesus
Christ. It is convenient to stress that this simulacrum of a corpse is not a female one,
as some authors say (8) because of a fine piece of cloth around the hips, and it gives
the impression of one of the many wooden articulated figurines used in that period as
a support in drawing religious figures. Several Christ’s wooden sculptures show the
curled long hair on their neck side, and many of them have mobile arms: even today
in Lisbon (Portugal) the Real Irmandade dos Passos da Graca dresses Christ’s

mannequin with articulated arms, to start the holy liturgy, that is followed by a
crowded religious procession every Easter since 1587. Furthermore, the masterpiece
by Donatello (1386-1466) hosted in Padua’s church of Holy Mary of Servants, since a
century before Vesalius’ arrival to the Venetian area, is another example of this kind
of sculpture (9). The famous anatomist and surgeon offers the instructive image of a
master inspecting with self-esteem and even sacredness the body after death,
starting a new paradigm in medical knowledge. Hence, the selected Christ-like
mannequin the body for excellence in the Christian tradition that’s dominating the
drawing’s background, reinforces this concept.
Figure 3a - Cadaverous Christ, Donatello. Figure 3b - Torso mannequin, Vesalius drawing.
From wooden-carved to printed anatomical models
The tradition of wooden articulated figurines of Christ starts in Italy during the 15th
century (quite later than in other parts of Europe, where it started in the 10th-11th X-
centuries) is linked to the celebration of the Easter Triduum (Adoratio, Depositio et
Elevatio crucis) in order to give a realistic representation of the religious events.
Sometimes ‘miracles’ were planned and performed by preachers, offering to the
public a show of chest wounds’ bleeding and the spectacular eyes, tongue, neck, arms
and pelvis movements of the mannequin (10).
A more fascinating and innovative pedagogic tool is the multi-layered printed

anatomy by Vesalius, an educational resource for anatomy teaching. The conceptual

shifting towards a multi-level body dissection, in a printed form with loose flaps, is
available in Vesalius’ book Epitome (1543): broadsheets or broadsides with
anatomical annotated details could be cut out as superimposed images on a satellite
woodcut leaflet (11). Similar images are available in the Historia de la composición
del cuerpo humano (Rome, 1556) by Juan de Valverde Hamusco (1525-1587)
(12), who disseminated the Vesalian anatomy in the Spanish world.
The Dutch Johann Remmelin (1583-1632) offers a large scale of fugitive sheets and
loose printed flaps in his Catoptron microcosmicum (1613/1619): the plates are
drawn by Remmelin and engraved by Lukas Kilian (1579-1637) (13). In the second
plate (visio secunda) – a man dissection’s drawing – we can see Christ at the cross, at
the bottom on the right corner, as a reference to the human nature of God that could
not be forgotten by the anatomist in the Vesalius’ tradition. Other examples of books
containing moveable flaps are Bebaiosis agonismou - Das ist Confirmatio
Concertationis (Berlin 1576) by Leonhardt Thurneisser zum Thurn (1531-1596) (14),
Ophtalmodouleia das ist Augendienst (Dresden 1583) by George Bartisch (1535-
1607) (15) and Nosce te ipsum vel Anatomicum Vivum (Frankfurt und Leipzig 1716)
by Christoph von Hellwig (1663-1721) (16). The last one is similar to Remmlin’s book,
but the drawing of the dissection of the man showed in the tabula III lacks the
crucifix showed in Remmlin’s second plate.
Figure 4 - Johann Remmelin, Catoptrum microcosmicum, plate II.

Undoubtedly models of the body were made for a wide range of purposes from
anatomical study to obstetric training, public education, fine art and fulfilment of
faith. In the religious practice, the belief of attaining the ecstatic level was reinforced
by doctrinal reaffirmation tools.
Wax anatomical models: genesis and purpose
An artistic way to represent the human body in a realistic perspective is wax

modelling. Since the ancient era it was used to mould religious effigies, candles and
ex-votos; from the 18th century onwards, it was used to teach anatomy too. Bologna
and Florence were the leading areas in the anatomical wax models’ production, known
in Italy as ceroplastica. Ercole Lelli (1702-1766), Anna Morandi (1714-1774),
Giovanni Manzolini (1700-1755) were active in Bologna, while Clemente Susini (1754-
1814) – among others – was active in Florence under the direction of Felice Fontana
(1730-1805) at La Specola (17).
In the 18th century Enlightenment, the catholic rulers were obviously engaged in
controlling lay-people knowledge and strengthening their belief even through wax
production of Christus anatomicus, mainly in the convents of the Carmelite nuns. Wax
models were meant both as an educational body and memento mori (an artistic
concept in Latin for “remember that you will die”) warning, very useful to remind the
viewers of death to urge them living a pious life to avoid divine punishment. They
often used images of the cadaver or skeleton as meditation tools (18).
The peculiarity is that this kind of male model is the main counterpart of the wax
anatomical Venus: they differ in size and gender, but both of them are demountable
and manufactured in few specimens. It seems that the Holy body of Christ has the
privilege to be virtually observed and dissected, if compared to the wax male whole-
body models realized during the 18th century, usually as échorchés, showing only the
muscles, or to the one-time demountable skinned man showing the lymphatic system
stored in the Museum for the History of University of Pavia (Italy).
Wax anatomical models: recognition, collection and interpretation
Very few anatomical wax models of Jesus Christ are extant from the past centuries,
and therefore they are almost unknown to the general public. His human – and
internal – essence, even in sufferance, is finely represented in a poor material like
wax, leading at the unification of art, religion and science, according to the Italian
ceroplastica tradition. From a medical point of view, the two well-known wax
specimens of Christus anatomicus – with a movable rotating door in the front side of
the torso – preserved in a museum of the history of medicine are in Ingolstadt
(Germany) (19).
In the first model, Christ is immensely suffering approaching death, without the cross,
and in the second model, He is lying dead and recumbent in the coffin.

The last one is a really rare piece of hand-craftsmanship. Turning the chest door over
the body left- side Jesus’ inner anatomy is offered to the pious audience.
It is useful to remember that religious images were read by their symbols to people
who did not know how to read or have no easy access to books.
Moreover, three wax models of the 18th century are still preserved in quite different
public institutions in central-southern Italy: the Museum of agriculture and rural world
in San Martino in Rio (Reggio Emilia) (20), the Diocesan Museum in Ostuni (Brindisi)
(21) and the Pinacotheca Caracciolo in Lecce. More few known models are housed in
private collections in southern Italy, and this recognition is a starting point to be
implemented through continuous research activity and broader study.
A previously unrecorded wax anatomic Christ is nailed to a wooden cross; overall
measuring 73 cm high, 36 cm wide, 10 cm depth, weight 1.6 kg.
Figure 5a - Christ in the cross. Figure 5b - Christ in the cross, front torso mobile wall .
The piece belongs to a private Italian collection3 since almost four generations and
was preserved under glass protection until thirty years ago when it was accidentally
broken. Subsequently, one arm was damaged. Therefore, the model was restored. We
do not know precisely when this specimen was manufactured.
3 The name of the owner’s family is reserved; they hold the right to be named at their request.

However, it seems it could belong to the 17th-18th centuries, taking into account
the following stylistic patterns: the model has some elements in common with the
Christ displayed in the painting “The Crucifixion with the Virgin and Saint John” by the
Dutch Hendrick ter Brugghen (1588-1629), an exponent of Caravaggism in northern
Europe (c.1625): the presence of the skull at the bottom of the cross in both the
representations and the vivid representation of bleeding from the holy wounds, that is
typical of the Gothic Christ in pain. The skull and crossbones symbolize several things
in Christian art, especially on Crucifixes.
The skull of Adam for one, as it was believed Christ was crucified over the Grave of
Adam. It is shown at the bottom of the Crucifix and reminds us memento mori, in
Christian art, especially on Crucifixes.
The skull of Adam for one, as it was believed Christ was crucified over the Grave of
Adam. It is shown at the bottom of the Crucifix and reminds us memento mori,
“Remember thy Death”. The skull and crossbones symbols carry an ancient tradition:
Adam was created and also buried on Calvary (from Latin calva: “bald head” or
“skull”), that is Golgotha (in Aramaic: skull) and this is the place where Christ was
crucified. His running blood offers the soul’s redemption to humankind.
Moreover, the lettering reading INRI displayed at the top of the cross is a single
acrostic written in Latin, meaning: Jesus, the Nazarene, the king of Jews. We can
observe similar details in the paintings by Luis Tristan, “The Crucifixion” (c.1613,
Figure 5c - Christ in the cross, front torso displaying deep internal anatomy.

Prado-Madrid), and by Pierre Subleyras, “Christ Crucified with St. Eusebius, St. Philip
Neri and St. Mary Magdalen” (1744, Pinacoteca di Brera-Milan): the title board is
hammered to the crucifix above the head of Jesus, and the skull with only part of long
bones is on the ground at the bottom of the cross.
The beautiful image of Christ crucified appears to draw divine love towards all the
creatures. Indeed, this devotional wax sculpture is an unusual representation of the
Christ because the front torso mobile wall (7 cm high, 3 cm wide) opens to show his
internal anatomical structures (chest wall, lungs, heart, stomach, pancreas, bowels
are visible), even if manufactured with some approximation. Usually, an internal iron
armature is unnecessary, as we could see if comparing the model with another broken
and recumbent one of the 19th century, preserved in another private collection in
Southern Italy. The model, preserved under a glass cover and with a pillow under its
head, is laying on pink satin hemmed by yellowed lace (22).
Integrative imaging studies - like Co-focal microscopy, CT scanning, X-rays and
chromatography are among the research tools planned to investigate the
manufacturing of this special waxwork, made not only to health education or
decorative entertainment but also to religious empowering.
Another privately owned wax specimen located in Southern Italy shows the Madonna
with a dead Jesus Christ: it was manufactured by the Neapolitan school of
ceroplastica during the 18th century and is preserved under a glass cover.
This Piety wax complex is stored in a private collection of the Apulia regional area
(Southern Italy, near Brindisi) and is up to now the only one Piety figuring in our
census. In deep sorrow and looking at the sky, the Mother holds the Holy body of her
Son, whose head is posed on her left thigh. The Christ abdominal wall could be
removed to show the differentiated parts of the internal anatomy. The Mother in pain
offers to the believers a double exhibition: the Son and his anatomic organs, as
unexpected gifts (23).
Piety, as well as scenes of martyrdom and crucifixions, were a traditional artistic
representation of the teachings in the Roman Catholic religion. The anatomic readings
invite faithful observers to have a closer look at the inner working of the holy body.
The torso door is opened (the pivot point usually being on the left side of the thorax)
to show the flesh turning to the Holy Spirit. Therefore, there is no pain elicited in the
viewers' eyes, but a deep sense of "spiritual" suffering.
Many popular religious guides, such as Loyola's Spiritual Exercises, encouraged 18th
century Catholics to feel grief and great affliction when they contemplated the passion
of Christ. Moreover, praying and possibly touching the anatomically cut wax simulacra
of Christ's body offered the chance to internalize Jesus' extreme sufferings (24).
Even if religion offers relief to the believers and calm their souls, it could turn
traumatic in specific or stressful situations (25); therefore, these wax models could be
disturbing to someone. Herein we have collected a list of the 14 models of Christus
anatomicus, as recorded up-to-now. The following synoptic table helps to identify all
of them:

Table 1-14 models of Christus anatomicus synoptic table.
MODEL DESCRIPTION LOCATION DISPLAY

Moribund Christ (26) Without cross Ingolstadt, Germany Yes
Moribund Christ (27) Without cross San Martino in Rio, Italy Yes
Moribund Christ (28) Without cross Ostuni, Italy Yes
Moribund Christ (29) Without cross, partial ? ?
thorny crown
Moribund Christ (30) Without cross, broken Rubenstein Library, Duke Yes
arms and legs, University, USA
photograph
Moribund Christ (31) At cross without INRI ? ?
Moribund Christ (32) At cross without INRI, Private seller, Italy ?
20 cm length, thorny
crown, restored
Moribund Christ At cross without INRI, Pinacotheca Caracciolo, Yes
thorny crown Lecce, Italy
Moribund Christ (33) At cross with INRI Museum, Sicily, Italy ?
Moribund Christ At cross with INRI, South-eastern Italy No
thorny crown
Fig. 5 a-b-c wax in the
text
Christ in the coffin (34) Whole body Ingolstadt, Germany Yes
Christ in the coffin (35) Whole body Europe ?
Christ in the coffin (36) Broken body on pink Campania region, South- Yes
satin western Italy
Madonna with dead Whole body Near Brindisi, South- Yes
Christ (37) eastern Italy
These rare models are dedicated to a private cult, remembering quite well the human
nature of God that is so typical of the Christian tradition, even if they are useless for
exact anatomical knowledge. Surely their impact on meditation about agony and the
end of life is strong enough to reinforce the Christian believers’ faith. Through
anatomical dissection and representation, it is possible to visualize the holy flesh
turning into the Holy Spirit to save human souls. Therefore, the wax was the perfect
medium, not only as a flesh envelope, to show to the devout public the internal
anatomy, even if it is not correctly represented.
Conclusion
Science is based on experimental verification and religions rely on faith; nevertheless,

the representation of Christus anatomicus is the paradigmatic synthesis of two
different ways of knowing ultimate truths in the Christian domain. Most of all, the
intersection of science and religion needs to be evaluated in its social and historical
context (38), just avoiding any cultural misunderstanding. Therefore, Christus

anatomicus and the better known Christus medicus (whose teachings influence
definite statements both of ethical codes and medical deontology) are the relevant
symbols in the Christian tradition, and they elicit a true Christo-praxis for the
believers. They belong to the historical medical inheritance in several cultures
because Jesus was a 1st century CE Jewish teacher and is still an important symbol in
other religions.
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muovevano-braccia-occhi-e-lingua/ (accessed: 28 October 2018);
La suggestione dei Crocifissi animati,
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des sciences médicales, XL, (2), 177-189.
(12)Valverde de Amusco, Juan (1556), Historia de la composición del cuerpo humano, Roma,
Antonio Salamanca y Antonio Lafreri.

(13)Remmelin, Johann (1619). Catoptrum Microcosmicum, suis aere incisis visionibus
splendens, cum historia, et pinace, de novo prodit, Augsburg; David Franck.
(14)Thurneisser zum Thurn, Leonhardt, (1576) Bebaiosis agonismou - Das ist Confirmatio
Concertationis, Berlin: im Grauwen Closter.
(15)Bartisch, George, Ophtalmodouleia das ist Augendienst (1583), Dresden: Matthes
Stöckel.
(16)Von Hellwig Christoph, Nosce te ipsum vel Anatomicum Vivum, (1716), Frankfurt: Georg
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(17)Henderson, John (1997), Piety and Charity in Late Medieval Florence, University of
Chicago Press. Musajo Somma, Laura (2007). In cera. Anatomia e medicina nel XVIII secolo,
Bari; Progedit.
(18)Ebenstein, Joanna (2017). Death: A Graveside Companion, London; Thames & Hudson.
(19)Precht, Richard David (2017). Erkenne dich selbst: Geschichte der Philosophie 2,
Munchen; Goldmann Verlag. Christus Anatomicus - Jesusfigur am Kreuz mit aufklappbarer
Bauchdecke und Organen © Deutsches Medizinhistorisches Museum Ingolstadt, Foto: Michael
Kowalski.
(20)Dal Forno, Federica (2013). Anatomia del sacro. Il crocefisso in cera del Museo di San
Martino in Rio, Regione Emilia Romagna; IBC.
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collezione/il-crocifisso-anatomico-in-cera/ (accessed: 22 August 2018).
(22)https://www.ebay.it/itm/Cristo-umanizzato-in-cera-del-700-
/202386606430nordt=true&orig_cvip=true&rt=nc&_trksid=p2047675.m43663.l10137(access
ed: 23 August 2018); https://picclick.it/Cristo-umanizzato-in-cera-del-202386606430.html
(accessed: 07 August 2018).
(23)https://www.subito.it/hobby-collezionismo/prestigiosa-madonna-in-cera-del-700- brindisi-
250793744.htm (accessed: 15 August 2018).
(24)Hills, Helen (2008), “Nuns and relics in Southern Italy” in: Cordula van Wyhe (ed.),
Female Monasticism in Early Modern Europe: Aldershot. 2008, 11-39.
(25)Winell, Marlene (May 2011), Religious Trauma Syndrome: It’s Time to Recognize It,
“Cognitive Behavioural Therapy Today”, Vol. 39 (2), 16-18.
(26)Precht, R. D. (2017). Christus Anatomicus – Jesusfigur, Foto: Michael Kowalski.
(27)Dal Forno, Federica (2013) (See note 20).
(28)De Giorgio, Teodoro (See note 21).
(29)Cenzi, Ivan, La mia wunderkammer, in: Bizzarro Bazar blog,
http://bizzarrobazar.com/2015/08/26/la-mia-wunderkammer/ (accessed: 28 August 2018).
(30)Buckley, Cali, Other objects #4: wax Jesus figures,
https://ivoryladies.wordpress.com/2016/09/13/other-objects-4-wax-jesus-figures/(accessed:
22 October 2017).
(31) Ibid.
(32) The model was realized in Sicily (Italy) during XVII-XVIII century
http://www.fleaglass.com/ads/italian-wax-anatomical-christ-xvii-xviii-c/ (accessed: 22
October 2017); https://www.pinterest.it/pin/290834088428505604/?lp=true (accessed: 07
August 2018).
(33) Buckley, Cali (See note 30).
(34) Precht, R.D. (2017). Christus Anatomicus - Jesusfigur, Foto: Michael Kowalski. Buckley,
(35)C. Buckley, Cali (See note 30).
(36)https://www.ebay.it/itm/Cristo-umanizzato-in-cera-del-700-
/202386606430nordt=true&orig_cvip=true&rt=nc&_trksid=p2047675.m43663.l10137(access
ed: 23 August 2018); https://picclick.it/Cristo-umanizzato-in-cera-del-202386606430.html
(accessed: 07 August 2018).
(37)https://www.subito.it/hobby-collezionismo/prestigiosa-madonna-in-cera-del-700- brindisi-
250793744.htm (accessed: 15 August 2018).

(38)Ferngren, Gary B. (2017). Science and Religion: A Historical Introduction, 2nd edn.,
Baltimore; John Hopkins University Press.

THE APPEARANCE OF BUBONIC PLAGUE IN OPORTO, 1899
Joao Martins e Silva1

Abstract
A bubonic plague epidemic broke out in the Portuguese city of Oporto in June 1899. Six
months later, when it had come to an end, 132 deaths along 320 patients had been recorded.
Although it was a city with industrial activity and the precursor of several technological
innovations, the hygienic and sanitary conditions of the population of Oporto at that time left
a lot to be desired. These features certainly made it easier for the plague to spread, which
was detected by unusual deaths in those residing in dilapidated and dirty houses by the river
Douro. Ricardo Jorge (1858-1939), the municipal doctor at the time, did not hesitate in
stating that the outbreak showed clinical, epidemiological and technological signs of bubonic
plague. Civil authorities and the press played down the event for more than a month. Finally,
by order of the Government, a wide cordon sanitaire was established around the city, to
prevent the spread of the epidemic to the rest of the country. As this resolution was not
welcomed by the population, traders, and medical associations, the Government was forced
to remove the city siege. Ricardo Jorge, who discovered the cause of the disease and was the
main individual promoting the sanitary measures carried out, decided to abandon Oporto and
settle in Lisbon after being unfairly misunderstood and subject to persecution.
Keywords
Oporto; bubonic plague; epidemic; cordon sanitaire; sanitary measures
Résumé
Une épidémie de peste bubonique a éclaté dans la ville portugaise de Oporto en juin 1899.
Six mois plus tard, une fois terminée, 132 décès et 320 patients ont été enregistrés. Bien que
ce fût une ville avec une activité industrielle et le précurseur de plusieurs innovations
technologiques, les conditions d'hygiène et d'hygiène de la population de Oporto à cette
époque laissaient beaucoup à désirer. Ces caractéristiques ont certainement facilité la
propagation de la peste, qui a été détectée par des décès inhabituels chez ceux résidant dans
des maisons délabrées et sales au bord du fleuve Douro. Ricardo Jorge (1858-1939), alors
médecin municipal, n'hésita pas à déclarer que l'épidémie montrait des signes cliniques,
épidémiologiques et technologiques de peste bubonique. Les autorités civiles et la presse ont
minimisé l'événement pendant plus d'un mois. Enfin, sur ordre du Gouvernement, un large
cordon sanitaire a été établi autour de la ville, pour empêcher la propagation de l'épidémie
dans le reste du pays. Cette résolution n'ayant pas été bien accueillie par la population, les
commerçants et les associations médicales, le gouvernement a été contraint de lever le siège
de la ville.
1 Full professor and ex-dean, retired, of the University of Lisbon Medical School. University of Lisbon
Faculty of Medicine, Lisbon, Portugal. Corresponding author: email: jsilva@fm.ul.pt

Ricardo Jorge, qui a découvert la cause de la maladie et a été le principal promoteur des
mesures sanitaires prises, a décidé d'abandonner Porto et de s'installer à Lisbonne après
avoir été injustement mal compris et soumis à la persécution.
Mots clés
Porto; peste bubonique; épidémie; cordon sanitaire; mesures sanitaires
Introduction
In 1899, about 300 years after the last major epidemic in Oporto, an epidemic of
plague broke out in this city. The source of the outbreak was never clarified, though it
was listed as an expansion of the Third Pandemic, which had started in China in the
middle of the 19th century. This pandemic, like the earlier ones, had as its infectious
agent the bacterium (1-3). The discovery of the infecting bacteria, as well as the
infection vulnerability of rats and other small rodents, was attributed to Alexandre
Yersin (1863-1943), then on duty at the Pasteur Institute in Hong Kong (4). The
process of disease transmission was unclear, the restriction of movement in countries
where there were outbreaks of plague was recommended. Three years later, Paul-
Louis Simond (1858-1947) identified the flea as the main vector of transmission of
the plague from rats to men (5). Until 1899, Oporto was the last European city to have
been hit by bubonic plague. The existence of endemic foci in Asia and Africa through
maritime and passenger intercommunication might be the focus of plausible
contamination in Oporto (6).
This essay focuses on the discovery, development, and the economic and social
consequences of the epidemic, and highlights the decisive contribution made by
Ricardo Jorge (1858-1939), at the time municipal doctor and professor of Hygiene
and Forensic Medicine of the Medical Surgical School of Oporto in the diagnosis of
plague in the implementation of local public health control measures.
Early signs of illness and sanitary measures
On 4 July 1899, an Oporto trader alarmed by several deaths which had recently
occurred on Fonte Taurina Street (a long filthy narrow road dating from the
fourteenth century, running along the Douro river quay), sent a note to the municipal
doctor, Ricardo Jorge, advising him of this occurrence. On the first observation, he
found that the death certificates associated with those deaths which had been
reported referred to banal causes of illness. After gathering local information on the
incident, he discovered there were additional people sick with fever, some of them
with axillary bubo. By confirming this information on the spot, he concluded that the
situation was an epidemic focus for a serious disease, centred on that route (7).
He immediately notified the civil authorities of the situation, and the clinical director

of the Hospital de Santo António was required to isolate the examined patients
urgently.
Figure 1-Graphic reproduction of the Hospital de Santo António. Author: Alberto. In: Manuel M.
Rodrigues, “Hospital da Misericórdia do Oporto”, Occidente, 7:243246, 1884. Courtesy: Hemeroteca
Digital da Câmara Municipal de Lisboa.
Table I
Health and information measures instituted by the Municipality of
OOporto
1- Sanitary
- Construction of public toilets for personal hygiene (free public baths);
- Use of municipal disinfection station;
- Use of hospitals and isolation centres for patients infected with plague;
- Establishment of a public sanitation body for street cleaning, funeral pickets,
disinfection, isolation, closure or fire disposal of uninhabitable or contaminated
houses;
- Extermination of rats (and fleas);
- Administration of serum and vaccination against plague;
- Autopsy of all suspected or confirmed cases
2- Statistics bulletin, with daily information about the epidemic

Sanitation and prophylactic measures were activated (Table I). House owners and
tenants were coerced into cleaning contaminated housing, after repeated insistence,
after this had been met with great reluctance. On 7 July some information in the
press referred to disease and the measures taken, though without any mention of a
possible epidemic.
The epidemic was reported to have started about a month previously in residents of
three adjoining houses on Fonte Taurina Street, mostly shippers and their relatives
from Galicia (Spain). The disease had progressed insidiously and gone unnoticed,
having been confused with typhus or typhoid fever by different doctors (8). The
condition had generally evolved with fever, severe prostration, gastrointestinal
changes and massive ganglion engorgement (buboes) in the armpits and groins.
Of the seventeen cases of which Ricardo Jorge was then aware, and had observed
with the symptomatology and evolution that raised no doubt as to the nature of the
disease, six had died. In addition, there were other patients who, because they had
revealed suspicious symptoms or who simply known about by information from third
parties, were awaiting further study. Thus, on 9 July, Ricardo Jorge was fully
convinced that the clinical picture indicated bubonic plague. This information was
reiterated in two reports sent (on 12 and 28 July) to the city authorities and the
Government, along with a critical analysis of the living, working and social
circumstances that had favoured the spread of the epidemic in the city (9).
Figure 2-Patient with bubo in the left groin. Unidentified author. In: Paul-Louis Simond "La peste, ses
causes et ses remèdes", Le Mouvement Thérapeutique et médical, N°6. Juin 1901. Courtesy: Institut
Pasteur/Archives Paul-Louis Simond.

The sanitation problems detected in the city particularly affected a zone close to the
river (known as “medieval Oporto”, such as the Sé, São Nicolau, Vitória and Miragaia
quarters) where about 1/3 of the population of Oporto lived. This overcrowded zone
was characterized by degraded housing, without minimum health and hygienic
conditions (8,9). Much of its inhabitants had been attracted to the city by the industrial
development which had been recorded in Oporto since the second half of the
nineteenth century, particularly in cotton textiles.
The growing expansion of this proletariat along with their families, coupled with the
parallel real estate speculation of the landlords, led to a severe housing crisis and a
virtual inability to lease by the poorest (10,11). They were left to settle in degrading and
filthy conditions, whether on floors or quarters of the old city, on slender three- and
four-level buildings separated by narrow paths, known as “colmeias” or on lots of
small single-storey or one-room dwellings, the “ilhas”, usually located at the back of
middle-class homes (12,13).
In these dark, smoky, foul-smelling neighbourhoods, humans sometimes cohabitated
in the small ground-floor space with domestic animals. Lacking any water supply and
sanitation facilities, these dwellings provided all the conditions to host outbreaks of
disease, in particular tuberculosis and plague (13-17).
Although there had been no official statement regarding the aetiology of the
epidemic, rumours were rife in the city and in certain elements of the press that it
was bubonic plague. Although this had not been confirmed, this was a source of great
surprise leading to inevitable insecurity and panic in a population aware of the
successive seasonal or occasional, and often deadly, epidemics that had devastated
the city during the nineteenth century (17-18).
The fact that the epidemic had not come unobtrusively, without the signals that the
collective memory conveyed of the devastating plague pandemics of the medieval
past, preceded by rat and other rodent epizootics, explained that neither the general
population nor some doctors accepted the clinical diagnosis advocated by Ricardo
Jorge.
By raising doubts about the nature of the disease, the source of the epidemic was
unknown. If maritime, it would have come by sea from Asia. However, the eastern
goods that had entered Oporto since 15 May had arrived from northern European
countries, where there were no signs of the disease, and had remained there for
months before being transported to Portugal.
Likewise, there was no news that vessels from India, China or other regions had
docked in Oporto (19). However, although with some credible opposition, the possibility
of the epidemic having spread through the cargo of the City of Cork ship, which often
made its way to Oporto from other European posts, was insistently disseminated (20-
22).
On its previous voyage, that ship had left London on 13 May and arrived in Oporto
coming from Newport on 5 June (23).

Confirmation of the plague diagnosis
There was an urgency to identify the disease-causing microorganism quickly, but all
attempts to isolate the contaminant that had been tested by Ricardo Jorge proved
unsuccessful. The scant number of patients registered in the first weeks of July gave
him hope that the epidemic was over; however, about two weeks later, it would break
out in the centre and highest points of Oporto, mostly in relatively clean, hygienic
housing or shops. However, the affected patients were usually servants and clerks,
poor people with a difficult life, and rarely their employers (24).
Finally, on 8 August, from the pus collected from one patient's bubo, Ricardo Jorge
was able to isolate the bacterium Yersinia pestis (25), confirmed two days later by
Professor Câmara Pestana in another sample of the same patient.
Figure 3-Microscopic observations of the plague bacillus identified by Professor Ricardo Jorge (1899).
Author: António Plácido da Costa. Courtesy: Museu de História da Medicina “Maximiano Lemos” da
Faculdade de Medicina da Universidade do Porto.
The Society of Medicine and Surgery of Oporto, presented with the evidence, took
away the doubts of the most sceptical who thus supported the diagnosis.

Subsequent inoculation of these cultures on rats and guinea pigs proved to be very
virulent and deadly. The method of bacterial collection was progressively diversified,
in buboes (in vivo) or all types of human ganglia and viscera (by autopsy), in the
blood of humans with septicaemia and ganglia of infected animals (cats and rats) (26).
The detailed information obtained from these results was only provided to the official
bodies in a report dated 17 August. By the end of this month, 54 plague cases had
been detected, resulting in 23 deaths (42.5% mortality rate).
One month later, these values rose to 120 patients, with 41 deaths (34.1%
mortality). It was hypothesised that there were further undiagnosed cases (about 1/5
of the total reported by September 29), either because they showed an irrelevant
clinical picture, or died without medical care or had not been notified. (27). Overall, the
percentage of deaths from the plague was much lower than that of other causes in
the same period (28). The epidemic turned out an attenuated form of the disease.
Bruised by the doubts that had beset his countrymen and the contradictions and
scant support of local authorities and the Government with regard to the epidemic, it
seemed to Ricardo Jorge that the diagnosis would have to be corroborated by foreign
experts who were familiar with the disease. Given this, the Pasteur Institute, with
extensive experience in the research and preparation of plague sera and vaccines,
was invited to send a medical mission from that institution.
Between August and November, besides the French mission, many doctors arrived in
Oporto to study and follow the evolution of the epidemic, most of them sent by their
governments or institutions, namely from Spain, Germany, Russia, Italy, Norway,
Sweden, Great Britain, and The United States of America.
While in Oporto, those doctors were able to collect and culture plague bacteria on
available samples, and to compare their results with the original Yersinia pestis
specimen, which had been isolated in the Ricardo Jorge laboratory, and with that
following by the French team. The identification among the various samples was total,
thus confirming the previous diagnosis (clinical, epidemiological and bacteriological)
advocated by Ricardo Jorge (29-31).
Official confirmation of the plague epidemic in Oporto
After the first reports received from Ricardo Jorge indicating the existence of an
outbreak of an epidemic in Oporto, and the lack of availability of further hospital
admittance at the Hospital de Santo António, the Government decided to support
some of the health measures already promoted or requested by the Oporto County,
namely the adaptation and activation of a tent hospital for the isolation and treatment
of plague patients, together with other measures, including means of transporting the
sick , sanitation of the city, sanitary inspection, disinfection services, compliance with

current public health and legal provisions, demolition or upgrading of buildings as well
as buildings harmful to public hygiene. Precautions against the epidemic were
extended to all districts of the country, hoping to prevent the spread of the epidemic
(32).
Figure 4-Incineration by firefighters of houses contaminated by the plague, in an "island" of Oporto.

Author: Aurélio da Paz dos Reis. Courtesy: Centro Português de Fotografia.
Figure 5-Municipal disinfection service car with a special corporation of fire brigade disinfecting
mattresses with disinfectant spray as they are removed from the vehicle. [MS.02952]. Author: Guedes.
Courtesy: Museu de Saúde- Instituto Nacional de Saúde Doutor Ricardo Jorge.

Figure 6-Photograph of patient being transported in an animal-drawn carriage by five salvation corps
staff [MS.02950]. Author: Guedes. Courtesy: Museu de Saúde- Instituto Nacional de Saúde Doutor
Ricardo Jorge.
Concern about the public health problems occurring in Oporto, and the potential risk
of their spreading throughout national territory had led the Government to demand
that all civilian governors in the country strictly comply with sanitary provisions.
However, certain elements of the national and foreign press were critical of the
situation in Oporto (33-35).
On 17 August the Government officially announced the existence of a bubonic plague
epidemic in Oporto (36). Subsequently, a set of restrictions on the city's
communication with the outside were imposed, namely: (a) Suppression of excursion
trains, fairs, pilgrimages and other gatherings that led to the entry or exit of
holidaymakers in or from the city of Oporto; (b) Medical inspection of all train
passengers and staff leaving Oporto; anyone with suspicious symptoms of plague was
prevented from travelling; (c) Travellers’ luggage and goods were disinfected on
departure from Oporto; goods which did not have such treatment were carried by
sea; (e) Passengers in transit carried a bulletin containing the results of such
inspections; (d) Passengers in transit had a guide containing the results of the
inspections to present at the destination.; (e) Passengers and train staff had to report
to the medical inspection within nine days of arrival; the inspection was carried out in
Lisbon by the health sub-delegate and, in the remaining destinies, by the municipal
party doctor; (f) Passengers with suspected signs of illness were referred for isolation
in hospital facilities, lazarettos or wards, as available locally; g) The responsible for

any place of accommodation would have to report daily to the police the origin of all
individuals who settled there;
(h) Violators of the previous provision were subject to penalties of qualified
disobedience and a fine, and, when found in contravention, immediately arrested,
until they tried.
About a week later, the Government decreed the isolation of the city of Oporto by
military forces. The project which had been approved consisted of a large terrestrial
and marine cordon, which was officially active between 27 August and the end of
December 1899 (37).
In order to ensure public defence against the epidemic, it was established that
people, luggage and goods coming from Oporto could only leave the cordon at
predetermined locations. Plans were set in motion to install a lazaretto for the prior
quarantine and disinfection of those who wanted to leave the city. Those violating the
rules which had been laid down were subject to fines and imprisonment of three to six
months, even without being charged.
About a month later it became clear that the carriages taking the passengers coming
from Oporto had to be identified abroad. Passengers could disembark only at the
stations stated in their bulletins. Those who reported or captured passengers who had
avoided health inspection were rewarded. Concealment of patients with plague or
those suspected of the disease was also punished. The population was instructed on
individual and domestic defence against bubonic plague, and were issued notices and
preventive legal texts for transportation, hospitalization and disinfestation, which in
the following months added financial support for sanitation works in several cities in
the Kingdom.
Reaction of Oporto institutions and population to the sanitary cordon
Admittedly, much of the illiterate population and most of the disadvantaged classes
reacted in response to their living difficulties and with little knowledge of the cause.
However, a part of the more enlightened and economically savvy public also doubted
the seriousness of the situation, or contested the sanitary measures imposed (38).
Moreover, the inhabitants, and in particular trade and industry associations, seemed
more concerned with the economic consequences of the blockade than with the
course and spread of the epidemic (39, 40). The city was being deprived by all kinds of
necessary goods, including food, and was also prevented from exporting local
products, especially to the north of the country and abroad. Faced with this situation,
most of the representatives of commerce, industry and city owners held a first large
meeting on 25 August near the Stock Exchange building, to assess the economic
effects caused by the isolation of the city (40). This type of meeting was repeated
almost daily in the following weeks. Their resulting conclusions, sent by telegram to
the civil authorities of the district and Government, and complaints about the
progressive worsening of the situation, called for precise, sensible and effective
instructions regarding the movement of passengers and goods out of the city. The
president of the Government would usually give reassuring answers regarding the
forthcoming resolution of the claims submitted, but these did not soon materialise.
Following this governmental attitude, the commerce commission, as well as the
mayor, resigned on 1 September, and three days later the city's industrialists had
shut down the factories and trade and industry strikes followed. The redundancies
following the closure of shops and factories, plus the famine, fear of the future and
the depression that set in among those most affected by these decisions, led to the
natural worsening of the social situation (41, 42, 43).
On the same day, it had determined the installation of the sanitary cordon, the
Government appointed a medical commission that, sent from Lisbon, was in charge of
presenting a report on the type of disease existing in Oporto, sanitary conditions in
the city and the effectiveness of the measures provided in the meantime, for their
improvement, and advice on any changes to be made in defence of public health (44,
45). In other words, it seemed that the Government wanted to postpone the necessary
solutions.
Once the mission had been accomplished, the commission presented a report of what
it had observed to the Government. It also proposed a set of measures, namely,
reduction of the cordon to facilitate medical inspection; (b) Locating medical posts on
the way out; (c) Restoration of trains, together with medical inspection and
disinfection of passenger baggage, goods and foodstuffs from Oporto; (c) Installation
of a disinfection station in the port of Leixões and (d) The abolition of quarantine in
the other national seaports for the goods sent there (46).
These proposals, fully supported by the Lisbon Society of Medical Sciences and the
Oporto Commercial and Industrial Associations, were ignored by the Government
that, after hearing the Consultative Health Advisory Board, decided to maintain the
sanitary cordon, in line with previous facts. This attitude caused great indignation on
the part of the medical profession of Oporto and the referred commission, the reason
why, in a telegram sent to the King, he was invited to visit and to verify the
uselessness of that measure, and to undertake the resignation of the that Health
Board. Other individuals and medical societies also pronounced negatively on the
exaggerated rigour or the actual implementation of the sanitary cordon (47-49).
Sanitary cordon failure
The Government's decision to isolate the city of Oporto during the period of the
epidemic had been made with the intention of preventing the spread of the plague to
the rest of the country. These attempts would soon be thwarted after four months of
the cordon.
In addition to weak compliance by the population with the institution of sanitary
measures, several factors contributed to the failure of the sanitary cordon. On the one

hand, the carelessness and/or insubordination of certain technical and civic personnel
responsible for executing and enforcing sanitary precautions systematically challenged
the preventive intentions established (50). The sanitary cordon, which was set up on
23 August, took about ten days to install, so that between 20 000 and 40 000 (out of
180 000) of the Oporto population would have been able to get ahead of the plague
and also perhaps food shortages and popular riots. They drove away from the city by
road or rail, which provided access in unchecked areas (51-53). However, even after it
was established, the sanitary cordon was quite permeable, so the occurrence of new
plague cases in September, outside the cordon limits, namely in Barcelos, Braga,
Guimarães, Santo Tirso, in some villages of the Douro, and along the Oporto-Lisbon
railway, raised concern for an epidemic with unforeseen dimensions (54). All
communications between the Portuguese coastal and islands ports had been
interrupted (55). The cordon proved ineffective and counterproductive. Members of the
foreign medical expert missions present in Portugal also firmly rejected the
application of the sanitary cordon, which supported the position of the sanitary
commission sent to Oporto, that of the medical scientific societies of Oporto and
Lisbon, and supported the complaints by the Oporto press, traders and industry
associations (56, 57).
Perhaps decisive for the popular rejection of the cordon has been the news, reported
by the periodical press, about the International Sanitary Conferences on the methods
of containing major epidemics. At the 10th Conference in Venice, 1897, scientific
consensus had been reached as to the nature of the infecting agent, the participation
of small rodents in its spread, and the uselessness of sanitary cordons and lazarettos
(58).
Pressured by the chorus of protests against such an economic and social debacle, the
Government decided to prepare a lighter set of reforms to be implemented as soon as
possible. To achieve this objective, it appointed an inspector for the health services of
Oporto, whose mission was to combat and prevent the spread of the plague, to map
out better coordination (until then distributed between the municipal services and the
civil governor of that city) and to centralise the fight against the plague (59). This
governmental resolve was supported by major investment, and was considered a
good omen for an indispensable and urgent sanitary reform of the city and for the
replacement of the cordon by a system of inspection and disinfection of people and
luggage (60-62).
Changes were emerging, albeit somewhat slowly. Between early September and the
following two months, the list of goods banned from being exported from Oporto was
substantially reduced (63), compulsory hospitalization of patients was replaced by
isolation in their homes (perhaps coinciding with the further spread of the epidemic)
(64), and in early November the sanitary cordon was replaced by patrolled inspection
posts, plus a set of measures recommended by national and international societies

and commissions, in accordance with the needs of the city's commercial and industrial

institutions (65, 66). Furthermore, merchants sought to avoid the isolation and damage
of the city (67-69).
Press intervention
In a common movement of ignorance and ill will, which started in the areas of Oporto
most affected by the epidemic, the population refused to report patients, to transport
them to isolation and hospital treatment, and to participate in disinfection measures
(70, 71).
It is plausible that the revolt of Oporto population was heightened by certain more
aggressive elements of the local periodical press, which, since mid-August, had not
spared governmental authorities, and continued to minimise or disbelieve the
existence of a plague epidemic in the city (72-74). This position, often biased and
pessimistic on the part of some press, created an atmosphere of revolt among the
population, as it connected the epidemic with “a disease” caused by the poor hygiene
of working-class neighbourhoods and by the daily inclusion in its pages of the total
number of inpatients and deaths, and the number of companies closed and workers
made redundant.
From another perspective, the representatives and population of Oporto refused to
accept the impositions of the Portuguese town, which they accused of being
conservative and centralizing (75, 76).
Meanwhile, the press suggested that the Government intended to publicly restrict the
plague to the city of Oporto, so as not to damage Lisbon and the rest of the country's
communication and trade with other international markets (77). On the other hand, the
cordon imposed on Oporto was defended in the editorials of certain elements of the
Lisbon press, which invoked the good of the country and opposed local and partisan
interests, and governmental uncertainties and compromises (78). This type of
positioning by certain newspapers in both cities would eventually spill over into
reckless, iniquitous, mutual accusations.
On 6 September, the Portuguese Industrial Association, in addition to requesting the
easing of the measures imposed on Oporto by the Government, took the opportunity
to protest the false news published by certain newspapers of that city, which
attributed the sanitary measures decreed to pressures made by traders which would
benefit from the loss of Oporto markets (79). Likewise, the Oporto Society of Medicine
and Surgery disagreed with the style and content of the news published at the time
by the local press, as it contributed to the “madness of the public” (80). For its part,
the Association of Portuguese Doctors advised the public not to be alarmed by the
news in the newspapers (81).
Faced with this situation, the Government decided to sanction those responsible for
the dissemination of “false news about the plague epidemic or which challenged the
measures taken to combat it, which delegitimised public authorities and which

insulted their agents”. Magazines or newspapers that disregarded the points

mentioned were to be suspended for as long as it seemed convenient and, if this were
repeated, would be suppressed (82).
Only one of the newspapers was punished on the grounds that it created even more
confusion and controversy in the city by publishing an interview with the newly-
returned former Portuguese health director of Macao, allegedly experienced in the
fight against frequent epidemics of plague in that territory (83, 84).
In this interview, and in later public statements and in a book, that doctor devalued
the situation, understanding that it could not be an epidemic but an endemic, given
the low patient mortality. He also doubted that the laboratories in Oporto were
capable of accurate bacteriological diagnosis, and added criticism to local and
governmental authorities for the harshness and ineffectiveness of the measures they
had instigated (85, 86). Such statements gained him great popularity among the
institutions and individuals of Oporto who opposed the nature of the disease and the
sanitary measures imposed by the municipal doctor and the Government (87, 88). On
the other hand, those unfortunate comments were widely criticised by most of the
national medical class and by foreign doctors present in Oporto (89, 90).
International repercussions of the Oporto plague
The knowledge of the above-mentioned breaches, the public contestation and

disrespect for the measures recommended by the Board of Health, and other negative
aspects related to the way in which the prevention and fight against the disease
evolved, crossed borders. As soon as the Government officially communicated that
there was a plague in Oporto to foreign governments, the exports it sent via the pier
in Leixões (to various European and American markets to which they were usually
shipped) were substantially affected. Brazil (from 11 July), Spain, Greece and
Denmark, for example, imposed quarantine on all maritime transport arriving from
Portugal, while Norway and Egypt restricted it only to that coming from Oporto, while
others limited themselves to following the resolutions of the Venice Congress (e.g.
Austria, Belgium) or establishing health precautions (e.g. Germany, France, Italy,
Russia and Sweden) (91).
It became known that the English Government, as soon as it became aware of the
official confirmation of the plague epidemic in Oporto, gave instructions for their ships
departing from Southampton not to call at this city (92). At the end of September, US
authorities prescribed compulsory disinfection control for all articles coming from any
port in Portugal. The Government of Spain decided to provide restrictions on all traffic
of persons and goods across the common land border (93-95). Passengers (including
many Spanish holidaymakers who frequented Portuguese beaches) were subject to
medical inspection and disinfection at the borders between the two countries, and
the entry of those with apparent signs of plague was prohibited (96, 97).

Serum and vaccine prevention and therapy
The early results obtained by Yersin with an antiserum were very positive (98), despite
his subsequent studies and those of other researchers proving contradictory (99, 100).
When the French delegation of the Pasteur Institute arrived in Oporto on 3 September
with instructions to assess the curative and preventive value of the anti-pest serum,
only two patients with very modest doses had been inoculated, one of whom had died
(101).
Ricardo Jorge decided to propose a scientific evaluation of the preventive and curative
efficacy of serums and vaccines then available against the disease, which was
immediately authorised by the appointment of an international commission made up
of some of the doctors present in Oporto (102, 103, 104). In the light of the results of its
various trials, this committee gave immediate consent to the use of anti-pest serum
on all patients admitted thereafter to Bomfim Hospital (105,106).
During the aftermath of the catastrophe, it was found that of the 320 patients
registered between June 1899 and February 1901, 132 succumbed, including
Professor Câmara Pestana (1863-1899) (107). His death on 15 November 1899 was felt
with regret at home and abroad, and he received multiple honours (108, 109, 110-112).
At the end of 1899, the press reported the epidemic in Oporto had declined since
November, and the emergence of cases of the disease in Lisbon. In the early 1900s,
the disease became rare and the last patient was admitted to the Bomfim Hospital on
16 January (113, 114).
Ricardo Jorge and the reorganisation of the Public Health system
As the social situation worsened or was not compensated for by concrete solutions for
a worsening epidemic, virtually any event that interfered with the life of the
population, especially the poor, served as a pretext for almost daily riots. The popular
mood, hitherto more directed toward challenging government decisions, eventually
concentrated on growing defamation, discrediting, persecution and even personal
aggression against the health authorities seeking to isolate and treat it.
There were unbelievable situations of persecution and even stoning of sanitation and
hearse personnel (sometimes required to perform their duties under cover of the
night and in different journeys), police escorts and disinfection cars, and hospital
gatekeepers (115, 116-120).
Protesters believed that the plague was brought or spread by the doctors themselves,
which made it difficult to accept and/or enforce established health measures. Thus,
the main targets of popular rage became the national and also the foreign doctors,
who fought against the epidemic. All were held responsible for having diagnosed or
corroborated the existence of a disease which no one wanted to believe or accept,
and therefore rejected the sanitary measures imposed, which were considered
inconvenient by all (121- 124).

Table II
Manifestations of non-compliance and revolt regarding the
sanitary procedures instituted
(a) Escape from disinfection;

(b) Refusal of vaccination, treatment and hospitalization;
(c) Rejection of isolation of family members in contact with patients and
belongings;
(d) Concealment of plagued patients;
(e) Attempted burial of plague dead without prior medical certificate;
(f) Stoning of health personnel and their homes.
Ricardo Jorge, considered the main target of the contestation, was even accused of
malevolence (the popular insinuation should be recalled that he spread plague rats at
night in the gutters, with the intention of poisoning the city's water supply), was
assailed in the streets and threatened with lynching, and there was a serious life-
threatening situation when a mob approached him and his family at his residence,
and they were saved through intervention of the Municipal Police cavalry (125).
The threatening situation to which he had been subjected, particularly since the
establishment of the sanitary cordon (a measure which he had indeed always
opposed), led to Ricardo Jorge moving to Lisbon on 15 October 1899 (126).
The sanitary needs evidenced in the fight against the epidemic called for an urgent
reorganization of the public health system, which had started to be planned by that
doctor while at the head of the Oporto Public Health Services, and was later
implemented when in Lisbon, as General Health inspector (127, 128).
Acknowledgements
I thank Dr David Hardisty for the competent translation of this work into English.

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Medicinae, vol. XIX, n. 1, (2013), 19-23.

PORTUGUESE AND SPANISH CONTRIBUTIONS TO THE DISCOVERY

OF RENAL AND OCULAR FINDINGS IN PRIMARY HYPEROXALURIA
Davide Viggiano1, Giovambattista Capasso2, Francesca Simonelli3, Valentina di Iorio4,

Natale G De Santo5
Abstract
Primary oxaluria is a rare hereditary disease of the metabolism, characterized by damage of

the kidneys (kidney stones) and the eyes (retinal oxalosis). Its recognition required first the
discovery of oxalic acid in the 17th century. The presence of this substance in normal urine
and food led to a long dispute between supporters of the “diathesis hypothesis” and the “diet
hypothesis”, that is between the congenital and acquired metabolic disorder. Both were right,
according to the present view: we recognize a very rare hereditary, genetic condition
(primary hyperoxaluria) and an acquired one (secondary hyperoxaluria). Notably, the main
findings in this paradigm were timed by the discovery of new scientific tools (chemistry,
microscopy, organic chemistry and others), except for the eye disease, recognized only 100
years after the invention of the ophthalmoscope. This “organ blindness” phenomenon is
further discussed along with the main historical steps of this condition.
Keywords
Oxaluria; urine; eye disease; nephrocalcinosis; biochemistry
Résumé
L'oxalurie primaire est une maladie héréditaire rare du métabolisme, caractérisée par des
lésions des reins (calculs rénaux) et des yeux (oxalose rétinienne). Sa reconnaissance a
d'abord nécessité la découverte de l'acide oxalique au XVIIe siècle. La présence de cette
substance dans l'urine et la nourriture normales a conduit à une longue dispute entre les
partisans de «l'hypothèse de la diathèse» et de «l'hypothèse du régime», c'est-à-dire entre le
trouble métabolique congénital et acquis. Les deux avaient raison, selon le point de vue
actuel: nous reconnaissons une maladie génétique héréditaire très rare (hyperoxalurie
primaire) et une autre acquise (hyperoxalurie secondaire). Notamment, les principales
découvertes de ce paradigme ont été chronométrées par la découverte de nouveaux outils
1
Corresponding author: Davide Viggiano, Dept. Scienze mediche traslazionali, Univ. Campania “L. Vanvitelli”, Naples, Italy,
Dept. Medicine and Health Sciences, Univ. Molise, Campobasso, Italy, email: davide.viggiano@gmail.com 2 Giovambattista
Capasso, Dept. mediche traslazionali, Univ. Campania “L. Vanvitelli”, Scienze Naples, Biogem Scarl, Istituto di Ricerche Gaetano
Salvatore, Ariano Irpino, Italy. 3Francesca Simonelli, Dept. Ophtalmology, Univ. Campania “L. Vanvitelli”, Naples, Italy. 4
Valentina di Iorio, Dept. Ophtalmology, Univ. Campania “L. Vanvitelli”, Naples, Italy.5 Natale G De Santo, Dept. Medicine, Univ.
Campania “L. Vanvitelli”, Naples, Italy.

scientifiques (chimie, microscopie, chimie organique et autres), à l'exception de la maladie

oculaire, reconnue seulement 100 ans après l'invention de l'ophtalmoscope. Ce phénomène
de «cécité des organes» est discuté plus en détail avec les principales étapes historiques de
cette maladies.
Mots clés
Oxalurie; urine; maladie oculaire; néphrocalcinose; biochimie
Introduction
Primary oxaluria (PRIOX) is a rare hereditary disease (incidence about one over a
million subjects); a non-hereditary form also has been described and is named
secondary hyperoxaluria.
It is a disease of glyoxylate metabolism, causing excessive production of oxalic acid,
then lost with urine (oxaluria), with consequent kidney stones, nephrocalcinosis, and
kidney failure. The oxalate crystals can deposit in other organs (oxalosis), e.g. the
eye, the liver is also affected1.
Oxalic acid is a substance that is normally present in our organism, and normal
subjects can often show microscopic crystals of oxalic acid in their urine, which are,
therefore, not a pathological sign. Therefore, PRIOX is diagnosed only when the levels
of oxalic acid are higher than normal and pathological consequences occur.
Historical overview
The pivotal steps, from 1700 to 2010, which led to this paradigm, are here
summarized.
The term “oxalic acid” has an interesting origin. οξύς (oxýs) in Classical Greek means
acid, and it is used to name the plant Oxalis Acetosella (the wood sorrel sometimes
confused with shamrock- trifolium), whose leaves have a distinct acidic taste.
Indeed, in the Tractactus De Herbis, dated around 1300, we read “Alleluja herba est,
quod in alio nomine dicitur pane de cuccho. Hec herba nascitur omnibus locis et circa
viam et ad pedem parietibus, sed habet saporem acetosum.” (Alleluja is a grass, also
named “bread of the donkey”. It grows everywhere, both on the streets and on the
walls, but it tastes like vinegar)2.
There was some early knowledge of the chemical substance behind this acidic taste
already in the second half of 1600 by Duclos. Indeed, Samuel Cottereau du Clos also
called Duclos (1598-1685) was the physician of Louis XIV (1638-1715), and one of
the founders of the Académie Royale des Sciences. Duclos obtained in 1668 crystals
from the juice of Oxalis Acetosella, which he called “salt of sorrel” (today acid
potassium oxalate)3.

Herman Boerhaave (1668-1738), a Dutch botanist and physician, repeated this

experience and isolated in 1745 from Oxalis Acetosells the salt, afterwards called
oxalic acid. He describes the preparation of the substance: “Procedure 7. A natural
salt of plants Acetosa prepared from their juice freshly pressed” (“Processus VII. Sal
nativum plantarum de succo illarum recens presso, hic acetosae”)4. Furthermore, he
gives also some interesting biological properties of the new substance: “Can be mixed
with human fluids. Can penetrate in small vessels” (“humoribus humanis miscibilis.
Penetrabilis in casa corporis satis parva”). In 1773, Savary obtained the oxalic acid
from the potassium salt first described by Duclos, and in 1776 Bergmann obtained
"acid of sugar" by oxidation of glucose with strong nitric acid5.
The German-Swedish chemist Carl Wilhelm Scheele (1742-1785) was able to
demonstrate in 1784 that the “acid of sugar” could be extracted from the sugar of
rhubarb and was identical with the acid from Oxalis6.
At the time, interest in the chemical composition of kidney stones aroused thanks to
the work of the French chemist Antoine François de Fourcroy (1668-1738). An
excellent review of the initial steps towards the identification of the composition of
kidney stones and a list of famous people suffering from kidney stones (from Heinrich
II (972-1024) to Napoleon III (1806-1873) can be found in Eknoyan 20047.
In 1797, the English chemist William H. Wollaston (1766-1829) found the 'oxalate of
lime' in a urinary stone which he named 'mulberry calculus'8. Oxalic acid became a
well-known naturally occurring vegetable acid, with unusually high oxygen content,
which played an important role in the development of chemical theories by the British
chemist Thomas Thomson (1773-1852) in 18089.
The French doctor and bacteriologist Alfred Donné (1801-1878) in 1838 first identified
oxalate crystals in the urine10. He was the discoverer of the trichomonas vaginalis, a
protozoan parasite.
A contemporary, the British chemist William Prout (1785-1850), in 1840, supposed
that some individuals might have a predisposition to form oxalic acid and coined the
term oxalic diathesis. In a commentary dated 1854, we read that Dr Prout observed a
special tendency to this kind of disorder in certain persons and families. Believing that
diabetes, which he considered on chemical grounds to be a kindred malady, was
constitutional and to a certain extent hereditary, he was led to suppose that the
particular tendency to the formation of oxalic acid and the joint disorder of health had
its origin in a peculiarity of the constitution. As already mentioned, he designated this
supposed peculiar constitution to the oxalic diathesis. There is, however, no constant
connexion between the disordered state of health and the presence of oxalate of lime
in the urine”11.
Golding Bird (1814-1854), a British physician, studied the collection of urinary stones
at Guy's hospital and described oxaluria, an excess of oxalate of lime in the urine,
now called Bird's disease. The chapter IX of his book Urinary deposits is entirely
dedicated to the “chemical pathology of oxalate and oxalurate of

lime/oxaluria”, with beautiful illustrations of the form of oxalate crystals that can be
found in urine12. The Scottish physician James Warburton Begbie (1826-1876) in
1848 also supported the pathological nature of oxalate crystals in urine13.
Prout, Golding Bird and Begbie therefore were later recognized as the first topostulate
a predisposition to hyperoxaluria, and several terms were then used to identify this
nosologic condition: “oxalic acid diathesis”, “syndrome of oxaluria”, “oxalemia”,
“oxalic gout”.
Arnaldo Cantani (1837-1893), a physician from the Naples hospital, further
elaborated an influential theory of the individual predisposition to explain oxaluria in
1856 (“oxalate diathesis”). Cantani's hypothesis of an oxalate diathesis was then
challenged by the British bacteriologist James Craufurd Dunlop (1865-1944) in 1895
14: “the theory of the excretion of oxalic acid in urine which I supported is (1) that it
is normal and constant (2) that it is dependent on the adsorption of oxalic acid, oxalic
acid being a constituent of the common foodstuff; (3) that oxalic acid is not produced
in the metabolism; (4) that a precipitation as calcium oxalate occurs very frequently
in healthy urines, and indicates the presence of a comparative excess of oxalic acid;
and (5) that the presence of calcium oxalate in urine as a diagnostic sign is
valueless”. He adds: “Oxaluria is no pathological entity”.
Current assessment
As we see it today, Dunlop was right in some of his statements, but he denied the
possibility of a hereditary form with higher excretion of oxalic acid. This was certainly
due to the fact that (i) these instances are dramatically rare (the “oxaliate diathesis”
would be today the “primary hyperoxaluria”), and (ii) he was convinced that oxalic
acid is only exogenous; it was only later, thanks to the work of Krebs, that oxalic acid
was definitely demonstrated to be formed by our normal metabolism.
Cantani and Dunlop were actually discussing two different phenomena: Cantani was
right in the rare form of primary oxaluria; Dunlop was discussing the oxaluria that is
present in normal subjects. The fallacy of Dunlop was in his logical reasoning: his
premise “oxaluria is present in normal subjects and can increase with diet” does not
lead to the consequence “increased oxaluria must be due only to diet and cannot be
hereditary”.
The hypothesis by Dunlop was later supported by Helen Baldwin (New York) in 1900
who also claimed that oxalic acid derived only from diet15. In contrast, Maurice Loeper
(1875-1961) in Paris further investigated the metabolic origins of oxalemia16 and
wrote in 1912 an influential work17, basically showing the effects of hyperoxalemia on
the gastrointestinal system 18. This work supported the oxalic diathesis.
The diathesis-diet discussion was finally settled with the description, in 1925, by
Carlos Lepoutre (1882-1950), professor of Surgery at the University of Lille (France),

of a newborn with multiple calculi of oxalic acid, with kidney infiltration by crystal
deposits19: this case undoubtedly demonstrated that oxalate crystals could be formed
without increased dietary intake and was due to metabolic derangement.
A note about the geographic distribution of studies on hyperoxaluria, made by
Jeghers in 1945 is interesting and fun: “The German literature is conspicuous for the
paucity of reports on this subject. A few papers have appeared in the English
andAmerican journals, but the greatest source of information has been the work of
French and Italian investigators, who, it would seem, have been unduly influenced at
times by the great European spas”.
Hyperoxaluria as a genetic disorder
The heredity in primary hyperoxaluria was first disclosed by Hans C Gram (1853–
1938). The famous Danish bacteriologist, known for his development of the Gram
stain, devoted his last years, in 1932, to the study of five generations of his own
family, with a high frequency of oxalate stones. He concluded that the diathesis was
probably autosomal dominant, although present only in males20. This work was only
preceded by a previous one on the heredity of urinary calculi (not specific for oxalic
acid) in 189421.
Meanwhile, the seminal work by the German-born, British biochemist Hans Adolf
Krebs (1900-1981) described the metabolic cycle, leading to the understanding that
oxalic acid derives from the metabolism of glyoxylate22.
In the 30s' additional work was done in France on symptoms of primary
hyperoxaluria: “The patient is irritable, depressed, anxious, hypochondriacal,
dyspeptic and neurasthenic. In addition, he may show periodically one or any
combination of the following clinical pictures”23,24.
The Canadian H.G. Dunn then summarized these data in 1955 with a new case and a
collection of microscopic images, radiographs and updated information on the origin
of oxalic acid from the Krebs' cycle25.The heredity of primary hyperoxaluria or PRIOX
was later confirmed in 1957 by a British group 26: usually the description of PRIOX
type I is attributed to Archer, notwithstanding the previous work by Gram.
E.F. Scowen, A.G. Stansfeld and R.W.E. Watts report the first findings of ocular
involvement in primary hyperoxaluria in 195952, immediately followed by a number of
other authors 27. It is unclear why this observation came so late, given the existence
of the ophthalmoscope since 1850 by Hermann von Helmholtz (1821-1894).
In 1962, the first form of hyperoxaluria secondary to enteric malabsorption was
described by Deren, Porush, Levitt, Khilnani in the USA. This was soon recognized by
other authors, and termed idiopathic enteric hyperoxaluria 29. In 1968 Williams H.E.
and Smith L.H. Jr, from California, described a second, much rarer form of primary
hyperoxaluria on biochemical basis30. The familial form was thus divided into two
types. The X-ray diffraction technique developed by the British physicists W.L. Bragg

and W.H. Bragg in 1912, was much later used to analyze the composition of renal
stones31.
The years from 1980 were devoted to the hunting for genes responsible for primary
hyperoxaluria. The gene for PRIOX type I was identified in 1986 by Danpure C.J.,
Jennings P.R. in the UK as “Peroxisomal alanine:glyoxylate aminotransferase”-AGXT
32. The gene for PRIOX type II was identified in 2009 by Cregeen D.P., Williams E.L.,
Hulton S., Rumsby G. in London as “glyoxylate reductase/hydroxypyruvate

reductase”33. A multinational group identified other cases of PRIOX (type III) as due
to an unknown gene, DHDPSL, in 2010 34.
The first report of successful combined liver-kidney transplant to treat PRIOX was
done in the UK35. The previous attempt by the same group, in 1985, resulted in the
death of the patients due to CMV dissemination. A group from Santa Cruz de Tenerife
shows that haemodialysis or kidney transplant did not lead to survival of the patients
and liver + kidney transplant or isolated liver transplant give a favourable survival (12
years)36. Later the kidney-liver transplantation for PRIOX is critically revised by a
group in Coimbra37.
Table 1: timeline of primary oxaluria discovery

Year Discovery Key for the discovery
1300 oxalis acetosella herbal interests
chemical revolution
1700 chemistry of stones (Lavoisier)
1745 isolation of oxalic acid -
1784 - -
1797 oxalate in kidney stones -
1808 - -
microscopy (urine sediment
1838 oxalate in urine analysis)
1840 oxalic diathesis -
ophthalmoscope by von
1848 - Helmholtz
Charles Darwin (diathesis vs
1856 - environment)
1900 oxaluria from diet X-ray diffraction
1920 congenital hyperoxaluria Heredity
1932 heredity of PRIOX Krebs' cycle
1955 biochemistry of hyperoxaluria -
1957 - -
1959 ocular findings -
1962 enteric hyperoxaluria -
1968 hyperoxaluria type II
1970 X-ray analysis of stones -
1986 gene of PRIOX I genetics
2009 gene of PRIOX II -
2010 gene of PRIOX III -

The group of Salido, Torres, Lorenzo, Alvarez, Torregrosa, Hernandez from the
Nephrology of the Hospital Universitario de Canarias, Santa Cruz de Tenerife,
observes a high incidence of PRIOX I in Canary Islands, Atlantic, particularly in the
small Island of La Gomera (17.000 inhabitants)38. They identify the first patients
observing oxalate deposits in undecalcified bone biopsy after double tetracycline
labelling.
Salido E. and Torres A., then, with the help of L.J. Shapiro in California, and A.
Santana, find that the Canarian patients have the common mutation I244T in AGXT,
but they discover that the protein lacks activity and aggregates; in collaboration with
other US groups from Florida, New York and St. Louis, they developed the first animal
model of PRIOX I, by deleting the gene AGXT: the mice were stone formers and could
be cured by gene therapy39.
Concurrently, further characterization of the disease occurred from Lisbon, Portugal
from the observation of a series of “recurrent stone formers” with the conclusion that
hyperoxaluria is the most frequent abnormality in these patients40. The same group
that first isolated PRIOX in the Canarian Islands further characterized the clinical
evolution and therapeutic options: the first presentation of PRIOX occurs late in life
(>13 years); furthermore, haemodialysis or kidney transplant does not improve the
survival of the patients. The combined liver and kidney transplant or isolated liver
transplant gave a favourable survival (12 years).
Furthermore, Salido, with the collaboration of the group of Structural Biology in
Madrid (Armando Albert, Yunta, Arranz, Peña, Valpuesta, Martín-Benito) come to the
determination of the 3D structure of the AGXT enzyme mutated41.
Very recently a new form of hyperoxaluria has been described as due to
malabsorption, by Abreu, Bento, Oliveira, Morgado in Vila Real42 and EDTA by a
research group in Oporto43.
Conclusion
The history of hyperoxaluria is an interesting example of how new experimental tools

have changed a paradigm and how the initial paradigm can lead to what we define as
“organ blindness”. The chemical tools, the invention of the microscope, the discovery
of the biochemical processes and the genetic tools have finally modified the original
description of hyperoxaluria into its final form as we know it today. On the other side,
the very late observation of retinal involvement in hyperoxaluria is not explainable
based on technological limitation, as the ophthalmoscope was known for almost 100
years. This specific “organ blindness” is likely due to the initial paradigm itself, forcing
other scientists to focus on some aspects of the disease and to neglect others.

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involvement in primary hyperoxaluria type I”, Br J Ophthalmology 76, 1992: 54-57.
29
Brown, JM, Chalmers, AH, Cowley, DM, McWhinney, BC, “Enteric hyperoxaluria and
urolithiasis”, New England Journal of Medicine 315, 15, 1986:970-971.
30
Williams, HE, Smith, LH Jr, “L-glyceric aciduria. A new genetic variant of primary
hyperoxaluria”, New England Journal of Medicine 278, 5, 1968:233-238.
31
Sutor, JD, Wooley, SE, “Composition of urinary calculi by X-Ray diffraction: collected data
from various localities 8. Leeds, England.”, Br J Urol 42, 3, 1970:302-305.
32
Danpure, CJ, Jennings PR., “Peroxisomal alanine:glyoxylate aminotransferase deficiency in
primary hyperoxaluria type I”, FEBS Lett, 201, 1, 1986:20-24.
33
Cregeen, DP, Williams, EL, Hulton, S, Rumsby G, “Molecular analysis of the glyoxylate
reductase (GRHPR) gene and description of mutations underlying primary hyperoxaluria type
2”, Hum Mutat 22, 6, 2003: 497.
34
Belostotsky, R, Seboun, E, Idelson, GH, et al., “Mutations in DHDPSL are responsible for
primary hyperoxaluria type III”, Am J Hum Genet, 87, 3, 2010:392-399.
35
Watts, RW, Calne, RY, Rolles, K et al., “Successful treatment of primary hyperoxaluria type
I by combined hepatic and renal transplantation”, Lancet, 2, 8557, 1987:474-475.
36
Lorenzo, V, Alvarez, A, Torres, A, Torregrosa, V, Hernández, D, Salido, E, “Presentation and
role of transplantation in adult patients with type 1 primary hyperoxaluria and the I244T
AGXT mutation: Single-center experience”, Kidney Int, 70, 6, 2006:1115-1119.
37
Leal, R, Costa, J, Santos, T, et al., “Combined liver and kidney transplantation in two
women with primary hyperoxaluria: Different roads led to different outcomes”, Nefrologia, 37,
4, 2017: 433-434.
38
Lorenzo, V., Torres, A., Hernández, D. et al. “Evolution of bone disease in patients with
primary hyperoxaluria undergoing chronic hemodialysis”, Nefrología, 1, 1990: 53–60.
39
Santana, A, Salido, E, Torres, A, Shapiro, LJ., “Primary hyperoxaluria type 1 in the Canary
Islands: a conformational disease due to I244T mutation in the P11L-containing
alanine:glyoxylate aminotransferase”, Proc Natl Acad Sci U S A, 100, 12, 2003 :7277-7282
40
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idiopathic calcium stone disease in Portugal”, Acta Med Port, 17, 1, 2004:27-34.

41
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intermediate of alanine glyoxylate aminotransferase”, J Biol Chem, 285, 9, 2010:6371-
6376.
42
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nephrocalcinosis”, Clin Cases Miner Bone Metab, 13, 3, 2016:247-248.
43
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Single Cause Is Not Crystal Clear”, Am J Kidney Dis, 70, 5, 2017:722-724.

TH
EXOTIC PLANTS IN THE ITALIAN PHARMACOPOEIA OF THE 18
CENTURY
Federica Rotelli1
Summary
The importance of exotic plants in European botany of the 18thcentury concerned not only the
species of edible plants but also the abundant vegetal species used for therapeutic purposes.
Italian pharmacies also made sure to have available plants with certified therapeutic
properties. In many pharmacies of that time, we can find pharmacopoeias, medical
formularies and recipes where these exotic plants were mentioned as ingredients of brews
and decoctions celebrating their healing properties. Some pharmacies had full collections of
vases to store these medical products. In this view, the literary sources from the Emilian
pharmacies of the 18th century are particularly rich. Emilian pharmacists could also take
advantage of the studies of the University of Bologna, one of the leading medical universities
in Europe, whose tradition dates back to the medieval period. In the 18th century, famous
physicians and scientists lectured at Bologna, such as Marcello Malpighi (1628-1694),
Ferdinando Marsili (1658-1730), Giovanni Battista Morgagni (1682-1771), and Antonio Maria
Valsalva (1666-1723). At that time, the inclusion of the new exotic drugs in the Hippocratic-
galenic tradition was not an easy task. It was also not easy to conciliate the different
approaches that the introduction of these new plants brought to medical science. Thanks to
this material, it is possible to reconstruct its significant practical and theoretical contribution
to the Italian medical culture of the 1700s.
Keywords
Exotic medicinal plants; Biodiversity; Italian pharmacopoeias; Pharmacology
Résumé
L’importance des plantes exotiques pour la Botanique européenne au XVIIIe siècle ne réside
pas seulement dans la connaissance des plantes comestibles mais aussi dans l’abondance des
espèces végétales à usage thérapeutique. Les pharmacies italiennes s’étaient en effet
toujours procuré des plantes aux propriétés pharmaceutiques reconnues. Dans plusieurs
pharmacies à cette époque, on trouvait des pharmacopées, des formulaires et ordonnances
médicales, dans lesquels des plantes exotiques étaient mentionnées comme ingrédients,
servant à produire des infusions et des décoctions, dont on appréciait les propriétés
médicales. Certaines pharmacies avaient des collections entières de pots servant à stocker
leurs produits médicaux. De ces apports pharmaceutiques, les sources littéraires dans les les
pharmacies en Emilie sont particulièrement riches.
1
Federica Rotelli, PhD in Bioeconomics, University of Verona, member of the Società Botanica Italiana,
Optima (Organization for the Phyto-Taxonomic Investigation of the Mediterranean Area) and
International Society for the History of Medicine. Strada Maggiore 13, 40125, Bologna, Italy.
E-mail: federicarotelli@libero.it

Les pharmaciens émiliens pouvaient avoir accès aux études de l’Université de Bologne, une
des plus réputées d’Europe, avec une tradition datant du Moyen-Age. Au XVIIIe siècle, des
médecins célèbres enseignaient à Bologne, tels que Marcello Malpighi (1628-1694),
Ferdinando Marsili (1658-1730), Giovanni Battista Morgagni (1682-1771) et Antonio Maria
Valsalva (1666-1723). Il n’était alors pas évident d’inclure ces nouveaux ingrédients
exotiques dans la tradition Hippocratico-Galénique, ni de réconcilier les différentes approches
que l’introduction de ces nouvelles plantes avait apportées à la science médicale. Grâce aux
éléments apportés par cet article, il devient possible de reconstruire leur contribution pratique
et théorique à la culture médicale italienne du XVIIIe siècle.
Mots-clés
Plantes exotiques médicinales; biodiversité; pharmacopées Italiennes; pharmacologie
Luigi Castiglioni and East-Asian plants in the 18th-century Italian

pharmacopoeia
Towards the end of the 18thcentury, a book entitled Storia delle piante forastiere le
più importanti nell’uso medico, od economico by the Italian botanist and traveller
Luigi Castiglioni (1757-1832), was printed in Milan.1 It is a fascinating book, collecting
in a single treatise, all the available knowledge about the significant novelties on the
plants of exotic origin beyond the scientific works by physicians, naturalists and
explorers written within the speciality. In the four volumes of this work, the author
describes 96 species of useful plants, 85 of which were exotic, labelled with an
etching made by Piemontese etchers. Beyond the information purely botanical about
the vegetable species, related to their systematisation and taxonomy, Luigi Castiglioni
devotes himself to the explanation of their use, chiefly in medicine, historical data
about their place of origin and diffusion, cultivation, transportation and trade.
Henceforth, this work is a history of exotic plants comprising most of the botanical
knowledge of the end of the 18thcentury.
In this period, several exotic plants used for medicinal, dietary and ornamental
purposes, had been introduced in Europe as a result of the geographic explorations
and colonial trade promoted since the 16thcentury in the overseas lands, first by the
Portuguese and the Castilian Crowns, later by the Dutch, French and English. Sub
tropical and tropical species, but also those from the temperate zone, had been
cultivated in Italian botanical gardens, where their acclimatisation had been
attempted.2 Castiglioni’s interest in exoticism within the field of plants is precisely the
possibility of transferring and cultivating allochthonous plants that could be beneficial
for medicinal and dietary purposes.
This work includes many plants of oriental origin, some already used for medicinal
purposes for centuries. Others less known were introduced later. Plants like nutmeg,

cloves, myrobalan plums, cardamom, sandal, pepper, rhubarb, camphor, cinnamon

and ginger were well established as curative plants in most medical prescriptions for
many centuries.3 Others had only been introduced into the Italian pharmacopoeia
from the 16thcentury onwards. Chinese Smilax or China root, used as a decoction
chiefly in the treatment of syphilis, was one of them.4
Other Asian plants had started to be used by Italian physicians just between the 17 th
and the 18th century, such as Garcinia cambogia L., called carcapulli by Castiglioni.
This one was a tropical plant from Indonesia, from whose bark a gum resin with
purgative and vermifuge properties was extracted, being used to root out tapeworms
and against dropsy.5 Another was St. Ignatius bean, whose seeds, extracted from the
fruit of Strychnos ignatii Berg., prepared as an infusion or powder, were used in the
treatment of intermittent fever, neuralgia, epilepsy, cholics and the plague by that
time. As late as the 19thcentury, strychnine was still extracted from the flour obtained
from these seeds; supposedly, it would act as stimulant and laxative, but since it was
highly toxic, its use became restricted.6
One of the novelties was the tea tree, officially introduced into the Italian
pharmacopoeia at the end of the 17thcentury, figuring in the second edition of the
Milanese Antidotarium (1698).7 Among the qualities of the tea tree, its sudorific effect
and capability to treat rheumatisms and calculi stood out.8
Arabian coffee, which came from Africa, was also introduced into medicine at the end
of the 17thcentury. Castiglioni describes it as a stimulant, diuretic, anticephalgic and
vermifugal plant.9
The introduction of American plants and the Galenic tradition in Italian

medical science of the 16th through the 18thcenturies
Plants of American origin were equally numerous in this treatise. Some, like guaiacum
wood and resin, sarsaparilla, Peru balsam, sassafras, American sweetgum
(liquidambar), michoacán (Convolvulus mechoacan Vandelli) and tobacco had already
been included in most official pharmacopoeias of various Italian cities in the
16thcentury.10
The physicians’ choice of using only these plants in the pharmacopoeia of that period
depended largely on the alternative that most represented to the botanical species
used earlier in European medicine. The knowledge of many other American plants had
been conveyed in various treatises of natural history and medicine of the West Indies,
especially the work of Nicholas Monardes (1565-1574).11
Such was the case of the Peru balsam, first indicated in the Italian pharmacopoeia as
a substitute for Oriental Balm: its resin, whose scent was quite similar to the other
European balsams, presumably had the same cicatrising properties.12
Michoacán, to which purgative properties were attributed, was quite suitable as a
substitute for

known plants, used in the humoral model. The medical science still followed this
doctrine, one of its tenets consisting of driving out the excess when an imbalance of
humours was thought to be at the origin of the disease. In this context, purging the
patient was one of the best treatments to restore his health.13 Other American plants,
such as guaiacum and sarsaparilla, were used chiefly to treat diseases like syphilis,
endemic in the West Indies.14
So, one of the main problems the 16thcentury physicians had to deal was the
management of the new healing plants to establish the level of their therapeutic
efficacy. However, it was equally difficult to include the new plants in the galenic
system and classify them within it. A barrier or a considerable limitation in their use
resulted from these remedies being classified as hot and dry in the second degree,
therefore not seeming suitable to treat the main symptoms of the diseases, such as
fevers and inflammations, appearing to be marked by excessive heat, requiring
cooling treatments, according to the galenic tradition.15
During the 16th and 17thcenturies, these plants were fairly valued, and, in the case of
guaiacum, quite famous. Notwithstanding, as early as the 18thcentury, guaiacum
began to lose its importance in the treatment of syphilis. By the 20 thcentury it had
disappeared completely from the official pharmacopoeia.16 From the 17thcentury
onwards, doubts had arisen about its antisyphilitic properties, and the medical science
began, once again, to value the therapeutic effectiveness of mercury. The latter,
wisely used, succeeded in alleviating cutaneous manifestations of syphilis up to the
beginning of the 20thcentury. In 1910, it was replaced by arsenobenzene, and, at the
end of the nineteen-thirties, by penicillin. However, in the 18th and 19thcenturies,
guaiacum continued to be prescribed in the treatment of other conditions (skin
diseases, gout, rheumatismes).17
Sarsaparilla, reasonably successful in the treatment of syphilis throughout the 16 th
and 17thcenturies, started losing its reputation as a reliable treatment for this disease
in the 18thcentury. Sarsaparilla was highly esteemed for its diaphoretic properties and
as a remedy for rheumatismes, fevers and inflammatory complaints. It was still
prescribed in the 18thcentury and the subsequent centuries also for its diuretic and
detoxifying properties.
Sassafras, whose roots and bark were used for in the preparation of a decoction, was
prescribed for its sudorific properties and as a remedy against syphilis, stomach ache,
gout, scurvy and jaundice. In the 20thcentury it was banned by the American Food
and Drugs Administration.18
Other American medicinal products mentioned by Castiglioni had been included in
pharmacology from the 17thcentury onwards. Among these, there were cocoa,
copaiba balsam, Tolu balsam, jalap root, contrayerva and tacamahac, to mention just
a few. Contrayerva was used as an antivenin, tacamahac as an anticephalgic and
antiemetic.19
Nevertheless, more products were introduced into the Italian pharmacopoeia
between,

the 18th and the 19thcentury. Among the exotic novelties, stood bitter quassia, which
in infusion was believed to be beneficial in cases of fever, arthritis and calculi;
cascarilla, prepared as a tincture, electuary or powder, was used for intermittent
fevers, several types of dysentery, asthma and gout; and Peruvian calaguala, whose
root, prepared as a decoction, was used for treating syphilis and haemoptysis, and as
an antipyretic and emmenagogue.20
Simaruba, whose decoction, prepared with the bark of the root, was used against
haemorrhages, fevers and several types of dysentery; Virginian snake-root or
serpentary, prescribed for its antiseptic properties and against intermittent fevers are
also to mention; and sabadilla, whose seeds, pounded into powder, had vermifuge
and purgative properties.21 Winter bark and seneca snake-root were other two
botanical novelties: the bark of the former was used to prevent scurvy, to help
digestion and as a sedative, while the root of the latter was used as an antivenin and
against pleurisy and dropsy.22
Ipecacuanha and cinchona were the two most successfully widespread American
plants in the 18thcentury. Despite their difficult management when they appeared,
they had the most extended life, still surviving in 20thcentury medicine.
Ipecacuanha root, according to Castiglioni, was one of the emetics most frequently
employed at that time, and an excellent remedy for dysentery.23 Cinchona bark was
used for preparing decoctions, extracts, syrups and tinctures, being chiefly prescribed
to treat intermittent fevers, particularly Malaria tertiana and Malaria quartana.24
The high demand of some American plants, such as cinchona bark, ipecacuanha, and
balsams continued throughout the 18thcentury, fulfilling the physicians’ therapeutic
expectations. In this century, the efficacy of medicinal plants and their
pharmacological experimentation became an essential trait of the medical culture.
Some balsams, such as Peru and Tolu balsam, American sweetgum and copaiba
balsam, prescribed in the treatment of wounds, had antiseptic properties and were
also expectorants.25
Ipecacuanha roots, used in the 18thcentury not only for their emetic properties but
also as antiseptics and expectorants, were also prescribed to treat amoebic dysentery
due of one of their alkaloids, emetine (1817).26 The same satisfactory results were
obtained with cinchona bark, which became the most popular American plant in the
European medicine of the 18thcentury.
A large quantity of cinchona bark dispatched by the Royal Pharmacy (Real Botica) of
Madrid, part of the domains of Charles III (1759-1788) reached Italy since the king of
Spain was also the king of the Two Sicilies.27 In 1820, most active principles in
cinchona bark were isolated, including quinine, that proved to kill the parasites of
malaria in the blood.
Although quinine was almost put aside in the last decades of the 20 thcentury due to
the discovery that it provoked a particular state of narcotism, one of the alkaloids of
cinchona bark, quinidine (1848) continued to be used in the treatment of
arrhythmia.28

The controversy about the use of Cinchona in the struggle against malaria in
th
18 century Emilia
The Italian official medicine was quite reluctant in accepting the therapeutic
effectiveness of cinchona bark. Several European countries already discussed this
matter on the second half of the 17th century, some advising its use, others objecting
to it.
The prejudices against the new medicine originated chiefly in the belief of the
followers of the humoral theory that the effects of the American febrifuge did not
provoke evacuation enough, not creating conditions to eliminate the excess of
humours of the affected patient.29
The dispute on the use of cinchona bark is exemplary to understanding the evolution
of Italian medical science in the 18thcentury. The success of this remedy inflicted hard
blows in the humoral medical concepts of the time.
One of the greatest supporters of the effectiveness of chinchona bark was a physician
and professor from Modena, Francesco Torti (1658-1741). In his Therapeutice
specialis ad Febres quasdam Perniciosas (1712), he tried to demonstrate the
therapeutic in the treatment of malignant intermittent fevers.30 In Torti’s opinion, the
humoral doctrine was no longer able to explain within its framework the
unquestionable power of cinchona bark in the treatment of malaria.31 In the years
following the publication of Torti’s work, other Emilian physicians began to uphold the
therapeutic effectiveness of cinchona bark such as Ferrante Ferrari (d. 1757), a
physician from Modena and a student of Torti in his Mutinensium medicorum
methodus antipyretica vindicata (1719).32
Among others, stood Ippolito Francesco Albertini (1662-1738), a physician and
professor from Bologna and a student of Malpighi, in his De cortice peruviano
(1748);33 Morando Morandi (1693-1751), a physician from Forlì and a student of
Morgagni and Vallisneri in Padua, in his work Della cura del vajolo con la china-china,
e col bagno tiepido (1753).34
Aside doctrines, the use of this remedy was widespread in the pharmacies for several
decades, and its positive testimonies also figured in many other treatises of that
period.35 Known in Italy since the middle of the 17thcentury, the Jesuits became its
leading distributors, boosting the diffusion of its use.36 A Jesuit, the Spanish cardinal
Juan de Lugo (1583-1660), received some cinchona bark from a Genoese merchant,
Antonio Bolli, in 1649, and introduced it into the apothecary’s shop of the Collegio
Romano, where it was distributed free of charge.37
In the same years, the Jesuit Pietro Paolo Pucciarini (1600-1662), a nurse and
apothecary of the pharmacy of the Collegio Romano, left several written testimonies
(1651 and 1659) on the introduction of this American plant from Peru, concerning its
use, efficacy and diffusion in the treatment of tertian and quartan fevers. The Cardinal
Juan de Lugo, chief-manager of the pharmacy of the Ospedale di Santo Spirito of

Rome, was one of the main experimenters of cinchona bark and promoters of its
diffusion. He transformed the Roman hospital into one of the greatest European
centres for the importation of the root of the plant.38
Friar Domenico Auda (c. 1614-?), a chief apothecary of the Ospedale di Santo Spirito
helped the hospital to become a leading centre of pharmaceutical culture from 1652
onwards. He authored the Pratica de’ Spetiali (1666), one of the most widespread
pharmacopoeias of that period. In his treatise he dealt with cinchona bark, stating
that it was of hot, dry nature, but often falsified. He also mentioned michoacán root,
sarsaparilla, and China root from the East.39
These are some of the medicines contained in Auda’s hospital formulary, witnessing
that medicinal preparations obtained from American plants were administered in a
Roman hospital at the end of the 17thcentury. The Church’s state pharmacopoeia also
drew on its own Antidotario Romano, and the medical school of the University of
Bologna and its antidotarium.40
th
Exotic plants in the 18 century Bolognese hospital pharmacopoeias
In Bologna, among the hospital pharmacopoeias of the 17thcentury, aside a few

treatises by hospital physicians, no documentation has been preserved concerning
medical formularies expressly drawn up for the Ospedali della Vita e della Morte.41
These two hospitals had been established as early as the 13th and 14th centuries; in
1801, they were merged, forming the Grande Spedale, the present-day Ospedale
Maggiore. The library of the pharmacy of the Ospedale Maggiore, and the pharmacy
were destroyed in 1944.42
It is possible, however, to reconstruct a part of the history of the two old hospitals,
thanks to the 18thcentury set of Faenza ceramic vases that had belonged to the
pharmacy and had been shared by the two institutions: part of them, about a
hundred, miraculously survived the destruction of the entire hospital.43
Besides, thanks to an inventory of this set of vases published in 1920, containing the
classification of 222 vases, including majolica jars, amphoras and ampullas, we have
a throughout overview of the entire collection, and of the medical materials of the
pharmacy of the two Bolognese hospitals, regarded as the most outstanding in that
city in the 18thcentury. Among the medicines, some came from America: Tolu balsam,
cinchona bark, copal resin, guaiacum resin, caranna gum, ipecacuanha, bitter
quassia, michoacán, contrayerva syrup and tobacco syrup.44
Some medical treatises, conceived by Emilian physicians, written for hospital use are
extant, providing information about the exotic medicines administered to the patients
in the Bolognese hospitals. The Trattato di medicamenti spettanti alla Cirugia by Paolo
Andrea Parenti (1699-1771), Emilian surgeon and apothecary at the Ospedale di S.
Maria della Vita, was printed in 1739.45 It was one of the first surgical pharmacopoeias
to be published and just included medicines for external application

in surgery.46 Among the risolventi drugs, figured copaiba balsam and tobacco; among
the detergent, figured caranna gum and Peru balsam; while among the epolutoci ones
there were guaiacum, sarsaparilla and Peru balsam again.47
Another pretty successful 18thcentury Emilian pharmacopoeia was devised by a
Bolognese physician and professor of the University of Bologna, Germano Azzoguidi
(1740-1814), entitled Spezieria domestica (1782).48 The purpose of the author in
naming only 29 medicines was to simplify the entire pharmaceutical apparatus,
providing information exclusively on the preparation of the most widespread
remedies, held as indispensable.49
Some of the medicinal preparations required the use of American plants such as
Polvere antisettica dell’Huxam, prepared with cinchona bark and Virginian snake-root,
Pillole antiveneree containing Peru balsam, and Penniti antielminitici containing,
among other plants, cascarilla root.50 A separate chapter was dedicated to other
American plants such as ipecacuanha and cinchona bark.51
The Bolognese Antidotaria of the 18thcentury and the first establishment of

Pharmaceutical chemistry
To gain knowledge on the indication and preparation of medicines, the Bolognese

physicians and apothecaries could consult the official pharmacopoeia of their city, the
Antidotarium Bononiense. The value of this pharmacopoeia reflects the evolution it
underwent from the first edition of 1574 to the last ones of the 18 thcentury, following
the development of the pharmaceutical technique and pharmacology.52 Its first 18th
century edition, which came out in 1750 and was reprinted in Bologna and Venice in
1766, 1770 and 1783 with the addition of a few medical preparations,53 was a real
novelty among Italian pharmacopoeias, because it was the first time that the
chemical pharmacy was officially acknowledged.54 Before that, in the previous editions
of 1641 and 1674, it had been included just as an appendix;55 later, it was an integral
part of the antidotarium. The inclusion of chemical pharmaceuticals among medicinal
preparations was supported by the Collegio Medico of Bologna, whose chairman was
Marc'Antonio Laurenti (1678-1772), pontifical chief physician and professor of
chemistry at the Istituto delle Scienze.
This choice reflects the zeal and the scientific orientation of this institute, founded in
1714 by Luigi Ferdinando Marsili (1658-1730), and its reception by the Bolognese
schools, attentive to the new European trends towards the creation of an alliance
between chemistry and medicine.56
The pharmaceutical forms of galenic pharmacy included in the first part of the
Bolognese pharmacopoeia (1750) and was represented by 472 medicines (De
medicamentis galenicis), followed, in the second part (approximately 40%), with a
description of 329 chemical medicines (De medicamentis chymicis) prepared as
tinctures, extracts, waters and oils, spirits, salts, flowers and metal preparations.

The first and the second part of the text contained a description of medicinal
preparations obtained from American plants or included items that did not figure in
the 16th and 17thcentury editions.
While Oleum guaiaci, Unguentum de nicotiana, Syrupus de Peto Quercetani and
Extractum Guaiaci, E. Mechoacana and E. Salsaparilla had already been presented in
the previous editions, the edition of 1750 included some new galenic medicines made
from new American plants. The contrayerva root figurered in the preparations of
Electuarium Orvietanum, prescribed against the plague, in Pulvis bezoarticus, in the
treatment of pernicious fevers, and in Syrupus de contrayerva for malignant fevers.57
Cinchona bark was used in Electuarium antifebrile for intermittent fevers, in Tabellae
de china-china and Syrupus de china-china to treat fevers; and jalap root was
included in the Electuarium catholicum.58 At last, Tolu balsam was an ingredient of the
Syrupus Balsamicus, Peru balsam of Balsamum Locatelli and Balsamum apoplecticum,
cocoa of Butyrum cacao, and tacamahac of Ceratum tacamahaca.59
Among the chemical medicines, several solutions also required the use of American
plants. The tinctures included Tinctura contrayervae and Tinctura china-china;
cinchona bark was present also in Extractum chinae-chinae for the treatment of
intermittent fevers.60 Among the balsamic tinctures, Balsamum Innocentianum was
obtained from Tolu balsam, and among the distilled waters Aqua vulneraria contained
tobacco leaves.61 Vanilla was one of the ingredients of Spiritus volatilis aromaticus,
and guaiacum of Spiritus ligni guajaci, Oleum et spiritus acidus ligni guajaci and
Magisterium ligni guajaci. At last, jalap was present in Magisterium sive resina
jalappae.62
The final index of the pharmacopoeia pointed out the medicines which should figure in
all the pharmacies of Bologna. Among the 159 mandatory products, figured
Magisterium jalappae and Syrupus de contrayerva.63 The edition of 1770, adding nine
preparations, introduced Magisterium chinae-chinae (cinchona bark resin), the only
mandatory compound of American bark in the Bolognese apothecary’s shops.64
The period straddling the 18th and the 19th centuries witnessed the early development
of modern pharmacology with the gradual rise of pharmaceutical chemistry and the
contemporary decrease in the use of plant remedies. The establishment of the School
of Pharmacy in the University of Bologna with the first chair of pharmaceutical
chemistry, in 1802, was the initial stage of this scientific journey.65
A few ancient pharmacies still functioning in Bologna preserve their sets of 18th
century pharmaceutical vases, providing means of identifying some of the medicines
prepared and sold in the Bolognese apothecary’s shops in that period. Farmacia
Toschi, formerly Spezieria Pietro Galli after the name of the apothecary who founded
it, was inaugurated in the second half of the 18thcentury; in 1775, maybe the very
year of its opening, its owner, Pietro Galli, placed an order for a collection of majolica
vases, 143 of which have been preserved, still being displayed on the 18thcentury
shelves of the pharmacy.66

Some of the pharmaceutical products were prepared from American plants: guaiacum
resin, cinchona extract, ipecacuanha root, and contrayerva root. The pharmaceutical
equipment in the 19thcentury was further enriched by the acquisition of new glass
vases and wooden boxes to preserving officinal herbs. Among the latter, other
preparations with American plants figure, such as resin and powder of jalap root,
purgative chocolates, tincture and syrup of cinchona, quinine hydrochloride,
cinconina, vanillin, sassafras, ipecacuanha pills, sarsaparilla extract and passionflower
extract.
The diffusion of exotic medicine in the 18th-century Emilian pharmacopoeia
In Emilia and Romagna, preserved manuscripts, convent prescriptions books, hospital

pharmacopoeias and pharmaceutical sets provide means of reconstructing the history
of the diffusion of exotic medicine in the pharmacology of the main cities during the
18thcentury. The set of vases of the pharmacy of the Ospedale di Santa Maria della
Scaletta of Imola (1765) discloses the use of exotic plants such as cocoa beans,
vanilla, peruvian calaguala, cascarilla fina, a variety of cascarilla, cinchona bark, an
ingredient of Giulebbe di China China, contrayerva, whose root was also an ingredient
of Orvietano di Charas and Giulebbe di contrayerva, the resin of copal, copaiba
balsam, guaiacum resin, tacamahac resin, ipecacuanha, bitter quassia, sassafras,
michoacán, seneca snake-root, sarsaparilla, dragon blood, jalap root, also an
ingredient of Rotelle solutive, Virginian snake-root, cocoa butter, sabadilla, and
tobacco in Giulebbe di peto.67
In the Registro de’ Medicamenti of the Grande Spedale of Modena (1759), the
following medicines containing exotic plants appear. Among balsams: copaiba and
Peru balsam; among sinapismi, tacamahac, within the decoctions obtained from
sarsaparilla root; and among the tinctures, cinchona bark tincture. Among the
extracts, cinchona bark; among the gums, tacamahac; among woods: guaiacum and
sassafras; among the roots: contrayerva, jalap, ipecacuanha, michoacán and
sarsaparilla; among the syrups, Torti’s cinchona bark, and among the rinds, cinchona,
Virginian snake-root, and simaruba. Finally, among the resins, figure jalap and
michoacán.68
The pharmacopoeia of the Grande Spedale of Modena (1760-62), devised by the
physician Giambattista Moreali (1699-1785), includes Decoctum ad scabiem, with
guaiacum, Tinctura ad Quartanam, Pilule ad Quartanam and Febrifuge with cinchona
bark.69
In the inventory of the apothecary’s shop of the Benedictine convent of San Pietro of
Modena (1763), copaiba and Tolu balsam are referred to along with myrrh, oriental
balm and myrobalan plums.70

The Catalogo de’ medicamenti71 of the Ospedale of Parma (1772) prescribed two vini
preparati, one with sarsaparilla and the other with guaiacum, recommended in the
treatment of syphilis, while treating malarial fevers, the officinal formulas contained
the best-quality cinchona bark.72
In the set of vases (18th19th centuries) of the apothecary’s shop of the hospital of the
Benedictine monastery of San Giovanni Evangelista of Parma,73 figure some products
obtained from exotic plants: guaiacum rind, Tolu balsam, powder of cascarilla bark,
cut-up cinchona, sassafras, calumba root, of African origin, used for its digestive and
vermifuge properties, and also powder of kousso flowers, of African origin, also used
as a febrifuge and for its vermifuge properties, and kamala, of Asian origin, used
against dysentery and diarrhoea, as well as green tea.74
The Receptarium peculiare (1769) from the Convento di Santa Maria di Campagna of
Piacenza75 mentions, among the American plants that appear most frequently in
medicines, cinchona bark, Peru balsam and American sweet gum. Jalap root,
guaiacum, sarsaparilla, sassafras, tobacco, simaruba, copaiba balsam, and Tolu
balsam.76
The Farmacopea ferrarese (1798-99)77 by professor Antonio Campana (1751- 1832)
mentions, together with the simple medicines of American origin, most frequently
included in the various pharmacopoeias of that period (Peru balsam, Tolu balsam,
cocoa, copaiba balsam and vanilla), the leaves and roots of the American aloe and
terra oriana obtained from the fruits of the annatto tree.78 The roots of the Peruvian
calaguala, winter bark and cinchona bark are also mentioned. Among the
succedaneums for treating fevers, figure other plants of exotic origin, such as St.
Ignatius beans, gum-gut, extracted from Garcinia Cambogia L., and American
persimmon (Diospyros virginiana L.).79 Among the compound medicines, Alcool con
china composto, containing Virginian snake-root and cocoa soap, besides chinchona
bark and Pasticche antielmintiche and Pasticche marziali, with chocolate.80
Conclusions
Over the period between the sixteenth century and the first years of the nineteenth,
plants of American origin increased considerably in the Italian pharmacology. While,
up to the seventeenth century, the number of exotic plants figuring in the
pharmacopoeias was approximately fifteen, in the first years of the nineteenth
century their number had more than doubled, being less in the official antidotaria,
more cautious in including them, than in the medical treatises and the
pharmacopoeias of hospitals and monasteries. Whereas the sixteenth-century medical
science, still bound to the humoral concepts, had made the acceptance of exotic
plants difficult, the medical experimentation of the 17 th and 18th centuries and the
proved efficacy of medicinal plants facilitated their diffusion, hitting the old medical
system quite hard.

With the introduction of “Chemical Pharmacy” in medicine of which the Bolognese
pharmacopoeia was the forerunner in Italy, thanks also to the scientific spirit that
marked out the medical school of that city, the knowledge on the therapeutic
effectiveness of some American plants increased considerably. One of them was
cinchona bark, from which, during the nineteenth century, quinine, a remedy
prescribed to treat malaria at least up to the middle of the twentieth century, was
extracted.
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Idem, respectively 302 and 335-336.
62
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Catalogo de’ medicamenti semplici, e composti galenici e chimici ad uso interno, ed
esterno. Parma, Nella stamperia degli eredi Monti, 1772.
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Corvi A., ‘Un innovativo ricettario dell’ospedale di Parma alla fine del XVIII sec.’. Atti e
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73
Sani E., ‘Farmacisti privati e monaci dell’antica farmacia S. Giovanni Evangelista in lite, a
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1960. Reggio Emilia, Centro Italiano di Storia Ospitaliera, 1960, pp. 1134-1139; Fornari
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Maestri, 2001, in particular pp. 105 ff.
74
Fornari Schianchi L. (ed.), op. cit. note 73.
75
Receptarium peculiare ad usum Officinae Farmaceuticae Conventus St.tae Mariae de
Campanea Placentiae anno 1769. Ex variis manuscriptis vetustis decerptum et novis adhuc
Formulis locupletatum is preserved in the Biblioteca Comunale Passerini Landi, Piacenza,
fondo Frati. Ms. n. 12.
76
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(2003) 21 (3): 209-222.
77
Campana A., Farmacopea ferrarese. Ferrara, per gli eredi di Giuseppe Rinaldi, 1798-99.
See also Cingolani E., Colapinto L., op. cit. note 56, 84-85.
78
Campana A., op. cit. note 77, respectively p. 7, 8, 9, 54, 2 and 52.
79
Idem, respectively 8, 55, 14-15, 22 and 25.
80
Idem, respectively 83, 180, 170 and 173.

“HE WHO WANTS TO TRAVEL SHOULD…” – TRAVEL REGIMENS IN

MEDIEVAL ISLAMIC MEDICINE
Zsuzsanna Csorba1
Abstract
The present study aims to offer a concise picture of medieval Arabic health regimens written
by physicians for those travelling on land or sea by focusing on the typical subjects discussed
by such guides and their arrangement, as well as the customary recommendations given by
the physicians. The sources selected for this purpose date from the 9th–13th centuries.
Keywords
Travel guide; medical regimen; Islamic medicine; medieval Arabic physicians
Résumé
Cette étude tente de donner une idée précise des régimes de santé arabes, écrits par les
médecins pendant la période médiévale, pour les voyageurs terrestres ou sur mer. Le but de
cette étude est de décrire ces guides et leur contenu, ainsi que les recommandations
coutumières données par les médecins. Les sources sont limitées à la période du IXe au XIIIe
siècle.
Mots-clés
Guide pour voyageurs; régime medical; médecine Islamique; médecins Arabes médiévaux
Introduction
Travelling was an essential part of life in the medieval Islamic world. Journeys were
undertaken for numerous reasons and motivations and in many forms. However, all
sorts of travel had something in common: health risks. The medieval Arabic medical
tradition was concerned with these risks, as stated by the existence of a genre of
health guides written for travellers: tadbīr al-musāfirīn, ‘travel(lers’) regimen’. Some
physicians included their travel regimens in their medical encyclopaedias as separate
chapters, while others dedicated full monographs to discuss the topic. Several
physicians wrote shorter treatises for the travellers.
1 Zsuzsanna Csorba, M.A, is a PhD candidate at Eötvös Loránd University, Doctoral School of
Philology, Arabic Studies Program (Budapest) and a young research fellow of the Avicenna Institute
of Middle Eastern Studies (Piliscsaba). Contact: csorba@avicenna-kkki.hu, csozsuzsi@gmail.com

Instructions for armies were sometimes included in these travel regimens, while some
authors dedicated separate, shorter chapters to these matters.
The present study aims to offer a concise picture of these regimens according to two
questions that follow. What were the usual subjects of these guides and how were
they arranged? What were the general practices advised by physicians for those who
travel?
To achieve this goal, we surveyed a few selected sources from physicians of the 9 th–
13th centuries, namely Qustā ibn Lūqā’s (d. 912) monograph for pilgrims and parts of
the encyclopaedias of al-Tabarī (d. ca. 864), al-Rāzī (d. 925/935), al-Majūsī (10th c.),
Ibn Sīnā (d. 1037), and Ibn al-Quff (d. 1286).
Topics and structure of health guides
Qustā ibn Lūqā, a famous Christian scholar and translator, dedicated a monograph to
the regimen during a pilgrimage, the Risāla fī tadbīr safar al-hajj (‘Regime for the
Pilgrims to Mecca’) (1). In the introduction, Qustā ibn Lūqā lists the following topics
that he deems necessary to be discussed in such treatises as translated by Bos (2):
1. Knowledge of the regimen in regard to resting, eating, drinking, sleeping
and sexual intercourse.
2. Knowledge of different kinds of fatigue and their cure.
3. Knowledge of diseases which are caused by the blowing of the different
winds and their treatment.
4. Knowledge of prophylaxis against vermin and of treatment of the injuries
caused by them.
There are four additional points to discuss regarding the pilgrimage to Mecca as
translated by Bos (3):
1. Knowledge of different waters and the improvement (of the quality) of
contaminated water.
2. (Knowledge of) the expedients with which one can quench one’s thirst in
case of lack or paucity of water.
3. Knowledge of prophylaxis against the matter from which the dracunculus
medinensis and haemorrhoids arise.
4. (Knowledge of) prophylaxis against snakes and the treatment of the injuries
caused by them.
Qustā ibn Lūqā followed this list in his work, expounding on all the topics mentioned
above. He added chapters on massage, earache and dust getting into the eyes
(intraocular foreign bodies) as well (the latter two are mostly due to the change of
weather or winds, so those can be considered as included in the list). So far, we have
not found any other listing of topics to be discussed in travel regimens, what makes

Qustā ibn Lūqā’s classification a unique starting point for examining the usual subjects
and structures of these health guides.
How did the physicians mentioned above arrange their instructions when they wrote
for travellers in general, and not primarily for those undertaking the pilgrimage?
Al-Tabarī in his most famous work, the Firdaws al-hikma (‘Paradise of Wisdom’),
which is one of the earliest medical encyclopaedias written in Arabic, devoted a
chapter to the regimen of travellers (4). He gives his advice for those who travel
during winter and those who travel during summer; then, he gives instructions
specifically for armies for wintertime and summertime as well. In these parts, the
components of regimens later listed by Qustā ibn Lūqā can be observed, namely
eating, drinking, resting, bathing, and sexual activity. His section on impure waters is
a part of the instructions written for armies, dealing with leeches and other vermin
that can be drunk by accident. An interesting aspect of his regimen is that on three
occasions, he shares his personal experience with the readers. These are, however,
not unparalleled episodes, as similar remarks can be found in other parts of his work
as well.
Al-Rāzī’s health guide takes up a whole treatise (maqāla) in his Kitāb al-Mansūrī fī al-
tibb (‘The book dedicated to al-Mansūr on medicine’) (5). He divides his guide into
smaller sections and gives his advice on preserving oneself from the dangers of heat,
a type of burning wind called samūm, thirst, travelling in cold weather, treatment of
frozen body parts, fainting due to hunger, preserving the limbs, treating various
afflictions of the eye, dealing with fatigue, preparing the body for travelling and the
rules for eating, and he also discusses different waters.
He gives his advice for armies and travellers on the sea, then returns to general
topics, such as lice, paleness, caring for the feet, and what to do when one falls when
riding an animal. This one is the only work mentioning this topic among those
included in the present study. His discussion is richly detailed, as it considers various
circumstances and situations under his sections instead of just giving general
instructions.
Al-Majūsī’s Kāmil al-sināʿa al-tibbiyya (‘The complete book of the medical art’), also
known as Kitāb al-malakī (‘The regal book’) (6) was quite popular until Ibn Sīnā’s
Qānūn outweighed it. The physician dedicated a chapter to the regimen of travellers.
Firstly, he gives general advice on preparing for a journey, by listing the things one
should do in advance, mostly dealing with purging the body and getting accustomed
to the circumstances of travelling. This one is the first appearance of instructions on
preparation amongst the sources discussed here. Then, the author writes for those
who travel on foot in the summertime and wintertime, occasionally about riding as
well. He even includes a recipe for those travelling in the summertime, so that they
can prepare thirst-quenching pills. In the end, he also gives some useful insights on
sea travel, discussing nausea, vomiting, and lice.

Several physicians wrote shorter treatises for the travellers. Instructions for armies
were sometimes included in these travel regimens, while some authors dedicated
separate, shorter chapters to these matters. Ibn Sīnā in his Qānūn fī al-tibb (‘The
canon of medicine’) (7) is truly a master of organizing his material, as we will see. He
dedicated a clause (jumla) to the regimen of travellers, in 8 chapters. The 1st is on
various symptoms indicating diseases; the 2nd on the regimen for travellers in
general; the 3rd on protection against the harmful effects of heat and the regimen of
those travelling in hot weather; the 4 th on the regimen of those travelling in cold
weather; the 5th on the preservation of limbs against cold; the chapters, while others
dedicated full monographs to discuss the topic. 6th is on the preservation of
complexion; the 7th is on the harmful effects of different waters and how to prevent
these effects; the 8th on the regimen for the traveller on the sea. The 1st chapter is
unique amongst the discussed texts. With the 2nd chapter, we find our second source
for preparations, where a surprising practice against hunger is recorded (to be
discussed later).
Ibn al-Quff’s Jāmiʿ al-gharad fī hifz al-sihha wa-dafʿ al-marad (‘The comprehensive
[book] of the effects on preserving health and preventing illness’) is the latest source
included in the present study (8). In his work, Ibn al-Quff dedicates a separate
chapter to the regimen of those travelling on land and sea. He starts by discussing
the different waters, then moves on to other general issues, followed by pieces of
advice for travelling in summertime and wintertime. He is the only one who gives
instructions on how to prepare for travelling on the sea, instead of just dealing with
typical diseases.
As it can be observed, arranging the material varies from author to author. It seems
that the most convenient structure is to write on preparation, travelling on land,
during summertime and wintertime, and travelling on the sea. Sometimes, the needs
of armies are discussed as well.
These discussions follow Qustā ibn Lūqā’s list in the sense that they deal with how to
eat, drink, rest, and others in certain circumstances. Specific topics, e.g. burning
winds, preserving complexion or limbs, are discussed after or in the parts dealing with
summer or winter travels, respectively.
What is intriguing, however, is that all sources discussed here include the issues on
Qustā ibn Lūqā’s second list apart from the dracunculus medinensis (Guinea worm),
namely waters and their purification, thirst, and snakes and bites (or at least vermin).
“He who wants to travel should…”
Reviewing the structure of the chosen travel regimens provided us with a general
overview of the contents of such works. In the following, more detailed examples are
given on how the subjects above were discussed in such guides.

When preparing for a journey, the traveller should purge his body through
bloodletting and laxative remedies. When doing so, his habits of purging should be
taken into consideration. Besides this, he is to get accustomed to the circumstances
of his travel: exercise and walk each day, more and more day by day. He is to change
his eating and sleeping habits as well, trying to time them according to how and when
these activities will be possible for him during his travels. The key to the preparation
is doing all these things slowly and gradually (9). Al-Majūsī recommends wrapping the
thighs and waist in cloths and bandages, as well as using a walking stick (10).
Travelling in the summertime has its own rules for daily regimens. In general, the
traveller should consume moist foods and drinks which cool him. He is to travel when
the weather is cooler and rest when it is hotter. It is also advised to have cooling
baths when possible and use rose or violet oil, since those have a cooling effect.
Sexual intercourse should be avoided. Al-Tabarī recommends wearing a garland made
of cooling plants or, more directly, sniffing flowers with similar cooling qualities
(Egyptian willow, Safsaf willow, rose, water speedwell) (11).
Al-Rāzī advises those who become feverish, to rest until they recover, or if resting is
not possible, to make the next days’ travel more relaxed. He notes, however, if the
fever persists, then the traveller should find a doctor (12).
A significant portion of summertime travel regimens is how to prevent thirst. It is
generally recommended to mix vinegar into the water, since this way even a small
amount satisfies the thirsty traveller. Al-Majūsī gives the following recipe for a thirst-
quenching pill: take the kernel of gourd seeds, long-fruited muskmelon seeds,
cucumber seeds and purslane seeds, five dirham of each; cornstarch, tragacanth and
sugar, two dirhams of each; pulverise them together finely; knead them with
mucilage of cotton seeds; form big, flattened pills; put them in the mouth (13). Ibn
Sīnā also mentions a similar pill.
Another important topic for travelling in hot weather is the precautions against the
samūm, a hot and burning wind. It is generally recommended to eat and drink before
the wind strikes, then cover the face with a turban or any other cloth. The best
repellent for the harms caused by this wind is to soak an onion cut into small pieces
in buttermilk for a night, then consume it. During the samūm, the traveller should not
drink water; drinking more than a few sips causes immediate death, according to the
physicians.
Travelling in cold weather or during winter has its own regimen as well. It is
recommended to travel during the daytime since it is warmer. The traveller should
dress in multiple layers and take special care of protecting his feet if he will be riding,
as in that case, he will miss the warming effect of walking. It is advised to use oils
with warming qualities, e.g. bay laurel or lily oil. Eating warming foods rich with
onion, garlic, and hot spices is advised as well. When resting, the traveller can use
the heat of his animals when sleeping next to them. It is better to drink pure wine.
One of al-Tabarī’s personal accounts is related to travelling in cold weather: he
saw the
people of Tabaristan’s mountains overcome the cold by eating garlic and kebab, and
drinking pure wine. Some of them got drunk and slept on the snow, and it snowed on
them, but they did not feel it (14).
Protection of complexion is a general topic of wintertime travel regimens, usually by
smearing a thick layer of warming oils or fats onto the face.
As for the protection of the limbs, besides using goat’s underwear, paper and cloths
under the fur clothing are massaging with warming oils. Al-Majūsī advises the
traveller in case the precautions were not enough, and something happened with his
fingers. If the fingers are swollen but not discoloured, he should anoint them with
warming oils and put them in warm water with camomile, melilot, dill and other
warming and dissolving herbs. If the fingers became green or black, then the traveller
is to cut them deeply and put them in warm water so that the blood comes out of it.
When the bleeding stopped, the cut should be covered with Armenian bole kneaded
with vinegar and rosewater and left to harden for a day and a night. Then it should be
washed off with wine, and the coating is to be put back on until the flesh grows back,
and the wound hardens and dries. However, if it looks like the fingers will fall off,
there is nothing to do. They should be bandaged with mallow and gooseberry leaves
pulverised and mixed with violet oil and changed 2-3 times a day until the rotten
parts fall off. Then the wounds should be healed the same way as wounds caused by
drying (15). Ibn Sīnā gives similar advice in his encyclopaedia.
Hunger can be an issue during summer and winter as well. It is quoted, for example
by Ibn Sīnā, that drinking a ratl52 of violet oil mixed with wax to achieve a plaster-like
consistency, one will not feel hunger for ten days (16).
Of course, there are less dramatic ways to keep hunger away from the traveller, for
example, consuming kebabs made from liver, fats and oils.
As for the different kinds of waters, the advised treatment sometimes was to use
certain plants to compensate for the taste. However, boiling the water, cleaning it
with sieves, pieces of cloth, and different methods of filtering were devised. It was
also advised to bring water and clay from the traveller’s homeland and mix it into the
waters he encountered, always keeping some of this mixed water to mix into the next
one.
Al-Tabarī noted in his work that Egyptians put pulverised peach and apricot
kernels into the muddy water of the Nile since it cleaned it and made it potable
(17).
Those who will travel on the sea can prepare themselves as well by purging according
to their purging habits, to avoid nausea and vomiting once on board. Purging also
helps to prevent the mixing of good humours with bad or corrupted ones, as well as
their movement to the weaker organs (18). When the travel started, it is advised to
consume and sniff sour things, while trying to eat a bit less. In case the traveller
becomes nauseous, there is not much to do other than completely emptying his
stomach. When he wants to drink and eat again, it is important to

consume only small amounts of food or drinks, and mostly those that are good
against nausea.
Bathing is not usually possible, which makes lice a serious trouble. Covering the body
with lily oil, lice-bane or oleander oil is advised as a precaution, as well as long and
thorough bathing once the travel ended.
As for armies, the authors who wrote instructions focused mostly on how to camp
according to the season. In wintertime, they should dig out holes and heat them with
fires before using them. They are to set up their tents close to each other and their
animals and surround them with heated stones. When the weather is hot, however, it
is best to stop on hills, far from each other, and to cover the tents with cold wood. If
the air is thick and foggy, it is best to tire the soldiers’ body, make them drink pure
wine, eat acrid food and sleep a lot.
Conclusion
As can be seen, the most common way to arrange a travel regimen is to write for
those who travel on land and sea. As for the former category, the regimens are
usually separated into two parts, for travelling during summertime and wintertime.
Certain issues are discussed in the appropriate section, while purifying water usually
has its own section. While this short introduction can offer insight into the
arrangement and content of these guides, it is important to point out that only a part
of the sources was discussed here. Therefore, the relationship between the texts was
not studied, neither the Graeco-Latin medical tradition’s influence on the Arabic
tradition. It is worth mentioning that manuscripts containing travel regimens are only
recently available so that their contents might be added to our knowledge of this
genre as well.

References
1. Qustā b. Lūqā, al-Baʿlabakkī. Qustā ibn Lūqā’s medical regime for the pilgrims to
Mecca. The Risāla fī tadbīr safar al-hajj. Edited and translated by Gerrit Bos.
Leiden/New York/Köln: E.J. Brill, 1992 (For a detailed survey of the contents, see 6–
12).
2. Ibidem, 18-19.
3. Ibidem, 18-20.
4. al-Tabarī, Abū al-Hasan ʿAlī b. Sahl Rabban, Firdaws al-hikma = Firdausu’l-Hikmat or
Paradise of Wisdom of ʿAlī b. Rabban-al-Tabarī. Edited by Siddiqī, Muhammad Zubayr.
Berlin-Charlottenburg: Buch- u. Kunstdruckerei “Sonne” G.m.b.H., 1928.
5. al-Rāzī, Abū Bakr Muhammad ibn Zakariyyāʾ, al-Mansūrī fī al-tibb. Edited by Ḥāzim al-
Bakrī Siddīqī. Al-Kuwayt: Maʿhad al-Makhtūtāt al-ʿArabiyya, 1987.
6. al-Majūsī, ʿAlī b. al-ʿAbbās, Kāmil al-sināʿa al-tibbiyya, 2 vols. Būlāq, 1294/1877 (repr.
Frankfurt am Main: Institute for the History of Arabic-Islamic Sciences at the Johann
Wolfgang Goethe University, 1996).
7. Ibn Sīnā, Abū ʿAlī al-Husayn b. ʿAlī, al-Qānūn fī al-tibb, 4 vols. Ed. Saʿīd Lahhām.
Bayrūt: Dār al-Fikr, 1994.
8. Ibn al-Quff, Amīn al-Dawla Abū al-Faraj b. Muwaffaq al-Dīn Yaʿqūb b. Ishāq al-Malakī
al-Masīhī al-Karakī, Jāmiʿ al-gharad fī hifz al-sihha wa-dafʿ al-marad. Ed. Sāmī Khalaf
al-Hamārnah. ʿAmmān: Manshūrāt al-Jāmiʿa al-Urduniyya, 1989.
9. al-Majūsī, Kāmil al-sināʿa, II/81; Ibn Sīnā, al-Qānūn, I/321.
10.al-Majūsī, Kāmil al-sināʿa, II/81.
11. al-Tabarī, Firdaws, 109–110.
12. al-Rāzī, al-Mansūrī, 282.
13. al-Majūsī, Kāmil al-sināʿa, II/82.
14.al-Tabarī, Firdaws, 110.
15.al-Majūsī, Kāmil al-sināʿa, II/83.
16.Ibn Sīnā, al-Qānūn, I/321.
17.al-Tabarī, Firdaws, 111.
18.Ibn al-Quff, Jāmiʿ, 172.

POISON, PROOF, AND FORENSIC MEDICINE IN NINETEENTH-

CENTURY FRANCE
Claire Cage1
Abstract
This essay argues that expert authority was both constructed and challenged in suspected
poisoning cases in nineteenth-century France, amidst varying degrees of skepticism about
and confidence in scientific and medical evidence. At the heart of legal medicine was the
problem of proof and determining what constituted reliable evidence, a problem that was
especially pronounced in the nascent field of forensic toxicology. A new confidence in the
power of scientific inquiry to establish guilt, innocence, and legal responsibility was coupled
with uncertainty about the reliability of forensic evidence, particularly when assessed by
poorly trained practitioners. Medico-legal experts during this period struggled to discern
whether a suspicious death was caused by poisoning or natural causes, particularly during
cholera epidemics, and faced difficulties in detecting traces of poison in cadavers. The
prevalence and nature of poisonings shifted over the course of the nineteenth century, largely
in response to the evolving state of scientific knowledge. However, forensic experts’ public
battles over the state of scientific and medical knowledge in poisoning cases raised concerns
that the very means by which they sought to establish their authority might undermine it.
Key words
Forensic medicine; 19th century; France; Marie Lafarge; Mateu Orfila; François-Vincent Raspail
Résumé
Cet article donne des arguments à la thèse que dans les cas d’empoisonnement suspecté en
France au XIXe siècle, l’autorité experte était autant construée que mise en doute, dans un
environnement diversément sceptique, respectivement confident envers l’évidence
scientifique et médicale. Au coeur de la médecine légale résidait le problème de preuve et de
détermination d’évidence fiable, un problème particulièrement prononcé dans le domaine
naissant de la toxicologie médico-légale. Une nouvelle croyance dans le pouvoir de l’enquète
scientifique à découvrir la culpabilité, l’innocence et la responsabilité légale était couplée à
l’incertitude concernant la fiabilité de cette évidence médico-legale, surtout quand celle-ci
était évaluée par des praticiens mal formés. Les experts médico-légaux avaient des difficultés
à discerner si un décès suspect était causé par un empoisonnenment ou par une cause
naturelle, surtout pendant des épidémies de choléra; ils avaient des difficultés de détecter
1 Associate Professor, Department of History, University of South

Alabama, USA Contact: ccage@southalabama.edu Mobile, AL
36688

des traces du poison dans les cadavres. La prévalence et la nature de l’empoissonnement

changeait durant la période du XIXe siècle, surtout grâce à l’evolution de la connaissance
naturelle, surtout pendant des épidémies de choléra; ils avaient des difficultés de détecter
des traces du poison dans les cadavres. La prévalence et la nature de l’empoissonnement
changeait durant la période du XIXe siècle, surtout grâce à l’evolution de la connaissance
scientifique. Cependant, les batailles entre experts médico-légaux concernant l’état de cette
connaissance médicale dans les cas d’empoisonnement ont mis en doute si les méthodes par
lesquelles ils tachaient d’établir leur autorité n’induisait pas justement leur sape.
Mots-clés
Médecine légale; XIXe siècle; France; Marie Lafarge; Mateu Orfila; François-Vincent Raspail
Introduction
In 1840 a young aristocratic French woman went on trial for poisoning her husband,
Charles Lafarge. Lafarge had presented himself as a wealthy manufacturer and owner
of a large chateau. Shortly after their marriage, Marie Lafarge (1816-1852) found that
her husband was bankrupt and that their residence was dilapidated and rat infested.
Figure 1- Marie Lafarge, frontispiece of Memoirs of Madame Lafarge, Philadelphia: Carey and
Hart, 1841. Unknown author. Credit: Wiki Commons.

She obtained arsenic to exterminate the rats. Not long afterwards, her husband
fell violently ill and died. Doctors who conducted the autopsy and chemical
analyses found that arsenic was present in Charles’s stomach and in the
remains of the milk that Marie served him. But subsequent tests performed by
chemists from Limoges using the newly developed Marsh apparatus indicated
that there was no trace of arsenic in the exhumed corpse2 (1).
Figure 2- Group of experts performing an analysis using the Marsh test (right). According to J.
Plantadis (Bulletin of the Société d’Histoire de la Pharmacie, 1921).
Disagreements among medical experts during Marie’s trial at the assize court in Tulle
led to the summoning of the renowned toxicologist and professor of legal medicine
Mathieu Orfila (1787-1853) to settle the dispute. To the defense’s dismay, Orfila
found traces of arsenic in the samples taken from the cadaver. Marie was convicted of
murder and sentenced to life imprisonment. Controversy surrounding the trial
persisted, as the chemist and physician François-Vincent Raspail challenged Orfila’s
findings—but arrived in Tulle eight hours too late to testify—and as questions about
Marie Lafarge’s guilt continued to divide French society (2-5).
_
2 In 1836 the British chemist James Marsh (1794-1846) published a paper describing his construction
of a glass apparatus capable of detecting and measuring minute—as little as 0.02 mg—quantities of
arsenic by placing a sample as well as zinc and sulfuric acid in a flask that opened into a narrow,
horizontal tube. If the material contained arsenic, arsine gas would form and pass into the tube. A
flame beneath the tube heated the gas, and elemental arsenic would condense as a dark metallic film
or ‘mirror’ when it reached a cold part of the tube. See Marsh 1836.

At the heart of legal medicine was the problem of proof and determining what
constituted reliable evidence, a problem that was especially pronounced in the
nascent field of forensic toxicology. A new confidence in the power of scientific inquiry
to establish guilt, innocence, and legal responsibility was coupled with uncertainty
about the reliability of forensic evidence, particularly when assessed by poorly trained
practitioners. Cases like the Lafarge trial led the public to ask whether legal medicine
would prevent miscarriages of justice, or lead to them.
This essay seeks to highlight the tensions between confidence, which medical experts
projected in their efforts to establish their authority, and uncertainty in nineteenth-
century French medico-legal investigations of poisonings (6-9).
Medical experts in nineteenth-century France often struggled to discern whether a
death was caused by poisoning or natural causes and had difficulty detecting small
traces of poison in cadavers. Nonetheless, they played an increasingly decisive role in
trials. Poisoning investigations and trials often revealed conflicts and tensions among
medical experts. Their conflicts, which involved the changing and contested state of
knowledge concerning poisoning and toxicology and their disagreements about
standards of proof, raised broader questions about the certainty of scientific
knowledge and its utility in the pursuit of justice. Forensic experts sought to expose
errors that could compromise the pursuit of justice and harm the dignity and
reputation of their professions. However, forensic experts’ public battles over the
state of scientific and medical knowledge in poisoning cases raised concerns that the
very means by which they sought to establish their authority might undermine it.
Poisoned Bodies and the Corpus Delicti
In the early nineteenth century, medical experts articulated growing concerns about
inadequate forensic reports in poisoning cases, and some published works to expose
the flawed methods and findings of their colleagues, particularly those whom they
deemed had insufficient knowledge or training. An investigation into the sudden death
of a twenty-two-year-old woman in 1814 in the department of Loiret gave rise to a
battle over the findings and competencies of the medical experts involved. The
doctors who conducted the autopsy, Dufour and Raige, observed a dark lesion in her
stomach and concluded that the cause of death was arsenic poisoning. Another
doctor, Elie Calabre de Breuze, later examined the stomach and refuted Dufour and
Raige’s findings. He declared, “the most novice doctors would easily recognize here
an upset stomach that ended with cholera morbus. No wise and reflective doctor
could find in any of these symptoms the slightest indication of a poisoning.”(10).
He criticized Dufour for signing off on Raige’s “incoherent” and “most inept report”
and for Raige’s solicitating the signatures of four military surgeons who had been in
Montargis by chance and had never seen the cadaver. Calabre de Breuze insisted that
none of these individuals had the appropriate forensic training or knowledge to weigh

in on this affair (11). When the woman’s husband went on trial for her murder before
the assize court of Orleans, seven professors at the medical faculty in Paris
intervened, declaring that Raige and Dufour’s forensic report was deeply flawed in
every respect. They described it as “absurd, contradictory, and reprehensible” as well
as “a monument…of ignorance.” The following month, five other members of the Paris
faculty of medicine intervened on behalf of the accused and issued a similar
assessment. The editors of one medical journal3 publicly urged Raige and Dufour not
to contest these findings in their own interests and that of the profession: “Why would
forensic doctors, before magistrates and before all citizens, dare to dampen
confidence [in forensics] and expose themselves to ridicule?” (12). Nonetheless,
Dufour and Raige published a defense of their report, insisting that they were right to
dismiss cholera as a cause of death, on account of the lack of vomiting. Moreover,
they accused Calabre de Breuze of libel (13).
Later in 1819, Raige’s son, Jacques Raige-Delorme, publicly defended his father and
argued that the chemical detection of poisons might not even be necessary when
doctors could identify distinctive lesions indicative of poisoning. In his work on
poisoning by corrosive substances, Raige-Delorme suggested that doctors too
frequently erroneously attributed deaths by poisoning to natural causes, due to their
flawed ideas about the burden of proof. Raige-Delorme warned of the dangers of the
precept, widely adopted by jurists and doctors, that it was better for ten guilty men to
go free than one innocent man be convicted. He insisted that this laudable precept,
indebted to Enlightenment-era critiques of miscarriages of justice, had become
harmful when observed too rigorously and had allowed too many poisoners to escape
justice. Raige-Delorme acknowledged that doctors in the past had frequently wrongly
concluded that poisonings had occurred by relying upon equivocal signs and
misleading indications. But he insisted that there was now a better understanding of
how natural causes could produce traces or lesions on organs that resembled those
produced by poison and of how certain distinctive lesions on cadavers, specifically
those produced by corrosive poisons, could provide proof of poisoning. Raige-Delorme
maintained that an autopsy alone, without a chemical analysis, could provide proof of
poisoning in a number of cases—the material discovery of poison was not necessary.
He noted that chemical analysis could be difficult or impossible when dealing with
small quantities of poisons or poisons that have been evacuated through vomiting.
What is more, he argued that absolute certainty was an illusion in the natural
sciences and an impossible criterion for forensic evaluations of poisoning (14).
But during this period, a growing number of medical practitioners and the first
scientists who were referred to as toxicologists were tackling the challenges that
Raige-Delorme identified, and they insisted, on the contrary, that chemical evidence
was the most decisive and necessary form of proof of poisoning.
3
Journal général de médecine, de chirurgie et de pharmacie 51 (Paris, 1814), 317-18.

Orfila (15) had emerged as the leading figure in forensic toxicology after publishing
his influential Treatise on Poisons (1814-15), which systematically classified poisons
and examined the chemical properties of various poisons, their physiological effects
on the living body, the treatment of poisoned persons, and signs of poisoning in
cadavers (16).
Figure 3 - Mathieu Orfila (Mateu Josep Bonaventura Orfila i Rotger, 1787-1853). Lithograph by
Alexandre Collette (1814-1876), Credit: Wiki Commons.
But during the years that followed, there was considerable uncertainty among
magistrates, the public, jurors, and doctors about what were the limits of toxicological
knowledge. There was also dissension among forensic physicians concerning the
importance afforded to the physical symptoms of poisoning as proof of crime and the
methods for detecting poison. Many forensic doctors, who recognized their inability to
distinguish between the symptoms of poisoning and those of cholera, insisted that
discovering the corpus delicti, the poison itself, was crucial. However, jurists often
observed that physicians and scientists were unable to establish the corpus delicti in
many cases in which the guilt of the accused seemed evident. Proliferating works on
poisons and toxicology often questioned what constituted proof of poison and sought
to expose errors in the detection of poisoning.
Some experts felt uneasy in their role and ability to detect poisoning. In a report to
the Minister of the Interior in 1838, the president of the assize court of Riom
lamented the incompetence of the experts involved in the investigation of Anne
Betoin, who was accused of poisoning the woman whom she employed as a wet-
nurse. The doctors and chemists in Montluçon could not detect the presence of

arsenic. The jurist attributed the experts’ inability to do so to their incompetence or

their faulty instruments and laboratory—possibly both. These experts were aware of
their own limitations and stated in their report that they only used part of the
samples provided to them and conserved the remainder in order for them to be
analyzed by more knowledgeable experts or those with better laboratories. The court
ordered new experiments to be performed by more distinguished scientists, as the
president of the court was eager for the jury to hear the testimony of the new experts
who could better articulate and elucidate their findings in clear terms to the jurors
(17).
Toxicology and the Search for Justice
Other medical experts warned that false positives in chemical tests and flawed
forensic reports resulted in the wrongful conviction of innocent men and women. In
the 1840s, François-Vincent Raspail (1794-1878) emerged as Orfila’s most dogged
critic and was convinced that Orfila and other forensic experts were committing tragic
errors, which advances in toxicology would later bring to light. He argued vehemently
that Orfila was personally responsible for a number of these cases, such as that of
Marie Lafarge’s wrongful conviction. Raspail was confident that Orfila and other
doctors and chemists were committing tragic errors that advances in toxicology would
soon bring to light. He expressed these concerns in reference to the Lafarge trial of
1840 as well as the 1839 trial of Louis Mercier, whose conviction for poisoning his son
with arsenic was also primarily the result of Orfila’s toxicological report. When
combatting Orfila in the Mercier trial, Raspail declared, “Gentlemen, you must doubt
the omnipotence of forensic chemistry because it refutes itself every six months.”
(18,19). Raspail accused Orfila of overconfidently presenting uncertain evidence as
definitive and of operating under the principle that it was better for one innocent to
perish than for one guilty person to escape justice4 (20).
Raspail’s warnings about the risks of testing for arsenic with the Marsh apparatus and
his attacks on Orfila’s overconfidence led Orfila to defend himself vigorously and to
spread public awareness of the Marsh apparatus.
As lay and expert knowledge of methods of detecting arsenic spread, some expressed
concerns about criminals using this knowledge to their advantage. Jules Barse (1812-
1878), a chemist and toxicologist, observed in 1845 that criminals could come to
know the limits of forensic toxicology and discern which poisons are the most difficult
to detect by studying forensic treatises and toxicology. Barse noted that some of his
contemporaries were calling for a ban on the sale of arsenic but warned that this
could lead to criminals using poisons that were less familiar to forensic experts and
were thus more easily undetected.
_
4 In contrast, Raspail declared that it was better for twenty guilty persons to escape justice than to
compromise the life or liberty of one innocent person.

Figure 4 - François-Vincent Raspail. Painting by Denis Bonnet (Carpentras: Musée Contadin).

Photographic Rights: The Bridgeman Art Library. Out of copyright.
Barse also insisted that highly trained experts should be the only ones conducting
chemical analyses and tests of poisons. He noted, however, that in the majority of
cases of suspected poisoning, an overzealous mayor, justice of the peace, or police
commission would enlist an herbalist, grocer, or empiric to examine a portion of the
suspect substance when a doctor or pharmacist was absent.

Barse lamented that many villagers respected their flawed findings more than the
scientific findings of experts from Paris (24). Consequently, skepticism toward these
elite outsiders could lead jurors to side with local medical experts who were often
unable to detect traces of poison, even in veritable cases of poisoning.
The state of toxicological knowledge was in flux throughout the nineteenth century
but particularly dramatically during the early 1840s. During this period, suspected
poisonings were subjected to new scrutiny and cases were reopened, such as that of
Julie Phalipon. Phalipon was suspected of poisoning her husband, Jean- Antoine
Gautier, in 1839 in order to marry her lover, who was an employee in her husband’s
mill. Gautier’s death immediately raised suspicions that Phalipon and her lover had
poisoned him. Experts in Villefranche conducted chemical analyses using the Marsh
apparatus but did not detect any arsenic. Phalipon was released on the basis of the
report. She then gave birth eight months after her husband’s death, and the paternity
was attributed to Gautier. The child lived only twelve days, and upon the child’s
death, Phalipon gained inheritance rights to her husband’s estate. She married four
months later in May. In June 1841, samples of Gautier’s stomach and intestines,
which had been hermetically sealed and preserved, were sent to Montpellier and
newly examined, since forensic experts had refined their methods of detecting arsenic
since the initial examination and Lafarge’s trial inspired the reopening of the case.
Three professors of the faculty of medicine and pharmacy in Montpellier detected
arsenic in Gautier’s remains. Phalipon went on trial before the assize court of Aveyron
in 1842, and the doctors who had performed the initial analyses acknowledged that
Gautier’s death could only be attributed to poisoning. The court sentenced Phalipon to
death, and her case was among a number that were reopened in light of new
toxicological techniques (25-26).
Nonetheless, many jurists, doctors, and ordinary French men and women were concerned
that many instances of poisoning never culminated in an autopsy, legal investigation, or
prosecution. The cholera epidemics of 1832 and 1849 heightened fears of innocent people
being falsely convicted of poisoning as well as fears that guilty persons would go free since
their crimes would be mistaken for natural deaths. There were also concerns that poisoning
was on the rise, as some saw a moment of opportunity in the cholera epidemics to poison
those whom they wished dead5. The recent cholera epidemics were likely one of the
foremost reasons the serial killer Hélène Jégado (1803-1852), was able to poison so many
victims.
In 1833, Jégado was working as a domestic servant for a priest in Guern. Within the
span of three months, seven people in his household became violently sick and then
died, including the priest and Jégado’s sister. Hélène then assumed her late sister’s
former position working at the rectory of a parish priest in Bubry, where three people
died in the span of three months, including Jégado’s aunt and relatives of the priest.
5 The Gazette médicale de Paris reported in 1832: “Everywhere where cholera has broken out, rumors
of poisonings are widespread.” Gazette médicale de Paris 3, no. 7 (1832).

Figure 5 - The poisoner Hélène Jégado, denounced for having poisoned 37 people, of whom 23 died.
Pellerin, 1852. (Paris: Bibliothèque nationale de France).
The pattern continued in the subsequent households where Jégado was employed as
a cook or servant for nearly two decades in various towns across Brittany. In 1850
Jégado entered into the service of Théophile Bidard de la Noë (1804-1877), a law
professor in Rennes. Two weeks after Jégado’s arrival, the domestic servant Rose
Texier became ill and died. Her replacement became ill and promptly quit her
position. A doctor later determined that she had been given poison in small doses.
Then another servant, Rosalie Sarrazin, died. Bidard and local doctors suspected foul
play. The autopsies of Texier and Sarrazin revealed the signs of arsenic poisoning.
Faustino Malagutti (1802-1877), professor of chemistry in Rennes, conducted the
chemical analysis of the samples extracted from their corpses and one other. He
detected arsenic in all three. In December 1851, Jégado went on trial in the assize
court of Ille-et-Vilaine for three murders by poisoning, three attempted poisonings,
and eleven thefts. Many other poisonings, attempted poisonings, and thefts were not
tried due to the statute of limitations on these crimes. The estimated number of

poisoning victims was over thirty; some, like Raspail, considered it to be over forty.
Jégado’s mental state was an issue in the trial, but she was deemed sane. She was
convicted and executed6 (27-28).
Some forensic experts, like Raspail, decried the fact that these murders had gone on
for so long without doctors calling for legal inquiries or identifying poisoning as the
cause of death for Jégado’s numerous victims prior to 1851. Raspail lamented in 1857
how many poisonings had been mistaken for natural illnesses. Raspail claimed that on
average only one out of every twenty murders by poisoning were investigated.
Ultimately forensic experts’ past mistakes were to blame.
He argued that as a result of previous forensic and judicial errors, people were
hesitant to throw suspicion on the truly guilty. Moreover, when scientific and medical
experts intervened, their flawed reports often absolved the guilty of responsibility.
Raspail’s criticisms represented a shift from his stance earlier in the 1840s, when he
had focused less on guilty persons going free and more on flawed forensic reports
that resulted in the wrongful conviction of innocent men and women. Furthermore,
Raspail insisted that many medical experts called before the courts were not
competent to evaluate poisoning cases, while he also challenged the findings of the
most well respected toxicological experts (29).
Over the course of the nineteenth century, the prevalence and nature of poisoning
shifted as the state of scientific knowledge evolved. Arsenic had been the preferred
poison, since it was readily available and also odorless and tasteless, but as forensic
experts refined methods of arsenic detection with the Marsh apparatus, poisoning by
other mineral poisons and plant alkaloids became more common. By 1860, trials
involving phosphorous, most often extracted from matches, became more common
than those involving arsenic (30, 31). Doctors widely attributed to the shift in
prevalence of phosphorous poisoning to the ease with which medical experts could
detect arsenic and their difficulties in detecting phosphorous poisoning (32-35).
Furthermore, the overall number of poisoning trials was declining. Poisoning
prosecutions had peaked during the late 1830s, in the years directly preceding
Lafarge’s trial. During the period from 1825 to 1854, over 1200 persons faced
criminal charges of poisoning in the assize courts in France. More than 500 were
acquitted, and over 600 were condemned (36).
It is of course impossible to quantify how many people were wrongly convicted or got
off scot-free. Some forensic experts struggled with balancing the need to proceed
cautiously amidst scientific uncertainty in order to protect and safeguard the innocent
with the risk that too much circumspection would result in crimes of poisoning
continuing unabated and without justice.
6 Condamnation à mort et exécution d'une servante coupable de quarante-trois empoisonnements

(Arras: Vve J. Degeorge, [1852]); Acte d'accusation de la fille Hélène Jédago, auteur d'un nombre
considérable d'empoisonnements ([Paris]: Chassaignon, [1851]).

Conclusion
One of the most significant reasons why poisoning inspired so much fear and interest
among both experts and the general public in nineteenth-century France was that it
was a crime shrouded in secrecy that could easily go undetected. Expert authority
was both constructed and challenged in poisoning criminal cases amidst varying
degrees of skepticism about and confidence in scientific evidence as well as growing
concerns about judicial errors. Doctors and chemists’ involvement in poisoning trials
was in some cases highly contentious, especially when controversies arose that pitted
Parisian experts against lesser trained provincial practitioners. Their interventions
served both to undermine and shore up their authority during a crucial period in the
history of the rise of professionalization and expertise.
Archive Sources
1. Archives Nationales de France (AN) BB/18/1831.

References
1. Marsh, J. “Account of a method of separating small quantities of arsenic from

substances with which it may be mixed.” Edinburgh New Philosophical Journal, 1836,
21: 229-236.
3. Lafarge, M. Procès de Madame Lafarge. Paris: Pagnerre, 1840.
4. Fouquier, A. Causes célèbres de tous les peuples. Paris: Lebrun, 1858, 1: 1-32.
5. Raspail, F.-V. Accusation d'empoisonnement par l'arsenic. Paris: Gazette des hôpitaux,
1840.
6. Bertomeu-Sánchez, J.R. “Managing Uncertainty in the Academy and the Courtroom:
Normal Arsenic and Nineteenth-Century Toxicology.” Isis 2013, 104 (2): 197-225.
7. Bertomeu-Sánchez, J.R. “Arsenic in France: The Cultures of Poison During the First
Half of the Nineteenth Century.” In: Compound Histories: Materials, Governance and
Production, 1760-1840. Lissa L. Roberts and Simon Werrett (Eds.). Leiden: Brill, 2018,
131-158.
8. Essig, M.R. Science and Sensation: Poison Murder and Forensic Medicine in
Nineteenth-Century America. Ph.D. diss., Cornell University, 2000.
9. Burney, Ian. Poison, Detection and the Victorian Imagination. Manchester: Manchester
University Press, 2006.

10.Calabre de Breuze, Mémoire justificatif et consultation médico-légale, en faveur de

Dominique François, etc. [Paris]: Didot jeune, 1814, 8-9.
11.Idem, 12-17.
12. Poilroux, J. Traité de médicine légale criminelle. Paris: Levrault, 1834, x.
13. Dufour and Raige, Réponse à un libelle diffamatoire de M. Calabre Debreuze (n.p.:
[1815]).
14. Raige-Delorme, Considérations médico-légales sur l'empoisonnement par les
substances corrosives. Paris, 1819.
15. Bertomeu-Sanchez, J.R. and Nieto-Galan, A., eds. Chemistry, Medicine, and Crime:
Mateu J.B. Orfila (1787-1853) and His Times. Sagamore Beach, MA: Science History
Publications, 2006.
16. Orfila, M.J.B. (Mateu-Josep-Bonaventura Orfila i Rotger). Traité des poisons. Paris,
1814-15.
18. Rognetta, Fr. and Raspail, Fr.-V. Nouvelle méthode de traitement de
l'empoisonnement par l'arsenic. Paris: Gardenbas, 1840, p. 81.
19. Bertomeu-Sánchez, J.R. “Orfila, Raspail et les cercles vicieux de l'expertise.” In:
Jonathan Barbier (Ed.). Une imagination républicaine: François-Vincent Raspail (1794-
1878). Besançon: Presses universitaires de Franche-Comté, 2017, 39-62.
20. See reference 18, 83.
21. Raspail, Fr.-V. Accusation d'empoisonnement par l'arsenic: Mémoire à consulter, à
l'appui du en Cassation de Dame Marie Cappelle, Ve Laffarge. Paris: Gazette des
hôpitaux, 1840, 161-162.
22. See reference 18, 82.
23. Whorton, J.C. The Arsenic Century: How Victorian Britain was Poisoned at Home,
Work, and Play. Oxford: Oxford University Press, 2011.
24. Barse, J. Manuel de la Cour d'assises dans les questions d'empoisonnement, à l'usage
des magistrats, des avocats, des experts, des jurés et des témoins. Paris: Labé, 1845.
26. La Phalange: Journal de la science sociale découverte et constituée, ser. 3, vol. 5, no.
75 (1842), 1227.
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pharmacie, October 1, 1857, 65-76.
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32.
29. See reference 27, September 1, 1857, 37-41.
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le phosphore. Paris: Baillière, 1862.
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ed. 8, 417-418.

REPRESENTATION OF SPINAL TUBERCULOSIS IN A PTOLEMAIC

DWARF STATUETTE
Veronica Papa1, Francesco Maria Galassi2, Elena Varotto3
Abstract
Still today, tuberculosis (TB) represents one of the world’s deadliest communicable diseases,
hence understanding its history is of vital importance. The principal causative organism is
Mycobacterium tuberculosis, an obligate pathogen member of the M. tuberculosis complex
(MTBC). Palaeopathological findings suggestive of tuberculosis from Predynastic Egypt have
been reported. As a matter of fact, tuberculosis has long been recognized in Egyptian
mummies in its most characteristic skeletal form, Pott’s disease. In this essay, we describe a
statuette of a dwarf exhibited in the National Archaeological Museum of Naples (MANN) as a
potential ancient representation of Pott’s disease. According to so far published data, spinal
tuberculosis can be identified by studying the morphology and shape of the gibbus, since an
angulate gibbus often points out to Pott’s disease. We additionally offer differential diagnoses
and a full contextualization of Pott’s disease in the days of Ancient Egypt.
Keywords
Tuberculosis; Pott’s disease; dwarfism; disease in art; palaeopathology
Résumé
La tuberculose représente encore aujourd’hui une des maladies infectieuses les plus mortelles
au monde. La connaissance de son histoire reste dès lors d’une importance vitale.
L’organisme responsable de la maladie est le Mycobacterium tuberculosis, un pathogène,
membre du complexe M. tuberculosis (MBTC). Plusieurs trouvailles paléopathologiques,
datant de l’Egypte Prédynastique, pouvant suggérer des atteintes de la tuberculose, ont été
rapportées. En fait, la tuberculose a été depuis longtemps identifiée dans sa forme
squelettique la plus caractéristique, à savoir le mal de Pott, sur des momies égyptiennes.
1 Department of Motor Sciences and Wellness, University of Naples « Parthenope »; FAPAB Research
Center, Piazza Umberto I 5, 96012 Avola SR, Sicily, Italy.
Corresponding author: Veronica Papa, PhD; Telephone number:
+39 0815464649 Email address: veronica.papa@uniparthenope.it
2 Archaeology, College of Humanities, Arts and Social Sciences, Flinders University, Adelaide, SA 5001,
Australia; FAPAB Research Center, Piazza Umberto I 5, 96012 Avola SR, Sicily, Italy.
3 Archaeology, College of Humanities, Arts and Social Sciences, Flinders University, Adelaide, SA 5001,
Australia; FAPAB Research Center, Piazza Umberto I 5, 96012 Avola SR, Sicily, Italy; Department of
Humanities (DISUM), Piazza Dante 32, 95124 Catania CT, Sicily, Italy.

Nous présentons ici une statuette d’un nain, exposée au Musée National Archéologique de
Naples (MANN), Selon la littérature, la tuberculose du rachis peut être démontrée en étudiant
la morphologie et la forme de la bosse thoracique: une gibbosité anguleuse est en effet
maintes fois le signe d’un mal de Pott. Nous présentons également plusieurs diagnostics
différentiels et une contextualisation du mal de Pott dans la période de l’Egypte Ancienne.
Mots-clés
Tuberculose; mal de Pott; nanisme; maladie dans l’art; paléopathologie
Introduction
In our times, tuberculosis, considered a global disease of significant relevance,

remains one of the world’s deadliest communicable diseases, with 10.4 million new
cases and 1.3 million casualties in 2016 according to WHO data a. Current
therapeutical strategies show their limitations due to multi-drug resistant strains;
effective vaccines are still not available. For this reason, understanding its origin and
history is relevant to a complete appreciation of this medical problem from an
evolutionary perspective.
Initially, it was believed that humans acquired tuberculosis from animals, especially
following domestication (1) because this coincided with the observed human
palaeopathological record. Since Mycobacterium tuberculosis is an obligate pathogen
with no environmental reservoir, its persistence is related to the density of human
populations. Therefore, the long hunter-gatherer stage in human evolution, consisting
of small populations, would select for commensal organisms or pathogens which could
be transmitted decades after infecting a host, after new susceptible individuals had
been introduced into the population through births or migrations (2).
A more recent theory based on palaeo-genetic data suggests that the bovine form of
the disease derived from the human strains, thus implying a completely different
notion of the origin of tuberculosis, in which an important role might have been
played by sea mammals, capital to its spread (3).
As we currently know that the human tubercle bacillus is of a more ancestral lineage
(4), animal domestication was likely influential in sustaining a denser human
population, thereby enabling tuberculosis to become endemic (5).
The most characteristic visible skeletal changes in bioarchaeological cases of
tuberculosis are those affecting the spine. The bacilli locate in the anterior portion of
the vertebral bodies (mainly at the thoracic tract) causing the collapse of the
vertebrae themselves (from one to three in the majority of cases) which results in an
a Global tuberculosis report 2017. For further reading, see:

http://www.who.int/tb/publications/global_report/en/accessed 15-3-2020.

exaggeration of the physiological kyphosis of the thoracic spine, also known as

gibbus. This peculiarly curved spine is named after Sir Percivall Pott (1714-1788)
who, as a surgeon at St Bartholomew’s Hospital in London, first described it in 1779
and in earlier times it may even have contributed to the genesis of mythological
characters and masques (6).
Palaeopathological evidence of tuberculosis has long been adduced from Egyptian
mummies, starting from one of the fathers of scientific palaeopathology, Sir Marc
Armand Ruffer (1859-1917), who was one of the first to record it in 1910 by
highlighting a combination of skeletal changes and a large psoas abscess (7).
Moreover, Mycobacterium tuberculosis complex DNA has been detected and
characterized from the Predynastic era, the Old, Middle and New Kingdoms and has
been found in the young and old, from high- and low-status burials (8-13).
These multimodal biological demonstrations compensate for the lack of literary or
iconographical descriptions suggestive of spinal tuberculosis (14-21). Specifically,
according to Donoghue and colleagues (22), as well as Crubezy and colleagues (23),
tuberculosis was present in Ancient Egypt more than 5,400 years ago, its prevalence
being particularly high in the Predynastic and Late Periods, as additionally testified by
skeletal lesions.
However, the overall scarcity of such lesions in archaeologically retrieved human
remains has probably originated in the poor state of preservation and fragility of the
affected bones, as much as to the fact that even today, skeletal tuberculosis only
occurs in 3% to 5% of untreated cases. For this reason, the prevalence of
tuberculosis in the past must have been far higher than the one solely suggested by
the number of bony lesions observed (24).
Materials and Methods
Here we present a claystone dwarf statuette [inv. number: #27676, «Nano assai
deforme, altezza 82mm; lunghezza 59; Catalogo Fiorelli collezione pornografica n.
8»] exhibited in the National Archaeological Museum of Naples (MANN) as a potential
ancient portrayal of Pott’s disease. To the best of our knowledge, this statuette
portraying its character in the typically Egyptian squatting position has not been
studied in depth so far from a medical perspective. It is currently part of the erotic
objects in the Borgia Collection, and it is exhibited in the secret Cabinet of the MANN.
The Cabinet was established in 1819 by the will of the future king Francis I Duke of
Calabria (1777-1830) who, during a visit with his daughter Carlotta, suggested to
the director of the museum that it would be better to form a separate collection with
such artefacts.
That section would become known as the “Cabinet of obscene objects” and it could
only be visited by “people of mature years and known morality”.

It consisted at the time of 102 “vile monuments to pagan licentiousness”, namely

numerous small bronzes, oil lamps and personal amulets, worn by men and women
with an apotropaic function. In the Roman world, the virile member was considered a
symbol of fertility.
A section of the “Gabinetto Segreto” is devoted to erotic objects from the Borgia
Collection, which was saved during the late 18th century by Archbishop Stefano Borgia
(1731-1804), and then purchased in 1815 by Ferdinand IV of Bourbon (1751-1825).
The Borgia collection was assembled between the 17th and the 18th centuries by
Clemente Erminio Borgia (1640-1711).
However, Cardinal Stefano Borgia, who was Secretary of the Sacred Congregation for
the Propagation of the Faith (1770-1789), transformed the core collection into a
treasure of artefacts. After his death in 1804, the cardinal’s nephew Camillo Borgia
(1773- 1817), who had inherited half of the collection, started negotiations to sell it
to Joachim Murat (1767-1815) and afterwards to Ferdinand IV of Bourbon.
The collection includes a series of stone-made dwarfs with enormous phalli of
Egyptian provenance dating back to the Ptolemaic Period (305-30 BC) since a drawing
by the French Egyptologist Vivant Denon (1747-1825), who had accompanied
Napoleon Bonaparte (1769-1821) during his Egyptian Campaign, records similar
artworks (25).
Results and Discussion
The statuette seems to be a representation of Harpocrates, originally “Horus, the

Child”. When the Macedonian army conquered Egypt in 331 BC, he became the Greek
god “Harpocrates”, the god of silence, keeper of secrets, deity of confidentiality,
always portrayed as an infant (26). According to Herodotus (485-425 BC) [The
Histories, II, 144] and Plutarch (46-120 AD) [De Iside et Osiride, 21], Harpocrates as
a youth seems to be closer to Apollo. Moreover, Fisher (27) and Malaise (28) maintain
that the phallic cult in Herodotus’ Histories (II,48) is clearly connected to the myth of
Osiris-Dionysus; Harpocrates, therefore, becomes more and more the god of fertility
and fecundity, often being portrayed as an ithyphallic boy (29). If this identification
were to be questioned, one could more generally look at the statuette as a
representation of a primarily Greek type of theatre artist, dancer or acrobat,
performing on stage for the wealthy upper classes. Whether the peculiar left-hand
gesture approaching the dwarf’s ear is to be further interpreted as typical of a singer,
potentially of the “chironome” type, remains open to debate.
Dwarfism is commonly defined as abnormally short stature, over three standard
deviations below the mean height of a population of the same age and sex (30-31).
Although completely unaware of correct endocrinological interpretations, in ancient
times Aristotle (384-322 BC) (or the Pseudo-Aristotle), in his work Problemata, was
able to make a distinction between two types of dwarfism which could be either
congenital or caused by other conditions such as limited intrauterine space or overly
scarce food supply, both necessary condition for the proper growth of the foetus.
Moreover, in his treatise De Historia Animalium the famous author adds that dwarfs
had a large, mule-like, phallus (32).
According to Grmek, spinal tuberculosis can be demonstrated in ancient art by
studying the morphology and shape of the gibbus: an angulate gibbus often
represents Pott’s disease; moreover, he states that, also according to Franz Schede
and Henry Meige, an angulate gibbus morphology is generally associated with
vertebral tuberculosis in Graeco-Roman art (33). Furthermore, recent findings appear
to suggest that an angulate kyphosis can be considered as a clinical sign of Pott’s
disease (34).
Unfortunately, the morphology of the gibbus does not seem to be sufficient to
diagnose Pott’s disease in ancient statuettes, even because the gibbus can also be
associated to spondylitis or other kinds of traumatic events involving the spine such
as crush fractures. Therefore, additional morphological changes of vertebral
tuberculosis need to be associated with the shape of the gibbus in order to clarify and
better understand the real cause of the anomaly (35).
The MANN statuette shows not only an angulate morphology of the gibbus but also
pectus carinatum, which may together speak for a highly incapacitating combination
of multiple muscular-skeletal disorders. Pectus carinatum is a congenital
malformation, while the gibbus is secondary to the bacterial infection. Despite the
lack of an aetiological or physiopathological link between the two conditions, this
particular instance has also been noticed in other ancient statuettes considered to be
representations of Pott’s disease, namely an ivory figurine from the Ptolemaic era
housed in the British Museum [inv. number: 1814,0704.277] (36).
Figure 1-MANN, #27676 claystone dwarf statuette. Photo: MANN, Naples, Italy.

Conclusions
In conclusion, the reassessment of ancient art can help the global appraisal of the
actual existence of pathological entities, such as tuberculosis, still affecting
humankind, and offer interesting perspectives on their historical trends (37).
Acknowledgements
All authors declare that there have been no involvements that might raise the
question of bias in the work reported or in the conclusions, implications, or opinions
stated. The authors wish to thank the National Archaeological Museum of Naples
(MANN) for the kind permission to reproduce images of the analyzed artwork. This
research did not receive any specific grant from funding agencies in public,
commercial or not-for-profit sectors.

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Jars at the Crossroad of Medicine and Archaeology: Overview of 100 Years of
Research and Future Scientific Expectations. Pathobiology. 2018; 85(5-6):267-275.
14. See refer.7.
15. See refer.8.
16. See refer.9.
17. See refer.10.
18. See refer.11.
19. See refer.12.
20. See refer.13
21. See refer.14.
22. See refer.10.
23. See refer. 8.
24. See refer.10.
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Edizioni. 2000.
26. Mark J. Horus. Ancient History Encyclopedia. Available at
https://www.ancient.eu/Horus/. 2016.
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Ägypten. In Chronique d’Egypte. 1998.
28. Malaise M. Arpocrate au pot. In U. V. Graefe, Religion und Philosophie im alten Ägypten.
Festgabe für Phillipe Derchain. 1991:219-32.

29. Abdel-Aziz H. Ithyfallic Harpocrates in Graeco-Egyptian Magic. In: II Congresso

Internazionale “Alessandria ed il mondo Ellenistico-Romano.” 1995.
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height velocity and weight velocity. Arch Dis Chilhood 1966; 454–71.
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Achondroplastic Dwarf. Clin Orthop 1976; 8–23.
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33. Grmek M. Diseases in ancient art. 1998, 190-191.
34. Wong Y, Samartzis D, Cheung K, et al. Tuberculosis of the spine with severe angular
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35. See refer. 33.
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37. Galassi FM, Habicht ME, Rühli FJ. Poliomyelitis in Ancient Egypt? Neurol Sci. 2017;38
(2):375.

SOFIA IONESCU-OGREZEANU (1920-2008), FIRST FEMALE

NEUROSURGEON IN ROMANIA AND FIRST FEMALE
NEUROSURGEON IN SOUTH-EASTERN EUROPE
Sinziana Ionescu1, Eugen Bratucu2, Mirela Renta3
Abstract
Dr Sofia Ionescu (1920-2008) started performing surgical interventions during her years as a
student in 1944 when she performed a trepanation to save the life of a child. She obtained
her PhD thesis in medicine and surgery in 1945, and it is in the next year when she becomes
a certified surgeon, and, later on, in 1954, she becomes a consultant in neurosurgery. She
worked in the surgical team of Dr Constantin Arseni (1912-1994), the most famous
neurosurgeon in Romania at that time. She practised for 47 years, bringing new
contributions, innovations and resourceful medical solutions; in neurosurgery, mostly in the
fields of the spine, and also of the brain. Furthermore, her papers appeared and were cited in
famous international surgery magazines. She was the first female neurosurgeon in Romania
and also the first female neurosurgeon in South-Eastern Europe. She had numerous famous
patients such as singers, spouses of political leaders, wives of Princes, and also poets. Dr
Sofia Ionescu was a professor at the University, a Member of the Romanian Society of The
History of Medicine, a Member of the Academy of Medical Sciences and she was declared a
HERO DOCTOR by the World Health Organisation, next to other 65 great doctors.
Keywords
Sofia Ionescu; neurosurgery; the first female neurosurgeon in Romania
Résumé
Le Dr. Sofia Ionescu (1920-2008) commence à faire des interventions chirurgicales en 1944
pendant ses études médicales, quand elle exécute une trépanation afin de sauver la vie d’un
enfant. Elle obtient son diplôme de docteur en médecine et chirurgie (PhD) en 1945. L’année
d’après elle devient chirurgien attitré, et peu après, en 1954, elle est promue consultante en
neurochirurgie. Elle a travaillé dans l’équipe du Dr. Constantin Arseni (1912- 1994), le
neurochirurgien le plus connu de Roumanie à l’époque. Elle a pratiqué pendant 47 ans. Elle a
laissé plusieurs contributions, innovations et solutions médicales originales; en neurochirurgie
surtout dans les domaines du rachis et du cerveau. De plus, ses articles ont été publiés et
cités dans nombreuses revues de chirurgie internationales.
1 First Clinic of General Surgery and Surgical Oncology at the Bucharest Oncology Institute, Romania,
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania. Contact:
ionescu_sinzy@yahoo.com
2 idem.
3 Specialist in Neurosurgery at the “Bagdasar-Arseni” Hospital, Bucharest, Romania.

Elle a été la première femme neurochirurgien en Europe du Sud-Est. Elle avait plusieurs
patients très célèbres, chanteurs, épouses de politiciens et de princes, ou poètes. Dr. Sofia
Ionescu était professeure à l’Université, membre de la Société Roumaine d’Histoire de la
Médecine, et membre de l’Académie des Sciences Médicales; elle a été déclarée Docteur-
Héros par l’Organisation Mondiale de la Santé, avec 65 autres grands médecins.
Mots-clés
Sofia Ionescu; neurochirurgie; première femme neurochirurgien en Roumanie
Introduction
A proper presentation of one of the first female neurosurgeons in the world would
probably take the length of several articles, or maybe, even several books. To be a
pioneer in one's field, starting a surgical career in times of war and continuing to
develop oneself continuously for nearly half a century as a successful surgeon,
requires too many qualities for just one human being. Nevertheless, Dr Sofia Ionescu
managed to be the personification of intelligence, hard work, proficiency,
resourcefulness, assertiveness, and endurance, all for the major purpose of any
doctor, namely being able to provide the optimal cure, whenever this is in his hands.
The authors carried out a detailed review on life and work of Dr Sofia Ionescu,
including articles and books concerning the theme of her work. The research utilized
the operative protocols from the archive of the Bagdasar-Arseni Hospital in Bucharest,
Romania (in the period 1943-1990), which furthermore stand as proof of Dr.
Ionescu’s surgical achievements and vast operative experience. The contributions by
this remarkable doctor to the field of neurosurgery can be summed up in five main
chapters.
1. A 47- year-long career in neurosurgery
The story of her life starts on April 25, 1920 in Falticeni, a small town in north-
eastern Romania. She completes her first years as a pupil in primary school and
college also there, being among the best of students in every subject, year after year.
Her senior college years were accomplished in Bucharest, continuing her education
there, at the Faculty of Medicine, from 1939-1945. World War II marked her years as
a university student, and during her summer practice as a medical student, she
learned to take care of common procedures from basic manoeuvres of
cardiopulmonary resuscitation to basic operative instrumentation (1-3).
Her years as a medical student were inspired by eminent personalities of the
Romanian Medical School: Dr Francisc Rainer (1874-1944), Dr Alfred Rusescu (1895-
1981), Dr Ionescu Sisesti (1888-1954), Dr George Emil Palade (1912-2008).
.

Figure 1- Dr Sofia Ionescu’s childhood home in Falticeni, Romania.

Archive of the Bagdasar-Arseni Hospital in Bucharest. Author’s photo.
In 1943 she started her neurosurgical residency in the department ruled by Prof. Dr
Dumitru Bagdasar (1893-1946), who was the founder of the Romanian Neurosurgery
Department and Neurosurgery as an independent discipline in our country, after
having completed a surgical clerkship of two years with Prof. Dr Harvey Cushing
(1869-1939) (4-5).
Figure 2- The first Neurosurgery Pavilion, Bucharest, 1934.

In 1944, she carried out an emergency surgical intervention in a small child in coma
under Prof. Dr Bagdasar's direct supervision. Indeed, Dr Bagdasar had a finger
infection, and the other two experienced neurosurgeons of the department were not
available at the moment. That moment marked her future surgical career, as she
explained in various interviews, due to the unique feeling experienced as an operator
solving the case. Moreover, Dr Bagdasar appreciated her technical skills and asked
her to remain in the speciality. In January 1945, she finished her PhD Thesis and
married Dr Ionel Ionescu, another valuable member of Dr Bagdasar’s surgical team.
Later, in 1946, she became a “secondary in neurosurgery”, a title similar to that of

the specialist nowadays, and in 1954, a consultant neurosurgeon, a title recognized

officially by the Minister of Health in 1958 after the completion of further exams.
2. Part of the “golden surgical team”
Dr Sofia Ionescu worked since 1943 under the supervision of Prof. Dr Dimitrie
Bagdasar. She was part of his golden team, next to other two remarkable doctors: Dr
Ionel Ionescu and Dr Constantin Arseni, who later on became professor of
neurosurgery, succeeding Prof. Bagdasar’s after his death as Head of the
neurosurgery clinic.
3. Career
The constant and consistent devotion to her career was also expressed, literally,
through her continuous presence at the hospital, where she lived with her husband
for several years, both ensuring a continuous “on-call” service for neurosurgery
demands. Between 1943 and 1950, she basically lived in the Nr. 9 Clinical and
Emergency Hospital Bucharest.
Figure 3- The Neurosurgery hospital, Bucharest, 1954-1975.

In the years 1966-1967, the vertebro-medullar department was founded in the

Neurosurgery Hospital. She was in charge of most operations performed there. Her
main fields of activity were brain tumours and degenerative spinal diseases. She took
part in the anniversary of the 20.000th neurosurgical operation of the department.

Figure 4-Neurosurgery hospital, new building, Bucharest 1975.

Figure 5 -Surgical protocol from 27/11/1948 describing a Meningocele reduction in the sacral area,
intervention performed by Dr Sofia Ionescu.

Figure 6-Surgical protocol describing a lobectomy (02/06/1949) in a patient with schizophrenia,

another intervention among the many performed by dr Sofia Ionescu as leading surgeon.
4. Scientific activity
Her prolific scientific activity comprises 120 articles written between 1957 and 1987 in
collaboration with the distinguished members of the neurosurgical team mentioned
above (Dr. Constantin Arseni, Dr Ionel Ionescu). Among many important works, we
enumerate those published and cited in International Journals:
• Acta chirurgica Belgica 1958 (“Les ostéomes craniens”, with Prof.Dr. Arseni)
• Wiener Klinische Wochenschrift 1962 (“Das Spontanhämatom des Hirnstammes”
with E. Facon-B. Schwartz)
• Revue d’oto-neuro-ophtalmologie 1969 (“Severe posttraumatic epistaxis
through rupture of an intracranial aneurism of the carotid artery”)
• Neurochirurgia Stuttgart 1970 (“Spontaneous nasal CSF fistula after progressive
hydrocephaly, through a meningioma of the clivus”)
5. Prizes
She was awarded several prizes for her outstanding surgical career, such as the Sign
of Distinction of The Red Cross in 1943, the Ensign OfThe Medico-Sanitary Work in

1957, the “Engineer Leonida Zamfirescu” Prize, and “The Star of The Republic”
distinction in 2008.
6-8. Ionescu’s contribution to neurosurgery
Dr Sofia Ionescu was the first woman neurosurgeon in Romania and in South-Eastern
Europe (9) but has even been proposed as the first one worldwide (10-11). Indeed,
one of the proposed candidates for this was Dr Louise Eisenheardt from the United
States, the first editor of the Journal of Neurosurgery, a member of the American
Association of Neurological Surgeons, and a Charter Member of the Harvey Cushing
Society; however, at the World Congress of Women in Neurosurgery in Marrakesh,
Morocco (17-09-2005), it was established that she was initially trained as a
pathologist, and not as a neurosurgeon.
Another argument why some scholars thought Sofia Ionescu to be the first woman
neurosurgeon in the world was that in March 1970 the Sheikh Zaied Bin Sultan al
Nohaian from Abu Dhabi looked worldwide for a woman neurosurgeon because he
needed a specialised consult from a female doctor for one of his wives. After
extensive research, he only found Dr Ionescu meeting the appropriate requirements
at thet time.
Our research led, however, to the conclusion that Dr Sofia Ionescu probably was the
third woman neurosurgeon in the world. The arguments that we found for this
statement are the following:
a) Dr Diana Beck (1902-1956) (12) from the UK set up the neurosurgical unit at
Frenchay Hospital in Bristol, becoming afterwards a consultant neurosurgeon in 1943
at the Royal Free Hospital, while Dr Ionescu was still in the medical school. Dr Beck
died in 1956. Therefore, at the time that the Sheik needed a female neurosurgeon, it
is really possible she was the only one available worldwide, or at least among the few,
as we shall see further;
b) Another woman pioneer in neurosurgery was Dorothy Klinke Nash (1898-1976),

the first female neurosurgeon in the US, Head of the department of neurologic
surgery at St Margaret Memorial Hospital and a member of the Staff of West Penn
and Children’s Hospitals. Dr Klinke-Nash also preceded Dr Ionescu in her training as a
neurosurgeon. She graduated from the Columbia University College of Physicians and
Surgeons in 1925, she became a resident of the New York Neurological Institute in
1926 and moved to Pittsburg in 1936. Only a few years later, she was working as a
neurosurgeon at the Bellevue Hospital (author’s mention around two or three years
later, differing from one article to another, but earlier than 1944, when Sofia Ionescu
performed her first cranial flap) (13-14).

Another important point discussing Dr Ionescu’s tribute and surgical heritage is

represented by the original and innovative techniques succeeding to manage
intraoperative problems on the spot. So, it happened once that a nearby operating
colleague asked Dr Ionescu for help in a case of rupture of the carotid artery at the
level of the neck; Dr Ionescu constructed and used a flap from the sterno-cleido-
mastoid muscle to cover the defect, just as she had seen before in experimental
surgery on laboratory animals. The intervention resulted in success.
Another distinctive and practical salvation came when she was confronted with an
intraoperative block at the level of Sylvius’ aqueduct with consecutive hydrocephaly
and altered consciousness. She would perform Torkildsen’s procedure (ventricular-
cysternostomy), but the operation required a special tube (Spitz-Holter’s valve). As
this special valve was not available, she used a urinary tube instead. The patient
survived and was routinely followed for the next 35 years.
The third special surgical situation, in 1968, solved with elegance, precision and
originality was the drainage of a left frontoparietal haematoma causing right
hemiplegia and aphasia, with the help of a trocar, a fine spatula and a small vacuum
system, this method being a precursor of modern neuro-endoscopy. This patient also
recovered and lived for more 16 years.
Figure 7- In the operation room (left Dr Sofia Ionescu, next to her, Prof Dr Constantin Arseni and
collaborators). Photo from Rodica Simionescu. Reproduced with permission.

Figure 8- During a trip to Abu Dhabi.

Photo from Rodica Simionescu. Reproduced with permission.
Figure 9- Artistic Homage from a patient’s friend (sculpture by Florica Hociung).

Photo from Rodica Simionescu. Reproduced with permission.

In conclusion (15-16), Dr Sofia Ionescu was an exceptional female neurosurgeon,

lifelong dedicated to the practical and scientific development of this speciality. In a TV
show at the Romanian National television, she was asked what she considered to be
her greatest achievement. She answered that she was proud and happy to have been
able to accomplish her teacher’s last wish (Prof. Dr Bagdasar) in developing the field
of Romanian Neurosurgery and in transmiting practical skills to future generations of
students and residents.
Archive sources
Archive of the Bagdasar-Arseni Hospital in Bucharest, Romania.
References
1) Simionescu Rodica. Neurochirurg Sofia Ionescu. Calarasi, (Romania): Neodihna Binelui,

1998 (in Romanian).
2) Ceapa Irinela. “Prof. Dr. Sofia Ionescu-Ogrezeanu prima femeie neurochirurg din
lume”, paper presented during the National Congress for the editura Alas, 1998,
History of Medicine, 7th of May 2006, Brasov, Romania, (In Romanian).
3) Nicolau Sevastian. “Repere iatro-istorice”. JMB (In Romanian) (www.webbut.unitbv.ro).
4) Dumitrascu D.L. “Dumitru Bagdasar-father of Romanian neurosurgery“. Mayo Clin.
Proc. 1996.
5) Mohan A.G. “Neurosurgery in Romania in the centenary of The Great Union (1918-
2018). Rom. J. Morphol. Embryol., 2018.
6) Mihailide M. “O legenda a neurochirurgiei romanesti”. Viata Medicala, decembrie 2011
(in Romanian).
7) www.aiimsnets.org
8) Greenblatt Samuel H and co. (Eds.). ”History of neurosurgery”. Park Ridge Illinois,
1997.
9) Rasulic L. “Neuroscience and Neurosurgery in Southeast Europe”. International
Neuroscience Journal 2015, March.
10) Ciurea A.V., Moisa H., Mohan D. “Sofia Ionescu, the first woman neurosurgeon in the
world”. World Neurosurgery, 2013.
11) Zuzeac D. “Povestea primei femei neurochirurg din lume, Sofia Ionescu”,
www.adevarul.ro (in Romanian).
12) Gikes C.E. “The account on the life and achievements of Dr. Diana Beck”.
Neurosurgery, 2008.
13) Spetzler Robert E. “Progress of women in neurosurgery”, Asian Journal of Neurosurgery
2011, Jan-Jun.
14) Mejia-Perez S.I, Cervera-Martinez C., et al. “The woman in neurosurgery at the
National Institute of Neurology and Neurosurgery”. Gaceta Medica de Mexico, 2015.
15) WHO Edition of “Caring physicians of the world”, 12.10. 2005 Santiago, Chile.
16) www.rofacts.ro

ANTÓNIO DE SOUSA PEREIRA (1904-1986) THE NOBEL PRIZE

NOMINATION
Catarina Janeiro1, Amélia Ricon Ferraz2

Abstract
This article aims to provide an insight into the origins of modern medicine and the characters
and personalities that made it as it is today by including original research about Professor
António de Sousa Pereira (born in 1961) by bringing his story forth, along with relevant
archival material (mostly manuscripts) in international literature. The research was carried
out mainly in the Museum of History of Medicine Maximiamo Lemos and the Library of the
Faculty of Medicine of the University of Oporto. The descendants and relatives of Professor
Sousa Pereira were contacted to gather all available information on his life and works. In his
time, the disparity between the knowledge of the scientific community on the lymphatic and
portal system was abysmal. De Sousa Pereira and some of his colleagues developed methods
enabling the observation of the lymphatic system in vivo through radiographic techniques and
direct observation during surgery. Considered by many scientific academies as a master in
neurovascular diseases, we must thank Professor António De Sousa Pereira for the current
Oportography method, as well as a remarkable contribution to the first lymphangiograms.
Keywords
Portuguese Surgery; António de Sousa Pereira; René Leriche; 20th century;

lymphangiography
Résumé
Cet article vise à donner un aperçu des origines de la médecine moderne et des personnages
et des personnalités qui l'ont faite telle qu'elle est aujourd'hui, en incluant dans la littérature
internationale des recherches originales sur le professeur António de Sousa Pereira (né en
1961), en présentant son histoire, à travers des documents d'archives pertinents
(principalement des manuscrits). La recherche a été menée principalement au Musée
d'histoire de la médecine Maximiamo Lemos et à la Bibliothèque de la Faculté de médecine de
l'Université de Oporto. Les descendants et proches du professeur Sousa Pereira ont été
contactés pour recueillir toutes les informations disponibles sur sa vie et ses travaux. À son
époque, la disparité entre les connaissances de la communauté scientifique sur le système
lymphatique et le système porte était considérable. De Sousa Pereira et quelques collègues
ont développé des méthodes qui leur ont permis d'observer le système lymphatique in vivo
grâce à des techniques radiographiques et à une observation directe au cours d’interventions
chirurgicales. Considéré par de nombreuses académies scientifiques comme un maître des
maladies neurovasculaires, nous devons remercier le Professeur António De Sousa Pereira
1,2 Museum Maximiliano Lemos of History of Medicine. Faculty of Medicine of University of Oporto, Portugal.
Contact: catarinajaneiro.md@gmail.com

pour la méthode de portographie actuelle, ainsi que pour sa contribution notable aux
premiers lymphangiogrammes.
Mots-clés
Chirurgie portugaise; António de Sousa Pereira; René Leriche; XXe siècle; lymphangiographie
Introduction
In 1953, Hans Adolf Krebs (1900-1981) "for his discovery of the citric acid cycle" and
Fritz Albert Lipmann (1899-1986) "for his discovery of co-enzyme A and its
importance for intermediary metabolism" were awarded the Nobel Prize in Medicine
after their achievements [1]. What most people do not know about it is that, on that
same year, the Nobel Committee asked the opinion of several professors of the
Faculty of Medicine of the University of Oporto, Portugal (FMUP), on one of their peers
- Professor António De Sousa Pereira - in what concerned his scientific contribution on
circulation problems and blood vessels’ surgery [2].
His colleagues ended up not meeting the deadline appointed by the committee
providing their feedback, and his Nobel Prize nomination seems to have fallen into
oblivion. In the History of Medicine, the biographical details about António De Sousa
Pereira are almost hidden. To bring his story known, relevant archival material
(mostly manuscripts) was researched, and his descendants contacted to gather all
available information on him.
Early years
António De Sousa Pereira was born in Bustelo (a small village in the outskirts of
Penafiel, in the north of Portugal) in April 14th of 1904[3], from a humble farmers’
family (José Manuel de Sousa was his father and Ana Campos, his mother) [4]. The
slim boy walked ten kilometres every day through the green hills from his village to
Carmo’s private school in Penafiel [5]. Despite living in the countryside, where he had
no access to books or cultural references, he stood out from his peers at an early age.
Being aware of his potential growth, Sousa Pereira was sent by his father to study at
the Alexandre Herculano high school in Oporto, in 1919 [6].
From there he proceeded attending the preparatory courses of Physics, Chemistry and
Natural Sciences between 1921 and 1922 [7]. In that same year, he was admitted to
FMUP, where he finished his degree in Medicine in 1927. Once again, his skill and
dedication granted him high praises in almost all classes (best grade in pathology,
medical specialities, surgical clinic, topography and operative medicine, while also
receiving a prize in physiology, bacteriology and parasitology) [8]. After finishing his
degree, he volunteered as a professor of anatomy, and on November

18th of 1927, he was appointed assistant to this class, and kept in charge operative
medicine practical activities [9].
Figure 1 - Professor António De Sousa Pereira (1904-1986) (reproduced with courtesy of Dr Ana Sousa
Pereira, Oporto, Portugal).
The Young Doctor
Most of Sousa Pereira’s time was dedicated to the students and scientific investigation
[10], which allowed him to research in the following areas: operative anatomy,
anthropology, operative technique and experimental surgery. He attended several
meetings of international medical societies [11]. He published numerous articles in
Portuguese and international journals on the following subjects: myology [12,13],
morphology of the nerves of the peripheral nervous system [14,15,16,17] and their
state in health and disease by the study of dissections performed in rabbits, dogs,
apes, otters and later on human corpses [18]. In an article of the time, Schaffer
(1864-1939) reflected on the dominant trends of scientific investigation in medicine
and highlighted surgery of the vegetative nervous system as one of the main
problems in neurology deserving of attracting scientists’ attention [19]. Surgery on

the sympathetic nervous system had first been carried out in 1883 by William
Alexander (1844-1924) [20].
Figure 2 – A representative scheme with the three surgical approaches to the splanchnic nerves as
proposed by G.P. (Gino Pieri), R. (Rossi) and S.P. (Sousa Pereira).
In August 1930, in the third International Congress and 25th Anatomists Association
Reunion, Sousa Pereira gave a lecture on the anatomic relationship between the
splanchnic nerve and the crus of diaphragm, suggesting new surgical access to the
splanchnic nerves through an infra-diaphragmatic approach [21]. His view was
something contrary to the practice used at the time - Gino Pieri (1881- 1952)
performed a para-vertebral or a supra-diaphragmatic approach to correct the stomach
and intestinal atony [22], and Rossi used the posterior infra-mediastinal space [23].
This new infra-diaphragmatic and extra-peritoneal technique enabled avoiding injury
of the parietal pleura (unlike the other techniques) and was also easier to perform
[24]. After publishing his results in 1929, Sousa Pereira presented his PhD
dissertation on the splanchnic nerve in 1931 [25]. This dissertation, housed in the
Faculty of Medicine of Oporto, addressed the morphology of the splanchnic nerves
and highlighted their physiological and surgical importance. His work presented a
systematic study of fifty foetuses and adult corpses of different nationalities, in
which he tried to gather materials and

information that would allow him, based on such observations, to identify precisely
the origin, path, terminations and relations of the splanchnic nerves.
This work deserved many praises in both national and international medical press,
mainly by Hernâni Monteiro (1891-1963) in the Revista da Sociedade Portuguesa de
Antropologia e Etnologia, by Silva Carvalho (1861-1957) in Medicina Contemporânea
and by Professor Henri Vallois (1889-1981) in L’Anthropologie [26].
His eagerness to evolve while cementing his knowledge lead Sousa Pereira to travel
to Paris on the 3rd of April 1930, as a fellow from the Portuguese National Education
Board, to attend an internship in the Faculty of Medicine of Paris under the
supervision of Professor Henri Rouvière (1876-1952) in his laboratory of anatomy.
There, he expanded his studies on the lymphatic system anatomy and physiology
(thoracic duct and the remaining lymphatic vessels of the neck base). He learned new
techniques such as lymphatic injections and radiographic post-viewing [27], which he
reproduced in dogs in the Operative Medicine Lab in Oporto in order to perfect this
evaluation method and expand it as a common practice among his peers in Portugal
and abroad [28].
During this internship, which lasted for four months, he also attended the Institute of
Histology of Professor Pol Bouin (1870-1962) in Nancy, where he studied the
sympathetic nervous system [29]. Finally, he ended his internship in Strasbourg, in
the Experimental Surgery Department and Clinical Surgery of Professor René Leriche
(1879-1955). During the experiences and studies conducted there [30], Sousa Pereira
and René Leriche became close friends until the end of their lives. Leriche became
Sousa Pereira’s reference [31]. Professor and apprentice shared ideas about medicine
and surgery [32], developed new research methods and created a whole new body of
knowledge that paved the way for continuing neurovascular surgery innovation up
until the present day [33].
On the edge of scientific investigation
The disparity between the knowledge and information the scientific community had
regarding the lymphatic system and all the other ones was abysmal [34]. The
discovery of the lymphatic system and its characterisation anatomically and
physiologically took place between the second half of the 19 th century and the first
half of the 20th century for the first time. Up to that point, the only surgical procedure
performed on the lymphatic system was confined to the drainage of lymph nodes
containing tuberculous or cancerous lesions.
The lack of means of observation of the lymphatic system in vivo was the main
reason that led to the abandonment of scientific research on this subject [35].
Through the teachings of Professor Henri Rouvière in Paris, Sousa Pereira and some
of his colleagues (Hernâni Monteiro, Roberto Carvalho, Álvaro Rodrigues, Teixeira
Bastos) developed methods which allowed them to observe the lymphatic system in
vivo through radiographic techniques and direct observation during surgery [36].
Figure 3 - Professor René Leriche, Mrs. Leriche, Maria do Carmo (Mrs Sousa Pereira) and Professor
Sousa Pereira and his daughter Ana (reproduced with courtesy of Dr Ana Sousa Pereira, Oporto,
Portugal).
His subsequent studies took him abroad from 1936 to 1938, as a fellow of the
Rockefeller Foundation, while also working at the Surgical Clinical of the University of
Strasbourg. On 8th September 1938, he married Maria do Carmo Cardeal - his every
day and everywhere companion. Sousa Pereira and his wife travelled and
worked together. In fact, he was accompanied by his wife during his entire career.
They had three children: Ana, José Manuel and António Manuel [37]. As a fellow of
the Portuguese Instituto de Alta Cultura, between 1944 and 1946, he also worked at
the Johns Hopkins Hospital, the Mayo Clinic, the Lahey Clinic and the Massachusetts
General Hospital [38]. There, he collaborated with and developed a solid friendship
with Professor Walter Dandy, primarily after showing him a peripheral neurotomy
used to treat trigeminal nerve neuralgia (from which Dandy suffered).

In 1949, he published the first article in the History of Medicine and Surgery on portal
vein and superior mesenteric vein phlebography - portography - the radiological
visualisation of the portal vein and its various afferent branches as well as their
distribution in the liver [39], evidencing venous disturbances in portal circulation
dependent organs (thrombosis, obstructing mass, spasms, dilations).
It also made it easier recognizing the differentiation between intra-hepatic and extra-
hepatic causes of portal hypertension [40]. He presented the results of the first
phlebographies in the World Congress of Cardiology (Paris, 1950), catapulting FMUP
to the international medical spotlight of the time [41].
The later years
In his later years, Sousa Pereira divided his time between the anatomy theatre,
Hospital de São João’s wards and operating rooms, his house in Avenida da Boavista,
Oporto, and the green fields of Bustelo where he had grown up.
He continued attending several national and international meetings, became a
member of numerous scientific societies and institutions, mainly as a member of
“L’Académie de Chirurgie de Paris” (1952) [42] and a corresponding fellow of the
“Association of Surgeons of Great Britain and Ireland” (1961).
He naturally created a school of devoted and hopeful disciples around him. Sousa
Pereira was appointed director of the Surgical Pathology Department of São João
Hospital. He held many other relevant positions, not only hospital-related but also in
Portuguese scientific research organizations and public departments. He was the dean
of the University of Oporto from September of 1969 until 14th April 1974 [43].
At the time, Portugal was living high political instability, and Sousa Pereira had to deal
with the college crisis and student rebellions preceding the carnation revolution in
April 1974.
During his time as dean, he conducted a profound reorganisation in teaching methods
increasing the operating budget to grant more significant support to scientific
investigation and improvement of infrastructures and working conditions.
Thanks to this reorganisation, the University of Oporto had one of the most
considerable periods of expansion since 1911 - the Faculty of Languages and
Humanities was reintroduced in Oporto during his mandate [44].
Sousa Pereira continued publishing new work until very late in life, systematically
contributing to advancing medical progress as stated by his peers. His friend and
colleague Álvaro Rodrigues (1904-1987) described him as “an example of selflessness
and scientific dedication” [45]. His wife passed away in 1985, which impacted him
deeply and made him seclude to his office writing letters and memories of his strolls
through the beautiful landscape where he was born.
António De Sousa Pereira died on 19th October 1986, taking an endless pursuit of
scientific excellence with him, and, for those who had the privilege of knowing him
personally, his honest and captivating smile [46].

Figure 4 - First phlebographies (portal vein and superior mesenteric vein from Sousa Pereira ́s article).
In "De Sousa Pereira A, Melo Adrião M, Lino Rodrigues J. O estudo flebográfico do sistema porta.
Portugal Médico 1949, 1."

Figure 5 - Letter from the Association of Surgeons of Great Britain and Ireland to Professor Sousa
Pereira - invitation to become the Corresponding Fellow. 13th January 1961.
(Reproduced with courtesy of Dr Ana Sousa Pereira, Oporto, Portugal).

Figure 6 - Personal letter from Professor Leriche to Professor Sousa Pereira.

Strasbourg, 8th March 1937.
(Reproduced with courtesy of Dr Ana Sousa Pereira, Oporto, Portugal).
Conclusion
Considered by many scientific academies as a master in neurovascular diseases, we

must thank Professor António De Sousa Pereira for the current Oportography method
and his remarkable contribution to the first lymphangiograms. The Nobel Prize
nomination will endure as one budding block in the real history of science. Scientist,
doctor, teacher and father - and in the words of Professor Leriche as stated on his
correspondence, when sharing his thoughts regarding Sousa Pereira - “my dear
Sousa, you are something else entirely, and you have a strenuous work capacity
along with a tremendous spiritual conscience and honesty”.

References
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nobel_prizes/medicine/laureates/1953 (accessed 28 February 2017).
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do Porto.
3. Sousa Pereira A. Curriculum vitae de António de Sousa Pereira - Professor Extraordinário
da Faculdade de Medicina do Porto. Porto: Araujo & Sobrinho, 1942, p. 3.
4. Sousa Pereira Rocha A. Personal communication, 4 Mar 2017. 5. Sousa Pereira A.
Curriculum Vitae. Report, Faculty of Medicine of Oporto, PT, 1931.
5. [see note 4]
6. [see note 4]
7. [see note 3 and 4]
8. [see note 2 and 4]
9. Monteiro H. Argumentos nas Provas de Concurso dos Candidatos Álvaro Rodrigues e Sousa
Pereira. Report. Faculty of Medicine of Oporto, PT, May 1931.
10. Moreira Gomes A. Personal communication, 27 Feb 2017.
11. [see note 9]
12. Sousa Pereira A. Sur le muscle chondro-epitrochlearis rudimentaire. Annales d'Anatomie
Pathologique et d'Anatomie Normale Médico-Chirurgicale 1929; 6.
13. Sousa Pereira A. Sur trois variations musculaires chez le même sujet. Bulletin de la
Société Portugaise des Sciences Naturelles. 1929; 19: 211-216.
14. Monteiro H, Rodrigues A, De Sousa Pereira A. Sobre os ramos de origem do nervo frénico.
Arquivo de Anatomia e Antropologia. 1927; XI: p. 373.
15. Monteiro H., Rodrigues A., De Sousa Pereira A. Quelques cas de nerf dépresseur chez
l'Homme et chez le Singe. Annales d'Anatomie Pathologique et d'Anatomie Normale Médico-
Chirurgicale 1928.
16. Monteiro H., Rodrigues A., De Sousa Pereira A. Sur la duplicité du nerf dépresseur.
Comptes Rendus des séances de la Société de Biologie.1928 C: 9.
17. Monteiro H., Rodrigues A., De Sousa Pereira A. Le nerf dépresseur chez l ́Homme.
Comptes Rendus des séances de la Société de Biologie.1928 XCIX: 958.
18. Monteiro H., Rodrigues A., De Sousa Pereira A. Sur lánthropologie des nerfs
périphériques. In: Congrès International dÁnthropologie et d ́Archéologie Préhistorique,
Coimbra, Portugal, 1930.
19. Schaffer K. La neurologie en 1929 (revue annuelle). Paris Médical. 1929 40: p.269.
20. Alexander W. The Treatment of Epilepsy. Edinburgh, 1889.
21. Sousa Pereira A. Os nervos esplâncnicos em cirurgia. Portugal Médico. 1929 10.
22. Pieri G. La resezione die nervi Splanchnici. Annali Italini di Chirurgia. 1927 VI:7.
23. De Sousa Pereira A. Résection des nerfs splanchniques par voie sous- diaphragm
tique. La Presse Médicale. 1929.
24. De Sousa Pereira A. Nervi Splanchnici. PhD Thesis, Faculty of Medicine of Oporto, PT,
1929.
25. [see note 24]
26. [see note 9]
27. Pina L., Rodrigues A., De Sousa Pereira A. Relatórios das Viagens de Estudo. Report.
Faculty of Medicine of Oporto, PT, 1930.
28. Carvalho R., Rodrigues A., De Sousa Pereira A. La mise en évidence par la radiographie
du système lymphatique chez le vivant. Annales d ́Anatomie Pathologique et d ́Anatomie
Normale Médico-Chirurgicale. 1931 2: p.193.
29. [see note 27]
30. [see note 27]
31. [see note 4]

32. Leriche R., Personal letters to De Sousa Pereira A; 1937-1952.

33. Poppen, JL., Lemmon C. The surgical treatment of essential hypertension. Journal of the
American Medical Association 1947: 1-9.
34. De Sousa Pereira A., Rodrigues A., Carvalho R. Sur une nouvelle méthode de mise en
évidence des lymphatiques chez le vivant. In: XXVI. Réunion de l ́Association des
Anatomistes, Warsaw, Poland 3-7 August 1931, 19.
35. [see note 34]
36. Garret A. Da investigação à clínica: o exemplo do laboratório de cirurgia experimental da
Faculdade de Medicina do Porto. Portugal Médico 1961, 6.
37. LLoyd Fox W. Dandy of Johns Hopkins.1th ed. Baltimore/London: Williams & Wilkins,
1984, 271.
38. Barata da Rocha L. Personal communication, 4 Mar 2017.
39. Léger L. SplénoOportographie: Étude Radiologique et clinique de la circulation portable
normale et pathologique. Masson et C., Paris 1949.
40. De Sousa Pereira A., Melo Adrião M., Lino Rodrigues J. O estudo flebográ fico do sistema
porta. Portugal Médico 1949 1.
41. De Sousa Pereira A. Contribuição da Escola do Porto para o Estudo da Circulação do
Sistema Porta. Imprensa Médica 1961.
42. Leriche R., Personal letter to De Sousa Pereira A; 3 Jan 1952.
43. [see note 42]
44. Parlamento - Publicações Online. Os Procuradores da Câmara Corporativa - ANTÓNIO DE
SOUSA PEREIRA Legislaturas: X,
http://app.parlamento.pt/PublicacoesOnLine/OsProcuradoresdaCamaraCorporativa%5Chtml/p
df/p/ pereira_antonio_de_sousa.pdf (accessed 3 December 2017).
45. Alves J, Araújo, F. António de Sousa Pereira, Os Reitores da Universidade do Oporto
1911- 2011. Porto, U. Porto / Fundação Engenheiro António de Almeida, 2011, 191.
46. Atinge amanhã o limite de idade o Prof. Dr. António de Sousa Pereira - catedrático da
Faculdade de Medicina e reitor da Universidade do Porto. O Tripeiro, 13 April 1974.

WALTER B CANNON: A HISTORY OF COMMITMENT
Carmen Pérez-Aguado1, Alberto de Leiva-Hidalgo1-3,

Alejandra de Leiva-Pérez1, Eulalia Brugués1-2.
Abstract
Walter B. Cannon (1871-1945), Professor of Physiology at Harvard University, visited Spain in

1930 invited by the universities of Madrid and Barcelona. His conversations with Juan Negrín
(1892-1956), Rossend Carrasco i Formiguera (1892-1990), Gregorio Marañón (1887-1960)
and Juan Bautista Bellido (1878-1953) (key figures of the history of Physiology and Medicine
in 20th century Spain) alerted him to be entirely informed about the course of events in this
country. When the Spanish Civil War broke out in July 1936, his interest grew even more.
Cannon was one of the founders of the American Friends of Spanish Democracy Association.
In March of 1937, he was elected President of the Spanish Medical Bureau of the American
Friends of the Spanish Democracy (AFSD). The Medical Bureau received the donation of
hundreds of thousands of dollars and sent to Spain physicians, nurses, ambulance drivers,
tons of foods, ambulances, equipped mobile surgical units, medicines and additional surgical
material. Dr Cannon’s commitment to Spain did not stop when the Spanish Civil war came to
its end in 1939. Since then, and until he died in 1945, his major concerns were about the
victims of reprisals and exiles. He kept maintaining abundant correspondence to try to solve
their problems. This chapter focuses on the search of the correspondence between Dr W.B.
Cannon and different leading figures, preserved at the Center for the History of Medicine at
Francis A. Countway Library of Medicine, Harvard University.
Keywords
Walter B. Cannon; History of Physiology; Spanish Civil War
Résumé
Walter B. Cannon (1871-1945), professeur de physiologie à l'Université de Harvard, visita

l'Espagne en 1930, invité par les universités de Madrid et de Barcelone. Ses échanges avec
Juan Negrín (1892-1956), Rossend Carrasco i Formiguera (1892-1990), Gregorio Marañón
(1887-1960) et Juan Bautista Bellido (1878-1953), (figures clés de l'histoire de la physiologie
et de la médecine au 20e siècle en Espagne), le conduisirent à se tenir complètement informé
du déroulement des événements dans ce pays. Lorsque la guerre civile espagnole éclata en
Juillet 1936, son intérêt s'accrut encore. Cannon fut l'un des fondateurs de l'Association
américaine des amis de la démocratie espagnole. En mars 1937, il fut élu président du
Bureau médical espagnol des Amis américains de la démocratie espagnole (AFSD).
1 Coresponding author- Carmen Pérez Aguado, Fundación DIABEM. Contact: cperezaguado@yahoo.es;

2 Instituto de Investigaciones Biomédicas-Hospital de San Pablo,
3Universidad Autónoma de Barcelona, Barcelona, Spain.

Le Bureau médical reçut des centaines de milliers de dollars et envoya en Espagne des
médecins, des infirmières, des ambulanciers, des tonnes de nourriture, des ambulances, des
unités chirurgicales mobiles équipées, des médicaments et du matériel chirurgical
supplémentaire. L'engagement du Dr Cannon en Espagne ne s'arrêta pas lorsque la guerre
civile espagnole prit fin en 1939. Depuis lors, et jusqu'à sa mort en 1945, ses principales
préoccupations concernèrent les victimes de représailles et les exilés. Il continua à maintenir
une correspondance abondante pour tenter de résoudre leurs problèmes. Ce chapitre se
concentre sur la recherche de la correspondance entre le Dr W.B. Cannon et différentes
figures de proue, conservée au Centre d'histoire de la médecine de la bibliothèque de
médecine Francis A. Countway, à l’Université Harvard.
Mots-clés
Walter B. Cannon; Histoire de la physiologie; la guerre civile espagnole
Introduction
Walter B. Cannon was born in 1871 in Prairie du Chien, Wisconsin. He was a member
of the third generation of a family of Scottish farmers belonging to the Congregational
Church. Strongly Calvinist in the 18th century, by the 19th century, Congregationalists
maintained a broadly orthodox faith while cultivating a passion for freedom, equality,
and justice.
Figure 1 - Walter B Cannon, 1934.

Photo from Walter B. Cannon’s papers.
His time in St. Paul High School, his readings, and the controversy between science
and religion led him to leave the Congregational Church in 1888. During that period,

he befriended a young Unitarian pastor, Samuel McChord Crothers (1857-1927), who

coined in 1916 the term “bibliotherapy” (bringing up the idea that reading can have a
beneficial effect on mental health). This friendship lasted for the rest of their lives
being one of the pillars upon which revolved the humanitarian work of Cannon. The
Unitarian Service Committee (USC), a non-profit membership organization of the
Unitarian Universalist Association, still works nowadays to provide emergency
assistance and promote human rights and social justice around the world (1).
In 1929, Cannon, at that time Professor of Physiology at Harvard University, received
his third nomination for the Nobel Prize in Physiology or Medicine. He had already
published much of his work on gastric physiology and homeostasis. In 1930, he was
invited to give two lectures at the Faculty of Medicine of the University Complutense
of Madrid (UCM) and at the Residencia de Estudiantes, a cultural centre founded in
Madrid in 1910 which promoted the dialogue between Science and the Arts (awarded
in 2015 the European Heritage Label).
In Madrid and Barcelona, Cannon met most leading figures in Spanish medicine and
science of the first third of the 20th century. One of them was Juan Negrín, Chair of
Physiology at the UCM, becoming President of the Government of the Republic after
the outbreak of the Spanish Civil War. The friendship with Negrín would last until
Cannon’s death in 1945 (2).
Figure 2 - Ambulance donated by students, faculty and employees of Harvard University.


Spanish Civil War
The war began on July 18, 1936, when a part of the Spanish army, led by General
Francisco Franco (1892-1975), rebelled against the legally constituted government of
the Second Republic of Spain.
Cannon was aware of what was happening through the abundant correspondence with
Spanish scientists since the beginning of the conflict. His growing concern during the
summer and fall of 1936 was most related to the safety of his acquaintances.
At the insistence of Roger Chase, Executive Secretary of the AFSD, Cannon agreed to
participate as Chairman in a debate to be held at the Harvard Club in November
1936.
The AFSD had been created in New York City in 1936 to get support for the
government of the Spanish Republic, raise funds for medical aid and refugee relief. In
the letter sent by Cannon to several Harvard professors, he pointed out the following:
I have agreed to allow my name to be used because, as far as I have been able to
learn, the Government was properly elected and represented the opinion of the
majority of the Spanish people (…).
Although the political aspects of the matter were not emphasized, there were
humanitarian considerations. (3)
Cannon became increasingly involved in activities in favour of the Spanish Republic.

On December 31, 1936, he wrote to the US Secretary of State, Cordell Hull, asking
him to allow the transport of ambulances, medical equipment and medical personnel
to Spain (4).
On January 5, 1937, Cannon sent a letter from the Institute of Physiology of
Barcelona to Dr Rossend Carrasco i Formiguera, who had worked at his laboratory at
Harvard between 1921-1922. In the letter, Cannon wrote:
Who could have predicted so short a time as a year ago that Spaniards would be killing
each other in this dreadful way? (5).
He also informed Carrasco about the creation of the AFSD and that he had joined the
Doctor’s Committee.
During the first months of 1937, Cannon maintained an extensive correspondence
with members of the AFSD, professors from different American universities and
American politicians. From May 3, 1937, his name appears as Chairman of the
Medical Bureau to Aid Spanish Democracy (MBASD) (6).

The entire Cannon family closely followed from Boston the bombing of Guernica by
the Italian-German troops (among Cannon’s papers there were several newspaper
clippings from the Boston Globe regarding the bombing). From that moment, Cannon
became even more involved in organizing humanitarian aid (7), requesting medicines
from US pharmaceutical laboratories, participating in public meetings and raising
funds.
Figure 3 - NYC Hippodrome Meeting.


Figure 4 - Appeal Letter sent by Walter B Cannon informing of the help to the Spanish Republic.
Cannon was very concerned about the nutritional deficits that were arising in Spain as
a consequence of the war. The division of Spain in two war fronts meant that, to a
great extent, the agricultural regions remained under the authority of the rebel army.
The scarcity of food in republican Spain resulted in nutritional deficits and

avitaminosis. In 1937, at the University of Indiana, Dr Paul J. Fouts demonstrated

that pellagra could be successfully treated with the administration of nicotinic acid
(8). In a letter sent to Carrasco i Formiguera, Cannon informed him about the
shipment of 25 pounds of nicotinic acid via the American relief ship Erica Reed. He
ended the letter with the following lines:
As I pointed out to the headquarters of the Medical Bureau, it is rather futile to cure
the disease and not to provide the proper food for keeping people well (9).
Cannon’s correspondence reflects his efforts to obtain insulin and quinine; letters he
sent to Dr Gustavo Pitaluga (1876-1956) (10), an Italian naturalized Spanish and,
since 1911, Chair of Parasitology at the Complutense University of Madrid, who led
the fight against malaria in Spain. Pitaluga, at that time Chairman of the Hygiene
Committee of the League of Nations, had asked quinine to Cannon Aid to Refugees.
The Civil War finished in the spring of 1939 with the victory of the rebel army.
Nevertheless, Cannon continued his humanitarian work to help the defeated
republicans, many of them in exile. The aid organizations and the Medical Bureau
were dissolved and replaced by associations whose aim was to help prisoners and
refugees. Many were religious organizations, such as the Unitarian Service Committee
(USC), under the Unitarian Church to which Cannon belonged, and the American
Friends Service Committee (Quakers). Others were a coalition of liberals, socialists
and communists, like the Spanish Refugee Relief Campaign (SRRC), led by Bishop
Francis J. McCornell. Despite their differences, these institutions worked together in
launching campaigns in support of the defeated, especially at the national level.
Among Cannon’s papers, several documents from the SRRC urged him to sign a letter
addressed to President Roosevelt (1882-1945) asking to intercede before France
authorities for the release of thousands of Spanish Republicans imprisoned in
concentration camps in southern France. Other public figures sponsoring the SRRC
were writers like Thomas Mann (1875-1955) and Ernest Hemingway (1899-1961),
actors like Paul Muni (1895-1967) or historians of medicine like Henry Sigerist (1891-
1957) (11).
Another important campaign in which Cannon was also involved was the American
Rescue Ship Mission, whose aim was to charter ships to evacuate to Spanish
Mexican refugees held in French concentration camps (12). This campaign was
sponsored by Eleanor Roosevelt (1884-1962), Dorothy Parker (1893-1967) and
other prominent figures of the time. Cannon even wrote to the US Secretary of
State to ask that the American Red Cross (ARC) ships carrying humanitarian aid to
Europe to allow the travel of Spanish refugees retained in France on their way back
to the US. Paul T. Culbertson, Assistant to the Division of European Affairs, replied
that the proposal was not feasible because the ARC had pledged to the belligerent
powers to transport only Red Cross personnel (13).

Refugee children were also among Cannon’s concerns. His papers include
correspondence with Eric G. Muggeridge, Executive Secretary of the Foster Parents
Plan for Children in Spain. This organization, which now stands under the name of
Plan International, was founded in 1937 by the British journalist John Langdon-Davies
(1897-1971), author of the book Behind the Spanish barricades.
He wanted to provide the children not only food, shelter, and education, but also a
feeling that some people somewhere were thinking about them as individuals. In a
letter of March 16, 1939, Muggeridge, back in the US after his last trip to Spain (a few
days before the end of the Civil War) thanked Cannon for the assistance provided,
and sent him a Memorandum entitled "I saw it happen". He had witnessed the
Francoist victory in Catalonia and the exodus of nearly half a million civilians and
soldiers fleeing to France across the Pyrenees mountains to claim asylum in a
movement that is known as “la retirada” (“the retreat”). Many of these people were
detained in concentration camps in southwest France. Muggeridge describes his
personal experiences in the retreat and the camps. Cannon read the Memorandum
carefully, evidenced by highlights in the text of files kept in his archives (14).
An important chapter of Cannon’s humanitarian work was the energy deployed in
helping Spanish scientists. He sent letters of recommendation to American and Latin
American universities to help these scientists to find a job. He acted as Chairman of
the Finance Committee of the Latin America Refugee Fund (LARF), whose aim was to
facilitate the migration of European refugees to Latin America providing social and
financial support (15).
LARF had been created by the former Dean of the University of Valencia, the
physiologist José Puche- Álvarez (1895-1979), who would become later director of the
Department of Physiology at the Autonomous University of Mexico.
The name that appears most frequently in Cannon’s papers is Jesús María Bellido
Golferichs (1880-1952), Chair of Pharmacology and Therapeutics at the University of
Barcelona. Cannon met Bellido during his first trip to Spain in 1930, and they
immediately sympathized each other.
A profoundly religious man, Bellido was appointed by President Negrín as Commissar
of the Government of the Republic in December 1938. Bellido fled to France early
after the Republican defeat. Cannon tried to help him to migrate out of Europe.
Bellido is mentioned in more than 60 letters written by Cannon: in missives to the US
State Department, to his editors (Bellido translated Cannon’s text The Wisdom of the
Body into Spanish), to the Joint Anti- Fascist Refugee Committee, to the American
Red Cross, to the American Committee for Christian Refugees, to the American
Friends Service Committee and even to the Refugee Committee of the General Union
of the Israelites of France (16).
Until his death, on October 1, 1945, Cannon worked intensively supporting the
Spanish refugees. On November 5, 1945, the Harvard University organized the
eulogist ceremony in the memory of Cannon. In the book edited on such occasion,
untitled Walter B Cannon, A Memorial exercise, the Executive of the Spanish Refugee
Appeal, through her president, Florence H. Luscome (1887-1985), wrote the following
lines:
In distant lands, Africa, Mexico, France, the world is a bleaker, lonelier place for tens
of thousands of Spanish Republican refugees because they have lost their never-
failing friend, Dr Walter Bradford Cannon. His was a clarity of vision to perceive the
threat to civilization in fascism’s opening assault upon democracy in Spain (…). His
devotion to the Spanish Republican cause has never wavered.
In recent years he has actively participated in relief work for the surviving Spanish
Republicans. Perhaps Dr Cannon’s last public actions, during his final illness, were:
the penning of an appeal for funds for medical care for these refugees released after
six years in concentrations camps, and secondly, intercession for the lives of two
Republican leaders just captured and condemned to death by Franco (17).
Figure 5 - Letter from Medical Bureau with references of Premier Negrin, Box 47, Folder 614. WBCA,
CLM.
Photo from Walter B. Cannon’s papers

Figure 6 - Letter to Cannon from Robert Chase (AFSD). Box 47, Folder 612. WBCA, CLM.

Figure 7 - Latin America Refugee Fund.


Figure 8 - Rescue Ship Campaign.


Figure 9 - Children Campaing of Medical Bureau.


Acknowledgements
We acknowledge the cooperation of Dr Scott Podolsky (Director and Professor of the

Center for the History of Medicine and Global Health and Social Medicine, Countway
Medical Library – Harvard Medical School) and the library staff. Their kindness and
help made possible our tasks during the stay in Boston and the elaboration of the
present manuscript. Walter B. Cannon’s papers, donated by his family to the
Countway Library are contained in a total of 209 boxes. We have read the
correspondence related to Spain from 1922 to 1945, stored in boxes 45-54, files 579-
712 covering more than 3,000 documents.
Abbreviations
Walter B. Cannon Archive, Countway Library of Medicine, Boston= WBCA, CLM,

Boston
American Friends of Spanish Democracy = AFSD
Medical Bureau to Aid Spanish Democracy = MBASD
References
1. Crothers, S. Mc. “A Literary Clinic,” Atlantic Monthly, 118:291-301, Aug. 1916.

2. Box 45, Folder 585. WBCA, CLM, Boston.
3. Letter to Dr Richard C. Cabot, November 18, 1936. Box 47, Folder 611.
WBCA, CLM, Boston.
4. Letter to Cordell Hull, December 31, 1936. Box 47, Folder 611. WBCA, CLM, Boston.
5. Letter to Carrasco i Formiguera, January 5, 1937. Box 45, Folder 583. WBCA, CLM, Boston.
6. Letter to Cannon from MBASD, May 3, 1937 Box 47, Folder 614.WBCA, CLM, Boston.
7. Letter to Carrasco i Formiguera, May 4, 1937. Box 45, Folder 583.WBCA, CLM, Boston.
8. Helmer, O. M., and Fouts, P. J. “Gastric analysis methods”. Am. J. Clin. Path. 7: 41, 1937.
9. Letter to Carrasco i Formiguera, November 23, 1938. Box 45, Folder 584 WBCA, CLM,
Boston.
10. Letter to Pittaluga, Nov 5, 1937. Box 45 Folder 589. WBCA, CLM, Boston.
11. Letter from SRRC, January 4, 1941. Box 54, Folder 700. WBCA, CLM, Boston.
12. Letter from Edward Barsky, February 25, 1941. Box 54, Folder 704 WBCA, CLM, Boston.
13. Letter from the Department of State, June 21, 1941. Box 54, Folder 710. WBCA, CLM,
Boston.
14. Letter from Eric G. Muggeridge, March 16, 1939. Box 52, Folder 682. WBCA, CLM,
Boston.
15. Box 54, Folder 706. WBCA, CLM, Boston.
16. Carmen Pérez-Aguado and Alberto de Leiva-Hidalgo. “Walter Bradford Cannon:
Correspondencia y Relaciones con el exilio científico español”. In: Científicos y Científicas en
el exilio, 1936-1939. Donostia, Hamaika Bide, 1917: 527-540.32.
17. Memorial: Walter B. Cannon, Held at Harvard Medical School, Monday, November 5,
1945. WBCA, CLM, Boston, 71.

THE ROLE OF RELIGIOUS ORGANIZATIONS IN THE PROVISION OF

HEALTH CARE FOR NEGLECTED POPULATIONS: THE CASE OF CASA
HOSPITAL SAN JUAN DE DIOS OF RAMOS MEJÍA (ARGENTINA,
1942)
Jaime Elías Bortz1, Nadia Gonzalez2, Marisa Emilia Cetra2,

María Dolores Martigani2
Abstract
The Order of the Hospitable Brothers was founded by João Cidade Duarte, later known as
Saint John of God (Montemor-o-Novo, Portugal, 1495 - Granada, Spain, 1550). Pope Leo XIII
appointed him Patron Saint of Hospitals and Sick. At the end of 1942, this Catholic
community settled in an old chalet acquired in Ramos Mejía. The scope of this research was
to study the creation of the Saint John of God Hospital House. Our particular interest in the
study of this order of Catholic priests led us to review the background of the creation of
health care institutions linked to the Catholic Church in the Spanish colonial era and of
Argentina as an independent nation to provide a historical context. Our working hypothesis
was that the institution would have come out from the initiative of priests of the order to
provide asylum and health care to children with polio sequelae, fulfilling a need of this
vulnerable population that required rehabilitation and specialized care; and that this
realization benefitted from the combination of the skills of the priests, companies, political
officials and landowners, members of the upper class. Our materials have been textual
(foundational records and journalistic archives) and iconographic (photographs, plaques of
remembrance and other museum objects) to which we had access, studied through text and
image analysis to identify the main actors, their origins and motivations. We conclude that
the emergence of the Saint John of God Hospital House of Ramos Mejía is an example of the
work of religious groups, guided on charity and mercy principles to provide health care to
specific groups that seem to have been made invisible by the governmental powers of the
time.
Keywords
Order of Hospitable Brothers; Saint John of God; Hospital-home of Ramos Mejia;

poliomyelitis; rehabilitation
1 Universidad Nacional de La Matanza, Departamento de Ciencias de la Salud, Ciclo de

Complementación Curricular - Escuela de Formación Continua. Florencio Varela 1903, (B1754JEC) San
Justo, Province of Buenos Aires, Argentina.
Jaime E. Bortz, MD, MA, PhD. Tel +5491149467624, jaimebortz@yahoo.com.ar
2 Universidad Nacional de La Matanza, Departamento de Ciencias de la Salud, Ciclo de

Complementación Curricular - Escuela de Formación Continua. Florencio Varela 1903, (B1754JEC) San
Justo, Province of Buenos Aires, Argentina.

Résumé
L’Ordre des Frères Hospitaliers a été fondé par João Cidade Duarte, mieux connu comme
Saint Jean de Dieu (Montemor-o-Novo [Portugal] 1495 – Grenade [Espagne] 1550). Pape
Léon XIII l’a nommé Patron Saint des Hôpitaux et des Malades. Fin 1942 cette communauté
catholique s’est établi dans un vieux chalet, acquéri à Ramos Mejia en Argentine.
L’objectif de cet article était d’étudier les circonstances de la création de cette Maison-Hôpital
de Saint Jean de Dieu. En premier lieu, nous avons revu les origines de la création
d’institutions de soins de santé, liées à l’Eglise Catholique en période coloniale Espagnole, et
le début de l’Argentine en tant qu’état independent, afin de présenter un contexte historique.
En second lieu, nous nous sommes attardés à l’oeuvre spécifique de cet Ordre de prêtres
catholiques. Notre hypothèse de travail était que d’une part cette institution provenait d’une
initiative des prêtres de l’ordre à établir un asyle et fournir des soins médicaux à des enfants,
atteints de séquelles de poliomyélite, et pourvoyant ainsi aux besoins d’une population
vulnérable qui nécessitait une révalidation et des soins spéciaux; d’autre part que cette
réalisation a été favorisée par la l’intégration des capacités de prêtres, de compagnies, de
mandataires politiques et de propriétaires fonciers, membres de la classe supérieure. Nos
sources étaient autant textuelles (rapports de fondation, archives de journalistes)
qu’iconographiques (photographies, plaques de commémoration, objets divers de musée). Ce
matériel a été étudié afin d’identifier les acteurs principaux, leurs origines et leurs
motivations. Nous en concluons que l’émergence de la Maison-Hôpital de Saint Jean de Dieu à
Ramos Mejia est exemplaire pour le travail de groupes religieux, basé sur la charité et les
principes d’indulgence, en pourvoyant des soins de santé à des groupes spécifiques de
patients, qui semblaient rester invisibles aux pouvoirs politiques de cette époque.
Mots-clés
Ordre des Frères Hospitaliers; Saint Jean de Dieu; Hôpital-Maison de Ramos Mejia;
poliomyelitis; révalidation
Health care in Hispanic colonial America
In the America of Hispanic colonization, institutional development was characterized

by the participation, to varying degrees, of numerous political, social, economic, and
cultural actors. Diverse interests led them to dispute the predominance over the
crystallization of power made through the creation of numerous institutions, some
directly or indirectly linked to the basic functions of government, and others away
from it.
The first entities of this type arose, mainly, following the organizational models
coming from the Spanish empire, from the direct participation of representatives of
the Hispanic government.
The demographic growth and the colonial social development, together with the
consolidation of administrative units such as viceroyalties, audiences and

governorates, gave rise to a steady expansion of the participation of the population in

the public life of the colonial territories. Both Spaniards and Creoles, representing
heterogeneous interests, disputed the construction of the meaning of the measures
carried out by the governing bodies; measures among which may stand those linked
to health care (which we will define later as public health policies).
The framework of health care structures has been a substantial part of this process of
institutional creation and organization, and as such, was crossed by the participating
actors’ diversity of interests. Hence, the Laws of the Indies had issued an action plan
for the colonial territories to provide hospital assistance where the sick poor could be
treated, and Christian charity exercised (1).
This political line promoted a plan of sanitary actions that required much time to
develop and the active participation of sectors of the Catholic Church, as an actor with
the capacity to initiate projects and cover the disabilities (technical and material and
human infrastructure) of the apparatus of colonial government.
The Jesuits were the first of the religious orders that participated in the institutional
framework, as an actor with interests in conflict with local governors and other
officials. Their work in alleviating the native population promoted their defense and
social inclusion, opposing the system of charge based an exploitation of the Indians.
The Jesuit organization also took care of the health care needs, from the care of the
sick and the study and use of recipes and treatments for the healing of the indigenous
people. The different interests of Jesuits and the local governments grew, leading to a
confrontation with the Spanish Crown and the expulsion of the Jesuits from colonial
territories at the end of the 18th century.
The Bethlemites Order
The territory that currently occupies the Argentine Republic was not exempt from this
process of institutional formation, characterized by the dispute of interests between
different groups. Concerning health institutions, since the end of the sixteenth
century, Juan de Garay (1528-1583) developed numerous measures for the
construction of a hospital in Buenos Aires.
In 1580, the area for this establishment was reserved, considered of great necessity
for the care of the sick poor; and finally, the hospital was inaugurated in 1614,
displaying the difficulties involved in the implementation of health care (2).
The Order of the Bethlemite Brothers, founded in American territory in the mid-17th
century, had a remarkable participation in the development of health care in the River
of the Silver. Upon their arrival in Buenos Aires in 1748, they were assigned by the
Cabildo to take charge of the hospital, abandoned for several years, shortly after its
foundation, and rehabilitated at the beginning of the 18th century; the

institution was then known as Hospital of the Bethlemites or Santa Catalina.

Consequently, this religious Order was integrated into the official sanitary operation.
The Protomedicato
The creation of the Viceroyalty of the Río de la Plata in the year 1776 fostered higher
institutional and administrative growth, aiming to cover new functions and meet the
needs of the population and the government of Buenos Aires. In this way, the
Protomedicato of Buenos Aires was established, first provisionally and then
definitively by Miguel Gorman. This new institution represented the underpinning of
the professionalization of the medical practice in the River of Silver.
The Protomedicato was responsible for the supervision of the practice of medicine in
its various branches and the development of the teaching of this profession for the
training of specialized human resources for the proper treatment of medical care. In
this way, the Protomedicato had a double responsibility: on the one hand, to teach
medicine and supervise professional practice; and, on the other hand, ensure
collective health and public health care.
In 1801, the School of Medicine was inaugurated. Its activities took place in a room of
the Hospital of the Bethlemites, and until the year 1809, they managed to form an
interesting medical corps. One of the policies reaching the vast population carried out
by the Protomedicato of Buenos Aires was the vaccination campaign against smallpox,
promoted by the Crown for all its colonial territories.
Under Gorman’s leadership, the concept of public health and health care policy began
to be conceived from the Protomedicato in the modern sense. "It can be said that
Gorman, the first major Argentine health figure, carried out a regulatory policy to
guarantee access to the medical care of his time, specific and global, achieving a
broad array of Public Health including sanitation and the various components and
subsectors of Health Care. Among the components, were the training of human
resources (e.g. School of Medicine), the regulation of health goods (e.g. drug prices)
and the health status of other goods (e.g. bakery products)" (3).
The beginning of independent times
The emancipatory movements that led to the so-called May of 1810 Revolution
represented more clearly the division of interests present in the institutions of the
River of Silver. In addition to the opposition between Spaniards and criollos, the
various existing positions within the revolutionary group came out, mainly concerning
their link with the metropolis and the course that the new stage should take.
As a consequence of divisions and lack of a unifying national project, the institutions
from the colonial regime were discarded in a few years with no emergence

of others to fulfil their functions. Soon, the organizational forms denoting a link with
the Spanish Crown and any representation of the colonial regime were left aside.
From 1810 until the battle of Caseros (1852) there was no agreement between the
political and social sectors on the direction to follow, which was reflected in health
policy by the absence of a standard guideline for the entire territory. The attempts to
configure a national policy continually failed, due to the clash of interests between
Buenos Aires, the seacoast and the provinces of the interior. These had to take
charge of the assistance, responding primarily to the needs that the civil war
imposed. On numerous occasions, doctors and professionals had to be present on the
battlefield to respond to the military needs and epidemics that arose at that time.
For almost half a century, attempts to shape a national policy failed continuously,
following the political disputes that occurred during that period. The liberalism of the
areas nearby the ports constantly clashed with the protectionism of the provinces,
aiming to consolidate their economies through the growth of the domestic market.
The struggles to occupy power reflected these fundamental economic disputes,
damaging institutional development, and delaying the organization of a modern state
(4).
The National Constitution, sanctioned in 1853, did not result in a closure of the
conflict until a decade later, when all the provinces adhered to its norms; marking the
beginning of a new stage for the country, with the clear predominance of the liberal
position, mainly supported by the political sectors of Buenos Aires and, therefore, the
port’s interests.
The Argentine National State
The framework of the Argentine National State, culminating in the governments of the
last two decades of the nineteenth century, was structured on the precepts of "Order
and Progress": the conservative political order, of limited suffrage and minority
government, together of liberal economic progress, centred in the port of Buenos
Aires, whose doors were open to products from all over the world, neglecting any
local industrial economic development.
This new national political form was developed within the framework of political and
economic insertion in the international market of Argentina, as manufacturer and
exporter of agricultural raw materials. However, the dispute over the institutional
predominance did not end, but changed its characteristics in the face of the new local
and global scenario.
Argentina, in the second half of the nineteenth century, was marked by profound
demographic and social changes, determining the functioning of state institutions,
including health care. The population growth caused by the migrations (first from
Europe and then from the interior of the country), in conjunction with the

wars, the cholera and yellow fever epidemics and the socio-economic situation, made
explicit the intense need of the country for the framework of a permanent healthcare
organization with capacity to protect society from the new urban hazards.
The Argentine National State was gradually developing the necessary institutions to
face a new reality. They were, mainly, government administrative spaces (ministries,
secretariats, national departments and others, organized based on the different
activities intended to be covered, guided by the positivistic and scientific streams
predominating in the Western world. Concerning health care, the European technical
advances of the late nineteenth century had a strong impact on American medicine,
where representatives of the hygienist thought held important positions in the public
health administration. This perspective led many doctors and officials to be guided by
the improvement of hospital establishments, which were mostly in terrible conditions
of hygiene and infrastructure, which threatened any possibility of improving patients’
health (5).
On the other hand, the precarious state of these institutions promoted that they
functioned as hospitals for the poor sick poor since the wealthy population chose to
take care of themselves in their homes or private institutions. At the same time,
hospitals of foreign (i.e. immigrants: Italians, Spanish, German, French, Jewish and
alike) communities were also opened as an option for health care, within the
framework of the development of the mutual association as a way of integrating and
recomposing bonds of solidarity between migrants of the same nationality. The
Catholic Church also gave a strong impetus to the development of mutual institutions,
promoting Catholic circles of workers from a Christian social doctrine supported by
the encyclical Rerum Novarum3.
The Hospitable Order of Saint John of God
In this line of work can be framed the arrival in Argentina and the work of the
Hospitable Order of Saint John of God, which was installed in the 1940s in the
western area of Great Buenos Aires to work for low-income patients. The Hospitable
Order of Saint John of God was founded in Portugal by João Cidade Duarte, later
became Saint John of God (Montemor-o-Novo, 1495 - Granada, Spain, 1550).
In this last city, he left a hospital for the poor and the sick. Pope Leo XIII appointed
him Patron Saint of Hospitals and Sick. At the end of 1942, this Catholic community
settled in an old chalet acquired through public auction in the street today named
Gabriel Ardoíno number 714, in the town of Ramos Mejía.
It was established as a free-of-charge centre for the care and rehabilitation of
children affected by poliomyelitis, although patients with other conditions were also
treated. The institution functioned as a free refuge for those children, a home for
those whose families did not have economic resources.
3
Enacted in 1891 by Pope Leo XIII, it was the first social encyclical of the Catholic Church.

Figure1 - Image of the old chalet acquired for the hospital building.
Saint John of God Hospital Home archive.
In its early years, it had voluntary collaborators who cared for the sick, helping them
to eat and sanitize themselves.
The work was supported by voluntary contributions, donations of money and products
and the performance of solidarity activities. Merchants and neighbours collaborated
monthly with a fee for the maintenance of the House - Hospital. From the Municipal
Executive Power, tax exemptions were granted to Saint John of God Hospital House 4
to promote the efforts that carried out this Order towards the community.
In 1945, it was possible to face the construction of the building. On December 1,
1945, the cornerstone of the hospital was placed. A wealthy landowner, Adela Unzué
de Leloir, donated the land adjacent to the primitive site, which made possible the
widening of surface facilities.
4 Article No. 42 of the current tax ordinance and decree n ° 2830 of 09/15/1944.

Figure 2 - Placement of the first stone.

Figure 3 - The building. The sign reads “Saint John of God Hospital Home for Poor Handicapped
Children”.
In the 1950s, Argentina experienced two outbreaks of polio, one in 1953 during the
Peronist government and the other in 1956, when the democratic institutional order
had been interrupted, and the government deposed. The observation of the treatment

given to these epidemics by the respective governments allows us to analyze

institutional practices and power disputes within governments, in addition to their
links with other actors of civil society, as is the case of the Catholic Church. Although
the government of Perón gave high impulse and promotion to the development of
trade unions and union social works - with a vertical structure and compulsive
participation - in parallel, institutions that responded to interests and logics different
from that government continued to develop.
The Hospitable Order of Saint John of God arrived in Argentina in the 1940s, but with
a vast history and journey, in Europe and America, in health care tasks with the poor
and humble patients. Their work values were focused on humanitarian assistance
from a Christian and Universalist perspective, protecting the dignity of the person and
prioritizing the most humble.
The installation of the Hospital-Home in Argentina in the 1940s was, thus, the result
of the joint work and collaboration of various sectors of society, with the combination
of the capacities of religious, business, political officials and members of the upper
class that owned lands; and aimed at the health care of low-income people, mainly
patients with pneumo-locomotor paralysis.
Faced with the epidemics of poliomyelitis of 1953 and, centrally, that of 1956, this
Hospital functioned as the fundamental space for the treatment and rehabilitation of
children with this disease in the western zone of Great Buenos Aires (6).
Figure 4 – Ward for patients with sequelae of poliomyelitis.


The hospital was not just a healthcare institution: was also a home, an asylum, for
those children. They received not just medical care but also recreational and
educational services.
The institutional development of Saint John of God Hospital House continued in the
following years, adapting itself to the needs of the population, already in a model of
health care with the participation of new actors and broad growth of the private
sector (7). In May 1969, a volunteering service was organized at the hospital, focused
on the first instance on children hospitalized due to sequelae of polio, then in the care
of the elderly and finally in that of the motor system disabled.
The chapel was oriented towards the railroad tracks and was consecrated to the cult
of Saint John of God, under the advocation of Christ the King, and inaugurated on
October 24, 1969.
Figure 5 - A priest and an assistant looking after the children.


Figure 6 - A priest playing with the children

Figure 7 - Educational services for standing children.


Figure 8 - Educational services for lying children.

Figure 9 - Rehabilitation of polio sequelae.


In the '70s, with the reduction of polio cases, welfare services were reconverted. The
children's housee was moved to Luján, province of Buenos Aires. The facilities of
Ramos Mejía were converted into a general hospital for acute diseases. It remained a
confessional institution of the Catholic faith, of private management, nonprofit, which
charges for its services. It was recognized as a charity organization by the
municipality of La Matanza in 1970.
Currently, it is also an educational centre affiliated with the School of Medicine of the
University of Buenos Aires in the careers of Internal Medicine Specialist and Internal
Medicine Residency. Since 2012, one can also study there in Nursing, Professional
Nursing, Bachelor of Physical Therapy and Bachelor of Occupational Therapy, under
agreement with the Universidad del Salvador. The facilities occupy 7400 m 2 of surface
distributed in the main building of 5 floors, annexes premises for offices, spaces
destined for ambulatory rehabilitation, services, parking and chapel, all distributed in
the middle of gardens and green spaces. The Hospitable Order of Saint John of God is
also in charge of Our Lady of Pilar Clinic in Luján and the Saint Joseph Nursing Home
in La Rioja (8).
Figure 10 - The current facade of Saint John of God Hospital House.


Conclusion
The institutional development of Argentina, and more specifically the aspects related
to health and health care policy, has taken place through the political, economic and
social conflicts that have characterized its entire history since before the Argentine
Declaration of Independence in 1816. The dynamic tensions between the State can
explain a large part of these conflicts, the actors of civil society and religious
institutions, which for centuries have disputed the terrain of health care as a space of
responsibilities, territories, budgets and social control.
Throughout this journey, the Catholic Church has always occupied a prominent place
in the formation of health care spaces for the needs of the population, centrally of the
most vulnerable sectors of the population: the children, the elderly, the poor and
patients suffering incurable diseases.
In this presentation, we tried to provide a broad contextual and historical framework
to understand the place occupied by a Catholic religious organization with a global
trajectory and centennial history, such as the Hospitable Order of Saint John of God,
and an organization founded by it in particular, the Saint John of God Hospital House,
dedicated to the care of poor children affected by the aftermath of polio since the
1940s in Argentina.
We have seen how the hospital brothers were able to articulate their spiritual
objectives with the interests of the actors from civil society, landowners, politicians
and neighbours to carry out the construction of their hospital and realize their mission
of health care, education and recreation, occupying a space that government powers
did not cover in the care with children with polio. An additional result of this
presentation was to retrieve and edit part of the very rich archive of photographs of
institution’s origin which were not in the public domain until recent years.
Acknowledgements
This article shows part of the results of the project entitled “Survey of the Cultural
Historical Medical Heritage of the Municipality of La Matanza” carried out at the
Universidad Nacional de La Matanza and funded within the PROINCE Research
Program 2014-2017, project code E-008. The general purpose of that project is to
contribute to the understanding of the healthcare resources of the La Matanza area
(Province of Buenos Aires, Argentina) based on the understanding of their history,
development, conflicts and foundational narratives. We thank the authorities of Casa
Hospital San Juan de Dios Hospital de Ramos Mejía (Hereinafter called in this article
“Saint John of God Hospital Home”) for their kind provision of photographs and
relevant information.

References
1. Barragán H. L. Fundamentos de Salud Pública. La Plata: Editorial de la Universidad

Nacional de la Plata, 2007.
2. Veronelli J.C. & Veronelli Correch M. Los orígenes institucionales de la salud pública en la
Argentina. 2 tomos. Editados por la Organización Panamericana de la Salud (OPS/OMS),
2004.
3. Barragán, op.cit. 2007, 366.
4. Oszlak O. La formación del Estado argentino. Buenos Aires: Editorial de Belgrano, 1982.
5. Lourau R. El análisis institucional. Buenos Aires: Amorrortu, 1991.
6. Testa D. Poliomielitis: La Herencia Maldita y la esperanza de la rehabilitación. La epidemia
de 1956 en la ciudad de Buenos Aires, Revista Intersticios, Vol. 5 (2), 2011.
7. Rovere M. y otros. Las epidemias de poliomielitis como analizadores del cambio en los
abordajes y las políticas sanitarias en Argentina antes y después de la llamada Revolución
Libertadora de 1955, enfocadas con particularidad en el distrito de La Matanza. Presentado
en las 6° Jornadas de Historia Regional de la Matanza, 2016.
8. Bortz Jaime Elías (Ed.). Zerbini, César Isidoro; Barrera, Marcelo Silvio; Cetra, Marisa
Emilia; Mamani, Raúl José; Mosteiro, Paola Elizabeth; Aquije Obando, Carolina; Helena,
Marcia Yanina; Sosa, Carla Marina; Romero, Alicia Beatriz; Fares, Mónica Silvia; Delgado,
Stella Maris. Relevamiento del Patrimonio Histórico Cultural de la Salud de La Matanza.
Primera Etapa. Catálogo Iconográfico. Colección “Patrimonio Histórico Cultural de la Salud
de La Matanza”. San Justo. Electronic book on CD-Rom, 2017.

PORTUGUESE TROPICAL MEDICINE AND INTERNATIONAL

NETWORKS: A GLOBAL HEALTH GOVERNANCE PROJECT IN THE
20TH CENTURY
Isabel Amaral1
Abstract
Tropical medicine became an independent scientific field, in the transition from the 19 th to the
20th century, with the institutionalization of teaching and research, at specialized schools,
founded in the context of European imperialism. As a scientifically recognized research area,
between 1902 and 1966, in Portuguese context, tropical medicine has developed its own
language and methodology, in order to improve the medical approach to diseases existing in
the tropics, which comprises the colonial project. During sixty-four years of history, the
internationalization of the Lisbon School of Tropical Medicine is fundamentally associated with
its outstanding contribution to the study of sleeping sickness. The research team led the
research, the endemic cartography in colonies, the collaboration with other international
institutions, the participation in international scientific meetings, and the representation in
international institutions, such as the sleeping sickness commission, in London, and the World
Health Organization (WHO), in Geneva. It is also significant to highlight the importance of
Portuguese tropical medicine in the study of malaria in Europeanan territory, with the
sponsorship of the Rockefeller Foundation. This paper aims at reflecting about the main styles
of governance of Portuguese tropical medicine, between 1902 and 1966, highlighting the
contributions of generations of prestigious researchers in the international scene ─ Ricardo
Jorge (1858-1939), Ayres Kopke (1866-1947), Fraga de Azevedo (1906-1977), and Francisco
Cambournac (1903-1994).
Keywords
Portuguese tropical medicine; Ricardo Jorge; Ayres Kopke; João Fraga de Azevedo; Francisco
Cambournac; governance and international networks
Résumé
La médecine tropicale est devenue un domaine scientifique indépendant, à la charnière des

XIXe et XXe siècles, avec l'institutionnalisation de l'enseignement et de la recherche, dans
des écoles spécialisées, fondées dans le contexte de l'impérialisme européen. En tant que
domaine de recherche scientifiquement reconnu, entre 1902 et 1966, dans le cas Portugais,
la médecine tropicale a développé son propre langage et sa méthodologie, afin d'améliorer
1 Assistant Professor, NOVA School of Sciences and Technology, New University of Lisbon. Invited
Assistant Professor, NOVA Medical School, New University of Lisbon. Co-coordinator of the
Interuniversity Centre for the History of Sciences and Technology (CIUHCT). Contact: ima@fct.unl.pt

l'approche médicale des maladies existantes sous les tropiques, qui compromettent le projet
colonial. Au cours de ces soixante-quatre ans d'histoire, l'internationalisation de l'École de
Médecine Tropicale de Lisbonne est fondamentalement associée à sa contribution
exceptionnelle à l'étude de la maladie du sommeil. L'équipe de recherche mena la recherche,
la cartographie endémique dans les colonies, la collaboration avec d'autres institutions
internationales, la participation à des réunions scientifiques internationales et la
représentation dans des institutions internationales telles que la Commission de la Maladie du
Sommeil, à Londres, et l'Organisation Mondiale de la Santé (OMS), à Genève. Il est
également important de souligner l'importance de la médecine tropicale portugaise dans
l'étude du paludisme en territoire européen, avec le parrainage de la Fondation Rockefeller.
Cet article vise à réfléchir sur les principaux styles de gouvernance de la médecine tropicale
portugaise, entre 1902 et 1966, en mettant en évidence les contributions de générations de
chercheurs prestigieux sur la scène internationale - Ricardo Jorge (1858- 1939), Ayres Kopke
(1866-1947), Fraga de Azevedo (1906-1977) et Francisco Cambournac (1903-1994).
Mots-clés
Médecine tropicale portugaise; Ricardo Jorge; Ayres Kopke; João Fraga de Azevedo;
Francisco Cambournac; gouvernance et réseaux internationaux
Introduction
To understand the process by which Portugal was able to introduce tropical medicine
in the complex network of relationships and negotiations resulting from the
establishment of the pink map at the Berlin Conference (1884-1885), it is necessary
to go back in time, when Portuguese bookish medicine gave place to experimental
research, by using the microscope and its modus operandi.
Pasteurian medicine taken in by the Portuguese medical community was a driving
force for the development of the biological and biomedical sciences in the first half of
the 20th century, and an instrumental vehicle for the establishment of a network on
public health, hygiene and epidemiology.
The emergence of tropical medicine and the establishment of professional networks
during the nineteenth and twentieth centuries is thus associated with four leading
figures in the history of medicine, with the greatest international projection: Ricardo
de Almeida Jorge, Ayres José Kopke Correia Pinto, Francisco José Carrasqueiro
Cambournac and João Fraga de Azevedo.
Pasteur's first interlocutor in Portugal was undoubtedly Ricardo Jorge, the "pivot" of
the modernization of Portuguese medicine inside and outside the national space,
creating "school".
From his legacy, it is important to draw attention to his intervention in public health,
which began in the city of Oporto, as a municipal doctor and a professor of

the Medical-Surgical School and obtained his highest aim when he became a member
of the Committee of Hygiene of the League of Nations (1).
Figure 1 - Caricature of Ricardo Jorge. Private collection of João Clode.
Ricardo Jorge held several positions as a doctor and researcher and published some
issues on demography and epidemiology in the city of Oporto. The first manifestation
of his interest in public hygiene appeared in 1884, after delivering four polemical
conferences conveyed in an incisive, innovative and disruptive language to many of
the country's social and economic interests. Public health was then in focus.
The threat of cholera epidemics, which came from Egypt, cruelly went across the
south of France in July 1884, arose fierce discussions and criticism in medical
societies and the daily press. At the Medical-Surgical School of Oporto, the Sociedade
União Médica organized a set of conferences to which Ricardo Jorge was invited. Four
of his conferences delivered in 1885 were compiled in a book, Social Hygiene Applied
to the Portuguese Nation (2), perhaps his most controversial scientific production (3).
Cholera pursued its tour through Europe and threatened neighbouring Spanish
territory. The interest in the threat of the epidemic had not disappeared from the
most enlightened minds in the medical field and press.
The Town Hall of Oporto fostered urban hygiene, with several initiatives: the chemical
laboratory of António Joaquim Ferreira da Silva, the disinfection station and the
Bacteriological Institute (directed by Ricardo Jorge), where he identified the
microorganisms responsible for the three epidemics that struck the cities of Lisbon
and Oporto between 1894 and 1899 (4). He identified the Yersin bacillus in the

bubonic plague epidemic of 1899, confirmed by the Pasteurians Léon Charles Albert
Calmette (1863-1933) and Alexandre Tourelli Salimbeni (1867- 1942) (5).
Figure 2 - Photograph of Ricardo Jorge with Calmette and Salimbeli at his laboratory at OOporto.
João Clode’s private collection.
After seeing his life threatened, by imposing strict measures of sanitary control to the
population, he escaped to Lisbon, joining the Surgical Medical School, in Lisbon, and
becoming the Inspector General of Health Services, and after that, director of the
Central Institute of Hygiene, where he began the project of reforming the Kingdom
Health Services.
The Lisbon School of Tropical Medicine (IMT) and the Colonial Hospital were founded
in 1902 to revert the technical inefficiency to fight some of the tropical diseases that
caused more victims to Portuguese colonizers than the war in Africa. These
institutions were created three years after the foundation of similar institutions in

England, the Liverpool School of Tropical Medicine in 1898, and the London School of
Tropical Medicine, in 1899 (6).
Figure 3 - Photograph of the Colonial Hospital and the School of Tropical Medicine in 1910. Source:
IHMT.
Institute of
Higiene and
School of Tropical Medicine
Public Health (1972-)
and Tropical
Medicine
Institute of (1967 – 1972)
Tropical
Medicine
(1935- 1966)
Overseas
Lisbon School Hospital
of Tropical (1952-1974)
Medicine
(1902-1935)
Colonial
Hospital of
Lisbon (1902-
1952)
Figure 4 - Institutional evolution of the Colonial Hospital and the Lisbon School of Tropical Medicine
since 1902.

The attention on malaria started when Portugal, member of the League of Nations,
was pressed to study and control the spread of this disease in Portugal. The flag of
hygiene and sanitation in the country was determinant to ensure the continuity of
Portugal as a member state, showing to be slow in the implementation of effective
measures to combat the disease.
The first bridge for the internationalization of Portuguese tropical medicine was
beginning, and the first studies came out from Ricardo Jorge who published the first
cartography of the disease in the country (called sezonism), in 1906 (7).
Figure 5 - Map of malaria in Portugal, Jorge, R., Sarmento, A. M., “La Malaria en Portugal, Premiers
Résultats d’une Enquête”, Annaes De Saúde Pública Do Reino, Inspecção Geral Dos Serviços
Sanitários, Secção De Hygiene, Tomo III, (Casa Portugueza, Lisboa, 1906).
These results led to the establishment of measures aiming to study and fight
malaria, determining the creation of the first antimalarial medical facilities in
particularly affected areas: Benavente, Azambuja, Alcácer do Sal, in the South of
the country, and Idanha-a-Nova, in the North, starting in 1931 with the
inauguration of the Experimental Station of Benavente. The foundation of this
antimalarial centre justified the availability of means for concerted national action

against the disease because it compromised the rural workforce dominated by the
migration of poor people employed in the rice cultures and their sanitary condition
(8). This question occupies a large part of the country's economic and social
backwardness.
Figure 6 - Photograph of the Experimental Station to Combat Sezonism of Benavente. Collection of the
Health Museum of Lisbon.
Spreading his interests in the Hygiene and Public Health, Jorge started assuming
public positions of increasing importance in the national and international arena.
Since 1912, he became the Portuguese representative in the Office International
d'Hygiène Publique, in the Commission of Hygiene of the League of Nations, an
organization for epidemic surveillance and advice of the public health policies of the
member states. He was the reporter of several cases of plague, cholera, yellow fever,
dengue and worldwide incidence of leishmaniasis with a focus on Portugal, Africa and
Brazil, thus highlighting his position on the importance of tropical medicine in hygiene
and public health (9).
The international sanitary conventions of 1903 and 1912 confirmed the innovative
orientation of Ricardo Jorge, marked by the regulation of maritime sanitation. The
international conferences on sleeping sickness conducted under the guidance of Great
Britain confirmed the paramount importance of Ayres Kopke in the prophylactic and
treatment of atoxyl and its derivatives to control the epidemics of the disease (the
main obstacle to European colonization in Africa).

The incursion of Francisco Cambournac into the World Health Organization (WHO), as
a specialist on malariology, tropical medicine and public health, and Fraga de
Azevedo, as a specialist in medical parasitology, would confirm the Portuguese
position in the complex network of actors who would define the guidelines of tropical
medicine after the World War II.
Consolidating a research programme in the European network of tropicalists
Ayres Kopke was one of the most emblematic researchers at the Lisbon School of
Tropical Medicine (EMT) who led and led an innovative research program on sleeping
sickness (in the general sense of Gerald Geison) (10) by catapulting him to represent
the country in all the European forums to discuss the measures needed to eradicate
the disease, in Africa.
In 1897, he published an article on the study of malaria in the Arquivos de Medicina
who was quoted by Charles Louis Alphonse Laveran (1845-1922), in 1907. In 1901 he
was appointed by the government to take part on the first mission to study sleeping
sickness disease in Angola. This mission resulted from the influence of the Society of
Medical Sciences of Lisbon in the Portuguese State, which justified sending doctors to
Africa, in articulation with the principles declared at the Berlin Conferences (11).
In 1902, Kopke took on duties as a professor of parasitology at EMT and director of
his laboratory. Since then, due to the novelty of his research on the sleeping sickness,
from an experimental and clinical standpoint, became the representative of the school
at international scientific meetings, particularly at the international conferences on
sleeping sickness led by Patrick Manson (1844-1922) (12).
In London, at the 1907 Conference, Patrick Manson appointed several physicians to
the study of sleeping sickness: Raphaël Anatole Émile Blanchard to the study of
dissemination agents; Alphonse Laveran to the biology of Trypanosoma and its
existence in men and animals; Paul Ehrlich (1854-1915) for experimental therapy,
and Ayres Kopke for applied therapy. In 1914, the Portuguese mission led by
Bernardo Francisco Bruto da Costa (1878-1948) eradicated sleeping sickness on
Principe Island, thanks to the application of experimental results obtained in the
parasitology laboratory of Ayres Kopke on the prophylaxis and treatment of the
disease, using atoxyl (13).
The report of this mission was published in the Arquivos de Hygiene e Patologia
Exotica, a publication directed by EMT, and translated into English the following year
(14). The results were praised in the European tropicalist community, by Heinrich
Herman Robert Koch (1843-1910), Alphonse Laveran, Paul Ehrlich and Patrick
Manson. This episode of Portuguese tropical medicine illustrates its position on the
international network of specialists in tropical medicine at the time.
During the First Congress of Tropical Medicine of West Africa, held in Luanda in 1923,
Ayres Kopke, represented the Lisbon School of Tropical Medicine and the

Society of Medical Sciences of Lisbon. His research was appreciated by Lucien Marie
Joseph Jean Van Hoof (1890-1949), a physician at the Léopoldville Laboratory, who
became the Belgian representative at the International Commission on Entebe, a
WHO commission. The following year, by determination of the Government, he
represented Portugal at the First meeting of the International Conference on Sleeping
Sickness, held in London, proposed by the League of Nations.
Henceforth, he became a proactive participant in the following meetings, denoting the
widening of the network necessary for the construction of a public medicine, more
comprehensive, more concerned with the African populations. A new colonial impetus
and expansion of medical services, the second era of tropical medicine, advocated by
Michael Worboys, was beginning (15), leading to the consolidation of the political
Salazar’s project in which tropical medicine held a very important place.
Figure 7 - Front page of the rapport of Ayres Kopke presented at the 2 nd International Conference of
Sleeping Sickness about the study of the disease in Mozambique1928; League of Nations; Geneva,
1930.

Pursuing international agendas to prepare African medical answers in the

post-colonial period
Francisco Cambournac started his clinical position at the Hospital of Santa Marta, in
Lisbon, but his vocation would be another. In 1930 he took a tropical medicine course
at EMT (a course he repeated at the Institute of Tropical Medicine Institute in
Hamburg in 1935 sponsored by the Rockefeller Foundation). He began his career as a
malariologist at the Antimalaria Experimental Station of Benavente, at the time of its
foundation.
The Director-General of Health, José Alberto de Faria (1928-1946) (successor of
Ricardo Jorge and director of the Lisbon Colonial Hospital), choose Cambournac as the
Portuguese representative to attend the International Course on Malariology of the
League of Nations (imposed on member states by the International Malaria
Commission).
The first two months of activity at Benavente revealed infection rates (38.9%) and
high anopheles’ infestation (99.37%), which led to a Rockefeller Foundation
intervention (16). In 1934, the Station for the Study of Malaria of Águas de Moura
was created, and Cambournac took hold as director.
This experimental station originated the Institute of Malariology in 1938, developing
the research on the disease in Portugal, and allowing to defining disease control
measures. This institute became an international school of malariology, training
national and international technicians, supervised by Cambournac, director from 1939
to 1954.
In 1937, Cambournac took charge as professor of medical zoology at the Institute of
Tropical Medicine (IMT). Five years later, he joined the teaching staff of the
institution. In 1948 he became a member of the Committee of Malaria of WHO due to
his contributions on malaria control developed in Portugal. He was elected Regional
Director of Africa of WHO in 1952, two years before the eradication of malaria in
Portugal. He remained in WHO until 1964 when he took over as director of IMT (17).
The experience of Cambournac at WHO was of paramount importance for the
modernization of the Portuguese community of tropicalists in the transition of tropical
medicine into social medicine. During this period, professors from almost all areas of
teaching and research at the IMT integrated specialized commissions of various
international organizations in the area of geographic and geopolitical reconstruction
after WWII: at the World Health Organization, João Fraga de Azevedo as
parasitologist in schistosomiasis, Manuel Reimão Pinto (1914-1978) in yellow Fever,
Guilherme Jorge Janz (1913-1999) in nutrition and Cruz Ferreira in parasitic diseases.
Others occupied some prominent positions at the Combined Commission for
Technical Co-operation in Africa South of the Sahara (CCTA): João Fraga de Azevedo,
Augusto Salazar Leite (1904-1986) (leprosy), Carlos Pinto Trincão (1903-?) (yaws),
Manuel Reimão Pinto (tuberculosis).

Figure 8 - Photograph of Francisco Cambournac at Brazzaville, 1954. Archives WHO, Genève.
A new look at tropical medicine to prepare the decolonization
Fraga de Azevedo, a graduated doctor from the University of Coimbra in 1929, was
contemporary of Francisco Cambournac. He was a naval doctor and remained
connected as a clinical pathologist to the Civil Hospitals of Lisbon. He attended the
tropical medicine course at EMT in 1930, after performing several missions abroad.
He was in charge of several wards at the Hospital da Marinha and its laboratory of
bacteriology and clinical analysis (where Kopke started his scientific research). In
1938, he became professor of medical zoology at the IMT and established the first
bridge between the Institute of malariology led by Francisco Cambournac and the
IMT. Two years later, he was appointed as full professor at the IMT and, as his
director in 1943. He was a specialist in helminthology and entomology and published
more than 300 scientific papers, such as on Portuguese continental parasites, malaria,
leptospirosis, leishmaniasis, ancylostomiasis, ascarids and taeniasis.

His expertise as a naval doctor provided him with strong skills in improving the
research at the IMT. His experience in the diagnostic techniques of infectious and
parasitic diseases in the civil hospitals of Lisbon, and also the privileged contacts he
pursued with political and economic structures in the country (the Calouste
Gulbenkian Foundation, the Nuclear Energy Board, the General Directorate of
Livestock Services, the Laboratory of Radioisotope Studies at the Overseas Research
Board, the Company of Diamonds of Angola, among other institutions) was
determinant for the renewal of Portuguese tropical medicine. After the retirement of
Ayres Kopke, no disciples continue the desired high standards for the research at the
IMT.
Fraga de Azevedo organized two main events and contributed to elevating the
prestige of the IMT: the First National Congress of Tropical Medicine held in
commemoration of 50 years of history, in 1952, and the National Congress of Tropical
Medicine and Malaria held in Lisbon, in 1958, hosting 1700 national and foreign
participants.
Figure 9 - Commemorative stamp of the First National Congress of Tropical Medicine, Lisbon, 1952.
Private collection Isabel Amaral.
At the closing session of the congress, he concluded by highlighting the importance of

the nodal network of influence on the development of tropical medicine across
borders: a long way has gone by, and great progress has been made, not only in
individual work, but mainly in joint work, because of collective efforts, often
philanthropic, and international collaboration.
He carried out several medical missions in the Portuguese colonies to study
schistosomiasis, onchocerciasis, malaria, leprosy, cholera and tuberculosis and

implemented permanent missions in Guinea, Cape Verde, Mozambique and Angola for
the Institute of Hygiene and Tropical Medicine (IHMT).
He was a precious help to Francisco Cambournac in the international courses of
malariology request by the WHO: He was also a privileged consultant on
schistosomiasis in Africa, whom he well knew. Fraga de Azevedo and Cambournac
were both members of the African Scientific Council (CSA) and the CCTA. At the
CCTA, the meetings started in European countries (the first took place in Lisbon in
1951), and then in the African countries (the 4th conference was held in Dakar, still in
1951). The CSA operated as a science academy for South Africa in the Sahara. Fraga
de Azevedo participated as a supplementary member in 1954 and only in 1957
became effective.
He won national and international recognition. He held several conferences on
helminthology, malacology (an area he founded in Portugal) and entomology (his
name was given to various zoological species). He contributed to the second
eradication programme of glossins in Ilha do Príncipe, in 1958.
Some concluding remarks
The fundamental support building a global health project (1902-1966) on Portuguese

tropical medicine framed the sociological notion of "agency" of Bruno Latour, John
Law and Callon. Using the concept of "actor" and the biography, as a recent
historiographical tool discussed in international meetings (STEP and ESHS 2014), we
can discuss the mainstream of the innovative incursion of Portuguese medical actors
in the international arena, which determines the construction of a new area of
approach to the diseases on the tropical environment, the tropical medicine. These
two complementary axes of analysis can define the space and its organization, sizes
and measures, values and standards, making other elements dependent on them,
translating their desires into their own language. Identifying these elements when
reflecting about tropical medicine in Portugal from Ricardo Jorge to Francisco
Cambournac, through Ayres Kopke and Fraga de Azevedo, we can identify several
bridges for internationalization, based on the construction of the Portuguese tropical
medicine network, as Deborah Neill pointed out (18).
Ricardo Jorge laid the foundations for a new public health organisation that allowed
following the epidemiological framework to contribute to the establishment of the first
steps on tropical medicine, particularly with the systematic study of malaria in
Portugal. His presence as a specialist in Hygiene and public health, representing
Portugal in the Committee on Hygiene, of the League of Nations was crucial to
maintain the political position of Portugal in the international health programmes.
Ayres Kopke founded the School of Tropical Medicine, and his research program on
sleeping sickness was decisive to project him as the Portuguese representative, in the

complex network of research, prophylaxis and treatment of the disease in colonial

Europe.
Francisco Cambournac, who started his course as a malariologist at the Experimental
Station to Combat Sezonism in Benavente, created under the anti- sezonism services
by Ricardo Jorge, became an international recognized malariologist and the first
representative of the WHO for African affairs, after WW2, one of the highest positions
in the WHO. He occupied a privileged place in the international network arena of
paramount importance for the European public health politics. Fraga de Azevedo
improved the frontiers of scientific research to parasitic diseases of European
incidence (the overwhelming majority of the so-called tropical diseases) and the
prestige and recognition that Francisco Cambournac had in WHO, that meant for him
a facilitator of the knowledge transfer to the new nations in the postcolonial period.
Jorge, Kopke, Cambornac and Fraga de Azevedo were acting in international networks
which allowed Portugal to participate in the global health governance agenda, in
which tropical medicine had a place.
Figure 10 – Schematic representation of actors, diseases, institutions and networks of governance of

Portuguese tropical medicine in the 20th century.

Tropical medicine has been a significant advance in the approach to vector diseases in
Africa, in the twentieth century, but almost all tropical diseases still exist today,
raising new challenges in the present and the future.
What place do neglected or re-emerging diseases occupy today in those territories in
the context of tropical medicine?
What does learning from the past mean?
References
1. Amaral, I. "A influência pasteuriana na obra de Ricardo Jorge e na emergência da

medicina tropical". in: Amaral, I.,Carneiro, A.,Mota,T. S.,Borges,V. M.& Dória,J. L.(eds.).
Percursos da Saúde Pública nos séculos XIX e XX – a propósito de Ricardo Jorge. (CELOM:
Lisboa, 2010) (ISBN 978-989-97011-1-3): 135-144.
2. Jorge, R. Hygiene Social Applicada Á Nação Portugueza. (Livraria Civilisação de Eduardo
da Costa Santos: Porto, 1885).
3. Alves J. “Ricardo Jorge e a Saúde Pública em Portugal – um “apostolado sanitário”.
Arquivos de Medicina 22 (2/3), 2008: 85-90.
4. Almeida, M.A. O Porto e as epidemias: saúde e higiene na imprensa diária em períodos
de crise sanitária, 1854-56, 1899 e 1918. Revista de História da Sociedade e da Cultura,
12, 2012: 371-391.
5. Jorge, R. La peste bubonique de Oporto (1899). (Typografia de António José da Silva,
1899).
6. Amaral I. “Building Tropical Medicine in Portugal – The Lisbon School of Tropical
Medicine and the Colonial Hospital (1902-1935),” Dynamis, 2008, vol. 28, 299-336.
7. Lobo, R., A história da malária em Portugal na transição do século XIX para o século XX
e a contribuição da Escola de Medicina Tropical de Lisboa (1902-1935). PhD dissertation,
New University of Lisbon, 2012.
8. Saavedra, M., Uma questão nacional: enredos da malária em Portugal, séculos XIX e
XX. PhD dissertation, Social Sciences Institute, Lisbon, 2010.
9. Ricon Ferraz, A. Ricardo de Almeida Jorge - Médico e Humanista Portuense, Higienista
intemporal. Arquivos de Medicina, 22 (2/3), 2008: 2183-2447.
10. Geison, G. Research Schools: historical Reappraisals. Osiris 8 (University of Chicago:
Chicago, 1993).
11.Amaral I. “Bacteria or parasite? The controversy over the etiology of sleeping sickness
and the Portuguese participation, 1898–1904”, Historia, Ciência, Saúde Manguinhos, 19,
2012: 1275–1300. doi: 10.1590/s0104-59702012005000004.
12.See note 6.
13.Kopke, A. Traitement de la maladie du sommeil. (A Editora Limitada. Lisboa, 1913).
9.
14.Wyllie, J. Sleeping Sickness: A record of four years’ war against it in Principe,
Portuguese West Africa. (Baillière, Tindall and Cox: London, 1916).

15.Worboys, M. “Germs, malaria and the invention of Mansonian tropical medicine: from
'diseases in the tropics' to 'tropical diseases'.”, Clio Medica, 35: 1996: 181-2017.
16.See note 7.
19.Fee, E., Cueto, M.; Brown, T. At the Roots of The World Health Organization’s
Challenges: Politics and Regionalization. American Journal of Public Health, 106(11), 2016:
1912–1917.
18.Neill D. Networks in tropical medicine: internationalism, colonialism, and the rise of a
medical specialty, 1890–1930. (Stanford University Press: Stanford, 2012).

DR CUNHA BELLEM AND THE OPERATIONAL MILITARY MEDICINE

REFORM IN 19TH CENTURY
Rui Carvalho1, Hugo Rodrigues2
Abstract
Dr Cunha Bellem (Belém in the current spelling) (1834-1905), a Portuguese Army Chief
Surgeon in the final 19th-century, had a multi-shaped personality (also being a politician,
journalist, editor, dramatist and travel literature writer) and contributed significantly to the
Military Medicine reform, mainly in the operational field. He was committed to supporting the
Operational Military Medicine training, promoting proper education of stretcher-bearers and
other Sanitary Company members, and establishing Tactical Medic Training and Simulation as
adopted in other European countries. He was a fruitful and proactive author of several
Reports, Manuals and Monographs available in the Army Library, still unknown to the public in
general. The authors screened the works he authored or co-authored, and found 21 titles at
the Army Library. From the medical textbooks or manuals, the authors found 9 titles explicitly
related to Operational Military Medicine, either exercise and military medical conferences
reports or instructional manuals. The authors will present a brief overview of those works and
evaluate their importance at that time. As a result of the above mentioned, it is our
conviction that Dr Cunha Bellem prominently stands out in the Portuguese Military Medicine
History, and that his foresight had a profound effect in the preparation and performance of
the Army Health Services on the dawn of the First World War.
Keywords
Portuguese Army; Military Medicine; 19th Century; Operational Training and Qualification
Résumé
Le Dr. Cunha Bellem (maintenant épelé Belém) (1834-1905), Chirurgien en chef de l’Armée
portugaise à la fin du XIXe siècle, avait une personnalité multiple (étant politicien, journalist,
rédacteur, écrivain de théâtre et de récits de voyage), et contribua de façon significative à la
réforme de la médecine militaire, essentiellement dans le domaine opérationnel. Il fut un
soutien engagé de l'entraînement opérationnel en médecine militaire et un promoteur de
l’éducation spécifique des brancardiers et autres membres de la Compagnie Sanitaire; il
établit l'entraînement et la simulation tactique médicale, comme cela avait été adopté dans
d’autres pays européens. Il fut l’auteur polygraphe de multiples rapports, manuels et
monographies, présents dans la Bibliothèque de l’Armée, mais jusqu’à présent très peu
1 Lieutenant Colonel MD (Reserve), Neurosurgery Consultant – Portuguese Army. Contact: e-mail:

rppc@net.sapo.pt
2 Major MD, Vascular Surgeon – Portuguese Army – Armed Forces Hospital.

établit l'entraînement et la simulation tactique médicale, comme cela avait été adopté dans
d’autres pays européens. Il fut l’auteur polygraphe de multiples rapports, manuels et
monographies, présents dans la Bibliothèque de l’Armée, mais jusqu’à présent très peu
connus du public. Les auteurs de cet article ont étudié toutes les oeuvres conservées à la
Bibliothèque de l’Armée, écrites par Bellem en tant qu’auteur ou co-auteur, et ont répertorié
21 titres. Parmi les livres ou manuels médicaux, les auteurs ont retrouvé 9 titres
spécifiquement dédiés à la médecine militaire opérationnelle, c’est à dire aussi bien des
rapports de conférences sur l’exercice et la médecine militaire, que des manuels d’instruction.
Les auteurs présentent un aperçu général de ces oeuvres et évaluent leur importance à cette
époque. Ils concluent que le Dr. Cunha Bellem était une figure de proue dans l’histoire de la
médecine militaire portugaise, et qu’il a eu une influence profonde sur la préparation et
l’instauration des Services de Médecine de l’Armée au début de la Première Guerre mondiale.
Mots-clés
Armée Portugais; Médecine Militaire; XIXe siècle; Exercice opérationnel et Qualification
Introduction
Dr Bellem (Augusto Manuel da Cunha Bellem) is one of the most respected

personalities of the Portuguese Army Health Services for his outstanding
achievements when dealing with several civilian and military health issues. He was
born in 1834, during the civil war. He graduated from the medical school in 1858
(when he was 23 years old). He got married at the age of 18, still as a medical
student, and by the age of 27, he already had four children.
As a consequence, he always struggled for financial independence, barely making
enough to have a modest living, even later in his career. He joined the Army Medical
Corps in 1859, with the rank of Assistant-Surgeon (Ajudante de Cirurgião), in the 11th
Infantry Regiment. Promoted to Surgeon-Major (Cirurgião-Mor) in 1871, he was
assigned to the 4th Caçadores Battalion. He was promoted to Brigade Surgeon
(Cirurgião de Brigada) in 1888 and appointed Director of the Reunited Military
Hospital of Chaves, Division Surgeon (Cirurgião de Divisão), in 1892.
Finally, he was appointed Army Chief Surgeon (Cirurgião em Chefe do Exército), in
1897, acting as Chief of the 6 th Department of War Secretary-General Direction (in
1899, ranking in the top of the medical officer career designated as Colonel from then
on.) (1).

Figure 1 - Dr Cunha Bellem bronze statue (author´s archives).
Materials and methods
The authors screenedthe works he had authored or co-authored, finding 21 titles at

the Army Library (some of them with more than one copy), 3 of them, about different
issues (excluding two plays and one travel diary). From the medical textbooks or
manuals, the authors found 9 titles related specifically to Operational Military
Medicine, either exercise and military medical conferences reports or instructional
manuals.
Discussion
During his brilliant career, he attended several major medical meetings, as Army
Delegate, which allowed him to get up-to-date with new trends in tactical sanitary
concepts. Those were the cases of Vienna (Hygiene International Congress), 1877,
Paris (Hygiene and Military Medical Science International Congress), 1878,
Amsterdam (Military Medical Science International Congress), 1879, Turin (Hygiene
International Congress), 1880, London, 1881, Geneve, 1882, and again Vienna (6 th
Hygiene International congress) in 1888, from which he made several official reports
and résumés.
In 1884, during the Cholera Epidemic in Spain, he was appointed responsible for the
Terrestrial Border Sanitary Defense (1884-1886). The task included the creation of
quarantine facilities (Valença, Vilar Formoso, Marvão, Elvas and Vila Real

de S. António) and inspection of the sanitary line disposal (insured by the Army, with
checkpoints along roads and railways), being accomplished with remarkable success
(2).
As a result of these experiences, he developed a particular interest in tactical sanitary
development, including training of physicians, nurses and stretch-bearers (maqueiros)
and improvement of sanitary equipment, promoting medical services participation in
field exercises (including training with simulated casualties). After organizing the first
simulated military medical exercises in 1888, in which he offered himself to steer the
sanitary services, he wrote in the official report:
We have no military surgeons, in the strict meaning of this professional designation.

We do have excellent and remarkable Military Hospital Clinicians, dedicated Hospital
Administrators, good willing Barrack Hygienists - which, although very satisfactory,
differ substantially from the real ability and experience of Military Medicine practice. (3)
(…) during the war, we may provide valuable services in hospitals; however, we will not
know how to perform our mission on the battlefield. (4)
As a consequence, he defended the following idea:
In a law project (…), one should care about the additional education of the future
military medicine candidates, teaching them a lot on specific issues, not ordinarily
available in medical schools that are essential to their knowledge. (5)
Figure 2 - Health Service Capacities Parade – Estrela Square, Lisbon – Circa 1897 – Dr Cunha Bellem is
the Officer mounted on white horse facing the photographer (author archives).

Dr Bellem was particularly concerned about their specific education of the stretcher
personal (maqueiros) and rescuers (socorristas). One must keep in mind that up to
that time, those militaries were picked up ad hoc among musicians and clerks (less
occupied in the battlefield), soldiers of the 1th Company of Military Administration
(created in 1866) or even among men with physical defects or that had mutilated
themselves (to discourage this subterfuge from getting exemption of military service)
(6). Keeping these examples in mind, he published the Projecto de Regulamento para
Instrucção das Esquadras de Maqueiros Regimentaes: Questões medico-militares,
1892 (Regulation Project for Instruction of Regimental Stretcher-bearers Squads:
military-medical topics).
Figure 3 and 4 - Projecto de Regulamento para Instrucção das Esquadras de Maqueiros Regimentaes:
Questões medico-militares, 1892 – Cover page and table of contents (Courtesy of the Army Library).
He was also very keen on sanitary material and tactical equipment, sanitary
evacuation means and hygiene conditions of both troopers and military facilities. He
wrote books (O material sanitário e os respectivos serviços nos exercícios de outono
de 1893, 1894, and Le matériel sanitaire de l'Armée Portugaise, 1900) about those
themes, promoting individual hygiene, better conditions and proper nutrition of the
soldiers.
He also imagined new stretchers, new ambulances and field hospital tents (one of
them designated by his name and even used during the 1 st World War), and new
sanitary bags among other devices.
b
a
c d
Figure 5 - Images from the book Le matériel sanitaire de l'Armée Portugaise (Army Library courtesy):
a) Regimental Sanitary vehicle (opened, with a stretcher), b) Ambulance tent, c) Medical kit (opened)
and d) Sanitary Havresac (opened) - (Courtesy of the Army Library).
Along with his military career, he had a busy social, political, cultural and private
practice life: he was a free-mason and author of works on that topic (O Grande
Oriente Lusitano e o Pedreiro Livre - which brought him acknowledgement from the
King of Prussia, among other distinctions).
He was also parliament deputy, physician of the Lisbon Town Council, journalist,
school director, dramatist and travel literature writer (O Pedreiro Livre, Amores de
Primavera, Quinze dias na Hollanda). He was a known medical journal editor
(Escholiaste Medico, Gazeta dos Hospitaes Militares e Medicina Militar).
The front page of his work Le matériel sanitaire de l'Armée Portugaise fully showcases
the above mentioned.

Figure 6 - Bellem Curriculum vitae in the front page of his work Le matériel sanitaire de l'Armée
Portugaise (Courtesy of the Army Library).
Conclusion
Dr Cunha Bellem was a strenuous organizer and planner with a foresight to the
relevant issues of the Sanitary Military Services. Dying in 1905, he left, as heritage,
an improved Military Health System in the dawn of the First World War.
References
1.Reis, CV. História da Medicina Militar Portuguesa. Lisboa: Edição do EME; 2004. Vol
II, 273-281.
2.Rodrigues, H. General Cunha Belém: contribuição para a Medicina Militar Portuguesa
– TII, CPOS 2014-2015. Lisboa: IUM; 2015.
3.Belém, C. Questões médico-militares: Estudo sobre os serviços sanitários de
campanha no exercício da Brigada Mixta de Manobra em setembro de 1888. Lisboa:
Imprensa Nacional; 1889, 19.
4.Belém, C. Questões médico-militares, 21.
5.Ibidem.
6.Reis, CV. História da Medicina Militar Portuguesa. Lisboa: Edição do EME; 2004. Vol I,
251.
Acknowledgements
The authors wish to acknowledge the Portuguese Army Library and Army Health Services
Direction cooperation
Appendix
Selected medical-military works by Cunha Belém – Army Library
● Belém, C. A Vida Médica no Campo de Batalha. Lisboa: Imprensa de J. G. de Sousa

Neves; 1879. - Cotas: 4191 BE, 4156 DAA

● Belém, C. e Enes, G. Clarões e Reflexos do Progresso Médico. Lisboa: Imprensa de J.G.

de Sousa Neves; 1880. - Cota: 4192 BE.
● Belém, C. Estudos sobre os serviços sanitários de campanha no exercício da Brigada
Mixta de Manobra em setembro de 1888: Questões médico-militares. Lisboa: Imprensa
Nacional; 1889. - Cotas 4753 BE; 4652 DAA.
● Belém, C. Projecto de Regulamento para Instrucção das Esquadras de Maqueiros
Regimentaes: Questões medico-militares. Lisboa: Imprensa Nacional; 1892. - Cota
3410 BE.
● Belém, C. O material sanitário e os respectivos serviços nos exercícios de outono de
1893: Questões medico-militares. Lisboa: Imprensa Nacional; 1894. - Cotas 9933
DAA; 4193 BE.
● Belém, C. Breves noções de hygiene militar para uso das escolas dependentes do
Ministério da Guerra. Lisboa: Imprensa Nacional; 1896. - Cota 4011 DAA.
● Belém, C. A lição da experiência sobre o simulacro dos serviços sanitarios do campo de
batalha. Lisboa: Imprensa Nacional; 1897. - Cota 3835 BE.
● Belém, C. Relatório sobre os serviços de saúde nos exercícios do Outono de 1896,
Colleção das Ordens do Exército: Parte não oficial. Lisboa: Imprensa Nacional; 1897. -
Cotas: 12967-22-5 BEP; 3720 DAA; 9288 DAA; 3835 BE.
● Belém, C. Le matériel sanitaire de l'Armée Portugaise. Lisboa: Typographia da
Companhia Nacional; 1900. - Cota 5206 BE.
Cunha Belém, other works - Army Library
● Belém, C. Amores de primavera (theatre comedy). Lisboa: Typographia do «Diário

Ilustrado»; 1876. - Cota: 32.951 BE.
● Belém, C. O Pedreiro Livre (theatre Play – Drama, 4 Acts). Lisboa: Imprensa de J. G.
de Sousa Neves; 1877. - Cota: 6.322/A BE.
● Belém, C., Enes, G. e Fonseca, J. Gazeta dos Hospitaes Militares. Lisboa: Typographia
das Horas Romanticas; 1878-1881, 2 vol: 1o Anno 1877 e 4o Anno, 1880. - Cotas:
2637-17-3 BEP, 1017/B BE.
● Belém, C. La prophylaxie morale de la phthisie dans l'armée: communication adressée
a la section d'hygiéne militaire et navale du Congrés International d'Hygiéne, rèuni a
Turin en Septembre 1880. Lisbonne: J. G. de Sousa Neves; 1880. - Cota: 4189 BE
● Belém, C. Quinze Dias na Hollanda (Notas de Viagem do Sena ao Amstel). Lisboa:
Livraria Editora de Tavares Cardoso & Irmão; 1884. - Cota: 34.996 BE.
● Belém, C. A Reforma do Exército e a Classe Médico Militar. Lisboa: Typographia das
Horas Romanticas; 1885. - Cota: 4184 BE.
● Belém, C. e Enes, G. Relatório apresentado à sociedade portuguesa da cruz vermelha.
Lisboa: Imprensa Nacional; 1887. - Cotas: 4633 DAA (dois exemplares), 3465 BE,
7709-15-5 BEP.
● Belém, C. e Enes, G Affirmações e dúvidas sobre os ultimos progressos da hygiene.
Lisboa: Imprensa Nacional; 1888 - Cota: 3432 BE; 2582 DAA; 2583 DAA; 6458 DAA
● Belém, C. e Enes, G La prophylaxie internationale du Choléra en Portugal. Lisbonne:
Imprimerie Nationale; 1888 - Cotas: 3463 BE, 4426 DAA, 4427 DAA.
● Belém, C. Estudo sobre os quartéis da guarnição de Lisboa: Questões medico-militares.
Lisboa: Imprensa Nacional; 1890.- Cotas 3410/1 BE; 5140 DAA.
● Belém, C. Factos e commentos relativos à Defesa Sanitária em 1890. Lisboa: Imprensa
Nacional; 1891. - Cota: 4190 BE Cota: 4190.
● Belém, C. Le Faux - Choléra á Lisbonne au printemps de 1894. Lisbonne: Imprimerie
Nationale; 1894. - Cota: 3987.

FRAGMENTS OF THE CONSTRUCTION OF THE MEDICAL

ASSISTANCE MEMORY IN THE HOSPITAL DOS CLÉRIGOS DO
OPORTO BETWEEN THE LAST QUARTER OF THE EIGHTEENTH AND
THE SECOND HALF OF THE NINETEENTH CENTURY
António Miguel Santos1
Abstract
Reports on health issues do not confine to archives produced by medical health care services.
Religious institutions such as the Irmandade dos Clérigos do Porto developed an interest in
assisting and treating the sick in its Hospital, attracting some of the best medical
professionals to work in its staff. An archive of this institution is dedicated to the Hospital
issues. However, aiming to find out further information concerning health care, we extended
our search throughout the whole archive in order to get a broader overview of the medical
assistance of this institution throughout time.
Keywords
Oporto; Hospital; Physicians; Clergymen; Nasoni
Résumé
Les rapports sur les questions de santé ne se limitent pas aux archives produites par les
services médicaux. Des institutions religieuses telles que l'Irmandade dos Clérigos do Porto
ont développé un intérêt pour l'assistance et le traitement des personnes malades dans leur
hôpital, attirant certains des meilleurs professionnels de santé parmi les membres de son
personnel. Une partie des archives de cette institution est dédiée aux problématiques
hospitalières. Cependant, dans le but de trouver de plus amples informations concernant les
soins de santé, nous avons étendu notre recherche à l'ensemble des archives afin d'avoir un
aperçu plus large de l'assistance médicale de cette institution au fil du temps.
Mots-clés
Porto; hôpital; médecins; ecclésiastiques; Nasoni
1 Historian by Faculty of Arts and Humanities of University of Oporto, Portugal. Contact:

antoniomiguelsantos@gmail.com

Introduction
This article aims to illustrate how the Hospital da Irmandade dos Clérigos do Oporto,
a Society of Clergymen including a Hospital created in 1754 during the Early Modern
period, located in the historical city centre of Oporto, which supposedly should only
accept and receive Clergymen, also accepting and treating laypeople. The
brotherhood adapted itself to the surrounding civil society throughout the time by
accepting and including the best medical Doctors of the city of Oporto in its structure.
Most were professors at the Escola Médico-Cirúrgica do Oporto (Medical-Surgical
School of Oporto).
Clergymen and laypeople, being two different social classes, were able to
communicate, providing the best medical assistance not only to the members of the
brotherhood but also to the people living outside, belonging to all social classes and
gender, especially during the 19th century.
The medical assistance could be provided inside the Hospital and also at the patients’
house whenever it was necessary. This article will recall not only the name of some of
the best medical doctors and surgeons but will also present examples of medical
diagnosis and recipes of the medical practice. It will present how the patients could
request medical treatment in the Hospital or in-home medical assistance.
An overview of the process of hiring physicians and surgeons will be carried out,
illustrated by their letters, focusing on how they managed to be accepted within the
Brotherhood, playing an important role and even becoming members. At least one
physician had the great honour of being buried inside the Clerics Church in a place
reserved for Clergymen, due to his admirable medical work.
Finally, being a historian with a great interest in the History of Medicine, this article is
an attempt to pursue the challenge once brought up by Professor João Lobo Antunes
(1944-2016), one of the most brilliant and prestigious Portuguese neurosurgeons:
It would be most useful to find someone (…), a scholar, someone really hard to find,
who would be knowledgeable of the history that could explain to us how we managed
to come to our time, pointing out what was lost and won on our way.2 (1).
Sources and medical assistance at the Irmandade dos Clérigos do Oporto
The primary source consulted for this study was the online Archive: Arquivo da
Irmandade dos Clérigos do Oporto (2), an outstanding storage of numerous
documents from this institution, available for further research. This institution is
among the first to provide full access to all documentation online and for free, in our
country. It is possible consulting
_
2“Era muito útil que existisse (…) o que é mais difícil de encontrar, um erudito, que conheça a história
e nos explique como se chegou ao tempo de hoje, o que se perdeu e o que se ganhou no caminho.”

documents at the Casa da Prelada, also known as Prelada House – D. Francisco de

Noronha e Menezes, located in Oporto. It has a pleasant surrounding being part of a
beautiful landscape. The main building was built in 1754 according to the plans of the
Italian architect Niccólo Nasoni (1691-1773). Between 2010 and 2013, extensive
rehabilitation works at Casa da Prelada were carried out. Further facilities were built,
such as the Historical Archive of the Misericórdia do Porto where the original
documents belonging to the Irmandade dos Clérigos do Oporto were housed after a
protocol signed between two entities: Irmandade dos Clérigos do Porto and Santa
Casa da Misericórdia do Porto (3).
The Archive contains information about the whole institution. It is divided into several
sections related to different topics, providing a section dedicated to the Brotherhood
Hospital which functioned between 1754 and 1924. For this essay, we will focus
mainly on relevant material on the History of Medicine. The section dedicated to the
Hospital provides a wide range of documentation concerning the medical activity
developed by the Brotherhood of Clerics of Oporto within its Hospital unit. Some
documents were selected to illustrate its functioning.
Figure 1 – Fragment of the description of the hospitalization costs of a patient at the Hospital.
Source: ICP, IC, Hospital da Irmandade dos Clérigos do Oporto, Despeza da Infermaria, fólio
3v.
(PT ICPRT IC/C/0029).
Figure 1 displays careful details on the costs of the Brotherhood in the Hospital
treatment of its Brothers, even their funeral, when nothing could save them.
In this detailed description, dated from 1754, the names of the Surgeon Bernardo de
Sousa and the Physician António de Mena Falcão, called: “o Médico o nosso Irmão o
Reverendo António de Mena Falcão” figure3 referring to his making his work for the
grace of God: “fez assistência gratis pro Deo”.4
The name of the Apothecary, João de Sousa Pinto, who assisted the sick Brothers, is
also mentioned. This detailed information was provided for each Brother assisted in
_
3 the Physician, our Brother António de Mena Falcão.

4 provided free medical assistance by God

the Hospital, allowing us to carry out studies related to other areas, such as Health
Economics.
To get a deeper understanding of the functioning of the Hospital, we must broaden
the research to other documentary sections, namely to the Mesa da Irmandade dos
Clérigos do Porto5. In the preceding centuries, the documentation could be grouped in
a certain order which no longer matches the logic of the present time. However, this
should only motivate us to deepen the research to find out elements that will allow us
to reconstruct how the medical activity was developed in its various strands.
As mentioned, the Brotherhood of the Clerics of Oporto provided medical assistance
not just to the Brethren in its Hospital. The document displayed in Figure 2 illustrates
an assistance request by a member of the Brotherhood. This kind of request was used
for a long time, namely throughout the late 17th century and 19th century.
Figure 2 – Assistance request by a sister of the Brotherhood. Source: ICP, IC, Mesa da Irmandade dos
Clérigos do Oporto, Contas e Recibos, Recibos do anno de 1783 athé 1810, fólio 5. (PT ICPRT
IC/A/016/0003).
The request was signed by Sister Bernardina Teresa da Conceição Silva complaining
of suffering from the successive misfortunes after the death of her husband. She had
been hit by severe and chronic diseases, lacking food and remedies6. In the upper
right corner of the document, we read that on September 12, 1806, the President of
The Bureau requested joining the certificate of Brother Doctor António Sousa Alão on
_
5 Corresponds to the Directorate of the Brotherhood.

6 os sucessivos infortunios, com que tem sido atacada depois da morte do seu marido; e as
gravíssimas, e cronicas molestias que tem padecido; a tem reduzido ao mais mizerrimo, e
compulsivo estado; sem ter com q se alimentar, nem medicinar.

the progress of the disease so that he could find the suitable assistance to the
supplicant7.
As displayed on September 14, 1806, the physician António Marques de Sousa Alão
made the clinical history, referring that she suffered from rheumatic pains throughout
the body for some days, and that frequent haemorrhages leaft her in great dismay8.
On September 15, 1806, the Reverend Secretary is said to have granted her the alms
of 960 réis9 to pay for her bandage. She should send the recipes to the Pharmacy
signed by the physician António Marques de Sousa Alão10.
This example highlights fundamental elements which enable us to broaden the high
level of care provided by the Brotherhood, inferring in particular that the assistance
was not limited to clerics or male personalities, but also offered to women who could
even become Sisters of the Brotherhood. As the physical space of the Brotherhood
Hospital was reserved to men, women received home care, also extended to men.
The aid provided by the Brotherhood did not comprise just medical care. It could take
the form of pecuniary assistance, allowing the brothers to subsist with the highest
possible dignity.
It should be noted that, in the legal framework of the Brotherhood, there was no limit
to the number of assistance requests for any Brother. Through a single document, it
is possible to visualize a whole flow of information involving different social figures
and the speed at which each agent went through the situation until the final decision.
By this example, we realize that since the Bureau’s knowledge of the request, the
President of the Bureau summoned the intervention of the physician António Marques
de Sousa Alão on September 12, who elaborated his medical evaluation on
September 14, 1806. He finished it September 15, 1806, when the Secretary of the
Brotherhood’s Bureau took charge of executing the final decision according to the
medical prescription.
This example demonstrates that physicians did not act autonomously within the
Brotherhood because they were an integral member of a large staff keeping in touch
with each other. This articulation between the different elements that comprised the
Brotherhood, including the medical class, illustrates the development of the health
care activity in its multiple strands. The information flow of requests can be viewed in
the following organization chart:
7 Juntando Certidão do Nosso Irmão Doutor António Sousa Alão, sobre o estado actual da moléstia será
socorrida a supplicante.
8 A supplicante se acha a muitos dias com dores reumathicas por todo o corpo (…) isto combinado com
as hymorrhagias do costume a tem posto em grande abatimento.
9 Name of the currency used in Portugal at that time.
10 O Reverendo Secretario socorre a Supplicante com a esmola de 9600 réis para o seu curativo e
enviará as Receitas a Nossa Botica para se satisfazerem sendo assignadas pelo Nosso Irmão António
Sousa Alão.

Figure 3 – Information flow of a request for assistance (elaborated by the author).
If a patient was admitted in the Hospital da Irmandade dos Clérigos do Porto, a

record of personal information was made, including not only the condition but also the
residence, profession, date of admission and discharge or death.
Since the patients accepted in the Hospital were Clerics, and from a young age,
whenever they should be prepared to deal with death, they should be instructed with
the poem by John Donne (1572-1631):
Death, be not proud, thou some have called thee mighty and dreadful, for thou art not
so… (4).
In another document, two patients were interned in the Hospital: the first suffering
from a stroke, the second from rheumatism.

Figure 4 – Two Brothers interned in the Hospital.

Source: ICP, IC, Hospital da Irmandade dos Clérigos do Oporto, Enfermaria Entradas, e Obitos,
fólio 5v. (PT ICPRT IC/C/0028).
Prescriptions by physicians working in the institution are relevant matters.

Figure 5 – Medical prescriptions. Source: ICP, IC, Hospital da Irmandade dos Clérigos do Oporto, Livro
para se assentarem as receitas dos Senhores Médicos, fólio 6 (PT ICPRT IC/C/0043).
This example shows the reason why several scientific areas should work together to
analyse properly the relevant information in this documentation. At least the following
scientific fields should work together in a multidisciplinary way: historians to find out
these precious documents among several other different documents and also to
analyse the writing, economists to find out if the costs mentioned at the right-hand
side of the document are correct or very high when compared with other costs,
chemists to find out which were the chemical compounds used and naturally,
physicians to determine whether these were the most appropriate therapies to treat
pathologies, taking into account the advances in scientific knowledge at that time.
This document, signed by Manoel Gomes de Lima Bezerra (1727-1806), one of the
most eminent Portuguese physicians of the second half of the 18th, states the quality
of the most advanced medicine at the Brotherhood’s Hospital. Among other activities,
Bezerra maintained correspondence with the Royal Academy of Medicine and Surgery
of Seville, founded in the 18th century to keep themselves informed on the scientific
advances of the time. The physicians should be first admitted into the Brotherhood as
Brothers and only then could prescribe.

Figure 6 – Hiring Process of a Physician as Brother in the Brotherhood of Clerics.

Source: ICP, IC, Mesa da Irmandade dos Clérigos do Oporto, Requerimentos, Entradas de
Irmaons Acceitaçoens de Cappelaens Licenças dos mesmos Varias cartas que nada valem,
fólio não
numerado (PT ICPRT IC/A/018/0001).
Figure 6 displays the official document in which the physician António Marques de
Souza Alão formalizes his request to be admitted to the Brotherhood of Clerics in
Oporto on January 7, 1802, intending to take care of all Poor Brothers of the
Brotherhood, either at the hospital or their houses, also assisting the relatives living
at the same house.
If the physician was admitted as a Brother of the Brotherhood, full registration of his
admission was carried out as evidenced in Figure 7 on the admission of the Physician
António Marques de Sousa Alão11 as a brother of the Brotherhood of the Clerics of
Oporto.
11 On the medical studies by António Marques de Sousa Alão, see:

http://pesquisa.auc.uc.pt/details?id=141915&ht=Ant%C3%B3nio|Marques|de|Sousa|Al%C3%A3o
accessed on 26th February 2020. Arquivo da Universidade de Coimbra.

Figure 7 – Registration of the admission of the physician António Marques de Sousa Alão as Brother of
the Irmandade dos Clérigos do Oporto.
Source: ICP, IC, Mesa da Irmandade dos Clérigos do Oporto, Entradas e Óbitos dos Irmãos, Livro das
Entradas e Óbitos dos Irmãos, fólio 130 (PT ICPRT IC/A/004/0002).
On several occasions, a physician would assist not only a sick Brethren but also his
family. Other elements of the physician’s household could also become Brothers. The
family of António Marques de Sousa Alão, due to valuable services provided in the
Brotherhood managed to obtain the admission of his wife 12 and daughters13 in the
Brotherhood.
We would also like to mention that through the valuable medical services provided in
the Brotherhood, a physician could receive honours that initially would only be
destined to the Clerics.
A valuable document shows that a physician who worked for several years within the
Brotherhood, helping the sick brothers free of charge, had the great honour of being
buried inside the Church of the Clerics February 10, 1862 (5). So far, this is the only
physician of which there is documentary confirmation that he is buried inside the
Clerics Church together with other clerics.
12 Source: ICP, IC, Mesa da Irmandade dos Clérigos do Oporto, Requerimentos, Entradas de Irmaons
Acceitaçoens de Cappelaens Licenças dos mesmos Varias cartas que nada valem, fólio não numerado
(PT ICPRT IC/A/018/0001).
13 Source: ICP, IC, Igreja e Sacristia da Irmandade dos Clérigos do Oporto, Contas da Sacristia da
Igreja da Irmandade dos Clérigos, Termos de sepultura, fólio 101v. (PT ICPRT IC/B/0050).

Figure 8 – Registration of the death of the Physician Luís António Pereira da Silva.
Source: ICP, IC, Igreja e Sacristia da Irmandade dos Clérigos do Oporto, Contas da Sacristia
da Igreja da Irmandade dos Clérigos, Termos de sepultura (PT ICPRT IC/B/0050) and Lemos, M.,
(1925).
História do Ensino Médico no Oporto. Oporto: Tip. a vapor da «Enciclopédia Portuguesa», p. 135.
Drawing by Professor Abel Salazar.
The physician Luís António Pereira had vast scientific knowledge. Among the
functions he developed throughout his life, he was a Lecturer at the former Medical-
Surgical School of Oporto14.
His death registration has great institutional relevance because, over the years,
several authors sought information about the place where this distinguished physician
was buried. By the duties, he worked at the Brotherhood of the Clerics of Oporto.
When he died, as stated in a document of the Brotherhood, he was called: “Nosso
Irmão Mesário Ilustríssimo Senhor Doutor”, proving that he died there.”15
As historians, we often are the voice of those who no longer have a voice, and
whenever possible, we should show whom we are studying. In Figure 8, we may
observe the physician Luís António Pereira da Silva through the painting by another
relevant Portuguese physician of the end of the 19th century, early 20th century, who
developed his medical work also in the city of Oporto, Professor Abel Salazar (1889-
1946).
We want to emphasize a piece of unprecedented information (6) found in the
institution’s archive about a remarkable Brother who received medical assistance from
the Brotherhood of Clerics: Nicolau Nasoni (1691-1773). He was an outstanding
personality responsible for several emblematic works in various institutions
throughout the North of Portugal, including the iconic Clerics Tower in Oporto and the
Hospital described in this article.
_
14 Escola Médico-Cirúrgica do Oporto.

15 Our Brother Illustrious Mr Doctor.

Figures 9 and 10 display the course of his last months of life. In Figure 9, we can
verify that he requested medical assistance from the Brotherhood of Clerics claiming
to be sick and indigent. Found in old age and complaining of chest pain, he requested
in-home care provided by the Clerics Brotherhood because he was living with his
maiden daughter. He has obtained an affirmative response from the Brotherhood to
his request.
Figure 9 – An Outstanding Brother receiving medical assistance from Irmandade dos Clérigos do
Oporto: Nicolau Nasoni.
Source: ICP, IC, Mesa da Irmandade dos Clérigos do Oporto, Contas e Recibos, Recibos dos
annos de 1759 até 1783, fólio não numerado nem rubricado (PT ICPRT IC/A/A016/0001).
Figure 10 displays the evolution of the hospital expenses with his home care until he
passed away (7).

Figure 10 – Expenses of the medical assistance with Nicolau Nasoni.

Source: ICP, IC, Mesa da Irmandade dos Clérigos do Oporto, Contas e Recibos, Recibos dos
annos de 1759 até 1783, fólio não numerado nem rubricado (PT ICPRT IC/A/A016/0001).
Conclusion
This study led us to results from which we highlight the following: despite being a
Brotherhood originally addressed to Clerics, it also admitted laypeople and women.
Physicians requested permission to be admitted as members of the Brotherhood and

to treat the brothers free of charge. The Brotherhood offered medical assistance not
only in the Hospital but also home care to illustrious personalities of the society of
that time such as Nicolau Nasoni.
Among the various topics to be discussed and for future study, it is of paramount
importance to know precisely who and how many people received home medical care,
because this information is scattered throughout the archive.
To conclude, we would like to comment briefly on a possible correlation between
History and Medicine which can be eventually be expressed as follows: health
professionals, namely doctors and surgeons, save people’s lives by allowing them to
live in the present. History tries to save health professionals and patients from falling
in the eternity of oblivion so that they can live in the eternity of our memories.
Bibliography
Archival Sources
Arquivo da Irmandade dos Clérigos do Porto
Secção A – Mesa da Irmandade dos Clérigos do Porto.
Contas e Recibos, Recibos dos annos de 1759 até 1783 (PT ICPRT IC/A/A016/0001).
Contas e Recibos, Recibos do anno de 1783 athé 1810 (PT ICPRT IC/A/016/0003).
Entradas e Óbitos dos Irmãos, Livro das Entradas e Óbitos dos Irmãos (PT ICPRT
IC/A/004/0002).
Requerimentos, Entradas de Irmaons Acceitaçoens de Cappelaens Licenças dos mesmos

Varias cartas que nada valem (PT ICPRT IC/A/018/0001).
Secção B – Igreja e Sacristia da Irmandade dos Clérigos do Porto.
Contas da Sacristia da Igreja da Irmandade dos Clérigos, Termos de sepultura (PT ICPRT
IC/B/0050).
Secção C – Hospital da Irmandade dos Clérigos do Porto
Despeza da Infermaria (PT ICPRT IC/C/0029).
Enfermaria Entradas, e Obitos (PT ICPRT IC/C/0028).
Livro para se assentarem as receitas dos Senhores Médicos (PT ICPRT IC/C/0043).
Arquivo da Universidade de Coimbra
Índice de alunos da Universidade de Coimbra 1536/1919-11-14, Letra A 1536-10/1925-01-30

References
1. Antunes, J.L., Um Neurocirurgião em Construção. Lisboa: Gradiva, 2019, 190.

http://portal.cehr.ft.lisboa.ucp.pt/arquivos/index.php/irmandade-dos-clerigos-do-porto
accessed on 26th February of 2020.
2. https://www.scmp.pt/casa-da-prelada/arquivo-historico accessed on 26th February of
2020.
3. Donne, John in Günther, J., Death Be Not Proud. In Antunes, J.L., (2019).
Um Neurocirurgião em Construção. Lisboa: Gradiva, 1949, 183.
4. Lemos, M., História do Ensino Médico no Oporto. Oporto: Tip. a vapor da
«Enciclopédia Portuguesa», 1925, 135.
5. Santos, A.M. da S., Hospital da Irmandade dos Clérigos do Porto (1754 – 1924). A
memória dos doentes e profissionais de saúde. Masters dissertation, Faculty of Arts and
Humanities of University of Oporto, Portugal, 2015, 41-42.
6. Idem, 85.

TEACHING AND LEARNING OF THE HISTORY OF MEDICINE AT THE

PEOPLES’ FRIENDSHIP UNIVERSITY OF RUSSIA (RUDN
UNIVERSITY)
Tatiana Sorokina1
Summary
In Russia ‘History of Medicine’ is a compulsory academic subject of Higher Medical Education.

At the Peoples’ Friendship University of Russia (RUDN University) it is a compulsory course
taught at the Department for the History of Medicine in Russian and English. It covers the
medical history of different countries and continents since the early being of the humankind
up to our days according to their national history, culture and religion. There are three levels
of teaching Medical History at our University: undergraduate – for students, post-graduate –
for post-graduate students, and professional course – for Professors and lecturers who teach
students. To provide students and lecturers with required essential knowledge on the History
of the World and Russian Medicine, a manual ‘History of Medicine’ has been created in our
Department; it is published in 13th editions (1992–2018, in Russian), and widely used for
medical education throughout the country and abroad. Our ‘Presentations of fourteen lectures
on the History of Medicine (in Russian and in English) were also published in 2018 as a CD-
supplement to the 13th edition of the manual in two volumes.
Keywords
History of Medicine; medical education; Peoples’ Friendship University of Russia (RUDN

University)
Résumé
En Russie, l'Histoire de la Médecine est un cours obligatoire dans le cursus de formation

médicale universitaire. A l’Université de l’Amitié des Peuples (Université RUDN), ce cours
obligatoire est dispensé dans le Département d’Histoire de la Médecine, non seulement en
russe, mais aussi en anglais. Il traite de l’histoire de la médecine dans divers pays et
continents du début de l’humanité jusqu’à nos jours, et avec un regard spécifique sur chaque
histoire nationale, leur culture et religion. Il y a trois niveaux d’enseignement d’histoire de la
médecine dans notre Université: pour les pour étudiants, pour les diplômés et pour les
professeurs et enseignants qui donnent des cours. Pour les étudiants et enseignants, qui
1 Tatiana S. Sorokina MD, PhD (Physiology), D.Sc. (History of Medicine), Professor, Head of the
Department for the History of Medicine, Medical Institute, Peoples’ Friendship University of Russia
(RUDN University), Moscow; Honorable Worker of Higher Education of the Russian Federation.
Address: Miklukho-Maklay Str., 8. RUDN University, Medical Institute, Dept. for the History of Medicine.
117198 Moscow, Russia. Email: sorokina-ts@rudn.ru

aspirent à une connaissance nécessaire en histoire de la médecine russe et mondiale, un

manuel d'Histoire de la Médecine a été créé dans notre Département; cette publication en est
actuellement à sa 131ème édition (1992-2018, en russe) et est largement diffusée partout
dans le pays et à l’étranger. Nos Présentations de 14 leçons sur l’Histoire de la Médecine (en
russe et en anglais) ont également été publiées en 2018 sur CD-rom en complément au
manuel édité en deux volumes.
Mots-clés
Histoire de la Médecine; education médicale; l’’Université Russe de l’Amitié des Peuples’

(Université RUDN)
Introduction
The teaching of the History of Medicine (HM) differs across the world by its aim,
contents, methods, duration, schedule of lectures and seminars, and place in the
curriculum. In different countries, HM is a compulsory or an optional subject. Its
duration is different, ranging from a short lecture course to a subject studied for one
term.
The exception is Intercalated BSc Studies at the Wellcome Trust Centre for the
History of Medicine UCL (UK) – an optional subject which is studied for an academic
year and usually called ‘the extra-year’ between the basic science and clinical blocks
of disciplines. Intercalated Studies are based on a special extensive programme and
finished with a particular thesis for a Bachelor’s degree in the field of Medical History
(BSc in History of Medicine).
During this year the students spend most of their time in the Wellcome Library –
which is the best in the world for research in HM. Thus, the study of HM in Great
Britain is closer to scientific research; that is why they have no manual on HM in its
classical understanding.
In the Russian medical institutes and universities, a teaching process takes place
according to the ‘State Educational Standard for Higher Education’. ‘History of
Medicine’ is an obligatory subject of Higher Medical Education (firstly introduced at
Moscow University in 1885 as an academic discipline ‘History and Encyclopaedia of
Medicine’). A current Standard Program for the subject ‘History of Medicine’ is worked
out at our Department for the History of Medicine, Peoples' Friendship University of
Russia in 2002–2003.
In the majority of Russian universities, ‘History of Medicine’ is a compulsory one- year
course for students of Medicine, Paediatrics, Dentistry, Medico-prophylactic studies,
Pharmacy, Nursing, Medical Biochemistry, Medical Biophysics, and Medical
Cybernetics. It is studied during the first of the second year (from 72 to 108 hours)
before students actually start the clinical part of medical education.

The teaching of HM (like other humanities) shares aspects connected with national
history, culture and religion, which is absolutely costomary and reasonable. In the
majority of countries, national HM is taught in the context of World HM.
However, in some countries, national HM is given separately, after a short general
introduction to the History of Medicine. Moreover, on the contrary, rather often, World
HM is given through national history and culture. The balance between national and
international parts is also somewhat different.
Subject ‘History of Medicine’
The Peoples’ Friendship University of Russia (RUDN University) is a miniature version

of the World uniting international students from more than 155 countries.
Our peculiarity is an international approach in programs and academic activity. That is
why in our University ‘History of Medicine’, as a cross-cultural course, entirely
corresponding to the slogan of the University – ‘Discover the World in one University’.
It is taught both in Russian and in English and covers the medical history of different
countries and continents from the early ancestors of mankind up to our days. The
Russian HM is given in the context of the World HM.
Moreover, at our University the ‘History of Medicine’ course includes some topics not
studied at other Russian universities, for example: ‘Early kinds of Healing’, ‘Arab-
Islamic Medicine’, ‘Medicine in Pre-Hispanic America’ and others, reflecting the
international character of the Peoples’ Friendship University of Russia, where
international students can learn about the medical history of their own country, its
peculiarities and influence on future development.
Study History of Medicine is a Long-Life-Learning (LLL). There are three levels of
teaching HM at our University: undergraduate – for students, post-graduate – for
post-graduate students, and professional course – for Professors and lecturers who
teach students.
Undergraduate course
The ‘History of Medicine’ course for undergraduate students is taught during the
second year and includes fourteen topics (36 hours for lectures, and 36 hours for
seminars) which cover all the period of the World History of Medicine – from Early
being of Mankind up to the Twenty century (Table 1).

Table 1. Contents of modules and topics
Lecture
№ Modules Topics Contents of Modules and Topics
hours
1.1. The Formation of Human Society and
Healing.
Introduction
1.2. Healing and Cults during the Maturity
Module I
Early kinds of Topic 1 2

and the Decline of Pre-class Society.
healing
Cranium trepanation.
1.4. Folk healing
2.1. Common characteristics.
2.2. Healing and Medicine in Ancient
Healing and Topic 2 Mesopotamia (Sumer, Babylonia, 2
Medicine in Assyria).
Module III Module II
Ancient East 2.3. Healing and Medicine in Ancient Egypt.

3.4. Healing and Medicine in Ancient India.
Topic 3 2
3.5. Healing and Medicine in Ancient China.
Healing and
Topic 4 4.1. Healing and Medicine in Ancient Greece. 2
Medicine
in Ancient
Mediterranean Topic 5 5.1. Medicine in Ancient Rome. 2
region
6.1. Medicine in the Byzantine Empire (395–
1453).
Topic 6 6.2. Medicine in Caliphates (VII–X centuries). 2
Medieval 6.3. Medicine in Central Asia (X–XV
Medicine (V– centuries).
Module IV
ХV centuries) 7.1. Medicine in Medieval Western Europe (V–

XV centuries).
Topic 7 2
7.2. Medicine in Medieval Russia (IX–XV
centuries).
Medicine in Topic 8 8.1. Renaissance Medicine in Western Europe. 2
Early Modern
Module V
Time (late XV 9.1. Medicine in Pre-Hispanic America.

- mid- XVII Topic 9 9.2. Medicine in the Russian state (XV-XVII 2
century) centuries).
Medico- 10.1. Biology and Genetics.
Biological 10.2. Anatomy.
Topic
Sciences in 10.3. Histology and Embryology. 4
10
Module VII Module VI
Modern Time 10.4. Pathology.

(mid-XVII – 10.5. Microbiology.
early XX Topic
11.1. Physiology and Experimental Medicine. 2
century) 11
Clinical 12.1. Internal Medicine (therapy) in Modern
Medicine in time.
Topic
Modern time 12.2. Medicine and medical education in the 4
12
(late XVII – Russian Empire.
early XX 12.3. Infectious diseases.

century) 13.1. Problems and Progress of Surgery in

Topic
Modern Time. 4
13
13.2. History of Nursing.
Medicine and 14.1. Nobel prize for Physiology or Medicine.
Module VIII
Public Health 14.2. Russian Medicine in the late XIX – early

Topic
in the XXI century. 4
14
Twentieth 14.3. International co-operation in the field of
century Public health and Medicine.
Every lecture is accompanied by a slide-presentation (of 50 to 100 slides), followed

by a seminar on the same topic where students present their essays and slide-show
and take part in the discussion on the topic.
Figure 1- Every student presents an essay at the seminar. Author’s photo.
Images are very important in teaching and learning the History of Medicine.
“It’s better to see once than to hear a hundred times”, says a Russian proverb. It is
especially important for international students doing their future specialization in a
foreign language. The initial idea was to show them some specific images of healers,
reflecting on their appearance and work habits in different countries. However, their
great interest in global medical history, as well to the Russian HM inspired me to
prepare a rich slide-presentation for every lecture, and now we have a vast collection
of slides that covers the entire field of the HM.
For example, in the lecture on ‘Problems and success of surgery in Modern time’ we
have more than twenty images of Nikolay Pirogov (1810–1881), an outstanding figure
in the Russian and the World Medicine, the most celebrated Russian surgeon

and one of the greatest military surgeons of all time, an anatomist, the founder of
topographical (surgical) anatomy and an experimental branch of surgery, a co-
founder of Military-field surgery, an educator, and a man of daring humanistic ideas.
Figure 2 - The monument to Nikolay Pirogov.

The first in Russia monument to a doctor.
unveiled in 1897 at the Moscow University Clinical area.
Designed by V. I. Shervud. Photo by the author.
Familiarity with different traditions of art and images of healers and their practice
broadens the historical understanding of students of Medical History significantly by
allowing them to appreciate the artefacts on which our understanding of HM depends.

In 2018 our ‘Presentations of fourteen lectures on the History of Medicine’ (in Russian
and in English) were published as a CD-supplement (enclosure) to the 13th edition of
our manual ‘History of Medicine’ in two volumes.
Figure 3. Manual ‘History of Medicine’ in 2 volumes. The 13th edition. Volume 1.

Moscow, Publishing House ‘Academia’. 2018.
Figure 4. Manual ‘History of Medicine’ in 2 volumes. The 13th edition. Volume 2.
Figure 5. CD ‘Presentations of fourteen lectures on the History of Medicine
in Russian and English’.
Supplement to the 13th edition of the manual ‘History of Medicine’ in 2 volumes.
Manual ‘History of Medicine’
The first edition of our manual ‘History of Medicine’ for students of the Russian
medical institutions became feasible after 18-year experience of teaching and
lecturing HM to international students at our University. It had been published in 1992
in ten thousand copies. It was written especially for students (and lecturers) to
provide the required essential knowledge for those who are preparing for seminars
and lectures.
A manual (as well as a text-book) for students is a very special kind of literature. It
cannot be considered as an encyclopaedia or a monograph; – this is a book for a
specific course for students with a concrete number of topics and volume of
information. Independently of the amount, the information held in such a book should
contain all necessary material required for every topic.
That is the reason why it is impossible to write a manual for students if there is no
experience of long and fruitful teaching and lecturing over the full course of the
subject to students (even if one is a brilliant scientist, an author of many books and
prestigious scientific publications)

Every other edition (1994, 2004, 2005, 2006, 2007, 2008, 2009, 2009, 2014,
2016, 2016, 2018, in all – 53 thousand copies, in Russian) had been improved and
supplemented with new materials (text, figures, tables, references), being currently
widely used for medical education throughout the country and abroad.
The 13th edition in two volumes (2018) consists of fourteen chapters (640 pages) and
includes 280 illustrations, 28 tables, references for every chapter, questions for
discussion and topics for essays, as well as a comprehensive Name index (1, 2).
This manual ‘History of Medicine’ completely corresponds to the topics of the
curriculum (see table 1) and contains extensive material on the global history of
medicine; at the same time, we pay proper attention to Russian medical history and
its outstanding achievers and priorities. After the publication of the 13th edition in two
volumes (with CD) an idea has occurred to translate this manual into English.
Figure 6 - Avtozhector – the first-ever world device for blood transfusion

designed in 1921 by Sergey Bryukhonenko (1890–1960).
From: Sorokina T.S. History of Medicine. Vol. 2. 2018, 310.
Besides the manual for students, we have written three books for school children who
are going to study medicine as their future profession. They are the following.

1. Сорокина Т.С. Медицинские профессии: Учебное пособие для

профессиональной ориентации и профильного обучения школьников. – М.:
Издательский центр «Академия», 2009. – 368 с. [Sorokina T.S. Medical
professions. Text-book for school children professional orientation and study.
Moscow: Publishing House ‘Academia’. 2009: 368 p.] (in Russian).
2. Сорокина Т.С. Профессиональное самоопределение школьников Москвы:

Медицина. Учебное пособие для учащихся 9-11 классов. – М.:
Образовательно-издательский центр «Академия»; ОАО «Московские
учебники», 2011. – 288 с. [Sorokina T.S. Professional choice of the Moscow
school children. Medicine: Text-book for school children of 9–11 years. Moscow:
Publishing House ‘Academia’; Publishing House ‘Moscow text-books’. 2011: 288
p.] (in Russian).
Figure 7. A cover of a book ‘Professional orientation of the Moscow school children.

Medicine’ Moscow, Publishing House ‘Academia’. 2011.
Figure 8. A cover of a book ‘Professional future of Yakutia. Public Health and Medicine’ by T.Sorokina
and A.Gorokhov. Moscow, Publishing House ‘Academia’. 2014.
3. Сорокина Т.С., Горохов. Профессиональное будущее Якутии.

Здравоохранение и медицина. – М.: Образовательно-издательский центр
«Академия», 2014. – 336 с. [Sorokina T.S., Gorokhov A. Professional future of
Yakutia. Public Health and Medicine. Moscow: Publishing House ‘Academia’.
2014: 336 p.] (in Russian).

Post-graduate course
Every post-graduate student in Russia studies the subject ‘History and Philosophy of
Science’ for one academic year. The course consists of two modules: ‘History of
Science’ (i.e. Medicine – for medical students) and ‘Philosophy of Science’.
The module ‘History of Science (Medicine)’ is taught at our Department for the History
of Medicine for one term. It is based on a special program (including lectures and
seminars) and finished with a particular thesis on medical history, close to a chosen
specialization.
During the other term, the students get learning on ‘Philosophy of Medical Science’ at
the Department of Ontology and Theory of Knowledge and finally pass an exam on
both modules.
Professional Course
This course had been organized in our University in 2010 for professors and lecturers
of History of Medicine. The main aim was to refresh and perfect our knowledge in
History of Medicine, according to modern achievements in different fields of Medicine
and related sciences, and renovations in the system of Higher Education. The duration
of this course is two weeks (72 hours).
Many of our colleagues from different universities of our country (from Arkhangelsk,
Grozny, Kazan, Moscow, Novosibirsk, Omsk, Smolensk, St. Petersburg, Tomsk, Tula,
Ufa) and abroad (Riga, Minsk) took part in this program and have got a proper
Certificate.
International co-operation
The staff of our Department for the History of Medicine takes an active part in
different international conferences and meetings in Russia and abroad.
We presented our papers in Congresses of the International Society for the History of
Medicine (ISHM): in Galveston 2000, Istanbul 2002, Barry 2004, Budapest 2006,
Mexico 2008, Cairo 2010, Padua 2012, Tbilisi 2014, Lisbon 2018 (3), and other
conferences, and maintain personal contacts with our colleagues working at foreign
Universities.
We visited the Wellcome Institute (now – the Centre) for the History of Medicine UCL
(UK) several times, and we are glad to welcome our colleagues from the Wellcome:
Andrew Wear, Vivian Nutton, Tilli Tansey, in Moscow.
Recently, for example, (in April 2019) Professor Vivian Nutton, a famous specialist in
the field of the History of Ancient Medicine, has been invited to our University as a
visiting Professor. It was his third visit to our Department. The first

took place in 1996 when Professor Nutton delivered lectures on Ancient Medicine for
the second-year medical students of our University for two weeks.
Figure 9. Professor Vivian Nutton delivering a lecture

‘Andreas Vesalius and his ‘Fabrica’
at the Peoples’ Friendship University of Russia. Moscow, the 22nd of May 2019. Author’s photo.
During his second visit last year, Professor Nutton – the top scholar in the field of the
studies on Galen – presented lectures about this distinguished ancient anatomist and
physician.
During this visit Professor Nutton took part in two seminars during which international
students presented their papers on “Medicine in Ancient India”, “History of Narcosis”,
“Nikolay Pirogov, the founder of Topographical Anatomy”, “History of Nursing”,
following by a remarkable lecture given by Vivian Nutton on the fundamental treatise
“De Humani corporis Fabrica” (1543) by Andreas Vesalius, the founder of Modern
Anatomy. After the lecture, the students asked Professor Nutton many questions and
talked with him at length on different topics of medical history.
We have also been invited to foreign and Russian Universities for lecturing on the
Russian and the World Medical History (Kazan, Mexico, Minsk, Ufa, etc.), and to
deliver lectures at our National TV (Channel ‘Culture’, Program ‘Academia’ and
others).

Figure 10- Professor Vivian Nutton (in the centre) among the students
of Peoples’ Friendship University of Russia. Moscow, the 22nd of May 2019.
Author’s photo.
The academic discipline ‘History of Medicine’ is a considerable part of medical

education in our country. It has both a scientific and ethical approach. The systematic
study of Medical History (LLL) is essential for broadening of the historical and cultural
outlook of both medical students, and medical teachers and practitioners, for
extending their ethical and professional horizons.
References
1. Сорокина Т.С. История медицины: в 2 т. Учебник. 13-е изд. переработ. идоп. Москва:
Издательский центр "Академия". Т. 1. 2018: 288 с. [Sorokina T.S. History of Medicine.
In 2 vol. Manual. 13th ed., re-casted. Moscow: Publishing House ‘Academia’. Vol. 1. 2018:
288 p.] (in Russian).
2. Сорокина Т.С. История медицины: в 2 т. Учебник. 13-е изд. переработ. и доп. Москва.
Издательский центр "Академия". Т. 2. 2018: 352 с. [Sorokina T.S. History of Medicine.
In 2 vol. Manual. 13th ed., re-casted. Moscow: Publishing House ‘Academia’. Vol. 2. 2018:
352 p.] (in Russian).
3. Sorokina Tatiana S. Teaching and Learning of Medical History at Peoples’ Friendship
University of Russia. 46th Congress of ISHM Abstract book. Lisbon, 3–7 September 2018.
Lisbon, 2018. 58.

HISTORY OF MEDICINE AND BIOLOGICAL ANTHROPOLOGY

INTERCONNECTED IN A POSTGRADUATE PROGRAMME: THE FIRST
YEAR OF OPERATION
Niki Papavramidou1, Rania Kalogeridou2, Christina Papageorgopoulou3
Abstract
This paper presents the elaboration of a new Interuniversity Postgraduate Programme,

leading to a Master’s degree that started in Greece in September 2017. The School of
Medicine of the Aristotle University of Thessaloniki and the School of History and Ethnology of
the Democritus University of Thrace organized the programme, the first Postgraduate
Programme in Greece involving History of Medicine and, at the same time, the first also
involving Biological Anthropology. We present the scope of the Programme, along with the
courses taught, the members of the faculty involved, and the methodology used. The first
year proved that there is great interest in our field, despite the deficient financial status of
the country. Students from diverse backgrounds (medical school graduates, graduates from
Humanities’ background, from Social Anthropology background and others) were interested
and are currently enrolled in this Programme, which ranks among the top 5 of the
Postgraduate programmes of the Medical School, in terms of enrollments. Faculty members
include professors not only from the two cooperating universities: a currently ongoing
attempt to establish a collaboration with almost all Greek professors teaching the History of
Medicine and Biological Anthropology, no matter the university of origin. We report various
difficulties that we still face but the enthusiasm of the students and Professors participating
empowers us to go ahead and improve the quality of the education provided.
Keywords
postgraduate programme; medical education; medical humanities; biological anthropology
Résumé
Cet article rapporte l’élaboration d’un nouveau programme de premier cycle

interuniversitaire, commencé en Septembre 2017 en Grèce, et qui doit mener à un Master. Le
1 Corresponding author: npapavramidou@auth.gr History of Medicine, School of Medicine, Aristotle University

of Thessaloniki.
2 History of Medicine, School of Medicine, Aristotle University of Thessaloniki.
3 Laboratory of Anthropology, School of History and Ethnology, Democritus University of Thrace
programme est organisé par la Faculté de Médecine de l’Université Aristote de Salonique, et la Faculté
d’Histoire et Ethnologie de l’Université Démocrite de Thrace.

C’est le premier programme de premier cycle en Grèce dédié à l’Histoire de la Médecine et

aussi le premier qui implique également l’Anthropologie biologique. Dans cet article les
objectifs du programme sont présentés, ainsi que les cours, les membres des facultés
participantes et la méthodologie suivie. La première année d’expérience nous a prouvé le
grand intérêt de ce champ d’étude, même dans cette période financière difficile pour le pays.
Plusieurs étudiants de diverses origines (diplômés en médecine, Humanités, Anthropologie
Sociale, etc.) étaient intéressés et se sont depuis lors inscrits à ce programme, qui se trouve
déjà dans le top 5 du classement des inscriptions aux parcours de premier cycle de notre
Faculté de Médecine. Les membres enseignants ne sont pas seulement des professeurs des
deux facultés organisatrices, mais tachent également d’inclure pratiquement tous les
professeurs d’Histoire de la Médecine ou d’Anthropologie Biologique de la Grèce entière,
quelle que soit leur université. Plusieurs difficultés sont apparues, mais l’enthousiasme des
étudiants et professeurs concernés nous encouragent à continuer, en améliorant la qualité de
l’enseignement.
Mots-clés
Programme post-gradué; enseignement en médecine; humanités médicales; anthropologie

biologique
Introduction: History of Medicine in Medical curricula
Those teaching History of Medicine in Medical Faculties occasionally have to argue on

the importance of our course and why it is necessary to include it in the medical
curriculum. Another issue that we usually face is the lack of interest from the
students, due to the traditional belief among many medical students that history is a
dull and uninteresting subject.
In Greece only one or – rarely – two undergraduate courses are offered in Medical
Schools: two at the Aristotle University of Thessaloniki, one at the University of
Athens, one optional at Democritus University of Thrace, two optional at the
University of Thessaly, one at the University of Ioannina and two at the University of
Crete. Unfortunately, the University of Patras removed History of Medicine from its
medical curriculum. Both History of Medicine and Biological Anthropology were taught
only at the undergraduate level, leading students to specialize abroad. Finally, all this
decrease in interest in the History of Medicine and Biological Anthropology led to
limitations in the number of university professors and PhD theses and research.
To renew the interest in the History of Medicine and Biological Anthropology in Greece
and to prove that they are fascinating subjects providing vast research opportunities,
we founded the postgraduate programme “History of Medicine and Biological
Anthropology: Health, Disease and Natural Selection”.

The organization scheme
The programme is an Interuniversity Postgraduate result of the official collaboration

between the School of Medicine of the Aristotle University of Thessaloniki and the
School of History and Ethnology of the Democritus University of Thrace. It is managed
by a joint Administrative Board of nine members, among which four are appointed by
the General Assembly of the School of Medicine, three by the General Assembly of the
School of History and Ethnology, and two are elected representatives of the
postgraduate students.
Scope
Among the official aims of the programme are as follows:

-to study the evolution of medicine and its integration into a broader social and
cultural frame,
-to reveal the factors determining health and disease in a historical frame,
-to elaborate on aspects of Biological Anthropology connected with the reformulation
of the history of geography and the evolution of diseases through the prism of human
evolution,
-to analyze the effect of diseases on human development, the interaction between
diseases and socio-cultural practices and the adaptability of populations in new
environments through the study of human remains of archaeological origin,
-to compare disease prevalence between older and modern populations.
The programme offers two options for specialization: History of Medicine or Biological
Anthropology.
Prospective students, admissions and fees
The programme is open to anyone interested in its curriculum, holding a university

degree but it mainly refers to graduates from the departments of Medicine, Dentistry,
History, Biology, History & Ethnology, History & Archaeology, Classics, Anthropology
and others. The positions offered are up to 40, and the admissions procedure is
divided into three phases:
1. Preliminary phase: prospective students are required to submit documents such as
their university degree, CV and a short essay (up to two pages) explaining why they
are interested in the programme.
2. The appointed admissions committee evaluates the submitted documents using a
point system and specific criteria such as the grade of the university degree, the
relativity of the university degree with the Postgraduate Programme, any previous
scientific activity, any relevant working experience, other relevant degrees, and
foreign language degrees.

3. Interview: the admissions committee interviews all prospective students to

understand their motives, their commitment to primary research, and their ability to
fulfill the scopes of the programme.
The tuition fee is set at 2,400 euros for the two years of study. Up to 30% of the
accepted students may seek exemption from fees, based on their financial situation.
Curriculum
The curriculum of the programme spreads into four semesters. During the first two
semesters, we set two courses on the History of Medicine and two courses on
Biological Anthropology for all students because we wanted to create for them a basic
common educational background, bearing in mind that they have or may have quite
different prior educational background.
During the first semester, all students take “Methodology in the History of Medicine –
Medical Historiography”, “Introduction to Ancient Medicine”, “Biological Anthropology:
Methodology”, and “Anatomy – Osteology”. During the second semester, all students
take “Historical Nosology and Epidemiology”, “Pain management in history”,
“Paleopathology: techniques and application”, and “Quantitative and qualitative
methods of research in social sciences”.
Before the beginning of the third semester, students are required to choose one of
the two specializations offered. The students who choose to specialize in the History
of Medicine take four courses on the History of Medicine, while those specializing in
Biological Anthropology take four courses in that area. Thus, History of Medicine
offers “Textual study of Greek Medicine from Antiquity until Byzantium”, “Modern
History of Medicine with an emphasis on Greece after the 18th century”, “Issues on the
History of Medicine”, and “History of Public Health”. On the other hand, biological
anthropology offers “Paleogenetics”, “Taphonomy and burial archaeology”, “Human
evolution”, and “Issues on paleodiet, paleopathology and paleodemography”. Each
course consists of 13 two-hour lectures. Finally, when the third semester ends,
students are required to decide on the subject of their MS thesis, under the guidance
of the staff of the programme, and to submit it by the end of the fourth semester.
Staff
According to Greek law, lecturers of postgraduate programmes must be either faculty

members from Greek or foreign universities or PhD holders with vast experience in
teaching specific issues. During the first two years of the elaboration of our
Postgraduate programme, 44 lecturers participated, with background studies on
History of Medicine, Biological Anthropology, Archaeology, History, Biology, Ob/Gyn,
Public Health, Demography, Forensic Anthropology, Forensic Medicine, Social
Anthropology Anatomy, Paleography, Radiology, Classics and others. Among those
lecturers, five were from foreign universities and institutes.
Our experience so far
During the first year of elaboration, 14 students were enrolled with background
studies on History & Ethnology, Medicine, Nursing, History & Archaeology, Biology,
German language & philology, Geology, and Social Sciences: 6 out of those 14
students chose to specialize in the History of Medicine and 8 in Biological
Anthropology. The great diversity in the students’ background was challenging for
everyone. Students with a background in the humanities found it hard to cope with
anatomy courses while those with a biological background found it hard to cope with
historiography and methodology of History of Medicine. Nevertheless, it is important
to note that their difficulty in specific courses did not influence their choice of
speciality. It is also noteworthy that the staff members with biological background
found it hard to adjust their teaching methods in training students with theoretical
background, taking for granted that those students could not handle more
complicated or sophisticated information. However, the motivation of the students
proved staff members to be wrong!
The programme is very demanding, time-consuming, with many hours of actual
teaching, not to mention the papers that the students have to submit. Students admit
having to put great effort to get along with the requirements of the curriculum, but
they felt good and proud when every course came to an end; this was mirrored in the
evaluation process of the programme where all students commented positively on the
quality of the curriculum and lecturers.
In all, we have concluded that the effort made to organize this postgraduate
programme was worthwhile since Greek students finally have the opportunity to study
in-depth subjects that were only offered abroad, often having to pay substantially
higher fees. Furthermore, we may have PhD candidates with higher expertise and
with ongoing research aims, fulfilling the purpose of the medical humanities after
specifically oriented studies.

46th Hist Med Lisboa 2018 XXVI SPECIAL ISSUE E-Supplement Final

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46th Hist Med Lisboa 2018 XXVI SPECIAL ISSUE E-Supplement Final

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ISSN 1373-4857

Journal of the International Society for the History of Medicine

Vol. XXVI, JUNE 2020, e-supplement

OPENING CEREMONY SPEECH – p.6

THE 46TH ISHM CONGRESS - LISBON: ISLANDS OF VIVID MEMORIES – p.8

A MEDICINAL DIALOGUE BETWEEN EAST AND WEST INDIES: THE

THE GOA STONE: MYTHS, EMPIRICISM AND INSIGHTS ON CHEMISTRY – p.36

ASPARAGUS THE DIURETIC, A RENAL AMBASSADOR FROM GREECE TO

ORIGINS AND EVOLUTION OF SURGICAL INSTRUMENTS IN THE COLLECTION

JEWISH PHYSICIANS AND THE PORTUGUESE MEDICAL DIASPORA – p.91

CHRISTUS ANATOMICUS, FROM VESALIUS DRAWINGS TO WAX MODELS –

THE APPEARANCE OF BUBONIC PLAGUE IN OPORTO, 1899 – p.121

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PORTUGUESE AND SPANISH CONTRIBUTIONS TO THE DISCOVERY OF RENAL

“HE WHO WANTS TO TRAVEL SHOULD …” – TRAVEL REGIMENS IN MEDIEVAL

POISON, PROOF, AND FORENSIC MEDICINE IN NINETEENTH-CENTURY

REPRESENTATION OF SPINAL TUBERCULOSIS IN A PTOLEMAIC DWARF

SOFIA IONESCU-OGREZEANU (1920-2008), FIRST FEMALE NEUROSURGEON

ANTÓNIO DE SOUSA PEREIRA (1904-1986) THE NOBEL PRIZE NOMINATION

WALTER B CANNON: A HISTORY OF COMMITMENT – p.218

THE ROLE OF RELIGIOUS ORGANIZATIONS IN THE PROVISION OF HEALTH

PORTUGUESE TROPICAL MEDICINE AND INTERNATIONAL NETWORKS: A

DR CUNHA BELLEM AND THE OPERATIONAL MILITARY MEDICINE REFORM IN

FRAGMENTS OF THE CONSTRUCTION OF THE MEDICAL ASSISTANCE MEMORY

TEACHING AND LEARNING OF THE HISTORY OF MEDICINE AT PEOPLES’

HISTORY OF MEDICINE AND BIOLOGICAL ANTHROPOLOGY

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OPEN CEREMONY SPEECH

- Your Excellency the President of the Portuguese Republic

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Distinguished Guests, thank you for your kind presence.

This Congress is an affirmation of a moral and cultural obligation: to preserve the

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THE 46TH ISHM CONGRESS - LISBON: ISLANDS OF VIVID

MARIA DO SAMEIRO BARROSO

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meeting, which I hope you will appreciate with interest.

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A MEDICINAL DIALOGUE BETWEEN EAST AND WEST INDIES: THE

Carlos A. Viesca T., Mariablanca Ramos de Viesca1

1 Corresponding author: Carlos Viesca Treviño. Contact: cviesca@frontstage.org;

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Cristóbal Acosta (Cristóvão da Costa) was also a Portuguese born in San

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In the early thirties, he returned to Seville, working with a renowned physician,

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Michoacán root (Ipomea purga)

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The primary purgative in European pharmacies was rhubarb. The introduction of

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China root (Smilax China L., Smilax Pseudochina L.)

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Opium and bangue

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