173 *Diseases* II, 73.

174 *Regimen in Acute Diseases* LXI.

175 *Timaeus* 77b: '… τὰ δὲ τῆς γεώδους ὁμοῦ κινουμένης τε καὶ αἰρομένης ζέσιν τε καὶ ζύμωσιν επίκλην λεχθῆναι, τὸ δὲ τούτων αἴτιον τῶν παθημάτων ὀξὺ προσρηθῆναι'.

176 *At. Bil.* V 111–2 K; cf. *Caus. Symp.* VII 245,15–7.

πολὺ δὲ δήπου τῆσδε τὴν ἐκ τῆς ξανθῆς χολῆς ὑπεροπτηθείσης γινομένην μέλαιναν ὀλεθριωτέραν εἶναι νομιστέον, ὅσῳπερ καὶ ὁ χυμὸς τοῦ χυμοῦ δραστικώτερος, ἡ ξανθὴ χολὴ τῆς οἷον ὑποσταθμης τοῦ αἵματος …177

You must remember, of course, that black bile which results from an excessive heating of yellow bile is more destructive than the black bile I mentioned before, just as one humour is more drastic in its action compared with another fluid, by which I mean yellow bile compared with a fluid that looks like the sediment of blood.

tr. Grant

This utterly destructive kind of black bile Galen just described is actually the result of excessively heated yellow bile. This is what Galen seems to designate as black bile in the proper sense. Its destructive power is related to the active power of yellow bile: since it is a kind of degenerated form of yellow bile, one that has become overheated, it becomes malignant; but it becomes powerfully malignant since yellow bile is the most active humour. This is important to note, since the hot aspect in the bipolar-like descriptions of black bile in the *Problemata* and Rufus were related to quick and intense movement, as well as to intellectual activity, as we have seen. The black bile that Galen distinguishes here as the most dangerous one, is a degenerated form of a humour that is preeminently active. The yellow bile is defined as particularly active compared to the black bile that Galen 'mentioned before', as he says here.  Here we have the same distinction that we previously found in Rufus: between a black bile that is like a sediment and becomes harmful only in particular circumstances; and a black bile that is the result of burning and that is harmful *per se*. For most of the rest of the treatise, Galen will continue to discuss the more common version of black bile rather than the harmful result of the overheating of yellow bile. What is this substance and how does it relate to the black bile of *HNH*, the black, sour, thick, dry and cold substance that

177 *At. Bil.* V 112 K.

178 *At. Bil.* V 108 K and 110–1 K; cf. *Hipp. Aph.* XVIIIA 22,3–4 'εἰς αὐτὰς ἰλυῶδές τε καὶ μελαγχολικὸν αἷμα'; other parallels below.

276 Case-Study IV

forms a normal part of the healthy human constitution and predominates in autumn?

It is different from what Galen calls 'black bile in the precise sense' (τῆς ἀκριβοῦς μελαίνης χολῆς), which is always fatal, as he emphasizes.179 This distinction is common throughout Galen's work. The black bile that is like the sediment of the blood is often compared by him to the lees of wine. It is a residue and a by-product of the production of something essential, namely blood, or wine in the metaphor, and it is contrasted with what he calls black bile in the precise or proper sense (ἀκριβής).180 If this sediment comes to be in excess, however, it can cause all kinds of serious afflictions. When it is isolated (from the other humours) it can cause a 'dark tumour' that can grow into a cancer, since isolated from the others it is 'very harsh and malignant'.181 So this black bile, even though it is a normal part of our constitution, is, indeed, potentially extremely dangerous. We previously noticed that, in *HNH*, an imbalance of the humours is the cause of disease. What we learn from *At. Bil.* about the black bile that is like the sediment of blood seems to be congruent with that theory. It is notable, however, just how extremely detrimental the black bile can become when it is in excess or isolation. Also, there seem to be no particularly beneficial aspects to this black bile, even though it is considered a normal part of our constitution.182 The general impression we get of this substance in *At. Bil.* is that of something very dangerous and detrimental that should be managed carefully by experts when it manifests itself, and that seems to have absolutely no beneficial qualities or purpose in itself. This corresponds to the notion of black bile as a potentially dangerous residue that we have found both in the Peripatetic tradition and in Rufus.  Prorrh.* XVI 512,10–12 K: 'διττὴ δ΄ ἐστὶν ἡ γένεσις τῆς μελαίνης χολῆς ἤτοι τῆς ξανθῆς ὑπερωπτημένης ἢ τοῦ παχέος αἵματος· ὑπεροπτᾶται δὲ διὰ θερμασίαν ἰσχυράν'. also 534,4–6 K: 'μεμάθηκας γὰρ ἔκ τε τῆς ξανθῆς χολῆς ὑπεροπτηθείσης καὶ τοῦ παχέος αἵματος γεννᾶσθαι τὴν μέλαιναν'. *Hipp. Epid. VI* XVIIB 322,1–2 K: 'ἐμάθετε γὰρ τὴν γένεσιν αὐτῆς εἶναι διττήν, ἔκ τε τοῦ παχέος αἵματος καὶ τῆς ξανθῆς ὑπεροπτηθείσης'. *Hipp. Aph. VI* XVIIIA 91,6– 16 K, XVIIB 622,4–6 K, XVIIB 685,1–6; *Hipp. Prog.* XVIIIB 278,3–10 K; *MM* X 974,14–8 K;

181 *At. Bil.* V 117 K; cf. *PHP* VIII, 4, 32, 504,24–6 De Lacy.

182 In other works, notably *Nat. Fac.* and *UP*, we do find suggestions that black bile can be useful in certain ways after it has undergone alteration in the spleen, see below.

the humoural theory of *HNH*, since that also does not mention any particular beneficial aspect of black bile, while it does, on the other hand, presents the aforementioned notion of disease as a consequence of imbalance or isolation of any particular humour. Indeed, Galen also cites from the Hippocratic *On the Nature of Man* in his description of the black bile that is like a sediment of the blood. He quotes the passage that states that health is achieved through a balance of the humours, while excess, lack or isolation of one particular humour causes pain and disease. Besides melancholy, excess or isolation of black bile can apparently cause cancer, ulcers, elephantiasis, phrenitis, varicoceles and haemorrhoids.183 Clearly, Galen is implying that these diseases are the consequence of a humoural imbalance in terms of an excess or isolation of the black bile that is discussed in *HNH*.

Still, despite all of its potential danger, Galen simply considers this black bile a necessary part of our body that is particularly related to digestion and the transformation of food into blood.184 Nature does its best to deal with this substance in the human body, in order to preserve life, but that seems to entail only getting rid of it as much as possible. This sediment is a normal part of our constitution as long as it is regularly evacuated.185 Our body gets rid of black bile through evacuation, sometimes even forcing excess black bile towards the surface of the body in an attempt to get it out, which can cause the skin to thicken and dry. As we saw before, thickness and dryness are qualities peculiar to black bile in the humoural theory of *HNH* as well. Likewise, the doctor's main concern seems to be for evacuation of the black bile, as well as for the development of a diet that produces better humours, which was also the main approach in Rufus' writings.186 However, it is not possible, according to Galen, to completely get rid of black bile; its production is necessary.187 What is possible, though, is to make sure that as little as possible of it is produced by regulating diet, since it is through processing food and drink that we obtain black bile in the first place.188

183 These can be found in *At. Bil.* and paralleled in other works, e.g. *Symp. Caus.* VII 224 K; *Hipp. Elem.* 146,5–7 De Lacy; *Hipp. Epid. VI* XVIIB 286 K; *Tum. Pr. Nat.* VII 719–20; *Alim. Fac.*  VI 661,15–662,2; *Hipp. Prorrh.* XVI 795,1–2 K.

184 Galen also refers to *HNH* in *At. Bil.* V 128 K, after his description of the black bile that is cleansed from the blood by the spleen and repeats that Hippocrates has shown that all the four humours are always in the human body (also *At. Bil.* V 135 K, 144–5 K).

185 *At. Bil.* V 115–6 K.

186 E.g. *Alim. Fac.* VI 526, 632 and 661–2 state that lentils and beef respectively increase the amount of black bile in the body; *Bon. Mal. Suc.* VI 798,8–10, those whose blood is more melancholic need foods that are wet and warm in mixture.

187 *At. Bil.* V 124 K.

188 *At. Bil.* V 124 K.

278 Case-Study IV

It is interesting that Galen brings up the impossibility of the complete absence of black bile in this manner, and then suggests reducing production of it. There have been predecessors, notably Erasistratus, who, according to Galen, did not consider black bile at all. Galen finds fault with them, obviously, but seems to agree that a complete absence of black bile appears like an appealing idea, given the description he just provided of its detrimental effects. We shall return to this suggestion later. In any case, there are also limits to the extent that the production of black bile can be regulated. Besides diet, people's specific constitution, the season, climate, and, notably, one's mental state, all have an influence on it. Interestingly, people with a hotter and drier mixture (θερμότερα καὶ ξηρότερα ταῖς κράσεσίν) are more prone to produce black bile. Also, production goes up in hotter and drier times of the year. This fits with the connection of black bile to autumn that was made in *On the Nature of Man*, since autumn comes right after summer, the season that is hot and dry and that, thus, increases the amount of black bile, which would make the season immediately following summer the period in which black bile is most abundant. Finally, hotter and drier places also increase the production of black bile, as do dry foods that consist of thick particles.189 Clearly, the elemental qualities of hotness and dryness, and their predominance, are related to the production and possible excess of black bile in *At. Bil.* This might seem remarkable, since, as has been pointed out by Jouanna, in other Galenic works it is rather the qualities of coldness and dryness that are ascribed to the black bile.190 However, there is no need to posit inconsistencies here. We simply have to note that the quality of hotness is associated with the *production* of black bile, while that of coldness is used to describe the state of black bile itself. Black bile is a substance that is cold and dry because it was formerly very hot, lost all of its moisture because of that hotness, and then cooled down. It is abundant in autumn because it is a remnant of summer. As we saw before, Rufus compares it with pieces of coal that have cooled down.191 Galen does not attribute the quality of hotness to the black bile itself, but rather attributes the quality of being burned to it, which already involves a receding of the hotness, leaving a remnant that cooled down to some extent or other. This comes to the fore clearly in the following passage from *On the Causes of Symptoms* (*Caus. Symp.*):

189 *At. Bil.* V 126 K; cf. *Alim. Fac.* VI 526–8 K.

190 Jouanna (2009) 235 f.

191 Rufus, Fr 11,18 f ed. Pormann; also *Problemata* 954a13–20.

τοὐναντίον γὰρ ἅπαν ἐξ ὑπεροπτησεώς τε καὶ ζέσεως, οἷον τέφρα τις ἡ μέλαινα χολὴ συνίσταται ψυχρὰ μὲν, ὅτι γεώδης, θερμότητος δὲ μετέχουσα, καθάπερ ἡ τέφρα τε καὶ τὸ ὄξος.192

On the contrary, black bile like ash arises entirely from overheating and boiling. It is cold in that it is earth-like, but partakes of heat just as do ash and vinegar.

tr. Johnston

Like ashes, black bile *comes to be* as a result of the overheating of something that then subsequently cools down.193 This is how Galen also defines the black bile in *HNH*, as Jouanna points out as well:

ἐγένετο δ΄ εἰκότως τοιοῦτος διὰ τὸ προατωπτῆσθαι τοὺς χυμοὺς τῷ θέρει. τὸ δ΄ ὑπόλειμμα τῶν ὀπτηθέντων, ὅταν δηλονότι σβεσθῇ τὸ θερμόν, αὐτίκα γίνεται ψυχρόν τε καὶ ξηρόν, ψυχρὸν μὲν διὰ τὴν τοῦ θερμοῦ σβέσιν, ξηρὸν δέ, ὅτι κατὰ τὴν ὄπτησιν ἐξεδαπανήθη πᾶν τὸ ὑγρὸν ἐξ αὐτοῦ.194

And it is reasonable that such a humour arises as a result of the cooking of the humours during the summer. The residue of this cooking, when the hot has been thoroughly quenched, then becomes both cold and dry, cold as a result of the quenching of the heat, dry because the process of cooking drives out all of the moisture from it.

tr. Hankinson

Both of these passages are reminiscent of the metaphor of the coals, and show that the qualities of black bile are not just to be cold and dry by itself, but rather to be cold and dry as the consequence of a previous heating that has now receded. This is brought to the fore even more clearly in a passage from *On Mixtures* (*Temp*.):

εἰ γὰρ τις εὐθὺς ἐξ ἀρχῆς ἐγένετο τῇ κράσει ψυχρότερός τε καὶ ξηρότερος, οὐ μελαγχολικὸς ὁ τοιοῦτος, ἀλλὰ φλεγματικός ἐστι τοῖς περιττώμασιν. εἰ δ΄ ἐκ

192 *Caus. Symp.* VII 246,3–6 K.

193 Cf. *Tum. Pr. Nat.* VII 719 for the comparison to ashes of an ulcer caused by black bile.

194 *HNH* 45,25–30 Mewaldt (XV 86 K); cf. *Temp.* I 641 K: 'For melancholic mixtures come about as a result of the burning of the blood; but when this process has just began, the baking effect is not a complete one'. (tr. Singer and van der Eijk)

280 Case-Study IV

μεταπτώσεως ἐγένετο ψυχρὸς καὶ ξηρός, ἐξ ἀνάγκης ὁ τοιοῦτος εὐθὺς ἤδη καὶ μελαγχολικός ἐστιν, οἷον εἴ τις ἔμπροσθεν ὑπάρχων θερμὸς καὶ ξηρὸς ἐκ συγκαύσεως τοῦ αἵματος πλείστην ἐγέννησε τὴν μέλαιναν χολήν. οὗτος γὰρ ἐστιν ὁ πρὸς τῷ ξηρὸς εἶναι καὶ ψυχρὸς εὐθὺς καὶ μελαγχολικὸς ὑπάρχων. εἰ δ΄ απ΄ ἀρχῆς εἴη ψυχρὸς καὶ ξηρός, ἡ μὲν ἕξις τοῦ σώματος τούτῳ λευκὴ καὶ μαλακὴ καὶ ψιλὴ τριχῶν, ἄφλεβος δὲ καὶ ἄναρθρος καὶ ἰσχνὴ καὴ ἀπτομένοις ψυχρὰ καὶ τὸ τῆς ψυχῆς ἦθος ἄτολμον καὶ δειλὸν καὶ δύσθυμον, οὐ μὴν μελαγχολικά γε τὰ περιττώματα.195

Someone who became relatively cold and dry in his mixture right from the beginning will not be melancholic, but phlegmatic, in his residues. On the other hand, someone who has become cold and dry through some change will of necessity be automatically also melancholic. This is the case, for example, with a previously hot and dry person, who has produced a very large quantity of black bile from the burning of the blood: such a person combines being dry and cold with, at the very same time, being melancholic. The bodily condition of one who was cold and dry from the beginning will be white, soft, devoid of hair, lacking in veins and in articulation, thin and cold to the touch, while the character of his soul will be lacking in resolve, cowardly, easily dispirited. Yet his residues will not be melancholic.

tr. Singer and van der Eijk

The same notion is also found in *The Art of Medicine*, with emphasis on the stage of life rather than the season. There, Galen remarks that when a mixture that is dry and hot changes after the prime of life into one that is dry and cold, it will have become melancholic.196 This is completely in line with the description of the transition between summer and autumn, and both passages show, in accordance with the descriptions from *HNH* and *Caus. Symp.*, that black bile is not merely dry and cold of itself but rather a remnant of excessive heat that has cooled down.

Jouanna restricts his discussion more to *HNH*, and regards the passage from *HNH* quoted above as establishing a bridge between two different notions of black bile in *Nat. Fac.* and *At. Bil.*, which associate it with coldness and hotness respectively.197 In this manner, as Jouanna argues, Galen reconciles the theory of black bile as a result of the burning of other humours, particularly yellow

195 *Temp.* I 642–3 K.

196 *Ars Med.* I 345,17–346, K.

197 Jouanna (2009) particularly 252–3.

bile, with the previous Hippocratic theory on black bile that did not consider it as the result of an alteration of another humour. Jouanna follows this distinction, as we find it in Galen, back through Rufus and the Hippocratic corpus.198 Thus, Galen seems to connect the different kinds of black bile distinguished by Rufus: the sediment-like black bile that is related to digestion becomes associated with the quality of being burnt that was reserved for the other kind of black bile. This makes sense, since digestion is a process that involves heating. Again, by this association Galen normalizes the production of black bile and obscures the difference between normal and dangerous versions of it.199 While I generally agree with Jouanna's interpretation – even though I would also note that the connective function that he attributes to *HNH* is more broadly attested in Galen's work, as we have seen – there is one aspect of it that I find confusing. This is his distinction between a black bile that is 'innée', innate, and one that is not. In his view, the black bile of the Hippocratic *On the Nature of Man* should be innate, as opposed to the black bile that is a result of the burning of another humour. I find this a somewhat confusing perspective, since all the humours, including blood, are always already the result of a productive process within the body. At the same time, we always have these humours in our body, already from when we are still an embryo, before we are actually born. To give an example: I see no reason why an embryo, from Galen's perspective, could not have the kind of black bile that is the result of burning, if, for example, its mother has this kind in her body. Then, when the baby is born, is this humour innate to it but not to another baby? It does not make sense to me, therefore, to primarily distinguish the different kinds of black biles in Galen as either innate or not innate. Both are produced, even though one is more of an aberration than the other. It seems to me rather that, for Galen, black bile is a necessary part of our constitution in as far as digestion is, as a necessary by-product of it. As such, it can be present in the body either in a way that is according to nature or in a way that is unnatural and causes disease, as becomes clear from *HNH*, *Nat. Fac.* and *At. Bil.* alike. Whether it is present in a normal or a harmful way, can depend on several circumstances: it is harmful when it is present in excess or isolation (i.e. unmixed) in various parts of the body or when it is the result of a severe heating. Likewise, Stewart also distinguishes between what he calls an 'ideal natural black bile', which he also calls 'innate', a 'non-ideal natural black

198 Jouanna (2009) 254–5.

199 See Stewart (2016) 166–75 for a different response to the issue Jouanna raises, which criticizes Jouanna's view of *HNH* fulfilling a kind of bridging function and explains the supposed contradiction in terms of Galen using different notions of black bile to fit the respective polemical aims in his different works.

282 Case-Study IV

bile', and an 'altered black bile'.200 The latter is the dangerous black bile that is the remnant of overheating of (other) humours. The distinction between the former two kinds, however, is a distinction that Stewart introduces between the black bile that we find in *HNH*, and the black bile that is described as a sediment of the blood and that is associated with digestion, as we find it in *At. Bil.* and *Nat. Fac.*, among other works. This distinction seems to me to be Stewart's own fabrication and to be without basis in Galen's texts. It seems to rest on the assumption that the black bile of *HNH* should be beneficial, for which I have not found textual warrant.201 The only passage that Stewart cites to justify the distinction between these two is actually from *Loc. Aff.* and will be discussed in the next paragraph, in which we shall discuss the harmful variation of black bile that is either the result of overheating, excess or isolation. We shall find that in *Loc. Aff.* too, Galen distinguishes between two kinds of black bile. One is normal (though potentially always harmful) and the other is extremely harmful. The latter is, in fact, the only variation that can be called black bile in a strict sense according to Galen, as we saw before. The former can function as a normal part of our constitution and is potentially harmful, as we have just discussed, when it is present in excessive amount or when it is isolated.

#### **2.4** *The Normal and the Harmful III: the Harmful That Used to Be Normal*

Let us look at the relevant passage from *Loc. Aff.* It is quite long, so I shall cite it in parts. Galen starts with making a distinction between different kinds of black bile or melancholic humour, as he did just before this passage with different kinds of phlegm:

ὡσαύτως δὲ καὶ ὁ μελαγχολικὸς χυμὸς ἐν τῇ συστάσει σαφεῖς ἔχει τὰς διαφορὰς, ὁ μὲν οἷον τρὺξ αἵματος, ἐναργῶς φαινόμενος ἱκανῶς παχὺς, ὥσπερ ἡ τοῦ οἴνου τρύξ· ὁ δὲ πολλῷ μὲν τούτου λεπτότερος κατὰ τὴν σύστασιν, ὀξὺς δὲ καὶ τοῖς ἐμέσασιν αὐτὸν φαινόμενος καὶ τοἶς ὀσμωμένοις· οὗτος καὶ ξύει τὴν γῆν, ἐξαίρων τε καὶ ζυμῶν καὶ πομφόλυγας ἐγείρων, οἷαι τοῖς ζέουσι ζωμοῖς ἐφίστανται.202

In the same manner also the melancholic humour has clear differences in its composition, one kind being like the sediment of blood, clearly

200 Stewart (2016) 155–190.

201 In this sense, I find Stewart's distinction between κατά φύσιν and παρά φύσιν both more helpful and more true to Galen's text, see Stewart (2016) 160–6.

202 *Loc. Aff.* Van der Eijk and Pormann 266 (VIII 176–77 K).

appearing very thick, just like the lees of wine; the other is much finer in composition than that, and it appears acidic both to those that vomit it as well as to those who smell it; this one also corrodes the earth, raising it up and causing it to effervesce and arousing bubbles, as those that surface in boiling soups.

Galen here distinguishes between two kinds of melancholic humour, a distinction that corresponds to the one we found in *At. Bil.* The first is the one that is like the sediment of blood, the second is a much more acidic and dangerous one. At the beginning of the discussion of black bile in *At. Bil.* he makes the same distinction between the acidity manifesting itself only to the person that vomits or to the bystanders as well.203 There, Galen distinguishes black bile in the strict sense (τὸν τῆς ἀκριβοῦς μελαίνης χολῆς χυμὸν) from the one that is like the sediment in the blood. Only the acidity of the black bile in the strict sense, the one that is extremely harmful and has a corroding effect on the earth, is not only perceived by the person vomiting it up but also by the bystanders, through smell. Galen now proceeds to further specify the black bile that is like a sediment of the blood, and remarks that this is not black bile in a strict sense, as he also did in *At. Bil.*:

ὅν δ΄ ἔφην ἐοικέναι παχείᾳ τρυγὶ, τήν τε ζύμωσιν οὐκ ἐργάζεται κατὰ τῆς γῆς ἐκχυθεὶς, πλὴν εἰ μὴ πάνυ σφόδρα τύχοι τότε κατοπτηθεὶς ἐν διακαεῖ πυρετῷ, καὶ ἥκιστα μετέχει ποιότητος ὀξείας, ἡνίκα καὶ καλεῖν αὐτὸν εἴωθα μελαγχολικὸν χυμὸν ἢ μελαγχολικὸν αἷμα, μέλαιναν γὰρ χολὴν οὐδέπω δικαιῶ τὸν τοιοῦτον ὀνομάζειν.204

The one which I said resembles thick sediment, does not produce the fermentation when it is poured out over the earth, unless it happens to have been burnt very intensely during a state of burning fever, and it only has very little share in the quality of acidity. Hence I'm used to calling it melancholic humour or melancholic blood, for I think that is not yet proper to call it black bile.

tr. Van der Eijk

Apparently, both of these kinds of black bile possess the quality of acidity to some extent, but the one that is like a sediment of the blood possesses only very little of it, which renders it much less dangerous. However, it can become

203 *At. Bil.* V 110–1 K.

204 *Loc. Aff.* Van der Eijk and Pormann 266 (V 177 K).

284 Case-Study IV

much more acidic when it is excessively heated due to a fever. Here, again, we see that we have to be careful to apply all too neatly developed distinctions on the different kinds of black bile that Galen discusses. The one that is like a thick sediment is a normal part of our constitution, unlike the one that is the result of an overheating of yellow bile, but it can become extremely harmful as well, when combined with fever, for example. Nonetheless, Galen does not consider it black bile in the strict sense and, therefore, as he says, also calls it melancholic humour or melancholic blood. But at the outset of this passage, as we have seen, he called both of these kinds of black bile 'melancholic humour'. What are we to make of this? Stewart sees Galen making a distinction between three different types of black bile here, one of which is the 'innate' black bile that Stewart considers as the only one that is properly speaking black bile – despite the contradiction that would generate with *At. Bil.* and other works, apparently, where it is only the acidic and malignant black bile that is properly speaking black bile – while the other two are the two defined above, which would then both be melancholic humours.205 However, in Stewart's reading, both of the two 'melancholic humours' would then not, properly speaking, be black bile, while it is clear from the text as cited and discussed above that Galen only says of the sediment-like black bile that it is not strictly speaking black bile, implying much rather that the highly acidic version *is* strictly speaking black bile. This also corresponds to the distinction between the two kinds of black bile as we find it in *At. Bil.* and elsewhere.206 Stewart's reading is not tenable in this light. How, then, are we to make sense of the fact that Galen first calls both of these types 'melancholic humours', and then says that only one of them is strictly speaking black bile, while the other one can be called a 'melancholic humour'? To solve this problem, we can have another look at *At. Bil.*, where Galen makes the same distinction at the very end of the treatise:

205 Stewart (2016) 155–190, Stewart's threefold distinction is completely based on this passage, as it is the only textual evidence he cites for the distinction between three types by Galen himself.

206 Cf. *Syn. Puls.* IX 460,9–13 K: 'οὔσης δὲ καὶ τὴς μελαίνης διττῆς, κατὰ τε τὴν γένεσιν καὶ τὴν δύναμιν, ἐπειδὴ καὶ τῆς ξανθῆς ὑπεροπτηθείσης γίνεται καὶ τοῦ παχέος τε καὶ ἰλυώδους αἵματος, ὅπερ ἀνάλογόν ἐστι τῇ κατὰ τοὺς οἴνους τρυγὶ'.; *Hipp. Prorrh.* XVI 512,10–12 K: 'διττὴ δ΄ ἐστὶν ἡ γένεσις τῆς μελαίνης χολῆς ἤτοι τῆς ξανθῆς ὑπερωπτημένης ἢ τοῦ παχέος αἵματος· ὑπεροπτᾶται δὲ διὰ θερμασίαν ἰσχυράν'. also 534,4–6 K: 'μεμάθηκας γὰρ ἔκ τε τῆς ξανθῆς χολῆς ὑπεροπτηθείσης καὶ τοῦ παχέος αἵματος γεννᾶσθαι τὴν μέλαιναν'. *Hipp. Epid. VI* XVIIB 322,1–2 K: 'ἐμάθετε γὰρ τὴν γένεσιν αὐτῆς εἶναι διττήν, ἔκ τε τοῦ παχέος αἵματος καὶ τῆς ξανθῆς ὑπεροπτηθείσης'. Also *Hipp. Aph. VI* XVIIIA 91,6–16 K; *Hipp. Prog.* XVIIIB 278,3–10 K; *MM* X 974,14–8 K; *Diff. Feb.* VII 376,15–6 K; *Plen.* VII 577,12–6 K.

καὶ μέντοι καὶ παρὰ τὴν ὁμωνυμίαν ἑαυτοὺς, οὐ γὰρ ἡμᾶς γε, σοφίζονται, τὸν μελαγχολικὸν χυμὸν, ὅν ἐν τοῖς ὑγιαίνουσι γεννᾶσθαί φαμεν, ἀκούοντες ἀεὶ κατὰ τῆς μελαίνης λέγεσθαι χολῆς, ἥν ἐν τῷ παρὰ φύσιν ἔχειν γεννᾶσθαί φαμεν. oὐ γὰρ ἡ αὐτὴ κατά γε τοὺς ἀκριβως ὑγιαίνοντάς ἐστι μέλαινα χολὴ, καὶ τινας τῶν παρὰ φύσιν ἐχόντων, ἀμφοτέρας δὲ μελαγχολικὸν χυμὸν ὀνομάζειν οὐδὲν κωλύει.207

And through homonymy they play tricks on themselves, but not on me, with regard to the melancholic humour, which we say is produced in the healthy, since they always understand what is said in relation to the black bile, which we say is produced in those that are in an unnatural state. For it is not the same black bile in those who are perfectly healthy and in some of those who are in an unnatural state, but nothing prevents us from naming both of them melancholic humour.

tr. Grant, modified

Here we find, first of all, the same basic distinction: the melancholic humour is also part of a healthy constitution, whereas black bile is produced in an unnatural state – the former is normal and the latter is harmful. But then, in the very next sentence, Galen simply proceeds to call both of them black bile: 'it is not the same black bile' in both of these types. What is more, he continues even to state that nothing prevents him from calling both 'melancholic humour'! Thus, what we find is that, strictly speaking, the sediment-like kind of black bile should be called a melancholic humour and the highly acidic harmful black bile that is the result of the burning of yellow bile (or sometimes another humour208) should be called black bile proper.209 At the same time, however, both can be called black bile and both can be called melancholic humour according to Galen, and he even says explicitly that there is no need to get hung up on these names. The reason for this, I propose, is that even though it is certainly important to distinguish between the two, especially with regard to therapeutic practice (as we notice in *At. Bil.*), there are also important similarities between the two. We have already noticed above that the normal black

207 *At. Bil.* V 147–8 K.

208 Cf. e.g. *Diff. Feb.* VII 376,9–14 K, for a description of thick blood changing into black bile when heated.

209 Cf. *MM* XIII,16, X 916 K, where we also find a clear distinction between the terms – a thick blood is drawn to the spleen, that has the potential to become black bile and is therefore called a 'μελαγχολικὸν ἢ μέλαν περίττωμα', a melancholic or black residue; *Hipp. Aph. VI* XVIII 91,12–6 K.

286 Case-Study IV

bile, the sediment-like kind, is potentially harmful. In the next sentences from *Loc. Aff.*, following the previous quotation above, this is affirmed:

γεννᾶται δ΄ ὁ χυμὸς οὗτος ἐνίοις πολὺς, ἢ διὰ τὴν ἐξ ἀρχῆς κρᾶσιν, ἢ δι΄ ἔθος ἐδεσμάτων εἰς τοιοῦτον χυμὸν ἐν τῇ κατὰ τὰς φλέβας πέψει μεταβαλόντων. ὥσπερ δ΄ ὁ παχὺς χυμὸς τοῦ φλέγματος, οὕτω καὶ οὗτος παχὺς χυμὸς ὁ μελαγχολικὸς ἐπιληψίας ποτ΄ ἐργάζεται κατὰ τὰς ἐκροὰς τῶν ἐν ἐγκεφάλῳ κοιλιῶν ἰσχόμενος, ἤτοι τῆς μέσης, ἢ τῆς ὄπισθεν· ὅτ΄ ἂν δ΄ ἐν αὐτῷ πλεονάσῃ τῷ τοῦ ἐγκεφάλου σώματι, μελαγχολίαν ἐργάζεται, καθάπερ ὁ ἕτερος χυμὸς τῆς μελαίνης χολῆς, ὁ κατωπτημένης τῆς ξανθῆς χολῆς γενόμενος, τὰς θηριώδεις παραφροσύνας ἀποτελεῖ χωρὶς πυρετοῦ τε καὶ σὺν πυρετῷ, πλεονάζων ἐν τῷ σώματι τοῦ ἐγκεφάλου.210

For that humour is generated in some people in large quantity either as a result of their initial mixture or by a habit of eating foods that changes into this during the digestion within the blood vessels. Just like the thick phlegmatic humour, this thick melancholic humour likewise sometimes causes instances of epilepsy, because it is contained in the places where the cavities of the brain, whether the middle or the posterior cavity, have their exit channels. But when it is present in excess in the very body of the brain, it causes melancholy, just as the other kind of humour of black bile, the one that has arisen as a result of the burning of yellow bile, results in violent deliria, both without fever and with fever, when it fills the brain excessively.

tr. Van der Eijk, modified

In the first sentence of this quotation we recognize the distinction we found in Rufus previously, but here it is applied to the sediment-like black bile, of which some people, apparently, naturally have a higher quantity, whereas others have increased its quantity through overheating of particular food-substances in the blood vessels.211 Presumably, in more excessive quantity, it becomes more harmful. It can also become harmful when it obstructs ventricles, or when it abounds in the brain itself. In the latter case, it can even act as the same kind of cause as the harmful, highly acidic black bile that is the result of the burning of yellow bile. Thus, what is striking here, is that while Galen clearly distinguishes these two types of black bile, both are at least potentially harmful and can cause melancholy. The normal, sediment-like form can do so in particular

210 *Loc. Aff.* VIII 177–8 K.

211 This distinction is parallelled in *At. Bil.* V 124–5 K.

circumstances, and the residue of the burning of yellow bile seems to do so without further qualification.

In the following passage from *Nat. Fac.* we find the same distinction between the normal and the harmful kinds of black bile, again phrased as being in accordance with or against nature respectively:

καὶ μοι δοκοῦσιν οἱ πλεῖστοι τῶν παλαιῶν ἰατρῶν αὐτὸ μὲν τ`κατὰ φύσιν ἔχον τοῦ τοιότου χυμοῦ καὶ διαχωροῦν κάτω καὶ πολλάκις ἐπιπολάζον ἄνω μέλανα καλεῖν χυμόν, οὐ μέλαιναν χολήν, τὸ δ΄ ἐκ συγκαύσεώς τινος καὶ σηπεδόνος εἰς τὴν ὀξεῖαν μεθιστάμενον ποιότητα μέλαιναν ὀνομάζειν χολήν. ἀλλὰ περὶ μὲν τῶν ὀνομάτων οὐ χρὴ διαφέρεσθαι, τὸ δ΄ ἀληθὲς ὧδ΄ ἔχον εἰδέναι.212

It seems to me also that most of the ancient physicians call 'melancholic humour' the portion which we have naturally of this humour and which is discharged from the bowel and frequently rises up to the surface as well; but they call 'black bile' that which has been altered into a more acidic quality through a kind of burning and putrefaction. There is no need, however, to dispute about names, but we must realise the facts, which are as follows.

tr. Brock, modified

Here, Galen projects his distinction between black bile in a strict sense – the harmful acidic one that is the result of a burning of humours – and black bile in a loose sense that is rather a melancholic humour – the one that is a normal consequence of the natural processes of digestion – unto the work of his predecessors, as he does more often.213 Again, he emphasizes that it is not so important to be precise about these names. After this passage he uses the property of causing the earth to effervesce again as a criterion for distinguishing the black bile in a strict sense, which is unnatural, from the melancholic humour, which is natural.

It is noteworthy that, in the passage from *Loc. Aff.*, Galen distinguishes the two by saying that the melancholic humour that is in accordance with nature has *not yet* (οὐδέπω) undergone the burning process that causes it to become highly acid. He repeatedly formulates the difference in this manner:

ὥσπερ γε καὶ τοῦ μέλανος χυμοῦ τὸ μὲν μήπω τὴν οἷον ζέσιν τε καὶ ζύμωσιν τῆς γῆς ἐργαζόμενον κατὰ φύσιν ἐστί, τὸ δ΄ εἰς τοιαύτην μεθιστάμενον ἰδέαν

212 *Nat. Fac.* II, 9 (II 136 K).

213 Cf. Stewart (2016) 29–47.

τε καὶ δύναμιν ἤδη παρὰ φύσιν, ὡς ἂν τὴν ἐκ τῆς συγκαύσεως τοῦ παρὰ φύσιν θερμοῦ προσειληφὸς δριμύτητα καὶ οἷον τέφρα τις ἤδη γεγονός ὧδέ πως καὶ ἡ κεκαυμένη τρὺξ τῆς ἀκαύστου διήνεγκε. θερμὸν γὰρ τι χρῆμα αὕτη γ΄ ἱκανῶς ἐστιν, ὥστε καίειν τε καὶ τήκειν καὶ διαφθείρειν τὴν σάρκα. τῇ δ΄ ἑτέρᾳ τῇ μήπω κεκαυμένῃ …214

Similarly with the black humour: that which does not yet produce this cooking and fermentation of the ground, is natural, while that which has been altered towards such an appearance and capacity, is already unnatural, as it has taken on an acidic character from the burning by unnatural heat and has already become transformed into ashes, as it were, in the same manner as lees that have been burned differ from unburned ones. For the former is a warm substance, able to burn, dissolve, and destroy the flesh. The other kind, which has not yet undergone burning …

tr. Brock, modified

Here we see that it is the normal, natural black bile (that should strictly be called 'melancholic humour') itself that can become the acidic, detrimental and unnatural black bile.215 The two kinds of black bile are closely related: the one can transform into the other. The harmful black bile that is here called unnatural, previously was a natural melancholic humour. It does not need to be black bile that is burned, but it can also be the yellow bile, as Galen adds right after the passage just quoted, and as we have seen before.

It appears that what Galen calls black bile in the strict sense is a degeneration of a humour (mostly yellow bile, but also black bile and blood216) that is in itself a normal part of a healthy constitution. At the same time, though, not all the humours are equally a normal part of our constitution. Even the normal black bile is described by Galen as a necessary by-product of digestion that is potentially dangerous and the production of which should be carefully managed and ideally reduced.217 Galen may have attempted to reconcile the Hippocratic notion of black bile as one of the four humours that constitute

214 *Nat. Fac.* II 9, II 137 K.

215 Cf. also *Comp. Med. Loc.* XIII 236,15–237,1 K, where Galen says that the black bile comes to be from the sediment of the blood ('τὴν οἷον ἰλὺν τοῦ αἵματος, ἐξ ἧς ἡ μέλαινα γεννᾶται χολὴ …'); *Hipp. Prorrh.* XVI 534,4–6 K: 'μεμάθηκας γὰρ ἔκ τε τῆς ξανθῆς χολῆς ὑπεροπτηθείσης καὶ τοῦ παχέος αἵματος γεννᾶσθαι τὴν μέλαιναν'.

216 *Temp.* II 6, 83,4 Helmreich (I 641 K) and *Hipp. Prorrh.*  There is clearly a gradual build-up there, not an essential difference; cf. *MM* X 916,16 f. K.

our nature with the Aristotelian notion of black bile as a residue, resulting in a theory of black bile that is a necessary by-product of our digestive system and that is, as such, a normal part of our constitution as long as it is properly managed. For this management, we are equipped by nature with an organ to dispose of black bile: the spleen. In the next paragraph, we shall discuss the role of the spleen, which shall shed more light on the role of black bile in the human body in Galen.

#### **2.5** *Spleen*

As Galen seems to suggest in *At. Bil.*, it might perhaps have been better if there were no need for us to produce black bile, but there is.218 Given our nature as mortal beings subject to continuous change, it is necessary for us to consume food and drink, which we need to digest and transform into blood, a by-product of which process is black bile. It is not uncommon for Galen to dwell on this necessity. In his commentary on the *Timaeus*, he notes that the gods made plants as nourishment for us since we would otherwise, given our elemental constitution, disperse our substance without sufficient restoration being possible.219 That is to say, the need for digestion, as such, is the direct result of an initially imperfect balance in our body. This is important to realize in our evaluation of black bile and the question of its usefulness. Perhaps black bile can to a certain extent be useful to thicken blood that would otherwise be too thin. It is, after all, the thickest of the humours. Some of it, upon thorough alteration by the spleen, can be useful as a nutriment for the spleen itself. Some of it, again upon alteration by the spleen, is disposed in the stomach, and can be beneficial to the stomach by tightening it and drawing it together so that it holds the food closer, which is good for digestion.220 Other than these functions, that already depend on the alteration by the spleen, I see no positive function of the stuff in Galen. In any case, the proper thickness of blood could have presumably been effected in another manner than adding a dark substance which one then needs to get rid of as much as possible, and which has horrible side-effects in various circumstances. The nourishment for the spleen itself is only necessary because the spleen is necessary, which is in turn only

218 *At. Bil.* V 124 K.

219 Schröder Fr II – 76e7–77c5; cf. *Hipp. Elem.* 118,16 f. De Lacy (I 473–4 K), where he says that the substances of all things that come to be and pass away undergo two kinds of changes, namely alteration and depletion, which require 'a double correction, one that curbs excess in the qualities, the other that refills the place of that which was lost'. (tr. De Lacy)

220 These functions are described in *UP* I 233 and I 264–5 Helmreich respectively (III 317 and 361–2 K respectively); cf. *UP* 273,15–20 (III 373 K); *Hipp. Aph. VI* XVIIB 681,15 f. K; *MM*X 920 K.

290 Case-Study IV

necessary for the breaking down of black bile in the first place. How, then, can the presence of black bile in the human constitution be reconciled with Galen's teleological framework, in which nature, that wise artisan, excels in making finely attuned products such as ourselves?

The answer has already been given: nature also gave us the spleen so that we can get rid of the black bile, instead of letting that pernicious substance wander around in our bodies:

ηὐξαμην οὖν κἀνταῦθ΄ ἐρωτῆσαι δύνασθαι τὸν ᾿Ερασίστρατον, εἰ μηδὲν ὄργανον ἡ τεχνικὴ φύσις ἐδημιούργησε καθαρτικὸν τοῦ τοιούτου χυμοῦ, ἀλλὰ τῶν μὲν οὔρων ἄρα τῆς διακρίσεώς ἐστιν ὄργανα δύο καὶ τῆς ξανθῆς χολῆς ἕτερον οὐ σμικρόν, ὁ δὲ τούτων κακοηθέστερος χυμὸς ἀλᾶται διὰ παντὸς ἐν ταῖς φλεψὶν ἀναμεμιγμένος τῷ αἵματι.221

At this point, also, I would gladly have been able to ask Erasistratus whether his artistic nature has not constructed any organ for clearing away a humour such as this. For whilst there are two organs for the excretion of urine, and another of considerable size for that of yellow bile, does the humour which is more pernicious than these wander about persistently in the veins mingled with the blood?

tr. Brock

Notice that Galen calls black bile a more pernicious humour than the others, while the subject is simply the normal black bile that is routinely separated out by the liver and then distributed to the spleen, as opposed to the highly acidic black bile that is the result of excessive burning and that is fatal. This pernicious substance comes to be as a kind of by-product or remnant of the normal digestive process of the liver, which transforms food into blood, and is then processed by the spleen. The black bile undergoes a long process of alteration in the spleen, which is powered by a flow of innate heat from the heart. In this process, some of it is changed into something else, namely a kind of thin, dark blood that can serve as nutriment for the spleen itself. The rest of it is discharged into the stomach, where it is normally not harmful, and is, again, even beneficial for digestion by virtue of its capacity for drawing the stomach together.

221 *Nat. Fac.* II 9, II 131 K; cf. *At. Bil.* V 136 K: 'Thus the system which formed animals did not neglect to form an organ which attracted the waste which belongs to black bile. But you cannot invent another part of the body which is capable of attracting this humour and ignore the spleen'. (tr. Grant)

If the spleen functions properly, the dangers of black bile are averted: most of the black bile is altered and subsequently separated off, and it seems that perhaps, indeed, a small quantity, which also needs to be most moderate in quality, can be useful to give the blood sufficient thickness:

τῶν δ΄ εἰρημένων χυμῶν ἐστί τις χρεία τῇ φύσει καὶ τοῦ παχέος καὶ τοῦ λεπτοῦ καὶ καθαίρεται πρός τε τοῦ σπληνὸς καὶ τῆς ἐπὶ τῷ ἥπατι κύστεως τὸ αἷμα καὶ ἀποτίθεται τοσοῦτον τε καὶ τοιοῦτον ἑκατέρου μέρος, ὅσον καὶ οἷον, εἴπερ εἰς ὅλον ἠνέχθη τοῦ ζῴου τὸ σῶμα, βλάβηην ἄν τιν΄ εἰργάσατο. τὸ γὰρ ἱκανῶς παχὺ καὶ γεῶδες καὶ τελέως διαπεφευγὸς τὴν ἐν τῷ ἥπατι μεταβολὴν ὁ σπλὴν εἰς ἑαυτὸν ἕλκει· τὸ δ΄ ἄλλο τὸ μετρίως παχὺ σὺν τῷ κατειργάσθαι πάντη φέρεται. δεῖται γὰρ ἐν πολλοῖς τοῦ ζῴου μορίοις παχύτητός τινος τὸ αἷμα καθάπερ οἴμαι καὶ τῶν ἐμφερομένων ἰνῶν.222

There is, however, a natural use for the humours first mentioned, both thick and thin; the blood is purified both by the spleen and by the bladder beside the liver, and a part of each of the two humours is put away, of such quantity and quality that, if it were carried all over the body, it would do a certain amount of harm. For that which is decidedly thick and earthy in nature, and has entirely escaped alteration in the liver, is drawn by the spleen into itself; the other part which is only moderately thick, after being elaborated [in the liver], is carried all over the body. For the blood in many parts of the body has need of a certain amount of thickening, as also, I take it, of the fibres which it contains.

tr. Brock

This passage seems to imply that we can use a small amount of the more moderate parts of the black bile, in order to provide certain parts of the body with the proper degree of solidity.223 It seems that the black bile, though pernicious in nature, can also be useful as long as it is adequately managed by the spleen. That is to say, as long as the bulk of it is separated off and evacuated, and the mildest bits are used for a moderate thickening of the blood.

The spleen has an especially apt composition for drawing black bile into itself, as becomes clear from *UP*, and as we would expect of the wise artisan that Galen believes nature to be.224 The spleen is particularly porous and has

222 *Nat. Fac.* II 9, 138–9 K.

223 Cf. *Sem.* 106,1–7 (IV 554 K), where Galen remarks that different body-parts require a different degree of thickness of the blood so that some need more black bile in it.

224 *UP* I 234 ff. and 273 Helmreich (III 319 f. and 373 K).

292 Case-Study IV

a loose texture, like a sponge, so that it can attract and take into itself the thickness of the black bile. The part that does this is called the *parenchyma*  (παρέγχυμα), a name that Galen seems to have taken over from Erasistratus. It is full of large arteries that break up and alter the thick melancholic humour by virtue of their incessant motion (which is opposed to the static nature of the black bile itself, as we shall see) and a strong innate heat that comes down from the heart.225 Some of these compositional characteristics are also found in Plato's description of the spleen in the *Timaeus*. There, Timaeus describes the spleen as an organ of loose texture constructed out of hollow and bloodless material, which takes into itself the impurities and cleanses them, while, in turn, it also needs to be cleansed itself, since it will otherwise grow out of proportion.226 The description is quite similar to Galen's in terms of general function and constitution, but in Plato the kind of stuff that is attracted by the spleen is less specific and is certainly not defined as the dark bilious residue of digestion. But, as we have noticed, the spleen is associated with black bile and melancholy in Rufus. Galen knew both Rufus and Plato, of course, and it might have been logical for him to combine both of these descriptions. Its sponge-like nature could cause the spleen to grow when it takes in much residue, both in Plato and Galen, which in turn can again be counteracted, according to Galen, by a so-called 'thinning diet'. This diet is supposed to help against enlargement of the spleen and hardening of the liver, that is to say, it is supposed to reduce the production of black bile in the body.227 Diet logically plays an important role in the production of black bile, since it is through processing food that we produce the stuff in the first place – this is a theme that we have also found in Rufus before. Thus, Galen also distinguishes between excess of black bile that is the result of weakness of the capacity of the spleen (see below) and excess that is the result of an abnormal diet.228 In normal circumstances, the spleen deals with the consequences of the necessary intake of food that produces black bile. But this normal situation is relatively precarious: when the spleen does not function well, or when our diet is such that we put too much burden on it, there will be an excess of the pernicious substance. With regard to the composition of the spleen itself, we also find a similar notion of the basic composition of the spleen in the Hippocratic *Ancient Medicine*, where the structure of the spleen is described as spongy (σπογγοειδέα) and porous (ἀραιά), which

225 *UP* I 232–3 Helmreich (III 316–7 K).

226 *Timaeus* 72c–d.

227 Ed. Singer (1997) 305.

228 *Symp. Caus.* VII 223 K.

makes it suitable for drawing in fluids.229 With regard to other possible precedents and antagonists for Galen's depiction of the role of the spleen, Stewart has provided an extensive and useful overview.230

As we noticed, thankfully, nature in all her wisdom has equipped the spleen with the proper constitution for neutralizing the dangerous potential of black bile, given the fact that she could not have entirely prevented its production. As soon as the spleen does not function properly, however, there is disaster in the making:

ἐπεὶ δὴ τὴν ἐνέργειαν ἔχει φύσει, τὸ μελαγχολικὸν ἐκ τοῦ ἥπατος ἕλκειν αἷμα εἰς ἑαυτὸν, τούτῳ γὰρ ἐδείχθη τρεφόμενος, τῆς οὖν ἑλκτικῆς αὐτοῦ δυνάμεως ἀτόνου γενομένης, ἀκάθαρτον εἰς ὅλον τὸ σῶμα φέρεται τὸ ἐξ ἥπατος αἷμα, καὶ κατὰ τοῦτο μελάντερον αὐτοῖς γίνεται τὸ χρῶμα.231

Since [the spleen] indeed by nature has the function to draw the melancholic blood from the liver to itself – for it has been shown that it is nourished by that melancholic blood – the blood from the liver is borne through the entire body uncleansed when this attractive power has come to be weak, and for that reason the colour of those people becomes darker.

If the spleen fails, the blood maintains the level of black bile that it had after its production by the liver, and carries this black bile through the entire body, causing the whole body to become darker.232 The process of digestion produces a substance that subsequently needs to be neutralized because its darkness will otherwise dominate the entire body. This neutralization is essentially the function of the spleen.233 Stewart interprets the quoted passage in a different manner and translates the part after the first comma as 'blood draws the melancholic humour from the liver to itself, for it was shown that it receives its nourishment by this humour'.234 The idea that blood (rather than the spleen) draws the black bile to itself and is nourished by it seems to fit Stewart's notion

229 Cf. *Nat. Fac.* II 9, II 132 K, where Galen names Hippocrates and Plato as having said that the spleen cleans the blood.

230 Stewart (2016) 199 f.

231 *Loc. Aff.* VIII 377–8 K.

232 Cf. *Hipp. Elem.* 144,9–12 De Lacy; *San. Tu.* VI 254,12–14; *San. Tu.* IV,4 (VI 254 K): '… while a change to a greater darkness shows black bile to be in excess …' (tr. Johnston); also *Plen.*  VII 574,1–8 K and *Comp. Med. Loc.*XII 1003,14–1004,1 K for descriptions of all humours changing the body to their respective colours.

233 Cf. the description in *UP* I 232,14 f. Helmreich (III 316 K).

234 Stewart (2016) 191–2.

of an essentially beneficial kind of black bile, as one of the three types he distinguishes. As an interpretation of this text it does not seem tenable, though.  Second, the context here is clearly a description of the natural function of the spleen, for which we also have many parallels, some of which we discuss in this paragraph. Finally, there are other places in which Galen unambiguously states that it is the spleen itself that is nourished by the black bile (that is to say, after the black bile has undergone a certain transformation through being processed by the spleen).235

In *At. Bil.*, Galen also stated that the whole body becomes darker when the spleen is diseased. According to Galen, the greatest doctors and philosophers have therefore held that the liver is cleansed by the spleen, drawing into itself that residual part of the blood that is comparable to the lees of wine.236 Interestingly, in these passages Galen presents us with an empirical basis for his conception of the function of the spleen, namely, that we become darker all over our body when the spleen is not functioning properly. The darkness of the black bile then becomes predominant and also manifests itself on the outside. In *Nat. Fac.*, too, the spleen is said to draw the melancholic humour to itself when it is properly functioning; when it is weak, the blood will become thicker and darker because it has not been cleansed of black bile well enough, which again causes the whole body to take on a darker colour.237 In this particular passage, both yellow and black bile are depicted as residues (περιττώματα). They are natural results of the alteration that our innate heat effects on the foodstuff that we consume, and need to subsequently be broken down by the gall bladder and spleen respectively:

οἶνον δή μοι νόει γλεύκινον οὐ πρὸ πολλοῦ τῶν σταφυλῶν ἐκτεθλιμμένον ζέοντά τε καὶ ἀλλοιούμενον ὑπὸ τῆς ἐν αὐτῷ θερμασίας· ἔπειτα κατὰ τὴν αὐτοῦ μεταβολὴν δύο γεννώμενα περιττώματα τὸ μὲν κουφότερόν τε καὶ ἀερωδέστερον, τὸ δὲ βαρύτερόν τε καὶ γεωδέστερον, ὧν τὸ μὲν ἄνθος, οἶμαι, τὸ δὲ τρύγα καλοῦσι. τούτων τῷ μὲν ἑτέρῳ τὴν ξανθὴν χολήν, τῷ δ΄ἑτέρῳ τὴν μέλαιναν εἰκάζων οὐκ ἂν ἁμάρτοις …238

235 E.g. *UP* I 233,6–7 Helmreich (III 317 K); *MM* XIII,17 (X 920 K).

236 *At. Bil.* V 127 K.

237 *Nat. Fac.* II 9 (II 133 K).

238 *Nat. Fac.* II 9 (II 135 K); cf. *Foet. Form.* IV 686 K; *Symp. Caus.* VII 222 K, where Galen distinguishes three περιττώματα, namely a 'bitter' bile (πικρόχολος) that is purified by the gall bladder, a black bile cleansed by the spleen and one that is watery (ὀρρώδης) that is cleansed by the kidneys.

Imagine, then, some new wine which has been not long ago pressed from the grape, and which is fermenting and undergoing alteration through the agency of its contained heat. Imagine next two residual substances produced during this process of alteration, the one tending to be light and air-like and the other to be heavy and more of the nature of earth; the one, as I understand, they call the flower and the other the lees. Now you may correctly compare yellow bile to the first of these, and black bile to the latter …

tr. Brock

It is a tiresome job, that of being a mortal being. First of all, one has to continually consume food in order to survive – for a short while, that is. Second of all, the consumption of food requires all kinds of secondary processes, which deal with the necessary by-products of the alteration of food into nourishing blood, and which in turn require their specific organs and processes, with which again all kinds of things could go wrong, leading to a fatal disease or disorder!

Galen, in this passage, distinguishes two of these necessary by-products, each with their own distinguishing characteristics. The comparison of black bile with the lees of wine is familiar from *At. Bil.* Here too, its production is clearly depicted as a by-product of the digestive system similar to those byproducts produced with fermentation. These metaphors or analogies that Galen repeatedly gives, that of the lees of wine, but also that of the watery part that runs out of olives when they are pressed, make it clear that black bile is understood as a by-product of a process that is aimed at making something different. What is essential in these processes, is the oil, the wine or the blood. These simply happen to be hard to get. First, the watery, yeasty, slimy residue needs to be evacuated from these useful substances. Indeed, as we saw, the providence of the demiurge helps us out here:

οὔκουν ἂν ἠμέλησεν ὁ δημιουρὸς τῶν τοιούτων ζῷων ἐκκαθαίρειν τοῦ αἵματος, ὅσον ἰλύς τις αὐτοῦ καὶ τρύξ ἐστι, καθάπερ οὐδὲ τὸ πικρόχολόν τε καὶ ὀρρῶδες περίττωμα.239

The crafter of these animals, just as it did not neglect to cleanse out of the blood all the sediment and dreg, just so it did with its bilious and serous residue.

239 *At. Bil.* V 135 K; cf. *PHP* VI, 386,12–4 De Lacy (V 536 K): 'For nature, treating the production of the nutritive fluid as completed and as having its proper form, provided organs for removing the wastes: kidneys, spleen, and gall-bladder'. (tr. De Lacy)

This process, to get rid of the residues caused by the digestive process, already starts from the very inception of the human being. Even when we are still a foetus, not yet in possession of our own functional system of evacuation in the form of a fully operational spleen, nature is already getting rid of the bilious residue of the blood for us:

ἐν γὰρ τῇ κυήσει τὸ χρηστότατον ἑλκούσης αἷμα τῆς διαπλαττούσης καὶ αὐξανούσης τὸ κύημα φύσεως, ὑπολείπεται τὸ μοχθηρότατον ἐν ταῖς φλεψὶν, ὅ μετὰ τὴν ἀποκύησιν ἀποκρίνεται, καθάπερ ἐν ἑκάστῳ μηνὶ τὸ περιττόν τε καὶ ἄχρηστον, οὐ κατὰ τὸ ποσὸν μόνον, ἀλλὰ καὶ κατὰ τὸ ποιόν· ὅπερ ὡς τὸ πολὺ μελάντερόν ἐστι τοῦ κατὰ φύσιν ἔχοντος αἵματος.240

The nature that shapes and augments the embryo during pregnancy draws the most useful blood and leaves behind in the veins the worst blood, which is secreted after birth like each month the superfluous and obsolete blood, not only with respect to quantity but also with respect to quality; this blood indeed is much darker than the blood we naturally have.

Even while still in the womb, black bile is separated out of the blood that is used to shape the foetus, and left behind in the body of the mother, who takes care of its evacuation. Before we are born, our mothers deal with the consequences of our need for nourishment. This indicates that there is no moment for a human being in which black bile is not produced as a by-product or residue of the processes that ensure its survival. And this by-product is always dangerous. As Galen remarks in *UP*, nature made sure that the organs involved in digestion have small nerves that perceive causes of pain, so that these can be disposed of. He then says that if these organs were not able to perceive in such a way, 'they would all, I think, be easily ulcerated, eaten away, and putrefied by the daily supply of residues flowing into them', since even now, with this capacity in function and the organs equipped to get rid of acrid and pungent residues straight away, they are still 'ulcerated, abraded, eroded and putrefied by pure bile, either yellow or black'.241 It is a finely balanced organism, our body, and in its very own depths continuously lurk detrimental substances out to destroy it.

240 *At. Bil.* V 137–8. Cf. *HNH* 32,20 (XV 59 K) and 50,10–16 Mewaldt (XV 94 K); *PHP* 510,29–512,4 De Lacy (V 686–7 K), where Galen approvingly cites from the Hippocratic *On the Nature of Man* a passage that states that man was born with all four of the humours.

241 *UP* 274,14–279,5 Helmreich (translations May).

Galen mentions yellow and black bile together here, as dangerous residues. In *Nat. Fac.*, as we have seen, the yellow bile is also defined as another residue besides the black bile, but analogous to what is called the 'flower' in wine-production. The two residues are described in opposite terms. The yellow bile is light and air-like. That is to say, of such quality that it would tend upward towards the heavens. The black bile is, as usual, described rather as heavy and earth-like, that is to say, of such nature that it would tend downward towards the earth. Thus, in the production of these residues, the digestive system displays a kind of vertical cosmological schema, a reproduction of the entire elemental gamut, to which we shall return in the next paragraph. For now, let us also recall that blood, the production of which is the essential aim of the digestive system, has an exceptional position among the humours and is considered to be 'well-mixed' or a mixture of all the humours, that is to say: a mean.242 In fact, in one passage in *Nat. Fac.*, Galen defines the other humours as the result of a disproportionate amount of innate heat in the veins:

ἀποδέδεικται γὰρ ἐκείνοις τοῖς ἀνδράσιν ἀλλοιουμένης τῆς τροφῆς ἐν ταῖς φλεψὶν ὑπὸ τῆς ἐμφύτου θερμασίας αἷμα μὲν ὑπὸ τῆς συμμετρίας τῆς κατ΄αὐτήν, οἱ δ΄ ἄλλοι χυμοὶ διὰ τὰς ἀμετρίας γιγνόμενοι …243

It has been demonstrated by these men that when the nutriment in the veins is altered by the innate heat in the right proportion, blood comes to be, while the other humours come to be because of disproportion.

Here, the humours as such seem to be the result of something gone wrong. This might seem paradoxical, given that Galen also repeatedly emphasizes that we contain all humours at all times. However, Galen expresses this notion in other works as well, and it may simply imply that *there is always something going wrong*, which does not seem implausible to me at all.244 On the contrary, it seems likely that the amount or intensity of innate heat is *normally* not perfect. The right amount would vary according to a myriad of factors, such as the type of food that is digested, one's individual constitution, the season, one's share of exercise, one's mental state, the climate etc. Would it always be completely proportionate, this passage seems to suggest, then we would

242 *HNH* 46,31–47,3 Mewaldt (XV 88 K), more on this below.

243 *Nat. Fac.* II 8 (II 117 K), Galen agrees with 'these men', as is clear from the context.

244 Cf. *San. Tu.* IV, 4 (VI 255–7 K), where the three other humours are explained as a kind of deviations from the mean of concoction, the result of which is blood; cf. Klibansky et al (1964) 50: 'Die völlige Gesundheit war ein Ideal, dem man sich annähern, das man jedoch niemals tatsächlich erreichen konnte'. See also their note 27.

produce only blood and not the other humours.245 There is some precedent for this notion of the humours in Aristotle, as we have seen, but also in Plato's *Timaeus*. There is a passage in the *Timaeus* – again, which Galen knew intimately – in which Timaeus speaks of a blood that has 'a multitude of colors and bitter aspects', and that will contain 'bile and serum and phlegm of every sort'. This is a specific kind of blood in the story of Timaeus: it has received waste from flesh that is in a bad shape. Its description, however, might be close to Galen's notion of blood as a mixture of the humours (it has a multitude of colors and aspects). The description in the *Timaeus* of these other humours is extremely negative, they are described as 'παλιναίρετα', 'back-products' and 'διεφθαρμένα', 'agents of destruction', which do not supply the body with any nourishment. They are 'hostile to one another' and 'wage a destructive and devastating war' against the parts of the body that are properly functioning.246 Elsewhere, Galen approvingly quotes the passage from the *Timaeus* in which Timaeus differentiates between two kinds of serum (ἰχὼρ), one being the gentle, watery kind of blood (ὁ μὲν αἵματος ὀρρὸς πρᾷος), the other being the sharp and malignant kind of black bile (ὁ δὲ μελαίνης χολῆς ὀξείας τε ἄγριος).247 Galen, of course, systematizes Plato's remarks somewhat to fit his humoural theory: what Plato said here, is that black bile is the most harsh (χαλεπώτατος) of the humours, while blood is the most suitable or good (ἐπιεκέστατος). Galen himself never describes the three other humours in such negative terms in such a general way as in the *Timaeus*, but this particular passage fits very well with his opposition between blood and black bile, his notion of a pure and a mixed blood, and with the exceptionally beneficial nature of blood compared to the other humours. In fact, he also sets out the distinction between these two ways in which the word blood is used in his explanation of the passage from the *Timaeus*: one is separate from the other humours and the other is mixed with it.248 Certainly, passages such as the one from *Nat. Fac.* quoted above, do seem to suggest that according to Galen these other humours are produced because it just cannot be helped, rather than because they are so beneficial in themselves. Better beings than ourselves, such as the stars, do not have our humours since they do not need to continuously nourish their constitution in a way that

245 Cf. *PHP* VIII, 504,1–2 De Lacy (V 677 K): 'The balanced mixture of all four elements generates blood in the precise sense'.

246 *Timaeus* 82e–83a, translations Zeyl.

247 *Timaeus* 83c, Galen quotes and discusses it in *Hipp. Epid. VI* XVIIA 983,6 f. K; he also quotes and discusses the broader passage in *Adv. Jul.* VIIIA 260,7 f. K.

248 *Hipp. Epid. VI* XVIIA 984,5–8 K: 'ἀλλ΄ ἐπειδὴ διττῶς τὸ αἷμα λέγομεν, ἐνίοτε μὲν ἀντιδιαιρούμενον πρὸς τοὺς ἄρτι λελεγμένους χυμούς, ἐνίοτε δὲ κατ΄ ἐπικράτειαν ὅλον τὸν ἐν τοῖς ἀγγείοις χυμόν'.

causes by-products. It might well be, in our case, that these humours serve a function within the (digestive) system of our bodies, but that is only already assuming the fundamental imperfection (the continuous need for nourishment) that made their generation necessary in the first place.

But is this idea of something going wrong all the time with our body, as such, not terribly incongruent with Galen's general teleological framework in which nature produces well-designed beings? Let us have a look at the following passage from *UP*, Galen's teleological work *par excellence*:

μάλιστα μὲν γάρ, εἴπερ οἷόν τ΄ἦν, ἄνευ παντὸς κακοῦ κατεσκεύαστ΄ ἂν ἅπαντα ταῦτα· νυνὶ δέ, οὐ γὰρ ἐνδέχεται τῆς ὕλης φυγεῖν τὴν μοχθηρίαν οὐδεμιᾷ τῶν τεχνῶν οὐδ΄ ἀδαμάντινόν τε καὶ πάμπαν ἀπαθὲς ἐργάσασθαι τὸ δημιούργημα, καταλείπεται κοσμεῖν αὐτὸ τὸν ἐνδεχόμενον κόσμον. ἐνδέχεται δ΄ἄλλον ἄλλη τῶν ὑλῶν· οὐ γὰρ ἐκ τῆς αὐτῆς δήπουθεν οὐσίας τά τ΄ἄστρα γέγονε καὶ ἡμεῖς.249

Surely if it had been possible, she [nature] would have arranged all these matters with no drawbacks at all, but as it is, since it is impossible with all her arts to avoid the inadequacies of her material and to make her creations of adamant, entirely invulnerable, it remains for her to arrange them as best as she can. Different materials admit of different arrangements; for certainly we are not made of the same substance as the stars. tr. May

Indeed, immediately following this passage, Galen elaborates upon some of these drawbacks. He proceeds to discuss the use, necessity, and manners of alteration and evacuation of the various humours (except for blood, since it is not a περίττωμα). The humours are there because we are not like the stars. This notion of not being like the stars is far from uncommon in Galen, and we shall return to it in the next section. For now, let us focus again on the spleen. Once the melancholic blood has been drawn to the spleen, the potential

249 *UP* I 260,5–13 Helmreich (III 355 K). Cf. Hankinson (2008) 228; see also *UP* I 174–5 Helmreich: 'Then do not wonder so greatly at the beautiful arrangement of the sun, moon, and the whole chorus of stars, and do not be so struck with amazement at the size of them, their beauty, ceaseless motion, and ordered revolutions that things here on earth will seem trivial and disorganized in comparison; for here too you will find displayed the same wisdom, power, and foresight. Consider well the material of which a thing is made, and cherish no idle hope that you could put together from the catamenia and semen an animal that would be deathless, exempt from pain, endowed with never-ending motion, and as radiantly beautiful as the sun'. (tr. May)

300 Case-Study IV

danger of black bile is not yet resolved. After all, were this the end of it, most of the black bile would just pile up in the spleen itself, presumably leading to a giant cancer and other unspeakable horrors. As we have mentioned above, some of it is altered into nutriment for the spleen itself. The rest is disposed of in the stomach after which it has to be discharged, partly through the vomiting that accompanies nausea and partly through the stools.250 This process of discharge is the *normal* course of events, it is not merely a description for those that are already affected by an excess of black bile. There needs to be a continuous evacuation of the stuff. Presumably, this entails that our stools normally contain black bile that has been drawn from the blood by the spleen, and has then been evacuated to the stomach after a process of alteration.251 When these evacuations are not properly performed and the black bile piles up, melancholy is the result:

καὶ χωρὶς δὲ τῆς τοιαύτης κενώσεως, ἀθυμίας τε καὶ δυσθυμίας μελαγχολικὰς ἐργάζεται …252

And without this evacuation, despondency and melancholic depression arise.

Melancholy can be a direct result of the inability to neutralize the potentially dangerous side-effects of normal digestive processes due to a weakness of the spleen. That is to say: if it were not for the continuous cleansing activity of our spleen, *ceteris paribus*, we would be naturally in a state of melancholy. In other words, *the spleen is making up for the tragic fact that we are not like the stars*.

Before we turn to discuss Galen's analysis of the condition of melancholy itself, we shall have a final look into the dark substance of its cause, now with less focus on its physiological reality, and more attention for the specific associations it evokes, for what we could call its spectrum of meaning.

#### **2.6** *The End of Summer*

The season of black bile, the time when it is most predominant, is autumn. Its abundance is prepared in the period before that, in summer, when the days are longest and the sun shines most vigorously, drying and heating everything

250 *Loc. Aff.* VIII 378,5–9 K.

251 Cf. *MM* XIII,17, X 921 K, where Galen mentions that the purging of superfluities from the spleen happens 'via the stomach alone', which corresponds to the two normal processes of purgation through stools and vomiting in the case of nausea.

252 *Loc. Aff.* VIII 378 K.

beneath it. In the summer, blood is still strong in the body, since it is the season following spring, but the bile increases:

τοῦ δὲ θέρος τὸ τε αἷμα ἰσχύει ἔτι καὶ ἡ χολὴ ἀείρεται ἐν τῷ σώματι καὶ παρατείνει ἐς τὸ φθινόπωρον. ἐν δὲ τῷ φθινοπώρῳ τὸ μὲν αἷμα ὀλίγον γίνεται· ἐναντίον γὰρ αὐτῷ ὸ φθινόπωρον τῇ φύσει ἐστίν. ἡ δὲ χολὴ ἡ θερινὴ κατέχει τὸ σῶμα καὶ τὸ φθινόπωρον.253

In summer blood is still strong, and bile increases in the body and lasts until autumn. In the autumn, the blood becomes small in quantity, since autumn is opposite to it by nature. The bile of summer also dominates the body in the autumn.

tr. Hankinson

The bile remains in autumn, after the heat recedes. As autumn approaches, the amount of blood decreases. The moisture has been driven out because of the heat, and what remains is the abundance of a substance that is dry and has now become cold:

ἐγένετο δ΄ εἰκότως τοιοῦτος διὰ τὸ προκατωπτῆσθαι τοὺς χυμοὺς τῷ θέρει. τὸ δ΄ ὑπόλειμμα τῶν ὀπτηθέντων, ὅταν δηλονότι σβεσθῇ τὸ θερμόν, αὐτίκα γίνεται ψυχρόν τε καὶ ξηρόν, ψυχρὸν μὲν διὰ τὴν τοῦ θερμοῦ σβέσιν, ξηρὸν δέ, ὅτι κατὰ τὴν ὄπτησιν ἐξεδαπανήθη πᾶν τὸ ὑγρὸν ἐξ αὐτοῦ.254

And it is reasonable that such a humour arises as a result of the cooking of the humours during the summer. The residue of this cooking, when the hot has been thoroughly quenched, then becomes cold and dry, cold as a result of the quenching of the heat, dry because the process of cooking has driven out all of the moisture from it.

tr. Hankinson, slightly modified

What we have in autumn, is a kind of remainder of summer, the bile that persists after the sun has departed. In fact, autumn is literally described as the end of summer in ancient Greek: it is composed of a combination of the verb φθίω, 'to perish, decline, decay, die' and the word ὀπώρα, 'summer' (for which θέρος is more common) or 'the latter part of summer' and also 'fruit'. The combination of these two words designate autumn as a kind of death of summer, or the time

253 *HNH* 44,25 Mewaldt (XV 84 K) – Galen quotes this from the Hippocratic text.

254 *HNH* 45,27–30 Mewaldt (XV 86 K).

302 Case-Study IV

when the fruits of summer decay. One might recall Rufus' words here, saying that excess of heat 'renders the humours black, just as the sun blackens fruits and human bodies'.255 The notion of excessive heating is already developed in Rufus, but he mostly relates melancholy to spring, rather than the period after summer, which might make more sense in this context of overheating and then cooling down.256 Galen's rendering of yellow bile being dominant in summer, while black bile already increases then and becomes dominant after summer, seems to have a parallel in the schema presented in a text from the *Medical Excerpts* by Paul of Aegina, that is there presented as a letter from Diocles (whose work Galen was familiar with) to a king Antigonus. The authenticity of this text is subject to debate, so we cannot be sure if it hails from Diocles himself.257 In this letter, it is noted that after the rising of the Pleiads, which would be around the end of April or early May, yellow bile increases until the summer solstice. The summer solstice, in turn, would have been around the 22nd or 23rd of June, and it is said that after this period the black bile starts to increase until the autumn equinox, which would be around the end of September.258 This corresponds well to the notion that black bile is produced in the latter part of summer so that it is predominant in autumn.

Walter Müri has noted that there is a parallel between the development of black bile as a separate substance – that is to say, the division of 'bile' into a yellow and black bile – and an expansion of the number of seasons from three to four – that is to say, the division of summer into summer and autumn. Somewhere in the 6th century, autumn (φθινόπωρον) was added to the already existent χειμών, winter, ἔαρ, spring and θέρος, summer, as the latter part or end of summer.259 This is an interesting parallel indeed, especially considering that yellow and black bile remain so closely related in Galen, and considering that Galen repeatedly remarks that the Greeks, when they speak of χολή, 'bile', simply, refer to the yellow bile, whereas if they want to indicate the black bile, the word for bile needs to be further specified with the additional μέλαινα, 'black'.260 That is to say, just as there previously was only a summer and there is now a summer and an end or decay of summer, there previously was only

255 *On Melancholy* Fr 11,21 Pormann (2008), see also Fr 75,3.

256 In the Hippocratic *Aphorisms*, quoted by Galen in *PHP* VIII 516,24–5 De Lacy, melancholy is also said to abound in spring, although it is again said to abound in autumn as well.

257 Cf. for text, translation and commentary of the text, van der Eijk (2001) fr 183A, specifically lines 107 ff.

258 Ibidem, also for the dating of these periods.

259 Müri (1953) 28.

260 *SMT* XII 275,13–8 K; *HVA* XV 637,8–10 K; *Hipp. Epid. VI* XVIIB 271,6–7 K; *Hipp. Aph.*  XVIIIA 132,12–5 K; *HNH* 40,10–5 Mewaldt (XV 75 K).

bile, while there now is also a degenerated bile that is a remnant of an excess of heat.

One notices that there is something negative or privative about the description of autumn: it is primarily understood as a negation of what precedes it.261 The description of its coming to be is remarkably similar to the production of black bile itself, which comes to be when, during digestion, there is too much innate heat so that instead of blood, black bile is produced. Likewise, in summer, there is excessive heat so that the amount of blood diminishes and that of black bile increases. Clearly, since fruits and summers are generally good things, this description implies a negative characterization of autumn, just as Galen sees the production of black bile as a deviation from the production of blood. The mere fact that this production is common, does not make it less of a deviation in this sense.

Another thing to note in this regard is that the qualities of black bile and of autumn are coldness and dryness. These are – in this specific combination – the qualities of death as well, since that is what we become when we die, or better: it is what the *remainder* of us becomes, after the life has flowed from our bodies. This is, in fact, a point that is noted by Galen in the context of a presentation of the position of followers of Athenaeus. They apparently claim that one of the four pairings of elemental qualities, hot and wet, is superior to the others, does not cause any illness, and is as such the best mixture and the mixture of life.262 They conclude this on the basis of the characteristics of death, which are the exact opposite:

καὶ μὲν δὴ καὶ τὸν θάνατόν φασιν εἰς ξηρότητα καὶ ψῦξιν ἄγειν τὰ τῶν ζῴων σόματα. καλεῖσθαι γοῦν ἀλίβαντας τοὺς νεκροὺς ὡς ἂν οὐκέτι λιβάδα καὶ ὑγρότητα κεκτημένους οὐδεμίαν, ἐξατμισθέντας θ΄ ἅμα διὰ τὴν ἀποχώρησιν τοῦ θερμοῦ καὶ παγέντας ὑπὸ τῆς ψύξεως.263

Furthermore, they state that death leads to dryness and cooling in animal bodies; and indeed, [they argue], dead bodies are referred to as corpses (*alibas*), on the grounds that they no longer possess any moisture (*libas*) and wetness, having at once lost their vapours because of the departure of the hot, and having been solidified by the cooling.

tr. Singer and van der Eijk

261 The exact same point applies to the stage of life which is associated with the black bile: ἡ παρακμή, literally the time past the prime, also indicating a time of decay (cf. *Hipp. Prog.*  XVIIIB 282,10–1, *Temp.* I 641,4–7 K).

262 *Temp.* I 522–3 K.

263 *Temp.* I 522,15–523,2 K.

304 Case-Study IV

If death is characterized by the qualities of dryness and coldness, then life must be characterized by their opposites, wetness and hotness. Thus, spring is well-tempered, because it 'consists in nothing other than the domination of these two qualities', as Galen presents the position of these followers of Athenaeus. Galen himself takes issue with this argument, since spring, according to him, is not characterized by a predominance of hot and wet in the same way in which winter, for example, is characterized by wet and cold. Rather, spring does not possess any of its qualities in a disproportionate sense – this, according to Galen, is what it means to be well-balanced. Galen defines spring rather as a precise middle with regard to all extremes.264 He approvingly quotes from the Hippocratic *Aphorisms* the saying that 'Spring is most healthy and least fatal'. But whereas he takes issue with the way spring is characterized by the followers of Athenaeus in terms of the predominance of wetness and hotness, he does not take any issue with their opposition of spring and autumn and their accompanying associations of life and death or health and disease respectively. In fact, he notes a particular problem with autumn – it is most conducive to illness, due to its irregularity of mixture:

καὶ τοῦτο γ΄ ἐστὶ τὸ μάλιστα νοσῶδες ἐργαζόμενον τὸ φθινόπωρον, ἡ ἀνωμαλία τῆς κράσεως. οὐκ ὀρθῶς οὖν εἴρηται ψυχρὸν καὶ ξηρόν, οὐ γάρ ἐστι ψυχρὸν αὐτὸ καθ΄ αὑτὸ θεωρούμενον, ὥσπερ ὁ χειμών, ἀλλὰ τῷ θέρει παραβαλλόμενον ἐκείνου ψυχρότερον. οὐ μὴν οὐδ΄ ὁμαλῶς εὔκρατον, ὡς τὸ ἔαρ, ἀλλ΄ ἐν τούτῳ δὴ καὶ μάλιστα διενήνοχεν ἐκείνης τῆς ὥρας, ὅτι τὴν εὐκρασίαν τε καὶ τὴν ὁμαλότητα διὰ παντὸς ἴσην οὐ κέκτηται.265

And it is this that makes autumn so particularly conducive to sickness: the unevenness of the mixture. It is not, therefore, correctly called cold and dry; for it is not cold when one considers it in itself, like winter, but only colder when compared with summer. Nor, on the other hand, is it evenly well-mixed, like spring, its chief difference from that season being that it does not possess an equal good-mixture and evenness throughout. tr. Singer and van der Eijk

Again, we find autumn defined in opposition to spring, in clearly negative terms. Whereas spring is well-tempered and evenly balanced, autumn is defined by the absence of these very qualities. Also, it is again defined negatively in terms of its precedent, summer: it is not cold in itself but only compared to summer.

264 *Temp.* I 524–7 K, in 526,16–17: 'φανεῖται τὸ ἔαρ ἀκριβῶς μέσον ἀπασῶν τῶν ὑπερβολῶν'.

265 *Temp.* I 527,13–528,5 K.

This opposition between spring and autumn is the same opposition as the one between blood and black bile, both pairs are opposed because of their respective mixture.266

We noticed earlier that the amount of blood decreases as the amount of bile increases, and that the amount of blood is least in autumn, since 'autumn is opposite to it by nature'. This was a text that Galen quoted from the Hippocratic *On the Nature of Man* itself. In his commentary on the Hippocratic text, Galen adds the following:

κατὰ μὲν τὴν πρὸ ταύτης ῥῆσιν εἴρηται ἐν τῷ φθινοπώρῳ τὸ μὲν αἷμα ὀλίγον γίνεσθαι· ἐναντίον γὰρ αὐτοῦ τὸ φθινόπωρον τῇ φύσει ἐστίν. ἡμεῖς δέ, ὅπως ἐναντίον ἐστίν, ἐδιδάξαμεν· εἴπερ γὰρ τὸ μὲν αἷμα θερμὸν καὶ ὑγρόν ἐστιν ὁμοίως τῷ ἦρι, τὸ δὲ φθινόπωρον, ὡς αὐτὸς ἔφη, ξηρόν τέ ἐστι καὶ ψύχειν ἤδη ἄρχεται τὸν ἄνθρωπον, εἰκότως ἐναντίον τέ ἐστι τὸ φθινόπωρον τῷ ἦρι καὶ τὸν χυμὸν ἔχει τὸν ἐναντίον τῷ αἵματι πλεονάζοντα, τὸν ξηρὸν καὶ ψυχρόν.267

In the preceding passage he said that 'In the autumn, the blood becomes small in quantity, since autumn is opposite to it by nature'; and we will explain in what way it is opposite. For if indeed blood is hot and wet in the same way as spring, then autumn, as he said, is dry, 'and man already begins to cool down', and it is reasonable both that autumn is opposite to spring, and involves an excess of the humour opposite to blood, namely one that is dry and cold.

tr. Hankinson, slightly modified

Autumn is opposite to spring and black bile is opposite to blood, by virtue of their respective pairs of elemental qualities being opposites. We noticed earlier, however, that blood has quite an exceptional status among the humours. We saw how Galen considers blood, if not the 'sole constituent' of human nature, then at least 'most closely affiliated to it' (οἰκειότατος).268 We also noticed how blood is produced when the ideal amount of innate heat is used in the process of digestion, whereas the other humours are produced as by-products when the amount is too great or too small.269 Indeed, blood and spring are attributed by Galen the same exceptional status:

266 Cf. also *PHP* 514,16–31 De Lacy.

267 *HNH* 45,15 Mewaldt (XV 86 K).

268 *HNH* 44,24 Mewaldt (XV 78 K); cf. *SMT* 617,1–8 K (blood is 'ὁ τοῖς ἀνθρώποις οἰκειότατος χυμὸς'); *Hipp. Epid. III* XVIIA 534,13–535,1 K, Galen ascribes to Hippocrates the view that blood is ἀδηκτότατον καὶ μάλιστα οἰκεῖον ἡμῖν, least biting and most natural to us.

269 *Nat. Fac.* II 8 (II 117 K) and *San. Tu.* IV 4 (VI 255–7 K).

ἔστι μὲν οὖν τις οὐ σμικρὰ ζήτησις καὶ περὶ τῆς τοῦ ἦρος κράσεως, ὅπως λέγεται θερμὸν καὶ ὑγρόν, ἣν διῆλθον ἐπιδεικνὺς ἄμεινον εἶναι λέγειν εὔκρατον αὐτό· καὶ δῆλον ὅτι καὶ τὸ αἷμα κατὰ τὸν αὐτὸν λόγον οὐ θερμὸν καὶ ὑγρόν, ἀλλ΄ εὔρκρατον.270

Yet the investigation concerning the mixture of spring – in what way it is hot and wet – is no trivial one, which I have already covered when I indicated that it is better to call it 'well-tempered'. And clearly by the same argument, blood too will not be really hot and wet, but well-tempered.

tr. Hankinson

Instead of having a pair of qualities that predominate, like in each of the other humours and seasons, blood and spring are rather described as 'welltempered'. In another passage in *HNH*, Galen makes a comparison between spring and autumn in which he calls spring 'the best of seasons' and 'the only one properly natural, as opposed to the one contrary to nature'.271 How odd, that one of the four seasons, which do seem to form a balanced natural order together, is said to be contrary to nature. What does it mean for the black bile itself, that blood and spring are the humour and season that black bile and its season are opposed to? Blood and spring are both defined as exceptionally beneficial, useful, healthy, moderate and close to our nature. If black bile and autumn are opposed to them, their characteristics must, to some extent at least, be opposed to those as well.272 Galen's commentary on the Hippocratic *On the Nature of Man* is one of the main texts in which we find this opposition between black bile and autumn on the one hand, and blood and spring on the other. This means that in Galen's most systematic continuation of Hippocratic humoural theory, black bile is not simply one humour among others. It is the worst of the humours, whereas blood is the best. Moreover, it appears to even be contrary to nature somehow, while at the same time being a part of it. Could it be, that black bile is both part of our nature and simultaneously contrary to it?

As we have noticed, black bile is often described by Galen as the sediment of the blood, as the nasty by-product that one needs to get rid of, like with the lees of wine or the watery part of olives: we are just stuck with those and have

270 *HNH* 46,31–47,3 Mewaldt (XV 88 K).

271 *HNH* 44,9 ff. Mewaldt (XV 83 K), translation Hankinson.

272 Cf. Klibansky et al. (1990) 51–3 on the opposition of blood and black bile and their exceptional position in the fourfold humoural theory.

to remove them if we want those fine products of wine and olive oil. In the following passage these two opposites are also clearly brought together:

τῶν δὲ χυμῶν ὁ μὲν χρηστότατός τε καὶ οἰκειότατός ἐστι τὸ αἷμα. τούτου δ΄οἷον ὑπόστασίς τις καὶ ἰλὺς ἡ μέλαινα χολή· ταῦτ΄ ἄρα καὶ ψυχροτέρα τ΄ ἐστὶ καὶ παχυτέρα τοῦ αἵματος.273

Of humours, the most useful and natural is blood. Black bile is a kind of sediment or dreg of this; it is thus colder and thicker than blood. tr. Singer, modified

Again, blood is the most useful of the humours and the one that is most congenial to us, while black bile is merely a dreg that is carried along by the blood and that needs to be evacuated from it.274 As we have seen above, yellow bile can also be understood as a by-product of the production of blood, and was involved in the same wine-metaphor as black bile. Black bile has much in common with yellow bile and can even be seen as an altered continuation of the same substance, as became clear in the context of the discussion of the seasons and their respective humours, as well as in the context of the dangerous black bile that is a burned yellow bile. However, black bile is in some ways opposed to yellow bile as well. Let us have another look at the passage from *Nat. Fac.* we quoted earlier:

οἶνον δή μοι νόει γλεύκινον οὐ πρὸ πολλοῦ τῶν σταφυλῶν ἐκτεθλιμμένον ζέοντά τε καὶ ἀλλοιούμενον ὑπὸ τῆς ἐν αὐτῷ θερμασίας· ἔπειτα κατὰ τὴν αὐτοῦ μεταβολὴν δύο γεννώμενα περιττώματα τὸ μὲν κουφότερόν τε καὶ ἀερωδέστερον, τὸ δὲ βαρύτερόν τε καὶ γεωδέστερον, ὧν τὸ μὲν ἄνθος, οἶμαι, τὸ δὲ τρύγα καλοῦσι. τούτων τῷ μὲν ἑτέρῳ τὴν ξανθὴν χολήν, τῷ δ΄ἑτέρῳ τὴν μέλαιναν εἰκάζων οὐκ ἂν ἁμάρτοις …275

273 *Temp.* I 603,8–11 K; cf. *Comp. Med. Gen.* XIII 667,15–8 K, where a red and useful blood is contrasted to a black and melancholic blood (οὔτε ἐρυθρὸν οὔτε χρηστὸν αἷμα περιέχειν, ἀλλὰ μελάντερον καὶ μελαγχολικώτερον).

274 As we have seen before, the term for dreg, ἰλὺς, is also used by Galen in *At. Bil.* to describe black bile; in *MM*, the adjectives ἰλυῶδες and μελαγχολικόν are used together to describe the part of the blood that is cleansed by the spleen, *MM* XIII,17 (X 920 K).

275 *Nat. Fac.* II 9 (II 135 K); cf. *Foet. Form.* IV 686 K; *Symp. Caus.* VII 222 K, where Galen distinguishes three περιττώματα, namely a 'bitter' bile (πικρόχολος) that is purified by the gall bladder, a black bile cleansed by the spleen and one that is watery (ὀρρώδης) that is cleansed by the kidneys.

308 Case-Study IV

Imagine, then, some new wine which has been not long ago pressed from the grape, and which is fermenting and undergoing alteration through the agency of its contained heat. Imagine next two residual substances produced during this process of alteration, the one tending to be light and air-like and the other to be heavy and more of the nature of earth; the one, as I understand, they call the flower and the other the lees. Now you may correctly compare yellow bile to the first of these, and black bile to the latter …

tr. Brock

The descriptions of these residual substances are opposed to each other: yellow bile tends to be light and air-like, whereas back bile is heavy and earthy. Here we have the traditional opposition between heaven and earth associated with the two biles, understood as the two by-products of digestion. What would be the role of the wine itself in this analogy? Obviously, the wine is the essential product, it is what the entire process is about. In the process of digestion, this is the blood. Blood, as we saw, is defined as the well-mixed mean and that which is closest to our nature. Blood holds a perfect middle position between the extremes. In this respect it is interesting to note that Galen on several occasions names wine as a remedy to melancholy. In *QAM*, he states that the daily consumption of wine relieves us of all sorrow and despondency (λύπης δ΄ ἁπάσης καὶ δυσθυμίας κουφίζει σαφῶς οἶνος πινόμενος).276 Indeed, Galen says this in a context in which he has just given melancholy as an example of the body (i.e. the brain particularly) causing damage to the rational capacities, and he also proceeds to present Zeno of Citium as an example of the beneficial effects of daily wine-drinking (alluding to his reportedly melancholic behaviour when sober).277 It seems there is more to the metaphor than black bile and yellow bile being comparable to the two by-products of the lees and the flower. The essential product, the wine itself, also has the tendency to produce affections in us that are opposed to the ones that black bile produces. Indeed, in another passage, Galen compares the end-product, the wine, to useful blood.278 Clearly,

276 Galen, in *QAM* IV 777 K, cf. 779 K, where he notes that 'one who drinks wine in moderation' has characteristics opposite to those of the melancholic, who is λυπηροτέραν καὶ ἀτολμοτέραν καὶ ἀθυμοτέραν.

277 See infra, note 124.

278 Cf. also *UP* 197,18–198,10 Helmreich (III 270 K): 'Let us, then, compare the chyle to wine just pressed from the grapes and poured into casks, and still working, settling, fermenting, and bubbling with innate heat. The heavy, earthy part of its residues, which I think is called the dregs, is sinking to the bottom of the vessels and the other, light, airy part floats. This latter part is called the flower and forms on the top of light wines in particular,

there is a double opposition here, between black bile and blood on the one hand, and between black bile and yellow bile on the other.

Blood, as the mean between those extremes, suits us. Human beings, in the Greek philosophical tradition, are defined as being in between heaven and earth: we are intelligent, like the heavenly bodies, but we do not have a substance as pure as those bodies, since we also consist of water and earth.279 Black bile is the earthy humour, the sediment in the blood, the heavy humour that weighs us down and binds us to the earth – it literally makes us depressed when it predominates. Yellow bile, on the other hand, is associated with the heavenly bodies, it is described as fiery and light, naturally tending in the opposite direction of the black bile, it is dry and hot like the stars.280 Galen also states that it causes intelligence, in a passage in *HNH* that refers to *QAM*, where intelligence was said to be caused by dryness, the quality that the stars possess to the extreme.281

whereas the dregs are more abundant in heavy wines. In making this comparison, think of the chyle sent up from the stomach to the liver as bubbling and fermenting like new wine from the heat of the viscus and beginning to change into useful blood; consider too that in this effervescence the thick, muddy residue is being carried downward and the fine, thin residue is coming like foam to the top and floating on the surface of the blood'. (tr. May)

310 Case-Study IV

Black bile is also dry, of course, but its dryness is nothing but a remainder of the heat of summer, as we have seen. It is there when the fire dies out. I think there is no doubt that we here have a link to the traditional relation between thinking and melancholy that we found in Rufus and the Peripatetic tradition as well. Intelligence is at its peak during summer since it is caused by yellow bile, which predominates in summer. But after this peak of activity of the intellect, a low point follows: the heat that inspired intelligence cools and a dark substance that is the cause of melancholy perseveres. Indeed, one might think here of the bipolar-like descriptions of melancholy from the *Problemata*. The only essential difference is that the cooling and heating of black bile is now further divided over two substances, the dry and hot yellow bile that increases intellectual activity, and the dry and cold black bile that increases sadness. But it might perhaps be more useful to have a somewhat broader association: what is depicted with these different substances is not so much a recurrent bipolarlike disorder that befalls exceptional people, but rather simply the fact that we, as human beings, are beings that relate ourselves in fundamental ways to both heaven and earth. Naturally, both of these extremes would have a place in our physical constitution, naturally we would swing from one to the other regularly, and naturally we would be most at ease when we rather produce that which essentially fits us and is closest to our nature: the mean, i.e. blood. With the transition from summer to autumn, from yellow bile to black bile, our substances change from something that is more similar to the heavenly bodies to something that is more similar to earth, as if portraying the course of a falling star which loses its heat as it descends. As we have seen, Galen considers black bile as one of the 'drawbacks' of the fact that nature needs to work with a matter that makes it impossible to make us like the stars, which are predominantly dry and hot. Likewise, we have argued how Aristotle attributed to the melancholic's constitution a particular sensitivity for the fact that we are not divine but composite beings. Both in Aristotle and in Galen the heavenly bodies serve as the embodiment of the divine *par excellence*, and in Galen black bile is the substance that is most opposed to the stars. In fact, it has the qualities of a star that has fallen to earth: it used to be hot, and therefore it is dry, but then it cooled down and therefore it blackened and now resembles thick earth. Galen links the very presence of residues such as black bile in our body to a necessary constraint presented to creative nature by matter. The fact of this matter implied certain drawbacks: it made it so that divine nature could not make us like the stars, as he remarks.282 That is to say, the fact that we are not capable of a divine life and are in a state of pain qua living beings – again, an idea that we

282 *UP* I 260,5–13 Helmreich (III 355 K).

previously found in Aristotle in the context of his discussion of melancholy – could be related in Galen to the fact that our matter determines that we cannot not be like the heavenly bodies. Indeed, this is what Galen says in *UP*:

μὴ τοίνυν, ὅτι καλῶς ἥλιός τε καὶ σελήνη καὶ τῶν ἄλλων ἄστρων ὁ χορὸς ἅπας διατέτακται, θαυμάσῃς, μηδ΄ἐκπλήξῃ σε τὸ μέγεθος αὐτῶν ἢ τὸ κάλλος ἢ τὸ τῆς κινήσεως ἀκατάπαυστον ἢ ἡ τῶν περιόδων τάξις, ὥστε τὰ τῇδε παραβάλλοντα σμικρὰ δοκεῖν εἶναι καὶ ἀκόσμητα· καὶ γὰρ σοφίαν καὶ δύναμιν καὶ πρόνοιαν ὁμοίαν εὑρήσεις ἐνταυθοῖ. σκόπει γάρ μοι τὴν ὕλην, ἐξ ἧς ἕκαστον ἐγένετο, καὶ μὴ μάτην ἐλπίσῃς ἐκ καταμηνίου καὶ σπέρματος ἀθάνατον δύνασθαι συστῆναι ζῷον ἢ ἀπαθὲς ἢ ἀεικίνητον ἢ λαμρὸν οὕτω καὶ καλόν, ὡς ἥλιον.283

Then do not wonder so greatly at the beautiful arrangement of the sun, moon, and the whole chorus of stars, and do not be so struck with amazement at the size of them, their beauty, ceaseless motion, and ordered revolutions that things here on earth will seem trivial and disorganized in comparison; for here too you will find displayed the same wisdom, power, and foresight. Consider well the material of which a thing is made, and cherish no idle hope that you could put together from the catamenia and semen an animal that would be deathless, exempt from pain, endowed with never-ending motion, and as radiantly beautiful as the sun.

tr. May

Here, the limitations of the human being compared to the heavenly bodies are explained in terms of the stuff we are made of: blood and semen. From these materials nature can only create a being in need of nourishment, which suffers pain and death, a being which lacks the light of the heavenly bodies and their unceasing motion. Black bile is one of the necessary residues of this nourishment, and seems to embody this fact of human life with its particular characteristics. It is the most heavy and earthlike humour, the one most opposed to the heavens; it is the darkest substance, lacking the light of the heavenly bodies more than anything else; it is the substance associated with death and mortality because of its qualities of coldness and dryness; and it is the most obstinate and immovable of the humours (as we shall see below).284

283 *UP* I 174,19–175,7 Helmreich (III 238 K).

284 Cf. *UP* I 175,26–176,9 Helmreich (III 239–40 K), shortly after the passage just quoted, where Galen puts particular emphasis on the earthy nature of the human being as cause of its shortcomings compared to the heavenly bodies: 'Bear it in mind and reflect whether your

312 Case-Study IV

Both in Aristotle and Galen man is understood as a being that is essentially imperfect in contrast to the divine, which, in turn, is embodied by the stars. Moreover, this imperfection is associated with the addition of 'another element', which the melancholics and the black bile seem to have a special relationship with, and which is rather opposed to the substance of the divine embodied in the heavenly bodies.285 Since we are not entirely divine, not of a star-like substance only, we suffer from the tension of being suspended between heaven and earth.

The transition from yellow bile to black bile, at the end of summer, embodies the course of this suspension, and gives its vertical hierarchy a place in the natural and regular passing of time. Therefore, this is also the time when blood, as the ideal mean, needs to be most absent. This transition from the predominance of a more heavenly substance to the predominance of the earthy black bile, happens in the time after which blood was predominant, and derails when blood recedes more and more. Then we come down, as it were, from resembling the substance of the stars closest when yellow bile is

substance is celestial light or slime of the earth, if you will permit to give such a name to the mother's blood flowing into the uterus. Then, just as you would never demand an ivory statue of Phidias if you had given him clay, so in the same way, when blood is the material you give, you would never obtain the bright and beautiful body of the sun or moon, for they are divine and celestial and we are mere figures of clay, but in both cases the art of the Creator is equally great'. (tr. May)

285 Cf. for Aristotle Met Θ 1050b23–9: 'Hence the sun and stars and the whole visible heaven are always active … Nor do the heavenly bodies tire in their activity; for motion does not imply for them, as it does for perishable beings, the potentiality for the opposite, which makes the continuity of the motion painful. The cause of this is that the substance is matter and potentiality, not actuality'. (tr. Tredennick, slightly modified); for Galen also *UP* I 260,5–13 Helmreich 'Surely if it had been possible, she would have arranged all these matters with no drawbacks at all, but as it is, since it is impossible with all her arts to avoid the inadequacies of her material and to make her creations of adamant, entirely invulnerable, it remains for her to arrange them as best as she can. Different materials admit of different arrangements; for certainly we are not made of the same substance as the stars'. (tr. May), cf. with *UP* II 446–7 Helmreich (IV 359 K): 'It is reasonable to suppose that the intelligence dwelling in them [the sun, the moon and the stars] is as much better and more perfect than that in earthly bodies as their bodily substance is the purer. For when in mud and slime, in marshes, and in rotting plants and fruits animals are engendered which yet bear a marvelous indication of the intelligence constructing them, what must we think of the bodies above?' (tr. May) Traditionally, this is not an unusual interpretation of the role of black bile and melancholy, as we find it, for example, in Burton's great *Anatomy of Melancholy* (143): 'Melancholy in this sense is the character of mortality. We are not here as those angels, celestial powers and bodies, sun and moon, to finish our course without all offence, with such constancy, to continue for so many ages …'. See also Pigeaud (1981) 125.

most predominant, being dry and hot, fiery and having our intellect at its peak, until we have reached the bottom of dark, cold, thick earth, risking sadness and despondency. According to the same analogy, black bile is dominant in the time of life after our prime (ἡ παρακμή), again a period which is literally defined negatively with regard to the preceding period, which is also the best period.286 Black bile is the residue of our ceaseless but natural attempts to approach the heavens, to soar up high towards the sun, since it is that part of the bile that persists after the fire that renders us intelligent periodically quenches. In this manner, the change of the seasons expresses in time a paradox (that of the suspension between heaven and earth) that is inherent to our constitution. Indeed, persistence is one of the major associations with black bile in Galen. This correlates to the thick, sediment-like nature of its substance, as well as to its association with earth. But it also manifests itself in other ways, as we can see from some of the following quotations:

ἀρότερον μὲν γὰρ διῃτημένου φλεγματωδέστερος ἀθροίζεται χυμός, ἐν πόνοις δὲ πλείοσιν ἤτοιπακρόχολος ἢ μελαγχολικός, ἐν θέρει μὲν πικρόχολος, ἐν φθινοπώῳ δὲ μελαγχολικός. ἀλλὰ καὶ τῶν πόνων τὸ μῆκος ἐπισκεπτέον· ὅσῳ γὰρ ἂν ὦσι πολυχρονιώτεροι, τοσῷδε μᾶλλον ἐπὶ τὸ μελγαχολικὸν ἐκτρέπονται.287

When a person's life is quite idle, a more phlegmatic humor collects. In greater exertions, it is either picrocholic or melancholic – in summer, picrocholic and in autumn, melancholic. But one must also consider the length of the labours, for the longer they are in duration, the more the tendency is toward the melancholic.

tr. Johnston

The longer the length of labours, the more melancholic one becomes. Now, one might say: well, that is because endless labour is bound to make one sad, but I think the issue here is not so much about a relation between labour and a psychological state that is melancholic, but rather between lengthiness or perseverance and black bile. Black bile is ponderous and heavy, it stays the same for a long time, static and unmoved. We can see this also in the description

286 *Hipp. Prog.* XVIIIB 282,10–1 K, the stage of life which matches black bile is ἡ παρακμή, the time after one's prime (the word also means decay); *Temp.* 641,4–8 K: 'We should not, then, think, just because someone is quite hairy, that he is automatically melancholic. This does not hold if he is still in the prime; it does hold if he is at the stage after the prime; and again, it does not hold in old age'. (tr. Singer and van der Eijk); *Diff. Feb.* VII 335,10–15 K.

287 *San. Tu.* VI 249–50 K.

of so-called quartan fevers that Galen quotes in his commentary on the Hippocratic *On the Nature of Man* (though Galen himself seems to not quite agree with it). These fevers last longest of all kinds, which is explained in terms of its subject having relatively less yellow and more black bile:

προσγίνεται δὲ αὐτοῖσιν ἀοὸ μελαίνης χολῆς τὸ περισςὸν τοῦτο καὶ δυσαπάλλακτον· μέλαινα γὰρ χολὴ τῶν ἐν τῷ σώματι ἐνεόντων χυμῶν γλισχρότατον καὶ τὰς ἕδρας χρονιωτάτας ποιεῖ. γνώσῃ δὲ τῷδε, ὅτι οἱ τεταρταῖοι πυρετοὶ μετέχουσι τοῦ μελαγχολικοῦ.288

This excessiveness and tenacity in them derives from black bile. For black bile is the most viscous of the humours of the body, and the one which remains unmoved for the longest time. You will understand from the following that quartan fevers have a share of the melancholic. tr. Hankinson

Black bile remains unmoved longest. Likewise, in *Hipp. Elem.*, Galen says that black bile is δυσκίνητος, 'difficult to move', 'obstinate'.289 The physical properties of the black bile itself are also translated into the psychological domain, where black bile is said to cause a kind of firmness or constancy of soul:

ἔστι δὲ καὶ ἕτερος τις λόγος φυσικὸς οὐ σμικρὰν ἔχων πιθανότητα, καθ΄ ὅν εἰς ἠθῶν ἐπιτηδείων γένεσιν οἱ τέσσαρες ἀποδείκνυνται χυμοὶ χρήσιμοι. προαποδεῖξαι δὲ χρὴ πάλιν ἐν αὐτῷ ταῖς τοῦ σώματος κράσεσιν ἑπόμενα τὰ τῆς ψυχῆς ἤθη, περὶ οὗ καὶ ἡμῖν ἑτέρωωθι γέγραπται. τούτου τοίνυν ὑποειμένου τὸ μὲν ὀξὺ καὶ συνετὸν ἐν τῇ ψυχῇ διὰ τὸν χολώδη χυμὸν ἔσται, τὸ δ΄ ἑδραῖον καὶ βέβαιον διὰ τὸν μελγχολικόν, τὸ δ΄ ἁπλοῦν καὶ ἠλιθιώτερον διὰ τὸ αἷμα· τοῦ δὲ φλέγματος ἡ φύσις εἰς μὲν ἠθοποίΐαν ἄχρηστος, ἀναγκαίαν δὲ φαίνεται τὴν γένεσιν ἔχον ἐν τῇ πρώτῃ μεταβολῇ τῶν σιτίων.290

There is also another physical account which has no little plausibility, according to which the four humours are proved to be effective in the generation of the states of character which are appropriate to them. In

288 *HNH* 85,5–14 Mewaldt (XV 167 K); cf. *Caus. Symp.* VII 190 K; *PHP* 520,20–1 De Lacy; *Cris.*  IX 659,7–13 K; *Hipp. Epid.* I XVIIA 115,2–4 K; we also find the association of excessive black bile with quartan fever later in Oribasius, see Fr 74 in Pormann's edition of Rufus (2008) and Al-Rāzī seems to ascribe it to Rufus as well (Fr 75, Pormann).

289 *Hipp. Elem.* 154,9 De Lacy (I 506 K); in *Cris.* IX 693,10 K, Galen qualifies the blood of the melancholic as σκιρρώδεις, 'of hard nature', 'obstinate'.

290 *HNH* 51,9–18 Mewaldt (XV 97 K).

it we first need to establish that the states of character of the soul are consequent upon the mixtures of the body, about which we have written elsewhere. On this basis sharpness and intelligence in the soul will exist as a result of the bilious humour, steadfastness and firmness as a result of the melancholic, simplicity and artlessness as a result of the blood. The nature of phlegm is ineffective with regard to the prediction of character, having as it evidently does its necessary generation in the first alteration of the food.

tr. Hankinson, slightly modified

Galen describes each of the humours as the cause of certain psychic states, except for phlegm. The words he chooses to describe the states caused by black bile show an interesting resemblance with its physical associations. They both suggest a kind of stability, as of something that stays the same, which fits with the thick and earthy nature of black bile. The word ἑδραῖος mostly means something like 'sitting' or 'sedentary'. It is also used for the horse-back on which a rider sits and can mean 'steady' or 'steadfast' as well. Finally, it is related to the word ἕδος, 'seat' or 'abode', which is the regular epithet of Earth in Hesiod's Theogony (ἕδος ἀσφαλὲς αἰεί).291 Likewise, βέβαιος means 'firm' or 'steady'. We also find both words together in Galen's commentary on the *Epidemics*, as adjectives with ὕπνος to describe a very deep sleep.292 The description fits well with the notion that black bile is the part of bile that stays throughout summer and autumn, remaining after the hotness recedes, and with the notion that black bile is most difficult to purge. Yellow bile is said to be the cause of intelligence here, and of a 'sharpness' in the soul, which fits its light, thin, dry, hot and fiery nature that is more akin to the heavenly bodies, which are supremely intelligent. The description of blood is more remarkable, as it seems rather negatively to come down to simplicity or even a kind of foolishness of the soul.293 I have not found any parallels for it in Galen, nor elsewhere in earlier authors. It seems likely that this description is based on the predominant wetness that is characteristic of blood. In *QAM* (to which the above passage quoted from *HNH* refers), Galen is not as specific on the humours as he is in other works and is more focused on the role of the elemental qualities, but he does present wetness as the cause for a lack of intelligence, while dryness is

291 *Theogony* 117, 128 ed. Most.

292 *Hipp. Epid. VI* XVIIB 175,3 K.

293 Hankinson, in a note to his translation also remarks that he is inclined to think a less negative characterization is intended by Galen.

316 Case-Study IV

presented as the cause for intellect.294 Blood is one of the two wet humours. Moreover, since phlegm is left out of the picture in the passage cited from *HNH*, blood is the only wet humour in this schema, which would make it suitable to fulfil a role opposite to that of dry yellow bile as the cause of intelligence, black bile being the persisting residue of this yellow bile.

With this passage from *HNH*, however, we are already discussing the psychological rather than the physiological domain, which we might take as a testimony of how closely the two are interrelated when it comes to Galen's humoural theory in general and to black bile and melancholy in particular. But before we discuss this psycho-somatic interrelation further, we shall discuss melancholy separately, to some extent, in the same way we discussed the black bile separately, and we shall briefly summarize our findings on black bile in Galen.

#### **2.7** *Conclusion on Black Bile*

The ambiguity between black bile as an exceptional and unnatural substance that causes disease, and black bile as a regular part of our constitution, is not so much solved in Galen's work, as it is fully retained and embraced. Galen makes a rather consistent distinction between these two kinds of black bile. However, at the same time, as we have seen, the two have much in common, are often difficult to distinguish, and the one can alter into the other. So much so, that there is, according to Galen, no need to apply different names to them. We have seen how, in Galen's work, this enigmatic and many-headed black bile, which was previously mostly seen as a useless residue or as something which, as an altered form of a normal substance, caused disease, has now become firmly integrated into a fourfold schema of humours, elemental qualities, elements, seasons and phases of life. Within that schema, black bile has a place of its own, which makes it a part of our nature and the grander order of things, while it remains, at the same time, a substance that forms a continuous threat to that very order itself. The necessity of this threat is generated by another necessity: that of the restrictions that matter imposes on the creative capacity of nature. Given the qualities of this matter, we cannot be like the stars and need continuous nourishment in order for our ephemeral existence to continue. Black bile is the worst and most dangerous by-product of the process of digestion, which is aimed towards the production of a beneficial mean: blood.  Yellow bile is related to summer, fire, the heavens, an upward movement, activity and intelligence. Black bile is related to the end

294 *QAM* 780–82 and 786 K; see infra, Case-Study III paragraphs 3 and 4.

of summer, an extinguished fire, the earth, a heavy downwards movement, and static and obstinate passivity.

It is necessary for us to produce such a substance, given what we are. We are not only living and not only divine after all, we are also mortal and of the earth. Therefore, we cannot be without the substance of black bile, but we also need our spleen to continuously neutralize it, so that it will not take us over and weigh us down. In Galen, black bile is both opposed to our nature, as well as a necessary part of it. As such, it fits the general tendency in Greek philosophy to define the human being in terms of something that it is not completely, but only partly. The rational capacity for the perception of the eternal is what defines us most, and it is what we should actualize in order to fulfil our nature – in Galen just as well as in Plato295 – but this capacity is limited in two senses that are interrelated and of which black bile becomes the physiological paradigm in Galen: our mortality and our matter. With black bile, we mortal beings carry our own negation with us, as if the remnant of our own life is always already inside us. I think, from the perspective of the role black bile plays in Galen's cosmology, Burton was right to say melancholy is an expression of the sense of our mortality, and Diderot was right to say it is a sense of our own imperfections.296 But the association of mortality with earth and darkness is primordial, and was there before black bile became a regular part of our constitution in Galen's writings. From this perspective, I think Kudlien's suggestions still make sense, and Galen's definitive incorporation of black bile into our nature builds on a range of implicit associations with darkness, night, death, earth etc.297 Given the typically ancient Greek notion of man as a being suspended between earth and heaven, aspiring to the latter but tragically bound to the former, there should also be a dark, obstinate and detrimental substance inside our very bodies, a substance opposed to the vital juices that maintain us, mixed together with them. There should be something in us that is more threatening and destructive than blood, that useful and nourishing substance, and that weighs down the part of us that is fiery and tends upwards to the stars, the yellow bile. With this incorporation of black bile into the cosmological order of things and into our very body – the two form

295 Cf. e.g. *Temp.* I 565 K: 'It is appropriate for a human being to be as intelligent as possible'. (tr. Singer and van der Eijk, modified)

296 Burton (1621), 142: 'Melancholy in this sense is the character of mortality. We are not here as those angels, celestial powers and bodies, sun and moon, to finish our course without all offence, with such constancy, to continue for so many ages …'; Diderot (1751–2) vol. XXI, 415: 'Mélancolie: C'est le sentiment habituel de notre imperfection'.

297 Kudlien (1967, 1973).

a continuum after all in Galen298 – the dangerous potency of black bile, and notably therefore also of melancholy itself, is *normalized* to a certain extent, incorporated into our nature despite its unnatural potency. We shall pursue this theme of normalization of black bile and melancholy in the next chapter, in which we shall focus on melancholy in Galen.

#### **3 Galen on Melancholy**

While the subject of melancholy itself is largely absent from Galen's treatise on black bile, *At. Bil.*, he devoted a few chapters to it in his *Loc. Aff.* In these chapters he discusses the three different types of melancholy and their respective causes, symptoms and treatment.299 The context in which he takes up the subject, is that of a discussion of the affections of the brain, and their distinction into affections that have their cause in the brain itself, and those that have their cause elsewhere but co-affect the brain:

νυνὶ δ΄ὅπως ἄν τις χωρίσειε τὰ κατὰ πρωτοπάθειαν αὐτῷ συμβεβηκότα τῶν κατὰ συμπάθειαν, ἐπισκεπτέον· ἴδιόν τε γὰρ τοῦτο τῆς προκειμένης πραγματείας, ἥ τε χρεία πρόδηλος εἴ γε πρῶτον ἁπάντων ἐστὶν ὡς πρὸς τὰς ἰάσεις ἐπίστασθαι, τίνι χρὴ μορίῳ προσφέρειν τὰ βοηθήματα.300

We now have to examine how one can distinguish the things that befall the brain because of a primary affection from those caused by co-affection. This is the specific topic of the present treatise, which is evidently useful, since if indeed it is primary to all things to know about the therapies, it is necessary to know to which part to apply the remedies.

This distinction runs throughout the work and will return in Galen's partition of the various kinds of melancholy as well.301 From book III, 6 onwards, Galen proceeds to discuss various affections of the brain in terms of the specific mixtures of elemental qualities that cause them. What this comes down to, is an analysis of the leading capacities of the rational soul, seated in the brain, in terms of relative wetness, dryness, coolness and hotness. For example,

298 Cf. Holmes (2013) 163–4.

299 Chapters 9 and 10 of book III.

300 *Loc. Aff.* VIII 129 K, cf. VIII 160 K, where Galen refers back to this passage, shortly before the chapters on melancholy.

301 See also *Loc. Aff.* 30–1 K. Cf. Holmes (2013) for a seminal discussion of the notion of sympathy in Galen.

conditions of excessive drowsiness and sleepiness, such as lethargy, are caused by excessive coldness.302 On the other hand, 'the warm and biliary diseases' are said to cause a lack of sleep, delirium and phrenitis. In general, dryness and heat cause (over-)activity, whereas coldness and wetness cause inactivity of the soul.303 In this context, Galen also discusses memory-loss, which is always caused by an excessive coldness, accompanied by either a predominant dryness or a predominant wetness, or a mean with regard to those two.  Another person, a vinedresser, because of the labours involved with wine-dressing and because of his light diet, was affected in the same way as him. Both of them clearly were damaged by all things that dried and heated, but benefited from all things that moistened together with warming.

I think here we have two examples of a condition in which the brain is heated and dried, as a result of which black bile is produced, that are by now familiar: the overactivity of the intellect caused by excessive thinking, which we know from Rufus, and the excessive labor that Galen identified as a cause of melancholy elsewhere (in this case perhaps particularly related not so much to the duration, but rather the circumstances of being out in the open field when it is hot and dry, and having an unsuitable diet for it). For these cases, obviously, drying and heating will not help, they are rather the cause of the affections. Moistening helps, as does warming. Why would warming help, given that the

302 *Loc. Aff.* VIII 161–2 K.

303 See also *Loc. Aff.* VIII 131 K: 'Heat produces the activity which causes sleeplessness and delirium without fever. But the affections of somnolence, coma and unconsciousness are all an affect of cold … Substances which are cold cause numbness and loss of consciousness; warm drugs, in turn, cause a loss of sleep and increase of bodily movements'. (tr. Siegel)

304 *Loc. Aff.* VIII 165–6 K.

cause was excessive heat? It must be the case that by the time the affections have set in, that is to say, when the rational capacities get damaged, the mixture has cooled. Therefore, the mixture is cold and dry – as is black bile – and must be moistened and warmed, not coincidentally the two basic therapeutical strategies to cope with melancholy that Rufus proposes with regard to changing the mixture, and that Galen also refers to at the end of his treatment of melancholy in *Loc. Aff.*305 And indeed, in the sentences immediately following the passage quoted above, Galen makes the transition to familiar affections of the brain, including melancholy:

γίνονται μὲν οὖν καὶ μετὰ πυρετοῦ βλάβαι τῶν ἡγεμονικῶν ἐνεργειῶν, ὡς ἐπὶ φρενίτιδός τε καὶ ληθάργου· γίνονται δὲ καὶ χωρὶς πυρετοῦ καθάπερ ἐπὶ μανίας τε καὶ μελαγχολίας· ὥσπέρ γε καὶ κατὰ συμπάθειάν τε καὶ πρωτοπάθειαν ἐγκεφάλου.306

It also happens that the leading functions of the soul are damaged in fever, as during phrenitis and lethargos. This also occurs without fever, as in mania and melancholy; also by sympathy and by a primary affection of the brain.

tr. Siegel

Melancholy can have its cause in the brain itself or co-affect the brain while it has its origin somewhere else. In general, Galen sees the hypochondriac melancholy as having its primary cause in the organs concerned with digestion, co-affecting the brain. Throughout *Loc. Aff.*, he uses the case of the rising of dark vapours from the stomach to the eyes and the brain, clouding them, as a paradigm-case of co-affection.307 When the cause is in the brain itself, Galen

305 *Loc. Aff.* 286 Van der Eijk and Pormann: 'I refer to friends who saw me treating such melancholy by means of baths and a moist, juicy diet, without any other remedy, when the harmful humour had not yet become difficult to remove as a result of lapse of time'. See infra, p. 256–7 for Rufus.

306 *Loc. Aff.* VIII 166 K.

307 *Loc. Aff.* VIII 44,13 f., 52,4 f., 137,12 f., 178 K; melancholy as one of the paradigms for the brain being co-affected by the stomach also recurs in *Caus. Symp.* VII 128 K, 137 K and *Const. Art. Med.* I 282–3 K; cf. Holmes (2013), who describes how Galen's notion of sympathy in *Loc. Aff.* revolves around the connection of gut and brain, 168: 'It is probably no accident that in his opening remarks on sympathy in On the Affected Parts, Galen uses the example of noxious vapors or humors rising up from the stomach cavity to the brain. In his more detailed discussions, too, affections frequently migrate to the brain from the stomach or its mouth'.

speaks of a primary affection (πρωτοπάθεια), rather than a co-affection (συμπάθεια). The former can happen in two ways:

οἱ γοῦν κατ΄ αὐτὴν τὴν οὐσίαν τοῦ ἐγκεφάλου πλεονάσαντες παχεῖς χυμοὶ ποτὲ μὲν ὡς ὀργανικῷ μορίῳ λυμαίνονται, ποτὲ δὲ ὡς ὁμοιομερεῖ· κατὰ μὲν τὰς ἐμφράξεις τῶν πόρων ὡς ὀργανικῷ μορίῳ, κατὰ δὲ τὰς ἀλλοιώσεις τῆς κράσεως ὡς ὁμοιομερεῖ.308

For instance, thick humours that are present in excessive quantity in the very substance of the brain sometimes cause damage to it as an organic part, sometimes as to a homoeomerous part: in the form of obstruction of the blood vessels as to an organic part, in the form of qualitative change of the mixture as to a homoeomerous part.

tr. Van der Eijk, slightly modified

Corresponding to the general distinction Galen makes between homoemerous and organic parts of the body, there are also two general kinds of causes for melancholy arising from the brain itself. I am not sure what exactly the differences in symptoms would be for these two, if there are any. However, Galen does add that when the organic part is damaged by black bile, this affects 'the body of the brain' (ἐπὶ τὸ σῶμα τοῦ ἐγκεφάλου), whereas in the case of black bile damaging the homoeomerous part of the brain, it is rather *the mind* that is affected (ἐπὶ τὴν διάνοιαν). This seems to suggest that the latter disturbs the rational capacities more directly or to a stronger extent; one might think of more intense delusions or despondency perhaps.309 Indeed, the case of generation of black bile in the brain itself, is further specified by Galen as having its cause in an abundance of local heat, which burns either the yellow bile or the thicker and darker blood, causing it to become black bile. We have seen previously that Galen considers the black bile that is the result of burning as the most dangerous kind, that always leads to severe damage of the rational capacities.310 Thus, it seems that the case of the burning of yellow bile or blood

308 *Loc. Aff* 270 Van der Eijk and Pormann (VIII 180 K).

309 Cf. *Loc. Aff.* VIII 161 K, where Galen remarks that the homoeomerous parts primarily act (πρώτως ἐνεργεῖ), i.e. in this context: primarily perform the rational functions (see infra, CS I section 1, 25–34).

310 *Loc. Aff.* 272 Van der Eijk and Pormann (VIII 182 K), but here I disagree with van der Eijk's translation, who translates 'γεννᾶται δ΄ ὑπὸ θερμασίας πολλῆς ἐγχωρίου, κατοπτώσης ἤτοι τὴν ξανθὴν χολὴν, ἢ τὸ παχύτερόν τε καὶ μελάντερον αἷμα' with 'It is generated by an abundance of local heat, which burns it [the blood] either into yellow bile or into thicker and darker blood'. I do not see why we would have to add an extra object (the blood), that is burned

in the brain itself is the most dangerous kind of melancholy, directly affecting the mind itself.311 The affection of the body of the brain in turn, seems to be further specified by Galen as caused by the melancholic humour flowing in from elsewhere.312 It seems that because of its relative thickness, when it flows into the brain, it affects the brain itself (which is why, presumably, it is a form of primary affection) by obstructing its blood vessels.

Besides this melancholy that is the consequence of a primary affection of the brain and the hypochondriac kind, Galen distinguishes a third kind of melancholy:

οὕτως ἐγχωρεῖ καὶ τὸν ἐγκέφαλον ἐνίοτε μὲν, ἅπαντος τοῦ κατὰ τὰς φλέβας αἵματος μελαγχολικοῦ γενομένου, τῷ κοινῷ λόγῳ τῆς βλάβης καὶ αὐτὸν βλαβῆναι.313

In the same way sometimes, when all the blood in the blood vessels has become melancholic, the brain, too, can be damaged for the same reason as the rest of the body.

tr. Van der Eijk

Galen does not specify clearly whether he understands this kind of affection of the brain as a primary or sympathetic affection, but it seems to make more sense to regard it as sympathetic. After all, it seems that this melancholy arises when too much black bile is produced in general. This would require either a high production in the organs involved with digestion (either due to a natural constitution or due to a specific diet) or a high amount of alteration of other humours into black bile in the blood vessels. The latter can be caused by excessive heat. There are obviously important differences with regard to treatment: if the blood in the entire body is melancholic, changes in diet are essential and bloodletting can be an efficient treatment. Thus, when a patient suffering from melancholy appears and one needs to determine whether it is a primary affection of their brain or whether it is caused by a generally high amount of the melancholic humour in all blood vessels, Galen advises first to

'into' something, when we can also translate 'which burns either the yellow bile or the thicker and darker blood', which makes more sense given the other Galenic passages on the burning of yellow bile or blood as a cause for the generation of (dangerous) black bile and melancholy; cf. also *Loc. Aff.* VIII 193 K, the last sentences of the chapter.

311 In *Hipp. Prorrh.* XVI 544–5 and 553–4 K, Galen explains the ecstatic forms of melancholy also in terms of the burning of yellow bile.

312 *Loc. Aff.* 272 Van der Eijk and Pormann (VIII 182 K).

313 *Loc. Aff.* 272 Van der Eijk and Pormann (VIII 181 K).