The cook always wins

Galen​ couldn’t stand gym bros. They were so occupied in the business of ‘amassing flesh’, he said, that they paid no attention to their souls, which were ‘smothered in a heap of mire’. Lucian, Galen’s contemporary, agreed. One of his short satires shows Hermes refusing to let a famous local beefcake called Damasius across the Styx to the underworld: passengers must be naked, and Damasius is wearing ‘so much flesh’ that he doesn’t meet the entry requirements.

By the time that Galen and Lucian were writing in the late second century ce, gym culture had been central to Greek and Roman identity for hundreds of years. The Olympic games were part of a huge network of gymnastic competitions across the Greek world. Each city state had its own rituals: the biggest festival in Athens, the Panathenaia, included an athletic competition in which shields were awarded for ‘manly beauty’. Physically demanding dance performances were held before the tragedies and comedies at the Dionysia. In Sparta, where physical fitness was even more prized, almost all young male citizens competed in tournaments called sphairomachiai (‘ball battles’): the games were probably something like American football with fewer rules and no protective equipment. Unusually in the ancient world, unmarried Spartan girls and women also took part in sport. Since they married later than other Greek women, many of them would have continued playing into their late teens or early twenties.

In Roman culture the gym was just as important, but it came with a luxurious twin: the bath. The most elaborate had huge arrays of plunge pools at different temperatures, steam rooms and underfloor heating. They often provided massages, clothes lockers, and recreational spaces for socialising and playing dice. By Galen’s time, even small provincial towns had their own baths. Chesters Fort on Hadrian’s Wall, at the furthest reaches of the empire, had hot and cold pools and a steam room. Some of the richest people in the empire would have had their own bath complexes, but for most – even the well-off – bathing was a communal and social activity. Both men and women used public baths (though not at the same time). Entry fees were usually modest, and different social classes mixed. The baths became part of the psychic furniture of daily life: the dream interpreter Artemidorus (another contemporary of Galen’s) had a client who dreamed about going to the baths to find there was no water in the pools and the roof had caved in.

As for diet, many in the ancient Mediterranean world – enslaved and free people – lived barely above subsistence level. But among the comfortably off, eating habits ranged from the demonstrative asceticism of the Stoic philosophers to the decadence of Trimalchio, a fictional Roman freedman at the time of Nero who held a banquet at which all of the many dishes on the table were made of disguised pork. Galen judged most of his fellow citizens to be at the Trimalchian end of the spectrum, obsessed with food while ignoring the eternal glories of Greek intellectual culture. ‘In a contest between a doctor and a cook before a jury of children or fools,’ he wrote, ‘the cook would win by a substantial margin.’ Most people, he complained, thought intellectual study as difficult and useless as ‘drilling holes in millet seeds’. For Galen, medicine showed how wrong they could be: it was not only a (highly useful) practical art but also a kind of philosophy. A good doctor had to have a thorough knowledge of diseases, anatomy and symptoms, alongside a theoretical grounding in logic, epistemology and cosmology.

Thrasybulus, one of the two texts in P.N. Singer’s new translation of Galen’s writings on health, is a speech given at a formal debate between a doctor and a gym trainer. In style if not in content, it’s a standard piece of ancient rhetoric. Many debates took the form of bracing dichotomies (there’s a short speech attributed to Plutarch on ‘whether fire or water is more useful’ which unfortunately breaks off before reaching a conclusion). Singer includes another, much longer text, Health, which is a loosely structured compendium of Galen’s theories and advice on all aspects of diet, exercise, bodily habits and the making of home remedies.

Singer’s volume is part of a project to publish up-to-date translations of and commentaries on Galen, who wrote a flabbergasting 12 per cent of all surviving ancient Greek. In part this is survival bias – his writings were widely used for teaching doctors through the Middle Ages – but it makes him the most prolific author of antiquity. About half his works haven’t been translated into English; a third remain untranslated into any modern language. There are previous English translations of Thrasybulus and Health but they are difficult to find, and, in the case of Thrasybulus, full of problems. They are presented together here because, as Singer argues, they provide a coherent and clearly articulated view on a major question in the philosophy of medicine: what is health?

Galen was born in 129 ce in Pergamon, a large but not especially important town on the Anatolian coast. It was the site of a huge sanctuary of Asclepius, the god of medicine, which may also have been a medical school. Galen probably trained there. His father, Nicon, was an architect, who wrote several treatises on buildings and ensured his son was schooled in maths and philosophy. Galen’s first medical position in Pergamon was as physician to the gladiators, appointed by a senior priest. He plied this trade for several years, and learned a lot about how to treat some of the nastiest wounds that human beings could inflict on one another. Gladiators, unlike most patients, were in their physical prime. Galen’s ideas about diet and exercise were probably shaped by this experience: the men he cared for were not training simply for show, but to get a physical advantage in a fatally competitive arena. Gladiators who survived their first contest were treated as prize fighters. They were fed well. Galen’s views about what to eat – stay away from semolina, barley soup for everyone – were refined on gladiatorial bodies.

He moved to Rome when he was in his early thirties, entering at the highest level of society thanks to his father’s connections and his formidable reputation as an anatomist. He had mixed feelings about the city. On the one hand, he loved being at the centre of the world stage. No other city would have allowed him such a variety of work – treating patients and giving public medical demonstrations – or access to the most important literary and political figures in the empire. On the other hand, Rome was full of backstabbers and social climbers – and, in Galen’s view, medical malpractice and quackery.

He probably moved mostly in Greek-speaking circles: it’s possible he never learned Latin. He certainly spoke Greek to the emperor Marcus Aurelius, whom he met some time in the 170s. He describes the encounter in characteristically dramatic terms in a work called On Prognosis. The emperor, sick in bed, had been seen by several expensive physicians who pronounced that he was at the onset of a potentially dangerous illness. Having heard of Galen’s abilities, he called him in for a second opinion. When it came, it was embarrassing: the only thing wrong with Marcus Aurelius was indigestion. The emperor took the news well, and Galen became personal physician to both Marcus Aurelius and his son and heir, Commodus.

Galen seems to have been ambivalent about this role. In treating the gladiators in Pergamon, he had dealt with dramatic life-threatening wounds. In his practice in Rome he had seen patients from different social classes, many with illnesses and injuries from intense physical labour. The leisured wealthy, by contrast, spent a lot of time chasing not only health, but a glimmering dream of something like the modern idea of ‘wellness’. Galen railed against this idea. He recognised that the full-time pursuit of health was unachievable for most people, under the obligations and oppressions of labour, poverty or slavery. He also realised that those raised with access to good food, warm baths and moderate exercise from a young age were more likely to turn out healthier than the children of the very poor.

As the emperor’s physician, Galen was able to exert considerable influence over Roman medical culture. We lose the narrative thread of his life during the Antonine plague, an epidemic that raged from 165 to 180 ce and killed millions (it may have been smallpox, or measles, or something else). Galen must have been busy, but he continued to write. In some ways it isn’t surprising that he dominated medicine so completely and for so long. His writings show an incredible range of content and style. He could turn in a moment from sensitive reflections on the care of infants to an outburst of vitriol against someone he disagreed with. For many people now his name conjures up images of the four humours and of medieval surgeons so cowed by his authority that they ignored what was before their own eyes. But viewed another way, Galen has proved a victim of his own strident success: where most people would have fallen into the margins of history, he adapted ancient medical doctrines in such a sophisticated and convincing way that he was not seriously challenged until Andreas Vesalius in the middle of the 16th century.

The English word ‘diet’ is derived from the Greek diaitē, which encompasses something much wider and was translated from the Middle Ages onwards as ‘regimen’ (these days you could almost translate it as ‘lifestyle’). Regimen was about habits of body: the things the sick needed to do to get better, but also the things healthy people did to stay healthy. Galen’s ideas on the subject were shaped by two popular schools of thought. The Empiricists argued that medicine should seek not to theorise but to accumulate a body of case histories. The Dogmatists, on the contrary, argued that disease could only be cured using a full theoretical understanding of the body. Galen was too idiosyncratic to belong to either school, but from both he drew the idea that doctors could not understand the diseased body if they did not understand the healthy body. To cure was to restore to health, so doctors needed to know the healthy constitution of the patient in front of them.

For Galen, the definition of health is relative to each individual, and encompasses a range of states from the ideal to the good enough. For an infant or a very old person, for example, the baseline level of physical functioning and capability is not the same as for an average adult. Galen also brings up an interesting case from myth, pointing out that health manifests rather differently in Achilles and Thersites: one is the Achaeans’ champion warrior at the peak of his physical powers, the other is described in the Iliad as having bandy legs, a club foot, a hollow chest and a pointed head. For Thersites, being healthy means having no further disease or injury on top of his disabilities: he is not, in Galen’s view, precluded from being considered a healthy person simply because he has physical limitations.

Galen’s suggestion was unusual in the ancient world, where there was a strongly entrenched assumption that beautiful meant good, and that outward physical disabilities reflected inward moral weaknesses. From Homer onwards, Thersites was used as an example of cowardice. The emperor Claudius, who is thought to have had mild cerebral palsy, was mocked as ‘slow’ because of his physical awkwardness and faltering speech. Galen wasn’t progressive in any modern sense, of course. But given the prevailing view, it is notable that he chose to focus on the individual patient, to see each person in the context of their own body and habits, and to direct their care to the restoration of their health, rather than to meet some external standard.

A common complaint about the institutional behemoths of modern medicine is that they no longer have the time or money for a patient-centred approach. Many of our tools for determining health are statistical: the body mass index (BMI), for example, is a useful demographic tool for considering whole populations but can lead to distortions when measuring individual people who are very muscular or very short. As Foucault argued, patients’ bodies are often examined not in relation to their own individual standards of health, but are instead clinical specimens, analysed as examples in big datasets. Galen lived in a world in which health was undeniably fragile: most diseases would kill you, there were no antibiotics and few analgesics. But, as he argues strenuously in both Thrasybulus and Health, it was not a world where health was unattainable.