GALEN ON THERAPEUTICS AND THE CAUSES OF DISEASE

12 May

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.

SUGGESTED READINGS

Brain,  P.  (1986).  Galen  on Bloodletting.  New  York:  Cambridge   University Press.

Cantor, D., ed. (2001). Reinventing Hippocrates.  Burlington,  VT: Ashgate. Celsus  (1960–1961).  De  Medicina.   3  Vols.  (Trans.   by  W.  G.   Spencer).

Cambridge,  MA: Harvard University  Press.

Dioscorides  (1959). The Greek Herbal  of Dioscorides (Illus. by a Byzantine in 512  A.D.,  Englished  by  John  Goodyear,  1655  A.D.).  Edited  by  R.  T. Gunther. New York:  Hafner.

Edelstein,  E. J., and  Edelstein,  L. (1998). Asclepius: Collection and Interpre- tation of the Testimonies. 2 Vols. New Introduction by G. B. Ferngren. Baltimore,  MD:  Johns  Hopkins  University  Press.

Flemming,  R.  (2001). Medicine and the Making  of Roman  Women: Gender, Nature,  and Authority from Celsus to Galen. New York:  Oxford  Univer- sity Press.

French,   R.  (2000).  Ancients  and  Moderns  in  the  Medical  Sciences:  From Hippocrates  to Harvey. Burlington,  VT: Ashgate.

Galen (1997). Selected Works. Trans., introduction, and notes by P. N. Singer.

New York:  Oxford  University  Press.

Galen  (1999).  On  My  Own  Opinions.  Edited,   translation,  commentary  by Vivian Nutton. Berlin: Akademie  Verlag.

Garc´ıa-Ballester, L. (2002). Galen and Galenism: Theory and Medical Practice from Antiquity to the European Renaissance. Burlington,  VT: Ashgate.

Grant, M. (2000). Galen on Food and Diet. London:  Routledge.

Grmek,  M. D. (1991). Diseases in the Ancient Greek World. Baltimore,  MD: Johns  Hopkins  University  Press.

Hippocrates (1957–1959). Hippocrates.  4 Vols. (Trans.  by W. H. S. Jones and E.  T.  Withington). Loeb  Classical  Library.  Cambridge,  MA:  Harvard University  Press.

Jouanna, J. (2001). Hippocrates.  Baltimore,  MD:  Johns  Hopkins  University Press.

King,  H.  (1998). Hippocrates’  Woman:  Reading  the Female Body in Ancient Greece. New York:  Routledge.

Kudlien,  F., and Durling,  R. J., eds. (1990). Galen’s Method of Healing. Pro- ceedings of the 2nd International  Galen Symposium. New York: E.J. Brill.

Laskaris,  J. (2002). The Art is Long: On the Sacred Disease and the Scientific Tradition.  Leiden: Brill.

Lloyd, G. E. R. (1987). Revolutions of Wisdom. Studies in the Claims and Prac- tice  of Ancient Greek  Science. Berkeley,  CA:  University  of  California Press.

Longrigg,  J. (1998). Greek Medicine: From the Heroic to the Hellenistic Age: A Source Book. New York:  Routledge.

Nutton, V., ed.  (1981). Galen:  Problems  and  Prospects.  London:   Wellcome Institute  for the History  of Medicine.

Pinault,  J. R. (1992). Hippocratic  Lives and Legends. Leiden: E.J. Brill. Riddle, J. M. (1985). Dioscorides on Pharmacy and Medicine. Austin, TX: Uni-versity Texas Press.

Rocca,  J. (2003). Galen on the Brain: Anatomical Knowledge and Physiological Speculation in the Second Century A.D. Leiden: Brill.

Sallares, R. (2002). Malaria  and Rome: A History  of Malaria  in Ancient Italy.

Oxford: Oxford  University  Press.

von Staden,  H. (1989). Herophilus:  The Art of Medicine in Early  Alexandria.

New York:  Cambridge  University  Press.

Temkin, O. (1971). The Falling Sickness: A History of Epilepsy from the Greeks to the Beginnings of Modern Neurology. Baltimore,  MD: Johns  Hopkins University  Press.

Temkin, O. (1973). Galenism: Rise and Decline of a Medical Philosophy. Ithaca, NY: Cornell University  Press.

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