Chapter Two

LEARNING MEDICINE

hen Galen was an adolescent of fourteen, his father—busy with civic responsibilities and no longer able to dedicate himself full-time to his son’s education—handed him over to teachers of philosophy, whom he interviewed with care. So Galen tells us in a passage from his treatise On Diagnosing and Curing the Affections of the Soul, written much later, in the 190s (see chapter 7). Galen’s teachers represented most of the major philosophical sects, and all had impeccable credentials and illustrious intellectual pedigrees. One was a Stoic in the tradition of the great Chrysippus of Stoli; Chrysippus’s works remained influential in Galen’s later life and form much of the subject-matter of one of his most important philosophical works, On the Doctrines of Hippocrates and Plato, written years later in Rome. Another of his early teachers was a Platonist student of Gaius, with whom Galen studied only “for a short time” (Gaius, whose name indicates Roman citizen status, is mentioned in several other sources and was famous in the second century, though his works are lost today). Galen also mentions a Peripatetic (Aristotelian) student of Aspasius; Aspasius’s works would later be cited by the late antique philosophers Porphyry and Boethius, and part of his commentary on Aristotle’s Nicomachean Ethics survives today. The Peripatetic, anonymous in this passage, is possibly Eudemus, one of Galen’s first patients in the city of Rome (see chapter 4). Finally, Galen mentions an Epicurean about whose background he is more reticent, but this teacher came from Athens, still considered the epicenter of philosophical education. Galen identifies the other three tutors as Pergamene citizens, probably with some pride and nostalgic reference to Platonic ideas of civic pedagogy, though the Peripatetic had just returned from a long journey abroad. Galen does not name his teachers—perhaps because their reputations were modest and these names would not have been impressive on their own; he identifies their teachers (except in the case of the Epicurean) and their intellectual affiliation. Intellectual influence, transmitted mostly orally, and pedigree was a matter of some importance (see below). Galen here stakes a claim to intellectual independence or philosophical “eclecticism” from his earliest youth.¹

Galen continued to seek education from philosophers throughout his life and considered himself a philosopher, as well as a physician. He long argued that all truly educated doctors were philosophers and that Hippocrates had been a philosopher; he wrote philosophical treatises on logic and ethics and a brief work That the Best Physician is Also a Philosopher; he boasts of his reputation as a philosopher, which is attested independently of his works. Galen was what the Greeks called a pepaideumenos, a cultured man, proud of his broad education, of his mastery of mathematics, geometry, Greek grammar, and especially philosophy, queen of the academic disciplines.²

Only a very small number of those calling themselves iatroi, doctors, acquired this type of education, as well as Galen’s astounding erudition in the whole medical tradition up to his time. Some epitaphs commemorate doctors as young as seventeen, suggesting a traditional apprenticeship (perhaps similar to those common in rural China today) and not an exhaustive, liberal intellectual education. In Italy and especially in the city of Rome, many doctors were slaves or freedmen, trained in the households of the rich. But medicine also had a place among the Greek world’s prestigious and esoteric disciplines, and Galen was not the only one who thought so. At Rome he would exploit medicine’s cachet among the ruling class, as I shall describe.³

Like most people, Galen believed that the gods spoke in dreams and he followed their commands. (He also believed that dreams could be the soul’s reflections on humoral imbalances in the body, thus useful for medical diagnosis; and that the soul could prophesy in dreams.) When Galen was sixteen, dreams convinced his father to alter the path of his only son’s education: “Exhorted by distinct dreams, he had me study medicine together with philosophy.” Galen offers no details and does not identify which god, if any, spoke to his father, but his readers might have assumed the dreams came from Pergamum’s most famous divine resident, Asclepius.⁴

Galen was now to take up the study of medicine; but not, as he emphasizes, to the exclusion of philosophy: “We came to cultivate the study of medicine, and throughout our whole life we applied ourselves to both disciplines [medicine and philosophy] in deeds more than in words” (Meth. Med. 9.4, 10.609K). Thus, a few years later at Smyrna, we find him studying with the physician Pelops and also the Platonist philosopher Albinus. Like Galen’s Platonist teacher at Pergamum, Albinus was a student of Gaius, and the publisher of what became Gaius’s main written legacy, his lectures on Plato.⁵ In retrospect, Galen emphasizes the diligence with which he attacked his studies while others, as he writes, spent more time socializing with the rich and powerful and cultivating their favor:

When I began to study medicine I repudiated all pleasure. . . . I spent all my time in the study of medical practice, deliberating and reflecting on medicine. Generally, I have gone without sleep at night in order to examine the treasures left to us by the Ancients.

(Opt. Med. Cogn. 9, 100–102 tr. Iskandar)

It is no wonder that, while others wandered around the whole city performing salutations, and dined with the rich and powerful and escorted them about, and we on the other hand labored diligently the entire time, we first learned all the things that were creditably discovered by the ancients; then through deeds we both tested and practiced them.

(Meth. Med. 9.4, 10.609K)

We know the names of some of his medical teachers at Pergamum: the most important, the one with whose intellectual legacy Galen later identified most, is Satyrus, a pupil of the illustrious Quintus who had practiced in Rome in the decades preceding Galen’s birth. Satyrus had been living at Pergamum for three years with Rufinus, the native Pergamene, Roman senator, and ex-consul who was apparently funding and overseeing the construction of the spectacular new Temple of Zeus Asclepius (see chapter 1). Satyrus had possibly met Rufinus in Rome while studying with Quintus, and returned to Pergamum with Rufinus as part of his entourage.⁶

Satyrus appears in Aelius Aristides’ account of his relationship with Asclepius, the Sacred Tales: “The doctor Satyrus was in Pergamum at that time, a sophist of no humble birth, as it was said” (3.8). The date of the story may be around 147 C.E., while Galen was Satyrus’s student; it may have been in his teacher’s company that Galen met Aristides, whom he describes as an example of a strong soul joined with a weak body—“I have seen only a few of these. One was Aristides, a resident of Mysia” (Plat. Tim., 33 Schröder). Satyrus advised his patient to leave off the harsh regimen of venesection commanded by Asclepius and use a simple plaster to treat his abdominal complaint. Aristides tried the remedy, but it only made his condition worse; the dream prescriptions of Asclepius were, of course, effective.⁷

Besides Satyrus, Galen mentions other physicians from whom he acquired his early education at Pergamum, in passing. These include “Aeschrion the Empiric, that old man most experienced in drugs, my fellow-citizen [of Pergamum] and teacher” (Simp. Med. 11.1.34, 12.356–57K), whose cure for rabies Galen describes with approval. The main ingredient was the ashes of crawfish. The crustaceans were collected on a single day in summer, between the rising of the dog star Sirius and the transition of the sun into the sign of Leo (that is, between July 22 and August 20 or thereabout), in the eighteenth day of the moon’s cycle, and cooked alive in a pan of red bronze. Galen also mentions a teacher called Stratonicus, “a student of Sabinus the Hippocratic” (Atra Bile 4, 5.119K): he once cured a long-standing abscess in the leg by extracting thick, black blood from the patient’s elbow over a number of days. Thus, Galen seems to have studied with several physicians at Pergamum, and it is likely that he does not tell us all of their names. It is unclear whether the “Empiricist teacher” Galen debates in his treatise On Plenitude (9, 7.558K) is Aeschrion or not, or possibly identical with another Empiricist teacher, Epicurus, whom Galen mentions only once, in an obscure passage. Galen also describes an argument in which he humiliated yet another teacher—a Pneumatist (the sect was founded by Athenaeus of Attaleia, and named for the role of the vaporous pneuma in its natural theory)—without transmitting his name; he was eighteen years old when the episode occurred and probably still living at Pergamum. It is tempting to identify this Pneumatist with Aeficianus, a student of Pelops, whom Galen mentions in On the Order of My Own Books as a Stoic-influenced interpreter of Hippocrates and in another passage identifies as one of his teachers. Pneumatist doctrine was heavily tinged with Stoicism, and Galen mentions Aeficianus in connection with Satyrus, suggesting that he learned from them at about the same time.⁸

Much of Galen’s medical training was intellectual—he clearly heard Satyrus and others expound on Hippocrates, for example, and I will discuss the intellectual heritage of medicine further below. But from the very beginning, his training also or mainly involved practical demonstration and clinical experience. With Satyrus, Galen observed the horrific effects of an epidemic whose victims “were stripped of skin, and of some also of the very flesh” (Anat. Admin. 1.2, 2.224–25K). Galen calls the epidemic “anthrax,” and as I mentioned in chapter 1, this was possibly the disease known today as cutaneous anthrax, caused by the Bacillus anthracis; although the symptoms he describes are much more extreme than what would be seen today, in an era when the infection is treated with antibiotics. Satyrus would demonstrate anatomy on the patients, instructing them to move in ways that showed the action of the muscles, even displacing muscles to better expose arteries and nerves:

As we practiced anatomy on one or another of the exposed parts, those of us who had observed Satyrus [previously, demonstrating on animal subjects?] recognized them [the parts] right away and made detailed distinctions, instructing the patients to make certain movements, which we knew to be controlled by certain muscles. We saw that some students, because, like the blind, they did not recognize the exposed parts, were forced to try each of two [experiments], or they raised and moved many parts of the naked muscles, and the patients were unnecessarily distressed.

(Anat. Admin. 1.2, 2.225K)

Sometimes putrefying diseases strip the whole of this region of the surrounding skin, so that the naked veins are seen clearly. This happened frequently over all parts of the body especially at the time when the epidemic of anthrax happened in Asia.

(Ven. Art. Dissect. 7, 2.803K)

These experiments on live, suffering patients disfigured by a hideous necrotizing disease were Galen’s earliest exposure to human anatomy and must have been unforgettable, although he tells the story without a hint at any emotion other than pride in his own training and disdain for the inferior skills of other students. The story occurs in a complicated passage explaining the importance of observing human anatomy by any available method, in a world in which the dissection of human corpses was taboo and rarely practiced.

The story implies that Galen had observed animal dissections under Satyrus, and animal dissection was certainly part of his early training. His teachers had demonstrated, for example, the muscles responsible for the motion of the lungs. Although he tells no explicit stories about youthful experiences with animal dissection, by the time he left Pergamum (around age nineteen or twenty) he had written his first anatomical treatise, On the Anatomy of the Uterus, composed for a midwife; the treatise survives. Galen was certainly a virtuoso anatomist by the time he returned to Pergamum from Alexandria in 157 and humiliated his rivals for the position of physician to the gladiators (see chapter 3).⁹

Clinical practice was a part of Galen’s medical training from the beginning—many of Galen’s anecdotes illustrate this point. Thus, his story about Stratonicus extracting black blood from a patient day after day, mentioned above, probably derives from his own observation. In an argument with “my Empiric teacher” about the indications for bloodletting, Galen cites several cases treated by the teacher himself, cases Galen had observed: “those whom I saw phlebotomized by you” (Plen. 9, 7.560K). Some of these early experiences remained with Galen throughout his life. One case, that of an emaciated and apparently incurable 40-year-old man with digestive problems, Galen recalls many years later in the seventh book of On the Method of Healing (7.8, 10.504–6K): “together with my teachers I first saw a patient, a man of mature age, who had been troubled for many months, but none of them could identify his condition, nor could I.” Here Galen attends the patient together with several other doctors, all called his “teachers.” The physicians consult together on the management of the illness (“And the doctors considered whether the man ought to bathe, some in favor, others opposed, and the opinion won out of those who thought he should bathe”); and Galen, though a student, has a voice (“we all decided that the weakness of the belly had been cured, but that the stomach had been chilled”).

Similarly, Galen describes a boy suffering from epilepsy whom he observed “in my youth, together with the best physicians of my homeland, who had come together to consider his treatment” (Loc. Affect. 3.11, 8.94K). This happened later, while he was at Smyrna (by “homeland” here Galen means the province of Asia). It was Galen’s first case of epilepsy; the boy was suffering horribly, having seizures every day. Among the physicians called to the consultation was Pelops, Galen’s teacher; Galen recalls Pelops’s diagnosis, and the treatment prescribed, although this treatise was written about fifty years later.

With Galen’s medical training, then, began his clinical experience, although he mostly played the role of observer. Thus, of an early encounter with a patient with amnesia, he writes that “I was still young, and had neither observed any of my teachers treating this condition, nor had I read about the treatment in the [works of] any of the ancients” (Loc. Affect. 3.5, 8.147K).¹⁰

Galen’s youthful stories not only show him observing and participating in treating patients but also vigorously debating his teachers in what seem like dramatic, even tumultuous scenes that foreshadow his conflicts and performances in Rome. Galen’s detailed catalog of cases, recalled perfectly from the physician’s own practice, stumped his “Empiric teacher”: “after these things, however, he was silent . . . he hesitated a long time about what he should answer.” His confrontation with the Pneumatist is decidedly dramatic—under the assault of Galen’s aggressive, Socratic-style questioning about ambiguities in his classification of the elements, the teacher is at first flummoxed (“he hesitated a long time”), then agitated (“now becoming angry and disturbed”), and finally cannot suppress a hostile outburst:

Looking at the other students, he said: “This man, raised on dialectics and therefore full of mange (for thus he himself called it), turns everything upside down and twists it around and mixes it up, and confuses it by playing the sophist with us, so that he may demonstrate his logical skills.”

(Elem. Hipp. 1.6, 1.462–65K)

This all happened, as the last quotation makes clear, in front of the other students, which was probably also the case in Galen’s debate with the Empiricist. Furthermore, we have seen Galen and his teachers consulting and debating at the patient’s bedside. Medical education was not the monotonous transmission of knowledge from authority to pupil; it was a passionate dialogue in which everyone participated.

It was probably also at Pergamum “as a lad” (meirakion—a word Galen uses for males in their late teens and early twenties) that Galen began to acquire his lifelong expertise in pharmacology; not only from his physician-teachers (Satyrus and Aeschrion are both cited in his compendia on drugs, as is Pelops, his next teacher)¹¹ but also he paid an exorbitant sum to an unnamed expert who taught him to prepare certain exotic drugs “so that what I prepared was indistinguishable from the genuine item” (Simp. Med. 9.3.8, 12.216K). Galen lists among the drugs he learned to produce those made from diphryges (a metallic mining by-product, possibly a pyrite), also signets of Lemnian earth and “Indian lycium” (catechu). Later in life he traveled widely around the eastern Mediterranean to obtain a lifetime supply of these ingredients: “for this reason I was zealous to travel to Lemnos and Cyprus and Palestinian Syria to acquire for myself a large enough quantity of each of these drugs for my whole life” (ibid., and see chapter 4 on these journeys). Did Galen learn, from the teacher who demanded such a high price (“a huge fee,” misthos megas), to counterfeit the genuine drugs or did he learn local secret recipes and methods for preparing the rare ingredients he later went to such effort to obtain? His comment above—that his own products looked exactly like the “genuine items” (alethina)—suggests that he had hired an expert pharmaceutical counterfeiter to teach him the tricks of the trade, and that perhaps this knowledge inspired him to acquire quantities of the true materials.¹²

Like his philosophical education, Galen’s medical education was eclectic: one or more of his early teachers was an Empiricist; one was a Pneumatist; and one, Satyrus, was not (at least, not strictly) aligned with either of these traditions, although he may have shared the Empiricist leanings of Quintus (see below). Throughout his life Galen vigorously proclaimed his independence from any sect. This intellectual independence he attributed to the influence and advice of his father, who warned him not to align himself with any tradition but to choose the best ideas from each (Anim. Affect. Dign. 8, 5.42, 43K). “I consider,” he writes, making his point sharply, “those who name themselves Hippocrateans or Praxagoreans or after any man at all to be slaves” (Libr. Propr. 1, 19.13K), that is, intellectually servile. There was a certain virtuosity to his position. “Whenever I chose to advocate a single sect, it was difficult for anyone to convict me of hesitation in improvised speech; for I learned them not from handbooks [hypomnemata], as some do, but from the most prominent teachers of each sect” (Loc. Affect. 3.3, 8.143–44K).

From the early Hellenistic period, medicine had encompassed vigorously competing intellectual traditions. Galen identifies three sects, or haireseis (from the Greek word for clinging or adherence), in his treatise On the Sects for Beginners and refers to them often in other works, notably Outline of Empiricism and On the Method of Healing (the title of the latter mocks the detested Methodists—Galen meant The [True] “Method” of Healing). The Empiricists defined themselves according to their epistemology, or theory of how knowledge is obtained: this, as Galen writes, they considered so important that they disdained the more usual appellation deriving from a founding figure. Their founder was in fact Philinus of Cos, renegade student of the renowned anatomist Herophilus. Philinus broke from his master and founded his own school in Alexandria on radical principles.¹³

Empeiria is “experience” in Greek, the sole source of medical knowledge in Empiricist doctrine. This experience could be an observation, usually of a cure (because of their methods, much surviving Empiricist writing—all fragments, as no complete work survives—concerns therapy and especially drugs). The cure might occur randomly, by accident; or the physician might make an educated guess and deliberate experiment; or, as Galen writes, he might be advised by a dream (Sect. Intro. 2, 1.3K). Empiric methods of discovery could thus have a tinge of mysticism. Galen, although he mentions without comment dream cures of Asclepius and the dream instructions given to his father about his own education, even criticizes Empiricists because “they refer nearly all the compound drugs [they devise] to dreams and fortune and chance” (Comp. Med. Gen. 1.1, 13.366K). One might speculate that Aeschrion’s aforementioned magical cure for rabies, using crawfish gathered by moonlight on a single day in summer, was inspired by a dream.

For a conclusion to be valid (x drug cures y condition), the observation had to be made repeatedly. Lest medical knowledge be limited to what each individual physician might observe in a lifetime, it was permissible to use conclusions based on the observations of other physicians, as recorded in books or transmitted orally—these reports Galen calls history (historia). History, in turn, must be evaluated according to specific criteria, especially the trustworthiness of the source, the number of sources attesting to a specific cure, and the degree of consensus among sources. It was also allowable to use simple reasoning based on similarity (a condition similar to y might also be treatable by x). But most forms of deductive reasoning, especially theorizing about the cause of disease, the Empiricists rejected as irrelevant or impractical. According to Galen they also rejected anatomical dissection; close observation of wounds in living persons was, they believed, an adequate method of studying anatomy, a position Galen excoriates.¹⁴

But some of his earliest training was in Empiricist methods. Not only did Galen study with two or more Empiricist teachers at Pergamum, but Satyrus himself, his main and most respected teacher, was the product of an Empiricist-leaning tradition. In particular, Galen attributes to Satyrus’s teacher Quintus—about whom more below—an Empiricist interpretation of Hippocrates, of which he is critical: “Quintus interpreted these books and also the Aphorisms badly . . . for Quintus says that this is known only by experience, without reasoning about the cause” (Hipp. 1 Epid. Proem., 17A.6K). Galen considered Satyrus the most faithful transmitter of Quintus’s views on Hippocrates, suggesting that Satyrus, too, had Empiricist leanings.¹⁵

Galen’s early exposure to Empiricism permanently influenced his vision of medicine as above all grounded in practice. Throughout his life, Galen would continually refer to “deeds among the patients” as the most conclusive form of medical proof and heap scorn on those who clung to theories contradicted by the observable facts or accepted the doctrines they read in written sources without testing them against experience.¹⁶ Late in life, in his treatise On the Affected Parts, he writes:

I myself, if truth be told, whenever I hear Empiricist doctors talking about [how knowledge is acquired, and particularly how it is not necessary to know the mechanism by which something is effective if it demonstrably works], I consider their arguments highly persuasive, and I find the counterarguments raised by the Dogmatists not especially genuine; but just as in all other things, for my whole life, I have always refrained from unconsidered approval, also in these matters I strove for a long time in clinical practice [literally, “among the patients”] to discover whether I needed in addition some logical demonstration of remedies, or whether what I had learned from my own experience and from that with my teachers was enough.

(Loc. Affect. 3.3, 8.141–43K)

He adds, “I have no hatred for the Empiricists, on whose arguments I was raised, nor against any of the Dogmatists” (ibid. 8.144K). And in another late passage, from the second half of On the Method of Healing (9.4, 10.609K): “If everyone who undertook to teach and write something would first demonstrate these things with deeds, altogether few false things would be said.”

Galen credited his skill with the pulse (a field in which, as he writes, Empiricist contributions had been very extensive) and understanding of the “critical days” of fever, among other things, to exhaustive and repeated observation and experience; that is, experience was not only helpful in therapeutics. Galen credits midwives and athletic trainers with valuable knowledge gained purely from their experiences with injury and regimen. Like modern physicians, he refers often to what he has seen personally in proving a point, for example: “all those that we have seen, suffering from phrenitis in this way, died on the seventh day; a few, rarely, survived longer” (Hipp. 3 Epid. 3.75, 17A.760K).¹⁷

The Empiricists did not differ from what Galen calls “Rationalist” or “Dogmatist” physicians in the symptoms they observed or the remedies they prescribed; Galen insists that they all used the same therapies. Empiricists, like Dogmatists, took account of age, location, season, occupation, and regimen in their prescriptions, but apparently without theorizing a cause explaining the relevance of these factors. Empiric method emphasized acute observation—of the patient, the symptoms, the effects of remedies, the body and its wounds, or as Galen writes, the phenomena, the “the things that are evident”—above all else.¹⁸

Galen’s early Empiricist training may explain the prominent role of case histories in his writings, although they are also attested in other ancient medical authors and especially in the Hippocratic Corpus, the canon of Greek medicine’s earliest texts associated with its half-legendary founder, Hippocrates of Cos, and already about five hundred years old by Galen’s time. The seven books of Hippocratic Epidemics were composed mostly or entirely of case histories. When Galen argues with his Empiricist teacher about the indications for bloodletting or explains how he confirmed the efficacy of snake venom as a cure for elephantiasis in his treatise Outline of Empiricism, he recalls cases from his own experience or that of his teacher, or even stories whose origin may lie in folklore; it is possible that this reflects an Empiricist tradition of using case narratives as evidence, though it is not attested elsewhere.¹⁹ Several of Galen’s stories recount his first use or discovery of a treatment that proved efficacious with further testing, reflecting Empiricist ideas of knowledge, although he may use forms of reasoning not allowed in strict Empiricist doctrine in deciding which remedy to try. For example, at the end of the story of how he miraculously cured a patient with “chalkstones” using rancid cheese—the story with which this book begins—Galen writes that “this, which was known from our own ingenuity (epinoia), was confirmed by experience.” He introduces another story with a complex epistemological statement reflecting his debt to Empiricism and particularly the value he ascribed to repeated testing of a remedy:

But I shall tell you about a patient of this type on whom I first dared, led by reason, to disregard the diatritos [a Methodist remedy] and to aim at strength[ening the patient]. Afterward, seeing others similarly [afflicted], I was encouraged to treat them in the same way as [I had treated] him. For when the first trial has affirmed those things that were [originally] discovered by indication (endeixis, a type of logical inference forbidden in Empiricist doctrine), it renders people more confident in using it a second time.

(Meth. Med. 10.3, 10.671K)

Thus the modern case history traces its intellectual roots to antiquity, where it served many of the same functions: encoding the knowledge gained by clinical experience.²⁰

Galen contrasts the Empiricists with two other schools of medical thought, the Dogmatists or Rationalists, and the Methodists. The designation “Rationalist” or “Dogmatist” was relevant mainly in opposition to Empiricists, as it signified all sects that used long-traditional theories of causation and deductive reasoning; these were, then, very nonspecific words that encompassed several important and conflicting traditions, some of which also referred to themselves—or each other—as haireseis.

Galen, citing his father’s admonitions, did not consider himself an adherent of any sect. Had he completely rejected Empiricist views, however, Galen should have qualified as a “Rationalist” of some sort—certainly he makes ample use of deductive reasoning and accepts most Rationalist theories of the nature of the body and the etiology of disease. It may be his continued sympathy for some Empiricist principles, or possibly his intensely critical attitude toward the writings of virtually all his predecessors—except Hippocrates, who played a foundational and complex role in his thought—that qualified Galen as a free agent in his own mind.

As I have mentioned, Galen also distinguished a third sect, called the Methodists. Galen detested Methodists with an unwavering hostility that did not diminish at any point in his life. Methodists rejected Empiric epistemology because they postulated a theory of disease, based on Democritus’s “atomist” theory of physics: bodies are made of atoms and pores, and all diseases either result from compaction (where the atoms are pressed too tightly together) or flux (where the atoms are too dispersed) or some combination of those two things. Methodists differed from the other schools in the radical reductionism of their theory, which led them to reject (as Galen claims) anatomy and the study of most other medical traditions. The art of medicine, they believed, could be mastered in six months.

The Methodist school was founded in the first century B.C.E. by the shadowy Themison and made famous in the reign of Nero by the charismatic Thessalus of Tralles, who authored a famous letter to the emperor (quoted by Galen) denouncing the worthlessness of all previous medical writers, and called himself “champion physician” on his monumental tombstone that graced the Appian Way.²¹ Methodism maintained a glamorous appeal also in Galen’s day and may have been the dominant doctrine of the time, at least in aristocratic circles. Many of Galen’s stories describe triumphs over rival Methodist physicians, including some of the most renowned doctors of his era. The royal lady Annia Faustina travels with an entourage of Methodists with which she confronts Galen during his treatment of the prince Commodus. One of the most illustrious physicians of the second century C.E. after Galen himself, Soranus of Ephesus, was a Methodist; the latter is the author of the Gynecology, one of the few surviving medical treatises of the second century C.E. besides Galen’s own work; of treatises On Acute and Chronic Diseases, of which a fifth-century Latin translation by Caelius Aurelianus also survives; and of many lost works.²²

Galen heaps invective on the sect and the figure he treats as its founder, deriding Thessalus as an uneducated, low-class quack, son of a weaver and trainer of household slaves and craftsmen; contemporary Methodist rivals of Galen are incompetent, “amethodic,” or “the Thessalian ass.”²³ He particularly mocks the diatritos, the Methodist three-day unit of therapy (especially, a three-day fast at the onset of fever) that was apparently much in vogue in his day. But the extreme quality of his polemic only underlines that the Methodists were worthy rivals, over whom Galen’s intellectual legacy triumphed presumably with some difficulty.

The tripartite division of medicine into the Empiricist, Dogmatist, and Methodist traditions was not Galen’s invention but is attested earlier in the Latin medical writer Celsus. It is, however, in some ways an oversimplification of a complex intellectual heritage, as the discussion of Dogmatism above suggests. Within Empiricism and Methodism also there were separate and competing traditions; and Galen often identifies rival physicians not as Empiricists, Dogmatists, or Methodists but as followers of a specific tradition identified by its founding figure. Among these are notably Asclepiadeans or followers of Asclepiades, who in adopting atomist physics was a founding influence on the Methodist sect but did not count as Methodist himself; and Erasistrateans or followers of Erasistratus, who argued that the arteries contained air (pneuma) rather than blood and eschewed venesection, positions Galen criticizes.²⁴

Empiricists declined to buy into speculative assumptions about disease and the body; but as I have mentioned, Galen insists that they used the same remedies as Rationalists and considered most of the same factors as relevant. But Methodist theories of disease as the constriction or flux of atoms departed radically from what was by then a long tradition. The earliest Greek medical texts, the treatises of the Hippocratic Corpus, share (although it is not always explicit) a humoral idea of the body and its relationship to the world. The humors, essential bodily fluids, literally “juices,” were thus an ancient concept by Galen’s time. The Hippocratic treatise The Nature of Man is the most coherent and explicit description of a humoral doctrine (it is not, however, in all ways consistent with the ideas of other Hippocratic authors, who mostly postulated two or three essential humors). The Nature of Man is sweeping and schematic in its view, identifying no less, or more, than four humors. The new humor—the one lacking in other Hippocratic texts, the one probably added to make up the canonical number four—was black bile. The other humors were blood, phlegm, and yellow bile, and all together they were the essential components of man, whose health depended on their proper balance. Linked to the four humors were the four elemental qualities of hot, cold, wet, and dry; the four seasons, each matched to a pair of qualities and a corresponding humor; and four stages in human life.

Galen had a special affinity for this treatise, of which he believed Hippocrates himself was the genuine author, despite that Aristotle clearly attributed it to Polybus, Hippocrates’ son-in-law. Galen wrote two commentaries on it in the course of his life: the first called On the Elements According to Hippocrates, and a second, written much later, which comes down to us simply as On Hippocrates’ The Nature of Man. Galen would take the Hippocratic treatise’s schema further by linking (in some respects, loosely) the four humors to the four elements of fire, earth, air, and water, in the theory of physics first expounded by the mystic philosopher Empedocles in the fifth century B.C.E. Galen also seems to have originated the idea of what he called the “mixtures,” or temperaments, in which each humor, except phlegm, affected the state and character of the psyche or soul. Galen also wrote a separate treatise On Mixtures, here emphasizing “mixtures” not so much of humors as of the elemental qualities of hot, cold, wet, and dry, and their manifestations in body and soul. In his view there were nine possible temperaments: one dominated by each of the four elemental qualities; one dominated by each of the four possible combinations of two qualities; and an ideal temperament in which all were equally balanced. Still, the theory of the equivalence of four canonical temperaments with four humors—the phlegmatic, sanguine, choleric, and melancholic temperaments—that became popular in medieval Europe is not found in Galen’s work but is a later development.²⁵

Although he avoided adherence to any sect, Galen was proud of his intellectual descent from Quintus, the pre-eminent physician practicing in Rome under Hadrian; “the best doctor of his time.” Quintus, who was of Galen’s father’s generation, died shortly before Galen began his medical education; but Galen sought out Quintus’s students and learned from as many of them as possible, sparing no effort or expense. He only disdained, as he writes, to seek out Lycus, whom, as he claimed later, he considered a mediocre physician. Quintus’s Roman first name reflects a grant of citizenship, either to himself or to one of his ancestors; he was an ethnic Greek, for Galen apparently calls him a fellow Pergamene. Galen may have seen himself as following, eventually, in his illustrious predecessor’s footsteps, rising to prominence in Pergamum and then moving to Rome.²⁶

Quintus was especially renowned as an anatomist: he is called “the most anatomical man” by the hostile audience at one of Galen’s demonstrations (Libr. Propr. 2, 19.22K), and Galen mentions him several times in his treatise On Anatomical Procedures (where, for example, his distinguished predecessor dissects the scrotum of a living goat). Quintus’s teacher had been Marinus, the author of the most comprehensive work on anatomy known to Galen or available in his student years, before the appearance, in the 170s, of a work of comparable length (nineteen books) by the despised Lycus, and before the composition of Galen’s own great treatises On the Usefulness of the Parts and On Anatomical Procedures. Marinus’s exhaustive work ran to twenty books, and Galen eventually published a summary of it in four (both the original and Galen’s summary are now lost, but Galen describes the contents of his summary at length in On My Own Books, chapter 4; here Galen writes, not to be accused of ignorance of his rival’s work that, he also summarized the inferior treatise of Lycus, but in only two books). Galen credited Marinus with reviving the art of anatomy in his era and clearly considered his work fundamental, but he also found it full of errors, which he would demonstrate before audiences in live anatomical dissections in Rome. His surviving criticisms of Marinus, however, are mixed with respectful praise of his predecessor.²⁷ (Later, in the Renaissance, Galen’s own works will play roughly the same role in the anatomical career of his remote intellectual descendant Vesalius as Marinus’s played in Galen’s; see the Epilogue.)

But Quintus, like Galen himself and all the other physicians with whom he studied, was not only an anatomical expert; he taught Hippocratic textual criticism, pharmacology, and presumably other subjects, and also practiced medicine. Galen’s anecdotes about Quintus suggest a vigorous, rough-and-ready man whose patients complained that he stank of wine and who was forced to flee a conspiracy of his rivals to charge him with murdering his patients.²⁸

Quintus left only an exiguous written legacy. Galen learned of his views on Hippocrates through his pupils: “We first heard Satyrus’s exposition of Quintus, and later I read some of those of Lycus” (Ord. Libr. Propr. 3, 19.58K). On anatomy—the subject for which he was most renowned—Quintus composed no written works at all. Galen considered Satyrus’s memory of Quintus’s anatomical knowledge to be the most reliable; and Satyrus also left written works on anatomy.²⁹

Quintus’s most famous pupil Numisianus, whose instruction Galen sought (see below), also left few written works: he composed prolifically, but his son Heraclianus was jealous of his legacy and did not allow the works to circulate. One story even told that the son burned his father’s books on his deathbed. Galen wanted to see Numisianus’s books and tried to persuade Heraclianus to show them to him, when he was in Alexandria, but without success. Numisianus’s student Pelops, also Galen’s teacher, kept Numisianus’s works a secret—Galen accuses him of wishing to take credit for some of Numisianus’s ideas. Pelops’s own works, apparently, were mostly lost in a fire, though some books he composed for his students were still in circulation.³⁰

Galen never describes himself and his teachers as “followers of Quintus” or “Quinteans,” nor does he identify a specific and unifying set of doctrines that would distinguish them from competing “schools” or haireseis. Furthermore, Galen shows no dogmatic loyalty to his predecessors, proclaiming his advances over their mistakes and errors many times.³¹ But his intellectual genealogy is important to him: he takes great pains to identify himself as a second- and third-generation student of the great Quintus, the most famous anatomist in recent history. And not only this, he suggests that medical knowledge and discoveries particular to Quintus, Numisianus, and Pelops were transmitted personally from teacher to student and not available to others; Galen inherited a body of knowledge that was, in some ways, secret. His claim to adhere to no sect must be qualified in this sense.

A massive written medical literature had accumulated by Galen’s time, and there can be no doubt that Galen considered mastery of these texts fundamental to professional competence. Besides the Hippocratic Corpus (on which see more below) he recommends the works of many of the “ancients;” one list mentions Diocles, Pleistonicus, Phylotimus, Praxagoras, Dieuches, Herophilus, Erasistratus, and Asclepiades. Some of these authors are lost entirely; others survive in fragments (especially Diocles of Carystus, who wrote in the fourth century B.C.E.; Erasistratus and Herophilus of Alexandria, in the early third century B.C.E.; and Asclepiades of Bithynia, in the first century B.C.E.), largely in quotations from Galen’s works. But Galen believed that every educated physician should master them. Galen himself continually flaunted his knowledge of his predecessors’ work; huge percentages of some treatises are given over to blow-by-blow analysis (most often, criticism) of the arguments of previous medical writers. After the fire of 192 that destroyed his most valuable possessions, the loss he mourned most was not that of his own works, but of the precious manuscripts of ancient writers, to which he had added his own notes and comments. Clearly, medicine of the type that Galen learned and practiced was at least partly a textual discipline and medical education depended partly on a long and, by Galen’s time, extensive and exhaustive written tradition.³²

Most of the authors Galen names in his recommended curriculum wrote many centuries before him, illustrating that the modern obsession with currency—only the most recent work can be valuable—did not obtain in his time; in some ways the reverse was true, although a sense of medical progress is also evident in Galen, who especially perceives anatomical discoveries as building on predecessors (see chapter 5). But a unique role in medical education was played by the oldest body of works, the treatises attributed to Hippocrates. Hippocratic exegesis had a long history by Galen’s time. Galen considers his own educators, “Quintus and his students,” explicitly including his own teacher Satyrus, mediocre commentators on Hippocrates (“they did not understand the mind of Hippocrates accurately,” Ord. Libr. Propr. 3, 19.57–58K). He goes on to direct explicit criticism against the despised Lycus, while recommending the Hippocratic commentaries of one of Quintus’s other students, Numisianus, and Numisianus’s student Pelops, who was also Galen’s own teacher. Pelops, as Galen mentions elsewhere, wrote an introductory work on Hippocrates in at least three books. Stratonicus, one of Galen’s teachers at Pergamum, had been the student of Sabinus the Hippocratean, whose Hippocratic commentaries were the most exhaustive known to Galen.³³

Hippocrates and Hippocratic commentary clearly played a foundational role in Galen’s medical education and in medical education generally. Almost all significant medical writers had, apparently, commented on Hippocrates, and Galen’s own commentaries cite the interpretations of many predecessors dating at least as far back as Herophilus, Hippocrates’ first known commentator, in the early third century B.C.E. Galen himself had hoped to publish commentaries on all genuine Hippocratic works before his death (Ord. Libr. Propr. 3, 19.57K).

Galen mentions Hippocrates more than 2,500 times in his surviving works.³⁴ To do justice to his relationship to the Hippocratic Corpus would require a volume in itself. Later, Renaissance scientists would criticize Galen as a mere transmitter of Hippocratic views, but this is not the case; his use of the Hippocratic Corpus is much more complex. Galen was like early Christian exegetes who expanded on biblical texts and altered their meaning with their interpretations. The genuine Hippocrates, in Galen’s work, is laconic, often enigmatic, and virtually never wrong; but Galen did not consider all works transmitted in the Corpus to be genuine—nor are modern scholars able to identify which, if any, of the dozens of treatises it contains were written by Hippocrates.³⁵

The latter is a shadowy figure, known to Plato as a famous physician of the previous century; his name attracted folktales, spurious documents, and late biographies written centuries after his death, but few reliable facts are transmitted about him. The founding father of Greek medicine was said to have lived on the island of Cos in the later fifth century B.C.E., and the works that survive under his name, the Hippocratic Corpus, are the earliest Greek medical writings; but ancient commentators recognized contradictions and inconsistencies within the corpus and had long postulated multiple authors and competing schools (the ancient theory that a rival tradition had arisen on the nearby island of Cnidus is still widely accepted today, on no real evidence). Some Hippocratic treatises were very influential in antiquity and even through the modern period, for example the treatise On the Sacred Disease, which demystified epileptic seizures, arguing that they were caused by a blockage of phlegm in the brain and not by divine disfavor. Also the treatise Airs, Waters, Places, on the relationship between climate, health, and race; its descriptions of Scythians, Egyptians, and other peoples contrasted with Greeks resonated through centuries of imperialism and colonialism (notwithstanding that the Hippocratic author considered white northern Europeans as different from, and inferior to, his own people as Asians or Africans). The Oath is a statement of ethics that has served, off and on and with long hiatuses, as a touchstone of the medical profession’s identity over centuries; modern versions (mostly unrelated to the original in content) are used today in many western countries, especially the United States. The canonical Oath began with a long section on the obligations of the apprentice to his master and to his master’s family, and also included an abjuration of surgery, of sexual contact with the men and women of patients’ households (both slave and free), of giving patients lethal drugs even if they ask for them, and famously, of providing women with drugs for abortion. Much of it was obsolete even in Galen’s time.³⁶

Galen disdained to name himself the follower of any sect or individual and did not call himself a “Hippocratean,” as some other doctors did. But he considered knowledge of the Hippocratic Corpus a basic foundation of medical expertise. While he subjects virtually all other authorities in the long tradition of medical literature—including the iconic Plato and Aristotle, and all of his own teachers—to at least some criticism, and in some cases to hundreds of pages of outright polemic, Hippocrates is the exception, rarely if ever attacked in his work. In his treatise That the Best Physician is Also a Philosopher, Galen holds up (his version of) Hippocrates’ life, education, and ethics as the ideal.

While Galen and other sources list Hippocrates as the first Dogmatist, Empiricists also claimed him as their founder, emphasizing different texts—and Galen learned some of this Empiricist Hippocrates from his early teachers, as I have mentioned. Only the Methodists treated Hippocrates like any other authority, accepting what was valuable but mercilessly attacking the errors they perceived as typical of an entrenched, outmoded approach to medicine. It is one of Galen’s accusations against Lycus, the subpar student of Quintus, and Julian the Methodist and others of his sect, that they published critical interpretations of Hippocrates or, as Galen sees it, attacks on the ancient physician’s views (both wrote commentaries on the Hippocratic Aphorisms, of which Galen published his own refutations). Not that this was inappropriate in theory; Hippocrates’ accusers are just profoundly ignorant and wrong:

No blame should attach to Lycus or to anyone who wishes to write against Hippocrates. Still more blameless are those who are able to demolish the accusations badly pronounced against him . . . and especially when the one who accuses has made bold first to learn the things said [by Hippocrates], and when the spokesman for the defense has been educated in the ancient dogma.

(Adv. Lyc. 1, 18B.196K)

Lycus, of course, does not meet the criterion of a learned accuser, as Galen proceeds to demonstrate in the rest of his treatise.³⁷

Thus, Galen has a complicated relationship to the written medical tradition. In the earliest, foundational work lies medical truth; the skilled physician knows and understands the Hippocratic Corpus thoroughly, has commented on it (as several or all of Galen’s teachers had published commentaries), and can recall or quote any part of it at will, at the patient’s bedside:

I arrived and saw that the youth’s face was of the type which Hippocrates once described in his Prognostic in the following terms: ‘sharp nose, concave eyes,’ and the other things which, we know, are said by him after that . . .

(Meth. Med. 10.3, 10.673–74K)

or in oral combat with a rival on the streets of Rome:

On his way down to the Sandaliarion he [Martianus, a leading Erasistratean physician in Rome who is following Galen’s treatment of the philosopher Eudemus] met me by chance, and straightaway, without greeting me as his custom was, he asked whether I was familiar with the second book of the Prorrhetics of Hippocrates, or whether I was entirely ignorant of that work; and hearing that I was familiar with it, and that it seemed to me that those doctors were correct who declared that it was not one of the genuine books of Hippocrates, “In any case you know therefore,” he said, “the statement in it, ‘I make no prophecy about these things?’”

(Praecog. 4, 14.620K)

Here Galen flaunts his status as expert on Hippocratic textual criticism, dismissing as spurious a work aggressively deployed by a rival in a high-profile case.

Thus, Galen studied and mastered the writings of his predecessors. Sometimes, he demonstrated his erudition in spectacular public displays—as when he produced all of the anatomical works then in circulation, amounting to an enormous pile of dozens of scrolls, claiming that he would prove the superiority of his own views over those of his predecessors in a live display of animal dissection. Galen also, in his turn, wrote didactic works for his own students—calling several of his treatises “for beginners” and recommending that these be read first.³⁸ But Galen intended these books to be used in conjunction with practical experience, not on their own. His anatomical treatises were handbooks for live dissection. Galen remarked on the difficulty of recognizing parts that one has not repeatedly observed—those who rely only on reading will have difficulty recognizing what they see the first time (Anat. Admin. 1.2, 2.223–24K). Indeed, as he writes,

of those who have seen the parts of the body shown by a teacher, none is able to remember accurately having seen them only once or twice, but it is necessary to see them many times.

(Comp. Med. Gen. 3.2, 13.608K)

Galen labels anatomical treatises a late phenomenon, originally unnecessary—the ancient physicians, in his imagination, learned dissection even as children and had no need for the works he calls “memoranda” or “notes” of the kind first produced by Diocles in the mid-fourth century B.C.E.; he uses the same word (hypomnemata) to characterize many of his own anatomical works.³⁹ The written anatomical tradition is a concession to what he perceives as the decline of medicine in later times. Not only anatomical treatises, but written works in general are only supplementary to medical teaching:

The best teaching is the teaching by live voice, and . . . from a book neither the helmsman nor the practitioner of any craft can be trained. These [books] are memoranda for those who are already learned, not a complete education for the ignorant.

(Aliment. Fac. 1.1, 6.480K)

The learning of methods only, without a variety of practices in them, is unable to produce well-trained students.

(Loc. Affect. 2.10, 8.123K)

Galen’s literary erudition has been much appreciated by modern scholars. But much of Galen’s medical education, as I have shown above, was also practical: he saw and even treated patients together with his teachers and drew on these experiences throughout his lifetime; he watched animal dissections and performed them himself; he mixed drugs; he will, at Rome, use these same methods to train his own students. Far from deferring passively to his teachers’ authority, he argued with them vigorously; his arrogance and, at times, open contempt must have been a trial to them. “I looked down on many of my teachers,” as he writes, “even as an adolescent” (Anim. Peccat. Dign. 3, 5.70K).

The last years of Galen’s adolescence at Pergamum were pivotal, as a story from On Good and Bad Humors indicates. His father was, at that time, no longer living in the city; perhaps exhausted and financially drained by the civic responsibilities he had taken on a few years earlier (and which had called him away from his personal instruction of his teenage son), he took up residence in the countryside as a gentleman-farmer. Galen remained in town to study. “I pursued my studies beyond all of my fellow students not only every day, but at night as well.” Now free from direct parental supervision, in the “dog days” of the late summer, he and his friends indulged their love of fresh fruit (which Galen considered unhealthy, and which, available only in season, was in any case eaten much less commonly than cooked, dried, or pickled fruit). In fall, Galen became very ill. His symptoms, from what we can tell based on other stories that may refer to the same incident, included a piercing pain in the abdomen and the excretion of clear mucus, and possibly a burning fever with delirium causing him to pluck at straws and imaginary pieces of wool. The modern medical term for the latter symptom is carphology, and it is an ominous sign. His father, who had apparently never allowed Galen to eat fresh fruit, returned to the city and reproached him for succumbing to peer pressure and altering his long-standing dietary habits; no doubt alarmed by the dangerous condition of his beloved and only son, he supervised Galen’s lifestyle personally for the next year. Then, when Galen was nineteen, he died.⁴⁰

Letting blood from a vein relieved Galen’s symptoms, but not for long. Galen had never, from childhood, had an especially healthy constitution, as he tells us in his treatise On Healthfulness (5.1, 6.308–9K)—“in childhood and later as a pubescent boy and an adolescent I suffered from no few and no trivial diseases.” In another passage he writes that in his youth he suffered four times from tertian fever, and once from the intense and burning fever called kausos (Trem. Palp. 7, 7.638K). As for the particular illness that struck him at eighteen, one modern study tentatively diagnoses amoebic dysentery; amoebic infections, if untreated, can persist for years and lead to abscesses in the liver, and are one of the world’s leading causes of mortality today. Galen’s condition recurred in the year following his father’s death, when Galen, once more a free agent, indulged liberally in the fruits of late summer and suffered a relapse. His condition returned annually—but skipping some years—until Galen was twenty-seven, when it reached a critical point: “I arrived at danger, lest there might be an abscess in the part at which the liver adheres to the transverse septum.” Galen was then at Alexandria; I shall take up the continuation of the story below.⁴¹

Galen makes no comment, here or elsewhere in his surviving work, on his father’s death. But he writes of him always with love and reverence, and this event must have affected him deeply; a sense of loss could explain the vehemence with which he excoriates his youthful dietary mistakes in the story from On Good and Bad Humors. It may also have catalyzed his decision to leave Pergamum to pursue his education in the wider world. This happened some time shortly after his father’s death; we do not know exactly when, but Galen was still an “adolescent,” meirakion, when he studied under his next teacher, Pelops, at Smyrna.⁴² Perhaps, having inherited his father’s estate, Galen was freer to indulge an increasing thirst for knowledge and professional advancement. He seems to have known he was a special student and may have already formed the project in his mind of tracking down and learning from all the students of the legendary Quintus. He perhaps hoped and believed that he would one day be the next Quintus.

Galen had already met Pelops. He had seen him debate medical epistemology with an Empiricist named Philippus who argued that medicine can be known through experience alone. He had later written up their arguments in one of his first treatises—this work On Medical Experience survives today in Arabic translation, although the Greek has been lost. Together with On the Anatomy of the Uterus, mentioned above, and another lost treatise On the Diagnosis of Eye Diseases, it made up the juvenile written legacy he left behind him at Pergamum. The works circulated in his absence and he came across them again when he returned from his first sojourn in Rome, almost twenty years later. Galen also describes a debate between Pelops and his Pergamene teacher Satyrus, which he may have witnessed as Satyrus’s student: the subject was similar, for Satyrus argued skeptically that most people do not know what blood is (Galen’s subject in this treatise is words and their meaning).⁴³

In any case, sometime not long after his father’s death in 148 C.E. Galen left Pergamum to study at Smyrna, principally, as he writes above, under Pelops, “my second teacher after Satyrus.” He would not return until 157. Pelops was the foremost student of Numisianus, Quintus’s most illustrious student; Galen will later seek out the latter as a teacher. I have mentioned above some of the details of Galen’s studies with Pelops—Galen visited patients with him, and particularly remembered a consultation on an epileptic boy of thirteen; from Pelops he learned “the signs of the humors,” anatomy, pharmacology, Hippocratic exegesis, and probably many more subjects that he does not mention; he criticized Pelops’s ideas that crab meat was a good cure for rabies, and that the source of all the blood vessels was the brain. Pelops wrote sparingly and was secretive about his books; he failed to copy them, he kept them in his house, and they mostly perished after his death. Among the lost treatises was an exhaustive work on anatomy of which Galen thought very highly. Only “such writings as he used to hand over to his pupils . . . when his pupils wished to return to their homes” survived and circulated (Anat. Admin. 14.1, 1:232 Simon, tr. Duckworth). We learn incidentally in this passage that Pelops had died by the time Galen wrote the first books of On Anatomical Procedures, in the early 170s.

While a student of Pelops, Galen himself produced one anatomical work, On the Motion of the Chest and Lungs, in three books

doing a favor for fellow student who was about to depart on a journey to his homeland, so that he could practice according to it, to perform a certain anatomical demonstration.

(Libr. Propr. 2, 19.17K)⁴⁴

The book does not survive, but Galen’s work on these muscles became one of his most important contributions to anatomy. This example, and also the story of Pelops’s works, illustrate once again how texts were produced not for their own sake, but for social and practical reasons—as memoranda to students about to depart, who would no longer be able to benefit from the live instruction of their teachers; as guides to dissection, which might be performed as a public demonstration; as favors to friends.

We do not know how long Galen stayed with Pelops. It is certain that during this period he traveled to cities he does not mention and studied with individuals whose names he does not record. “I knew all the students of Quintus, and I was not deterred by the length of the journey by land or by sea” (Anat. Admin. 4.10, 2.469–70K); “all of whom I took great pains to meet, and whom I found to be inferior to Satyrus and Pelops” (Anat. Admin. 14.1, 232 Simon, tr. Duckworth). As I have mentioned, he never met Lycus of Macedonia, a decision he defends in retrospect; “he . . . had no great reputation among the Greeks. Had that not been the case, I most certainly would not have omitted to go and see him also” (ibid., tr. Duckworth). Lycus would go on to publish a lengthy and well-received treatise on anatomy that appeared just before Galen’s own masterpiece on the subject, On the Usefulness of the Parts (see chapter 5), and Galen was obliged to dedicate considerable energies to demolishing that work and, perhaps, to explain why he never studied with the man who became Quintus’s most influential student of anatomy. (Later Galen will meet one Antigenes in Rome, also a student of Quintus, whom he either thought, like Lycus, unworthy of learning from, or of whom he had not heard previously; Praecog. 3, 14.613K)

Galen tells us that he pursued Pelops’s teacher, Quintus’s brilliant student Numisianus, to several locations: “Next [after Smyrna], I was in Corinth on account of Numisianus, who was himself the most famous of the students of Quintus, and in Alexandria and some other places in which I learned that Numisianus, the famous student of Quintus, was living” (Anat. Admin. 1, 2.217–18K). An alternate version of this passage is preserved in Arabic translation: “places in which I learned that a famous student of Quintus or of Numisianus was living,” which makes more sense—it seems unlikely that Galen pursued Numisianus around the Mediterranean without ever meeting him, as the first version of the passage implies, but he affirms elsewhere that he went to great lengths to track down the students of Quintus.⁴⁵ As mentioned above, Pelops had been unforthcoming with Numisianus’s anatomical discoveries—“[he] did not expound [Numisianus’s works] nor did he show them to anyone, for he preferred that certain theories, as yet unknown, should be attributed to himself” (Anat. Admin. 14.1, 232 Simon, tr. Duckworth)—and it is easy to imagine Galen’s frustration at being denied access to the discoveries of the greatest anatomist of his time. It is possible that Numisianus died shortly after Galen began to seek him out, and that this explains why Galen apparently never found him. Numisianus was considerably older, perhaps of the same generation as his own teacher Quintus, for “in [Quintus’s teacher] Marinus’s lifetime [he, Numisianus] had already become pre-eminent in Alexandria” (Anat. Admin. 14.1, 231 Simon, tr. Duckworth).

Galen’s quest for the intellectual legacy of Numisianus took him, eventually, to Alexandria in Egypt, the city in which Numisianus had achieved fame and where his son Heraclianus still lived. Galen arrived sometime between 151 and 153 C.E. and would remain until 157. He arrived in autumn. It was inevitable that his single-minded quest for the best and most brilliant medical education would take him to Alexandria, which was, in terms of prestige, the Harvard or Cambridge of antiquity. It boasted an ancient and famous tradition of medical research, particularly in anatomy. Galen’s era knew no medical schools in the modern sense; he studied with individuals, not institutions, but Alexandria’s glorious reputation attracted the best medical minds. Quintus himself had perhaps studied in Alexandria—Galen links the location vaguely with Quintus’s teacher, Marinus—and for Galen, perhaps intent on reduplicating his famous fellow citizen’s career, it was a natural destination.⁴⁶

Alexander the Great founded Alexandria on the Nile delta in 331 B.C.E. on campaign against the Persians—Egypt, as it happened, surrendered peacefully—and named it after himself. It became the capital city and residence of the Macedonian dynasty of Ptolemies that ruled Egypt after his death. In 30 B.C.E., after the defeat and suicide of Cleopatra VII, last of the Ptolemies, Egypt became a Roman province; Alexandria continued to be its administrative capital. In Galen’s time its population was probably second only to that of Rome itself (modern scholars usually estimate, on very little evidence, a population of about 500,000, while the figures of 300,000 and 750,000 transmitted in ancient sources have no more secure basis). It was famous for its lighthouse on the island of Pharos—one of the seven wonders of the ancient world, and its tallest Greek structure, over 100 meters high—for its royal palaces, its temple of Sarapis, and for the monumental tomb of Alexander, whose body was transported there after his death at Babylon, purloined, it was said, by Ptolemy I Soter, who was buried at the same site along with his royal successors. But today the archaeological remains of ancient Alexandria are very exiguous. Much of what survived the medieval and Ottoman periods was destroyed to build the modern city in the nineteenth century, and today even the locations of some of antiquity’s most renowned monuments—the tomb of Alexander, the Library (see below)—are unknown.⁴⁷

Alexandria’s Museum (Musaion, “place of the Muses”), with its attached Library—the second Ptolemy’s aggressive acquisition of its collection of books was the subject of much comment, anecdote, and legend—was antiquity’s first research institution. According to Strabo the geographer, writing in the first century C.E., it had its own grounds and buildings within the royal palaces; the fortunate scholars attached to the Museum, beneficiaries of royal (and later, imperial) patronage, enjoyed communal property rights and free meals for life in the common cafeteria (Str. 17.1.8).

Other Musea existed in the Roman world’s great cities, notably the one at Pergamum; but the Alexandrian Museum was the most renowned. However, Galen never mentions it—just as he never mentions the Museum at Pergamum—suggesting that it played little or no role in his education (nor is the Museum mentioned in connection with any of Alexandria’s other famous physicians, in any source). Alexandria attracted scholars through its reputation and the very illustrious record of research produced there, which was fueled partly by the Museum, but scholarly activity extended far beyond the narrow group of intellectuals it supported. From early in its history the city had been the center of ancient literary and textual criticism, and it was in Hellenistic Alexandria that many ancient texts took the form in which we know them today, under the scrutiny of early editors and commentators; and it was there that the canon of the Hippocratic Corpus took shape. Galen was himself a prolific and adept editor and exegete of Hippocrates, a skill he learned from his earliest teachers, but he also mentions the “Hippocratics” at Alexandria (see below).⁴⁸

Very early in its history, Alexandria acquired a reputation for medical research. Under the first two Ptolemies, the physicians Herophilus and Erasistratus became antiquity’s most renowned anatomists. Dissections and vivisections of animals had been practiced for some time, notably by Aristotle, who also refers to a treatise of his own authorship, now lost, on Dissections. Galen ascribes the first anatomical handbook to Diocles of Carystus, perhaps a rough contemporary of Aristotle, a generation or two before Herophilus.⁴⁹

But Herophilus and Erasistratus not only took the study of anatomy to new heights; they also dissected humans. They were the first, and almost the only, ancient physicians to do this; certainly they were the only physicians of antiquity whose discoveries based on human anatomy were ever published or known. Tradition recounted that they also vivisected humans, and that their victims, condemned criminals, were supplied by the Ptolemies. There is little doubt that Herophilus and Erasistratus, unlike any of the other ancient physicians whose names we know, dissected human corpses (Galen knew of Herophilus’s experience with human dissection, having learned this very early in his education; he mentions it in On the Anatomy of the Uterus, written while he was still at Pergamum with Satyrus). It is less clear that the vivisections actually happened. Those references that derive from Christian polemical literature—hostile to all scientific endeavor and eager to exaggerate pagan atrocities—are not especially trustworthy. But we also have the more reliable testimony of the first-century Latin author Celsus that live criminals were handed over to Herophilus and Erasistratus for experimentation. (Celsus also transmits the rationalization, notorious in modern times, offered by his sources for a practice he considered cruel and unnecessary: that the sacrifice of a few guilty criminals in order to seek remedies for the innocent masses is justified. The most likely sources of this rationalization—though he does not name them—are Herophilus and Erasistratus themselves.) Thus, we cannot exclude the disconcerting possibility (or likelihood) that some of the ancient anatomical knowledge on which Galen relied, and which he transmitted through his own writings down through the centuries to the founding fathers of modern medicine in the Renaissance, derives from the vivisection of live human subjects in experiments that are ghastly to imagine even on animals.⁵⁰

References to human dissection are otherwise very rare. It is unclear why these early Alexandrian physicians could ignore the taboo against cutting open human bodies. This taboo apparently reigned supreme in other eras, although medical writers such as Celsus and Galen not only believed in the value of human dissection but, to Galen, it became a holy grail of sorts. Scholars have suggested that an atmosphere of “frontiersmanship” in the newly founded city of Alexandria was responsible; also perhaps Greek prejudice against native Egyptians, who may have been the subjects and victims of dissection and vivisection, in a society more segregated than would later be possible. (In the Roman period, colleagues of Galen would be allowed to dissect the corpse of a German “barbarian”; see chapter 6.) Also, the native Egyptian tradition of mummification was well-known to Greeks. Social barriers probably prevented any direct transmission of knowledge, for which we have no evidence. Nor is there any evidence that Egyptian embalmers or native Egyptian physicians practiced scientific dissection or vivisection; quite the opposite, for the practice of embalming was itself hedged round with strict taboos. Nevertheless, the Egyptian religious practice may have helped justify what would otherwise have been unthinkable, even as the Macedonian monarchs, in imitation of the Pharaohs, shattered a different taboo by marrying their siblings.⁵¹

Whatever the reason, human dissection is very poorly attested outside of Alexandria, and there only in the first decades after the city’s foundation. But Alexandria retained some of its grisly reputation for experiment on human subjects. Cleopatra VII supposedly tested poisons on condemned criminals (like earlier Hellenistic monarchs, Mithradates VI of Pontus and Attalus III of Pergamum). Much later, Galen saw human bones at Alexandria, where they were used to demonstrate anatomy, a practice he describes with approval, and urges all students of medicine to visit Alexandria for this reason. Galen himself seized every opportunity to observe human anatomy, as when a river overflowed and washed away a tomb with its fully articulated skeleton, or when, by the roadside, he happened across the remains—so the locals told him—of a bandit murdered by his would-be victim. In On Theriac to Piso, which may not be genuine, Galen writes that he “often” witnessed executions in Alexandria and, recalling the memory much later as an old man, commented on the swiftness with which the venom of the snakes used for this purpose, possibly Egyptian cobras, took effect. The snakes, he writes, were hurled against the chests of the victims, who were then made to walk around.⁵²

The high expectations with which Galen went to Alexandria seem to have been disappointed. He was well received there—by Heraclianus, Numisianus’s son, among others. But despite paying assiduous court to the latter over what sounds like a long time, as I mentioned earlier, he never won a glance at Numisianus’s written legacy, the books still in his son’s possession. Thus, although Galen considered Numisianus the foremost anatomist of his time, he attributes no discoveries or ideas to him—whether out of spite or because he acquired no clear or useful sense of Numisianus’s legacy from its tight-lipped custodians or from the meager selection of his written works that circulated.

Nor does Galen mention any of his teachers at Alexandria besides Heraclianus, either directly or indirectly, with one dubious exception—he knew the Methodist Julian, though Galen disdains to call him one of his teachers. Galen’s hostility to Julian far outlasted his student days. Twenty years later, and at a distance, from Rome, Galen continues to rail against the Methodist—then still alive, as he writes—in his massive tract On the Method of Healing, recalling a debate in which he humiliated Julian partly by convicting him of contradicting his “grandfather in teaching,” Olympicus (a hypocritical remark from Galen, who does not hesitate to criticize his own intellectual ancestors). Presented with Julian’s work on the Hippocratic Aphorisms, Galen delivered improvised public lectures refuting it over the course of six days, and then, at the insistence of his friends, published his arguments in the extant Against Julian’s Criticisms of the Aphorisms of Hippocrates. The treatise is not mentioned in On My Own Books and may postdate it; if so, Julian had become a lifelong target of Galen’s polemics.⁵³

As for the other Hippocratic commentators of Alexandria—including those physicians formally calling themselves “Hippocratics”—Galen has nothing flattering to say about them either. He mentions Sabinus, the teacher of his own teacher Stratonicus, and Metrodorus of Alexandria, as execrable interpreters of Hippocrates. Of Metrodorus he adds that his understanding was so flawed that one of his students, Philistion of Pergamum, lost all of his patients after an embarrassing effort to treat a wealthy woman for infertility (after demanding a huge fee he made her eat half-roasted inkfish, which she vomited violently).⁵⁴

To sum up, then, Galen’s training in medicine before moving on: This began at age sixteen, with a number of physicians, representing different schools, in Pergamum. After his father’s death, Galen traveled to Smyrna, to Corinth, to other undisclosed cities, and finally to Alexandria, all in pursuit of medical knowledge. He especially sought out the students of Quintus, a Pergamene who had practiced in Rome, renowned as an anatomist and as continuator of the tradition of his own teacher, Marinus, whose comprehensive work on anatomy was the equivalent of the standard graduate-level textbook on the subject at the time. Galen learned anatomy through animal dissection and sometimes through human subjects, as when he saw human bones at Alexandria, or observed muscles and nerves through the wasted flesh of disease victims at Pergamum. He also learned Hippocratic exegesis, pharmacology, and especially, clinical medicine from his teachers. From the very beginning of his training, he saw patients, and throughout his life expressed disdain for the “word-doctors” (logiatroi) for whom medicine was more about texts and ideas than practice.

Alexandria must have been an experience in itself, not just a place to learn. In Roman times it had a diverse population of which the elite was the exclusive, Hellenized, gymnasium-educated class of Alexandrian citizens, who were alone eligible for Roman citizenship. But the population of resident Egyptians was very large. How much Galen interacted with ethnic Egyptians—people he did not consider Greek—in the city or in the countryside, and how much he observed of native culture, is unclear but seems quite limited. It is unlikely that he could communicate directly with the peasant population, which mostly spoke Egyptian. Galen tells one story of a peasant who was bitten on the finger by a snake “when I was at Alexandria;” the peasant hurried to the city and demanded that a physician amputate the finger, which proved effective (Loc. Affect. 3.11, 8.197K). He does not say that he knew the patient or the physician and may have heard the story from a third party.

Galen brought with him to Egypt a theory of the relationship between geographic zone, climate, and race, familiar to all educated Greeks, and expectations about the nature and temperament of the local population: Egyptians should be slender, hot, dry, and hard. He makes no comment on whether his experiences in Egypt confirmed these theories. As he does for other locations, Galen notes dietary practices that he considers unusual: Egyptians eat large quantities of pistachios, with no harmful (or beneficial) effects that he has observed. They are, he writes, also able to eat donkey meat and camel meat with no ill effects; however, in another passage Galen identifies donkey meat as the cause of Alexandria’s high incidence of elephantiasis. This ancient term “elephantiasis,” which Galen describes as a severely disfiguring skin condition whose victims were shunned as repellent and sometimes driven to suicide, signifies the disease called leprosy today (see further in chapter 4 below; Galen believed he could control or cure elephantiasis through phlebotomy and snake venom). Galen also observed “some people suffering from dropsy and many who were splenetic” treating themselves with applications of Egyptian mud, with good results.⁵⁵

All this reminds us that disease in antiquity, especially in an urban environment and perhaps especially in Egypt, was much more visible than it is in modern western cities or even in the poorest and most overcrowded cities of the developing world, where medical and public health advances of recent centuries have, with the exception of parts of sub-Saharan Africa, expanded life expectancy far beyond pre-modern parameters. Although Alexandria had a reputation for healthfulness and although its coastal location probably spared it some of the endemic diseases of the interior, Egypt was burdened with innumerable gastrointestinal and respiratory illnesses, fevers, and parasites, and a mortality rate shocking to modern sensibilities, a situation that did not improve much until the mid-twentieth century.⁵⁶

Alexandria had a large Jewish population and was the center of Hellenized Jewish culture in antiquity. The most ancient and widely used Greek translation of the Hebrew Bible, the Septuagint, originated there under Ptolemy Philadelphus in the mid-third century B.C.E.; according to legend seventy-two scholars, all working independently in isolation, miraculously produced the same translation. In the Roman era conflicts between the Jewish and Greek populations of Alexandria sometimes became violent, and anti-Semitic feeling among the Greeks seems to have been, at times, intense. “Acts” of Alexandrian martyrs who defied the Romans, often because of their perceived support for the Alexandrian Jews, were popular enough that several examples survive on papyrus. A particularly horrific sequence of events—in which the Alexandrian Greeks with the cooperation of the Roman prefect, Flaccus, rioted against the Jews, looted property, cruelly lynched many victims and drove the entire Jewish population into a single quarter of the city—is well-attested in a surviving speech by the Jewish philosopher Philo of Alexandria, who pleaded the Jews’ case to the Roman emperor Claudius. Closer to Galen’s time, in the second century, there are hints of violent episodes but we know little about them. It is clear, however, that Jews continued to be a large and vital force in the city. Galen does not mention interacting with Jewish intellectuals at Alexandria, at Rome or anywhere else. He was, however, familiar with Judaism, and also with Christianity. While his comments are typical of references to both religions in other Greek sources and do not necessarily reflect firsthand knowledge (see chapter 5), it is quite possible that he encountered both Jews and Christians at Alexandria.⁵⁷

Wherever he studied, Galen was part of a cohort of other students. Some of them were his friends. At Rome he knew Teuthras, “a fellow citizen and fellow student of mine”; probably they had studied medicine or philosophy together at Pergamum, and both had emigrated to Rome. In the story of the onset of his long illness at Pergamum, Galen refers to “my fellow students” and “my age-mates” as bad influences on his diet—clearly he was spending a lot of time with them and they were eating meals together. When delirious with fever and plucking at imaginary pieces of wool and straw, he remembers speaking semi-lucidly to two friends who were attending him, and who immediately set about bathing his head. Another story about travel with friends must refer either to Pergamum or Smyrna—Galen and his companions were all still adolescents (meirakia) when it occurred. “Traveling in the countryside not far from the city” they fell in with some peasant folk, and, famished, accepted their offer of boiled wheat, which caused all three of the young men severe indigestion. All of this suggests that friendships with young men of his own age, many of them probably fellow students, were important in Galen’s early years at Pergamum and Smyrna.⁵⁸

Also at Alexandria: later at Rome, Galen described the diet of “a certain youth who practices medicine at Alexandria,” perhaps a friend from his days of study there, in great detail. He was astonished that anyone could maintain health eating only raw foods for four years (this may be an indication that Galen lived in Alexandria for four years, the minimum time that fits the chronology of his life). He also observed the paroxysmal illness of another student, “a certain youth, one of our fellow students in Alexandria, when we first sailed there at the beginning of autumn”; Galen advised and encouraged him, recalling a female patient from his home country with similar symptoms. The cause of the man’s illness was eating fresh dates.⁵⁹

Galen himself continued to suffer from the illness whose onset, at age seventeen, had so preoccupied his father near the end of his life.

. . . sometimes I was sick every year, sometimes I would skip a year, until my twenty-eighth year; at which time I came into danger of an abscess in the part at which the liver adheres to the transverse septum, and I forbade to myself the use of all fresh fruits, except figs and perfectly ripened grapes, and even these only in moderation, not like before.

(Bon. Mal. Suc. 1, 6.756–57K)

Once again, friendships with his contemporaries are important: “I had a certain companion in this plan, two years older than I. Applying ourselves to the gymnasium and to not suffering from indigestion, we have remained free from disease until now, for a space of many years.” This friendship, like the one with Teuthras, seems to have migrated to Rome and endured a long time. Galen refers to his soundness of health from age twenty-seven again in his treatise On Healthfulness. Despite a stressful life of professional obligations and study, “from my twenty-eighth year, after the beginning of my persuasion that there is an art of health, I obeyed its commands for all my life after that, so that I have suffered from no disease, except an occasional daily fever” (San. Tuend. 5.1, 6.309K).

In these passages Galen attributes his recovery to regimen, but elsewhere he credits a radical new therapy that he tried for the first time on himself. He was saved by a series of dreams:

Exhorted by certain dreams, of which two came to me distinctly, I went to the artery in the middle between the forefinger and the middle finger of the right hand, and allowed the blood to flow until it stopped by itself. Not quite a whole pound flowed out. Immediately a chronic pain ceased which was fixed mainly in that part where the liver meets the diaphragm. This happened to me when I was young with respect to stage of life.

(Cur. Ven. Sect. 23, 11.314–15K)

Normally only veins were bled; Galen here at the end of his treatise On Treatment by Venesection is making a case for arteriotomy, or letting blood from the arteries, in certain circumstances. This incident, he writes, inspired him to use the procedure in other cases. The dream perhaps came from Asclepius: Galen does not say so in this passage, but goes on to tell a story about another patient, a suppliant of Asclepius at Pergamum, saved by similar means as directed in a dream. Later, Galen would tell the emperor Marcus Aurelius that “I had declared myself his [Asclepius’s] servant ever since he had saved me from a deadly condition of an abscess” (Libr. Propr. 2, 19.18–19K).

It is not entirely certain that all of these three references—the long story that Galen tells in On Good and Bad Humors about the onset, development, and resolution of his abdominal illness, and the briefer references in On Treatment by Venesection and On My Own Books to an abscess from which he was saved by dreams and by Asclepius—recall the same episode.⁶⁰ But if they do, I have several reasons for believing that Asclepius’s intervention occurred at age twenty-seven and not in Galen’s teens as some scholars have assumed. First, had the dream happened while he was still a teenager at Pergamum, Galen would not describe himself as “young,” (neos); he would call himself an adolescent (meirakion), as he does in all other anecdotes about his early education at Pergamum. Galen is consistent and precise in his use of words for the stages of life; as he emphasizes here with the phrase “young with respect to stage of life.”⁶¹ Also, in the passage from On Treatment by Venesection he refers to the pain of which he was relieved as long-lasting (chronion). Further, Galen tells Marcus that he was saved from an abscess; which condition only developed, or threatened to develop, late in the illness described in On Good and Bad Humors. Finally, Galen is explicit that his dreams prescribed arteriotomy; this is the whole point of the anecdote in On Treatment by Venesection. In the story from On Good and Bad Humors, Galen specifically states that in its early stages his illness was treated with phlebotomy, by cutting a vein, not an artery.

Thus we may reconstruct the following story of Galen’s illness: he suffered a condition causing him abdominal pain over a period of ten years, beginning at age seventeen. He diagnosed an abscess and attributed its cause to the unwise and immoderate ingestion of fresh fruits. The disease, he believed, would have been fatal, suggesting that his pain was very great; but when he was twenty-seven years old Asclepius, in several dreams and especially in two that made a strong impression, sent signs that Galen interpreted as directing him to cut the artery between his right index and middle fingers. With this—and also with a change of lifestyle, for Galen foreswore most fresh fruit and took up regular visits to the gymnasium—he was cured, and remained in remarkable health for decades afterward. This dramatic change of circumstances is the last dateable event of Galen’s stay in Alexandria.