CLAUDIUS GALEN: FROM A 20TH CENTURY GENITOURINARY PERSPECTIVE

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Vol. 161, 12-19, January 1999 Printed i n U.S.A.

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Historical Article CLAUDIUS GALEN: FROM A 20TH CENTURY GENITOURINARY PERSPECTIVE DAVID A. BLOOM,* MARK T. MILEN

AND

JOSEPH C. HEININGER

From the Diuision of Urology, University of Michigan Medical Center and the Department of English, University of Michigan, Ann Arbor. Michigan

ABSTRACT

Purpose: We review the life and contributions of Claudius Galen from a 20th century perspective and examine his genitourinary observations. Materials and Methods: All obtainable English translations of Galen's works were explored in addition to relevant commentaries. Results: Galen's remarkable observations and novel concepts expanded medical knowledge in general and contributed to fundamental genitourinary principles in particular. Galen was one of the first to describe correctly the function of kidneys and explain micturition. Among his many neologisms he coined the term ureter, and he was probably the first to recognize the value of a competent ureterovesical valve. Galen advocated catheterization for urinary obstruction. He was a teacher, practitioner and philosopher, and wrote voluminously. Conclusions: Galen's influence on medical theory, terminology and practice remained unquestioned in Europe and the Middle East throughout the Middle Ages and Renaissance. KEY WORDS: physiology, kidney, urogenital system

Since, therefore, eating and drinking are essential for animals there follows the formation of excrements; and nature not only has provided organs for their excretion but has endowed them with powers whereby some attract the excrements, some propel them, and some eliminate them. And it is necessary that these should neither be obstructed in their functions to keep t h e body always clean and free from impurities.] Claudius Galen

THE LIFE OF GALEN

Claudius Galen (in Greek, Clarissimus Galenus) was born circa 130 A.D. near Pergamum, an important town 50 miles north of present day Izmir, Turkey. In Galen's time Pergamum was a rival to Alexandria in learning, and it was t h e center of the parchment industry2 and the site of a great temple of healing. Most details of Galen's life come from autobiographical writings which it might be claimed constitute the first known scientific autobiography.3 Galen was t h e only son of Nikon, a scholarly and wealthy architect who took a deep interest in the education of his son.4 Galen described his parents in his treatise On Passions of the Soul. "It was my good fortune to have a father who was perfectly calm, just, serviceable and devoted; my mother on the contrary was so

irascible that she sometimes bit her maids, she was always babbling and quarreling with my father, a s did Xanthippe with Socrates."' Galen's name was derived from the Greek word galenos, meaning calm or serene. Although he admired his father's self-control, the maternal irascibility was often manifested i n Galen's demeanor.5 Under his father's strict supervision Galen was schooled at the family farm until he was 14 years old. Nikon intended a philosophical career for his son and during the next 3 years Galen attended formal lectures locally. Galen recalled his early education i n his treatise The Order of M y Own Books, which he wrote when he was between 50 and 60 years old (translated by P. N. Singer): My father was himself competent in the fields of mathematics, arithmetic, and grammar, and reared me i n these as well as t h e other subjects necessary to t h e training of the young. In my fifteenth year he steered me towards dialectic, with a view to my concentrating entirely on philosophy; i n my seventeenth year he w a s persuaded by clear dreams to make me study medicine at the same time as philosophy. And yet even with this great good fortune, and the fact t h a t I was able to learn whatever I was taught thoroughly and more quickly t h a n anyone else, I would still have gained very little understanding if I had not devoted my whole life t o the cultivation of medical and philosophical studies. And so it is small wonder that the great majority of people who study both medicine and philosophy do no good i n either: they either lack the right natural endowments or the necessary training - or else they abandon their studies in favor of political activity."

Accepted for publication August 28, 1998. Supported b the Babcock Endowment of the Section of Urolo Department ozsurgery, University of Michigan, Ann Arbor, Micg: gan. * Requests for reprints: Division of Urology. University of Michian Medical Center, 1500 East Medical Center Dr., 2916 Taubman enter, Ann Arbor, Michigan 48109-0330.

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FIG. 1. Medical Temple of Pergamum (Asklepeion) in Galen’s time. 1, east side entrance and forecourt reached by 3,000 foot covered walkway from city. 2, temple, after pattern of Pantheon. 3 , circular building with 6 apses for incubation.4 to 6 , covered walk (peristyle 1,137 feet long, 27 feet wide). 7, theater. 8, temple dedicated to Emperor Hadrian. 9, alter to Artemis (women’s health). lOond 11,courtyard. sacred spring and temple. 12, underground passage (9 feet high, 260 feet long) connecting incubation room with center of courtyard. Reprinted with permission

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Thus, Galen’s view of the physician as a lifelong scholar and philosopher had early roots. Galen’s medical training began at the famed local temple of Asklepios (the omnipotent Greek deity of healing) in Pergamum. This magnificent healing center was a well-known pilgrimage destination throughout Asia Minor (fig. 1). Practitioners of medical arts in the second century were equipped with the tools of observation, logic and tradition but lacked a unifying scientific corpus. Efforts to find a model that would encompass health and illness resulted in a number of paradigms or sects with distinctly different formulations of medical theory. Galen’s father urged him to refrain from fixed association with any specific sect, and instead t o take the best theories each had to offer (Appendix 1).When Galen was 20 his father died. Galen traveled during the next 10 years to study at the great learning centers of Smyma, Corinth and Alexandria where instruction included ape and pig dissection.5 His studies were greatly influenced by Hippocrates, Rufus of Ephesus, and the dogmas of Plato, Aristophanes and Socrates. About 158 Galen returned to Pergamum to practice medicine in time for the summer gladiator shows.“ As physician to the gladiators for 3 consecutive years he learned practical anatomy and treatment of serious trauma. In 162 he moved to Rome and befriended members of the royal family, such as Barbarus, a n uncle to Emperor Lucius, Sergius, a wellknown financier and Boethus, a n esteemed Consu1.l Al-

though a newcomer to the medical community, Galen’s successful treatment of a well-known Pergaman expatriate, Eudema, brought respect and recognition. Within 4 years 36-year-old Galen became one of the best known physicians in Rome. He wrote extensively in this period on Hippocrates and Plato as well as about pulse, bones and anatomy, and produced his first book On the Usefulness of Parts. Galen’s medical practice relied substantially on the Greek style of humoral pathology with the notion of 4 bodily humors of blood (the sanguine humor), phlegm (the phlegmatic character), black bile (resulting in melancholy) and yellow bile (generating choleric humor). According to this scheme any imbalance of the humors led to disease. Galen attributed life to 3 spirits, including the natural spirit formed in the liver, animal spirit from the brain and vital spirit from the heart.7 Galen remained free of any firm sect association and wrote at least 2 treatises on sects (Appendix l ) . a Galen’s view of anatomy was influenced not only by his dissection and trauma experience but also by the Stoic philosophy that life was determined by fate. He wrote: “Nature makes nothing in vain. . . In my view, there is nothing in the body useless or inactive, but all parts are arranged to perform their ofices together and have been endowed by the Creator with specific powers.”” It was no accident that one of his most significant works was entitled On the Usefulness of Parts. The empirical sense that flavored Galen’s anatomical concepts was largely derived from live dissections of birds,

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snakes, mice, pigs, horses, elephants, Barbary apes and rhesus monkeys.9 Despite the prohibition by Rome, Galen probably performed human dissections during visits to Alexandria.’ Circa 165 Galen concluded his first tenure in Rome, serendipitously just a few months before a devastating epidemic, and returned to Pergamum. Two years later he was summoned to accompany the Emperor Marcus Aurelius on a military campaign. The Emperor said of Galen: “He is not only a physician, but the only honest man around here.”’ After a year Galen was released from army duty and returned to Rome where he remained physician to the Emperor until 180 when Marcus Aurelius died.10 In this second Roman period he wrote extensively, including more works on Hippocrates as well as substances used in the preparation of medical remedies (materia medical, breathing, On the Natural Faculties, On Sperm, the remaining sections of On the Usefulness of Parts, Exercise and To Thrasyboulos, which explored the question of whether healthfulness is a part of medicine or gymnastics.fi Galen served as physician to the son and successor of Marcus Aurelius, Commodus, from 180 until 192.“Galen, independently wealthy, was reputed to have never demanded a fee from patients or students, although he did accept gifts.” Galen’s public lectures were theatrical performances which he sometimes dictated to a scribe. Audiences consisted of the lay public, students, fellow physicians and elite public figures. The recent analysis by Von Staden of the cultural framework of Galen’s anatomical orations and public dissections brings to life the sophistic brilliance that unquestionably helped to establish the roots of Galenism.9 At lectures Galen intimidated audiences by his attitude of superiority. A more enduring and less endearing comment (in the third person) was “Galen cannot be wrong.”12He freely criticized his predecessors and colleagues saying for example that Erasistratus (an esteemed Greek physician) was “foolish” and that other physicians were “absurd.”13 Galen’s verbal assaults engendered numerous enemies. However, Hippomates was generally spared such criticism. During his last 8 years of life Galen continued to write extensively, travel and lecture throughout the Roman provinces. He never married. Galen stated that a “longer healthful life” could be accomplished ”by eating easily digested meats and taking moderate exercise.”’ He achieved great longevity for his era, living to 70 to 80 years old. Galen died circa 200, although exact date and place remain unknown. There is no evidence of any surviving statue, public benefaction or inscription commemorating his life.14

GALEN’S CORPUS

Galen was not only a practicing physician but also a perceptive anatomist and experimental physiologist who asked questions and made novel, independent scientific observations of organ function. His compulsiveness was evident even in dissection, “personally skinning a monkey. . . lest a slave do it carelessly.“” Galen’s pioneering experimental physiology is best documented in his book On the Natural Faculties, which includes the first account of a competent ureterovesical junction and the first experimental ureteral ligation in a living animal (fig. 2).

. . .before the animal urinates, one has to tie a ligature around his penis and then to squeeze the bladder all over; still nothing goes back through the ureters to the kidneys. Here, then, it becomes obvious that not only in a dead animal, but in one which is still living, the ureters are prevented from receiving back the urine from the bladder. These observations having been made, one now loosens the ligature from the animal’s

penis and allows him to urinate, then again ligatures one of the ureters and leaves the other to discharge into the bladder. Allowing, then, some time to elapse, one now demonstrates that the ureter which was ligatured is obviously full and distended on the side next to the kidneys, while the other one - that from which the ligature had been taken - is itself flaccid, but has filled the bladder with urine. Then, again, one must divide the full ureter, and demonstrate how the urine spurts out of it, like blood in the operation of venesection; and after this one cuts through the other also, and both being thus divided, one bandages up the animal externally. Then when enough time seems t o have elapsed, one takes off the bandages; the bladder will now be found empty, and the whole region between the intestines and the peritoneum full of urine, as if the animal were suffering from dropsy.15 This quotation illustrates rational, classical scientific methodology at its best. As a n anatomist Galen correctly identified the maxillary muscles, all muscles of the eyeball and eye lid, frontal muscle, and muscles of the neck, spine, abdominal wall and extremities. He recognized 7 cranial nerves and described the styloid, squamous, mastoid, sphenoid, ethmoid, malar, maxillary and nasal bones, in addition to the nasal cartilages.8 In another perceptive investigation which would today be characterized as experimental physiology Galen cut the spinal cord of an animal and demonstrated that paralysis was not due to peripheral injuries of the limbs but damage of the involved nerves.12 This experiment proved that nerves have no innate power but are merely conductors of the impulses generated by the central nervous system.8 Galen dismissed a popular theory that sleep was caused by blood draining from the brain and death was the ultimate result of the brain becoming completely deprived of blood. He demonstrated that arteries carried blood rather than air, although he mistakenly concluded that blood flowed back and forth within the arteries, and independently in the veins instead of circulating in a closed system. Galen realized that arterial pulsation was the result of power transmitted from the heart and that blood “flowed from the liver to the veins and entered the left ventricle.”s Galen was the first t o record the difference between systole and diastole. However, he was

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mistaken in his belief that tiny pores in the heart allowed blood to pass from the right to left ventricle. According to Galen the diaphragm performed respiration so that the lungs could cool the cardiovascular system.* In his writings Galen rhetorically debated the definition of medicine. “Now, a possible answer to the question, ‘what is medicine? might be: ‘the art of healing the sick and preserving health in the healthy.”’ He questioned the distinction between health care and exercise: “should one then characterize medicine as the art whose aim is health, and gymnastics as the art whose aim is good condition.. .?”“ One of Galen’s books, The Exercise with the Small Ball, describes the virtues of physical exercise by means of an easily accessible game (with a small ball, perhaps a handball). He contrasts this vigorous sport t o the more elaborate games of his era: “The form of exercise we are considering, on the other hand, is the only one which is so democratic that anyone, no matter how small his income, can take part. You need no nets, no weapons, no horses, no hounds -just a single ball, and a small one at that.”” Galen’s studies also encompassed psychology but with an anatomical basis. Hysteria, he thought, was a disease unique to women, resulting from wandering of the uterus throughout the body.’” In explanation Galen supported the Hippocratic idea that the womb was “an independent living being, fleeing from foul smells but moving to seek out more pleasant odors.”1“ In addition to theories about body structure and function, Galen described therapeutic methods emphasizing the proper dosage of medications and the possibility of side effects. In his many works on materia medica, particularly The Mixture and Property of Simple Medicines, Galen described potions containing upwards of dozens of ingredients that became known as ga1eni~als.l~ In On Temperaments he suggested that animal poisons, including snake venom and rabid dog saliva, were not harmful unless they entered the blood stream. He classified jaundice as a symptom rather than disease.2 More than 500 books or works on medicine, philosophy and science have been attributed t o Galen. The important works are O n the Natural Faculties, On Anatomical Procedures, On the Method of Healing, Oti Prognosis, On Pulses for Beginners, On Temperaments and On the Usefulness of Parts. Many of his texts were lost in a fire in Rome in 192 at the Temple of Peace.18 One of Galen’s last books written in his final decade of life was called M y Own Books. Partly autobiographical, this small treatise classified his works into 17 categories (Appendix 2 ) . Galen noted that he did not have personal copies of many of these works, particularly those which he had dictated to students or presented to friends.“ Although Galen was brought up in a mostly polytheistic society, his later works convey a sense of monotheism and are noteworthy especially in his reference to a Creator or Master the individual parts within the embryo itself are first of all the skin, created by the Craftsman of it as a natural covering or garment; then, beneath that, the parts inside the skin that are continuous with the four vessels.””

GALEN[(‘ LIKOI.OGY

Kidneys. Five centuries before Galen, Aristotle offered only a brief and ambiguous description of renal anatomy, asserting that “kidneys acted as anchors, fixing the large veins to the posterior part of the body.”lg Galen viewed organs from a functional perspective, considering them attractive, repulsive, retentive or secretive. He labeled the kidneys attractive organs2 and categorically rejected Aristotle’s conclusion that the kidneys were not crucial for the existence of living organisms.”0 Galen proved that the kidneys generated urinez1 in

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his classic experiment: “the secretion of urine takes place first in the kidneys following which the urine arrives into the bladder by the ureters from whence it is evacuated ( Fig. 2).”p2 This was a controversial postulate in academic circles but not in the real world, as Galen recorded with irony bordering on sarcasm in On the Natural Faculties: That these [kidneys] are organs for secreting [separating out] the urine, was the belief not only of Hippocrates, Diocles, Erasistratus, Paraxagoras, and all other physicians of eminence, but practically every butcher is aware of this, from the fact that he daily observes both the position of the kidneys and the duct (termed the ureter) which runs from each kidney into the bladder, and from this arrangement he infers their characteristic use and faculty. But, even leaving the butchers aside, all people who suffer either from frequent dysuria or from retention of urine call themselves ‘nephritics,’ when they pass sandy matter in their water.15 Through these descriptions Galen credited the kidneys with the ability to attract a large portion of blood in process of urine formation. Later in On the Natural Faculties Galen became impatient with older authorities and ideas, such as the contention by Erasistratus that a number of organs are useless:

For, according to him [Erasistratusl, the spleen was made for no purpose, as also the omentum; similarly, too, the arteries which are inserted into kidneys although these are practically the largest of all those that spring from the great artery [aortal! And t o judge by the Erasistratean argument, there must be countless other useless structures; for if he knows nothing at all about these structures, he has little more anatomical knowledge than a butcher, while if he is acquainted with them and yet does not state their use, he clearly imagmes that they were made for no purpose, like the spleen.’“ In On Anatomical Procedures Galen noted that the right kidney “lies higher in all animals, sometimes touching the large lobe of the liver. At the spine i t is attached to the renal artery and vein.”””This misconception arose from his dissections of rhesus monkeys which, in contrast to humans, indeed have a higher right kidney.”.‘ This Galenic error in human anatomy persisted until the Renaissance and Vesalian era of anatomical study. Another curious belief was stated in The Construction of the Embtyo: “It is on account of the liver that the kidneys and the 2 bladders come into being (that which receives bile growing out from the liver itself, and that which receives urine being attached to the kidneys).?” However, aside from such errors Galen blended common sense with observations that have generally proved accurate. Ureters. Galen not only recognized the role of the ureter as demonstrated in his experiment but may also have coined the word: . . . activities must necessarily correspond each t o one of the special parts, just as each part has its special use - for example, those ducts which extend from the kidneys into the bladder, and which are called ureters; for these are not arteries, since they do not pulsate nor do they consist of two coats; and they are not veins, since they neither contain blood, nor do their coats in any way resemble those of veins; from nerves they differ still more than from the structures mentioned.l5

In On the Natural Faculties Galen made the first extant reference to vesicoureteral reflux: “why nothing regurgitates

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from the bladder into the ureters, I think he [Asclepiades, a renowned Greek physician] will be persuaded by this also of the forethought and art shown by nature in relation to animals.”’s Louver urinary tract. Galen had a sophisticated view of bladder function. To explain voiding Galen stated that peristaltic movements of the bladder would be in vain without the oblique insertion of the ureters and the aid of the abdominal muscles.”’ This is another reference t o the importance of a competent ureterovesical junction. He recognized the dangers of urinary retention: . . . and the urinary bladder; this also may be plainly observed to receive and accumulate fluid until it is so stretched by the amount of this and to be incapable of enduring the pain; or it may be the quality of the urine which irritates it; for every superfluous substance which lingers in the body must obviously purify, some in shorter, and some in a longer time, and thus it becomes pungent, acrid and burdensome to the organ which contains it.15

Galen suggested the use of a catheter when “one suspects that pus or thick and viscous humor obstructs the passage.” However, he noted the possibility of infection or inflammation as a side effect of catheterization. The translation by Zorgniotti of the first book of Sites of Diseases reveals a case report of a young man who was injured in the perineum by a sword. After 3 days of urinary retention the patient passed “4 heminas” (about 1,100 ml.) of urine and felt relieved. Galen wrote “it is evident that he had been wounded in the bladder.” However, in all likelihood this must have been a urethral injury. The Zorgniotti translation further reveals Galen’s use of logic and anatomy to determine the site of disease, as the book title declares: Thus suppose a person who for three days has not voided any urine at all, shall we not immediately try to determine which part of the body is the cause of illness? Is it in the kidneys, in the ureters, in the bladder, or in urethra? We will surely not look in the liver, the lung, the spleen, the stomach, and the heart nor elsewhere since none of these is a urinary organ.22 Galen distinguished obstructive uropathy, neurogenic bladder and ischuria, a term used to denote retention or suppression of urine:

. . . if you place the patient in such a manner so that the neck of the bladder be in a sloping position, and with your hands you press on the tumor against nature the urine will be expelled. If this attempt produces no result, one must abandon the idea the trouble resides in paralysis and suppose that the urethra is obstructed.22

In Sites of Diseases he uses symptomatology, physical findings, anatomical knowledge and logic to ascertain diagnosis and formulate treatment. This combination represents the essence of modern medicine without the crutch of technology. Uroscopy and bladder stones. Galen believed in uroscopy, the macroscopic inspection of urine and its sediments?” to diagnose illness of a specific body part and forecast prognosis of the patient.26 He supported the Hippocratic notion that “flaky bodies voided with the urine indicate a n ulceration of the bladder and fleshy bodies an ulceration of the kidneys.”zz Galen recognized obstructive uropathy. He wrote if“the signs of the stone do not appear to have preceded the retention and that there has been a flow of blood, it is to be presumed that a clot obstructs the urethra.”*2

Galen was interested in diagnosis and treatment of the kidney stones:

. . . one must examine the symptoms preceding the suppression of urine, to ask if the kidneys had been affected by stone, an inflammation, or from some other disease. One must further study the general disposition of the body in order to distinguish as much as permits a conjecture based on the art, if it is in the kidneys themselves where the obstruction originated as a result of stones or thick humors or if it is in what one calls ureters which are the conduits which extend from the kidneys to the bladder.”’ Galen expanded his comments on stones in On the Natural Faculties: “I do not suppose that Asclepiades ever saw a stone which had been passed by one of these sufferers [nephritics], or observed that this was preceded by a sharp pain in the region between kidneys and bladder as the stone traversed the ureter, or that when the stone was passed, both the pain and the retention at once ceased.”l5 In Sites of Diseases, Galen made a reference to pediatric stones and offered this therapeutic solution: Suppose that the patient is a child showing previously the symptoms of stone, a watery urine loaded with sandy deposits, this child constantly squeezes his penis which is limp or in erection without reason, and then suddenly the urine is suppressed. Following that, one would have to suppose not without reason that the stone is engaged in the neck of the bladder. Make the child lie down on his back, the legs elevated much higher that the rest of the body then shake him in various directions, in this way to cause the stone to fall from the passage. After these maneuvers, tell the child to try to urinate. If the attempt succeeds and the urine is secreted, you will be convinced that you have an exact diagnosis of the cause and at the same time, you have found the mode of treatment. If the retention persists, you will shake him again more strongly. . .zz Although lithotomists existed well before and during Galen’s time27 no direct evidence suggests that he participated in that surgical practice. Among his wide-ranging comments in To Thrasyboulos Galen decries such subspecialization (Galen uses the term arts in the sense of medical arts or medical practice):

It should be sufficiently plain from the above how great is the error of believing that arts should be defined according to individual activities. For surely no one would be so stupid, or so capricious, as to subtract the above activities from the art of medicine and set up a separate art for each - the art of herniotomy, for example, (a term which is nowadays employed in some quarters) of lithotomy or of tapping. Even if someone may have the particular reputation of being a ‘herniotomist’ or a ‘tapper’ o r ‘lithotomist,’ he will still be called a doctor. So too will those doctors who are named for a specialism in a particular part of the body; they are known as ‘ophthalmic’ doctors or doctors of the ear or teeth and still others are called after the materials they employ. . .6 Genital anatomy and reproductive function. Galen’s Art of Medicine lists the 4 principal parts of the body as the brain, heart, liver and testes. The humoral pathology scheme permeated his anatomical view: “of mixtures of the testicles, the hot is the most erotic.”lb Galen’s 14th chapter in On the Usefulness of the Parts of the Body concentrates on genital anatomy. To explain why the spermatic vessel (vas deferens)

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inserts into the testis via the epididymis and not directly, he wrote: Now why did Nature not insert the spermatic vessel into the testes themselves instead of putting the part called the epididymis between them? The answer is that the exceedingly soft, porous, spongy testis could not safely be united with the dense, strong, hard spermatic vessels. Hence here too Nature appears to have done the thing which I have many times already shown [her doing], that is, she does not conduct into the same place parts with substances that are opposites, but always strives to place between them some bond bringing them into accord.28 Galen identified the cremasteric muscles and considered their purpose to prevent voluntary motion of the testis. Galen also studied genital innervation and blood supply: Indeed, if in dissections you should examine the size of each of the veins, arteries, and nerves arriving at the genital parts, you would admire, I am sure, the justice of the Creator. For nerves of moderate size arrive there, but the veins and arteries are not only as large as possible, but also double. . . . The male penis, on the other hand, as well as the neck [the cervix] of the uteri and the other parts at the pudendum, needing as they do extra sensation for sexual intercourse, with good reason receive a larger share.2H Galen merged anatomical ideas, humoral pathology and pneumatism with concepts of genital structure and function in his work On Sperm: When the semen falls into a suitable place, it becomes the principle of generation of an animal, but when it falls into an unfavorable one, the pneuma quickly escapes from it and there is left the viscous humor which subsides into itself. . . . The humor produced in those glandular bodies [the seminal vesicles] is poured out into the urinary passage in the male along with semen, and its uses are to excite to the sexual act, to make coitus pleasurable, and to moisten the urinary passageway.28

thing to come into being, followed by liver and heart in the same way as the foundations of a house or the keel of a ship. But at the same time that the power in the seed is constructing them, we may reasonably suppose that certain other parts are being constructed too.. .6

A curious reference to “Hippocrates on his disciple Polybus” describes coitus interruptus and abortion techniques to obtain fetuses for study.6 In On Hygiene Galen devotes a chapter to exercise and nutrition after sexual relations. His recommendations tit a holistic and humoral schema: . . . if the season of the year is suitable, one should not abstain from the cold bath; and let food be given in less quantity, but moister in quantity, in order that it may be well digested, and that the dryness from sex relations may be corrected. But the food should not be cold, but medium or comparatively warm for since by sex relations the body is made more relaxed, and colder and weaker and drier. It is needful to apply agents which thicken and warm and restore strength, and that these should be the objectives under these circumstances.1

The treatise The Best Doctor is Also a Philosopher, offers advice on sexual conduct to physicians, referring a t first to the Hippocratic ideal: If, then, this is the nature of one’s character, one will necessarily, not only despise money but also be extremely hard-working. And one cannot be hardworking if one is continually drinking or eating or indulging in sex; to put it briefly, one is a slave to genitals and belly. The true doctor will be found to be a friend of temperance and a companion of truth.6 Galen held to these high standards throughout his life.

GALEX’S LEGACY

Originally written in Greek, Galenic scriptures reached the Western world in Latin via a long Arabic and Mideastern detour.29 The Greek corpus provided much of the basis of Byzantine medicine and the 9th century translation into Arabic by Hunain ibu Ishaq in Baghdad constituted the prinIn On Hygiene, Galen further wrote: cipal foundation of Arabic medicine. The Latin translators, Some men produce warm semen, which irritates starting with Constantine the African in Monte Cassino, them a t its expulsion, after which they become relaxed Latinized the Galenic corpus for the Middle Ages.“ Although at the pylorus, which is also called stomach, not only by sprinkled with patches of then current beliefs, such as humoral pathology, Stoic philosophy and the 3 bodily spirits, the doctors, but also by other men, as it was called Galen’s volumes document a giant step in medical undercardia by the ancients; and they become relaxed and standing and disease treatment, including urinary and genweak in the entire body, and dry, and thin, and pale, ital tract disorders. Yet ironically the analytical and probing and hollow-eyed. But if, on account of this, they refrain curiosity of Galen transmuted into the rigid Galenism of the from sex relations, they have headache and stomach ensuing 1,500 years. Before the 16th century Galenic theotrouble, and are not helped much by their abstinence. ries and observations were rarely challenged. Vesalius of For they suffer the same harm from sleeplessness that Belgium and William Harvey, physician to Kings James I they did from sex relations.’ and Charles I of England, recognized not only the flaws but Comments on “pustules in the genitals in the summer” in his also the significance of Galen’s work. They modernized, refirst book On Mixtures may have alluded to venereal disease.6 fined and modified some of Galen’s misleading conclusions. Upon discovering a n error in the Galenic description of the In Construction of the Embryo Galen mentions smegma.6 Expending on his sense of Creator or Master Craftsman hip bone, Vesalius reluctantly explained his departure from Galen forecasts the chromosomal blueprint in Construction of Galen, asserting that “man had changed shape by wearing tight trousers.”8 Galen was a visionary in terms of education, the Embryo: terminology and urological practice. Many of his observations and neologisms, such as ureter (oureter), symphysis, It thus appears again, as stated previously, that the platysma myoides and popliteus, have stood the test of time seed must contain the scheme of the Craftsman, and for close to 2 millennia.8 Galen’s moral principles, high intelthat the vessels by which blood is distributed from the lectual standards, service to the ill, use of the scientific mother for the formation of the organs must be the first

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method and concept of lifelong education a r e at the heart of t h e best ideals in health care today. As late as 1790 medical education at centers as prestigious as Oxford and Cambridge still focused the curricula on Hippocrates and Galen.>” Looking back at Galen’s era one is tempted to view the struggles to gain a unifying vision of biology, health and illness, as evidenced by early healers such a s Aristotle, Hippocrates and t h e sects, with some smugness. Our 20th century eyes have t h e powerful lenses of microscopy, chemistry, mathematics, molecular biology, and the many other scientific disciplines and technologies. What Galen offered to biology. health and illness a miniature intellectual universe with highly relevant implications for everyday life) was a fairly consistent vision, although too far flung and randomly arranged to be a model. That vision is clear and far more often right than wrong a s one examines his works. Contemporary thinkers seek a larger constant vision for all of human knowledge. The tools of logic, method and creative intellect t h a t Galen invoked to explain the miniature universe he sought to master not infrequently satisfy a modern definition of science. A recent description by Wilson of science satisfies u s intellectually a n d aesthetically, and no doubt would have satisfied Galen in the best sense of Galen’s rhetorical skills. By any reasonable measure of achievement, the faith of the Enlightenment thinkers in science was justified. Today the greatest divide within humanity is not between races, or religions, or even, as widely believed, between the literate and illiterate. It is the chasm that separates scientific from prescientific cultures. Without the instruments and accumulated knowledge of natural sciences - physics, chemistry, and biology - humans are trapped in a cognitive prison. They are like intelligent fish born in a deep, shadowed pool. Wondering and restless, longing to reach out, they think about the world outside. They invent ingenious speculations and myths about the origin of the confining waters, of the sun and t h e sky and the stars above, and the meaning of their own existence. But they are wrong, always wrong, because t h e world is too remote from ordinary experience to be merely imagined. Science is neither a philosophy nor a belief system. It is a combination of mental operations that has become increasingly the habit of educated peoples, a culture of illuminations h i t upon by a fortunate t u r n of history that yielded t h e most effective way of learning about the real world ever conceived.”’ Medical history records few figures as great as Galen. The advantage of a privileged upbringing in t h e ancient Middle East helped him to achieve a lifetime of innovation and creativity unmatched in its legacy. In t h a t much of his legacy is based on his tremendous productivity and vision in scientific philosophy, Galen in a real sense fulfilled his father’s original educational vision for him. Galen’s autobiographical comment in On Hygiene would have made a n ideal epitaph: “I have slaved in the service of the art, and have served friends, relatives, and fellow citizens in many respects and have stayed awake the greatest part of nights, sometimes for the sake of the sick, but always for the beauty of study.”lI Martha L. Bloom, Ann E. Hanson, and t h e staff of the Alfred Taubman Medical Library at the University of Michigan, Ann Arbor gave time and made contributions. The extraordinary translations of Galen by P. N. Singer brought much of the Galenic corpus to 20th century light.

APPENDIX

1:

IMPORTANT MEDICAL SECTS OF GALEN’S ERA O R I G I N S A N D KEY P O I N T S ’

’-

1. Hippocratic. FiRh to fourth century B.C. Island of Cos. Large corpus of work, including Oath and Aphorisms. Humoral pathology - 4 elementdqualities. 2. Dogmatic. Fourth century B.C. Carystus and Cos. Reconciled physiologic concepts of Cos with Sicilian theories, Aristotalian influences and later thinkers (Diocles, Praxagoras). 3. Empirical. Third century B.C. Alexandria. Anatomical studies. Medical practice based on the tripod of watching & vigdance (teresis), clinical stories (historia),and analogy (he t u homoiu metabasis). 4. Methodist. First century B.C. Rome. Pathological conditions a r e based on tight or loose pores of t h e body. 5. Pneumatism. Early first century A.D. Rome. Pneuma (air, breath, intestinal gases) is the basis of health, maintaining proper tonus which is recognizable in t h e pulse. Somewhat of a contrivance based on humoral doctrine. 6. Eclecticism. (Also called Episynthetic). First century. Tried to harmonize and pick t h e best from other paradigms (especially dogmatic and methodist). APPENDIX2: MY O W N BOOKS

Galen’s own classification of his work written between 193 and his death circa 200 to 210.

1. Works written during t h e first stay in Rome. (Including Bones for Beginners, The Pulse for Beginners, Outline of Empiricism, Hippocrates’ Anatomy. 2. Books of my composition given to me on my return home. (Including Dissection of the Womb, Usefulness of Parts.) 3. Works of anatomical science. (Including Anatomical Procedures. ) 4. Works of therapeutics. (Including 14 volume Method of Healing.) 5. The nature of the works of prognosis. (Including 3 books on Critical Days, 3 on Crisis, and 4 on Distinctions Between Pulses.) 6. Commentaries on Hippocrates. 7. Works expressing differences with Erasistratus. 8. Works relevant to Asclepiades. 9. Works expressing differences with the Empiric doctors. 10. Works expressing differences with t h e Methodics. 11. Works of use in the context of logical proof. 12. Books of moral philosophy. 13. Works concerning the philosophy of Plato. 14. Works concerning the philosophy of Aristotle. 15. Works expressing differences with t h e Stoics. 16. Works concerning the philosophy of Epicurus. 17. Works of both linguistic and rhetorical interest. Galen did not list the 2 books he wrote about his books, The Order of My Own Books and My Own Books.

REFERENCES

1. Green, R. M.: Galen’s Hygiene. Springfield, Illinois: Charles C. Thomas, pp. xvii, xix-xx, 9, 134 and 273, 1951. 2. Talbott, J. H.: A Biographical History of Medicine. New York: Grune & Stratton, pp. 12-14, 1970.

19

S GALEN

:I Siirton. R.: Galen of Pergainon. Lawrcncca, Kansas: Uniwrsity of Kansas Press. pp. 11, 15. 28. 37 and 89. 1954. 4. Hopkins. K.: Novel evidcncc for ronian slavery. I n : I’ast and

Present 138. Cambridge, United Kingdom: Kmg’s College, p. 9, 1993. 5. Bender. G. A. and Thorn, K. A.: Galen, Influence for Forty-Five Generations. In: Great Moments in Medicine. Detroit: Northwood Institute Press, pp. 56-58, 1966. 6. Singer, P. N.: Galen. Selected Works. A New Translation. Oxford, United Kingdom: Oxford University Press, pp. 191-198, 1997. 7. Singer, C. and Underwood, E. A,: A Short History of Medicine. Oxford, United Kingdom: Oxford University Press, pp. 59, 62-65, 1962. 8. Gordon, B. L.: Medicine Throughout Antiquity. Philadelphia: F. A. Davis Co. Publishers, pp. 706-711, 1949. 9. Von Staden, H.: Anatomy as rhetoric: Galen on dissection and persuasion. J. History Med., 50: 47, 1995. 10. Mettler, C. C. and Mettler, F. A,: History of Medicine. Philadelphia: The Blakiston Co. pp. 25, 1947. 11. Temkin, 0.:Galenism. Rise and Decline of Medical Philosophy. Ithaca, New York: Cornell University Press, pp. 12 and 47, 1978. 12. Haggard, H. W.: The Doctor in History. New Haven, Connecticut: Yale University Press, pp. 96 and 100, 1934. 13. Walzer, R. and Frede, M.: Galen. Three Treatises on the Nature of Science. Indianapolis: Hackett Publishing Co., pp. 94-102, 1985. 14. Jackson, R.: Doctors and Diseases in the Roman Empire. London: British Museum Publications, p. 64, 1988. 15. Brock, A. J.: Galen. On the Natural Faculties. Cambridge: Harvard University Press, 1991. 16. Gilman, S. L., King, H., Porter, R., Rosseau, G. S. and Showalter, E.: Hvsteria Beyond Freud. London: University of California Press; p. 25, 1993. 17. Nutton, V.: Galen, On Prognosis. Berlin: Akademie-Verlag, pp. 69-143, 1979.

18. (’ox(,. .I.

H.:Thc Writings of 1lip;n)cr;itc~smid ( ; : a h I’hiladc.l-

pliia: 1,inds:iy :ind I3lakiston. p. 29. 1846

19. Mrzzogiorno. V.. M(.zzogiorno. A. and I’assiatorcs. (’.. A contribution to thr h i ~ t o r - yof rr*n;ilstructure kniiwlcdp. Ifronl (;:iIcn to Malphigi 1. Ann. An;~tomy175: 395. 1993. 20. hlarondola. I’.. hlusitelli. S.. Jallous, 11.. Speroni A . and dc Bastiani. T.: Thc. I2ristotoli;in kidney. Amcar. J . Nc.;)hrol.. 14: :30‘2, 1994. 21. Kopple. J. I).: The Biblical vicw ofthe k d n r y . Anicbr. .J Ncyhrol.. 14: 279, 1994. 22. Zorgniotti, A. W.: Galenic UrolokT. Tr;insl;ition of urologic portions of De Locis Affectis (Book I . (’haptrr 1 I. L1roIcJp. 8: 638. 1976. 23. Singer, C.: Galen on Anatomical Procedures. London: Oxford University Press, p. 167. 1956. , J r . , Browning. F. M. and Schroeder. C. R.: An section Manual of Rhesus Monkey Anatomy. Tallahassee, Florida: Anatomy Laboratory Aids, p. 65. 1968. 25. Bloom, D. A,: A brief history of uroscopy: prognosis. diagnosis. and human waters. Monogr. Urol.. 17: 13, 1996. 26. Haber, M. H.: Pisse prophecy: a brief history of urinal Lab. Med., 8: 415, 1988. 27. Bloom, D. A,: Hippocrates and urology: the first surgical subspccialty. Urology, 50: 158, 1997. 28. May. M. T.: Galen. On the Usefulness of the Parts of the Body. lthaca, New York: Cornell University Press, pp. 641-644. 649-651, and 653, 1968. 29. Haggard, H. W.: Devils, Drugs. and Doctors. New York. Hlucs Ribbon Books, Inc., p. 131, 1929. 30. Bynum, W. F.: Science and the Practice of Mediclnc. in thc Nineteenth Century. Chmbridgc. Uniccd Kmgdom. (’amhridg:c~ University Press, p. 3. 1994. 31. Wilson, E.0.:Consiliencc,. Thv LTnity of Knowl(dgc. New York Alfred A. Knopf. p. 4.5. 1998 32. Castiglioni, A.: A History of Medicine. New York: Jason Aronson. Inc., pp. 148, 179. 201, 214 and 215, 1975.