Luis H Toledo Pereyra

In 130 A.D. Pergamon (as known in the Western world), a Greek town of Roman law near the Aegean in Asia Minor, became the birthplace of somebody particularly unique, someone who would drastically modify the course of history. Galen (130-200 A.D.), the revered physician and surgeon, saw his first light in this city of antiquity when the only serious medical concepts originated from Hippocrates.1-9 Galen learned the important Hippocratic precepts rather swiftly and then set out to improve the prevailing system of medical principles and treatments.

Galen came from a family of respectable economic means. His father Nikon, an engineer and landowner, believed in the extraordinary benefits of a humanistic education, particularly in philosophy, natural sciences and mathematics. Spurred by a dream from Aesculapius, the god of healing, Nikon advised his son to become a physician.2,3,7 Without hesitation, Galen pursued his medical education in Smyrna (today Izmir, Turkey), Corinth, Phoenicia, Palestine, Crete, and in the famous Egyptian city of Alexandria, the ancient site of so many anatomical discoveries. Five hundred years earlier, Herophilus and Erasistratus had established the greatest center of anatomical studies in Alexandria. The city had a great deal to offer a young and ambitious mind like Galen's.

Galen returned to Pergamon fully qualified to practice medicine and having completed a well-outlined and comprehensive postgraduate course (even better than contemporary postgraduate programs). Upon his return, he was offered the position of physician and surgeon to the gladiators. For 3 years, he absorbed the details of this profession, and then he left again, this time for the flourishing capital of Rome.

While in Rome, in 161 A.D., he patiently positioned himself to be considered by the political leaders of his time. When the wife of the Roman Consul, Flavius Boethius, fell ill, Galen cured her. The Consul became Galen's loyal supporter, to the extent of setting up a room for his animal dissections.6-9 This welcome sponsorship allowed Galen to expand his theoretical knowledge of anatomy, physiology, and surgery.

After four years in Rome, Galen quietly returned to Pergamon where two years later the Roman Emperor Marcus Aurelius recalled him to become the court physician in Rome (168 A.D.). Galen remained in this position under four emperors for more than 30 years until his death in 200 A.D.1-9 These decades in Rome proved extraordinary for both his writings and dissectional work.

Galen was a consummate and prolific writer, completing more than 400 books, of which 83 are well identified.5 To support his exhaustive writing in anatomical and physiological studies, he employed a group of scribes paid directly through his own funds. No other physician of antiquity, or of modernity for that matter, produced such a voluminous number of scholarly works. Since human dissections were not allowed by Roman law, the majority of Galen's anatomical and physiological studies concerned animals (macaque monkeys and pigs) rather than dead humans.2,5-9

Galen had an extraordinary acumen for diagnosis and treatment of common and unknown diseases. His outstanding diagnostic skills allowed him to advance his sociopolitical life. Galen was also a superb scientist and experimenter, one who wanted to demonstrate how natural phenomena occurred and to explain the function of the body. Galen took anatomy to the highest level achievable in his time. As an able anatomist and gifted surgeon, he understood the body, respected tissues, and aimed for the best tissue and organ function after surgical repair. While he cared for gladiators in Pergamon, an exceptional recovery rate was noted among injured slaves,2,3,7,8 which added luster to Galen's reputation as a respected surgeon and physician.

Galen's contributions to physiology were many and remarkable. He proposed that arteries contained blood, that severed arteries would bleed the blood contained in them, that arterial pulsations originated from the heart, that the diaphragm and chest wall created a partial vacuum for the lungs to inflate or deflate during respiration, that urine was produced in the kidneys and not in the bladder, that the phremic nerve controlled the diaphragm and partly the chest wall movements, that spinal cord transverse incisions resulted in paralysis of all the nerves below, and that voice came from the larynx and was directly related to the recurrent laryngeal nerve, as well as other important developments. But Galen was not correct in all his assumptions; he never understood circulation as William Harvey later brilliantly described it. He never fully perceived the Harveian principles of blood circulation. He presumed there were pores between the left and right ventricles that allowed the "pneuma" to pass through. And he thought that the liver transformed digested food into blood, supplying nourishment to the body.2,8,9

Galen's anatomical accomplishments were multiple and varied. He described the bones of the human skeleton, their anatomical configuration and details. The joints, ligaments, and muscles were largely introduced from his work with apes, pigs and oxen. He presented a superior analysis of the cranial nerves, the nervous ganglia, and the sympathetic system.8 His angiology needed some refinement and was not as well defined as his osteology and mycology.8 Galen's writings, as deficient as they were in some respects, were consistently followed until the high Renaissance when Andreas Vesalius and William Harvey debunked some Galenic writings and teachings.2,6-9

As a superb surgical professional, Galen made his mark. He operated on tumors, hemorrhoids, varicose veins, hydroceles, abdominal walls, intestines, and nasal polyps, and performed cleft-lip reconstructions and other procedures.9-11 He utilized common surgical instruments of the time, such as scalpels, forceps, hooks, arrow extractors, retractors, and scissors.9-11 He was a formidable surgical tactician with incredible anatomical and physiological knowledge, which he extrapolated into sound surgical practice. He advanced surgery by acknowledging well-known principles, improving surgical techniques, and enhancing his vast experience with gladiators, which permitted him to achieve better outcomes than his contemporaries.2,3,7,9

Galen's self-praised, egocentric, petulant, and intolerant personality was surpassed only by his brilliance, his determination, and the canonical status of his writings.8 That Galen impeded the advancement of medical sciences for more than a millennium cannot be readily accepted. Nor can the timidity of his medical peers, who did not have the necessary courage to challenge some of his perilous assertions. History

has judged all of them and they all remain equally responsible for accepting Galen's dogmatic writings on one hand and not proposing alternatives on the other hand.

In summary, Galen's influence remains unparalleled by any other physician's before or since. Even the father of medicine, Hippocrates, did not have the intense and pervading effect that the surgeon of gladiators had on the world's medical thought and practice.

References

1. Talbott JH. A Bibliographical History of Medicine. New York: Grune and Statton, 1970:12-15.

2. Nuland SB. Doctors. The Biography of Medicine. 2nd ed. New York: Vintage Books, 1995:31-60.

3. Sigerist HE. The Great Doctors. New York: Dover, 1971:68-77.

4. Bettmann OL. A Pictorial History of Medicine. Springfield: Charles C. Thomas, 1962:42-47.

5. Green JR. Medical History for Students. Springfield: Charles C. Thomas, 1968:41-47.

6. Inglis B. A History of Medicine. Cleveland: World, 1963:35A0.

7. Haggard HW. The Doctor in History. New Haven: Yale University Press, 1935:91-100.

8. Si nger C. A Short History of Anatomy and Physiology from Greeks to Harvey. New York: Dover, 1957:46-65.

9. Conrad LI, Nerve M, Nutton V et al. The Western Medical Tradition. 800 BC to AD 1800. Cambridge: Cambridge University Press, 1995:52-70.

10. Rutkow IM. Surgery. An Illustrated History. St. Louis: Mosby-Year Book, 1993:38-42.

11. Toledo-Pereyra LH. Galen's contribution to surgery. J Hist Med 1973; 28:357-375.

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