Chapter 7 GALEN MEDICAL SCHOLAR AND CELEBRATED ANATOMIST Ts most celebrated anatomist of antiquity was the great physician Claudius Galen (Fig. 36). He was bom in Pergamon, along the coast of Asia Minor, the son of a prominent Greek mathematician, archi, tect, and astronomer. His birth in A.D. 131 coincided with the period of greatest glory of the Roman Empire, which was marked by the great territorial ex- pansion of Trajan as well as the implementation of his social welfare policies and architectural expansion, Galen studied philosophy under the influence of the Stoics, the Academicians, the Peripatetics, and the Epicureans; however, later in his life, he studied med. icine after his father described to his son a dreagmthat he would become a doctor. From the age of 20, Galen travelled extensively in order to study with the great- est teachers of philosophy and medicine. He visited Greece, Palestine, Phoenicia, and Crete and finally, settled in Alexandria where he remained until he was 30 years old. He was exposed to anatomy by Satyrus, a student of Quintus, Pelops of Smyrna, and later to Heraclianus in the Alexandrian school (Green, 1951). ‘Galen's interests and writings went beyond medi- cal matters and included philosophy, religion, mathe- matics, and grammar. He was an extremely prolific writer (Iberg, 1889; 1892; 1896; 1897; 1902; 1930; Walsh, 1934a, b; Peterson, 1977) who even produced a guide, entitled On His Own Books, to his voluminous treatises. In the field of medicine alone, Galen is cred- ited with more than 130 treatises, which became the unquestionable repository of medical knowledge for more than one thousand years after his death in A.D. 201, Only 80 of these have survived. Nonetheless, Kuhn's edition of Galen's work took 12 years to com, plete and spans 20 volumes (Kithn, 1821-1833) When he was 28-years-old, Galen returned to the ‘ity of Pergamon where he served as surgeon to the 39 gladiators for four years, During this period, Galen made anatomical observations based upon what he leamed from attending to the wounds sustained by the gladiators. Human dissection was forbidden in Imperial Rome, Galen derived anatomical knowledge from the works of his teacher and his predecessors, as well as from the extensive dissections he carried out on many species of animals. Galen dissected apes, monkeys, dogs, pigs, and even bears. He even consid, ered the intemal organs of man as not very different from those of the pig. The voluminous writings of Galen contained many detailed anatomical deserip- tions (Withington, 1929) and there has been much debate over the years as to what constituted his per- sonal observations versus those of his predecessors, Galen recognized the importance of anatomy for the work of the physician, He encouraged his pupils to visit Alexandria, so they might examine the human skeleton that was there, which he himself had studied. This is evident from his work, which contains the most detailed and systematic description of the human bones (Singer, 1952). Galen’s writings have provided insight to the accomplishments of the early anatomists, Particularly those who had lived in Alexandria, Despite many errors and shortcomings, Galen's anatomical writings remained unchallenged up to the time of Vesalius in the 16th century (Persaud. 1984). Rather than accepting the errors in the work of Galen, the French anatomist Jacobus Sylvius (1478-1555) re- marked in response to Vesalius that, ‘then, man must fhave changed his structure-in the course of time, for the ‘caching of Galen cannot er.” The Royal College of Phy. sicians of London in 1559 even made one of its mem» bers, Dr. John Geynes, retract his statement that there were 22 inaccurate passages in the works of Galen. According to Clark (1964), “it the eyes of the College, hismk ea Figure 35. Claudius Galen (Wellome Institute Library, London). offence was double: indoors it was heterodoxy but out of doors, it brought the chosen intellectual foundation of the ‘medical art into question if nat into contempt” Dr. Geynes ‘was subsequently examined and admitted to the Col- lege in.November 1560. The influence of Galest continued for many de- cades and appeared in examination notices of the College. In 1595, Dr. Edward Jordana medical grad- uate of the University of Padua, was required to read five of Galen's works before being admitted to fellow- ship. A Dr, Hood was forbidden to practice, because he did not read Galen’s work. He confessed that the books were too expensive to purchase. In 1596, Dr. ‘Thomas Rawlins was failed “and was admonished to work harder, particularly at Galen” (Clark, 1954). Galen derived his knowledge of anatomy largely from the dissection of animals, but in his own work, A History of Human Anatomy On Bones, he mentioned that he was able to study human bones from tombs that were destroyed. He also observed the bones of a body that had been washed from its grave by a flood and deposited on the riverbank. He was able to observe the intact and ar- ticulated bones amidst the petrified flesh, and the skeleton “lay ready for inspection, just as though prepared ya doctor for his pupils” lesson.” In another instance, he studied the skeleton of a robber whose flesh was eaten away by birds and after two days, it was ready “for anyone who cared to enjoy an anatomical demonstra- tion” (Duckworth, 1962). The reason as to why op- portunities to dissect humans during Galen’s time ‘was, most likely, that the structures of man and ani- mals, in particular, apes and monkeys, were assumed to be fundamentally the same (May, 1968). The lack of enthusiasm for human dissection can be ascribed further to the prevailing hostility against such a pagan practice. Galen himself marveled at the complexity and del icate arrangement of the parts of the human body. Ac- cording to the Aristotelian philosophy, he saw nature as providing a form and structure in the parts of the human body, with nothing being superfluous, in car ying out their functions. Such perfection and exqui- site design can only be attributed to divine providence Christians, Jews, and Muslims accepted Galen’s ac- count of the structure of the human body and his works were translated into many languages and re- mained popular for more than 1,400 years. Although Galen’s contributions to our knowledge of human anatomy were not significant in number, he still stands as one of the greatest medical scholars of antiq- uity, due to the profound influence that his volumi- nous writings had on medical scholars through the Middle Ages (Temkin, 1973). Despite his intellectual progress and contributions to anatomy and medical science during this period, both the fields of medicine and anatomy suffered a decline. In AD. 161, Galen made his first visit to Rome. It was the beginning of the reign of the Roman Emperor Marcus Aurelius (A.D. 121-180}, and following the suggestion of his patron, the Consul Flavius Boethus, he began to compose his anatomical works, On Ana~ tomical Procedure (Duckworth, 1962; Galen, 1956) and On the Usefulness of the Parts of the Body (May, 1968; Pagel, 1970; Galen, 2003). He returned to Pergamon in AD. 163, but later joined the military expedition of Marcus Aurelius in Aquileia as a personal physician. Because of the outbreak of the plague, the army re- tured to Rome, and Galen was entrusted to care for the son of Marcus Aurelius, Commodus. For over 20Galen 4 years (A.D. 169-192), Galen remained in Rome in pursuit of his medical work and compiled his treatises. He returned to his home city where he died eight years later at the age of 70. ANATOMICAL TREATISES Galen's life, anatomical accomplishments, and other works, were critically discussed by Prendergast (1928;1930), Singer (1956), Sarton (1954), and May (1968). Sarton’s monograph provides an excellent in- troduction to the works of Galen, including the trea- tises translated from Arabic and the editions that are available in English, including his work, De Anatomicis Administrationibus, a description of his anatomical studies in 16 books. The first nine volumes were trans- lated by Singer in 1956 from the surviving Greek text into English, while the remaining seven books, which had existed in Arabic were translated by Max Simon (1906) and Duckworth (1962). A complete translation from Greek into English of Galen’s most influential work, De usu partium (On the Usefulness of the Parts of the Body), was performed by Margaret May and published in two volumes. It consists of 17 books, de- voted to both anatomy and physiology, which at the same time extolled the complexity and beauty of the human ereation (May, 1968; Galea, 2003). Sarton (1954) stated that Galen’s treatises, De An- atomicis Adminis trationibus, of The Anatomical Proce- dures, was unknown in the Middl& Ages; however, the \ + translation of the first nine books from Latin to Greek text was carried out by Johann Guenther of Andern- ach, and it was first published in 1531 in Paris, several years before the publication of Vesalius's work. The remaining seven books became available only follow- ing their translation from the Arabic edition by Max Simon in 1906. Owsei Temkin translated portions of the German text into English, of which Duckworth created amore complete translation. Some of Galen's other anatomical works included the following: one on the dissection of the veins and arteries (De Venarum Arteriarumgue Dissectioné; the dis section of nerves (De Nercorum Dissectiond); a Secun- dum Naturam in Arteriis Sanguis Continator (a discussion ‘on whether arteries are naturally filled with blood); and myology (De Musculorum Dissectione ad Tirones). Some of his physiological treatises included a fair amount of anatomical information, often evolving from his dissections. De Musculorum Motu deals with both voluntary and involuntary movements. His treatise, De Usu Respirationis, describes experiments on the pleura and the use of bellows for maintaining artificial respiration. ANATOMICAL STUDIES Galen described the bones and sutuses of the skull (Ginger, 1952; May, 1968). He distinguished the squa- mous, styloid, mastoid, and the petrous parts of the temporal bones. He also recognized the quadrilateral shape of the parietal bones. He described the essential features of the vertebral column; including the coccyx and the sacrum, which he considered to be the most important, Twenty-four vertebrae were recognized and these were divided into cetvical, thoracic, and lumbar. Galen’s descriptions of the ribs, the sternum, clavicle, and bones of the extremities, as-Well as their articulations, were fairly accurate, Although Galen’s descriptions of muscles were based on the dissections he carried out on animals, they were fairly accurate and more advanced than those made by any anatomist previously (May, 1968). Galen defined a muscle as a bundle of fibers terminat- ing in an independent tendon. These muscles includ- ed the mylohyoid, the thyrohyoid, the six extrinsic muscles of the eye, two muscles of the eyelids, four muscles of the lips, a muscle to each ala nasi, the fron- talis muscle and four pairs of muscles that move the lower jaw, the temporalis, masseter, digastric, and lat- eral pterygoid muscles. In a similar manner, he sy3- tematically described the muscles of the tongue, neck, upper and lower limbs, and trunk. In describing the brain, which he considered to be the seat of the soul he identified seven pairs of cere- bral nerves. Due to their origin, from the brain, the cranial nerves were believed tojbe nerves of sensa- tion, in contrast to the 30 pairs of spinal nerves, which he recognized as the nerves of motion. Galen did not recognize the olfactory and trochlear nerves. The cra- nial nerves were designiated as follows: the optic nerve the first cranial nerve, the oculomotor and abducens nerves as the second cranial nerve, the trigeminal nerve as the third cranial nerve, the facial and vestib- ulocochlear nerves were combined as the fourth and42 A History of Human Anatomy fifth nerves. Galen named the glossopharyngeal, vagus, and spinal accessory nerves as the sixth pair of nerves, and the hypoglossal was considered to be the seventh. He knew of the sympathetic nervous system and of the recurrent laryngeal branches of the vagus nerve on both sides of the neck. He described experi- ments involving the nerves that control movement of the tongue and production of speech (Persaud, 1984). Galen provided a detailed description of the dis section of the brains of animals, and the names of many structures that he identified are sill used today, including the corpus callosum, corpora quadrigemi- na, fornix, pineal body, and septum pellucidum. He knew of the cerebral ventricles, their communica- tions, and of the choroid plexus. Galen’s description of the cerebral hemispheres, and the third and fourth ventricles reflected keen observations. He also de- scribed various disorders of the brain and formulated anatomical explanations for pain. For example, he be- lieved pulsating headaches to be a result of inflamma- tion of the brain, stating, “I the vessels are congested, they disturb the muscles causing thir detachments, which brings nerve pain and pulsation as a consequence” (May, 1968). In Galen’s descriptions of the nerves, arteries, and veins, which he considered as “instruments common to the whole body,” he indicated that all nerves originate from the brain, thefarteries from the heart and the veins from the liver (Pérsaud, 1984). Galen\described the body's cirtulafory system as divided into two separate compartments with little communication; the first was made up of the right side of the heart, and the second part was made up of the left side of the heart. He believed that the right side of the heart was a derivative of the liver, from which blood exits to pass through the vena cava either by extending to either the head and arms or to the lower extremities. The pulmonary artery, recognized by Galen as the “arterial rein,” delivered blood to the lungs, which passed into the left side of the heart to supply blood filled with “oital spiris” to the body. The little communication present between the two com- partments was achieved by “minute pores” in the septum between the ventricles of the heart. Galen considered nature “not only just, but also skillful and wise” (May, 1968], because the blood vessel structures passed safely to their destination. Galen failed to dif- ferentiate nerves from tendons, and his inadequate and distorted account of the blood vessels prevented him from discovering the pulmonary circulation. Galen’s description of the reproductive organs and his views on fetal development are notable as well. Unlike Aristotle, Galen observed that the ovaries were homologous to the testes, and thus both organs produced sperm. He believed that the chorion devel- oped after the female testicles expelled semen, which passed into the uterus to provide nutrition to the male semen. Based upon his observations of the uteri of animals, Galen incorrectly described the human uterus as bircornuate, or consisting of two horns; however, he did correctly describe the cervix, vagina, and ovaries, and their accompanying arteries and veins. The suspensory ligaments of the ovaries and the round ligaments of the uterus were described as being homologous to the cremaster muscle, which he first described. His descriptions of the peritoneal rela~ tionships, pacticularly with respect to the urinary bladder, were accurate and remarkable. Despite the ‘many apparent errors in Galen's anatomical treatises, ‘one can still appreciate his meticulous anatomical de- scriptions of dissected animals (May, 1968) COMPARATIVE ANATOMY Galen meticulously dissected several species of -animals, including the’Barbary ape (Macaca inuus), the only European nonhuman primate, Galen completed his anatomical studies in a time when dissection was perceived to be a pagan practice and thus not neces- sary for the treatment of patients. This generation be- lieved that human dissection was not necessary because the human anatomy could be determined from animal dissection, Galen’s influential and invalu- able works in anatomy contained detailed anatomical descriptions of dissected animals, which he assumed were identical to the human anatomy (May, 1968). In describing the anatomy of the cranial nerves, Galen stated, “for many surgeons do not know that in his work ‘on the roots of the nerves Marinus has enumerated only those same rodts which Herophilus specifies, but Marinus has concluded that there are seven pairs, whereas Herophilus says there are more than seven, regardless of the others. Whoever does not know this is, as the proverbial expression goes, like a seaman who navigates out of a book. Thus, be reads the books on anatomy, but he omits inspect ing with his own eyes in the animal body the sev- eral things about which he is reading.”Galen 43 When describing the brain, Galen recommended “that the dissection is best made in apes, and among the apes insuch a one as has a face rounded tothe greatest extent pos- sible amongst apes. For the apes with rounded faces are mast ike kurman beings? (Duckworth, 1962). For studying the male reproductive organs, Galen gave specific dissecting instructions: ‘We say that in order for you to secure that the animal which you are dissecting resembles a man, you must take for that dissection 'an ape. But in order to achieve the effect of clarity in the appear- ance of such of those organs as are small and hard to see, then you must take a he-goat, a ram, bull or horse or male donkey for your dissection because that animal must necessarily possess a scrotum. (Duckworth, 1962) For studying the larynx, Galen recommended the use of the pig. For in all animals which have a larynx, the activity of the nerves and the muscles is one and the same, but the loathsomeness of the expression in vivisec- tion is not the same for all animals. Because of that for my own part, as you know already, I illustrate such vivisections on the bodies of swine or of goats, without employing apes. Bat it is necessary that you should extend your stifdies and examine the larynx. This is constructed in the same way in the bodies of apes and men, a construction Which is shared by the other animals which have a voice. You must, then, dissect a dead man and an ape, and other animals furnished with a voice, which have, besides the voice, the vocal apparatus, the larynx. For the animals which possess no voice have no larynx either. He who is not versed in anatomy thinks that in regard to the plan of the larynx great contrast sexist among the six Animal Classes, to which this our discussion refers. That is because neither the absolute dimensions nor the shapes of the parts of the larynx are precisely the same amongst all of them, a point that applies also to the number of the muscles that they have there. But in regards to the activity of each one of the parts of the larynx, and the service, which they perform, these are one and the same in all animals provided with a voice. That is because in the bodies of these animals the intention of the Creator was uniform with regard to the plan of the vocal apparatus, just as his intention was uni- form also with regard to the plan of the respiratory organs in those animals provided with respiration. For the contrasts between these organs and the bodies of these animals consists solely in their ab- solute dimensions and their shapes. (Duckworth, 1962) Galen’s accomplishment of performing dissections in animals as well as his comprehensive descriptions of those structures he observed, continuing in the tra- dition of Aristotle, has made him one of the earliest comparative andtomists (Persaud, 1984). PHYSIOLOGICAL SYSTEM OF PNEUMAS From simple experiments Galen demonstrated that the arteries contained blood and not air as was previ- ously thought. However, his dogmatic adherence to the pneumatic theory (Fig. 37) prevented him from un- derstanding more about the flow of blood (Singer, 1957; Siegel,-1968). Essentially, three types of special pneuma or spirit were thought to éxist which dominate the liver (natural spirid), the heart (vital spirid) and the brain (animal spiri). Galen thought that pneuma, which was the life force, was taken into the body during breathing. Pneuma entered the lungs via the trachea, and from the lungs it passed into the left ventricle through the “zein-like artery” (pulmonary vein). He demonstrated the presence of blood in the left ventri- cle, but believed that it originated”in the liver from chyle, derived from the intestinal tract, where it became imbued with “natural spirit” Galen believed that this activated blood ebbed and flowed through the venous system, including through the artery-like vein (pulmo- nary artery), to the lungs where impurities were re- moved. He held the view that the venous blood in the right ventricle flowed back into the general venous system, but some of it was filtered through tiny pores in the interventricular septum to the left ventricle, Here it came into contact with the pneuma and this gave rise to the “vital spiri,” which was then distributed by the arteries, When the vital spirit eaclied the brain through its arteries, it was changed into the animal or psychical spirit. Galen believed that this vital spirit was distribut- ed through canals in the nerves. The natural spirit in the liver was thought to con- trol the functions of nutrition, growth and reproduc- tion whereas the vital spirit of the heart regulated vital functions by transporting heat and life throughout the“4 A History of Human Anatomy Pre arterial system; the vital spirit of the brain regulated the brain itsel£. This pneumatic theory, which origi- nated during the Hippocratic period, was based on three dominant and regulating forces or spirits in the body on the basis of which all functions can be Figure 37 Galen's conception of the vascular and respi- ratory systems ~ the flow of pneuma (With permission from Major 1954) explained. Philosophical in its formulation and com- pletely lacking any scientific basis, Galen's physiclogi- cal system of pneumas survived up to the seventeenth century, until Harvey announced his discovery of the circulatory system (Persaud, 1984). EXPERIMENTAL STUDIES Notwithstanding Galen’s highly fanciful concept of bodily functions, based om the theory of the three pneu: mas (Singer, 1957; Siegel, 1968; May, 1968), he carried out a large number of anatomical and physiological experiments, which were of a practical nature and had clinical implications. He performed experiments to elicit the function of vital organs. He examined the lungs in order to understand more about respiration, studied digestion by feeding pigs with different diets and then opened their stoinachs, and he demonstrat- ced that arteries contained blood, rather than air, by placing two ligatures on an exposed segment of artery, which he then slit open. Galen accurately described the consequerices of spinal cord damage at different levels. He observed loss of sensation and paralysis of all muscles supplied by nerves originating from the spinal cord following complete resection below that level. In contrast, he found that hemisection of theGalen 4 spinal cord resulted in paralysis of the muscles only on the side with the lesion. Furthermore, a longitudi- nal medial incision of the cord did not lead to paralysis, Galen identified that the diaphragm was not solely responsible for enabling respiration as other muscles were involved as well. Galen's detailed description of the origin and course of the phrenic nerve, as well as. the accidental discovery of the recurrent laryngeal nerve, which subsequently led to his understanding of voice production in the larynx, is most impressive SCIENTIFIC ACHIEVEMENT In retrospect, Galen deserves greater recognition for his work than he has received in the past (Persaud, 1984). As mentioned in the introduction to Duck- worth’s translation of the later books on Anatomical Procedures, the avowed aim was to “focus the attention of scholars and scientists on one of Galen's greatest works, and to attempt to remedy the accidental, but disastrous di- chotomy from which it has suffered for so many centuries.” ‘The hope was also expressed that modern anatomists, with their interest in comparative as well as in human anatomy, and with their experimental approach to- wards the elucidation of anatomical problems, are likely to be more sympathetic towards Galen than have been their predecessors during the last 400 years ‘The eclipse of Galen’s reputation at the Renaissance ‘was perhaps inevitable. Although many recent writers have remembered Galen primarily for his errors, many now put his observations into perspective noting the era in which they were mada (Duckworth, 1962) A fitting tribute'to Galen has been provided by the commentary of Hunain Ibn Ishaq of Baghdad (A.D. 809-873), a medical scholar, linguist, and Galen trans- lator. Upon completing his translation of the fifteenth book, Ishaq stated that this excellent, outstanding work which is one of the compositions of a man who performed marvelous- ly, and revealed extraordinary things, the master of the earlier surgeons, and the lord of the more recent savants, whose efforts in the practice of medicine have been unequalled by any of the prominent since the days of the learned and great Hippocrates — I mean Galen. May God Almighty be merciful to him! (Duckworth, 1962) Galen is often described as the Prince of Physicians, second only to Hippocrates, the Father of Medicine. He was the last of the great medical scholars of antig- uty, and his death, 200 years after the Christian era began, coincided with the progressive decline of Greek science, Galen’s works have provided for future {generatiowis.a legacy of medical accomplishments of an era that would have been all but forgotten,