Five Quarts: A Personal and Natural History of Blood (3 page)

Galen saw no stronger argument for venesection than in the seemingly spontaneous bleedings orchestrated by “Nature.” He cites nosebleeds and menstruation as ways the body restores its humoral balance: “Does [nature] not evacuate all women every month by pouring forth the superfluity of the blood?” As a matter of fact, modern medical historians speculate that menstrual bleeding probably not only provided the initial inspiration for drawing blood but also helped reinforce its supposed benefits. After all, as my five sisters and numerous female friends attest, they feel great after their period is over.

“But enough of women,” Galen says dismissively to the crowd. To further his argument, he calls on a most unlikely ally: the hemorrhoid. “Come now to consider the men, and learn how those who eliminate the excess through a hemorrhoid all pass through their lives unaffected by diseases.” That bleeding hemorrhoids are to be appreciated and even encouraged, I daresay, surprises most of the assembled sufferers.

His provocative comments did not go unanswered. The Erasistrateans shot back rebuttals and insults, and, outside the hall, rivals spread malicious gossip. In time, Galen began to fear he’d be poisoned by his enemies. For his own safety, after barely a year in Rome, he stopped publicly antagonizing opponents. Galen turned to writing, producing books in which he both challenged the conclusions of the rival sects and put forth his own findings. He began to tutor privately, and his medical practice flourished. Among his patients were members of the royal court, including a son-in-law of Emperor Marcus Aurelius. In less than four years after his arrival in the city, Galen was consulting with the emperor himself. When Marcus Aurelius’s small son fell ill, Galen cured him, earning not only the father’s complete trust but also the title of Emperor’s Personal Physician. Chief among his duties: concocting antidotes for poisons that might be used to assassinate the ruler. Galen made himself an expert at creating a wide range of treatments from herbal extracts. These came to be called
galenicals,
a term still used for medications made purely from botanical ingredients.

The same son whose life Galen had saved, Commodus, abruptly fired the doctor upon succeeding his father as emperor at age nineteen. Commodus (portrayed by Joaquin Phoenix in the 2000 film
Gladiator
) was a brutal, decadent tyrant responsible, historians agree, for leading the Roman Empire into steady decline. Galen remained in Rome but kept a low profile, quietly continuing his scientific work and his ceaseless writing. He wrote eighteen books on the subject of the pulse alone, as well as tomes on fever, anatomy, the nervous system, nutrition, and philosophy. Most of his original manuscripts were stored for safekeeping at a temple guarded by priests. Unfortunately, in the same year as Commodus’s assassination,
A.D.
192, a fire destroyed the temple and half of Galen’s life’s work. About 120 books survived.

With Commodus gone, the doctor, now in his midsixties, slowly reemerged and again began making house calls to the royal palace. Instead of resuming his former duties, however, Galen realized that the new emperor and his wife had other ideas. The queen, aware of his genius for creating botanical remedies, commanded that he concoct equally miraculous beauty potions. Though the assignment was beneath him, Galen must’ve felt he had no choice. He whipped up extractions to turn black hair golden, face paints for eye shadow and rouge, perfumes and pomades. He was the Max Factor of his day, minus the screen credits or royalties. But he made the best of it, funneling what he learned about cosmetics into further research in pharmacology and, of course, into new books.

By the time of his death at age seventy, no aspect of the human body had escaped Galen’s scrutiny. No organ remained unidentified. No ailment could not be cured by his means. He left behind detailed opinions and instructions on everything from venesection in children to mixing up the perfect eyeliner. He did such a thorough job that, in the fourteen centuries following his passing, few dared challenge Galenism, as his teachings came to be known. His reach even extended to the Eastern world, where his books were translated into Arabic in the ninth century. Whereas Asclepius was the mythical god of medicine, Galen was close to the real thing. Indeed, in the early Middle Ages, church leaders declared his work to have been divinely inspired and thus infallible, dubbing him Galen the Divine. To oppose him was blasphemous, punishable with death—burning at the stake. All of which now seems ironic because Galen had never been a religious man and had, in fact, championed the value of scientific experimentation.

Still, the question remains, why did Galen hold sway for so long? Why did he, and not others, endure? Part of it was luck, to be sure, plus sheer volume. While half of Galen’s original works were lost, his surviving literary output—some 2.5 million words, according to one count—overwhelmed his competition. But most of all, Galen’s influence rested on his blazing self-confidence. As medical historians have observed, Hippocrates, by contrast, acknowledged the potential for error in his work, areas he did not yet fully understand. But not a whit of doubt appeared under Galen’s name.

At times I find his arrogance galling (a condition that Galen’s fifteenth-century followers would’ve diagnosed as an enflamed and leaky gallbladder, the repository of this particular emotion). But as a writer, I can’t help being impressed by the faith he inspired in others through the force of language. It’s all the more amazing to me because Galen was so often dead wrong.

The circulatory system as conceived by Galen

Truth be told, I find scientific blunders as fascinating as the great discoveries. It’s the main reason I enjoy reading archaic medical texts, a trusty form of time travel I undertake at libraries. Being in the position of knowing more than Galen did is satisfying, I will not deny. It’s also sobering. Two decades from now I’m sure I’ll look back and shake my head, amazed at the things Steve and I once did in the name of cutting-edge science. But there’s something else. Looking back at Galen looking forward, I am touched by his efforts to treat deadly illnesses, to alleviate suffering, however futile. Finally, he is most impressive not in having come up with so many answers but in taking on so many big questions, such as, What is the essence of life? What makes us human? Galen believed the ingredients were in the bloodstream, where a trio of incorporeal “spirits” flowed. (By contrast to the groupings of four used at that time to describe the inner and outer workings of the universe—the humors, the qualities, the elements—the spirits came in threes, reflecting the tripartite division of the soul theorized by Plato.) The first two ran in the dark, purplish blood of the veins: Natural Spirits, brewed in the liver, providing the body’s mass; and Animal Spirits, fired in the brain, producing movement. Completing the trinity were Vital Spirits, the essence that separated human beings from animals. In its fleet passage through the heart, the scarlet arterial blood was imbued with this zest, which disseminated warmth and verve throughout the body. In Galen’s reckoning, the spirits did not intermingle; the veins and arteries were separate streams.

As scientific bunglings go, Galen was in good company. No less a genius than Leonardo da Vinci (1452–1519) made some spectacular ones in his notebooks of anatomical drawings. Leonardo, who dissected cadavers and sketched directly from them, set out with the express goal of being faithful only to the evidence of his eyes. Unlike Galen, he held a lifelong aversion to verbiage and believed that drawing was the only uncontestable means of expression. That being said, Leonardo still could not escape Galen’s lingering influence. This groundbreaking artist who rendered with astonishing accuracy the chambers of the heart, for example, and the fetus in utero, nevertheless added fictitious plumbing to the human body—canals, ducts, and veins—to accommodate humoral theory. Likewise, he drew the spleen cartoonishly large, proportional to its inflated role in secreting the illusory black bile. Another fallacy perpetuated by Galen and then by Leonardo was the kiveris vein, which resolved the biological puzzle of why pregnant women stopped menstruating. The answer: Menstrual blood was converted into mother’s milk, of course, and this “milk vein” conveyed it from the uterus to the breasts. Uniquely male anatomy was fictionalized, too. In cross sections of the penis, Leonardo added a phantom vein for “vital impulse,” the life-giving
oomph
ejected alongside sperm. Of all Leonardo’s fabrications, the cleverest, I think, was his explanation for crying. A slender vessel carried tears from the heart, the organ of the emotions, up to the eyes. (One last phantom vessel of note is the
vena amoris,
the “love vein,” first described by the ancient Egyptians and absorbed into Christian ceremony in the fourth century. The
vena amoris,
it was believed, carried blood straight from the fourth finger of the left hand to the heart, which accounts for the enduring custom of wearing one’s wedding band on this finger.)

I take it that, in the past, it was easier to believe in the unseen, the unproven. To feel certain that universal forces were reflected in the human body. Modern medical technologies all but dash these notions. Still, I share Galen’s and Leonardo’s conviction that real answers can be found within, even though they don’t show up on MRIs, CAT scans, or blood assays. I do pin my hopes on intangibles, from my simplest expectations to my most fervent dreams.

But that faith is tested. Every three months Steve gets his blood drawn. Where, historically, the removal of blood was a remedy for disease, in modern-day phlebotomy it’s done for diagnostic purposes and to gauge how a treatment is working. Nothing brings Steve and me more down to earth than the reality of bad blood counts. Nothing launches us higher than when the results say his virus is “undetectable,” which has lately been the trend. That it’s
found
to be
undetectable
is a delicious oxymoron. What this means technically is that so few “copies” of HIV exist in his bloodstream that it cannot be measured. The virus, in essence, is neutralized, not rapidly replicating and therefore less capable of inflicting harm. It also speaks to the limits of present technology. The amount of virus Steve has simply falls below the radar. While, in truth, an undetectable virus is as much of an illusion as Galen’s Vital Spirits, the word nonetheless carries tremendous weight. Right now, it’s the closest we have to “cure.”

To the extent that one can manage a life-threatening disease, Steve has been unusually successful, adhering without fail for years to a difficult regimen of pill taking. “Comply or die” is his motto, though I doubt ACT UP will make a T-shirt of it. Since starting on protease inhibitors in late 1995, he’s had no AIDS-related illnesses, although painful nerve damage caused by earlier drugs (a condition called peripheral neuropathy) persists. Along with his meds, he does everything he can to keep his mind, body, and blood as healthy as possible. I would fault his one bad habit—an overly fond attachment to Diet Mountain Dew—were I not similarly addicted.

Steve has blood drawn about two weeks before his scheduled doctor’s appointments, so that the results will be waiting when he arrives. The logistics are no more complicated than that. It’s a cakewalk compared with how convoluted taking blood became in the Middle Ages. In the fifteenth century, for example, the process depended on a fussy convergence of factors, owing more to celestial bodies than to the patients’. A physician took into account the influence of the sun and moon, the principle being that earthly tides were reflected in the flow of humors. Signs of the zodiac were, in turn, linked to body parts. Aries, for example, was matched to the head, so in late March blood would only be let from the temple. In time, the calculations got so Byzantine that a doctor had to rely on bloodletting calendars and handheld devices adopted from astronomy to determine the right moment to snip a vein.

Steve’s quarterly blood draw has always been a joint ritual, in which I drive the car and provide companionship. After all these years, it’s still nerve-wracking, yet, thankfully, we’ve come a long way from the time when the results were so consistently poor that his doctor stopped testing his blood altogether. For the past ten years Steve has used a lab called Immunodiagnostic Laboratories, located in a downtown medical building. The door to IDL looks like a private eye’s office in a film noir: hand-painted black lettering on thick mottled glass, a dark oak frame, a well-worn mail slot. Unless you had business within, you’d be hard-pressed to guess what’s behind it. The tiny waiting room inside is narrow and dim, an overheated den dominated by old magazines.

Same magazines, different location: the old-fashioned barbershop, alive and well today in small-town America, with its trademark candy-cane pole out front. This, like IDL, is a descendant of medieval bloodletting establishments. Back in thirteenth-century Europe, venesection was the specialty of the “Surgeons of the Short Robe,” who were also called barbers. (“Surgeons of the Long Robe” performed more elaborate operations.) Barbers also cut hair, stitched minor wounds, gave enemas, and extracted teeth. At this stage of worldly enlightenment, it was considered healthy for an individual to be bled a couple times a year just to remove the buildup of toxic humors. Think of it as opening the window of a stuffy room. To advertise his services, the barber posted a striped pole outside his door. When I was a boy, this pole was a reminder of the candy I’d earn if I didn’t fidget. The truth is far more ghoulish. The red stripe symbolized blood; the white stripe, the bandages; the blue stripe, the vein; and the pole itself represented the stick the patient gripped to facilitate blood flow. Barbers continued to perform venesection up through the seventeenth century, and early colonists transported the practice to America.