Galen

(b. Pergamum, a.d. 129/130; d. 199/200), medicine.

The frequently cited forename “Claudius” is not documented in the ancient texts and seems to have been added in the Renaissance.¹

In earlier research four years were accepted as possible birth dates: 128, 129, 130, and 131. After J. Ilberg, one of the foremost experts on Galen’s biography, had committed himself to 129,² J. Walsh advocated the year 130, and the period around 22 September as the actual day of birth³. Ilberg defended his own date,⁴ and Walsh again established his case with weighty and well-grounded arguments in a detailed reply to Ilberg,⁵ whose sudden death prevented his responding. The writer is inclined, however, to accept Ilberg’s chronology. Complete certainty cannot be achieved, but 128 and 131 are out of the question.

Parentage . Galen’s father, Nikon, was an architect and geometer in Pergamum.⁶, ⁷ Galen’s personal relationships with his parents were such that he spoke of his father with the greatest respect but compared his mother to Xanthippe.⁸ Galen provided extensive data concerning his own life,⁹ following the ancient tradition of autobiography.¹⁰ The most important, composed in his later years, are On the Arrangement of His Own Writings and On His Own Writings.¹¹ A wealth of autobiographical statements are contained in many of Galen’s other extant writings,¹² and additional details are in the Arabic translations.¹³ The evocatively titled On Slander, in Which Is Also Discussed His Own Life is unfortunately lost.¹⁴ Good introductions and surveys are Sarton¹⁵ and Diepgen,¹⁶ but Deichgraber¹⁷ has justly remarked that these books are mainly biographies of Galen the writer.

Education. Continuing a family tradition, Galen’s father had received an intensive education in mathematics and was generally a very cultivated man; similarly, he began to give his own son private lessons at an early age.¹⁸ At fourteen, Galen received instruction in philosophy that encompassed the teachings of all the various schools.¹⁹ Two years later he had to decide on an occupation; a dream allegedly caused him and his father to decide definitely that he should undertake medical studies.²⁰ (The medical literature of the time advised those interested in the profession to begin the study of medicine at the earliest possible age, usually at about fifteen.²¹ Thus, Galen was not at all exceptional.) As to his motivation, the supposed dream is surely to be understood merely symbolically. It seems that at this time the young Galen was undergoing a kind of intellectual crisis as a result of his very extensive and eclectic philosophical education. According to his own testimony, he was rescued from this troubled state only through the help of mathematics—that is to say, geometry—with its certainty and its indubitable systematic foundation. Evidently, Galen was already seeking in the empirical realm the same certainty that he hoped to find in medicine, above all in a knowledge of the body.²²

Galen’s first medical teacher in Pergamum was Satyrus.²³ The latter, Galen reports, had been in that city for “four years already” along with Rufinus, the founder of the Asclepeum in Pergamum.²⁴ In all probability this Rufinus is Lucius Cuspius Rufinus, who had been consul in the year 142.²⁵ (The date Galen gives could refer to the year 146; this would fit with 130 as the year of his birth and at the same time agree with the report that Galen began his medical studies at the age of sixteen.) Hence it appears that even at this early date Galen was in contact with leading personalities of Pergamene society. It is not without interest in this connection that Satyrus treated the famous Sophist Aristides, and thus the young Galen very probably met the latter in Pergamum.²⁶ In these encounters, therefore, lie the origins of Galen’s relation to the so-called Second Sophistic, of which he was later to become one of the leading medical representatives and which was so important in the intellectual life of the early Christian era.²⁷

Galen composed several works while still a student in Pergamum. He himself names three of them: On the Anatomy of the Uterus, the Diagnosis of Diseases of the Eye, and On Medical Experience.²⁸ The second has not been preserved. The treatise on the uterus (written at the request of a midwife) confirms that Galen at first devoted his medical studies primarily to anatomy. The work on medical experience, on the other hand, shows that from the beginning Galen was also interested, both philosophically and practically, in the problem of certainty in the empirical sciences. This work was obviously written at the end of his first period in Pergamum—that is, about 150—since it reflects a two-day debate between the physicians Pelops and Philippus in Smyrna. This contact with Pelops induced Galen to go to Smyrna as his student.²⁹

These three works, however, are clearly not the only ones Galen wrote during the first Pergamene period of study. In the treatise On Medial Experience he explicitly refers to an earlier work, On the Best Sect, which consequently must have been among his very earliest writings.³⁰ It is at the least very questionable whether it was identical with what has come down to us under Galen’s name as On the Best Sect, for Thrasybulos; the latter work, as I. von Müller has shown, is very probably not genuine.³¹ Here then, perhaps, is one of the not unusual cases in which a forgery has strayed into the gigantic Corpus Galenicum. This happened even in Galen’s own lifetime, as he himself reports.³²

Finally, in this group of earliest writings should be included, tentatively, the short treatise On Pleuritis, for Patrophilus.³³ If Patrophilus were identical with Calvisius Patrophilus, who held a high position in Egypt in the year 147-148,³⁴ this would provide further evidence of Galen’s having had early links with influential people. Moreover, he later incorporated this short work verbatim into the larger On the Constitution of the Medical Art (also dedicated to Patrophilus),³⁵ a not unusual practice for Galen. The short treatise on pleuritis is constructed almost like a mathematical-geometric demonstration (it uses short, precise statements, and the phrase “from this it necessarily follows” recurs with striking frequency). This manner of construction seems, therefore, to be the first concrete application of the principle that he considered best suited to overcome his skeptical despair—namely, the employment of the form of the geometric proof in demonstrating the real facts of natural science and medicine.³⁶

The problem of Galen’s earliest writings has been discussed in detail as the best procedure for tracing what may be called the concretization of his original intellectual impulses. In what follows references to Galen’s writings and their chronology will be made only occasionally and allusively.³⁷

Galen’s father died when his son was twenty and still living in Pergamum.³⁸ Not long afterward Galen went to Smyrna to study medicine with Pelops, whom he called his second medical teacher,³⁹ and Platonic philosophy with Albinus.⁴⁰ In philosophy Galen was most influenced by Platonism, just as later Hippocratism exercised the greatest influence on him in medicine:⁴¹ indeed, he set forth a connection between the two in his great work On The Doctrines of Hippocrates and Plato.

From Smyrna, Galen went to Corinth, to continue his medical education with Numisianus,⁴² and finally to Alexandria,⁴³ then the most famous center of research and training in medicine. It is generally assumed that Galen remained there for several years,⁴⁴ considerably longer than in Smyrna and Corinth. Yet, he himself says that after a stay in Smyrna, “I was in Corinth...in Alexandria and among several other peoples.”⁴⁵ Doubtless Alexandria was very attractive to him. Moreover, it offered the only opportunity to examine human skeletons thoroughly (although not cadavers).⁴⁶ Nevertheless, Galen was highly critical of the research and pedagogical activity then being conducted at Alexandria, as is proved by numerous later sarcastic remarks about “Alexandrian prophets” and Alexandrian “scholasticism.”⁴⁷

Thus, Galen pursued his extended study of medicine purposively and intensively on the basis of definite intellectual presuppositions but was not, in fact, fully satisfied with them and at the conclusion of this study still had not completely decided on his own definitive approach. At the age of twenty-eight he returned to his native Pergamum as physician to the gladiators,⁴⁸ having studied medicine for about twelve years, much longer than was then customary. This does not mean, however, that he could not perhaps have practiced medicine on some occasions during this long period.⁴⁹

Galen continued to treat the gladiators in Pergamum for several years. His experiences in this capacity brought him some chance discoveries (for example, the behavior of certain nerves and tendons), which were important for his later researches.⁵⁰ Yet his most important work was still before him.

Galen and Rome. In the year 161, at the beginning of the reign of the two Antonine emperors, Galen arrived at Rome where he quickly established a medical practice. ⁵¹,⁵² He succeeded in effecting several startling cures of influential patients.⁵³ Among them was the Peripatetic philosopher Eudemus, who introduced Galen to the high government official Flavius Boethus. The latter prompted Galen to compose his first major anatomical and physiological works. At this point a basic observation regarding Galen’s literary activity should be made: as can be seen from the Anatomical Procedures, for example, Galen revised many of his works. The first version of the great anatomical work, written for Flavius Boethus during the first stay in Rome, contained only two books, ⁵⁴ only later did it reach the dimensions in which it has been preserved., For certain reasons Galen later revised other of his works stylistically or substantively. On the whole, he had not at first planned on a “public edition” of some of the works, and such writings or versions of writings are fundamentally different from those destined for publication. ⁵⁵

Flavius Boethus also inspired Galen to hold public anatomical lectures and demonstrations. Such public medical lectures had come into fashion in the first century b.c.⁵⁶ in the level of general knowledge, and they had been enthusiastically taken up again at the end of the first century. a.d. by practitioners of the Second Sophistic. Among Galaen’s auditors were not only high Roman officials, including the consuls Lucius Sergius Paullus and Gnaeus Claudius Severus, but also famous Sophists and rhetoricians, such as Hadrian of Tyre and Demetrius of Alexandria. This closeness among highly placed Romans, Sophist rhetoricians, and scientific experts (particularly physicians) is typical of the Second Sophistic.

Galen himself vigorously insisted that it was not primarily logoi sophistikoi but rather medical successes that established his fame in Rome.⁵⁷ On the other hand, the Second Sophistic exercised a great influence on him, and he cannot be seen apart from this intellectual movement. His own teacher Satyrus was referred to as a physician and Sophist;⁵⁸ and the “iatrosophists” and “iatrophilosophers” were a typical phenomenon of the age. Among them were some extremely dubious individuals, and the whole school of thought, the physicians who subscribed to it in particular, occasionally ran the risk of slipping into nonsense or irrationality.⁵⁹ Nevertheless, this specific form of intellectual-social culture also contained some very positive features, which Bowersock has recently described. Galen was among the very best representatives in medicine of this tendency, but he too is not free of its negative traits.

Three such characteristics, which are frequently discussed and which can perhaps be judged most fairly by viewing Galen as a Sophist, are his prolixity, his vainglory, and his taste for dispute and polemic. Undoubtedly many of Galen’s writings are fatiguingly diffuse—for which reason the great classical philologist Wilamowitz bestowed upon him the malicious epithet Seichbeutel (“windbag”).⁶⁰ Comparison of these writings with several of his terse, mathematically precise earlier works will reveal a change in style and an increased boastfulness, surely attributable to the Sophistic influence, which became especially intense while he was practicing in Rome. The same is true of his proclivity for debate and polemic—Galen may here have inherited something from his mother. Yet, at least as important are the professional quarrels that, under the influence of Sophism, were completely typical of that period.⁶¹ It is against this background that, for instance, Galen’s polemic with his colleague Martialius during the first stay in Rome must be seen,⁶² and no doubt his relations with other physicians were in general affected in the same way.⁶³

At the time of his dispute with Martialius, Galen was thirty-four.⁶⁴ He stayed in Rome for three more years. Looking back on his public lectures and polemics of this period, he felt a certain degree of remorse and declared that he had decided not to act in this manner in public again—one of the good resolutions in which he did not persevere. Although he often repeated assurances that he wished to approach all things sine ira et studio,⁶⁵ he could free himself from neither his own temperament nor tradition.

Apparently, however, the many quarrels and polemical debates during his first Roman period upset him inwardly, so that after a while he longed to return to Pergamum.⁶⁶ He states that his Roman patrons wished to keep him in Rome and that this strengthened his resolve to go back to his native city.⁶⁷ In any case, Galen left Rome in the spring, shortly before the return of Lucius Verus to the capital. As he himself records: “When the great plague [an epidemic that accompanied the soldiers Lucius Verus was leading back from the Parthian War] broke out, I left the city and hastened home.”⁶⁸ This departure has generally been explained as simply an escape in the face of the contagion—not exactly laudable behavior for a physician. On the other hand, Walsh has pointed out that even before this time Galen had become what might be called “Rome-Weary.”⁶⁹ Surely, many factors conjoined to produce his decision.⁷⁰

Galen relates that following his return “he stuck to the customary things.”⁷¹ It seems that he also undertook other journeys for scientific purposes.⁷² But this period did not last long: he received a letter from the two rulers Marcus Aurelius and Lucius Verus summoning him to Aquileia. He responded to this call and succeeded in escaping a renewed outbreak of the plague. He became personal physician to the young Commodus; he held this position for several years and was thereby able to pursue his medical research and literary activity in various Italian cities—although at first not in Rome. When Commodus became emperor in 180, Galen remained in close contact with him, just as he had been on friendly terms with Marcus Aurelius, and enjoyed his protection. He was likewise friendly with Septimius Severus, who became emperor in 193. Although Galen should not, on this account, automatically be considered “physician in ordinary” or “court physician” in a strict sense, beginning with his return to Italy he remained in contact with the imperial family as both a physician and a socially prominent personality: he was undoubtedly “a lion of society.”⁷³ Moreover, he enjoyed the favor of such highly placed figures as the Sophist Aelius Antipater, secretary to Septimius Severus.⁷⁴

Nor, in his second Roman period (which lasted several decades), was he spared public controversies. The most famous episode, concerning the originality of some of his anatomical conclusions, took place in the Temple of Peace in Rome.⁷⁵ A heavy personal blow for Galen was the loss of a large part of his library through a fire in the temple in the year 192. It is not known whether Galen spent the last years of his life in Rome or in his native city.

Standpoint and Position in Ancient Medicine W. Pagel’s general characterization of Galen is most concise: “a genius who is ‘modern’ and indispensable in so many ways and yet not easy to grasp in view of his limitations, obscurities, and apparent selfcontradictions.”⁷⁶ It is understandable then that there exists as yet no work that comprehensively and exhaustively treats Galen or even limited aspects of his personality and work. The following remarks are thus to be understood merely as hints or suggestions.

As a physician Galen accepted the “fourthfold scheme” which brought the humors, the elementary qualities, the elements, the seasons, age, and other factors into common accord.⁷⁷ This fundamental theoretical system obviously satisfied Galen’s striving for certainity, yet not infrequently he, who so often pleaded for a purely scientific basis and methodology in medicine, was forced to perform complicated intellectual maneuvers. This is especially evident in his making the mysterious black bile into a physiologically important humor, which subject he treated in On the Black Bile. Using the fourfold scheme, Galen attempted to restore medicine to its Hippocratic basis. After all the debates with many schools of medical thought, he still considered Hippocratism the most secure foundation and enunciated this belief most clearly in On the Elements According to Hippocrates, On Mixtures, and the commentary to the Hippocratic work On the Nature of Man. Galen constructed his own Hippocratism, however; Hippocrates himself (to the extent that we can grasp the genuine Hippocrates) was not acquainted with any fourfold system in Galen’s sense. Nonetheless, Galen’s suggestive construction was dominant for centuries.

Galen’s anatomy suffers from a similar conflict. On the one hand, he was an energetic advocate of anatomy as the foundation of medicine, and his own accomplishments in anatomy, both as writer and as researcher and demonstrator, are without doubt considerable.⁷⁸ The great work Anatomical Procedures is proof of this, as is a series of his more specialized writings. On the other hand, his anatomy necessarily suffered from the lack of opportunity to examine human cadavers (human dissection was no longer possible for cultural reasons). Moreover, in attempting to call into question—in principle, at least—some of the anatomico-physiological achievements of Erasistratus (especially in regard to the role of the spleen) and in trying to place anatomy as well on a kind of Hippocratic basis, he necessarily introduced a speculative element into his anatomy.

The same is true of Galen’s physiology. He had a clear conception of the importance of physiological experiment, and his knowledge of the physiology of the nerves was considerable and justly celebrated. Yet here again there is speculation, in substantial part teleological, as in the great physiologico-anatomical treatise On the Usefulness of the Parts of the Body.⁷⁹ As a teleologist in physiology Galen was a determined Aristotelian.⁸⁰ He consequently defended in almost hymnic praises the notion that the Demiurge has created everything for the best.

As a dietitian, Galen continued an illustrious and ancient tradition.⁸¹ In this area conflict is less noticeabel. Indeed, it is precisely in this field that Galen the author composed what even the layman would consider his most interesting and exciting works, especially the Hygieina.⁸²

Among those writings that best illustrate Galen’s Hippocratism are his commentaries on his predecessor. From them we learn that what Galen thought was genuinely Hippocratic was often subjectively established, as is obvious from his claims for the genuineness of the treatise On the Nature of Man. Many critics held that it was a work of Polybus; Galen, however, allegedly in agreement with most physicians, declared the work to be genuinely Hippocratic, because it provided the testimony he sought for his doctrine of the four humors.⁸³ He also composed a work now lost, On Genuine and Ungenuine Hippocratic writings. His commentaries were not at all confined to technical medical explanation but also treated purely philological problems (see below). Originally these commentaries did not take into account the explanations of other authors.⁸⁴ Later, when he was planning a public edition of his writings, he considered such interpretations and recast his already existing commentary to integrate it with them. Here Galen can be seen at work as a polemicist who not only criticized content but also did not shrink from personal defamation.⁸⁵ Thus, for example, he reproached a Jewish colleague for being incapable of understanding the books of the ancients and, consequently, being unable to comment on Hippocrates.⁸⁶ In this enterprise he not infrequently abandoned the principle of sine ira et studio, for which he argued so strongly elsewhere.

It must be stressed in regard to Galen as a clinician that he was without doubt a brilliant diagnostician. He composed a series of important works on the division of diseases and on their various symptoms.⁸⁷ A splendid example of Galen’s diagnostic art is his short treatise on malingerers;⁸⁸ surely the diagnostic accuracy of a physician is put to the test in this field.

If Galen had very great merits as a diagnostician (and naturally went far beyond his esteemed Hippocrates), the same cannot be said of his views on prognosis. In this field he remained far more of a Hippocratic: first, he developed, as a general principle, a self-reliance in prognosis that was unjustified. The resources he employed were the traditional ones—the famous doctrine of the “critical days,” saturated with several prerational elements as it doubtless was, could nonetheless satisfy particularly well Galen’s need for certainty and his predilection for mathematical regularity (apparent in his special studies On Critical Days and On Crises). As a Hippocratic he found in his model something that Lichtenthaeler has termed “logos mathématique.”⁸⁹ To be sure, the theory of the critical days had an empirical root in the observation of fever (malaria) cycles. On the whole, however, it had been expanded into a speculative system under the influence of a “rationalization of an old arithmological foundation,”as Joly has accurately expressed it.⁹⁰ As stated above, this speculative system of the critical days, penetrated by prerational elements, satisfied Galen’s desire for certainty, just as it suited his taste for theorizing. The same is true of the two other traditional tools of prognosis, which he used willingly and extensively: the doctrines of the pulses and of the urine. The behavior of the pulse, which like all bodily “palpitations” was originally considered a mantic phenomenon, is analyzed in extreme detail in Galen’s many works on sphygmology and is employed in both diagnosis and prognosis.⁹¹ Yet in just this subtle division of the “qualities” of the pulse lay the danger of speculation. (Characteristically, Galen had little respect for the quantitative measurement of the pulse, despite the beginnings that Herophilus, among others, had made.)

In his knowledge of the formation of the urine, Galen went far beyond Hippocrates; but, as a clinician, he cherished the same speculative conception as Hippocrates, who had employed the consistency, the sediments, and the color of the urine not only in diagnosis but also in prognosis. The crucial thing is that Galen, like Hippocrates, did not apply the three criteria of consistency, sediments, and color in an exact fashion but rather in a vague, subjective way.⁹²

Galen’s knowledge of therapeutics is set forth mainly in the voluminous work Therapeutic Method, generally known in English as On the Art of Healing. Once again much interesting and correct material stands side by side with conjecture, above all for the medical preparations Galen employs and for his notions of their mode of action (on this, see On the Mixture and Action of Simple Medicines, On the Composition of Medicines According to Locality, and On the Composition of Medicines According to Types). In general, while Galen did in truth place the highest value on the empirical testing of medicines, his speculative conceptions of the way they worked constrained him occasionally to see a positive value in such “medicines” as excrement and amulets, in spite of his rejection of the magico-irrational medicine, which was then very popular.⁹³

The impression that Galen possessed all clinical skills is only apparent. On closer examination he seems to have had no experience in operative gynecology⁹⁴ and obstetrics or in surgery in general, and it is obviously for this reason that he devoted none of his own writings to these fields.⁹⁵ Still more remarkable is his personal attitude toward surgery. On the whole, Galen was an inveterate internist and as such had a deep distaste for surgery, with the exception of surgery to repair injuries or suppurations, undertaken in treating gladiators. In those cases in which he did consider surgical questions, even regressive views can sometimes be detected. This prejudice is consistent with, among other things, his prolonged polemic against Erasistratus (and the so-called Erasistrateans), who had been one of the first to put operative surgery on a new basis. Galen, on the contrary, was, so to speak, a Hippocratic even as a surgeon; that is, he confined operative surgery—when he allowed it at all—to a relatively narrowed concept and area. Here the characteristic inconsistency and limitations of his otherwise universal mind show themselves with particular clarity.

In summary, then, as a physician, Galen was a Hippocratic and, as a scientist (anatomist and physiologist), an Aristotelian; and he adhered to these basic commitments even when he was ostensibly an electric. To this extent he was far from being primarily an eclectic, a designation he is not infrequently given. His inclination for philosophy went so far that he attempted to reconcile Hippocrates and Plato, and in a work whose title was chosen with this purpose in mind, too, he claimed “that the best physician is also a philosopher.” On the other hand, he recognized and emphasized the boundary between medicine and philosophy.⁹⁶ All this, together with the contradictions in his behavior sketched above, should perhaps be viewed in the light of his constant striving for certainty. Thus, in the end, Galen became as much the “savior of a medicine which had become bankrupt” as the “executor of a faulty development.”⁹⁷

Philosophy and Philology. Aside from his medicophilosophical efforts, Galen not only interpreted the work of other philosophers (Plato, Aristotle, Theophrastus, Chrysippus, Epicurus) in some of his works⁹⁸ but also became known as a philosopher in his own right, above all in the field of logic, in such works as On Scientific Proof and Introduction to Logic. His many ethical writings have not been preserved, but this is not a significant loss, since as a philosopher Galen was essentially unoriginal.

His most outstanding appearance as a philologist and grammarian is in his commentaries on Hippocrates.⁹⁹ He also wrote a series of works dealing with lexicographical and stylistic problems, but they have been lost.¹⁰⁰ The work that has come down under his name as Hippocrates Glossary is quite possibly not genuine. Galen’s philosophical and philological interests were, moreover, only part of the total activity of a man of truly universal education whose numerous writings contain an abundance of information.

Religion. This is a subject which perhaps merits separate examination. Here, too, a good deal of inconsistency seems to become evident. On the one hand, Galen has been called a typical representative of the “cultivated religion” of his time.¹⁰¹ This means that as an enlightened man he quite possibly took a certain interest in religious phenomena, but one without genuine religious commitment behind it, and that, for the rest, he “officially” believed in the gods in the traditional manner. This view is supported by the lack of any real understanding in his utterances about Judaism and Christianity.¹⁰² Furthermore, it is certain that he did not yield to his age’s widespread passion for mysticism, often encountered even among the educated and particularly among physicians.¹⁰³ On the other hand, he has been termed “deeply religious”¹⁰⁴ because of the almost hymnic praise of the “Creator” (demiourgos) in his great physiological work On the Usefulness of the Parts. But, is teleology—the real subject of this treatise—identical with religiosity? Do we have here a secret religious yearning, or is it simply a question of the stiff, formal language of allegory? We would like to know the answer for several reasons. First, it would be significant to learn whether Galen considered religious commitment to be an unavoidable component of medical ethics. Second, Galen’s revered predecessor Hippocrates was surely not “deeply religious” in the ordinary sense of the term.¹⁰⁵ In this connection one would wish to ask how Galen viewed the problem of Hippocratic religiosity. In addition, his relationship to Asclepius and to the “god-sent” dreams would have to be thoroughly analyzed once again.¹⁰⁶ Perhaps Galen’s religiosity, too, must be considered in terms of that dichotomy characteristic of so much of his work.

Pseudo-Galenica Those writings falsely attributed to Galen form a special chapter in the history of his influence. That such spurious writings existed during Galen’s own lifetime has already been noted and is proof of the great authority and attractiveness of his name, an obvious incentive to forgers. In many instances the intellectual milieu out of which such falsifications arose is known (although more work should be done in this area). For example, the extant treatise For Gauros, On the Question of How Embryos Are Ensouled belongs to circle of Porphyry, that is, to early Neoplatonism; and the lost work On Medicine in Homer appears to have come from the group around Sextus Julius Africanus, that is, from early Christianity and Neoplatonism.¹⁰⁷ In these cases, there was an attempt to legitimate certain views by placing them under a great, authoritative name.

Other spurious writings emerged when something written on a popular subject could more easily be sold under a distinguished name. For example, the forged works on urine, printed in volume XIX of Kühn’s edition, must have originated in this way (witness the popularity of urine prognostication in late antiquity and the Middle Ages). Likewise, the treatise On Sudden Death was a contribution to the much discussed subject of the forecasting of death.¹⁰⁸

Still other false Galenic works obviously had their origin in the medical teaching of late antiquity and the Middle Ages. Among these are the so-called Summaria Alexandrina, in which Galen’s longer writings are presented in the form of a summary or abridged edition—and thereby often simplified and distorted.¹⁰⁹ Such compendia must have begun to be produced soon after Galen’s death; an early example is the short tractate on Galen’s Hippocratic princeples.¹¹⁰ The great majority of these forgeries were probably written in Greek. The Greek originals of some of the works of this kind are extant, while others are available only in Latin or Arabic translations. The Arabs were well aware that such spurious works existed and to some extent made an effort to discover which ones they were.¹¹¹ Yet it is not out of the question that among the mass of Arabic writings in Galen’s name one or another was actually composed by an Arab author and smuggled into the Galenic corpus. Works were still being forged in the Renaissance—e.g., the commentaries on the pseudo-Hippocratic On Nourishment¹¹² and On the Humors.¹¹³

The spurious Galenic writings will someday have to be studied as a whole. In view of the mass of Galen’s works that are still unedited and in the absence of a critical, philologically sound complete edition of Galen, such a task would be arduous. In considering the extant Greek writings in the course of such an undertaking, one would have to employ, for example, stylistic comparison; but little preparatory work for a study of Galen’s style has been done.

Galen’s Influence. Far too little attention has been paid to the fact that, although he was very interested in medical pedagogy, Galen had no real students of his own¹¹⁴ and, unlike many of his colleagues, founded no school. Even in his own lifetime he was a quite exceptional figure. His stature was explicitly acknowledged immediately after his death; it was the enormous range of his literary works, above all, that led to his being called divine.¹¹⁵ In the medical schools of late antiquity and the Middle Ages, Galen’s writings constituted the principal element of the curriculum (the Summaria Alexandrina has already been cited), and excerpts from Galen occupy considerable space in the great medical encyclopedias of Oribasius and Aetius of Amida. Byzantine physicians—Alexander of Tralles, for example—did not always accept Galen uncritically by any means’ in general, however, they were all crucially dependent on him.

In the non-Greek world Galen’s influence was based on innumerable translations of his works. Of those in Latin only a few need be cited; those by Cassius Felix, who in the fifth century translated Greek authors logicae sectae, including Galen, in his De medicina liber; and, in the medieval period, the important translations of Pietro d’Abano¹¹⁶ and Nicola da Reggio.¹¹⁷ In addition, Galen was early translated into Syriac;¹¹⁸ but the Arabic translations had the greatest impact. In this regard the achievements of Ḥunayn ibn Isḥāq and his school are especially outstanding; moreover, he has also provided a survey of the Syriac and Arabic translations.¹¹⁹

The influence of Galen, transmitted equally by his own writings, in both the original Greek texts and translations, and by summaries, compendia, commentaries by other physicians, and even forgeries, created Galenism, which dominated the medicine of the Middle Ages. The real battle between the Galenists and the medical “revolutionaries” took place in the Renaissance. With the introduction of printing there occurred a revival of the genuine Galen in the form of text editions and commentaries.¹²⁰ The most important criticisms directed against him were in the fields of anatomy (where he was exposed as an “ape anatomist” and corrected), physiology (in which his dogma of the liver as the starting point of the blood was overthrown), and therapy (from which the bloodletting controversy linked primarily with the name of Brissot emerged). If Galen’s authority was not destroyed in the Renaissance, it was seriously called into question.¹²¹ Yet his influence was far from being eliminated thereby. For one thing, the results of the criticism of Galen (for example, Harvey’s discovery of the circulation of the blood) occasionally required a long time to be definitively accepted among physicians. For another, the conception of, for example, humoral pathology in the form codified by Galen, encompassing such ideas as bad humors and blood purification, was so deeply rooted outside of the socalled school medicine that even around 1900 one could speak of a “Neogalenism.”¹²²

Fridolf Kudlien

GALEN (GALêNOS)

(b. Pergamum, September 129; d. c. 216, Rome),

medicine, biology, physiology, anatomy, psychology, logic, philosophy. For the original article on Galen see DSB, vol. 5.

Galen was one of the most important and influential medical practitioners and theorists of antiquity. His synthetic but innovative general accounts of anatomy, physiology, pathology, and therapeutics dominated medicine in late antiquity, and, by way of the Arabic world, were reintroduced into the West in Latin translation from the twelfth century, where they rapidly became canonical. His anatomy was not superseded until the publication of Vesalius’s De Humani Corporus Fabrica (1543); his physiological and therapeutic views remained influential until the nineteenth century.

The very size of Galen’s surviving corpus, and the fact that much of it as of 2007 has yet to be properly edited according to modern critical methods, has held back the development of Galenic scholarship. But this situation is gradually being remedied, and the thirty-five years that have elapsed since the appearance of the previous DSB have witnessed a resurgence and quickening of Galenic studies. New texts of Galen, now generally equipped with detailed commentaries and a translation into a modern language, have been appearing with increasing frequency from the Corpus Medicorum Graecorum; a number of individual translations of important texts have appeared in English and other languages (see bibliography for some examples); and three volumes have now appeared in the ambitious project Les Belles Lettres has undertaken to produce substantial new editions and French translations of Galen’s work. In addition, a series of international conferences have begun to open up new avenues of exploration in Galenic studies; his contributions to philosophy, in particular, have benefited from substantial and sympathetic detailed treatments. That he was honoured in 2007 with a volume in the Cambridge Companion series is a testament to the revival of his scholarly fortunes.

Life and Work . Galen (sometimes still mistakenly referred to as Claudius Galen) was born in September 129 C.E. in Pergamum, a rich and thriving Greek city on what is now the west coast of Asian Turkey. His father was a successful architect of broad intellectual interests, and Galen was given a fine education, studying philosophy as a teenager with leading representatives of the major schools—Platonist, Aristotelian, Stoic and Epicurean, before his father, moved by a dream, decided to turn his son toward a career in medicine. On his father’s death in 149, Galen traveled for several years in search of the best doctors and teachers of his time, to Smyrna, Corinth, and finally Alexandria. He returned to Pergamum in 157, where, as a result (as he relates in On Recognizing the Best Physician, Kühn, 1965, vol. IX, pp. 4–7) of his superior knowledge and competence in a public display of animal dissection and surgery, he won the position of physician to the gladiatorial school, a post he held for four years. He then set off once more, this time for Rome, after a further period of travel, observation, and collection of materia medica in the eastern Mediterranean that took him as far afield as the Dead Sea.

Arriving in Rome in 162, Galen immediately (on his own account) began to make a name for himself in the cut-throat world of upper-class medical practice, as a result of his skill in prognosis and treatment, and his spectacular public demonstrations in functional anatomy. His work On Prognosis, written perhaps fifteen years later, paints a vivid, if undeniably self-interested, picture of his meteoric rise in Roman society, culminating with his appointment in 169, after a brief return to his native city, as one of the imperial physicians to the philosopher-emperor Marcus Aurelius (r. 161–180), with special responsibilities for the latter’s son Commodus. There is less information available about Galen’s later years, but it is clear that he remained within the imperial orbit until his death, which probably took place around 216 (a very late tradition which has him dying at the age of seventy— that is, in 199—has been definitively exploded, although it is still often recycled in popular histories). His working life covered almost seventy years, and there are literary remains from all of it, although what survives intact of Galen’s work probably amounts to no more than a third of his total, voluminous output. Even so, millions of words survive, more—much more—than from any other ancient author. He himself stated that he dictated to relays of slaves, often working on several texts at once.

Scholars know more than otherwise might have been even about his lost output, because Galen wrote two texts, On My Own Books and The Order of My Own Books, motivated by the need to expose forgeries that were circulating under his name during his lifetime (and several such spurious works are to be found in the Galenic canon), and in order to recommend an order of study for the genuine works. These are late treatises, but are not complete. Obviously they do not refer to works composed later; but in one case at least (On Prognosis) where the work was written earlier, the autobibliographies contain no mention of it, presumably because Galen himself supposed no genuine copy still to be extant. He had lost most of his own library in the fire that destroyed the Temple of Peace (which served as a public depository and intellectuals’ meeting place) in 192. The first surviving work from his hand is a school exercise, On Medical Experience, composed when he was about twenty; his last work, On My Own Opinions, a summary of his views on philosophy and science, may even have been composed on his deathbed. In the interim, he wrote voluminously on anatomy, physiology, therapeutics, pharmacology, diagnosis and prognosis, and the pulse, as well as composing numerous polemics against other doctors, and commentaries on the Hippocratic texts (which he regarded as being the basic source of medical wisdom: the surviving commentaries— and many are lost—run to thousands of pages, about 20 percent of his total surviving oeuvre); he also wrote on grammar, logic, and scientific demonstration, and other topics in philosophy. In what follows, this author will seek to sketch the outlines of his achievement.

Galen and the Medical Schools . Galen distinguishes the medical practitioners of his own and earlier times into three general classes or “sects”: Dogmatists (or Rationalists), Empiricists, and Methodists. The distinction is not Galen’s own (it occurs a century earlier in the medical encyclopedia of Celsus); but Galen makes it canonical, and it is to Galen that scholars owe most of their knowledge of them (he wrote a short treatise On Sects for Beginners, but he scatters remarks, usually of an uncomplimentary nature, on the schools and their adherents throughout his works. It is a rough and ready taxonomy (the Dogmatist category in particular is a very broad one), but for all that, it is a serviceable one. Roughly, Dogmatic doctors are those who believe that sound medical practice must be founded on etiology, accounts of the fundamental structure of things and how they work that serve to explain how organisms function properly, what accounts for their failure to do so, and how such failures can be countered and repaired. But as their various opponents, in particular the Empiricists, were not slow to point out, there was no agreement at all among the various Dogmatic schools as to the facts of physiology and pathology.

In the face of this dispute, Empiricists declared such attempts to determine the hidden, fundamental structures of things both hopeless and unnecessary (thus they dismiss anatomy as of little importance; see Anatomical Procedures, Kühn, 1965, vol. II, pp. 282–85). The Empiricists argued that perfectly successful medical practice could be founded simply on the observation and categorization of the regular conjunctions of suitable observable phenomena: If one sees that diarrhea is stayed by the ingestion of pomegranates on a sufficiently large number of occasions, then one may conclude that pomegranates cure diarrhea; one does not need to know how they do. Empiricists rely on personal experience, and on the reports of others, to build up their empirical connections, while some of them also allowed a certain type of analogical reasoning at least to suggest candidates for therapy. But officially they insist that all medical knowledge is the result of random successes subsequently repeated and tested.

Methodists held that there were only three basic disease types: the pores of the body might be too loose, too constricted, or a mixture of the two (in different places of course). To the moderately trained eye, the existence of these conditions was evident; treatment simply consisted in seeking to counteract them. Thus no causal theory, or indeed developed physiology, was required of the practitioner. Methodism was developed in the first century CE by Thessalus of Tralles, who promised to teach it all in six months, a claim that Galen dismisses contemptuously on several occasions. For Galen, medical competence could only be won by years of study and effort, and only by someone versed not only in the best medical theory, but also in all aspects of philosophy. Indeed, he wrote a short treatise, The Best Doctor Is Also a Philosopher devoted to establishing this premise. A properly competent doctor must understand the basics of physical science (in Galen’s view the canonical four-element and quality theory: all substances are composed of the elements earth, water, air, and fire, which in turn exhibit pairs of the qualities, cold/dry, cold/wet, warm/wet, and warm/dry, respectively), because the majority of illnesses consist in damage to the body’s natural functions that result from an imbalance in the qualities. The doctor needs to be able to recognize the signs of specific imbalances, and to treat them (allopathically, “opposites cure opposites” is for Galen an a priori Hippocratic truth). Galen outlines his physics (which involves an attack on monisms and atomism) in Elements According to Hippocrates, whose title indicates one of Galen’s particular intellectual debts, and in On Temperaments. The doctor also needs to understand logic, in order to avoid the traps of the “sophists,” and to distinguish demonstrative arguments from those that are merely probable (or worse). Finally, he should be versed in ethics: He should value knowledge for its own sake and realize that the good life consists not in the pursuit of pleasure, fame or riches, but in the service of mankind.

Much of attitude is self-serving, but contempt and disgust at the venality and incompetence of his medical opponents is a constant refrain throughout Galen’s work, and there can be no doubt either of Galen’s own vast learning. He himself, he says, belongs to no school, preferring the truth to sectarian affiliation. Although by temperament he is a Dogmatist (because he believes that comprehensive medical practice is to be founded on a causal secure understanding of physics and physiology), early in his career he noted the apparently intractable nature of their disagreements. In fact, he says, it might have made him a skeptic had he not been aware of the demonstrative certainty of geometry. Thus he is in some ways sympathetic to the charge made by the Empiricists that the Dogmatists cannot securely found their own theories, but he ascribes this to the Dogmatists’ own shortcomings rather than to any intrinsic impossibility in the enterprise. Again what is needed is a thorough grounding in demonstrative theory, and serious intellectual application. For this reason, he is not as hostile to the Empiricists as he is to the Methodists. Within limits, he allows, Empiricists can become reasonable practitioners. They observe the same phenomenal regularities that allow someone like Galen to deduce the hidden, internal states of the body, but instead of doing so and then working out the appropriate therapy, they simply infer therapies directly from them on the basis of experience alone. This means that Empiricists are at a loss when confronted with unfamiliar concatenations of symptoms, and have to trust to luck and improvisation. At the same time, the Empiricists’ emphasis on empirical testing is perfectly justified, and a corrective to the excessively aprioristic attitude of

some of the Dogmatists. In fact, Galen sets out to elaborate (largely successfully) a new scientific epistemology that seeks to unite theoretical and practical considerations in a fruitful synthesis. Proper medical science requires a theoretical underpinning, and its practical suggestions should all be undergirded by a true causal theory, as the Dogmatists insist; yet those suggestions, and hence the theory that delivers them, should also be subjected to constant and rigorous empirical testing, in the manner of the Empiricists. It is for this reason that he consistently abjures certain metaphysical and cosmological questions, such as whether there is more than one cosmos, and whether a void exists outside it, or what the nature of the human soul is and whether it is immortal, as being unanswerably pointless.

Anatomy and Physiology . In order to be able to preserve health and cure disease, the fully armed doctor needs to understand the structures and proper functioning of the body and its parts. This (pace both Empiricists and Methodists) requires extended and difficult study. This is not just a matter of distinguishing and mapping the various structures of the body; it also involves determining their functional interrelations, of seeing why things are where they are and doing what they do, and this in a particularly strong sense, for Galen is committed to a strong version of biological teleology. One can only understand the body and its workings, he thinks, on the assumption that it is the product of intelligent and benevolent design. The view of the atomists (and other mechanists) to the effect that the structures of animals’ bodies (and indeed every structure) are simply the outcome of the interplay of random physical forces is simply, he thinks, rationally unsustainable when one has a sufficiently clear and detailed understanding of the complexity of those systems and their degree of functional interrelatedness. The establishment of this teleological anatomy is the object of On the Utility of the Parts, a long treatise that Galen himself describes as a hymn to purposive nature, which he personifies using the Platonic designation of the “Demiurge.” The whole of the first book is devoted to a discussion of the human hand (although Galen’s treatment is vitiated by the fact that he was forced to rely on dissections of apes, and his over-confidence in interspecies homology). Galen is particularly impressed by the fact that nature has supplied only as many tendons as are required to move the fingers and thumb in the appropriate directions, and he heartily endorses Aristotle’s claim (against Anaxagoras) that humans have hands because they are intelligent rather than the other way round. In effect, while the general tenor of his teleology is Platonic (he believes that the complexity of animals’ structures entail that they were intelligently designed, although as he regularly says, he has no idea of the precise mechanisms by which such a design are realized: see On the Formation of the Foetus, Kühn, 1965, vol. IV, pp. 652–702), the fine detail of his teleological analysis owes a great debt (which he acknowledges) to Aristotle.

But whereas Aristotle was prepared to allow that certain structures lack functions, being the necessary “residual” causal consequences of others which were purposive, Galen is far less willing to water down the teleology in this way; thus, in On the Natural Faculties, a treatise in which he argues that the body’s organs must be supposed to dispose of specific faculties for attracting, retaining, metabolizing, and eliminating what is appropriate (and in the last case inappropriate) to them, he contends that, first appearances notwithstanding, the gall bladder, spleen, and omentum all fulfill important roles in the overall economy of the animal. For Galen, nature does nothing in vain, and with a vengeance. This commitment in turn provides him with a powerful heuristic: If at first no function is discernible in some structure, look more closely until you find one (and, as far as it goes, this is a reasonable heuristic, even if Galen is wrong to suppose that there can be no functionless structures). Nature also strives to produce economical design solutions: In the last book of On the Utility of the Parts, Galen marvels at the structural economy of the elephant’s trunk (he had dissected one of the emperor’s beasts), which it can use as a hand, but also as a kind of snorkel when fording deep rivers, in order to allow for which nature has providentially extended the nasal passage along its entire length.

For Galen, widespread experience and regular practice in dissection (and vivisection) was absolutely essential in order for the aspirant doctor to form a proper understanding of the structural arrangements of animal (and by extension human) bodies. Galen himself reports dissecting goats, pigs, bears, horses, and cattle (as well as elephants and apes), and recommends that the student take any opportunity to examine human skeletons they happen to come across, if they are not lucky enough to be able to visit Alexandria, which is the only place where medical training involved actual human skeletons. With application and ability, the doctor can come to an understanding, by means of dissection and vivisection, of how the various parts of the body work, and of what they contribute to the overall functioning of the animal; only then will he be in a position properly to understand, and hence to treat, diseases, since diseases are, by definition, physical conditions (“dispositions”) which serve to impair the proper functioning of the parts of the body. The individual parts themselves are attributed the appropriate mixture of the natural “faculties” required in order to perform their function. In turn, these faculties make use of, but are not reducible to, the simple potentialities of the elements and qualities. Such “explanations,” as Galen was well aware, risk vacuity, and he is clear that such talk of faculties and potentialities is useful only up to a point. But for all that, it is useful to know what things do, and (if they do) that they do them per se, as a result of their own structure. And that is what one needs to know in order to become a successful theoretician and practitioner of medicine.

Conclusions: Galen’s System . In this brief survey, it is not possible to do full justice to the range and diversity of Galen’s achievement. In particular, his contributions to pharmacology, largely contained in three vast theoretical and practical compendia, On the Composition of Simple Drugs, On the Composition of Drugs According to Places, and On the Composition of Drugs According to Type, in which Galen not only records (critically) a vast amount of existing drug lore, but also seeks to classify drugs and their efficaciousness according to his fundamental physical categories (drugs work in virtue of their particular mixtures of the fundamental qualities of hot, cold, wet, and dry), have not been surveyed here.

Galen’s systematization of pulse-doctrine, contained in four major treatises (Differences of Pulses, Diagnosis by Pulses, Causes of Pulses, and Prognosis by Pulses), and two summary ones (Pulses for Beginners and the possibly spurious Synopsis Concerning the Pulse), is also beyond the scope of this article. Here as usual he built upon his predecessors (all the while trumpeting his own innovations and excoriating their mistakes), but in this case, uniquely, he was prepared to allow that the great Hippocrates had fallen short and had not realized the immense diagnostic importance of the pulse. Accordingly, Galen produces an extremely detailed taxonomy of pulse types, where the variables included speed, vigorousness, depth, and regularity, which could be used (along with other diagnostic and prognostic signs) to determine the internal conditions of the patient’s system; the pulse is highly responsive, in Galen’s view, to internal imbalances, and hence serves as an invaluable tool for distinguishing them—although here, as elsewhere, Galen emphasized that the doctor also needed to know the particular patient’s normal sphygmology, because every individual’s natural condition was idiosyncratic, an English term which in fact derives from Galen’s term for the “particular admixture” of the patient’s body. Moreover, the normal ranges differ with age, gender, and location. Doctors in the Islamic tradition still make use of the Galenic classifications of pulse.

Equally exhaustive was Galen’s classification of types of disease and distemper (Differences of Diseases, Causes of Diseases, Differences of Fevers, Opportune Moments in Disease, On Crises, On Critical Days, as well as a number of short treatises on particular types of illness), and of symptoms (Differences of Symptoms, Causes of Symptoms, and On Affected Parts). In Galen’s view, once the doctor understood the physical basis of human physiology, and what sorts of things could go wrong with it, and once he was armed with a reasonably sure set of diagnostic and prognostic tools for determining the precise natures of the distempers involved, then the appropriate therapy (in general terms) followed as a matter of the logic of allopathy: an individual or part that was too hot or dry needed cooling and moistening, and so on. For all that, particular clinical decisions still required long experience and precise skills, as well as the application of logical reasoning (whether to employ drugs or other remedies; whether the patient’s constitution was capable of withstanding a particular treatment or not); and so it is no surprise that his masterpiece of therapeutics, On the Method of Healing, should have occupied more than a thousand pages (he also wrote a shorter compendium: Therapeutics to Glaucon).

Galen’s system was thoroughgoing and comprehensive; it offered a rationally constructed account (indeed one which Galen supposed—or at least pretended to suppose—was securely founded on logical demonstration) that made sense of the body and its ills within the context of general, if traditional, physics. It was learned, stressing both theoretical understanding and historical engagement, and Galen never wavers in his view that all wisdom is owed ultimately to Hippocrates and Plato. He wrote a massive work, On the Doctrines of Hippocrates and Plato, dedicated to proving that, on all major points of method and substance, the two great masters of old were both correct, and in agreement with one another (thus he thinks that Plato’s view of the tripartition, and trilocation, of the soul can be given an empirical demonstration using the discoveries and methods of later dissective and vivisective anatomy). But his system was also rooted methodologically (at least in theory) in empirical observation and (occasionally) experiment, and here he owes (avowedly) a debt to Aristotle and the later scientific tradition. Galen insisted continually that the deliverances of theory, physiological, pathological, prognostic, and therapeutic, should be subject to empirical testing. Moreover, this methodology is, as far as it goes, an admirable one. Galen had neither the instruments nor the conceptual machinery to carry it through into a fully scientific medical theory. Yet, in the former case at least, he was aware of the deficiency. Lacking reliable thermometers, determinations of heat and cold are always going to be approximative. Still the ideal was an admirable one, and one which, albeit in an ossified, scholastic form that Galen himself would have found most uncongenial, was to dominate Islamic and medieval medicine for a millennium and a half, and was to have its reverberations felt much later still than that (for example, in the practice of therapeutic phlobotomy, on which Galen wrote three short treatises). Indeed, its faint echoes may still be detected in a not entirely superseded medical, and psychological, terminology.

SUPPLEMENTARY BIBLIOGRAPHY

WORKS BY GALEN

Marquardt, J., I. Mueller, and G. Helmreich, eds. Claudii Galeni Pergameni Scripta Minora. 3 vols. Leipzig: Teubner, 1884–1893. Contains critical editions (but no translation) of short works.

Brock, Arthur J., trans. Galen on the Natural Faculties. London: William Heinemann, 1916.

Singer, Charles, trans. Galen on Anatomical Procedures. Oxford, U.K.: Oxford University Press, 1956. What survives in Greek of Galen’s major anatomical treatise, On Anatomical Procedures.

Duckworth, W. L. H., trans.; M. C. Lyons and B. Towers, eds. Galen on Anatomical Procedures: The Later Books. Cambridge, U.K.: Cambridge University Press, 1962. Translation of Arabic version of On Anatomical Procedures.

Kühn, C. G., ed. Galeni Opera Omnia, 20 vols. Leipzig: Georg Olms, 1821–1833. Reprint, Hildesheim, 1965. The most comprehensive edition of Galen’s works, it is incomplete, and in many ways inadequate. The process of producing proper modern critical editions continues, in particular in the series Corpus Medicorum Graecorum, published by Akademie Verlag.

May, Margaret Tallmadge, trans. Galen on the Usefulness of the Parts of the Body. Ithaca, NY: Cornell University Press, 1968. Includes Galen’s great work of teleological anatomy, On the Utility of the Parts.

Siegel, Rudolph E., trans. Galen on the Affected Parts. Basel: S. Karger, 1976.

De Lacy, Phillip, ed., trans., and commentary. On the Doctrines of Hippocrates and Plato. 3 vols. Berlin: Akademie Verlag, 1978–84.

Nutton, Vivian, ed., trans., and commentary. On Prognosis. Berlin: Akademie Verlag, 1979.

Walzer, Richard, and Michael Frede, trans. Three Treatises on the Nature of Science: Galen. Indianapolis: Hackett, 1985. Includes three important methodological treatises, one of which, On Medical Experience, survives mostly in Arabic, and was translated by Walzer in 1944.

Brain, Peter, trans. and commentary. Galen on Bloodletting. Cambridge, U.K.: Cambridge University Press, 1986. Includes Galen’s three treatises on bloodletting.

Hankinson, R. J., trans. and commentary. Galen on the Therapeutic Method Books I and II. Oxford: Clarendon Press, 1991. Includes first two methodological books of The Method of Healing.

De Lacy, Phillip, ed., trans., and commentary. On Semen. Berlin: Akademie Verlag, 1992.

De Lacy, Phillip, ed., trans., and commentary. On the Elements According to Hippocrates. Berlin: Akademie Verlag, 1996.

Singer, P. N., trans., with introduction and notes. Selected Works. Oxford: Oxford University Press, 1997. Good English translations of several important texts.

Nutton, Vivian, ed., trans., and commentary. On My Own Opinions. Berlin: Akademie Verlag, 1999.

Grant, Mark, trans. Galen on Food and Diet. London: Routledge, 2000. Includes important texts on diet and regimen; covers more ground than the Powell volume.

Powell, Owen, trans. On the Properties of Foodstuffs. Cambridge, U.K.: Cambridge University Press, 2003. Includes important texts on diet and regimen; more reliable and easier to use than Grant volume.

Johnston, Ian, trans. Galen On Diseases and Symptoms. Cambridge, U.K.: Cambridge University Press, 2006. Includes several important works in nosology.

Boudon-Millot, Veronique, trans. Galien. Vol. I. Paris: Les Belles Lettres, 2007. Includes new material from a previously unknown Greek codex.

OTHER SOURCES

Boudon-Millot, Veronique, and Antoine Pietrobelli. “Galien ressuscité: Edition princeps du texte grec du De propriis placitis.” Revue des Études Grecques 118 (2005): 168–213. Includes new material from a previously unknown Greek codex.

Hankinson, R. J., ed. The Cambridge Companion to Galen. Cambridge, U.K.: Cambridge University Press, 2007. A work covering many aspects of Galen’s achievement, by several hands.

Nutton, Vivian. Ancient Medicine. London: Routledge, 2004. Offers a magisterial general survey, with fine chapters on Galen and his achievement.

Rocca, Julius. Galen on the Brain. Leiden: Brill, 2003. A fascinating modern reconstruction and analysis of Galen’s dissective experiments.

Siegel, Rudolph E. Galen’s System of Medicine and Physiology. Basel: Karger, 1968.

———. Galen on Sense Perception. Basel: Karger, 1970.

———. Galen on Psychology, Psychopathology, and Function and Diseases of the Nervous System. Basel: Karger, 1973.

Smith, Wesley D. The Hippocratic Tradition. Ithaca, NY: Cornell University Press, 1979. Deals with Galen’s debt to (and construction of) Hippocrates.

R. J. Hankinson

GALEN

GALEN (130?–200? ce, or later) was a Greek physician and philosopher. The last and greatest medical scientist of antiquity, Galen exercised an unparalleled influence on the development of medicine. Galen was born in Pergamum (modern Bergama, Turkey), an important city in western Asia Minor, the only son of Nikon, an architect and geometer. He was educated by his father until the age of fourteen, when he began to attend lectures in philosophy. When Galen was sixteen his father decided that he should become a physician and thereafter spared no expense in his education. After studying under prominent medical teachers in Pergamum, Galen traveled to Smyrna in western Asia Minor, Corinth in Greece, and Alexandria in Egypt, to study medicine.

At the age of twenty-eight he returned to Pergamum, where he was appointed physician to the school of gladiators. This position provided him with broad medical experience that laid the foundation of his later career. In 161 Galen left Pergamum for Rome, where he quickly established a reputation as a successful physician and made many prominent acquaintances. He returned to Pergamum in 166, claiming as the reason the envy of his colleagues, but more probably to escape a severe plague. Shortly after his return, however, he was summoned by the emperor Marcus Aurelius to Aquileia (at the head of the Adriatic), where he was engaged in preparations for war against the Germans. Galen followed the emperor to Rome in 169 and avoided further military service by gaining appointment as physician to the emperor's son Commodus. His position gave him the leisure to pursue medical research, writing, and lecturing, which he did with great success. Not much is known of Galen's later career. He continued to attend Commodus after he ascended the throne in 180 as well as Septimius Severus, who became emperor in 193. The date of Galen's death is uncertain. One source states that he died at the age of seventy, which would be about 200 ce. However, according to Arab biographers, he lived to be more than eighty, which would place his death later than 210.

Galen was one of the most prolific authors of classical antiquity. He wrote more than four hundred treatises. Many of his works have been lost, including a large number of his philosophical treatises that were destroyed in a fire in the Temple of Peace at Rome in 191. Nearly 140 works in Greek that have survived either in whole or in part are attributed to Galen. Some are of doubtful genuineness and others are spurious. Still other works, while lost in Greek, are extant in Latin and Arabic translations. His writings are extremely diverse and include works on anatomy, pathology, therapeutics, hygiene, dietetics, pharmacy, grammar, ethics, and logic, as well as commentaries on Hippocrates and Aristotle. Most of his extant works deal with medicine. Galen wrote clear Attic Greek, but he was prolix and diffuse and his works are not easy to read. Moreover, he was vain, tactless, and quarrelsome, and his writings are often characterized by a polemical tone.

Galen was a brilliant student of anatomy. His exactness in dissecting primates and other animals (from which he drew inferences for human anatomy) was unequaled in the ancient world. His understanding of the human body and medicine followed traditional lines. He admired Hippocrates, whom he regarded as the repository of medical wisdom, and he claimed merely to reproduce his doctrines. Thus he accepted humoral pathology, which viewed health as the product of an equilibrium of the four humors. The basic principle of life for Galen was the pneuma ("spirit"), which he thought responsible for many vital processes. Galen's medical theory is deeply indebted to philosophy, the study of which he believed was essential to the education of a physician. He did not follow exclusively the teachings of any one philosophical school, though he was deeply influenced by Aristotle. As an eclectic, he borrowed freely from most philosophical schools with the exception of the Skeptics and Epicureans, whose doctrines he opposed.

Galen's writings reveal a strong teleological emphasis. He believed that everything had been made by the Creator (or Demiurge) for a divine purpose and that the entire creation bears witness to his benevolence. In his treatise On the Usefulness of the Parts of the Human Body he expresses the belief that true piety lies in recognizing and explaining the wisdom, power, and excellence of the Creator rather than in offering a multitude of sacrifices. He accepted the Aristotelian principle that nature does nothing in vain and he attempted to show that every organ was designed to serve a particular function. In the minutest detail the human body exhibits its divine design.

Although Galen believed in one god, his depiction of him as a divine craftsman was drawn not from Judeo-Christian sources, but from Plato's Timaeus, as was his argument from design. He criticized Moses for holding (in the account of creation in Genesis ) the doctrine of creatio ex nihilo and the belief that nature was created as an act of God's sovereign will. Galen was acquainted with both Jews and Christians and he refers several times in his philosophical and medical works to their beliefs. He was the first pagan writer to treat Christianity with respect as a philosophy rather than, like most educated Romans, as a superstitious sect. He admired Christians for their contempt of death, sexual purity, self-control in regard to food and drink, and their pursuit of justice: in all of which he regarded them as not inferior to pagan philosophers. He criticized Christians and Jews, however, for their refusal to base their doctrines on reason rather than solely on faith and revealed authority. A group of Roman Christians in Asia Minor, led by Theodotus of Byzantium, attempted in the late second century to present Christianity in philosophical terms. They are said to have admired Galen and it is likely that they were influenced by his philosophical works. They taught an adoptionist Christology, and for this and other heresies they were excommunicated by church authorities.

Galen enjoyed an enviable reputation in his own time both as a physician and as a philosopher. Soon after his death he came to be recognized as the greatest of all medical authorities. His eclecticism, which permitted him to take what was best from all medical sects, his claim to reproduce the ideas of Hippocrates, the encyclopedic comprehensiveness of his medical works, and his greatness as a scientist were largely responsible for his influence. Because his writings were voluminous they were summarized in handbooks, synopses, and medical encyclopedias. The pre-Galenic medical sects gradually disappeared and were replaced by an all-embracing Galenic system that united medicine and philosophy and came to dominate medicine for over a millennium. As anatomical and physiological research ceased in late antiquity, medicine became increasingly scholastic and was taught from a selection of Galen's works.

Galen's direct influence was initially greater in the Byzantine East, where his ideas were relayed by medical encyclopedias, than in the Latin West. In the ninth century many of his works were collected and translated into Arabic and Syriac by Hunayn ibn Ishaq, a Nestorian Arab physician, and his school. In the course of the eleventh century they were translated from Arabic into Latin and Hebrew and came to dominate medicine in the West just as they had dominated Byzantine and Arabic medicine. The authority of Galen was regarded as second only to that of Aristotle. Although a pagan, he appealed equally to Jews, Muslims, and Christians, who found his teleology and monotheism compatible with their own faiths. The appearance of his collected Greek works in the sixteenth century spurred new interest in Galen and led to a revival of medical experimentation. It was during the Renaissance that his reputation reached its apex, but it soon began to be challenged by new discoveries, particularly in the fields of anatomy and physiology. Nevertheless, ideas championed by Galen (particularly humoral pathology) continued to influence medical theory until the nineteenth century.

Bibliography

The only complete edition of Galen, with Latin translation, remains C. G. Kühn's Claudii Galeni Opera Omnia, 20 vols. (1821–1833; reprint, Hildesheim, 1964–1965). While the text is unreliable, Kühn's edition is still useful in the absence of critical editions of most of Galen's works. Several of Galen's treatises have been translated into English. See in particular Galen on the Usefulness of the Parts of the Body, 2 vols., translated and edited by Margaret T. May (Ithaca, N.Y., 1968). A representative selection of extracts from Galen's writings is found in Greek Medicine, edited and translated by Arthur John Brock (London, 1929), pp. 130–244.

Brief but reliable introductions to Galen and his background are D. E. Eichholz, "Galen and His Environment," Greece and Rome 20 (1951): 60–71; and G. W. Bowersock; Greek Sophists in the Roman Empire (Oxford, 1969): 59–75. Aspects of Galen's life and work are explored in the composite volume Galen: Problems and Prospects, edited by Vivian Nutton (London, 1981). Several of Nutton's essays that deal with Galen's career are reprinted in From Democedes to Harvey: Studies in the History of Medicine, edited by Nutton (London, 1988). On Galen's theology and his attitudes to Christians and Jews, see Richard Walzer's Galen on Jews and Christians (Oxford, 1949); and Fridolf Kudlien's "Galen's Religious Belief," in Galen: Problems and Prospects (cited above). On the influence of Galen on medical thought, see Owsei Temkin's Galenism: Rise and Decline of a Medical Philosophy (Ithaca, N.Y., 1973).

Gary B. Ferngren (1987 and 2005)

Galen

Galen (130-200), Greek physician, anatomist, physiologist, philosopher, and lexicographer, was probably the most influential physician of all time.

Throughout his life Galen was a prolific writer, producing his first books, Three Commentaries on the Syllogistic Works of Chrysippus, at the age of 13 and his last, Introduction to Dialectics, in the year of his death. His total output has been estimated at more than 2 1/2 million words. Those of his writings which survive make up over half the extant works of ancient medicine.

Various birth dates from 127 to 132 have been suggested, but 130 is generally accepted. Galen was born at Pergamon, Asia Minor, into a well-to-do family with strong scholarly traditions and influenced by the renaissance in Greek culture which had started at the end of the 1st century A.D. This renaissance had led to increasing Hellenization of the Roman world, the adoption of Greek models of learning, and the use of Greek as the cultural language.

Galen's father, Nicon, mathematician, architect, astronomer, philosopher, and devotee of Greek literature, was not only his sole instructor up to the age of 14, but the example of Stoic virtues on which Galen consciously modeled his own life. In his book On the Passions and Errors of the Soul he says he was "fortunate in having the least irascible, the most just, the most devoted of fathers," but of his mother he says "she was so very much prone to anger that sometimes she bit her handmaids; she constantly shrieked at my father and fought with him." Galen continues, "When I compared my father's noble deeds with the disgraceful passions of my mother I decided to embrace and love his deeds and flee and hate her passions." He defined passion as "that unbridled energy rebellious to reason" and had its control as one of his life's aims. Not surprisingly, perhaps, he himself remained unmarried.

Philosophical and Medical Training

In his fourteenth year Galen attended lectures given by Stoic, Platonic, Peripatetic, and Epicurean philosophers from Pergamon. Encouraged by Nicon, he refused to "proclaim [himself] a member of any of these sects" and said "there was no need for [the philosophy] teachers to disagree with one another, just as there was no disagreement among the teachers of geometry and arithmetic." Later in life he adopted the same attitude to the medical sects, and he urged physicians to take whatever is useful from wherever they find it and not to follow one sect or one man because that produces "an intellectual slave."

Galen relates that Nicon "advised by a dream made me take up medicine together with philosophy … if I had not devoted the whole of my life to the practice of medical and philosophical precepts, I would have learned nothing of importance … the great majority of men practicing medicine and philosophy are proficient in neither, for they were not well born or not instructed in a fitting way or did not persevere in their studies but turned to politics."

Galen, being well born, fittingly instructed, and eschewing politics, persevered with his studies at Pergamon for the next 4 years, as he puts it, "urging [myself] above [my] companions to such a degree that I was studying both day and night." His first anatomy teacher was Satyrus, a pupil of Quintus, who through his students played a major role in the resurgence of anatomical activity that culminated in Galen's work.

Nicon died in 150 and the following year Galen went to Smyrna. While there he wrote his first treatise, On the Movements of the Heart and Lung. In 152 he went to Corinth and on to Alexandria, where he remained for 4 years studying with Numisianus, Quintus's most famous pupil. Although Galen admired Numisianus and "the physicians [who] employ ocular demonstrations [of human bones] in teaching osteology," he tells us that "in Alexandria the art of medicine was taught by ignoramuses in a sophistical fashion in long, illogical lectures to crowds of fourteen-year-old boys who never got near the sick." He "went away surprised and sorrowful—sorrowful at [Julian the sectarian methodist's] lack of sense, and surprised … there could be sufficient stupid pupils to fill his classes."

To counteract the poor teaching and the misunderstandings of the students, Galen produced a number of dictionaries, both literary and medical. He also started a major work, On Demonstration. Unfortunately, no copy survives.

Physician to the Gladiators

In 157 Galen returned to Pergamon, where he "had the good fortune to think out and publicly demonstrate a cure for wounded tendons" which gained him, in 158, the position of physician to the gladiators. He was reappointed annually until the outbreak of the Parthian War in 161.

The traumatic injuries of the arena provided Galen with excellent opportunities to extend his knowledge of anatomy, surgery, and therapeutics, and throughout his life he drew on this fund of experience to illustrate his arguments. While physician to the gladiators, whose daily lives can be reconstructed from his writings, Galen produced some of his most original work, including his demonstration of the part played by the recurrent laryngeal nerve in controlling the production of the voice. This for him and his contemporaries had wide implications, since it impinged on their ideas of the soul.

Practice in Rome

In 163 Galen went to Rome, where he was befriended by the philosopher Eudemus and the consul Flavius Boethius. Galen's public anatomical demonstrations and his success as a physician so aroused the jealousies of the Roman physicians that Eudemus "warned him he was putting himself in danger of assassination." Galen, who accepted the Stoic teachings "to scorn honors and worldly goods and to hold only truth in esteem," scorned the self-seeking of his adversaries and deplored their inability to understand honesty of motive and intellect when they encountered it. He says "his training and studies [did] not fit him to cope with the ignorance and craftiness of his enemies," yet he felt it imperative "to continue to speak out freely." This passion to disseminate knowledge as widely and as publicly as possible is the key to understanding Galen and is the explanation of much of the polemical writing he directed at those who set themselves up as authorities and teachers and who either passed on false information or secretively withheld knowledge in their possession.

Galen returned to Pergamon in 166. However, a severe outbreak of plague among the Roman troops in Aquileia in 168 caused the emperors Marcus Aurelius and Lucius Verus to send for him and appoint him physician-in-ordinary. In 169 Marcus made Galen physician to his son, Commodus (emperor 180-192); and so until 175, when Commodus rejoined Marcus on his military campaigns, Galen lived in one or another of the imperial country houses. During this time he completed his major physiological work, On the Usefulness of the Parts of the Body in 17 books, and wrote another major physiological treatise, On the Natural Faculties, and many other treatises. In 176, as physician to Marcus, Galen returned to Rome permanently. Now under imperial protection, he continued his writing, lecturing, and public demonstrations.

In the winter of 191/192 a fire destroyed most of Galen's library. Yet in spite of this loss (which he met with Stoic calm, saying "no loss was enough to cause me grief"), we are very well informed about his writings, because he wrote two treatises on his own books and their order of production. The first he wrote as a young man when "a certain book … plainly inscribed 'Galenus Medicus' proved on inspection … to be a forgery." The second was compiled in 198. Both works provide authoritative information on the authenticity of his writings and are major sources of biographical detail.

From 179 to his death in 200, Galen continued his medical research and writings, producing such major works as The Method of Cure. However, during his last decade he wrote in a more philosophical vein, giving us such treatises as On the Equality of Sin and Punishment, The Slight Significance of Popular Honor and Glory, and The Refusal to Divulge Knowledge. His last work was titled Introduction to Dialectics.

Assessment of Galen

That Galen was a man of his time is shown by his success and rapid preferment, by his acceptance of dreams as sound directives for action and treatment, and by his acceptance of the Hippocratic tradition and of the social role of public prognostics. That he provoked such strong reactions shows him to have been a dominant individual in an age of individuals. Galen believed the Hippocratic writings were never wrong—merely obscure—and he saw his own work as the extension and clarification of the Hippocratic corpus; for example, he systematized the theory of the four humors. Nevertheless, Galen was aware of the intervening intellectual progress, saying "the fact that we are born later than the ancients and receive from them the arts in an advanced state, is no small advantage … things that took Hippocrates a long time to discover one can now learn in a few years and one can employ the rest of one's life in the discovery of the things that remain to be learned."

The change in medical thought that Galen produced in his own lifetime was much greater than the changes from Hippocrates's time to his own. When Galen commenced his studies, there were as many "medicines" as there were sects and no criteria for judging "the best sect." He showed that a major source of sectarian conflict and error was due to the lack of philosophical training, which in turn led to "the use of unproven principles," the misunderstanding of "demonstrations," and "a disdain of dissection." Because he accepted the mathematical model of truth, with its criterion of agreement, he claimed that "if conclusions in connection with the cure of disease [were properly] grounded, physicians would manifest an accord like that of geometricians, though it would require [their] learning at the very beginning the meaning of every term, and what undemonstrable propositions commonly called axioms will be accepted."

Galen saw the science of medicine as "based on two criteria, reason and experience," which guaranteed the truth or falsity of its propositions. His systematic anatomical experiments provided a means of demonstrating to the senses those things which no sane man could deny any more than he could deny the self-evident axioms of mathematics. However, among his self-evident axioms we find "Nature [and/or the Creator] does nothing in vain." His frequent appeal to this axiom for explanatory purposes is in part responsible for the overemphasis on the teleological aspects of his writings by both his followers and his critics. Galen's concept of Nature is subtle and complex, and his Creator differs from the Christian God in not being omnipotent but subject to both the laws of necessity and the nature of matter. It was the very success of his program of unification of medical theory that led to its "rigidity" and supremacy in the ensuing centuries.

Most surprisingly, we do not know Galen's family name, because, not wanting to trade on his forebears' reputations, he used only his given name; the name Claudius often associated with him is probably a Renaissance misunderstanding. Galen said of himself, "I have worked only for science and truth and for that reason I have avoided placing my name at the beginning of my books." On the other hand, he was pleased to record Marcus Aurelius's lavish praise that he was "the first of physicians and the only philosopher."

Further Reading

The translation by M. T. May, Galen: On the Usefulness of the Parts of the Body (2 vols., 1968), contains an excellent introduction and an extensive bibliography. Other translations of his works are R. Walzer, Galen on Medical Experiences (1946); R.M. Green, A Translation of Galen's Hygiene (1951); A.J. Brock, Galen on the Natural Faculties (1952); C. Singer, Galen on Anatomical Procedures: The Later Books (1962); and P.W. Harkins and W. Riese, Galen on the Passions and Errors of the Soul (1964). A few selections can be read in M.R. Cohen and I.E. Drabkin, A Source Book in Greek Science (1948), and L. Clendening, Source Book of Medical History (1960). See also George Sarton, Galen of Pergamon (1954). □

Galen of Pergamum (ad 129–216), the most influential and prolific of all the physicians of antiquity, produced a philosophically sophisticated synthesis of earlier medical theories of the body that was dominant until the seventeenth century. The son of a rich architect, he began his medical career in ad 145–6; due to his family's wealth, he was able to train in his home town of Pergamum, and then at Smyrna and Alexandria for the unusually long period of ten years. From ad 157 he worked as physician to the gladiators in Pergamum, where he claims to have significantly reduced the death rate, before moving to Rome in ad 162. He left Rome in ad 165, alleging that other physicians in Rome were jealous of his success. His abrupt departure is, however, more likely to have been due to an attempt to avoid the smallpox epidemic which hit Rome soon after. On his return in ad 169 he became doctor to the emperor Marcus Aurelius and his family, although he managed to avoid accompanying the imperial household on a dangerous campaign in Germany by claiming that he could not go on religious grounds.

His work claimed to continue the tradition of Hippocrates, the fifth-century (bc) doctor to whom a large and disparate corpus of ancient Greek medical texts was attributed. Galen attacked other doctors of the time for failing to understand what Hippocrates really meant, but this is merely rhetoric; the ‘Hippocrates’ Galen gives us is one created in the image of Galen. Galen's very personal judgements of which treatises in the Hippocratic corpus were the ‘genuine works’ of Hippocrates have influenced all subsequent work on that corpus.

Galen's model of the body combined ideas from Hippocratic medicine, Plato, and Aristotle. The scientific logic is Aristotelian. The notion of three body systems – governed by the heart, the brain, and the liver respectively — comes from Plato, the fourth-century (bc) Athenian philosopher whose dialogue, the Republic, divides the soul into three parts, namely reason, ‘spirit’ or emotion, and desire. From some Hippocratic texts, Galen adopted the idea of four humours, or body fluids, the balance between which is necessary for health, and used these as the basis of a more far-reaching system in which each humour can be tied to a quality, a season, and a period of life. Blood, the warm and moist fluid, is associated with spring and predominates in childhood; yellow bile is warm and dry, and is associated with summer and youth; black bile, thought to be cold and dry, is associated with autumn and adulthood; phlegm, cold and moist, is the humour of winter and of old age. Healing for Galen involved the application of general principles to specific, individual cases. The maintenance of the correct balance amongst the four humours in any individual body constitutes health, while imbalances can be corrected by attention to air, food and drink, exercise, sleep, repletion and evacuation, and emotion.

In the Galenic body, heat plays a central role: the three ‘faculties’ of the body are, in ascending order of importance, the nutritive, the vital, and the logical faculties. In the nutritive sphere, food is partially cooked by the stomach, and then moved in the form of chyle to the liver where it is heated further. The portal vein then carries chyle to the liver, where further heat refines it into blood and adds the ‘natural spirit’. The liver draws in the chyle by ‘attraction’, and other parts of the body then attract to themselves for nourishment most of the ‘venous blood’ which the liver makes. Some fluid, however, travels on, by way of the vena cava, to the heart, where in a further stage of cooking it takes in ‘vital spirit’ to become lighter and thinner, as ‘arterial blood’. This transmits to other parts of the body the vital faculty, which gives warmth and the power of growth and can be measured through the pulse. The brain gives the blood psychic pneuma, which is distributed through the body by means of the nerves; with the brain is associated the logical faculty — the power of thought, will, and choice. In the Galenic body, veins, arteries, and nerves are thus separate systems with different functions. Veins originate in the liver, and carry food to nourish the body, while arteries proceed from the heart and carry vital spirit, although they also contain some blood.

Galen believed that medicine required both practical and theoretical elements. He claimed that he dissected every day, sometimes in public, even asking members of the audience to nominate the part to be dissected; his experiments on the spinal cord, in which he demonstrated that muscles are controlled by nerves, are still famous. However, these experiments were performed on animals, particularly pigs and apes, rather than on humans. Some parts of the Galenic body, which were questioned — and their existence eventually disproved — in the Renaissance, derive from incorrect analogies between animals and humans. The ‘rete mirabile’ at the base of the skull is one example. Other errors, such as the ‘invisible pores’ which Galen insisted must be present in the interventricular septum of the heart, were logically necessary to his model of the body.

Galen was a highly prolific writer, whose works included not only philosophically and logically argued treatises on the body but also texts on the practical side of being a doctor in the Roman world. He insisted that his enemies spread malicious rumours about him, including the slander that his extraordinary success in prognosis was due to magical rather than medical skills. On one famous occasion, described in his treatise On Prognosis, he detected that a woman's pulse rate increased when the name of the man she loved was mentioned. Galen himself attributed his prognostic skills to following Hippocratic principles based on reading bodily signs and being aware of all relevant features of the patient's life.

Helen King