The Other Humours

Humour is a strange word, in so far as we mostly use it in a very limited way today, a way that does not reflect the original wide range of its meanings. But such could be said of a host of other words in our common parlance today, which we use to describe certain instruments of human perception and expression. ‘Intellect’ being another one, a word that originally was never meant to be limited solely to a dry rational faculty. The constant confusion between words such as ‘spirit’, ‘self’ and ‘soul’ in modern language is another example (at least the learned people in medieval Europe and in the classic Islamic Era knew quite well that these three are completely different parts of our being). The word humour has also changed its meaning in a way that has made it more precise in some ways but also caused it to lose much of its original subtlety.

The word humour is originally a Latin transliteration of the ancient Greek χυμός (chymos), a word that literally means juice or sap but that, similar to the Sanskrit râsa, can also metaphorically mean ‘flavour ‘. According to the medical theory of the ancient Greeks, a tradition that we identify with ancient scholars such as Hippocrates and Galen, four ‘juices’ are flowing within every human being’s body: blood, yellow bile, phlegm and black bile. And it is the precise mixture and balance of these juices that determines both the character of an individual and their state of health.

The contemporary reader will recognise three of these juices easily as actually existing fluids of the human body. But the fourth will probably be a mystery to many. What is this enigmatic ‘black bile’? Blood and phlegm are easy to recognise. We also know the ‘yellow bile’ that we usually just call ‘bile‘, even though we also know that it is somehow related to bilirubin, the source of the characteristic skin colour that sufferers of diseases such as ‘yellow fever’, hepatitis and liver cirrhosis often acquire. Strangely, as a remnant of the old Greek idea of a connection between these humours and character traits, we also associate ‘bile’ and ‘bilous’ with unpleasant behaviour. But this ‘black bile’ is a stranger to most of us. At least it seems to be. In truth, it isn’t that much of a stranger to us. We only use words derived from it in their ancient Greek form. In ancient Greek, ‘black bile’ was called μέλαινα χολή (melaina chole). From which derives our word ‘melancholy’. A person who is melancholic is literally a person who suffers from an imbalance (usually an excess) of ‘black bile’.

Black bile is, in fact, nowhere to be found in the human body. There has been speculation that the idea may be based on a Greek misunderstanding regarding the formation of gall stones or the function of the spleen. The Greeks did not simply make up their theory of humours, however. It was based on their scientific understanding of the time and on observations and examinations. Naturally, during that era people were unable to observe the work of bacteria and viruses the way we can today so they developed a different theory of health and disease. The idea of the four humours formed the most significant element of their theory, but there were other important factors as well – such as the influence of ‘cold’ and ‘warm’ elements around us. Interestingly, even though we know that a tangible substance called ‘black bile’ does not exist in our bodies, we still use various concepts that eventually hark back to the ancient Greek theory. The idea of ‘melancholy’ being one of them. But we likewise employ an expression based on this theory when we say that we have caught ‘a cold’. We call certain people ‘phlegmatic’, a word that refers to an excess of phlegm. And others we name ‘choleric’ referring to a preponderance of yellow bile (chole). The word ‘sanguine’, indicating an excess of blood, isn’t used as often anymore, it seems, but it is still part of literary language.

Greco-Roman medicine, as mediated by Assyrian Christian and later Muslim scientists such as the great tenth century philosopher and physician Ibn Sina, was for centuries the default theory of medicine in a geographical region stretching from the British Isles to the Tianshan mountains. For much of the European Medieval and Renaissance period the most progressive developments and advanced state of knowledge was to be found in the Muslim World. At that time, Europeans often looked to translations from Arabic texts to broaden their medical knowledge. Some even ventured towards the East to gather first-hand information on the most recent breakthrough in the field of science. One such journey has been fictionalised in Noah Gordon’s 1986 novel The Physician, which relates the tale of a Christian English boy of the eleventh century studying medicine in Isfahan, Persia. Indeed, up until the eighteenth century Ibn Sina’s Canon of Medicine (Qanun fi’l-Tibb) was a major standard reference work taught at European medical colleges and consulted by all learned medical practitioners.

But a shift of paradigms had already begun in Europe in the sixteenth century, with a new medical theory emerging thanks to the efforts of the Swiss alchemist Paracelsus. Paracelsus’s theory was still quite different from our current ideas on disease and health but it set medicine on a new journey of discoveries. Inspired by his knowledge of alchemy, itself also an import from the Muslim World with Greco-Roman ancestry, he shifted attention away from the ‘humours of the body’ and to the study of substances such as toxins, thereby eventually enabling the rise of what we today understand as modern allopathic medicine. Granted that in the sixteenth century the glorious times of a Greco-Roman Islamic medicine based on humoral pathology were not yet over. The Muslim World still made important medical discoveries even at that time and this would later contribute to the current modern allopathic understanding of medicine as well.

In 1616, for example, Mughal emperor Jahangir, a man with a strong personal interest in medicine and other sciences, mentioned in his Jahangirnama that there seemed an apparent connection between rats and other rodents and outbreaks of the Plague amongst human beings. He credited this observation to his own niece. Much later, in the eighteenth century, as Iftikhar Malik writes in the Virus issue of Critical Muslim, Lady Mary Montagu learned the technique of smallpox inoculation from the women of Ottoman Istanbul and subsequently introduced it to England. Nevertheless, the Paracelsus paradigm had started to turn the tides as far as progress in medical science was concerned. From then on, European medicine seemed to have advanced steadily while the Muslim World appeared to have lost its leading role. While humoral pathology once used to be the default theory of medical science, it is now only used in some forms of alternative medicine, such as the traditions based on the medicine of the medieval German saint Hildegard of Bingen that remains popular amongst some people. Expressions such as ‘catching a cold’ and the romantic concept of melancholy belong to some of the very few persistent survivals of humoral pathology in our world.

It is fascinating that of all the humoral types, melancholy remains one of the most popular. Even though we still use words such as phlegmatic and choleric in certain contexts, but these terms never seem to carry the same weight that the idea of melancholy seems to convey. Melancholy is at the same time dreaded and loved. It is a type of depression but unlike the idea of clinical depression it also seems to carry inherent notions of beauty and creativity. The melancholic is often imagined as a genius or an artist, unlike the depresses, who more than often seems to be perceived as some sort of social failure. Melancholy is a mood related to yearning and nostalgia. But it may, just as clinical depression, also lead to suicide. In the Canon of Ibn Sina, already melancholy is something that may in some cases have to be treated. The presence of too much of ‘black bile’ must be curbed to guarantee the health of a human being. But on the other hand, people also carry their own particular mix of humoral juices within themselves and thus it is quite natural that some people have more ‘black bile’ than others and may be more inclined to melancholy than their counterparts. As such, unlike clinical depression, melancholy does not always have to be pathologised or treated.

Just as in the West the word ‘melancholy’ has a strange afterlife that is disconnected from any knowledge of humoral pathology, the Islamicate terminology surrounding ‘black bile‘ has acquired a certain autonomy from medical theory as well. More often than not, the idea of ‘melancholy’ is connected to specific types of music and poetry. The Arabic word for black bile is sawda. In the Islamic East this word became the takhallus or pen name of a famed Urdu poet, Mirza Muhammad Rafi ‘Sauda’, who died in 1781, something that led to an abundance of clever allusions to both him and the concept of melancholic madness both in his own poetry and the poetry of opponents and admirers alike. In modern Turkish, sawda is transcribed as sevda. An interesting assimilation of the word has happened here, for the Turkish verb sevmek means ‘to love’. Many modern Turks nowadays think of sevda as a word that is etymologically derived from sevmek. It is therefore understood as a kind of love. But according to its original meaning it can only be seen as an unhappy and unfulfilled love, a melancholic love. In the post-Ottoman Balkan nations, a whole genre of music is seen as the perfect expression of this kind of love, the sevdalinka. Bosnian Muslims see the sevdalinka and the melancholic spirit that comes with it as their very own, but it has its fans and its equivalents in all the other Balkan nations as well. Its orchestration draws on old Balkan folk music as much as from Sephardic Jewish and Turkish elements with lyrics full of broken hearts and shattered hopes. But even someone unable to understand its lyrics will immediately grasp the melancholic nature of this particular style of songs.

Another style of music often associated with intense feelings of melancholic desire is the Portuguese fado and it is therefore only slightly surprising that this type of singing is also associated with a word that seems somewhat reminiscent of the Arabic sawda: Saudade, a mood often described as a ‘profound longing for something or someone lost‘, a type of bitter sweet romantic yearning. In the case of saudade, the etymology is not as clear as in the case of the sevdalinka. The ultimate origins of the word have actually been a mystery to linguists. Many have tried to derive it from the Latin solitudo but that etymology has not convinced everybody. There is a certain tendency in the linguistic study of Iberian languages to explain away Arabic influences and to stress an uninterrupted Romance heritage but the fact cannot be ignored completely that Portugal has been a part of Islamicate Al-Andalus from 726 until 1249 and the last Portuguese Arab speaking Muslims were expelled only at the end of the fifteenth century. Cultural influences from that historical period persisted for a long time and even though what we know today fado only emerged centuries later, in the 1820s, it has often been noticed that the musical style does have audible similarities to North African Berber and Arab and Sephardic Jewish styles of music.

We see a strong Arab influence in Portuguese cuisine even today – with the popular Portuguese comfort food açorda for example derived from the Arabic al-thurda, allegedly the favourite dish of the Prophet Muhammad – and as food historian Rachel Laudan notes in Cuisine & Empire, the transmission of Arab recipes and techniques of cooking to the cuisines of later Catholic Iberia was often accompanied by a transmission of medical knowledge based on humoral pathology. In fact, it was most probably the Iberian peninsula where the work of Ibn Sina entered the awareness of Catholic Christian Europeans for the first time and gave birth to a renewal of medical sciences in Europe. Sawda was certainly a concept known to the Portuguese in the medieval and early modern period and the idea most likely had an influence on the emergence of saudade. It is also quite possible that, as in the case of the Turkish sevda, two etymologies merged into each other and saudade may be a love child of sawda and solitudo.

Thus, an Islamicate conception of the influence of ‘black bile’ has taken a musical form both in the most South-western and the most South- eastern parts of the European continent while it also still lingers on in the languages and folk medical ideas of Central and Northern Europe. The humoral tradition of medicine is still very much alive in other parts of the world, of course. In South Asia in particular there still exists a very vibrant tradition of alternative medicine that still carries the name Yunani, literally ‘Greek’, etymologically Ionian.

In countries like Afghanistan, Pakistan, India and Bangladesh it functions as a Muslim equivalent to the more Hindu-influenced Ayurvedic medicine and as a competitor to the likewise very popular homeopathic system. Yunani medicine directly carries on the legacy of Hyppocrates, Galen and Avicenna and up to this day many of its professionals often still consult the Canon of Ibn Sina in their practical work. For centuries Yunani medicine has coexisted with Ayurveda, however, and throughout the ages the two systems have become more and more similar to each other. Sometimes this similarity becomes a contentious object of nationalist sentiments. Hindu nationalists may often feel that Yunani medicine has borrowed far too extensively from Ayurveda, which they understood as the true origin of all medical knowledge. In fact, we can detect a lot of Ayurvedic borrowings in the writings and practices of Yunani practitioners, but there has also been a great deal of visible influence of Yunani medicine on Ayurveda.

The connection between the two medical systems may run even deeper than the Islamic period, for the dosha theory on which Ayurveda is based has so many strong parallels with the Greco-Roman humoral pathology that some scholars have speculated that it may have its origins in the Indo-Greek kingdoms that ruled over parts of today’s Afghanistan, Pakistan and North India in the period between the exploits of Alexander the Great and the beginning of the Common Era. Strong similarities also exist between both systems and other medical systems of Asia, such as Tibetan, Mongol and even Traditional Chinese Medicine. One may speculate that all of these systems owe something to mutual influences and exchange of knowledge along the Silk Roads, from the Hellenistic Age up to the times of Ibn Sina. We also have to acknowledge in this context that the ancient Greeks probably did not entirely invent their humoral medicine on their own but that they were strongly influenced by the vast medical knowledge of the ancient Egyptians and Mesopotamians, who in turn had interactions with the people of the Indus Valley Civilisation.

The idea that very different medical theories can nevertheless all benefit human beings often bothers the human mind. There has for long been a consensus amongst Western allopathic physicians that alternative theories of medicine are just quackery. But in recent decades Traditional Chinese Medicine in particular has made some strong inroads in the West and the results of its methods of treatment have been baffling to many people schooled in modern allopathic medicine. The theory behind practices such as acupuncture, for example, appears as complete nonsense according to the standards of modern allopathic medicine but nevertheless is has become a more and more accepted fact that acupuncture can seriously help people suffering from certain ailments, such as migraines, and that relief is based on more than just a placebo effect. These realisations have also engendered a more thorough scientific investigation of medical systems such as Yunani and Ayurveda. In India in particular it is nowadays not uncommon to find medical institutions where Yunani and Ayurveda are both studied and used along with allopathic medicine.

We should indeed not forget that, eventually, both Yunani medicine and modern allopathic medicine go back to the work of Ibn Sina. Even if the sceptical scientistic allopath cannot accept Yunani medicine as a valid alternative to his own theories and practices, he must at least regard it as an old relative, maybe one that is a little out of tune with the developments of the world. In reverse, to the Yunani practitioner, allopathic medicine would often look like a young man filled with vigour and energy but not yet able to entirely grasp what life is about and how to keep its quality in balance. Due to this old relationship, it is therefore not surprising that many of the practices and treatments of Yunani medicine actually do make sense from an allopathic perspective, even though the theories behind the two have diverged so significantly from each other. Hippocrates, for example, prescribed tea made from the leaves of willow trees to reduce high fever. Modern allopathy has identified acetylsalicylic acid as an active ingredient of willow that brings down fever and fights pain and we still use it today in the form of aspirin for other fevers. Humoral pathology has no knowledge of this chemical substance, instead it assigned certain humoral characteristics to willow leaves. The patient may or may not be aware of both the properties of acetylsalicylic acid or of his humoral constitution but whether treated by an allopathic physician or a specialist in Yunani medicine, he will notice that the treatment is successful and will give him relief.

In the case of melancholy, Ibn Sina prescribes for mild cases a treatment with lavender. His Canon notices that it purges out an excess of black bile. And, indeed, modern placebo-controlled studies have found that lavender has sedative, anxiolytic and neuroprotective properties and can give some relief in mild cases of clinical depression and anxiety attacks. Modern medicine has quite a different understanding of why some active substances in lavender my have these properties, according to Ibn Sina’s findings, but in practice the results are the same. Some other treatments suggested by Ibn Sina seem almost shockingly modern: Basing his claims on the works of Galen he writes in his Canon, ‘When a live electric-ray-fish is brought near the head of a patient, it serves as a sedative’. A surprising precursor to electrotherapy.

Sometimes we may today notice that allopathic medicine is in some ways turning back to the principles of Ibn Sina and the ideas of Yunani medicine. Modern medicine now accepts, for example, that the mental constitution of a person may be influenced by his nutrition, and may also have an influence on his immune system and his physical constitution. It was the observance of interactions such as these that originally gave rise to humoral pathology and produced ideas such as the concept of melancholy. Generations of modern medical professionals have treated phenomena such as clinical depression as either a purely psychological problem that could be changed through psychotherapy or as an imbalance in the brain that could be treated easily with antidepressants. Further study of the matter has then led many specialists to favour a combination of both. But a more recent understanding of clinical depression suggests that this disease can be rooted in a number of intersecting problems, some of them psychological and related to brain chemistry but some others also related to social factors, life circumstances, organic inflammation, lifestyle and nutrition. Ibn Sina and the masters of Yunani medicine did in fact keep an eye on most of these factors when treating a supposed excess in ‘black bile’. Ibn Sina would not just have given a person suffering from melancholy some concoction of lavender and other substances. He would have asked the patient about his daily routine, his food habits and his socio- economic situation. Where possible he would have suggested changes in diet and lifestyle. In fact, according to the principles of humoral pathology, unhealthy nutrition is one of the most common sources of humoral imbalances. At the same time, some of Ibn Sina’s treatments remind us of certain modern types of therapy employing nutritional and pharmacological knowledge as much as talking therapy.

A widely cited anecdote often told about the great man, first related by the Persian poet Nizami, is about how Ibn Sina cured a prince from a madness caused by an excess of ‘black bile’. The prince suffered from melancholy and gave up eating properly. His excess of ‘black bile’ only increased and his madness intensified to the extent that he imagined himself as a cow. And not only had he started to think of himself as a cow, but again and again he asked the people around him to slaughter him, cook him and eat him. Eventually Ibn Sina was called to help the young man. When he examined the prince for the first time he said, ‘this cow is too lean. If we want to slaughter it and eat it we should first fatten it properly’. Ibn Sina designed a diet for the young man, both providing him with proper nutrition and with medical substances to balance his humours. Under the pretence of being fattened for slaughter, the prince agreed to eat the diet prescribed by Ibn Sina. He examined him every day, talked to him, and showed his care while never trying to convince him that he was not a cow. Eventually the prince recovered from his madness.

Melancholy is not a humour that is meant to make us laugh. But Ibn Sina’s wit in healing the melancholic prince is something that should make us smile at least and it is certainly something that many modern medical professionals can still learn from.

* This text was first published in Critical Muslim magazine on 20 May 2021. Published with permission of the author.

Orphans of Uganda
Donate without Middlemen

100% of your donation reaches directly to the children in need!