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Galenic medicine in the 21st century.

With a graceful but ambiguous head-wobble the nurse at reception in Delhi's Ramanhar Lohia Hospital indicated that the Galenic doctor I was here to meet was probably in the direction I was currently looking. The large sign at the entrance fortunately confirmed this: 'Unani Out Patients Department'. I stood at the entrance to Doctor Zia's office ahead of a dozen patients already in waiting. "Ah, Dr Jimi! Do come in." I greet Dr Zia with the traditional title of 'Hakim', something that more closely approximates to 'sage' than doctor, but is the preferred title throughout the Muslim world. Immediately Dr Zia indicates the patient before him and says, "Presenting problem is furunculosis of the nose. After taking the pulse I asked him if he was constipated, which he confirmed. What is the Unani (Galenic) Diagnosis?" This last question was accompanied by a glint in his eye, which although warm, did nothing to ease the sense of trial by fire I was suddenly feeling. Deep breath. Trusting my gut, I stitched together concepts from the other traditional systems I have studied and translated them into the language of Galen: "Obstruction of the liver and accumulation of yellow-bile". Without a blink Dr Zia asks, "And the temperament?" I reply that it is probably Choleric and the doctor smiles very warmly and indicates that I should sit down at his desk.

The rest of the day was a series of footnotes to this basic insight; Dr Zia would ask the patient a series of questions, take their pulse, examine pathology reports and then conclude with a scrawled prescription and some detailed instructions on important lifestyle practices. Whenever possible he invited me to listen to the stethoscope, observe the condition and palpate the tissues involved. I understood the logic of the diagnosis more often than I did not. This man has colonic ulcer and fatty liver, he is too hot and dry, and in addition to herbal medicines he should eat more vegetables that are cooling and moistening. This woman has obesity, arthritis and fatigue; she should eat less food, but include more spices. This young man has stomatitis; last week he had a fever and took pharmaceutical febrifuges. The fever subsided but three days later he erupted in ulcers. Dr Zia smiles and shakes his head knowingly at me. What else to say?

In the interest of reigniting popular and professional interest in the traditional medicine of the West, I have compiled the following findings from my research after visiting many of the major Unani/Galenic research centres, hospitals and universities in India today.


The single most famous concept of Galenic medicine is that of the body's four main humours. These have been translated from Greek into the now familiar terms of blood, bile, phlegm and black bile. The critical point to understand when working with these concepts however--a point that far too many European Galenic doctors themselves missed--is that the terms denoting them do not simply indicate the corresponding biological fluid. Rather, the fluid represents a fundamental and dynamic process or principle within the body, and that fluid epitomises or embodies the otherwise abstract principle. When a Chinese doctor speaks of'stomach fire' he does not literally believe that there is a flame within the stomach, and when a modern Galenic doctor describes a skin condition as being caused by an excess of the bile humour, they do not believe that there is literally bile being excreted by the skin eruption, nor do they necessarily believe that the liver is producing too much bile; for humours and bodily substances are of two very different levels of being.

Ultimately for a vitalist, the heart of the issue is the nature of the process, not the nature of the substance. The confusion arises whenever naive literalism is invoked and substances are crudely equated with the processes that formed and shaped them. The following is a brief attempt to describe the essence of the biological processes behind these concepts, together with their classical Hippocratic associations.


The basic energetic quality of this humour is hot and wet. It was classically associated with the season of spring, the age of young adulthood and all tissues or fluids with a red colouration. The element attributed to the blood by the Romans was that of air, but based upon the primary qualities of heat and wetness it may perhaps be better understood by modern students as a mixture of fire (hot) and water (wet). Unlike other humours, blood was viewed as being of a generally beneficent nature. Observing natural processes such as menstruation, nose bleeds and bleeding haemorrhoids however, where nature chooses to evacuate this otherwise nourishing fluid, Greek physicians reasoned that even blood could be in excess (or more accurately the hot-wet principle was in excess) and like modern Traditional Chinese Medicine and Ayurveda, chose to induce controlled and moderate bleeding or leeching in certain conditions. Unfortunately, due to the dramatic effects of blood-letting this eventually led in the West to the era of heroic medicine where the practice was carried to an extreme by the non-Galenic ancestors of modern medicine. A critical feature of this clinical concept that I learned at the Carol Barg Tibbia College is that Blood is not just a dynamic humour, but also a physiological fluid that is the vehicle that carries all four of the humours to the body's various tissues. Cleaning the blood in Galenic medicine with herbal alternatives and diet is thus often prescribed for conditions that are caused by an imbalance of one of the other humours, such as Bile. The function of the Blood humour is warming and nourishing, imparting physical vigour and strength of character. Signs of deficiency are therefore obviously weakness and atrophy, with signs of excess being the classical symptom picture of plethora: heat, pain, headache and mania with sensations of fullness or throbbing. All of these symptoms are more likely in the spring when the blood stirs and rises like the sap in trees, but also in hot weather in general. Finally, Avicenna asserted that Blood also carried 'Ruh'--which seems to equate with both oxygen and energy/chi.


The basic energetic quality of Chole is hot and dry and is therefore associated with the corresponding season of Summer and from there the prime of life. It was classically associated with the element of fire, but due to its primary qualities could be justifiably understood by modern students as a combination of hot fire and dry air. A good medical mnemonic for the psychological action of Bile is that it is what gives us the 'gall' to rise to life's challenges. Indeed the fiery nature of this acrid humor is infamous for putting one in a bad humour, as it causes mental irritation that is akin to the physiological irritation of bile secretions on delicate tissues. Despite this, the Bile Humor (often called Yellow-Bile) is recognised for its many important stimulating functions so necessary for life. The most central of these is its role in 'coction'--the cooking or ripening of one substance into another. Bile not only drives important macro-digestive processes, but is also the principle behind cellular metabolism in all the body's tissues. Physiological waste products resulting in skin disorders are therefore often either a result of excess heat and dryness (too much Bile) or faulty coction/ metabolism (too little Bile). An interesting concept from the Persian physicians is that Bile not only aids in the digestion of fats, but also that it 'washes Phlegma', thus reducing congestion in general --a function aided by its thinning action on the blood which increases circulation. More broadly however, any disease involving excess heat and dryness is likely to be diagnosed as having a bilious nature and thus treated accordingly, as are any discharges or eruptions of a yellow-green colour. Finally, Avicenna stated that Bile is a nutriment to all tissues of a yellow hue, especially tendons and cartilage--a concept that overlaps with Chinese Medicine.


The basic energetic quality of Phlegma is cold and moist, (hence its association with the season of winter) a fact that the Hippocratic text On the Nature of Man encourages one to prove for oneself by simply touching phlegm and feeling its cool nature compared to blood or bile. Like Ayurvedic Medicine, Phlegmatic processes are seen to dominate the early processes of growth and are therefore associated with the period of childhood. The classical element of this humor is water, although I prefer to think of phlegm as a combination of cold earth and wet water. Despite the somewhat unappealing congestive connotations, Phlegma is the principle of fluidity in the body and is thus the vital process behind such diverse physiological and anatomical phenomenon as sweat, breast-milk, tears, sperm/ ova, lymph, plasma, the synovial and cerebro-spinal fluids, to name a few. The key to whether food is converted into the all-important fluids named above, or the congestive catarrh associated with so many infections is the process of coction, or digestion. After an initial round of coction in the stomach, Galenic medicine asserted that there was a secondary process of coction in the liver that formed all the humors sequentially: Blood first, then Phlegma, Bile and finally Black Bile. If this secondary digestive process was only partially completed the metabolic wastes create catarrh, hence the obvious association between Phlegma and the vast array of cold, moist, congestive infections from sinusitis to athlete's foot. In its balanced state however, Phlegma forms a major role in the nutritive aspect of Blood, with modern Unani doctors suggesting that even the globin in haemoglobin is formed by the Phlegmatic principle. Practitioners in India also assert the deeply Phlegmatic nature of the brain, a concept that has many, many fascinating implications. Finally, the amniotic oceans of the intra and extra cellular fluid matrixes are perhaps the most archetypal representation of this life-giving protoplasm.


The concept of Black Bile is utterly unique to Galenic medicine and therefore the most difficult to grasp in my experience. Its basic energetic quality is cold and dry, being associated with the season of Autumn and hence old age. The classical element it is associated with is earth, which doesn't adequately symbolise the nature of this process to modern readers. Instead I would recommend considering it as a combination of cold earth and dry air, which does reflect the primary energetic qualities but is non-traditional. As the final product of the secondary coction of food in the liver, Black Bile is the least nutritive and the most toxic. It has therefore been somewhat maligned historically and often only given negative attributes. In small amounts however, my Unani tutors were unanimous in asserting that Black Bile has a critical role to play in health, creating strong healthy bones, driving embryological development and vitalising the blood --all alchemical 'mecurial' processes. In excess however, the intensity of this cold dry principle is best described as 'caustic', eroding and ulcerating tissues in syphilitic-like processes. The opposite disease pattern is also found however, with cancerous growths being similarly often classified as Melancholic--perhaps best thought of as the body's attempt to wall off the excess caustic principle. Other illustrative conditions classically associated with Melancholia include vertigo, sciatica, epilepsy and headache. The final area of action associated with Black Bile is psychological and neurological disorders, with a range of significant disturbances other than simple melancholy being diagnosed as having this humor at their origin. Theophrastus emphasised the changeability of Melancholic symptoms, a notion that is reflected in the internal tension of the heavy consolidating effects of the cold principle, when coupled with the more motile nature of the dry principle.


I was personally confounded by how the Greeks came up with the notion of Black Bile, which unlike the other three humors doesn't immediately strike a modern reader as having any obvious physiological substances to correlate it with. My Unani tutors were quick to point out the following clinical examples that are still encountered in India but rarely seen in the West: the stool of patients with bleeding gastric ulcers is often black, the vomit of patients with advanced stomach cancer can be black as are some carcinomas, and black water fever, a complication of malaria, results in strikingly black-coloured urine. Historians of medicine tend to point to the ancient practice of blood-letting--which was then collected and examined by physicians for diagnosis--as the source of the humoral model. Upon resting the previously homogenous sample of blood coagulates and separates with bilirubin rising to the top to form a yellow layer (Bile), plasma sitting below this as a layer of white (Phlegm), haemoglobin forming a dark red mass below this (Blood) and a fourth black layer of clotting factors and other elements sometimes being observed as a thin layer at the bottom (Black Bile).


Galenic medicine, like Ayurveda, places considerable emphasis on the individual's constitution or 'temperament'. Assessment of a client's basic temperament has always been a complex process drawing upon a great deal of different streams of information collected via physical examination, pulse, urine, mental disposition and body shape, among others. However, popular and lay summaries of this facet focused primarily upon body shape and mental disposition, with a range of beautiful mind-maps, mandalas and ditties created that simplified the concepts but made them more widely available. This is akin to the modern appropriation of psychological concepts such as "ego", "introvert" and "shadow", which roughly equate to their original professional meanings. To say that someone was 'phlegmatic' invoked a constellation of connotations in much the same way that modern star signs do, as they were an important and valid typological map. From both my reading of the literature and the interviews I conducted, I now understand these types as follow

Phelgmatic: Contented, hard-working and unconfrontational in its positive expression of'the jolly fat man', but more often depicted in the European literature as shy, insecure, unadventurous, frigid, conservative, stubborn and dull-witted. Akin to the Cancerian archetype in some ways, with the bodily characteristics of pallor, flaccidity and hypo-function. Prone to catarrhal conditions and strongly parallel to the gastric, Kapha or endomorph type. Generally given a poor rap in the strongly Choleric intellectual climate of Europe in the middle ages, but with positive qualities of the Ayurvedic Kapha type being entirely relevant. One such example is the pragmatic nature of the phlegmatic type, which has the potential to keep its 'cool' under pressure. This can of course be carried to a fault by stubborn, pasty-skinned, sweaty-palmed, phlegmatic bureaucrats.

Sanguine: Literally 'blooded' but not the same as the modern notion of hot-blooded, which is decidedly choleric. The main difference is that a strong sense of idealism and sentimentality runs through the descriptions of Sanguines, with musicians being a favourite example. Physically strong and warm with a good appetite, at times this type is idealised to the point that it becomes merely a description of a balanced constitution. Generally attributed with robust health in modern Unani, this type is best seen as a positive variation on the metabolic, Pitta or mesomorph type with the emotional characteristics of a Chinese 'fire element' type. This denotes a strong social nature with heart and nervous system symptoms being the most common complaints. Great leaders are often given as examples of this type by Indian practitioners.

Choleric: This is the 'bilious' or 'liverish' type. The Chinese term here is the now the anglicised 'Gung-ho'--literally 'hot livered'. Cholerics are famous for their hot temper, pride, confidence, intelligence and vitality. The classical illustrations depict a military character, which is an apt illustration astrologically because the martial/ military arts were governed by Mars and therefore hot and dry like Cholerics. Their bodies are well muscled with prominent veins. Hepatic disorders are obvious, and accompanied by headaches, high blood pressure, eruptive skin disorders and plethoric venous congestion. Both diarrhoea and constipation are possible depending on the flow of bile. Despite the potential for flying off the handle, modern Unani practitioners seem to idealise this constitution at times because Cholerics have the 'gall' to achieve what others would never dare.

Melancholic: This is the mysterious 'Black Bile' temperament, which evaded my understanding for over a decade. Interestingly it appears to have been the first humor to have been mapped out as a temperament by a student of both Plato and Aristotle: Theophrastus of Lesbos (c. 371-c. 287 BCE). As the modern connotations of the name suggest, the mind and nervous system are central to this constitution. The key to unlock this concept however, was for me the realisation that like the Ayurvedic Vata/ Wind constitution, melancholics are cold and dry, thus being under the domain of the air element in most other traditional systems I have studied. The reason this is so significant is that the image of 'Black-Bile' has long since ceased to evoke much meaning in the Western imagination, whereas the concept of air or wind quickly calls to mind a great many associations to anyone familiar with vitalistic modes of thought. The key difference however is that popular Western descriptions of this biotype depict a kind of Saturnine old man; bearded, grumpy, distracted by his pontifications and somewhat disillusioned. The body shape however, like that of the Vata constitution, is thin, becoming emaciated and withered with time and neglect. Finally, darker skinned and haired races were often thought to be more Melancholic as a rule--due to the increased levels of melatonin from a modern perspective I am informed--but I would be cautious in following this personally. Theophrastus compared the emotional effects of Black Bile to the experience of having drunk too much wine, with rapid changes from hilarity to depression taking place. However, when in a state of equilibrium greatness results, with Theophrastus passing on the received wisdom of his time that geniuses, philosophers and statesman are often Melancholic. Students of Western typology will note some similarities with 'the consumptive taint'.

Historically the above typology was applied to just about everything, becoming a language to discuss the temperaments of things, animals, races and countries. An example here is that we could speak of the classical Greek era as a Melancholic culture due to the centrality and respect accorded to grumpy male philosophers. The Renaissance by contrast with all its youthful enthusiasm and idealism would be described as Sanguine (as would Homeric Greece), whilst the Cold War era was evidently a Choleric period in history.

Running parallel to the above model is a less used concept of 'basic intemperance', which describes people as being either predominantly hot, cold, dry or moist. This is an important tool to clarify complex cases when other models do not appear apply easily.


The above clinical models are a Western equivalent of the Chinese yin-yang diagram and Ayurvedic tri-dosha model in that they served as a compass for countless generations of Western physicians. Although scholars marvelling at the similarities with Far-Eastern systems have sometimes speculated a direct transmission of knowledge between India and Greece, current consensus is that the Western humoral model is a purely indigenous phenomenon. As with so many of the Andeo-Mayan cultural achievements in common with old world cultures, the only conclusion we are left with is that these myths and models are archetypal products of the human psyche as it reflects upon the world around it. Indeed, an anthropologist rejecting all distinctions between nature and culture may even describe vitalistic modes of thinking as biocultural Gaian adaptions.

Be that as it may, although holistic modes of thought are in the midst of an incredible renaissance, in European cultures this is often the result of the introduction of intact Eastern systems. Thankfully Persia and India have preserved the Western medical cannon whilst we explored other ideas; much in the same way they did during the Dark Ages. A true renaissance would therefore be to come full circle and discover our own culture and traditions again, and know them as if for the first time. In addition to the vast cultural implications of preserving our Western heritage, a coherent and intact model such as that provided by Galenic medicine also genuinely preserves holistic epistemologies in an era when modern naturopaths, although still prescribing herbs, are being taught to think within the dominant paradigm. In a molecularly obsessed culture, individuals who have thoroughly internalised a vitalist epistemology are dangerously hard to find in Western habitats. This may mean that modern Naturopaths and herbalists are chasing the same alluring phantasm that has led orthodox medicine to its current dangerous state. It is my genuine hope that the concepts of Galenic medicine and other Western traditions return to reinspire yet another generation of physicians.
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Author:Wollumbin, Jimi
Publication:Journal of the Australian Traditional-Medicine Society
Article Type:Report
Geographic Code:9INDI
Date:Jun 1, 2013
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