Monday, June 29, 2015

Learn about asthma controller medicine

This post was originally published at healthcentral.com/asthma on 


There are so many asthma controller medicines on the market that the choices can be overwhelming. A common question I get is: which one is best for me? To answer this, you must first understand the basic components of

Chronic: All asthmatics always have some degree of inflammation in their air

Acute: When this chronic inflammation is not controlled, exposure to asthma triggers may worsen the inflammation, resulting in increased mucus production and spasming of the air passages, both of which make it hard to

Based on this knowledge, physicians now know that the best way to treat asthma is.
  • Control: Control underlying inflammation.
  • Prevention: Prevent asthma symptoms. 
  • Treat Flare-ups: Treat acute symptoms when they occur 
Learn about the different levels of asthma severity, asthma control, and how to gain control of your asthma.

This post is to help those of you who have come to the point where you and your doctor have determined that the best way of gaining control of your asthma is with asthma controller medications. Once you’ve come to this level of asthma treatment, you are committing yourself to a lifetime of taking asthma medicines.

It usually takes about two to three weeks for the medicine to start working. In order for the medicine to work, you have to take it every single day of your life even when -- especially when -- you are feeling well. So, just because you are feeling good today means you will still have to take your controller medicines.

The wonderful thing about all the modern asthma controller medicines on the market is they all only have to be taken once or twice a day. This makes it very easy to be compliant. All you have to do is take your inhaler before you brush your teeth in the morning, and again in the evening. If you have a once-daily medicine, you only need to do this once.

Another thing that is important regarding taking asthma controller medicines is to learn how to properly take the medicine. Since there are so many inhalers on the market, and each one has a unique delivery device, I will provide a link with each medicine listed below so you can learn how to properly use that medicine. Learning how to properly use your asthma controller medicine is essential to good asthma control.

Also, as I list the various types of asthma controller medicines, I am going to note whether they are inhalers or solutions taken by nebulizer route. I want it to be noted here that most asthmatics do very well using inhalers. However, some asthmatics benefit from taking a nebulizer instead of an inhaler. These would include:
  • Small children and infants who cannot coordinate an inhaler
  • Adults who cannot coordinate an inhaler, such as mentally challenged and elderly
  • Severe asthmatics who have trouble generating enough flow to actuate inhalers
That said, what asthma controller medicine is best for you basically depends on the severity of your asthma. Usually your physician will start with a simple inhaled steroid, and if one of these works no further treatment is necessary. Common inhaled steroids are:

Inhaled Steroid
Frequency
Qvar (beclomethasone)
2 puffs twice a day/ inhaler
Flovent( fluticasone)
1-2 puffs twice a day/, inhaler
Pulmicort (budesonide)
twice a day/ solution taken by nebulizer

If one of those medicines work, great! You are good to go. However, if you take one of them for a month or two and your asthma is still considered to be poorly controlled, then your physician might recommend a long acting beta adrenergic combined with an inhaled steroid.

Combination inhaler
inhaled steroid
LABA
frequency
fluticasone
salmeterol
1 puff twice daily/ inhaler
or inhaler
budesonide
formoterol
2 puffs twice daily/ inhaler
mometasone
formoterol
2 puffs twice daily/ inhaler
fluticasone
vilanterol
1 puff once daily/ inhaler
aformoterol/
 

For the most part, most asthmatics (about 90 percent) should be able to obtain good asthma control with either an inhaled steroid alone, or with one of these combination inhalers. However, when necessary, there are other medicines available for trial to help you gain control. Some of these include:

Medicine
Frequency
2 puffs four times daily
One puff once daily
1-2 doses per day/ pill taken orally

Ideally, asthma control is determined by two things:
  • Use of rescue medicine less than 2-3 times in a two-week period, or...
  • You are comfortable with your present standard of living.
Usually, finding the asthma controller medicine that works best to control your asthma is a matter of trial and error. You will have to visit your physician regularly; you will have to heed his advice and instructions; you will have to take your controller medicine every day; and you will have to use proper technique when taking it.

It should be noted that just because you have obtained good control today, doesn't mean you will never have flare-ups. However, with good control, flare-ups should be less severe and less frequent.

When flare-ups occur, you may still use your asthma rescue medicine as prescribed. However, please note that if you require your rescue medicine more frequently than 2-3 times in a two-week period, or you are using it more often than normal, this can be a sign of worsening asthma, and you should seek medical attention to regain control.

The great news is, there are plenty of medicinal options to help you control your asthma. Finding out what one works best for you is usually accomplished by a matter of trial and error. Once you obtain good control, you should be able to live a normal life with this disease.

Never begin an asthma medication without first consulting with your doctor. If you experience adverse side effects, stop the medication and contact your doctor.

Sunday, June 28, 2015

200 A.D. Galen wonders what causes asthma

Galen saw that some of his patients presented with a symptom described by Hippocrates as asthma, and he saw this malady in his own patients.  By placing his ear to their chests he heard their wheezes.  He thus set off on a relentless quest to find the natural cause of asthma and remedies to cure it.

He relentlessly questioned and assessed his asthmatic patients. He would have loved to have dissected those who died of the malady, but such an act was forbidden under sentence of death and punishment by the gods.

So he cut into apes, pigs and monkeys instead.  He cut open their chests and observed their lungs.  He cut into the lungs and traced the air passages.  He concluded this was where the vital force of life, the pneuma, entered the body.

He traced vessels from the lungs to the brain.  Perhaps this confirmed his assumption, one Hippocrates had alluded to, that asthma was similar to epilepsy. Like epilepsy, asthma displayed no symptoms between attacks (sporadic), and left no observable traces of disease.

He believed epilepsy was caused by an increased abundance of phlegm in the brain, and this caused seizures of the air passages. So he concluded asthma was caused by an increased abundance of phlegm in the lungs, and this caused difficulty breathing by blocked air passages.

He also noted a second cause of asthma, and this was tubercles in the lungs.  (13, page 1)

In one experiment he severed the medulla spinalis (spinal cord) and artificially produced asthma.  He used this experiment to prove to his pupils that asthma could be produced artificially.  Perhaps later physicians used this experiment as proof that asthma was nervous in origin.  (13, page 1)

Actually, In 1851, Joseph Bergson said that Galen may even have been among the first to suspect that asthma was nervous in origin.  He wrote:
Galen, who made sections of the spinal marrow in different places in living animals, in order to demonstrate to his pupils the influence of it on motions of respiration. (12, page 374)
Asthma historian Mark Jackson said that on Galen's experience he wrote that "if the breathing is rough and noisy it indicates that a large amount of thick and sticky humors in the bronchial tubes of the lungs has accumulated and become annoying because it is difficult to expectorate." (4, page 24)

In this way Galen is credited by history as being the first to link asthma to the air passages of the lungs, and the first to describe asthma as a disease of obstructed air passages.

Remedies by Galen were meant to restore the balance of the elements and humors. If you sought him out to cure your asthma, he'd probably first recommend a bath, a good diet, and exercise.  Once these simple remedies were attempted and failed, only then would he dip into his stock of medicine.

In 1815, Thomas Young said that general remedies prescribed by Galen were copied from the likes of Asclepiades, Musa, Andromachus, Heron, Crito, Menecrates, Archigenes, and Phillipus.  Galen mentioned a treatment borrowed from Asclepiades for orthopnia, a common symptoms of asthma, that contained mellepedes, which were supposed to have a diuretic effect (makes you pee).  (5, page 145)

Arabic historian Paulus Aegineta said that for asthma Galen prescribed the following (in parenthesis is what modern experts believe would be the effect of the remedy): (6, page 407)
  1. Squill (alleviates coughing)
  2. Pepper (stimulates digestive system)
  3. Wormwood (stimulates digestive system)
  4. Opoponax (antispasmotic, respiratory decongestant)
  5. Storax (expectorant)
  6. Oxymel (expectorant)
  7. Sulfer (eases allergy symptoms such as sore throat and cough)
  8. Millepedes (diuretic)(6, page 407)
Jackson said he made about 70 references to asthma, sometimes as the symptom of rapid breathing described by Homer and Hippocrates, and sometimes as a disease that caused breathing difficulties.  (4, page 24)

The theories he postulated about asthma, as with all his medical theories, influenced the world for the next 1,800 year. Slowly, through the course of time, a few brave physicians would expound upon his ideas about asthma, and by this means the definition would mature.

References:  see the post "120-200 A.D.: Galen becomes world's greatest physician"

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Saturday, June 27, 2015

200 A.D. Galen becomes first pathologist

This was essentially how Claudius Galen was perceived during the middle
ages, where his word on medicine was considered as the final word. 
As a student, and later as a physician, Claudius Galen of Pergamum would study the human body, speculating about what caused a person to be healthy, what caused a person to become sick, and how to cure sickness. He came to conclusions and reported his findings to his fellows through his many writings.

It is said by many historians that Galen became an eclectic physician, meaning he incorporated the best ideas of both schools of medicine: Dogmatism, Pneumatism, Methodism and Empiricism. Some say that he wasn't even an empiricist at all but simply an independent thinker, blending all the best ideas he learned from the sages as he traveled the world with his own ideas

Yet first he had to learn about the great physicians. From Stratonicus he learned to appreciate the theories of Empedocles, Hippocrates and Aretaeus. From his Empiracist teacher Aeschrion, he learned to temper speculation in lieu of experience. (1, page 149) (14, page 11)

Like Aretaeus, a Pneumacist, he believed a vital force called pneuma was inhaled to the lungs, stored in the heart, and circulated through the body by the vessels.  He was the first to prove that arteries contained blood as opposed to air, although he believed that blood contained a vital spirit that influenced all the organs of the body. 

Galen believed that the body was a perfect machine created by god.  He believed that all parts of the body, from the largest organ to the minutest detail...
...have all been determined by a faculty which we call the shaping or formative faculty; this faculty we also state to be artistic—nay, the best and highest art—doing everything for some purpose, so that there is nothing ineffective or superfluous, or capable of being better disposed. (11, pages 24-27)
By this simple drawing of Galen's you can see how he
believed the body was a perfect machine created by God.
 The liver and veins provided natural spirit and nutrients to
the body.  The heart and arteries provided vital spirit and
passions to the body.  The brain and nerves provided animal
spirit, sensation and intelligence to the body.  
The following is a Galen-made-easy version of how it all worked.  You can determine for yourself if he was a true pathologist,or just a theorist.

He believed there were two basic forms of life: (11, page 2)
  1. Soul: Provides voluntary motion, which is particular to animals 
  2. Nature: Provides growth and nutrition, which is particular to plants and animals (11, page 2)
The two forms of life are ultimately responsible for the two basic effects of nature: (11, page 2)
  1. Animals: Are governed at once by their soul and their nature
  2. Plants:  Are governed by nature alone, not the soul. (11, page 2)
So Galen, therefore, gave us the two following definitions: (11, page 17)
  1. Effect:  The result of the faculty, i.e. veins, blood, nutrition, growth, health
  2. Faculty: The cause of the effect, i.e. the soul and nature make life, the veins and liver make blood, the blood makes nutrition, nutrition is assimilated into the organ to make growth, and adequate growth assures continued life as long as possible, or good health.  (11, page 17)
It's actually quite simple once you think about it. As noted by Galen:
The effects of nature, then, while the animal is still being formed in the womb, are all the different parts of its body; and after it has been born, an effect in which all parts share is the progress of each to its full size, and thereafter its maintenance of itself as long as possible. The activities corresponding to the three effects mentioned are necessarily three -- one to each -- namely Genesis, Growth and Nutrition." (11, page 17)
So the three principle faculties of nature are, according to Galen: (11, page 18-19, 33)
  1. Genesis:  This is the activity (alteration and shaping) of nature necessary to form effects such as bones, nerves, veins, arteries and organs necessary for the formation of the animal or plant as a whole
  2. Growth: The increase and expansion in length, breadth and thickness of the solid parts of the animal
  3. Nutrition:  The addition to the parts without expansion. It is the substances held in the blood that are assimilated into the various parts of the body for genesis and growth. In other words, nutrition is the nutritive faculty that causes the effect of genesis and growth. (11, pages 18-19, 31)
So Genesis, Growth and Nutrition are the first or principle faculties that are responsible for forming and shaping the various parts of the body.  In order for the body as a whole to function properly, each of these primary principles needs the help of the other principle faculties, and they also need the help of other faculties of nature, such as the faculty of breathing, of making blood, of motion of the blood, etc. 

He believed that food was ingested and went to the stomach.  The stomach cooked most of the food and turned it into chyle that was sent to the liver through veins. The uncooked food went to the intestines to be removed as waste.  The liver and veins turned the cooked food or chyle to blood that contained a natural spirit and nutrients that were vital for growth. (9, pages 58-60)(11, page 13)

This blood was transported by the veins to the right ventricle of the heart to be purified. Here blood was turned into a light, frothy substance that entered the lungs. Once returned to the right ventricle, this purified blood was transported through the venous system to nourish the various parts of the body (such as the organs).   (9, pages 58-60, 89)

Like Hippocrates before him, Galen believed in specific selection, whereby each organ had the ability, and therefor the affinity, to assimilate the exact nourishment it needed from the blood in order perform it's natural function for the body as a whole. (10, page xxvii, xxiv, 31, 49)

Some of this blood moved from the right ventricle to the left ventricle through invisible pores. Here the blood was mixed with the pneuma that was inhaled, and it became vital spirit.  This vital spirit contained passions (such as anger, revenge, courage, desire, happiness, satisfaction, and confidence), and was supplied to the various organs of the body through the arterial system. (9, page 58-60, 87)

Some arterial blood went to the brain, where it was supplied with animal spirit, which contained sensation and intelligence.  This animal spirit was sent through the body by the nerves.  (9, page 58-60)

This animal spirit was essentially what made animals, and humans, different from plants.

So you can see that in order for the nutrients of the blood to be properly absorbed and made useful for purposes of genesis and growth, various organs were necessary.  Each organ uses the faculty of nutrition to stay healthy in order to perform its own faculty of nature.  For instance, the heart assimilates the faculties of nutrients it needs to perform its faculty of mixing air and pneuma with blood, and the liver assimilates the faculties of nutrients it needs in order to perform its faculty of assisting veins turn chyle into blood. (11, page 33-34)

It must be understood that Galen had no concept that the blood circulated through the body, instead he believed the blood moved in a to-and-for movement.  For example, purified blood was transported from the right ventricle to the liver and then back to the right ventricle.  It moved from the right heart to the brain and back to the right heart.  It moved from the left ventricle to the brain an then back to the left ventricle. (10, page xxxvi)

The lungs had four functions: (9, pages 58-60
  1. Inhale air and pneuma
  2. Allowed air to flow from it to the heart in order to cool the heart
  3. Mixed air with its pneuma with purified blood in the left ventricle of the heart
  4. Acted as filters for the venous blood from right ventricle of the heart  (9, pages 58-60
The heart also had four functions:
  1. Right ventricle acted as filter for venous blood
  2. Left ventricle blended air and pneuma with blood
  3. Created the passions of the body
  4. Controlled the temperature of the body (it was the furnace for the body)
Health and sickness were determined by a separate theory.

He was a Dogmatist in that believed in the four elements of Empedocles:  (1, page 164
  1. Fire
  2. Air
  3. Earth
  4. Water (1, page 164
He believed from these were derived the four qualities of the body:
  1. Hot
  2. Cold
  3. Dry
  4. Humid. (1, page 164)  
He believed these were derived from the four humors of the body: 
  1. Blood
  2. Phlegm
  3. Black bile
  4. Yellow bile (1, page 164)
These beliefs were common for the time, and were probably learned from the writings of Hippocrates, whose ideas would eventually form the Dogmatic School of Medicine.

Since God created the body as a perfect machine, each organ functioned perfectly in order to maintain the natural balance. This natural balance was maintained by nature maintaining a natural (albeit unique for each body) balance of the elements, qualities and humors.   (1, pages 163-164)

Galen, like Hippocrates before him, believed nature could be assisted in maintaining this balance through good hygiene, or by doing simple things such as getting regular exercise at the gymnasium, cleansing daily in the baths, wearing clean clothing, sleeping in a comfortable bed, and eating a healthy diet.

Since each person has a unique blend of the elements, qualities and humors, each person would have a unique personality or temperament, which can be seen by the following chart:


                                          The Four Humors of Hippocrates                           
Latin Name
Modern Name
Qualities
Personality/Temperament
Haima
Blood
Red, Hot, Moist
Sanguine
Phlegm
Phlegm
Cold, Humid
Phlegmatic
Choli
Yellow Bile
Hot, Dry
Choleric
Melanchia
Black Bile
Cold, Dry
Melancholy

So as a perfect balance of these caused health, sickness was caused when something occurred that threw of this balance, thereby disturbing the pneuma.

Hippocrates believed the body as a whole was sick, and therefore treatment emphasized a general remedy aiding nature to re-establish the natural balance of that person's body.

Galen, on the other hand, believed one organ, or one part, of the body could be sick, and this would throw off the chemistry of the unity as a whole, causing the symptoms that were observed. In this way, Watson said that Galen was the first to link symptoms with a specific organ.   (1, page 168)

Fourgeaud said that as an empiric he thought diseases had a natural cause: (3, page 23)
As disease, according to Galen, consists in 'vel operationis vel structurae oblaesio,' he urged the importance of tracing the general symptoms to the parts or organs primarily affected.(3, page 23)
For exampleWatson said that inflammation occurred when blood entered an areas of the body that normally did not contain blood.  When such blood combines with phlegm, it becomes "aedematous."  (1, page 169)

So when pure blood enters the lungs it can lead to inflammation of the lungs, or pneumonia. It can also mix with phlegm and cause an accumulation of fluid in the lungs called dropsy or hydropsy.  An accumulation of phlegm may cause the symptoms (diseases) of dyspnea, orthopnea, tachypnea or asthma.

Since the pneuma was formed in the heart, he believed that disturbances in the pneuma could be observed by feeling changes in the pulse.  Galen would have become adept at understanding what a normal pulse felt like, and what constituted a change.

In his book "Semeiotics II: A Concise Treaties on the Pulse for Students," he said:
The heart and arteries have a uniform pulsation, though not equally sensible in all the arteries; wherever it is capable of being felt, it is equally adapted for observation; but some parts are superior to others, and of these the carpus is best... Each one may learn his own pulse by experience. (15, page 601)
The pulse is also indicative of various diseases.  He said:
Of the pulse of syncopal affections; of anger, pleasure, grief, fear, pain, and its varieties; of the pulse of inflammation; its locality and character, as of the diaphragm, in pleurisy, and its varieties; in empyema, marasmus, the hectic pulse in it, and in phthisis; pulse of peripneumony; of lethargy; phrenitis; catalepsy; catochos; convulsions; palsy; epilepsy; angina; orthopnoea; hysteria;— the pulse, and its diversity in various affections of the stomach; in dropsy, and its varieties; in elephantiasis, jaundice, and in those who have taken hellebore, &c. (5, page 601) 
Throughout Semiotics he described various conditions that could cause the pulse to vary, such as from man to woman, in infancy and adulthood, and youth and old age.  It may also be different based on the whether a person lives in the country or city, whether it's fall, winter, spring or summer, and dependent on the health of the patient. It changes during pregnancy, while walking, running, and sleeping. It also changes when the person eats certain foods, bathes, drinks wine, and any changes in habit.  Various habits could also change the pulse: anger, sorrow, grief, fear, joy, and pain. (15, page 601, 602, 607-613)

Along with feeling the pulse he would perform a full assessment of the patient. He would ask questions, and he would study the patient's surroundings. He would place his ears to the patient's chest to listen to lung sounds and heart beat. He would place his hand upon the patient's forehead to feel for a temperature*.

If he noticed an imbalance, yet the patient still appeared healthy, he would try to assist nature to maintain good health by treating similars with similars. (1, page 167-170)

For example, if a person was phlegmatic, by adding phlegm; if a person was sanguine, by adding blood; if a person was choleric, by adding yellow bile; if a person was melancholy by adding more black bile. (1, page 167-170)

This task could be performed by using remedies that contained the desired humor, or, more likely, through improved hygiene (diet, sleep, exercise, cleanliness). (1, page 167-170)

Essentially, as noted by Garrison, he combined the "humoral ideas of Hippocrates with the Pythagorean theory of the four elements and his own conception of a spirit or 'pneuma' penetrating all the parts." (8, page 103) 

He likewise incorporated into this the anatomical wisdom learned by the Alexandrian physicians Erasistratus and Herodotus.  (10, page xxxii)

Regarding disease, Bradford said he copied the Hippocratic idea of categorizing all diseases as follows: (7, page 43)
  • Acute (it's happening now) or chronic (it's permanent) (7, page 43)
  • Endemic (found among certain people), Epidemic (widespread), or sporadic (randomly occurring) (7, page 43)
  • Produced external (outside the body) or internal (inside the body (7, page 43)
  • External causes were air, food, drink, motion, rest, sleeping, walking, retention, excretion, and passion (7, page 43)
  • Internal causes were hidden, and set in motion by the external causes (7, page 43)
While Galen maintained health by treating similars with similars, he treated sickness by treating contraries with contraries.  He, therefore, is considered by many as the originator of contraria contrariis curantur, or curing contraries with contraries, or opposites by opposites, said Bradford.   (7,page 44)

However, this was an idea that was similar to that of Athenaeus of Attaleia, who lived around 50 A.D. and was the creator of the Pneumatic School of Medicine.

Regardless, an example of treating opposites with opposites is, if the disease was caused by an increase in the element of phlegm due to an increased in the quality hot and dry, the remedy must consist of the opposite qualities, such as hot, fiery pepper. (7,page 44)

For instance, since increased phlegm was believed to cause asthma, the treatment would be something that would decrease phlegm.  Since increased blood caused fever, decreasing blood through bleeding was the cure.

Galen, like Hippocrates, believed that each nostrum (drugs, natural remedy, herbal remedy) had a specific humor that it was attracted to or drew from the body. In this way, each remedy was specific to healing the symptoms caused by illness to a particular organ. For instance, purgatives were useful for attracting phlegm from the lungs.(11, page 69-70)

Unlike Hippocrates, who mostly advocated simple cures to assist nature in the healing process, Bradford said Galen was a proponent of nostrums, often recommending, among others cures, things like:
  • Cupping
  • Bleeding for congestion of the blood (dropsy, hydropsy)
  • Purgatives for dyspnea and asthma because they drew out some of the excess phlegm
  • Opiates for pain and to ease the mind
  • Ashes of crabs for hydrophobia (fear of water). (7, page 44)
Watson said that he tended to use the lancet (perhaps in bleeding) and purgatives to "extremes."  However, while leaches were recommended by Themison and commonly used by Methodists (solidists), he did not recommend them as a treatment. 

While he had experience with sprains, fractures, cuts, and bruises during his time in the gymnasium and coliseum of Pergamum, and with serious injuries during his time with the Roman military, he rarely recommended surgeries.  Although when they were necessary, he performed them with exemplary skill and a gentle hand. (1, page 170-171) (9, page 7)

Most historians acknowledge that he was a voluminous writer, and that many copies of his works were made.  Bradford said that he wrote over 500 treaties, (7, page 43) although most of these works have been lost.  Some, however, were preserved by future physicians either through copies or simply by plagiarizing his work.

This was a good thing in a way, because while the works of most ancient physicians were lost to time and forgotten, Galen's works were immortalized.  His words were worshiped as the Bible for the next 1800 years, and in this way Greek medicine -- the key to all medical wisdom -- was saved for posterity.

This was bad in a way too, because his words created a paradigm of ideas that enveloped the medical profession until well into the 19th century. This, in effect, slowed down medical progress.  But, as we will see, it did not stop it.

*John Redman Cox, who translated the works of Galen, said many times that he wondered if Galen didn't at least, for a brief moment, think that the blood might circulate as opposed to moving in a to and fro motion back and forth between organs.  He said that there are times, by reading Galen's work, that it appears that he was very close to this discovery.  He said that it might be possible, that by the writings of Galen's that are lost, there might be a link to conclude Galen did have such knowledge.  (15, pages 469, 495, 501, 515, 526,527, 536, 541, 547, 639, etc.)

For references and further reading: "120-200 A.D.: Galen becomes world's greatest physician."

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Friday, June 26, 2015

120-200 A.D.: Galen becomes world's greatest physician

Galen (About 120-200 AD)
Claudius Galen of Pergamum was a Greco-Roman physician who lived from about 130-200 AD, or about 500 years after Hippocrates. He was the first physician to search for and discover the answer to the question: "What causes disease?"

He would ask questions like:
  • What causes epilepsy?
  • What causes fever?
  • What causes pain?
  • What causes dypsnea?
  • What causes asthma?
He wasn't satisfied with the answer: the gods caused and cured diseases. Surely that was true, but he wanted to know specifics, like: 
  • Why do bodies form?
  • What causes life?
  • What causes maintains good health?
  • What changes occur to cause diseases?
  • How are diseases cured?
As a student these questions formed in his mind, and as a student, and later as a physician, he sought for answers. He inspected the human body every chance he got, although it was illegal to dissect the human body for learning purposes. So he usually had to be content to dissect mice, apes, pigs, and other such animals. Later, as a surgeon at the gymnasium at Pergamum, he was able to see the insides of wounded humans. Although most of what he learned was from other physicians and sages around the world.  

A depiction of what Galen may have seen as he approached Pergamum.
Galen was born in Pergamum (Pergamos, Pergamon), which was a city-state of Greece, according to historian Jeanne Bendick. She said there were grand palaces, houses and temples to the gods. There was a library second only to the library at Alexandria. There was gymnasium where young men learned to become athletes, and where they were educated.  It was also a place where baths were taken, and where amateur and professional philosophers exchanged ideas. There was also a coliseum where gladiators fought and where plays were performed.  (9, page 14)

The school Galen attended was build near a temple of the god of health and healing. To Galen and other Greeks this god was referred to as Asclepius, but to the Romans he was called Aesculapius. He was the most powerful of the gods of health and healing. Around his temple was a gymnasium, a school, a library, a large bath with cold and hot water, and together these were referred to as the museum.

View of Acropolis from Sanctuary of Asclepion as it would be seen today.
Bendick said that "about 250 years before Galen was born, the last ruler or Pergamum had given his city-state to Rome on the condition that Rome would protect its independence. But the people who lived there still considered it a Greek city." Today Pergamum is part of Turkey. (9, page 2)

Most physicians when Galen was born were poorly trained, and many were simply quacks.  This was because there were no requirements to be a physician and anyone could claim to be one. (7, page 53) (9, pages 3-4)

Pretty much, if a person claiming to be a physician succeeded in curing people he gained the respect of his peers and was able to continue his practice.  If he failed to cure, he often times was forced to seek another profession.  (9, page 3-4)

Galen's father was Nicon, and like most who were educated during this era, Nicon was educated in most wisdom of the day, and he specialized in one or two areas. Bendick said Nicon specialized in engineering and architecture, although he was also knowledgeable in philosophy, astronomy, and botany.  (9, page 9)

Medical historian Thomas Bradford said Nicon was a man of great wealth and influence in Greece.  Medical historian John Watson said that Galen's father made sure Galen received the best education in philosophy and medicine, of which Galen would specialize in.  (1, page 149)

Historian John Brock referred to a quote by Galen himself, where he describes his own parents.  Galen said  (10, page xv)
I had a great good fortune to have as a father a highly amiable, just, good, and benevolent man. My mother, on the other hand, possessed a very bad temper; she used sometimes to bite her serving-maids, and she was perpetually shouting at my father and quarreling with him -- worse than Xanthippe and Socrates. When, therefore, I compared the excellence of my father's disposition, with the disgraceful passions of my mother, I resolve to embrace and love the former qualities, and to avoid and hate the latter. (10, page xv)
Brock said Galen tried to collect in himself the best of his father, and to escape from his mother.  However, the fact that Galen continued to get into conflicts during the course of his life, and to openly toot his own horn and blast those who disagreed with him, may have been evidence he was never fully able to escape his mother's scorn.  (10, page xv)

Many Greek and Roman citizens did very little work.  This was because when lands were conquered, those who were taken prisoner were turned into slaves who did all the work.  The citizens, therefore, were able to enjoy the profits of the work of others.

Bendick said this was the case with Nicon and his son Galen.  He said:
They could spend as much time as they wanted reading, studying, discussing ideas, and amusing themselves. Nicon probably got paid for designing buildings and engineering projects, but he never had to earn a living. He and his friends never had to help around the house, or take the children to school, or even dress themselves if they didn't want to. They had slaves to do all the work." (9, page 9)
Bendick said that most children were educated by their mother until they were eight, but Galen's father took special interest in educating his son.  What Galen didn't learn from his father he learned from his father's slaves. Since young citizens were not allowed to go to the public library, this didn't matter to Galen, who had access to his father's private library, which had over a thousand scrolls.  (9, pages 9, 17-18)

Nicon could easily afford to send his son to the best universities.  Watson said that by the time Galen was seventeen:
"He was placed as a student at the Asclepion of Pergamum, under Satyrius, the pupil and successor of Quintus; and in the course of his studies had the advantage of instruction from Stratonicus, a Hippocratic rationalist, and from AEschrion, an emperic."  (1, page 149)
Medical historian Thomas Bradford said that the students of this era had very rare access to books, which was why it was important to learn at the Asclepions. Everyone educated was instructed in all the wisdom of the day, which is why pretty much all ancient philosophers were also considered physicians. Galen, however, paid special attention to medicine and surgery, and practiced it. He thus became one of the most prolific physicians of his time and of all time. (7, page 54)
It was at the ripe age of 14 that he commenced his studies of philosophy, and when he was seventeen he started his study of medicine, which took him three years to complete. (7, page 53)
After graduating from school it was important for those desiring to become exemplary in their skills to travel to in order to learn from those most proficient in their skills. This would explain why Galen, at the age of 21, " went to Smyrna, thence to Corinth, then to Alexandria and to other cities" before opening his own medical practice at Pergamum at the age of 28.  (7, page 40, 53)

Watson said that Alexandria was, at this time, "still the most celebrated school of medicine." (1, page 149

Historian Edward Meryon said that studying in Greece, Asia and Italy was common practice for aspiring physicians, "justly regarding such a course as essential to an accomplished physician." (2, page 77)

When he was 28 he returned to Pergamum and started his own medical practice. (7, page 40, 53)

Perhaps in order to broaden his skills, he also signed a three year contract to be a physician to the gladiators.  He trained the gladiators, and then he treated their cuts, scrapes, broken bones, and other wounds. (9, pages 62-70)

In doing this he became very proficient at the basic surgical wisdom of ancient physicians.  There were wounds that occurred during the practices that occurred daily, but there were severe wounds, and some deadly wounds, that occurred during the actual fights.  He would have seen some cuts so deep he would have seen the lungs, and the beating heart.  (9, pages 62-70)

This was significant because of his inability to dissect humans.  Perhaps this inspired him to learn more, and to come up with theories.

Of these years of Galen's life, Bradford said: 
Here he was held in such high esteem by the people that the priests of Esculapius, through the Sovereign Pontiff or High Priest of the city, placed him in charge of the gymnasium then attached to the temple, at which the athletes and gladiators were daily in the habit of assembling to exercise. This office he held for several years, and it is said that he acquired great reputation for his skill in the treatment of fractures, and the wounds incident to the fierce combats of the time. Owing to a revolt in Pergamos, which occured in the year 163-4, and when he was 34 years of age, he was induced to leave that city and settle in Rome. His great renown had preceded him, and his great erudition and practical knowledge soon placed him in the first rank of his profession. (7, page 40-41)
Bradford said he was 34 when he decided to leave Rome. Bendick said he was 31.  This is a common confusion when trying to compile the life of such an ancient person as Galen.  (9, pages 70-73)

Regardless, after three years as physician to the gladiators, Bendick said Galen decided to continue his studies, and open up a practice, in the greatest city in all the world: Rome.  The journey from Pergamum to Rome probably took him a year no matter what method he used to travel.  (9, pages 70-73)

Prior to his time in Rome he was not a famous physician.  As was typical of the ancient world, in order to gain fame you had to earn the favor of someone famous.
Bendick explains how Galen did this in Rome:
His fame began with his father's friend, Eudemus, who was getting sicker and sicker, even though his doctor was one of the most important in Rome.  Eudemus sent for Galen, who examined him carefully, made his own diagnosis, and prescribed treatment and medicine, which he made himself.  Eudemus recovered and suddenly important people all over Rome wanted Galen to be their doctor.  
The important people were not only those who were rich, or who were government officials.  Orators and architects, philosophers and lawyers, astrologers and famous athletes were equals in Rome.  
One of the important people was the ocnsul, Flavius Boethius, whose wife was ill. When Galen cured her, Boethius became his greatest fan. He paid Galen a fee of 400 gold pieces for the cures.  (9, page 78-79)
Bendick said it was Boethius who encouraged Galen to give lectures to explain his medical ideas and his methods of curing sickness.   Now he would spend time at the gymnasium not as the student, and not as the physician, but as the lecturer of medicine.  (9, page 79)

While his father encouraged him to be well learned, from his mother he appears to have obtained a "violent temper."  He was a very "boastful" speaker, and by his lectures he "attracted not only students of medicine, but also philosophers, politicians, and many others of the highest rank and influence," wrote Bradford. (7, page 41)(also see 9, page 9)

Perhaps we can see his "boastful" speaking by his "boastful" writing.  In his Natural Faculties, he blatantly criticizes Asclepiades, a vast critic of Hippocratic medicine. Galen said that Asclepiades had opposing views as to Galen when it came to yellow bile and jaundice, and black bile and the spleen.  Galen also quoted Asclepiades as saying that "nothing is naturally in sympathy with anything else, all substance being divided and broken up into harmonious elements 'molecules.'"(11, page 62-63)

Of this Galen took exception, and wrote: (11, page 63)
He (Asclepiades) is forced here, again, to talk nonsense, just as he did in regard to the urine. He also talks no less nonsense about the black bile and the spleen, not understanding what was said by Hippocrates; and he attempts in stupid -- I might say insane -- language, to contradict what he knows nothing about. (11, page 63)
So, according to Galen, while Asclepiades did a service by introducing Greek medicine to Rome, he was wrong to contradict Hippocrates.

Regardless, by the time Galen began his studies of medicine in Rome, medicine was in a state of flux. Historian John Brock confirms for us that the medical community was in a state of flux, or "ebb," at the time Galen started his practice. Brock said: (10, page xvii)
Medical practice at this time was at a low ebb, and Galen took no pains to conceal his contempt for the ignorance, charlatanism, and venality of his fellow-practitioners.  Eventually, in spite of his social popularity, he raised up such odium against himself in medical circles, that he was forced to flee the city. Thus he did hurriedly and secretly in the year 168 A.D., when thirty six years of age. He betook himself to his old home in Pergamos, where he settled down once more to a literary life. (10, page xvii)
Bradford likewise confirms that that after five years in Rome, and angering many of his fellow physicians, he moved to Brindusium, and then "set out to visit the East; he visited different parts of Palestine and the isle of Cyprus."  (7, page 41)

He ended up, as Brockk said, in Pergamus where he had a brief respite, although it was short lived.  Brock said after a year he was summoned by Roman Emperor Marcus Aurelius to return to Rome.  (10, page xvii)

Bendick said the year was 168 A.D. when Galen was summoned out of his respite to return to Rome, so once again you can see the confusion when it came to exact dates.  It is possible it was the same year that he left Rome and returned, although considering it took about a year to travel the distance between the two cities, this is probably not the case.

So it was about 168 A.D., give or take a year, that Marcus Aurelius championed his friends to the cause of winning the war.  He wanted Galen to be his own personal physician.  There were other amateur physicians called medici who took care of wounded soldiers.  Galen's job would be to tend only to the physician, and when he returned to Rome that is exactly what he did. Although he really wasn't in Rome, he was wherever the Roman military was.  (9, pages 102-107)

Regardless, Bradford said he was appointed by Marcus Aurelius and Lucius Verus as surgeon general of the army, Galen followed the emperor for a time, (7, page 41) but he was not concerned about the charm, glory, and patriotism of being on the front lines with the emperor.  He surely wanted to stay in the good graces of the emperor and his country, but he wanted out of his duty of following the emperor in battle.  (10, page xviii)

There may have been a variety of reasons for Galen's feelings about the Roman military, although Bendick speculates it may have been because of his fear of plagues. Bendick said that plagues (of all sorts) were common back in Galen's time, and it was very common for soldiers to come into contact with these plagues. Historians say that a plague wiped out about a third the population of the empire during Galen's lifetime, and some speculate based on descriptions of the disease that it was smallpox. (9, pages 102-107)(10, page xvii)

So Galen was afraid of getting the plague, and therefore he wasn't happy with his role in the military. He therefore managed to convince the emperor that his services would be better fit back in Rome, and thus obtained his honorable discharge. (9, pages 102-107)(10, page xvii)

Marcus Aurelius gave him his honorable discharge in exchange for being in charge of his nine-yearold son Aurelius Commodius. Galen then succeeded in curing the prince of a fever, and also curing his brother, Sextus. Of this, Bradford said: (7, page 41)
"(Galen) secured the favor of the boy's mother Faustina.  When the emperor came back he became ill, and the physicians said that he had ague; but Galen diagnosed dyspepsia and cured him. This greatly added to his fame, and the grateful emperor exclaimed: 'We have but one physician -- Galen is the only man in the faculty.'  Thus enjoying royal confidence, he devoted his time to practice, and to writing his immortal works on medicine, He passed the rest of his professional life in Rome."  (7, page 41)
So you can see that he had a pretty well established reputation among the aristocracy which, again, was something that was almost essential during this era in order to obtain a reputation among society.  He was also a great teacher, and gave lectures in the open.  Students yearning to learn might have traveled long distances to learn from the great physician.

Brock also said Galen spent the rest of his days in Rome, and it was during this time that he did most of his writings.  There are various dates surrounding the date of his death.  Some say he died in 201 A.D., some say 202, some 210.  Some Arabic physicians noted his date as 215 or 216 A.D.  Brock perhaps said it best when he wrote, "Probably he died about the end of the century." (10, page xviii)

Chances are, since all those numbers are similar, and since they were probably transcribed so many times, they were probably mixed up, and thereby making it impossible for modern historians to know when he actually died.

Through the course of his life he studied the works of the sages and physicians of the world, he studied all the books he could, and he performed experiments on his own.  He would find all the answers to his questions, write down his theories for other physicians to learn from, and he would go on to become the most famous physician not just of his lifetime, but of all time.

This was important, because it was essentially through Galen that medical wisdom survived the dark ages of medicine in the West, and made it's way to the East.

Further reading:

  1. Galen: the worlds first pathologist
  2. Galen wonders what causes asthma

References:
  1. Watson, John, "The Medical Profession from the Earliest Times: an anniversary discourse delivered before the New York Academy of Medicine November 7, 1855," 1856, New York, Baker & Godwini
  2. Meryon, Edward, "The History of Medicine," Volume I, 1861, London,
  3. Fourgeaud, V.J., "Historical Sketches: Galen," Pacific Medical and Surgical Journal," 1864, Vol VII, San Francisco, J. Thompson & Co., pages 22-29
  4. Jackson, Mark, "Asthma: A Biography," 2009, Oxford University Press, the quote from Jackson comes from On the Affected Parts by Galen
  5. Young, Thomas, "A Historical and Practical Treaties on Consumptive Diseases:  Deduced From Original Observations, And Collected From Authors Of All Ages," 1815, London, B.R., page 145
  6. Adams, Francis, "The Medical Works of Paulus Agineta: The Greek Physician; translated into English with a Copious Commentary," vol. I, London, page 407-8, 1834, Adams gives a long list of ancient physicians who wrote about asthma
  7. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
  8. Garrison, Fielding Hudson, "Introduction to the history of medicine, 3rd edition, 1922, Philadelphia and London, W.B. Saunders Company
  9. Bendick, Jeanne, "Galen and the gateway to medicine," 2002, U.S., Bethlehem Books Ignatius Press
  10. Brock, Arthur John, translator and author of introduction, Galen, author, "Galen on the natural faculties," 1916, London, New York, William Heinemann, G.P. Putnam's Sons
  11. Galen, author, Arthur John Brock, translator, "Galen on the natural faculties," 1916, London, New York, William Heinemann, G.P. Putnam's Sons
  12. Gill, M. H., "Review and Bibliographic Notices: "On the spasmotic asthma of adults," by Bergson, published Gill's book, "The Dublin Quarterly Journal of Medical Science," volume X, August and November, 1850, Dublin, Hodges and Smith, pages 373-388
  13. Freudenthal, Wolff, "Bronchial Asthma," New York Medical Journal: A Weekly Review of Medicine, edited by Edward Swift Dunster, James Bradbridge Hunter, Frank Pierce Foster, Charles Euchariste de Medicis Sajous, Gregory Stragnell, Henry J. Klaunberg, Félix Martí-Ibáñez, volume CV, January-June, 1917 (Saturday, January 6, 1917), New York, A.R. Elliot Publishing, Co., pages 1-5
  14. Curnow, Trevor, "The Philosophers of the Ancient World: An A-Z Guide," 2011, Bloomsbury Publishing plc
  15. Hippocrates, Claudius Galen, writers,  John Redman Coxe, translator, "Hippocrates, the Writings of Hippocrates and Galen," 1846, http://oll.libertyfund.org/titles/1988, accessed 7/6/14, also see the book online at Google books, Philadelphia, Lindsay and Blakiston
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