t this point we lose the narrative thread of Galen’s life. We know—from one vague reference—that he suffered in the reign of Marcus’s son and successor, the unstable and narcissistic emperor Commodus, fearing for his home and property if he should be arbitrarily exiled (Ind. 54–55). Galen’s writings, which contain many internal and cross-references, can be more or less organized in relative chronological order, but they contain few references to dateable events in his own life or in the world around him. There is a major exception—the fire of 192 C.E., which changed his life and which will be described in the next chapter. His treatise On Theriac to Piso, long considered spurious but now accepted as genuine by many scholars, addresses the emperors Severus and Caracalla and must date to after 204 C.E. because it refers to an event from the Secular Games of that year. If he did write this treatise, it proves that Galen was still to be found in Rome forty years from the date that Marcus Aurelius recalled him to Italy.1 He seems to have visited Pergamum, where he still owned property, at least once; he stopped at Lemnos for the second time on the way, as mentioned in previous chapters. But there is no obvious evidence in his writings of a long stay outside of Italy. He implies that he served each successive emperor after Marcus Aurelius in turn in some capacity, in his discussion of cinnamon from On Antidotes (see chapter 6), and probably remained on the imperial payroll. He continued to anatomize—this is very likely, because he continued work on the exhaustive treatise On Anatomical Procedures and rewrote the final books when they were lost in the fire of 192 (Anat. Admin. 11.11, 135 Simon). He continued to write very prolifically; his lengthy pharmacological treatises and the second half of his great therapeutic tract On the Method of Healing, among many other works, date to after the fire and the last decades of his life. But most importantly, he treated patients.
Galen describes hundreds of individual cases, anecdotally, in his surviving works. Visits to patients were a normal part of his daily life, and he performed these so diligently that it is difficult to understand how he also had the time to anatomize and to write, as he clearly did, or even to mix the emperor’s theriac. He visited his sick patients every day, sometimes more than once. He might respond to a summons in the middle of the night and might begin his round of examinations before dawn; he mentions visiting patients in the morning, afternoon, evening, and late at night. Into the room of one patient, suffering from a wasting illness, Galen brought a lactating donkey so that he could suckle its milk directly. Another patient, a steward (probably a slave or freedman) suffering from an eye inflammation, lived in a suburb too far for Galen to visit, so Galen brought him home to live in his house, where he bled him twice and treated him several times per day with eye salve.2
While this seems to be an exceptional case—most of Galen’s patients did not live with him—it is clear that he operated a clinic in his own house, as for example in the story of the patient with chalkstones from the preface to this book: this old man was carried to Galen’s doorstep, and the wording of several other stories suggest that patients came to Galen rather than the other way around. Just as other craftsmen in antiquity lived in or adjacent to their shops, so physicians like Galen worked from their homes, where they not only treated patients but also, for example, mixed drugs. One patient, arriving at Galen’s door with a knee injury exacerbated by a cold winter, asked him for a heating drug to relieve the pain and then departed for the baths. Galen did not have the drug he requested but prepared a concoction of euphorbia, oil, and melted wax, and handed it over when the patient sent for it (no doubt via slave messenger).3
Galen’s diagnostic techniques were extraordinarily subtle. He had trained himself since childhood to notice minute changes in a patient’s pulse and published several treatises on the subject. Galen built on an ancient tradition of pulse lore, tracing back through Herophilus, that had already developed an evocative and controversial terminology; he did not invent the “worm pulse,” the “ant pulse,” and so on, although he sometimes used these terms. The highly specialized and esoteric nature of pulse knowledge and of its vocabulary gave it pride of place in Galen’s diagnostic repertoire: few could perceive the minute distinctions of size, speed, strength, frequency, fullness, hardness, regularity, and rhythm that he claimed to feel, and still fewer could grasp the definitions over which he and his colleagues argued so strenuously.4
The pulse, as he believed, could reveal changes in internal organs, internal growths, mental conditions (especially anxiety), and fever, of which it was, in Galen’s view, the most accurate diagnostic indicator. In the case of Boethus’s son Cyrillus and in the case of the emperor Marcus Aurelius, discussed in previous chapters, Galen pronounced his patients free of fever based on a reading of their pulses; and Antipater’s fever, discussed below, will be detected from his pulse. In one patient Galen diagnosed an internal tumor from the pulse alone, before palpating the patient although the growth could be easily felt:
When I felt his pulse, I diagnosed a large visceral tumor, which had reached such a stage that it was apparent to the sight and touch, (even) to non-medical men. Those in attendance were amazed that I diagnosed a visceral tumor from the patient’s pulse.
(Opt. Med. Cogn. 5, 80 Iskandar, tr. Iskandar)
On the pulse as on other points Galen insisted on individual variation; ideally the physician had intimate knowledge of a patient’s normal, baseline pulse, which would also change as the patient moved through the stages of life from childhood to old age. The same for temperature; Galen could measure small changes in heat by touch, and a patient’s normal temperature would vary according to age, individual temperament, and other factors. Long before laboratory testing, he examined urine and feces, sweat, sputum, and other substances coughed up by the patient, vomit, pus, and blood for color, texture, viscosity, and sediment. He scrutinized his patients’ faces for signs such as a change in skin color or the sunken eyes of wasting or extreme dehydration. He boasted that he could take in many of these features at a glance and sometimes this allowed him to show off with a flashy diagnosis.5
It is not clear that Galen had a routine procedure for examining patients; he seems to have drawn on the techniques described above as circumstances suggested. He could, however, be very thorough, as in the story of a youth with fever:
Finding that his fever was rather hot, but that his pulse was regular, very large, swift, frequent and vigorous; that the heat was not of the type that is biting to the touch, and that his urine was not much different from its usual state in density and color; and learning that the man had neglected his habit of exercise for around thirty days, and that on the day before he had exercised vigorously, but not too much; and that he had nevertheless taken his accustomed food, and had managed to digest it, but slowly and with difficulty … and since the man appeared ruddy and plump, and even said that he perceived a sense of fullness …
(Meth. Med. 9.4, 10.610K)
Here Galen comments on several characteristics of the patient’s temperature, pulse, and urine, as well as on his physical appearance (ruddy, plump). This passage also illustrates another feature of Galen’s clinical procedure: he talks to his patients, here eliciting information about history (the patient’s neglected exercise routine) and perceptions (“[he] said that he perceived a sense of fullness”); these are indicators, in Galen’s view, that the patient requires bloodletting.
Galen considered patient history critical to clinical practice and often comments on events that happened prior to the illness and may have caused it. For example, one patient’s dangerous fever is related to a host of subtle causes that have heated and dried his body, including travel, temperament, character, and a fight at the gymnasium (this is one of Galen’s most fascinating cases but it is little-known today, and so I will quote it at length):
The youth, who was now seized with fever, was twenty-five years old, slender and muscular in body like a dog, and of a markedly dry and warm temperament. He enjoyed gymnastic exercises and was otherwise a serious and industrious type. While out of town, this man received some bad news, and was vexed; exerting himself, he hurried to the city. Throughout the previous day he had exerted himself moderately and bathed and dined, and rested at an inn, but for the most part without sleeping. On the next day, he hurried still more and completed the journey, which was entirely sandy and dusty, under a hot sun; and he arrived at about the seventh hour and a half in the city. Learning better news about the matters on account of which he had hurried, he went to the gymnasium intending to bathe; when he had been oiled, he had a massage together with one of the youths there. And when asked by [the other youth] to move a little, a quarrel arose between them, the kind which gymnastic types are often accustomed to fall into, and he exerted himself more than usual; and he was already unusually dried out. As he was leaving the gymnasium, he encountered some of his friends fighting; he separated them, without realizing that he was again undertaking no small additional exercise as he dragged them apart, and shoved some of them, and seized others around the waist, and objected to some of them that they were doing wrong, and became angry on behalf of the wronged, so that he returned home extremely dry, and became aware of his own fatigue and that something was abnormal. Therefore he drank water as he was accustomed to, but he became no better; rather, the abnormal feeling increased, and he vomited.
(Meth. Med. 10.3, 10.671–73K)
This is a complex and subtly sympathetic portrait of a patient of the urban leisure class, male, in the prime of life, susceptible to vexation (note his stress response to the “bad news”) and righteous indignation (over his place on the massage table at the gymnasium and in the fight among his friends outside, in which he enthusiastically intervenes; but the youth avoids actual violence, which would be distasteful to Galen). He is also vulnerable to the stresses of intellectual life, being “serious and industrious”—the first of these words, phrontistes, being one that Galen here and elsewhere associates with the health hazards of intellectual work and worry. In this case Galen has formed a compelling image of the patient, of his lifestyle among other competitive youths at the gymnasium, and of the events leading to his illness—all of which could only have come from a careful questioning of the patient or his entourage, for Galen himself does not arrive on the scene until several days into the illness.
This patient is one of Galen’s best-developed characters, and he does not go into such detail in all of his stories. But many of them describe or hint at or suggest—in offhand, and therefore illuminating, ways—Galen’s discussions with, and interrogations of, his patients. Little comments show that he took note of their exact words: “his fingers were difficult to move and numb and, as it were, making a crackling noise, as he himself called it” (San. Tuend. 6.11, 4.434K); “someone bitten by a scorpion said that he seemed to be struck by hailstones” (Loc. Affect. 3.11, 8.195K); “I asked if he felt bitten at the wound by the medicine. And he said that he was not ‘bitten,’ but had a sort of itching sensation” (Comp. Med. Gen. 3.2, 13.585K). Here Galen is questioning patients not about history but about current symptoms, including perceptions of pain, which can only be elicited by such questioning:
In cases of pain around the head I am accustomed to ask the patients, what kind of quality [of pain] they have. Some perceive a sense as though their body is worn away with pain, while others [feel] as though they are being stretched or crushed, or pounded, or that violent heat or cold alone predominates.
(Comp. Med. Loc. 2.1, 12.545K)
Galen gave thought to the question of how to distinguish the different types of pain that patients might experience and describe. He rejected the formal terminology of pain developed by Archigenes, a physician of his grandfather’s generation (who had also developed a new and specialized vocabulary of the pulse of which Galen is equally critical); but Galen clearly paid attention to his patients’ sometimes very striking analogies and word choices. He could also become frustrated when some patients lacked the vocabulary and intellectual sophistication to describe their pain (Loc. Affect. 2.6–9, 8.86–120K).
Most of the stories Galen tells are about successful diagnosis and treatment, and it is rare that a patient in his stories dies despite Galen’s best efforts. An exception is a case well known at the time: “Everybody knows,” Galen writes, “what happened to Antipater the physician.” This patient was “less than sixty but more than fifty years old,” younger than Galen himself, if the case happened recently before its publication in On the Affected Parts. It is an example of subtle diagnosis from the pulse. Antipater’s pulse had developed an irregularity (“anomaly”) after a brief fever. Unsure what to make of it, one day when he met Galen by chance he laughingly asked for his colleague’s advice. Galen was shocked when he felt the pulse and surprised that Antipater was still alive. Hedgingly, he asked whether the patient suffered any difficulty breathing; Antipater said no. Galen continued to monitor his patient’s condition for six months, and when Antipater asked for his diagnosis, told him that he had an inflammation of the pulmonary vein, which had become clogged with viscous substances; and that his fever, caused by the inflammation, had in fact never resolved. In consultation with his patient, Galen prescribed the same regimen as for asthma. But over the next six months Antipater developed breathing difficulties, as Galen had predicted, along with heart palpitations. These attacks became more frequent until they were occurring fifteen times per day; then Antipater died. Today’s physicians would disagree with Galen’s diagnosis of the cause of Antipater’s problem in the pulmonary vein; but not only did Galen predict the disease’s course despite misidentification of its cause, he also provides enough detail to pose an intriguing puzzle. Modern diagnostic guesses might be atrial fibrillation and/or aortic insufficiency following an infection of the heart muscle or of the endocardium or pericardium. His heart unable to pump strongly enough to clear fluid from the lungs, the patient developed pulmonary edema and died, either of suffocation or ventricular fibrillation.6
A sick person coming to Galen for treatment would, then, find him- or herself the central focus of the intense, penetrating intellect that has emerged so clearly in our investigation of all other aspects of his life. Galen brought this focus not only to his anatomical researches, his studies, and his debates with rivals; he brought no less of it to his clinical practice, to which he devoted unlimited energy both mentally and physically. Even when patients needed extensive hands-on therapy, Galen seems to have performed many these tasks himself. It is clear that he also delegated work to the patient’s servants or to his own slave assistants (these last are shadowy figures, but it is likely that they followed him everywhere—he calls them “my [people]”). But in his world of abundant servile labor, there is, perhaps surprisingly, no clear division between the functions of a physician and those of an assistant or domestic servant. In the case of the “ruddy and plump” patient mentioned above: Galen bled the patient in the middle of the night (taking so much blood that the patient fainted, then broke out in diarrhea, vomiting, and a cold sweat; 10.612K). Galen gave the patient food and orders to rest; on a later visit, he writes, he gave the patient gruel broth, suggesting that he fed the patient himself and perhaps even cooked the food himself. Elsewhere Galen writes of bathing, massaging and feeding patients, applying plasters, and mixing drugs. While it is possible or likely that “I did x” or “we did x” in the first person sometimes means “my slaves did x,” this is probably not true of all examples; especially when Galen could, and does, describe delegating tasks to servants in some passages.7
Regarding his female patients, Galen sometimes mentions midwives—as in the case of Boethus’s wife, discussed in chapter 5—and acknowledges issues of modesty. He seems to avoid touching women’s genitals, but otherwise does not treat them noticeably differently than his male patients. Galen interrogated midwives and laywomen on obstetrical matters (accumulating folk wisdom about conception and pregnancy; he accepted the notion, attested also in the Hippocratic corpus but apparently common among the women of his era, that women could feel conception taking place as the uterus contracted around the semen). He mentions speaking with many women who described themselves as “hysterical,” that is, having an illness caused, as they believed, by a condition of the uterus (hystera in Greek) whose symptoms varied from muscle contractions to lethargy to nearly complete asphyxia (Loc. Affect. 6.5, 8.414K). Galen, very aware of Herophilus’s discovery of the broad ligaments anchoring the uterus to the pelvis, denied that the uterus wandered around the body like an animal wreaking havoc (the Hippocratics imagined a very actively mobile womb). But the uterus could, in his view, become withdrawn in some direction or inflamed; and in one passage he recommends the ancient practice of fumigating the vagina with sweet-smelling odors to attract the uterus, endowed in this view with senses and desires of its own, to its proper place; this technique is described in the Hippocratic Corpus but also evokes folk or shamanistic medicine. Galen attributed “hysterical” conditions to the noxious accumulation of female seed or menstrual fluid and was inclined to explain a wide variety of women’s disorders by disruption of the menstrual cycle.8
Galen accepted and expanded the ancient Hippocratic theory of humors, as I have described in chapter 2, and a humoral view of the body pervades his ideas about disease and his approach to medicine. Still, in practice, he does not apply a rigorous doctrine of humors but takes a more general approach, often emphasizing the elemental qualities of hot, cold, wet, and dry rather than the humors per se. To see this we need look no further than his youthful patient with fever, described above. The patient’s innate temperament, which is warm and dry, his stage of life, his lifestyle, habits, and state of mind (worried, anxious, angry), and his history of travel in hot, dry weather, all contribute to the hot, dry imbalance that causes the anomaly, or disease. Galen never invokes a humor here—if he did, it would certainly be the hot, dry humor of yellow bile—but a sense of the delicate balance of qualities, and of the intricate relationship between internal and external, individual and environment, body and soul, reflect the subtle, ancient and Hippocratic “humoral” view of disease.
The humors yellow bile, black bile, or phlegm might cause fever, if they accumulated in excess and putrefied; excess blood might cause fever if it changed into some other humor. Tumors, inflammations, ulcers, cancers, and rashes were noxious accumulations of undigested, unevacuated humors, or of rotten and putrefied humors. Accumulations of humors in the brain could cause apoplexy, epilepsy, melancholy, and other conditions. Diet could rebalance the humors or elemental qualities, if foods of the right sort were eaten. Medicinal ingredients, too—herbs, minerals, parts of animals—had their own qualities and could be used to restore balance, as Galen explains in On the Mixtures and Powers of Simple Drugs, in which he assigns qualities and sometimes degrees of strength to the ingredients he describes. Exercise, bathing, and massage, as well as purgative and emetic drugs could evacuate noxious substances. So could bloodletting, especially in patients with certain signs indicating that an excess of blood, or plethos, was the problem; but Galen interpreted these indications liberally, and considered venesection a good treatment for virtually any serious illness.9 He sometimes took pints of blood from a patient, in a procedure that could be so drastic that one observer jokingly compared him to a butcher:
I carefully drew enough [blood] from him [the patient] that he fainted, having learned from reason and experience that this is the best remedy for continual fevers when [the patient’s] strength is vigorous. At first his body moved rapidly to the opposite state, chilled by the loss of consciousness. It would be impossible to discover anything more pleasant or useful than this.… In bodies of this kind an evacuation of the stomach necessarily follows, and sometimes also a vomiting of bile, and immediately following these things a dampness over the whole body, or sweats. When all of these things in turn happened to him [the patient] too, they immediately extinguished the fever, so that some of those who were present said, “man, you have slaughtered the fever,” whereupon we all laughed.
(Meth. Med. 9.4, 10.612K)
Galen was well aware that taking a lot of blood from a patient would cause a severe reaction, which he describes accurately in this passage; in this case of fever with plethos he deliberately provoked the reaction by bleeding the patient until he fainted, which also, as he believed, cured the disease. Venesection was a dangerous treatment when used aggressively, as here, with a narrow margin for error between perceived efficacy and lethality. Galen knew that patients could die of being bled. One must monitor their pulse carefully to prevent this, as he wrote, and he knew doctors who had killed their patients by taking too much blood. Other patients might recover but their constitutions were permanently cooled; they became pale and weak and susceptible to other diseases, which more easily claimed their lives.10
Bloodletting plays a minor role in the Hippocratic Corpus, but was an established therapy by Galen’s time, and would go on to have a very long history in European, Islamic, and Jewish medicine, partly as a result of his influence, and also in some other cultures. Today bloodletting retains a very limited place in western biomedicine, but it is so pervasive in history that scholars still sometimes search for observable positive effects that would explain its popularity. This is probably futile, as it is hard to avoid concluding that the damage done by bloodletting outweighed any placebo effect or the occasional clinical benefit for some conditions. It is best to see bloodletting in the context of ancient ideas of disease—Galen attributed most diseases to the buildup of toxins in the body, and this view seems to have remained deeply embedded in western culture.11 Thus, it was not only physicians who foisted the procedure on their patients; Galen writes that it was a custom of “the people among us” (that is, the area around Pergamum) to be bled every spring and tells of a peasant youth who asked for a routine venesection only to have an inexperienced doctor slice into an artery (Meth. Med. 5.7, 10.334K).
Nevertheless, we must acknowledge that, by enthusiastically endorsing the practice of bloodletting, Galen contributed to the suffering and death of many patients in the future. 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, also mostly did not question, one wishes that he had turned his scorn on this therapy, rather than on the Methodists’ three-day fasting cure. For while Galen did not invent bloodletting, he had the power to consign it to oblivion.
Bloodletting was contraindicated if the patient was weak, too young (under age fourteen), or too old, if the patient was pregnant, if the weather was hot and dry (because excesses could then be evacuated by sweat and breathing), and in certain other circumstances. However, Galen did not shrink from using venesection on a woman—she was “not obscure,” and the case won him many similar patients—who was so wasted with anorexia that she had not menstruated in eight months. (Galen does not name the cause of this patient’s failure of appetite, but it could have been psychological; anorexia nervosa is not a condition limited to the western world or the modern era, and many historical and cross-cultural cases are known.) In Galen’s view suppressed menstruation was an ominous condition; residues were being retained, and venesection was the cure. From this patient he took over a pint of blood on the first day and as much again over the next two days.12
Galen opposed narrow specializations in medicine, and his position on the status of the professional surgeon (the Greek cheirourgos, one who “works with the hand”) is not clear. Nevertheless, he rarely mentions performing surgery himself—his operation on the slave of Maryllus is the major exception to this—and in general he wrote little about it.13 He may often have left these procedures to surgical specialists, or patients sought out the specialists on their own. He avoided cranial trepanation (cutting a hole in a patient’s skull with a chisel or circular saw), a common procedure that he gratefully relegated to the specialists in Rome; if he had stayed at Pergamum, he might have had to become more proficient at the skill himself, as he writes (Meth. Med. 6.6, 10.454–55K). However, Galen clearly performed some trepanations, discussing his preferred methods in one passage from On the Method of Healing (6.6, 10.446–55K). The main condition he mentions treating this way is skull fracture, as in a case when he removed part of one patient’s frontal bone (Galen’s comment that “even now [the patient] has lived many years” suggests that this was unusual). He emphasizes the need to protect the dura mater from perforation and describes the effects of pressing on it too hard during the procedure.14 In general, however, Galen considered surgery a last resort and thought those doctors most worthy of praise who could treat conditions such as abscesses, tumors, or kidney stones with diet and drugs (Opt. Med. Cogn. 10, 116 Iskandar).
A passage from his commentary on the sixth book of the Hippocratic Epidemics describes the attention to many factors demanded in therapy (and also suggests that Galen’s typical patient was an urban resident with servants):
Thus in medicine it is not the same thing to learn the art and to make appropriate use of what one has learned, knowing to ask and to speak at the right time, and to listen at the right time to the patient or to his household [oikeioi] and to talk with them [about] how they might be most useful for service, and to pay attention to the external things, which have been overlooked by the doctors and the household of the patient. Among which the most useful things pertain to sleep, or to either the whole house or the rooms in which the patients are lying, if they are squalid because of a foul odor or air that is very hot or cold or full of mold. And, regarding disturbances from neighbors or from those in the public streets, it is necessary for the doctor to pay attention, and to talk about all of these things with the household and the friends of the patient.
(Hipp. 6 Epid. 2.47, 17A.1000K)
This passage also evokes the social aspects of illness in Galen’s world: the hypothetical patient is surrounded by friends, household, servants, neighbors on the other side of a dividing wall, multiple physicians, people in the street just outside the courtyard. It could be impossible to clear a room of busybodies even for surgery, where the modesty of the patient required privacy and the physician could do no more than promise to try his best to hide genitals or buttocks from prying eyes (Hipp. Off. 1.13, 18B.687–88K). (Male) friends of (male) patients in particular played a key role in illness: they seem to be present day and night, to help with the patient’s care (applying cold compresses, assisting in procedures such as bloodletting), and they argue with physicians about the best treatment. Illness was not a private experience but a social event that rallied one’s connections and created both cohesion and rivalries, as one group might support one physician’s advice against another’s.15
The patient’s bedside could be a scene of dramatic conflict, rivalry, victory, and humiliation. Sickroom contests were similar to the public debates and demonstrations typical of Galen’s life in Rome that I have discussed in earlier chapters, and Galen makes no clear distinction between them. I mentioned in chapter 4 one of his early conflicts with Erasistrateans, including Martianus who would become his bitter enemy, over the treatment of a young woman desperately in need (in Galen’s view) of bloodletting. The debate moves from the bedside to the street when Galen’s friend Teuthras produces and reads publicly from Erasistratus’s own case histories as proof of the necessity of bloodletting (these patients, whom the famous physician had not bled, died); and the question of the usefulness of bloodletting was also posed in what had become a daily public debate on medical (or philosophical?) points. Galen himself responded, and Teuthras had his friend’s comments transcribed by a slave so that he could bring the resulting treatise on a projected return home to Pergamum, “so that he might say the same things [that I said] against Martialius [sc. Martianus] in his examinations of patients.” 16 Thus, a prodigious contest between the upstart Galen and Rome’s most illustrious physicians begins at the patient’s bedside, is dragged out into the street, and then back to the sickroom in the form of Galen’s treatise, ammunition in the hands of his friends against their enemies.
Galen’s case histories often feature rivalries with other doctors or, more commonly, groups of physicians (sometimes labeled Methodists, Erasistrateans, or something else), with much bitter polemic, dramatic proof of Galen’s superiority, and affirmation from the astounded witnesses. A good example is the story of the twenty-five-year-old youth who enjoyed gymnastic exercises, whose history is quoted earlier in this chapter (Meth. Med. 10.3, 10.671–78K). In this story Galen’s rivals are “doctors of the diatritos” (that is, proponents of a trendy three-day fasting treatment popularized by Methodists).
The patient had become feverish—he was “seized by fever”—as a result of the circumstances described in the history, namely travel, vexation, physical exertion in more than one fight, hot and dry weather. “He returned home extremely dry and became aware of his own fatigue and that something was abnormal” (Galen uses the ominous word anomalia, Meth. Med. 103. 10.672K). The patient drank water but only became more ill (“the anomaly increased”) and vomited. At the eleventh hour of the day—about 4 P.M.; this will become the “suspect hour” of the story, the hour of the paroxysm’s onset every two days—he lay down. He spent a sleepless night. The next day some Methodist “physicians of the diatritos” came to call on him, and prescribed their trademark three-day fast; they returned that evening, saw that the fever was in decline, and stood by their advice, although at this point another physician (Galen does not say who) argued strenuously that the patient ought to be fed. They returned on the morning of the third day and repeated their advice.
Galen now visited the patient for the first time, on the third day of the illness, in the afternoon, after the Methodist doctors had left. (He does not say whether he was summoned or was simply paying a call on a friend.) A glance showed him the ominous “sharp nose, concave eyes” of Hippocrates’ Prognostic, which Galen quotes here (ibid. 10.674K); this is still known today as the facies Hippocratica or “Hippocratic face” of impending death. The patient was dangerously ill and was, in Galen’s view, on the verge of lapsing into a combined hectic and wasting fever, which would be fatal and incurable.17 “The suspect hour,” as he writes, “was the eleventh of that day” (ibid. 10.673K); Galen anticipated a serious paroxysm, and was alarmed at the thought that the patient would endure it without food. Seizing control of the situation, “I prepared a porridge of groats as quickly as possible and I gave it to him to eat” (ibid. 10.674K; note that Galen writes as though he did this with his own hands).
At the eleventh hour, the paroxysm struck. The patient’s extremities went cold; his pulse nearly vanished (“his pulse became small and extremely weak”). The next day Galen fed the patient twice, in the morning and the evening—not only, as he writes, to strengthen the patient, but to rehydrate him, “for his skin was dry, like a hide” (ibid. 10.674K). On the fifth day, anticipating another paroxysm, Galen mixed pomegranate seeds in with the groats, hoping to correct for the hot and dry imbalance of the patient’s stomach. Again the paroxysm struck, “about the same” as before (ibid. 10.675K). Galen returned on the sixth, seventh, and eighth days; “we fed him… in the same way.”
With Galen in firm control of the patient, the Methodists had, nevertheless, not entirely left the scene. They continued to advocate fasting. It was apparent to Galen and, as he claims, to everyone else that the patient would never have survived his second paroxysm—the third night of the illness—if Galen had not intervened and insisted on feeding him. For a while Galen ignored their “madness” and “contentiousness,” not daring to try to refute them with a demonstration while the patient’s health was so delicate. But the paroxysm of the ninth day was a little less severe; the patient’s pulse was a little stronger. At this point Galen gave way to his aggravation and the weakness he calls “love of contention” (philoneikia): “I could no longer bear the jabbering of the doctors” (ibid. 10.676K). He announced to the patient’s friends that he would prove unequivocally that his treatment had saved the patient, and, without feeding the patient, he allowed the paroxysm to attack. The result was one of the most theatrical events of his long career.
“Complete asphyxia occurred … and an extreme chilling of the whole body, so that he could not utter a sound nor scarcely feel things pressing on him” (ibid. 10.676K). Galen called together all the doctors who had been treating the patient. Also present were the patient’s oikeioi, a word Galen uses of the household or intimate friends: these, he writes, might be angry enough almost to tear him and the other doctors apart, for the doctors’ ignorance and for his own risky move that endangered the patient’s life to prove a point. The Methodists, sensing a trap, “became paler and colder than the patient himself, and were considering a means of escape.” Galen ordered the entryway door to be locked and gave the key to one of his (or the patient’s) friends. “Standing in the middle,” Galen now berated the other doctors for their stupidity. In order to refute them and to convince those whom they had swayed to their views (Galen probably means the patient’s friends, companions, and household here) he had allowed his treatment to lapse, based on his considered judgment that the patient would survive the paroxysm. Now Galen would further prove his point by reviving the comatose patient. “I opened his jaws and poured in three cyanthes’ worth of barley broth through a funnel” (ibid. 10.677K). The patient miraculously sat up “and began to hear and speak and recognize those present, when before he had been stretched out dry and insensible and speechless.”
Somewhat unusually, Galen omits to record his large audience’s response to this Lazarus-like demonstration. Perhaps this seemed unnecessary: the astonishment and wonder and spontaneous expressions of praise that he so often attributes to those who witness his superior skills can be assumed here and need not be described.18 Galen ends the story with a summary of how he treated the patient over the following week, resulting in a complete recovery.
The story of the “gymnastic” youth, as it builds toward Galen’s head-to-head confrontation with his rivals, is an excellent example of the agonistic theme in Galen’s case histories. His rivals may be an individual physician (even the patient himself, as in the story of Glaucon’s friend, chapter 4) or—and this is more common—an anonymous group of physicians (like the physicians treating Boethus’s wife in chapter 5 or those treating Marcus Aurelius in chapter 6). Galen’s deed might be a dramatic cure or a preternaturally accurate prediction. His audience might be the patient; or the patient’s friends; or the other physicians, who may admit defeat or convert to his views; or sometimes an authority figure (the head of household, as in the stories about Boethus’s family; the owner of a slave; the emperor Marcus Aurelius), whose judgment and expressions of admiration carry special weight.19
The same story also illustrates other important themes, however. I have remarked how Galen’s detailed history of this patient reflects the intimate knowledge gleaned from close questioning—his dialogue with the patient and/or with those around him. This is also one of the stories in which Galen’s clinical practices are best described, and we see him visiting the patient twice daily over a two-week period, preparing his meals and overseeing his care.
I also emphasize that Galen’s stories about patients usually had a scientific purpose—they are not only literary creations, although they are not documentary “records” either. This particular story, for example, may have happened early in Galen’s career (he opens by saying that this was the patient “on whom I first dared, led by reason, to disregard the diatritos”) and is thus being told long after the fact, sometime in the 190s when he composed the second half of On the Method of Healing. Galen probably wrote this story from memory after having repeated it orally many times. It aggrandizes Galen, and it creates a sympathetic portrait of the patient and of the social class to which both he and Galen belonged. When Galen locks the door on his rivals to prevent their escape from his verbal assault he recalls a famous scene from the Odyssey, the hero’s slaughter of the suitors, and this embellishment, along with others, may have crept into the story as it was told and retold. But Galen introduces the case with reference to none of these things (though he is not above making his own triumphs the overt message of a story, as in the case of Glaucon’s friend or most of the stories in On Prognosis) but with a subtle epistemological point: this is the first case in which he dared to ignore the diatritos, the dominant prescription for fever in his day. It describes an initial experiment which Galen afterwards confirmed by many repetitions, a classically Empiricist method. But Galen also writes that he was inspired by “indication”—endeixis, a type of logical inference specifically banned in Empiricist doctrine.20 The story, then, is not simply an entertaining or self-aggrandizing anecdote; it offers a kind of proof.
In his introductory sentence, Galen calls the patient an arrhostos—“I shall tell you about an arrhostos of this type on whom I first dared, led by reason, to disregard the diatritos” (Meth. Med. 10.3, 10.671K). Galen normally calls his patients kamnon (“sick one”) or anthropos (“person”) or by any number of other words; arrhostos (meaning literally “the weak one”) had a special significance. It is the word for the patients in the case histories of the Hippocratic Epidemics; Galen and others used it to mean, substantively, the Hippocratic stories themselves. One could read an arrhostos or write an arrhostos. Thus, it was a technical word approximating our term “case history.” Significantly, the other context in which Galen often uses arrhostos is when he appeals to clinical experience as evidence, which he does often: “I have observed this among the arrhostoi.”21
Galen thought the story of the gymnastic youth and most of his stories served a purpose similar to that of the Hippocratic case histories and, perhaps, also was influenced by his Empiricist background, as I have argued in chapter 2. Galen cited case histories in oral debates with his teachers, and they played a role in at least one of his bedside disputes and discussions with rivals and colleagues. Discussing the famous case of Pausanias, cured of nerve damage to his fingers, with the other physicians in attendance, Galen queries them to make a point concerning the distinction between motor and sensory nerves:
I said, “and so have you never observed the opposite, that movement is lost but sensation preserved?” Almost all the others said they had never seen this, but one claimed that he had, and he gave the name of the patient and he promised to provide witnesses.
(Loc. affect. 1.6, 8.58–59K)
(Both sensation without motion and motion without sensation can happen in Galen’s view, although the distinction he traces between motor and sensory nerves is complex.) 22 Thus, case histories could teach and transmit medical knowledge, as they still do today, even though in antiquity they were mostly told orally and we have no evidence for systematic patient records.
Galen offers no diagnosis for the patient in the story of the gymnastic youth, but it is likely he would have called the disease tertian fever. A possible modern diagnosis, given the patient’s neurological symptoms, is falciparian malaria, the most dangerous form of malaria (also sometimes called by its old-fashioned name “malignant tertian fever”). The life-cycle of the P. falciparum protozoon is forty-eight hours, and especially in established infections this can cause a cyclical pattern of paroxysmal symptoms. But intermittent fever is at best only a coarse indicator of malaria.23 Symptoms of dehydration in the story are very striking (sunken eyes, leathery skin). Dehydration can be a symptom of malaria, but this patient also had a history of physical exertion and travel in hot, dry weather, which Galen and the patient himself considered highly relevant. Heatstroke and/or severe dehydration, either of which can cause low blood pressure, weak pulse, and neurological symptoms, could be primary or complicating factors.
Fever had pride of place in Galen’s practice. As I have mentioned in chapter 5, he devoted several treatises to describing and classifying fevers, with much attention to their periodicity, which could reach dizzying levels of mathematical complication: On Critical Days, On Crises, and On the Differences in Fevers. In this he reflected an environment rife with infectious, febrile diseases, and a medical tradition, many centuries old, that sought to predict the course of fevers by mapping their waxing and waning over days. The story of the gymnastic youth is a good example of Galen’s view of fever as a series of paroxysmal attacks. Among other diseases that he treated I have mentioned tuberculosis and leprosy (in chapter 4) and “the great plague” (in chapter 6). Most poignantly, he treated children for kidney stones, although he does not mention performing the dangerous surgery that is described in book 7 of Celsus’s first-century treatise On Medicine (and may have left this procedure to Rome’s surgical specialists); Galen picked up the children and shook them to dislodge the stone. When blood clots develop in the urinary tract as a result of stones or other causes, Galen writes, one can try to break up the clot with medicines, and in one case he succeeded in removing the clot with a catheter; but almost all of these patients die (Loc. Affect. 6.4, 8.408–9). He treated women for breast cancer, which he believed to be the most common type of cancer, and his treatise On the Method of Healing to Glaucon preserves a striking description of an advanced case:
We have often seen in the breasts a tumor exactly similar to that animal, the crab [cancer, in Latin; karkinos, in Greek]. For just as in the crab the feet are on either side of the body, so also in this disease the veins, extending from the unnatural tumor, make a shape similar to a crab. This disease we have cured often in its beginning, but when it has progressed to a substantial size no one can cure it without surgery.
(Meth. Med. Glauc. 2.12, 11.140–41K) 24
Galen believed the condition was caused by the accumulation of black bile, if it was not adequately cleared through menstruation, and that he could cure it in early stages with purgative drugs. He purged one woman every year in the spring, “and if ever the purgation was neglected, the pain arose from the depths, and she herself would call me.” 25 Galen recognized that some cancers were incurable by any method available to him, and that some, including those on the roof of the mouth, would only be made worse by cutting or cauterizing, and should not be treated. Intervention in such cases might shorten the patient’s life or cause unnecessary suffering.26
Galen was especially proud of his prowess in healing patients with nerve damage and of his knowledge of the anatomy of the nervous system. One case was especially well-known because of the patient’s celebrity; he was a renowned sophist, whose name, Pausanias, Galen reveals in one version of the story. (Very likely he is Pausanias of Caesarea in Cappadocia, who studied in Athens with the great Herodes Atticus. The biographer Philostratus grants this Pausanias a perfunctory paragraph in his Lives of the Sophists, telling us that he spoke his brilliant declamations with a vulgar, heavy Cappadocian accent, and that he was therefore called, in a reference to Plato’s Phaedrus, “a cook who prepares expensive delicacies badly.” This Pausanias held the chair of rhetoric at Athens and also at Rome, where he spent much of his life and where he died approaching old age.) 27
The cure of Pausanias happened some time before the mid-170s, when Galen composed the earliest of his four surviving versions of the story, and went something like this (the four versions are all slightly different and contradictory but agree on enough detail to safely identify the patient): Pausanias fell out of a vehicle, perhaps on the way from Syria to Rome. (In On the Examinations by which the Best Physicians are Recognized, which survives only in Arabic, he falls off an animal he is riding rather than from a carriage.) He landed on his upper back, which hit a rock. For six days he suffered intense pain, which resolved; but beginning on the fifteenth day, he began to lose sensation in the two little fingers and half of the middle finger of his left hand. This gradually became worse, and he consulted either a single physician, or two or more physicians, whom Galen labels Methodists in one version of the story. They applied plasters to the affected fingers, but with no result. After some time—a month; three or four months—Pausanias consulted with Galen, who first summoned and interrogated the patient’s other doctor(s) about the drugs. But the treatment seemed appropriate. Galen then questioned the patient: Had he been beaten or chilled? Had there been any inflammation? Hearing no, he pressed on: Had Pausanias not suffered some blow to the spine? Of course! The patient recalled his fall from the carriage and told Galen all about it. Galen now knew and explained exactly what had happened: the nerve below the seventh cervical vertebra had been damaged in the fall. Galen’s diagnosis of what would now be called a textbook case of cervical radiculopathy at the C8 nerve was certainly correct, although his treatment would probably be considered ineffective today (modern remedies, which include physical therapy and sometimes surgery, are of contested effectiveness but most patients improve on their own over time).28 In any case Galen applied an external medicine (he does not say what it was) to the area of the nerve root. Pausanias, as he writes, recovered immediately, much to the surprise of those who witnessed the events: “it seemed amazing and surprising to those who saw it [sc. the rival physicians, implied later in this passage], that the fingers of the hand were cured when medicine was applied to the spine” (Loc. Affect. 1.6, 8.58K). Galen lectures his rivals patiently on the nature of nerve injuries at the end of one version of the story.29
Epilepsy was an illness of some mystique in antiquity and, indeed, throughout western history, which may explain its prominence in Galen’s work. In popular belief it was vaguely supernatural and contaminating; people spat to ward it off, and epileptics felt the shame and disgrace of public revulsion. A popular and particularly gruesome folk remedy, according to Pliny, was drinking the blood of gladiators (Naturalis historia 28.4). Beginning with the treatise called The Sacred Disease in the Hippocratic corpus, ancient medicine had directly and deliberately challenged the common, superstitious view of epilepsy. The term epileipsia has its root in the Greek word “to seize,” and it signified an attack, or recurrent series of attacks, that struck the patient down unconscious, with or without full-body convulsions of classical grand mal type. A number of causes were postulated, but for Galen, loosely following Hippocratic tradition, its origin was a blockage in the brain: specifically, a thick humor, either phlegm or black bile, blocked the outlet of cerebral pneuma from the ventricles. This blockage could be either primary or secondary to something else; that is, in some patients, a problem arising elsewhere (especially in the cardia, between the stomach and esophagus) could affect the brain and cause epileptic seizures and other neurological problems, if vaporous exhalations carried the suspect humors upward.30
Galen seems to have treated many patients for epilepsy, including some that I have already mentioned: two boys he saw with his teachers as an adolescent, in Smyrna (chapter 2); the boy who was protected by his amulet of peony root (chapter 5). Galen wrote a special treatise on the disease for a Roman father, one Caecilianus (many identifications are possible), about to depart for Athens with his physician and his epileptic son; Galen had never examined the boy, but agreed to offer advice nevertheless. This was under Severus, after the fire.31
Galen’s most illustrious patient with epilepsy was Diodorus the Grammarian, whom he mentions several times, although only once by name. Diodorus is a “youth” in the story; that is, a man in the prime of life, probably between about twenty-five and forty. “He was seized by the epileptic disorder if he taught very forcefully, or worried [ephrontisen], or fasted for a long time, or became angry [ethumothe].” Galen diagnosed the problem as arising from the cardia, and he prescribed a special diet and thrice-yearly purgations with aloe. The patient did well on this regimen, but would occasionally suffer an attack if a busy schedule caused him to skip meals.32
The case of Diodorus calls attention to the prominent role of emotions and psychology in Galen’s practice. Galen makes no special distinction between physical causes of epileptic seizures and psychic ones; in particular, the emotions of anger or worry might precipitate them. The emotions Galen most often implicates in disease are anger, fear, grief (called lupe), and anxiety (also called lupe but linked to words for worry, for example, about a guilty secret, an upcoming contest, or a future contingency—rational or irrational—rather than loss).
The full proof of my last statement is subtle and will have to wait for another venue, but it evokes discussion of one of Galen’s most famous cases, the case of the wife of Justus, whom he also calls “the woman in love.” This happened early in his career, during his first visit to Rome, and (as he implies in On Prognosis) shortly after his anatomical demonstration for Boethus and other intellectuals. Galen mentions it several times, always comparing it to the legend or folktale of Erasistratus, who discovered that prince Antiochus of Syria, son of the Hellenistic King Seleucus I, was in love with his stepmother (or, in the version of the story that Galen knew, with his father’s concubine).33 Some scholars have doubted the truth of Galen’s story, based on (I think) an unnecessarily stringent interpretation of the language in one of Galen’s versions of it. I have no doubt that Galen’s memory tailored the story to enhance its resemblance to the legend of Erasistratus, which clearly delighted him, but I do not think he invented it from whole cloth—also because he writes as though it were a well-known event.34
Galen is very specific, here and elsewhere, that what he detected and diagnosed in his patient was not, strictly speaking, love; nor did Erasistratus do this. There is no “erotic pulse,” he explains, and no way that his famous predecessor could have identified the emotion of love through the pulse, as legend seemed to imply. What Erasistratus had felt was a change in the pulse (it became “anomalous and irregular”) when the concubine entered the room, and a change back to normal when she left (Hipp. Prog. 1.8, 18B.40K). In the case of Justus’s wife, Galen was called because she was suffering from insomnia, an ominous symptom in his view. He questioned her, but she was mostly unresponsive, and finally, when she wrapped herself in her veil and turned away in her bed, Galen gave up and left. Since he found no sign of fever, he determined that she was either suffering from depressed mood (dysthymia) caused by black bile, or she was distressed by something that she was unwilling to reveal. Galen returned the next day and the next, but was sent away by the chambermaid. On the fourth day he had better luck with the maid: he managed to engage her in casual conversation, in which she revealed that her mistress was worn down with lupe, an anxiety or grief.
At this point someone happened to walk in, coming from the theater, and say that Pylades was dancing that day. Galen noticed a change of gaze and color in the patient’s face, and her pulse became suddenly irregular, indicating, as Galen writes, that her soul was disturbed. “The same thing,” he says, “happens to those who are about to compete [agonizein].” Galen formed the hypothesis that the woman was in love with Pylades. A secret crush on a low-class entertainer, probably a slave, was a plausible cause of mental anguish in a married lady of the leisure class. Galen proceeded to test his theory: the following day (he seems to have visited this patient daily for some time) he told one of his servants to come in as he was examining the patient and say that Morpheus was dancing. No change in the patient’s pulse. Galen tried the same ploy every day using the name of a different dancer, and although it is hard to believe that the patient did not become suspicious after the second or third try, she was unable to control her reaction on the fourth day, when Pylades’ name was mentioned; her pulse became “disturbed in many ways” (Praecog. 6, 14.630–33K). Galen does not say what advice he gave the patient, or her husband.
He mentions this distinct pulse of anxiety in other places: recall that he found out the funny secret of Cyrillus, Boethus’s little son who was hiding food, by feeling his pulse. In that story too Galen writes that he knew from the pulse that the child was not feverish but rather “disturbed,” like someone about to compete in the pankration or plead in court (Praecog. 7, 14.640K). He claimed to be able to use the pulse as a lie-detector and, for example, to know whether a patient had followed his instructions or not.35 Fear, anger, anxiety, and joy all had specific pulses and physical symptoms. Fear and, paradoxically, joy could be instantly fatal, in extreme cases.36 Anxiety could be fatal in the long term: first it caused insomnia (as in the case of the woman in love), then fever, then the patient would waste until he or she died. As an alternative, anxiety might change to melancholy, an accumulation of black bile in the brain, which in Galen causes not just depression and a dark mood (misanthropy, suicide) but also, and especially, psychosis. The prognosis is especially bleak if the underlying worry is irrational (Hipp. Aph. 23,18A.35–36K).37
Some of Galen’s most intriguing stories are about patients suffering extreme cases of anxiety. A patient of Erasistratus believed a ghost was calling him by name from the cemetery and was wasted by insomnia and fever. The famous doctor cured him by pretending that he had been the one who called the patient’s name, shouting for help against bandits (Hipp. 2 Epid. 2, 207–8 Wenkebach and Pfaff). A man of Pergamum, Meander the augur, died of anxiety after predicting his own death. His symptoms, according to Galen, were similar to those of the woman in love when she heard the name of Pylades: “He went from the bird-flight area back to the city demolished, wretched and yellow in color, so that everyone who met him asked him whether he had some bodily illness. He told the truth to those in whom he trusted. Then he began to lie sleepless at nights while grief oppressed him all day, so that he deteriorated entirely” (Hipp. 6 Epid., 485–86 Wenkebach and Pfaff). Finally he developed a fever and took to his bed; two months later he was dead, having gradually wasted away.
My favorite patient—one Galen says that he saw himself 38—believed that Atlas would grow tired of holding up the world and drop it, causing universal catastrophe.
I know a man from Cappadocia, who had gotten a nonsensical thing into his head and because of that declined into melancholy.… His friends saw him weeping and asked him about his grief. At that he sighed deeply and answered, saying that he was worried that the whole world would collapse. He was worried that the person, of whom the poets relate that he carries the world and is called Atlas, would become tired because he had carried it for so long. Thus there was a danger that the sky would fall on the earth and smash it.
(Hipp. 6 Epid., 487 Wenkebach and Pfaff)
In this passage, surviving only in Arabic (and that I have used in its German translation), Galen’s theory of anxiety progressing to melancholy shines through several retranslations in an especially striking example of mental illness. “When [this patient] was with us in the morning, as usual,” he writes elsewhere, “he said in response to a question that he had lain awake all night considering what would happen if Atlas became sick and decided no longer to hold up the sky. And when he said this, we deduced that this was the beginning of a melancholic episode.”39 Galen obviously considers this patient’s anxiety irrational, and thus the dangerous course of its progress is not surprising.
Galen recognized many kinds of illness affecting reason, memory, or other functions of the rational soul, and arising from a disorder in the brain, either primary or secondary; they might have positive symptoms (psychosis) or negative ones (lethargy, coma, loss of memory).40 For psychotic symptoms, that is, delusions and hallucinations, he most frequently uses the words paraphrosyne and phrenitis; these are both often translated as “delirium” in English. Although he explains that phrenitis is paraphrosyne or psychosis with fever causing inflammation of the brain or meninges, and mania is psychosis without these factors (thus paraphrosyne is the more general term and phrenitis the more specific one), he does not maintain this usage rigorously, and sometimes uses paraphrosyne where we would expect (by this definition) mania. He also sometimes writes of paraphrosyne as psychosis secondary to causes outside the brain, whereas phrenitis has its primary cause in the brain and meninges, or possibly the diaphragm (Loc. Affect. 5.4, 8.327–29K).41 Psychosis might arise as a complication of pleurisy or pneumonia, or might result from aggressive cauterization of the head, or an accumulation of black or yellow bile in the head, during a burning fever or as a secondary result of gastric problems. It might be caused by anything that inflames the brain or meninges, or the diaphragm, which Galen considered highly sympathetic with the brain, explaining in this way the belief of many ancient writers who located the seat of intelligence in the thorax.42
Psychosis affected either reason or perception or both: Galen offers the example of Theophilus the physician, who when ill retained his ability to talk reasonably, but thought he saw oboe-players in the corner of his room and kept ordering them to be thrown out of the house. He remembered the oboe-players even when he had recovered (Sympt. Diff. 3, 760–61K). Galen himself as an adolescent, suffering from a burning fever—most likely during the illness he describes contracting in Pergamum as a result of eating fresh fruits—thought he saw pieces of straw sticking out of his mattress, and pills of wool on his clothes, and kept plucking at them. When he heard his friends comment on his erratic behavior he was able to understand them and asked them to help him since he was suffering from phrenitis. His friends brought him wet compresses, but he was up all night screaming with nightmares (Loc. Affect. 4.2, 8.226–27K). As a counterexample of a patient who perceived his environment clearly but had lost his reason, Galen offers, perhaps drawing on folktale or urban myth, the story of the glassmaker who lived on the upper story of a residence in Rome. He threw his glassware out the window, naming each item precisely; then, responding to the joking demand of the crowd that had gathered, and to their horror, he threw his roommate.43
Galen does not sharply distinguish physical and mental illness. He believed in the existence of a psyche or soul, as I have mentioned earlier (chapter 5). He expressed agnosticism, as I have also mentioned, on the question of whether the soul was immortal, and on whether it was a material substance or not; for the physician’s purposes, as he believed, the soul could be treated as part of the body. The rational soul, the seat of consciousness, was housed in (and possibly identical with) the cerebrospinal fluid, the pneuma, contained in the ventricles of the brain; remedies that would purge the noxious humors affecting the brain and causing melancholic depression or psychosis ought to cure those disorders.
Galen’s psychiatric observations strike me as unusually subtle. Although he drew on a long written tradition and not all his ideas were original to him, the medical literature on melancholy being especially voluminous by his time, it is also clear that he paid close attention to psychiatric symptoms in his patients (insomnia, delusions, anxiety). His psychiatric ideas are perhaps the most readily familiar to the modern practitioner, who might be confounded by Galen’s beliefs about innate heat or humors, but recognize an anxiety disorder in the Atlas patient. Galen also wrote treatises on the soul (psyche) that focused on ethical problems and were similar to other philosophical tracts of his time. Two of those that survive were written after a catastrophic event in his life: the fire that ravaged Rome in 192 C.E. This event, and Galen’s response, is the subject of the next chapter.