Healthcare Provider

For thousands of years, the treatment of illness involved some combination of superstition, trial-and-error, inadvertent torture, and just plain dumb luck. A treatment counted as effective if the patient survived.

Whatever doctors were doing before the middle of the 19th century, it’s hard to consider it medicine – certainly not by the standards of the 150 years or so since the advent of local anesthesia. Physicians have understood the principles of antisepsis for about as long, while aspirin was synthesized only in 1897. We are spoiled. Not for us the clinical technique of Theodoric of York -- the medieval practitioner Steve Martin used to play in a "Saturday Night Live" sketch – whose treatment for every condition included the draining of excess blood.

Comforting one patient’s mother, Theodoric reminds her of how far the healing arts had advanced as of 1303: “Why, just 50 years ago, they thought a disease like your daughter's was caused by demonic possession or witchcraft,” he tells her. “But nowadays we know that Isabelle is suffering from an imbalance of bodily humors, perhaps caused by a toad or a small dwarf living in her stomach.”

Insofar as Theodoric and his colleagues brought any book-learning to their practice, it came from the pen of the Greco-Roman philosopher and physician Galen, born circa 130 A.D. in what is now Turkey. Susan P. Mattern, a professor of history at the University of Georgia, does not exaggerate in calling her biography The Prince of Medicine: Galen in the Roman Empire (Oxford University Press). His posthumous career was, if anything, one of almost regal authority.

An earned authority, just to be clear about it. Galen had an ego the size of the Empire itself. He never tired of pointing out the abject ignorance of other physicians, and was prone to quoting tributes by illustrious people to his own erudition and skill. It is not charming. But Mattern shows Galen to have been tireless as both a practitioner and a scholar -- and his output of treatises, case histories, popular textbooks, and editions of Hippocrates and other medical authors was astounding. “The most modern edition of his corpus runs to 22 volumes, including about 150 titles,” writes Mattern, “and is one-eighth of all the classical Greek literature that survives.”

Tireless in his efforts to accumulate, compare, and synthesize the recorded medical knowledge of previous centuries, Galen also conducted a great deal of anatomical research (including animal vivisection) to test the theories of the day. In his 20s, he did the second-century equivalent of a residency as the physician-on-call to the gladiators of his hometown. A standard treatment for open wounds was to bathe them in hot water, followed by a plaster made of boiled flour, which Galen reports as totally ineffective – crippling, when not lethal. By contrast, he “soaked linen cloths in wine and placed the folds on the wounds,” the biographer says, “covering the cloths in soft sponges which he moistened day and night.” Whether or not the technique saved the lives of all the gladiators in his care during his first year (so Galen claimed) he definitely understood the antiseptic property of alcohol.

Opening a practice in Rome, he distinguished himself in the constant, cutthroat battle of reputation among physicians, both for his skill in diagnosis and treatment and his erudition. He seems to have been acutely sensitive to changes in a patient’s pulse and body temperature. “Long before laboratory testing,” Mattern writes, “he examined urine and feces, sweat, sputum,” and “vomit, pus, and blood for color, texture, viscosity, and sediment.” Galen’s case histories show he “scruitinized his patients’ faces for signs such as change in skin color or the shrunken eyes of wasting or extreme dehydration.” And he knew how to interview patients about their history and symptoms with more finesse than you can expect from one HMO that I could name.

Mattern stresses that Galen was also an exemplary product of Hellenistic culture – urbane, deeply familiar with Greek philosophy and literature as well as the medical authors, and capable of writing in either a matter-of-fact or a high-flown style as the circumstances required.

She notes that we have no evidence that Galen bothered to learn the language of the Empire. He wrote in Greek and did not cite Latin authors, and his reputation took root among the aristocracy, for which familiarity with Greek was the sine qua non of intellectual sophistication. Medical science in particular was a fashionable topic, and a number of Galen’s works were composed as memoranda or instructional guides for the amateurs in his entourage.

The audience for Galen’s work was not limited to the scroll-buying public. He had also learned the arts of oratory and debate practiced by the sophists -- and his encounters with other physicians were brutal rhetorical showdowns, as were his lectures on anatomy, during which slaves held down monkeys and livestock as Galen and his opponents cut them open to demonstrate their points.

Much of it was done in the street. At one point while reading the book, I got an image of the Prince of Medicine crossing paths with the adherent of some medical philosophy he opposed -- the Empiricists, say, or the Dogmatists -- and performing dissection battles while surrounded by their respective crews (students, patients, slaves, aristocratic fanboys, etc.) as well as random passers-by. Like break-dancing, in togas, with gallons and gallons of blood.

It did not hurt Galen’s reputation that he had inherited considerable wealth and could refuse payment for his services. He disdained the very idea of practicing the divine art of Asclepius (the god of medicine who had visited Galen’s father in a dream to provide vocational guidance on the boy’s future) for money. This, too, had its rhetorical side: it meant he could cast aspersions on doctors with more worldly motivations than pursuit of the pure good of healing.

In his writings, Galen expressed reluctance at being summoned by the emperor, Marcus Aurelius, to serve as court physician. He accepted, of course (it was an offer he couldn’t refuse) and was also retained by the succeeding emperors. Mattern suggests that there may have been more to his professed misgivings than thinly disguised braggadocio. Whatever the boost in prominence, the position also meant less autonomy.

Self-aggrandizing as Galen’s devotion to medicine may have been at times, the biographer calls him “a surprisingly pious man,” fascinated by the “cumulative and overpowering evidence of an intelligence at work” in the animals he dissected in hopes of understanding the human anatomy. This made him one of the more appealing pagan thinkers for adherents of the three major monotheistic religions, who translated them into Hebrew, Latin, and Arabic. A number of his works have survived only because Islamic scholars translated them, although it’s entirely possible that the original Greek texts may yet resurface. As recently as 2007, Galen’s treatise “On the Avoidance of Pain” – long presumed lost in any language – turned up in a Greek monastery.

His biographer points out how unfortunate it is that Galen never challenged the medical value of bloodletting – a practice that continued for so long that historians have wondered if it perhaps have had therapeutic value in treating something, though it could prove fatal when done with a shaky hand.

“While it is perhaps wrong to blame him for failing to break from a tradition that his followers, including the great physicians of the Islamic Middle East and of the European Renaissance and Enlightenment mostly did not question,” writes Mattern, “one wishes he had turned his scorn on this therapy” instead of on the “three-day fasting cure” promoted by some of his peers. “For while Galen did not invent bloodletting, he had the power to consign it to oblivion.”

Maybe he did change his mind, but history lost the memo?