Hnstory and Fhrlosophy Galen of Pergamon A Sketch of an Original Eclectic and lntegrative Practitioner, and His System of Medicine
by Peter Holmes, L.Ac., M.H., A.H.G.
The Greek doctor, philosopher and natural scientist believe that coming directly to grips with Galen's work Claudios Galenos (c. 129-199), also known as Galen without prejudice may hold a key that can help us inte- of Pergamon, holds a unique position in the history of grate the various current types ofherbal medicine into traditional Greek-Western medicine. An original a powerful new synthesis. thinkeq researcher, writer and practitioner of extraor- Summarizing Galen's enormous contribution to dinary caliber, his life and work is characterized by an Greek-Western medicine and scientific thought, and unbridled creative energy that has been compared to detailing his contemporary significance in a brief arti- that of Alexander the Great (Lichtenthaeler 1982). cle is challenging and humbling. challenging Galen's influence in medicine, philosophy and the nat- Equally and us having terms ural sciences was so widespread and longJasting that humbling for is to come to with the his very name was given to the Greek-Western medical very lack of transmission of our own traditional problem system that lasted nght up to the nineteenth century, holistic medical system in modern times. The under the name of "Galenic medicine." His work in the we now face is one of epistemology: given the scanti- quality area of herbal medicine was so influential that herbal ness and poor of available information on Peter Holmes medicine preparations in general came to be known as Galen and Greek medicine, especially in English, how "galenicals." And yet, because none but an extremely can we truly understand and correctly interpret any Peter Holmes is a medical small fraction has ever been information that does become available? To fi.rther of Galen's written works herbal st and Chinese translated into English, very little is still generally that understanding and promote more accurate inter- known in the English-speaking world about this pretations of Greek material, therefore, we should herbalist. He researches, human phenomenon. Most of what is generally known begin by first considering the context itself in which writes and lectures ofhis work has come down to us second-hand through we hold Greek medicine todav. extensively in the field of his successors. The Modern Resurgence both Western and Although Galen's life and work has been fairly well Since the 1960s there has been anamazitgresurgence Or ental botanlcal documented and translated by French, German and of interest in traditional and vitalistic systems of med- medicine, and is a faculty Italian historians and philologists over the centuries, icine. This includes extant classical medical systems there is no modern evaluation of his medical practice such as Chinese medicine, Ayurvedic, Tibetan and member of the Southwest and theories from a perspective free of a modern posi- Greek medicines. At the same time interest has also College of Naturopathic tivistic bias. Certainly his paramount role in the early focused on herbal medicine rather than on drug-based Medicine in Tempe, development of herbal medicine in the West has not medicine. It has included not only the herbal medicine recognized been clearly and defined. In this article we backbone ofthese four classical systems, but also the Arizona. He is author of will explore Galen's output specifically in relation to various herbal medicine traditions indigenous to the three herba medicine Greek medicine general herbal in and to medicine in West. The result can be seen in various key phenome- particular. method ideas speak textbooks, and lives in Our is to allow his to na that are currently here to stay. for themselves rather than trying to rationalize them Boulder, Colorado. from the analyic-scientific perspective. In the same First, the advancement of traditional Chinese medicine He can be reached at vein, we will also refrain from comparing them to (TCM) in the West. There is no doubt now that Chinese other related vitalistic medical concepts from Chinese acupuncture and herbal medicine have made a suc- pete rh o I m es@ estr eet. ca m or Ayurvedic medicine, for example. cessful implant on Western soil. The transmission has been successfully accomplished in terms of philoso- Our thesis is that Galen was an original Eclectic physi- phy and principles, medical terminology and clinical cian; a synthesist or integrative thinker without paral- practice-with more time essentially needed only to lel in the history of the West; and a pioneering medical "fill out the details" of the Western context, as it were. herbalist who laid the foundation for a holistic, vital- Chinese medicine now meets an important need in ism-based system Western herbal medicine. We of Western health-care for the treatment of chronic disor- believe that an exploration philosophy, patholo- ofhis ders in particular, and generally by providing a pre- gy and herbal medicine theories is vital for under- ventive medicine context and a holistic life-enhancing standing the numerous medical practitioners who suc- human philosophy in a holistically-deprived West. ceeded him during the next sixteen centuries-many of whom are much better known to us today than is Second, a renewed interest in traditional Western med- Galen. They are all children of Galen. More: we ical theories, such as the "four-humour " theory the
Journal of the American Herbalists Guild 7 o= € C - .t
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6 I- ! jo o c o 6 .9 E both still possess their entire med- "doctrine of signatures" theory, the "specific sympto- Chinese medicine in both their original language and in their matology" theory the "elimination treatment" theory, ical canons language' The canonic works of the Hippokratic "four-element constitutions," the modern-day medicine exist in original Greek "remedy potentisation" theory, and so on. These theo- Greek/Western (mainly the Hippokratic corpus and the works of later ries derive from various periods during the last 2'000 and Alexandrian doctors); in original Arabic years, often propagated by certain individuals with Greek (mainly the key texts of Ibn Sina, Ar-Razi); in Hebrew whom they have now become tightly associated' Most (e.g. the works of Moses ben Maimom)' Further of these theories are incongruent among each other, important texts were written in medieval Latin (e'g' while at the same time they are often held to be a fun- Boerhaave); in ancient/Renaissance German, French, damental truth or principle by its adherents, to the and Italian; and latterly in modern English, detriment of all other theories. The diversity of theo- English and German if we allow the inclusion of eigh- ries is usually accompanied by an exclusive monistic French teenth and nineteenth-century texts (which would belief in a particular theorY. include Thomsonian, Eclectic and Physiomedical texts "energy Thir{ the development of various forms of of the nineteenth and twentieth century.) Unless a per- cata- healing" modalities, now truly too numerous to son is fluent in all these languages, it will be impossi- polar- logue, such as Reiki healing, chakra-balancing, ble for them to understand the GreeldWestern medical ity therapy, magnet therapies, color therapies, music tradition in its entiretY. and sonic therapies, and so on. The main reason we do not possess this Western body However, what seems to be missing from this larger of medical knowledge in its entirety today is because picture of renewed interest in non-modern medical of the recurring interruptions that occurred during its approaches is nothing less that the presence of tradi- transmission from one Western culture to another tional Greek medicine itself (see below for a definition (Diegpen 1925). Using anthropological methodology, of this classical system)' Because of the relatively we assume that for any medical system to develop recent (from the historical perspective) interruption of coherently and thereby increase its overall average suc- the Western Greek medicine tradition, we seem unable cess rate, it will need to effectively transmit its knowl- here to engage a true historical perspective' We are edge and wisdom-base from one generation to anoth- probably too close to our own tradition (both spatially er, while at the same time being able to grow and and temporally) to be able to view it from the impartial change, on the basis of this tradition, in response to and complete perspective of a critical historical ever-changing health-care needs. This is exactly the observer. For instance, it is still too early yet to say case with Chinese medicine, for example, which con- definitively whether Western-Greek medicine was cut tinues to be a viable medical system today-many mil- off for good by the nineteenth-century modern science lennia after its original conception. It is a historical takeover, or whether the tradition was only temporari- fact that the enotmous cultural and social class diver- ly interrupted by it (with complementary medicine sity in the West-unlike the greater homogeneity in now once again picking up that tradition)' We believe China-worked consistently against an accurate and that the jury of history is still out on that issue' effective transmission of Greek medicine' The biggest example of this is how the transmission of the canonic The Transmission of Greek- Hippokatic medical theory to Central Europe was Western Medicine extremely corrupted and only poorly-existent until the What is needed at this point is for the Western tradition Renaissance era (approximately the 16th century)' itself to be fully transmitted to us. Whether we believe Very few translations of those Greek canonic texts poorly that the Western tradition was entirely cut off or sim- were available; those that were available were ply temporarily eclipsed by modem science, the fact is translated into medieval Latin, full of inaccuracies and discussion thut *. have forgotten and have no access to the whole usually incomplete (see also the Four Fluids from and accurate body ofits basic medical principles, diag- below). In addition they were usually translated rather than nostics and therapeutics-herbal or othelwise' We cer- other languages such as Hebrew and Arabic only those tainly possess pieces of this tradition, as mentioned in from the source language. This was because accurate the above examples. We may not realize though that two middle-eastern languages ever possessed jig- Yet paradoxically, these are but the small pieces of a gigantic medical translations of the Greek originals. transmission of saw puzzle. It is a fact that we do not possess in the despite the corruption in the believe that it is this English language the complete, accurate and commen- GreekAVestern medical theory we taried medical texts that constitute the core of very cultural diversity that caused the Greek, Hebraic, European, etc', cul- GreeUWestern medicine. In contrast, Ayurvedic and Arabic, Spanish, Italian, Central
8 Spring/Summer 2002 Hrstory and Fhf losophy
tures to make significant contributions to the tradition, two Greek medical canons. Because we are currently if only partly rooted in the original theories. It is the in a situation of possessing incomplete, often inaccu- to very diversity of Greek medicine that stirs our fascina- rate information-much as we were with respect years best to first tion and inspires our desire for exploration. It certain- Chinese medicine about 100 ago-it made in ly goes to make up its uniqueness, complexity and, clarify the key assumptions and terminologies ultimately perhaps, its comprehensiveness. this article that might cause concern.
If we believe that modern science effectively severed Basic Assumptions and Terminologies the GreeUWestern tradition, it is clear that this tradi- Traditional Greek Medicine, or TGM tion needs to be transmitted all over again in its origi- It is clear from all sources consulted (see References) nal and complete form. This would allow us to devel- that the medical system that originated in Greece with op a vitalistic, non-allopathic type of Western herbal the Hippokatic texts survived in Europe into early medicine based on genuine and mutually-integrated modern times. It is a single continuous stream, even as concepts rather than a grab-bag of mutually-exclusive it underwent at least six distinct stages by six different concepts. On the other hand, if we believe that Greek cultures in various countries, involving practitioners medicine simply went more-or-less underground for working in the languages of ancient Greek, Latin, to be re- two centuries, then the tradition simply needs Hebraic, Persian and Arabic, Ecclesiastical Latin, and on a more transmitted so that we can continue to build modern Italian, Spanish, French, German and English. a truly integrated herbal secure foundation and develop Likewise, Chinese medicine today is considered a sin- key medical texts still need to be medicine. Either way, gle stream, despite the numerous schools, different understood; and the tradi- identified translated and philosophies, and so on, that it underwent (Unschuld ofpathology, diagnostics, herbal thera- tional concepts 1985). Moreover, just as Chinese medicine was prac- py, so still need to be integrated into our cur- and on, ticed in many different Asian countries, and is now then put into clinical practice. This rent mindset and practiced in communities worldwide, so traditional transmission process will take time and, to say the Greek medicine was practiced in all Mediterranean least, may at first seem like bad news in our instant and European countries. Today it is practiced predom- world of today. inantly in the Middle East and India (where its clinics However, the good news is that this process can be and hospitals serve about one-third of the continent's greatly accelerated by two factors. First, our current health-care needs). The diversity of a phenomenon fluency in another vitalistic medical system, such as does not preclude its unitary nature. Ayurvedic or Chinese medicine. The basic assump- When Greek medicine migrated to Baghdad in the tions of these classic systems, in most of their aspects, eighth century with the collapse of Graeco-Roman civ- tend to be largely the same. The medical terminology ilization, the medical system was called tibb-e al- is also not that different between them. Even the herbal yunani, "medicine from Ionia," meaning "medicine and physical treatment methods, as well as the actual from Greece" (Ionia being its representative island). herbs employed, are either similar or often identical. Its Hindi name, tibb unani, also means "Greek medi- Major remedies such as rhubarb root (Rheum spp.) and cine." seems semantically correct, therefore, to Indian spikenard (Nardostachys jatamansi) are two It retain this universal name, "Greek medicine," in among many that belong to the materia medica of all English, despite its occuffence in other countries and three classic medical systems. What differs mainly is other languages-again like the term "Chinese medi- the medical theories regarding pathology, diagnostics cine." We propose here the acronym "TGM" (tradi- and therapeutics. tional Greek medicine) as an accurate parallel concept Second, we can accelerate the transmission process by to "TCM" (traditional Chinese medicine). learning from key herbal medicine practitioners of the (TGM) is the third classic past. In the case of the GreeUWestern medicine tradi- Traditional Greek medicine alongside traditional Chinese tion, a practitioner that may hold the key for many of extant medical system, our current failures and dilemmas is Galen of medicine (TCM) and Ayurvedic medicine. Pergamon. The four fluids It is generally acknowledged that Galen's writings Known as tessara chymoi in original Greek texts, they form one of the twin pillars of Greek medicine-the refer to the body's four nutritive 'Juices" in Greek other pillar being the Hippokatic corpus, texts written medical physiology that keep the individual in physical in the Greek island of Kos during the fourth century and mental health. A temporal or bodily imbalance, i.e. BCE. What we clearly cannot assume, however, is a a dyslcrasia, of these fluids is the cause of disease. fuil transmission and accurate interpretation of these Chymoi is pronounced as in the German hiiten.
Journal of the American Herbalists Guild 9 its source in the Greek Chyrnos is the Greek for'Juice;" it is the source ofow humiditas, which in turn has to translate chymos as word "ch1.rne" (Webster 1990). A literal translation of wordhygros-not chymos. Thus "moisture/damp'" tessara chymoi, then, would be "the four juices." We "humour" literally makes it signif' a consti- propose the word "fluid" as a better translation today, It mistakes the body's "juices" for "damp" as which in keeping with the modern physiological concept of tutional qualiry or for the body's "innate damp," "body fluids" and with the English translation of the is another Greek medical concept entirely. From the the body's fluids for equivalent Chinese medicine concept ofiinye, medical point of view, mistaking the quality of damp is a serious error. In TGM physi- is The traditional English rendering of chymos ology, the body's fluids are the essential working sub- this "humour." For better or worse, three factors render stances that maintain day-to-day individual health' this term unsatisfactory as a modern translation of Damp is one of the four qualities that make up the indi- Greek medical term. First, since its original four- vidual constitution, along with dryness, warmth and teenth-century medical usage, the word 'humour" in cold. Fluids have to do with the balance of one's our language has acquired many associations and dynamic ongoing condition, while damp has to do with current changes of meaning. Certainly its dominant the balance ofone's inborn constitution' meaning is "something . . . comical, amusing'" It has to ffans- been argued that the combined vagueness and tradi- The third reason for not choosing "humour" translations of tional cultural associations ofthis word can work in the late chymoi is circumstantial. German 1831, favor of its being understood as a technical term in the Hippokratic and Galenic texts (e.g' Kiihn Diegpen 1955, context ofTGM. However, to the Greeks who used this Neuburger 1906, Meyerhof 1933, term in clinical practice, the word chymoi did not Sch
1O Spring/Summer 2002 Hrstory end Fhrlosophy
dryness and moisture the primary four qualities that discoveries add up to make him the greatest anatomist characterize all of life. All other qualities are derived until Vesalius. Especially path breaking is Galen's from these fundamental four. The element of Air, for research on the nervous system, part of which involved instance, possesses the primary qualities of heat and spinal dissection, and his experimental proof that the damp; the fluid phlegm, for instance, possesses the pri- brain is very much the seat of the mind and spirit. mary qualities of cold and damp. In Greek pharmacol- Galen also showed, among other things, that the arter- ogy the warmth quality of a remedy is known as taxis ies circulate blood, not air; that the fallopian tubes lead or apostasis; it refers to a remedy's ability to warm up to the uterus, not the bladder; that urine is formed in cold conditions or conversely cool down hot condi- the kidneys, not the intestines. tions through the principle of contraries. Note that In his youth Galen also advanced medicine during his warmth is different from temperature, which is a mod- position as chief doctor and surgeon to the Pergamon ern scientific measurement, not a vitalistic quality gladiators, when he developed new first-aid and trau- description. ma medicine techniques. His noteworthy later discov- Moisture, hygros, refers to a remedy's ability to treat eries include the difference between congenital and dry or damp conditions by respectively either moisten- acquired disease, between primary fevers and acciden- ing d4'ness or drying out damp. tal (secondary) fevers, between the seat ofdisease and the manifestation ofdisease; the concept oflatent dis- Galen the Original Researcher ease, and the relationship between breathing and the Growing up Pergamon, a cultured, affluent in Greek pulse. His system of pulse diagnosis was especially town in the Eastern reaches of the Roman Empire, refined and to nineteenth-century observers, unneces- Galen's education in the basic Greek schools of phi- sarily complex. Certainly his 27 basic pulse qualities losophy and mathematics was ensured. At age 77, rivaled those of the famous Chinese doctor, Li Shi-jen, motivated it seems by a dream interpretation of his in subflety, fifteen centuries before the latter's lifetime! father's, Galen decided to concentrate on medical stud- ies. After studying medicine in his hometown for four Whereas today medicine emphasizes the psychological years, with a proclivity for performing anatomical basis of psychosomatic disease conditions, Greek experimentation, he left for Smyrna and Korinth, and practitioners emphasized their physiological founda- later Alexandria. Galen's drive to explore new reme- tion. Galen was no exception in this. Taking dies as well as different schools of medicine took him Hippokates' t e s s ara lcras ei s, four-temperament, theo- on endless travels: to Palestine and Lycia to research ry for his basis, he developed four psychological char- the medicinal nature of bitumen and gagate; to acter tlpes that are still widely known and caricatured Lemnos to research Lemnia clay; and to C1prus to in Europe today. Each temperament is based on one of obtain various metals used in medicine (Berendes the four elements (tessara stoicheia) and qualified by 1891). It was Galen's endless thirst for knowledge that two of the four basic natural qualities. The Water type, makes his biography so extraordinary, with layers for instance, is based on the nafure of water and is within layers of activity unfolding tkoughout his life. characterized by damp and cold. Eventually the Water If only he had remained a simple herbalist like his type was also named the Phlegmatic tlpe, as the fluid Alexandrian colleagues. No, Galen the herbalist must associated with this element was phlegm (phlegma). be understood within his work as a physician. His work patient's as a physician in turn can only properly be understood Knowing a constitutional hasrs was impor- in the context of his work as a philosopher, which in tant in Galenic medicine. First, it showed the severity turn is closely linked to his work in philology, in his- of a particular condition by noting whether the disease torical and comparative linguistics. qualities were similar to or different from those of the inborn temperament, i.e., by helping determine Galen's anatomical and physiological discoveries have whether the disease was more superficial or more con- thankfully been well documented (Meyer-Steineg stitutional. Second, it was helpful in prognosing and 1912, Prendergast 1929, Singer 1962). He assumes treating the condition by selecting remedies that bal- that organ functions, for example, depend on an anced the particular excessive qualities present. organ's outer form and inner structure. Because ofhis Aristotelian training, Galen always ends up question- Galen wrote prolifically, and this reflects his varied ing the functional purpose served by a particular interests as well as his boundless energy and organ, bone, muscle, and so on-much like Goethe's endurance. His output is estimated at 300 to 600 tracts enquiries seventeen centuries later. Although naturally of various lengths. The majority of these were housed at times his thinking becomes purely speculative, his in his clinic library on the Via Sacra in Rome, which-
Journal of the American Herbalists Guild 11 espoused methodology was miserabile dictu-butnt down when the neighboring Empiricists, whose chief clinical experience unsullied by temple of peace caught fire. The cause of the fire is empeiria, empirical the Methodicists, who method- unclear. Less than 200 of his works survive today- any conceptualization; highly effective clinical system of although some scholars estimate that uncatalogued ically organized a the Pneumaticists, whose works of his in Arabic translation are still gathenng diagnosis and therapeutics; and practice revolved atound pneuma, the dust at this very time in certain Islamic mosques. Only theory and quickens the physical tis- one other Western medical author rivals the scope and "breath" that vitalizes the Eclectics, the "selectivists" (to quantity of Galen's work: Rudolf Virchow, the nine- sues; and finally Ephesos also belonged), well-known teenth-century developer of cell pathology, who also whom Rufus of of various different ideas and doubled as a political activist and wrote over 2,000 for their incorporation essays and books. techniques. the other hand while an Eclectic practition- Galen's contribution to the field of herbal medicine Galen, on was not content to remain with any of these medical will be discussed in detail below. As if all this were not er, cliques. Still restless and searching (figuratively and enough, we should simply mention in passing that, in literally), at age 34 he moved to the Roman capital, addition to his medical activities, Galen also where his most productive period then unfolded under researched and wrote on Euklidian mathematics, lin- imperial patronage. It was here that Galen was able to guistics, philosophy and theology. digest and systematize the many approaches to medi- Galen liked to start Galen the Eclectic and cine he had experienced first hand. and then go on to particular lnteg rative Practitioner from broad principles facts, with the aim of organizing them comprehensive- At the time Galen was practicing, four centuries had ly. Balancing his analyical Aristotelian background already elapsed since the demise of the last medical with a phenomenological approach acquired from the school, the Hippokatic practitioners on the island of Empiricists, he also managed to strike a judicious har- period had seen medicine's ful- Kos. The intervening mony between the two extremes of anaiysis and where the Hellenistic crum move to Alexandria, empiricism in his approach to medicine. (Alexandrian) period was to last for another 600 years' Although Galen has been slotted as an Alexandrian Working steadfastly in this way, Galen essentially physician-he completed his medical training in that ended up blazing a trail from eclecticism to synthesism the best of what was Egyptian Mecca of leaming at age 28-his contribu- (Diegpen 1955). He selected on his impeccable tion far outstrips the characteristics of this second available to him at the time, based judgment, molded this to create alarget sy'nthesis' phase of Greek medicine. It is true that Galen was and the musician J.S. Bach, he borrowed themes Alexandrian in the sense that his interests ranged Like freely and widely in creating new works directed by his widely, and Eclectic in particular in that he took ideas own genius (a practice that in the past was held to com- from numerous sources; that he enlarged the materia plement the source, not cheapen the borrower)' Galen medica and almost always utilized herbal remedies in thus subsumed his eclectic mannerism to serve a high- treatment; that he furthered diagnostic techniques such er purpose: namely to create order out of the divisive as pulse and urine diagnosis; that he conducted inno- chaos that rypified Hellenistic medicine. By so doing vative anatomical experiments and physiological he ended up virtually re-creating a Greek medicine research; and that he prolifically wote philological system that was both ideally watertight in theory and critiques on medical texts going back five centuries highly effective in clinical practice. In this sense Galen (Lichtenthaele r I 9 82). embodies and represents both the apotheosis of medicine and the birth of Galenic- But here the common ground ends. The Hellenistic Hippokatic-Greek medicine. The music history analogy here period essentially was a period ofdecadence: it saw a Greek would be L. van Beethoven who, while consolidating dispersal of the unitary Hippokatic medicine into and completing one music period the Classical period numerous medical factions. The wonderful holism that also initiated anotheq the Romantic period. the practitioners on Kos had spent many centuries empirically polishing and perfecting was simply aban- Although Galen's interests in the natural sciences doned-astonishingly to us. The Alexandrian sects fell ranged widely, as far as medicine was concerned his back to particular ideologies and/or techniques, and to true master was Hippokrates (Siegel 1968)' His med- idle speculation and empty contention, while often ical synthesis reposes fairly and squarely on delighting in ongoing ideological altercations. The bet- Hippokatic medicine. Unlike his Alexandrian col- ter known sects included the Herophilists, pupils of leagues, Galen saw Hippokratic medicine not as a final Herophiles, who greatly advanced pulse diagnosis; the statement but as a timeless living truth to be explored
12 Spring/Summer 2002 Hrstory end Fhrlosophy
and developed. His famous saying comes to mind: can thus suffer an excess (plethora) or deficiency "Hippokates has pointed the way for us; everything (kenos) of phlegm (lthlegma), yellow bile (xanthe else we need to do." True to his word Galen single- chole) or black bile (melan chole). In itself, the blood handedly revitalized Hippokatic medicine by putting fluid can suffer primarily from an excess or deficien- the master's broad vitalistic concepts consistently into cy, which is often secondary to a blood kakochymia clinical practice. Galen also wrote the first and only (fluid imbalance) (Dezeimeris 1828). So a condition of reliable commentaries on Hippokratic medicine excessive xanthe chole (yellow bile) in the blood, for (Lichtenthaeler 1982). These five-volume instance, would be described as a xanthe chole diathe- Commentaries on Hippobates are uniquely significant sls, a yellow bile syndrome (diathesis, pattern). A rn that to this day they rcpresent the best in-depth kakochymia can be simple (with one fluid dominat- introduction to the source of Greek medicine written ing), or mixed (with two or more fluids dominating); it as they are by a master theorist and clinician com- can be equal (affecting all organs or body parls equal- bined. Moreover, Galen able, predictably, articu- is to ly) orunequal (affecting these differently). In addition, late and refine Hippokatic theory. A master of dialec- the excessive quality (ofcold, heat, dry or damp) cre- tic reasoning schooled in Stoic and Aristotelian ated by any particular fluid is termed auimonia, an thought, he always critically asks the "why" and the acrimony. Note that the four-fluid syndromes "how" of a particular concept. He then proceeds to described in Hippokratic and Galenic medicine are dif- give his in-depth explanations, commentaries and ferent from diseases; they are to be understood as a pri- digressions, based partly on his clinical experiences mary functional disturbance seen through the symp- and partly on his fine erudition that spans five cen- toms-signs presenting, and in that sense are similar to turies. the TCM zandu syndromes. The cornerstone of Greek medicine for describing Key to diagnosing four-fluid syndromes are the health and disease is the four-constitution (tessara lva- semeia, the signs, which "follow disease like a shad- sels) theory, which is based on the four natural quali- ow." Great attention is paid to any fluid discharges, ties of cold/hot, dryldamp. The old physician including the urine and stool, as well to accompanying Alkmaion of Kroton had stated" "health is the even (and possibly secondary) signs and symptoms. Care is mixture (synmetros lcrasis) or balance (isonomia) of taken to differentiate between symptoms of elimina- the effective qualities (dynameis)," while disease is a tion, symptoms of retention and symptoms of injured "predominance of one of the four qualilies (moni- action. Treatment of the fluid syndromes runs along archia)." However, to achieve a balance of the four the principles of either kata physis or kata diqthesis. qualities in physiology, i.e. to treat a quality's imbal- Treatment kata physis, literally "through the constitu- ance, usually meant going to the four nutritive fluids tion," means supporting nature and conserving consti- (tessara chymoi), since they are the vehicles ofthe four tutional strength. It is employed mainly in kenos, defi- qualities. The Hippokatic doctors therefore eventually ciency conditions, in which the aim is plerosis, sup- developed a specific four-fluid (tessara chymoi)phys- plementation or replenishment. Treatment kata diathe- iopathology and treatment whose ultimate aim was to srs, literally "through the syndrome," on the other qualities re-establish a balance ofthe four based on the hand implies dispelling the mochtheros chymos, the individual constitution (physis). toxic fluid, or the hyle blabetike, the noxious sub- A fluid (chymoi) is a nutrient found in the blood that stance, with the use of contrary remedies (remedies whose dynamels, qualities, opposite to results from food and drink intake, whose function is effective are that the disease condition). is used mainly in to maintain internal homeostasis and to nourish and of It pleros, or fuIl, conditions in which the aim is kenosis, vilalize the body. Galen's usage of this theory in prac- draining or elimination. Here Galen fleshes out in full tice provides a key example ofhow he elaborates and detail the principles oftherapeutics that his predeces- fine-tunes the basic Hippokratic concepts. For sor had outlined along pure vitalistic lines. instance, while blood (haima) in Hippokatean theory is strictly one of the four fluids that maintains internal Treatment of the four-fluid syndromes aims essential- homeostasis, in Galen's view blood is special in that it ly to correct the particular f\tid dysbasia,4r.akochymia represents a "balanced mixture (eukrasia) of the other presenting. It consists primarily of dietary measures three fluids." In pathology therefore, the blood itself and herbal treatment. Focusing on the latter, the basic can become injured mainly by a poor mixture of the theory for herb selection is the four-quality (tessara fluids (kakochlrnia, originally called dyskrasia by dynameis) theory. Among Galen's three major herb Hippokates), in which one or more of the fluids classes, Eliminants, Alterants and Restoratives, it is the becomes dominant, and the others deficient. The blood Alterants that can directly change the balance of the
Journal of the American Herbalists Guild 13 four fluids (note that "alterants" are different from without having access to, and comprehension of, hrs today's "alteratives"). The specific aim is to balance complete work (or a good condensation thereof--a any excessive qualities or aloimonia caused by a fluid "portable Galen," no less)-it is extremely difficult not dyskrasia with the opposite qualities of the herbal to present a one-sided picture of the medical system. remedies. For instance, in the patient presenting the The same problem existed with texts on Chinese med- yellow-bile excess syndrome, the excessive qualities icine written before the 1950s, most of which just por- present are heat and dryness-those being the primary trayed selected aspects of the whole system, such as qualities of that particular fluid. Treatment will there- acupuncture, for example. fore aim to reduce injurious heat and dryness with the Galen's breatr (pneuma) model of vitalistic physiolo- use ofherbs possessing the opposite qualities of cold- gy also survived up to the nineteenth century, albeit in ness and moisture. Decoctions of col{ moist-natured corrupted form. As with the four-fluid theory linguis- remedies and foods are then prescribed, such as marsh tic-cultural problems hindered its effective transmis- mallow root, Solomon's seal root, purslane, chickweed times, in addition to the fact that the and endive. Other influences-social, climatic and sion into modern concept is possibly by nature the most difficult of all geographic-that can increase the cold, moist qualities concepts understand. Ibn Sina in the patient's life are also encouraged, as the individ- of Galen's to (Avicenna), the foremost developer of Galenic medi- ualh internal condition will, from the Platonic "ener- the eleventh century, for instance, spent an getic" point of view, resonate in sympathy with the cine in inordinate amount of ink and paper explaining what external environment. Galen in his practice would lit- and what is not (Ibn Sina 1930). The erally order his wealthy patients to make prolonged breath is it physician makes it clear that pneuma rs not stays in far-flung outposts of the Roman Empire, Persian "spirit," or even "vitality," while being at the including North Africa (to promote heat and dryness), "soul," source all of those particular faculties. Galen's the Italian Alps (to promote cold and dryness), as well of three-breath concept originated with Plato's tri pneu- as to locations closer to home, such as the North Italian mata (three breaths), in which the original breath pass- lakes (to promote cold and damp) and the Southern es through different body-centers to generate three dis- coastal resorts (to promote heat and damp). And all his tinct breaths: admonitions were carefully thought out in relation to the patient's age, sex and four-element constitution I Pneuma physikos, the "natural breath," housed in (lvasis). the Liver, which governs growth and digestion, and innate moisture. Using Hippokatic medicine as the foundation, Galen is linked to the the eclectic incorporated numerous other strands into 2 Pneuma zotikos, the "vital breath," housed in the his medicine. Key among them is Aristotle's tissue his- Heart, which governs warmth and circulation. tology, Plato's widely accepted teaching on pneuma, 3 Pneuma psychikos, the "soul breath," housed in the and the Methodicists' system of physiotherapy. Brain, which governs thinking. Aristotle's differentiation of organs and tissues had important consequences for the Methodicists, who dif- The three-breath and the four-fluid theory are comple- ferentiated between a status strictus and a status laxus mentary and form the basis for Galen's physiopatholo- of tissues-a "tightness" and "weakness" of tissue ten- gy system. sion or tone. Galen's adoption of this essential tissue pathology meant nothing less than its survival to the Galen's Pharmacy modern era among Eclectic and Physiomedical physi- Galen utilized a large number of rcmedies, phar' cians, via numerous practitioners in between (as in makon, in his practice. In keeping with Greek medi- Robert Brown's irritability theory). Certainly this tis- cine in general, these were obtained from plants, min- sue pathology has survived longer into modern times erals and animal parts (as in the other classical medical than the four-fluid pathology, which in the early 1800s systems). The remedies were sourced mainly from the was jettisoned by French clinicians, and then soon by Mediterranean basin, which was also the essential the rest of the West. It is thus a mistake to think that extent of the Roman Empire, and included what is now Greek medical pathology and treatment is entirely modern Greece, Turkey, the Middle Eastern countries based on fluid pathology. This one-sided view was bordering the Eastern Mediterranean, Egypt and all inadvertently fostered by the many popular writers on other North African countries to Spain. health and domestic medicine between about 1500 and 1700. With limited access to Galen's work, they never- Galen stresses the importance of determining the theless compensated for their lack of reliable sources authenticity of the herbs and minerals in light of com- by a particularly infectious enthusiasm. This again mercial substitutions and falsifications-especially points to the perennial problem with Galen's work: those from distant lands. Examination should be done
14 Spring/Summer 2O02 HEstory anol Phnlosophy
should be understood as relative, dynamic concepts, however. It is the human condition that ultimately determines whether a remedy will act as an antidote or a nutritional remedy, or possibly as both.
Galen's groups of similar-acting herbs he possibly cre- ated for memorisation purposes. These were handed down in materia medicas and formularies right down to the eighteenth century. Examples of these are (uncertain modern plant names have been left in the € original): =c F . The five greater opening roots ("Opening" implies o "opening obstructions," especially of the kidneys): Rosa rugosa (rosehips) fennel, celery, asparagus, parsley, butcher's broom . The five minor opening roots: Capparis, eryngium, through visual inspection, tasting and water macera- couch grass, Omonis, madder tion (the latter process shows whether the herb remains . The five emmollient herbs: marsh mallow, mallow, compact or dissolves, thereby proving a falsification). Mercurialis vel Beta, Parietaria, Violaria vel For instance, Myrrh resin and Costus root to gen- be Mercurialis uine possess particular visual characteristics. Crocus . The four major warm seeds: aniseed coriander, stamens should be bright yellow and should possess a cumin, fennel pleasant, tenacious scent; this remedy should be stored . The four minor warm seeds: cretan arnmy, car- with particular care in a cool shadowy place to pre- damom, celery, carrot serve its color and fragrance. Cinnamon bark should . The four major cold seeds: cold and moist water- have a pleasant, ineffable (anetos) fragrance and a melon seed, cucumber seed squash seed, melon warming but not biting taste. seed
In his texts Galen also describes the careful preparu- . The four minor cold seeds: cool and moist chicory tion of remedies to preserve their qualities, as well as endive, letluce, purslane the preparation of compound remedies, or formulas. A . practical herbalist as well as a theorist, he preferred to The four cordial flowers: rose, violet, borage, prepare his own formulas into decoctions, fluid bugloss extracts, syrups, plasters, etc. Galen stored his simple and compound remedies in closed wooden boxes Galen's Vitalistic Pharmacology (aggeia psylina) in a special room in his clinic, which Galen classifies his remedies in a number of different he called the apotheke. Pragmatic also, in one text he ways, some more practical, some more theoretical and gives an alphabetical list of remedies and their possi- based on Aristotelian principles. They can all help us ble substitutes, in case one should run out of a partic- today understand the way he would use them in clini- ular remedy. The substitution is made on the basis of cal practice. His fundamental classification for clinical both remedies having identical qualities. practice is the three remedy classes, which are organ- ized as follows: Galen's pharmacy thus included both single remedies (eililcrinos echon) and compound remedies or formu- I Eliminants, which promote an elimination of toxic las. Single remedies are prescribed for specific condi- fluids (including diaphoretics, diuretics, purgatives, tions on an empirical basis with respect to their inner emmenagogues, expectorants) nature and specific actions. Provings or experimenta- 2 Alterants, which alter the balance of the four nutri- tions of the single remedies are carried out first on tive fluids individuals in good health, second on those with ill- ness and third on those with debility. Here Galen's 3 Restoratives, which supplement in deficiency or exposure to the Empirical doctors of Alexandria has exhaustion conditions clearly left its mark. These particular categories were preserved in the Those remedies designed solely for internal use and materia medicas and formularies of Galen's Islamic for dispelling pathogens he calls antidotoi or antidotes. successors and then in the Central European phase of These are in contrast to the trophe or nutritive reme- Greek medicine well into the eighteenth century. They dies used for supplementation (tonification) in defi- can thus be considered the backbone categories for ciency conditions. Antidotal and nutritive remedies traditional herbal medicine practitioners.
Journal of the American Herbalists Guild 15 The fundamental concept for describing remedy cold and moist in the second degree; henbane, hem- actions in terms of treating quality or fluid imbalances lock and poppy are cold in the fourth degree; horsetail is the effective quality (dynamis). Each remedy pos- is dry in the second degree. Juniper berry is warm in sesses primary secondary and tertiary qualities, the the third degree, aromatic and drying; its tertiary qual- balance of which makes up its unique actions and indi- ify would be urination-causing and detoxiffing. cations. The balanced or temperate remedies that neither cool . Primary effective qualities: hot/cold (the warmth nor warrn are calledmesa pharmaka, middle remedies; grades), dry/moist (the moisture) they are a yardstick by which warming and cooling . Secondary effective qualities: relaxing, astringing, remedies can be evaluated. This warmth-grade system softening, hardening, thinning, thickening, etc. derives from the Dogmatic and Pneumatic medical . Tertiary effective qualities: sweat-causing, urina- schools in Alexandria. purging, detoxifying, tissue-repairing, tion-causing, Galen also rates each remedy's warmth grade on an etc. intensity scale of weak, medium or strong, as follows: qualities used The primary and secondary effective are . Weak intensity: remedies that possess a mild qualities' The to treat conditions opposed to that ofthe amount of heat or cold; e.g. rose ointment has a actions on tertiary qualities are the remedy's specific weak intensity. diuresis, diaphoresis, purga- organs or tissues, such as . Medium intensity: remedies that possess a moderate are not derived (i.e. inde- tion, tissue-healing, which amount of warmth, etc.; e.g. rose is moderately cold qualities. pendent) from the primary and secondary (i.e. cold of medium intensity). in some remedies the primary qualities can Note that . Strong intensity: remedies that possess a powerful produce action like that ofthe terti- already a specific amount of watmth, etc; Rhus, Alumen, Galla' ary qualities. While Galen considers the various remedy qualities possess following secondary The primary qualities the extremely important, curiously enough, of the 475 qualities: remedies mentioned in his extant texts, only 16 I actu- indications. Harig's conclu- . Hot: thinning, resolving, detoxifl,ing, opening, soft- ally have warmth-grade sion (1974) is that perhaps the grade system was less ening, etc. important in practice than in theory. He speculates that . Cold: repelling, thickening, rendering crude in actual practice the remedy's intensity was perhaps . Dry: astringing . an even more important consideration than its warmth. Moist: smoothening Certainly Galen always considers the basic warming or The warmth-grades (tarls) belonging to the primary cooling effect of remedies when discussing the treat- qualities are: ment of hot or cold disorders; but he rarely mentions . required to hot - balanced - cold the particular grade of warmth or coolness counteract the intensity of a heat or cold condition. Both the heat and cold grades were in theory subdi- vided into four grades, resulting in a total of eight pos- Galen considers the remedy's taste mainly as a confir- sible warmth grades (this was multiplied by two in Ibn mation of its primary qualities rather than independent Sina's later system). Likewise, dry and moist were also secondary qualities. The resulting correlations are as divided into four grades each. A later example ofthis follows: grading system is seen in William Cole's 1656 The Art . Sweet: warm, moist of Simpling, for instance which sticks closely to . Bitter: warm, dry Galen's original grading system and herb examples. . Pungent: hot Some examples to illustrate how the primary qualities . Sour: cold, dry earthy ofherbal remedies are described. Fenugreek is hot in . Acid: somewhat cool, moist, dissolving the first degree and moist in the second; holy thistle is . Astringent: cool, dry, thickening hot and dry in the second degree; angelica is hot in the . Salty: warming, detoxifuing, corroding and second and dry in the third degree; thyrne, hyssop . Insipid: cold moist hot and dry in the third degree; leek, marjoram are all . Oily: warming cress and garlic are all hot and dry in the fourth degree; myrtle is cold and dry in the first degree; rose is cold Aromatic or fragrant remedies are always considered and moist in the first degree; shepherd's purse is cold "of thin substance and therefore warming," while non- in the first degree and dry in the second; chickweed is fragrant remedies tend to be more earthy, dense and
16 5pring/Summer 2002 Hrstery end Fhrlosophy
thus cold. Herb color can also indicate various quah- ties in general:
. Pale or white: moist . Yellow: hot . Red or scarlet: hot, dry . Green: moist
Ultimately, it is the human response to the remedies that deterrnines their qualities. Despite Galen's fine analytical thinling, he acknowledges pragmatically that "it is unimportant whether a substance is innately warm, cold, moist or dry; rather what is important is whether it acts warming, cooling, etc. in the human body." He gives the example of sea water, which is wetter than the body but has a drying and warming effect. Because of this, he stresses that remedies can exert different actions according to a person's age, sex, habits, diet and do on. Galen clearly defines a vitalis- tic pharmacology system that is not fixed or linear, but rather dynamic and dialectic-despite its solid analyt- ical underpinnings. This fact, which is borne out in his clinical practice, should be kept in mind when review- ing the finely differentiated analysis ofremedy actions to follow.
When discussing remedies in terms of their effective qualities and the dyskrasias they address, Galen defines three pharmacological categories of remedies:
1 Remedies that convey the primary effective quali- possess a moderate action and are to be used ties (dynameis). Predominantly warming, cooling, halfway between the onset and the resolution of a moistening or drying by nature, the remedies in this disease condition. category have the sole function of altering the indi- vidual's balance of the qualities of heat, cold, damp In another text Galen discusses what we would call and dryness. They are thus used only to treat partic- pharmacodlnamics, and defines the following four ular dyskrasias. mechanisms of remedy actions: 2 Remedies that convey both primary and secondary I Remedies that are not altered after ingestion, but qualities. For instance, some herbs are primarily that alter the body. warm and secondarily bitter, sweet or pungent. 2 Remedies that are stimulated by the body and Other herbs are primarily cool and secondarily sour become altered and thus alter the body. or salty; and so on. These first two remedy tlpes are called deleteria or 3 Specific remedies which work "through their entire toxic remedies, and should not be used; they include substance" to create a physiological response, such mercury. belladonna. aconite. etc. as purging. sweating, vomiting. etc. 3 Remedies that produce an effect on the body with- out injuring it. These include most generally used Galen further differentiates between three different remedies. types of balance of remedy effective qualities: 4 Remedies that produce an effect on the body as well I Remedies thatpossess an "absolute" or single qual- as becoming altered themselves, i.e. becoming com- ity (haplostherma); e.g. solely cold, hot, dry or pletely assimilated. These are nutritive/trophic moist in quality remedies and foods. 2 Remedies that possess a predominant quality and Only remedies with the last two tlpes of effects should other secondary qualities (kat epilrratedin); e.g. be used therapeutically. mainly warm and secondarily dry 3 Remedies that possess an even mix of qualities In addition, a remedy can have one of four types of Qtros to symmetron homogenes). These remedies effects, natural or accidental, and actual or potential.
lournal of the American Herbalists Guild 17 1 Remedies that possess a natural effect are those Dezeimeris, Olivier. Dictionnaire historique de la m5decine ancienne et moderne (4 vols.). Paris, 1828-1839 whose effects result from their own nature. A natu- Diegpen, Paul. Geschr'chte der Medizin. Berlin 1949-1955 the immediate cooling or ral effect can be sensed by Kultur and Medizin. Stuttgart, 1925 warming sensation on the skin or tongue; it tends to Galenos, Claudios. Complete works (see Daremberg, Kuhn, increase after ingestion. -.translators) opera omnia. Yenezia, 1525 2 Remedies that possess an accidental effect are those Techne iatrike [Ars magna, or Megateqnd (translat- whose effects result from an accidentally acquired -.ed bv Gerard of Cremona as A's,1487; translated by quality. Water, for instance, although cooling by Nich6las Culpeper as Galen's Art of Physick, London, 1652) -. magna, or innate quality, can produce warmth by accidental . fhsr'6p6utike methodos [Ars Meqateqnil, translated by Thomas Linnacre as Methodus reaction; plantain is primarily cool and accidentally n"'dendi,- Paris, 1519; trjnslated by P Engrish as Galen's drying, as coolness can also astringe; peppermint is Method of Physick, Edinburgh, 1 656) Ali Alhossain (Avicenna) Al qanun' vol. 1. innately warm and accidentally cool by the acciden- lbn Sina, Abu Bagdhad, 1 1th cenury. Translated and edited by O.C. tal reaction of sweating. These types of remedies Gruner, London '1930 tend to weaken in potency after ingestion. Harig, Georg. Bestimmung der tntesit1t im Medizinischem System Galen's. Berltn, 1974 Remedies that possess an actual effect are those that 3 Holmes, Peter. The Energetics of Western Herbs: Treatment possess a dominant quality. These remedies are Strategies lntegrating Western and Oriental Herbal directly warm, cool, dry or moist to the touch. Medicine (2 vols.). Boulder, 1998 llberg, J. Aber die Schriftstellerei des Klaudios Galenos. those 4 Remedies that possess a potential effect are 1889-1897 whose effect is capable of becoming an effective lnstitute of History of Medicine and Medical Research, quality only upon body contact, when it becomes an Deoartment of Pliilosophv of Medicine and Science. Th6ories and Philosophiei ol Medicine. New Delhi, 1973 effect. This includes a large number ofherbs' actual Kremers, E., and Urdang, G. A History of Pharmacy A remedy's potential effect can only be determined Philadelphia, 1940 retrospectively by deductive conclusion. Kuhn, C.G., editor and translator. Galeni opera omnia (22 vols.). Leipzig, 1 821 -1 833 In addition, Galen notes that a remedy's effect can be Lichtenthaeler, Charles. Geschrchte der Medizin Koln, 1982 hippocratique. Neuchatel, 1957 judged by four different mechanisms of action: La mddecine Littr6, Emi le, tra nslator. Oevres com pl dtes d' H ip pocrate (10 vols). Paris, 1839-1861 1 By the absolute action of the four effective qualities -. Meyer-Steineq, T. On Galen's Physiology. Archiv der 2 By the actual action of the primary effective quality Geichichte der Medizin. '1912 where one or two qualities predominate Meyerhof, M. Die Materia Medica Vol ll des Dioskurides, in "Qiellen und Studien zur Geschichte der judged by the mean 3 When the remedy action is Naturwissenschaften und der Medizin." Stuttgart, l933 effect, e.g. on both children and old people Neuburqer, Max. Geschrchte der Medizin Stuttgart, 1906- 4 When the remedy action is judged by accidental 191 1 J.S. Galen on the Vascular System PR S.M. people Prendergast, comparison, e.g. in two different 1927-1928, xxt Schelenz, Hermann. Geschichte der Pharmazie Berlin, 1904 While this survey of Galen's herbal medicine is far Schoner, Erich. Das Viererschema in der Antiken Humour from complete, it will give some idea of its fully artic- alpathologie. Wiesbaden, 1 964 ulated yet dialectical complexity. It will hopefully also Siegel, Rudolph E. Galen's System of Physiology and Medicine. Basel and NewYork, 1968 convey a sense of its deeply vitalistic nature, which is Sigerist, Henry E. The Great Doctors New York, 1933 highly "user-friendly" for the practitioner. Sinqel Charles, and Ashworth Underwood, E A Short Hislorv of Mediclne. Oxford, 1962 that this brief sketch of an original thinker It is hoped Sprengel, Cutt. Histoire de la mldecine. Paris, 1815 the path for and herbal medicine practitioner will clear Sudhoff, Karl. Kurzes Handbuch der Geschichte der further explorations of Galen the man and the medical Medizin. Berlin, 1 922 u Ph a rmacoru m U n iversa le. system he helped develop. Greek medicine is our Tri I ler, D.W. D ispe nsatori m Frankfurt, '1764 therapeutic wisdom-one that Western heritage of a Tsch i rch, Alexander. Gesch ichte der Ph rma kognoscie may hold a key for herbal medicine today. (3 vols.). Leipziq, 1909-1925 Ullman, Manfred. Die Medizin im lslam. Leiden, 1970 1985 References Unschuld, Paul. Medicine in China. Berkeley, Urdang, George . History Ethics and Literature of Pharmacy Mediclne. New York, Ackerknecht, E.H. A Shoft History of Baltimore, I944 1 955 Walzer, R. Galen on Medical Experience. London, 1944 Artelt, Walter. Einfuhrung in die Medizinhistotk. Stuttgart, E.f .W. Medical History from the Earliest Times. 1949 Whitington, London, 1 894 Bayle, A.L.J., and Thillaye, A). Biographie mddicale Paris, Wilder, Alexander. A History of Medicine. 1904 1 855 Berendes, J. Die Pharmazie bei den Alten Kulturv1lkern (2 vols). Stuttgart, 1891 Daremberq, Charles, translator. Oeuvres anatomiques, phys- '1854-1856 iologiqueiet mddicales de Galien (2 vols). Paris,
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