When writing about the nature of therapeutics, Galen argued that scien- tiﬁc knowledge of the causes of disease was essential for successful treatment. For prognosis, Galen relied on traditional tools, such as the examination of the pulse and the urine, and a rather rigid version of the Hippocratic doctrine of the ‘‘critical days.’’ Like Hippocrates, Galen was an excellent clinician and a brilliant diagnostician who believed that the physician must explain disease in terms of natural causes. ‘‘Do not inquire from the gods how to discover by divination,’’ he warned his readers, ‘‘but take your instruction from some anatomy teacher.’’ All diseases might have a natural cause, but Galen was willing to accept medical advice offered by Asclepius, the god of healing. When Galen was suffering from a painful abscess, Asclepius appeared in a dream and told him to open an artery in his right hand. A complete and speedy recovery followed this treatment.
Humoralism, as embodied in Galenism, apparently was capable of explaining the genesis and essence of all diseases and rationalizing all clinical ﬁndings. According to Galen, the humors were formed when nutriments were altered by the innate heat that was produced by the slow combustion taking place in the heart. Foods of a warmer nature tend to produce bile, while those of a colder nature produced an excess of phlegm. An excess of bile caused ‘‘warm diseases’’ and an excess of phlegm resulted in ‘‘cold diseases.’’ Several Galenic texts dealt with food, the humors, and the relationship between food and the humors. These text included On the Humors, On Black Bile, On Barley Soup, and On the Power of Foods.
Averting disease by rigid adherence to the principles of Galenic hygiene required continuous guidance by a competent physician, as set forth in Galen’s On Hygiene. In contrast to Celsus, who believed that the temperate Roman had little need for medical advice, Galen argued that a highly individualized regimen was essential ‘‘for Greeks and those who, though born barbarians by nature, yet emulate the culture of the Greeks.’’ The individualized health-promoting regimen prescribed by the physician required constant attention to the ‘‘six non-naturals,’’ a confusing Galenic term for factors that, unlike geography, weather, sea- son, and age, could be brought under the patient’s control. Today’s health and ﬁtness experts would refer to the non-naturals as lifestyle choices, that is, food and drink, sleeping and waking, exercise and rest, ‘‘regularity,’’ and ‘‘mental attitude.’’ Eventually, in the hands of less gifted practitioners, Galen’s program for a sophisticated individualized approach to the prevention and treatment of disease degenerated into a system of bleeding, purging, cupping, blistering, starvation diets, and large doses of complex mixtures of drugs.
Despite his reverence for Hippocrates, when confronted by disease, Galen was not willing to stand by passively, doing no harm, while wait- ing for nature to heal the patient. A major work called Method of Heal- ing and many other texts make this preference for action abundantly clear. Galen regarded bleeding as the proper treatment for almost every disorder, including hemorrhage and fatigue. Great skill was needed to determine how much blood should be taken, which vein should be incised, and the proper time for the operation. For certain conditions, Galen recommended two brisk bleedings per day. The ﬁrst bleeding should be stopped just before the patient fainted. But the physician should not be afraid to provoke unconsciousness with the second bleed- ing, because patients who survived the ﬁrst operation would not be harmed by the second. Galen was so enthusiastic about the beneﬁts of venesection that he wrote three books about it.
As proof that nature prevented disease by ridding the body of excess blood, Galen argued that many diseases that attacked men did not affect women, because their superﬂuous blood was eliminated by menstruation or lactation. Women with normal menstrual cycles supposedly enjoyed immunity to gout, arthritis, epilepsy, melancholy, apoplexy, and so forth. Men who frequently eliminated excess blood through hemorrhoids or nosebleeds could also expect to enjoy freedom from such diseases.
In terms of humoral doctrine, bleeding accomplished the ther-apeutic goals shared by patient and physician by apparently ridding the body of putrid, corrupt, and harmful materials. Some scientists suggest that bleeding might actually have beneﬁted some patients by suppressing the clinical manifestations of certain diseases, such as malaria, by lowering the availability of iron in the blood. Generally speaking, anemia is not a desirable condition, but the availability of iron in the blood may determine the ability of certain pathogens to grow and multiply. Bleeding would also affect the body’s response to disease by lowering the viscosity of the blood and increasing its ability to ﬂow through the capillary bed. Bleeding to the point of fainting would force the patient along the path to rest and tranquility. Given the importance of good nursing and a supportive environment, it should also be noted that when a feverish, delirious, and difﬁcult patient is ‘‘depleted’’ to the point of fainting, the caretakers might also enjoy a period of rest and recuperation.
Famous for his knowledge of drugs, Galen investigated the proper- ties of simple medicines, complex concoctions, and exotics from distant places, such as ‘‘Balm of Gilead’’ from Palestine, copper from Cyprus, and Lemnian Earths from the island of Lemnos. Lemnian Earths, or ‘‘Seals,’’ were packets of specially prepared clay (much like Kaopectate) with the seal of the goddess stamped on them. Galen recommended these packets of clay for use against poisons, bites of serpents, and putrid ulcers. Various kinds of ‘‘earths’’ have been used as medicines for hundreds of years. Obviously, adding the image of the goddess to packets of Kaopectate would do no harm, but the consumption of some forms of clay and similar impure materials could be dangerous.
Complex drug mixtures were later called Galenicals and the sign of ‘‘Galen’s Head’’ above the door identiﬁed apothecary shops. Some Galenicals were pleasant enough to be used as beauty aids by wealthy Roman matrons. Unguentum refrigerans, an emulsion of water in almond oil, with white wax and rose perfume, is similar to modern cold cream. The Prince of Physicians also prescribed some rather nauseating remedies, such as bile from bulls, spiders’ webs, skin shed by snakes, and a digestive oil compounded from cooked foxes and hyenas. As explained in one of Galen’s minor works, physicians were often involved in detecting malingerers and may have used noxious remedies to test slaves who did not wish to work, or citizens and soldiers trying to escape political and military duties.
Galen also developed elaborate speculative concepts about the way in which medical preparations worked and provided rationalizations for the positive medicinal value of amulets and excrements. Anecdotes about the accidental discovery of the medical virtues of various noxious agents were also put to good use. For example, in On Simples, Galen provided a lively account of the way in which a miserable old man suffering from a horrible skin disease was cured after drinking a jug of wine in which a poisonous snake had drowned.
Throughout the Roman Empire, the rich and powerful lived in fear of encountering poison at the banquet table, while poisonous plants and venomous creatures were constant threats to farmers, travelers, and sol- diers. Galen was interested in the bites of apes, dogs, snakes, various wild animals, and (perhaps remembering his mother) human beings, all of which were presumed to be poisonous. Given the universal fear of poisons and venoms, the invention of bizarre antidotes was to be expected. Recipes for antidotes included herbs, minerals, and animal parts or products, such as dried locusts and viper’s ﬂesh. Roman recipes for theriacs, or antidotes, can be traced back to Mithridates (132–63 B.C.E.), King of Pontus in Asia Minor.
Famous for his knowledge of medicinal herbs, poisons, and anti- dotes, Mithridates demonstrated the value of his recipes by means of human experimentation. When exchanging recipes for antidotes with other researchers, Mithridates is said to have sent along a condemned prisoner to serve as a guinea pig. By taking a daily dose of his best antidotes, Mithridates supposedly became immune to all poisons. In 66 B.C.E., trapped in his fortress by the Roman army, Mithridates poisoned all his wives, concubines, and daughters, but no poison could kill Mithridates. According to Galen, Nero’s physician Andromachus used Mithradates’ poison lore to prepare the ultimate antidote, a formidable concoction containing some 64 ingredients, including opium and viper’s ﬂesh. Andromachus claimed that his theriac was a health tonic as well as a universal antidote.
Galen’s skill and integrity were so highly regarded by his patrons that three Roman emperors entrusted the preparation of their theriac to him. Because others faced the danger of encountering inferior or counterfeit products, Galen suggested that purchasers test the strength of theriacs by taking a drug that induced mild purging. If the alleged theriac prevented the normal effect of the drug, it might be genuine. Authentic theriac must be made with ingredients of the highest quality. Although the pounding, mixing, heating, and stirring of the ﬁnal prep- aration could be accomplished in about 40 days, some authorities thought that a maturation period of 5 to 12 years was essential. During the Middle Ages, theriac became an important trade item for cities such as Venice, Milan, Genoa, Padua, Bologna, and Cairo. In some cities, the production of theriac became a major public event. Theriac, viper’s ﬂesh and all, was still found in French and German pharmacopoeias at the end of the nineteenth century. In England, a degenerate form of the universal antidote became the candy known as treacle.
Highly respected as a physician and philosopher, Galen was appar-ently as skillful in the art of medicine as in the science. Aware of the bad repute brought to the profession by displays of ambition, contentious- ness, and greed, Galen emphasized skill, dignity, and a disdainful attitude towards money. He urged physicians to cultivate the art of eliciting clues about the patient’s condition even before entering the sickroom. One way was to casually question the messenger who called for the physician, as well as the patient’s friends and family. A secret examination of the contents of all basins removed from the sickroom on their way to the dung heap and the medicines already in use could provide further clues. The pulse, casually examined while observing the patient, was another valuable source of information. To escape blame for failures and to win universal admiration, the physician must cultivate the art of making his diagnoses and prognoses seem like acts of divination. A clever application of this tactic was to predict the worst possible outcome while reluctantly agreeing to accept the case. If the patient died, the physician’s prediction was vindicated; if the patient recovered, the physician appeared to be a miracle worker.
In many ways, Galen was truly a miracle worker; his contempo-raries acknowledged the remarkable quantity and quality of his work. Even those who had engaged in bitter disputes with Galen respected his intelligence, productivity, and the passion with which he defended his doctrines. Yet, despite his brilliance in disputations, public lectures, and demonstrations, Galen seems to have had no students or disciples. Perhaps the personality traits that captivated Roman emperors and high government ofﬁcials repelled colleagues and potential students. While some of his voluminous writings were lost in the centuries after his death and many were neglected, excerpts of his writings, commentaries, and translations of his texts were to form a major component of the medical curriculum and learned literature of late antiquity and the Middle Ages.
A simpliﬁed, transmuted, and partially digested version of his work known as Galenism dominated medical learning throughout the Middle Ages of Europe and the Golden Age of Islam. Galen’s authority was not seriously challenged until the introduction of printing and a revival of interest in the true classics of antiquity made the genuine works of Galen and Hippocrates widely available. When Galen’s anatomical and physiological doctrines were ﬁnally subjected to serious challenges in the sixteenth and seventeenth centuries, the physicians now remem- bered as reformers and revolutionaries began their work as Galenists. Perhaps their attacks on Galenism should be regarded as the triumph of the true spirit of Galen, physician, philosopher, and scientist.
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