The Rise and Fall of Alexandria (37 page)

On the basis of remarks made in Plato’s
Laws,
it seems that prior to Galen the medical system in the Hellenistic world was two tiered. Physicians for the wealthy treated their patients in accordance with theoretical principles (they were known as Dogmatists). Physicians for slaves relied upon trial and error, and were known as Empiricists. Detractors claimed that the Dogmatists honored theory above observation and experience. Between these two extremes were the Methodists, whose sole concern was the disease itself, ignoring the patient, his or her medical history, and so on. Galen claimed to belong to none of these schools, though we know that he was certainly educated in the Dogmatic school and practiced both Empirically and Methodically. He recognized that it was necessary both to develop theories from practical observation and experience, and to test existing theory against observations, modifying or abandoning it if it seemed not to work.

Much of Galen’s theory was based on the teachings of Hippocrates, the Greek “Father of Medicine.” Hippocrates held that the human body was controlled by four humors: phlegm, blood, black bile, and yellow bile. Each humor was also related to parts of the body: head (phlegm), heart (blood), liver (black bile), and gallbladder (yellow bile). Imbalance in these four basic humors caused illness, and it was the job of the physician to right this balance. From Plato, Galen also employed the four-element theory (earth, air, water, fire) and the theory of contraries (hot/cold, wet/dry). Like the four elements, humors were characterized by two qualities. The earth was considered the heaviest of elements, and black bile, with its coldness and dryness, was seen as the heaviest of the humors, an excess of which caused melancholy. Blood (like air) had the qualities of heat and moisture, phlegm (like water) had coldness and moisture, and yellow bile (like fire) had heat and dryness. He then formulated an almost quantitative scale of admixture of such things, which he wrote up in a book called
On Mixtures.
So if a person was suffering from a cold, wet condition, such as a chest infection, he should be treated with a hot and dry drug, such as certain molds and fungi (penicillin, perhaps?). While Western medicine may have moved away from such elemental concepts (we should note that much Indian and Chinese medicine has not), what Galen was doing was making the task of diagnosis and treatment multidimensional, looking at both the illness and the cure from multiple perspectives. He himself acknowledged his eclectic, pluralist approach, and this is perhaps Galen’s most enduring contribution to the history of medicine.

Inspired by this theoretical grounding and the anatomical mysteries he witnessed in Alexandria, Galen returned to his native Pergamum to begin his medical practice. Pergamum would prove a difficult place for him to work, however, as it did not allow its doctors to dissect human bodies. Fortunately, an official appointment came up that suited him perfectly—as physician to the gladiators.

Gladiatorial combat was a standard entertainment in the Roman world and was not always the deadly spectacle it is imagined to be. Gladiators were the football superstars of their day, the subject of adulatory graffiti in public baths and the pinups of young girls everywhere. A good gladiator, although a slave, was worth a fortune to his owner and hoped to win one day the “wooden sword” that would mark his retirement and freedom. So he would be attended on by the best physicians his master could afford—the sports physiotherapists of their day, whose job it was to keep the gladiator healthy and fighting.

Although Galen could not dissect criminals or corpses, he could use the skills he had learned in the Alexandrian anatomy theaters to cure the gladiators’ often horrific wounds. Provided it was a gladiator who made the incision in the arena and not a doctor on the operating table, no one complained if he then used these wounds—or “windows onto anatomy” as he called them—to explore the inner workings of the body. At the same time he also pioneered the treatment of the more usual sports injuries—sprains, breaks, dislocations, and concussions. From these he developed 130 of the 150 basic surgical techniques that are still in use today—everything from brain surgery to repairing compressed fractures to the use of traction beds to straighten broken limbs. Even at the end of a gladiator’s career there was one last procedure that Galen developed that would assist his patient in his new life as a free man: the removal of the tattoo that marked him as a slave.

It was not long before it became clear that Pergamum was too small a world for such a great doctor, and five years after his return there from Alexandria, he moved to Rome. Here he found medicine in a similarly primitive state, held back by its taboos against Alexandrian anatomy. The Roman poet Martial noted ironically: “Until recently, Diaulus was a doctor; now he is an undertaker. He is still doing as an undertaker, what he used to do as a doctor” (Martial,
Epigrams,
book 1.47).

Not surprisingly then this new doctor from the East dazzled the court, and as a superb self-publicist, Galen took every opportunity to put his rivals in the shade. One such occasion was provided by the arrival of a Persian merchant complaining of a loss of feeling in the ring and little fingers and half the middle finger of one hand. For some time Roman doctors had been applying unguents and creams to the fingers in the hope of stimulating them, but to no effect. Galen asked him an unusual question: Had he hurt his arm recently?

The question must have been quite surprising. The man’s problem was clearly in his fingers. What did that have to do with his arm? But Galen was right. The man said he had taken a bad fall and hurt his back. Galen diagnosed a spinal lesion and recommended bed rest and soothing compresses for the injury site. It worked, and the man’s fingers recovered. It may sound like a small thing, numb fingers, but in curing them Galen was laying the foundations of modern neurology.

Such demonstrations made Galen famous, while his arrogance, his outspoken attacks on his detractors, and his withering humiliation of less successful doctors made him many enemies. Galen was not a modest man, and in later life he would happily compare himself to a Roman emperor: “I have done as much for medicine as the Emperor Trajan did for the Roman Empire when he built bridges and roads through Italy. It is I, and I alone who have revealed the true path of medicine” (Galen, quoted in F. Marti-Ibanez,
The Epic of Medicine,
p. 93).

In 166, sensing a plot by his powerful enemies, Galen slipped secretly out of the city in the nick of time. Though he claimed the plot as the reason for his abrupt exit, an impending outbreak of the plague, which he had successfully identified, may have been the more compelling motive.

However, after a couple of years in obscurity he was recalled to Rome by none other than the emperors Marcus Aurelius and Lucius Verus, who asked him to accompany them on a military expedition against the invading barbarians. Galen was to be their personal physician. Some scholars claim that he turned down the offer to be imperial physician on the campaign, but either way a year or so later he was made personal physician to Marcus Aurelius, and this brought him back to the city of his training with his grateful rather than vengeful master.

During Marcus Aurelius’s reign there were huge improvements in medical care in the army, and Galen must have had a hand in many of these. To keep their troops fit they built military hospitals. Tucked away in the corner of the fort, away from the noise and bustle of the army, such a hospital was a very modern-looking institution. Passing through the wide gatehouse, a patient would enter the first wing of a square building constructed around a wide courtyard. Ahead was a light, spacious ward where new arrivals waited. Beyond was the operating theater, projecting out into the courtyard to allow the maximum amount of light for the surgeons. At the hospital in Neuss, in modern Germany, raised hearths were even found in the operating theater. These were probably where the surgical tools were sterilized in the fire before use—just as Galen had suggested.

In one corner stood a complex of baths with a block of flushing toilets attached—hygiene was very important to doctors like Galen. In another stood the kitchens where the healthy balanced diets required by convalescing patients were prepared. In other wings lay a series of small wards designed to reduce the risk of cross-infection, consulting rooms, a dispensary, and—for the unfortunates that even a man as great as Galen couldn’t save—a mortuary.

We know so much of Galen’s work because, like the true Alexandrian scholar he was, he wrote prolifically. Although much has been lost, the definitive modern edition of his work, edited by K. G. Kühn, still runs to over twenty thousand pages. In these volumes he describes not only surgical procedures such as the removal of cataracts and the making of false teeth but the correct tools with which to perform operations. Galen was very particular that his instruments should be made with iron from Noricum, which could be made into what was basically surgical steel, and his bag contained the catheters, hooks, probes, needles, bone chisels, dilators, and forceps familiar to any modern surgeon. He also hypothesized about the cause of illnesses, particularly those contagious diseases such as the plague he witnessed tearing through the troops on Verus’s return from Parthia. Though as late as the eighteenth century many thought the cause was “polluted air” or some evil miasma, Galen reasoned that there were tiny particles, or “bad seeds” as he called them, so small they could not be seen, which carried infection. He could not have seen them— there were no microscopes in the ancient world—but using logic he inferred their existence. And he was absolutely right.

Galen lived to serve another two emperors after Marcus Aurelius, dying at the great age of eighty-seven. He was clearly a doctor who took his own medical advice. Because of his insufferable arrogance he was not popular, and few mourned his passing—indeed, not a single statue was ever known to have been erected to him. His works, however, achieved wide circulation and were still being taught in Alexandria in 500, although they largely disappeared with the demise of the classical world. But they were rediscovered by the Arab Renaissance in the ninth century. From the late eleventh century the Arabic versions of his works were then translated into Latin and rapidly became the core teaching materials in the medical schools of medieval universities all over Europe.

Galen’s undoing came in 1543, at the hands of the Flemish anatomist Andreas Vesalius. As much of Galen’s later work had been carried out in Rome, a city where human dissection was forbidden, he had been forced to use animals to study anatomy. When Vesalius, who had free access to human cadavers, compared what he saw in the anatomy theater with what was written in Galen, he realized that much of Galen’s work was simply wrong. The inside of a dog, or even the inside of his preferred Barbary apes, was not the same as the inside of a human. So Galen was abandoned, and even his most insightful works forgotten. What Alexandrian inquiry had made, Roman taboos had broken. Suddenly his own boast seemed rather hollow: “Whoever seeks fame need only become familiar with all that I have achieved” (Galen, quoted in F. Marti-Ibanez,
The Epic of Medicine,
p. 92).

 
 
Galen and Claudius Ptolemy were the two great scientific comets blazing their way across the star-studded cosmos of second-century Alexandria, but there was a third figure, altogether darker and more mysterious but no less influential on the modern world.

Alchemy was a subject largely scorned and dismissed by modern scientists until the great economist John Maynard Keynes bought a box full of papers in 1936 at an auction at Sotheby’s in London. The papers dismissed as of “no scientific value” when offered to Cambridge University fifty years earlier had been written by none other than Sir Isaac Newton. They were almost all concerned with his lifetime passion for alchemy, and they so amazed Keynes that he felt it necessary to entirely redraw the established view of who Newton was and how his mind worked. In 1942 Keynes addressed a distinguished group of members of the Royal Society:

 
And where did Newton get his alchemy from? Why, Alexandria of course.

The roots of alchemy lie in the origins of metallurgy, in the discovery that by applying intense heat to specific rocks they can be purified and transformed into metal. From the very start this process acquired occult or secret status, and the objects produced by this sacred craft—ornaments, jewelry, and currency from gold and silver; weapons and tools from copper, its alloys, and iron—were always given high prestige and value. It’s clear from ancient texts that iron especially had divine qualities: The Egyptians called it the “metal from heaven”; the Babylonians, “celestial fire.” These and other sources make it seem likely that people first encountered iron as meteorites which had fallen from heaven to earth. When they later discovered the same metal underground, inside the womb of Mother Earth, it must have seemed like confirmation of the metal’s divine status.

This notion of “Mother Earth” was the starting point for the alchemists. The first smiths and metallurgists were either farmers or pastoralists, both depending for their sustenance on the fecundity of the surface of the earth. When people began to extract both metals and precious stones from within the earth, from the womb of Mother Earth, they attributed life, or at least evolution, to the materials they extracted, albeit at a very different pace from the beings living on the surface. If left to gestate slowly in the womb of Mother Earth, rocks would gradually evolve into precious stones (for example, quartz was considered to be a juvenile, “soft” form of diamond). Likewise lead, if left in Mother Earth’s womb, would eventually transform itself into gold, and copper would develop into iron. It was therefore the task of the early smiths and forgers to accelerate this natural process of gestation by purifying metal ores through the application of heat. The alchemist’s task, however, was to transform, by secret occult means, the base materials from one form to the next on the scale of metallic evolution.