Wednesday, August 28, 2019


Keith Andrew Stewart, Galen's Theory of Black Bile: Hippocratic Tradition, Manipulation, Innovation. Studies in ancient medicine, 51. Leiden; Boston: Brill, 2018. Pp. ix, 178. ISBN 9789004382787. €94,00.

Reviewed by Courtney Roby, Cornell University (

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This brief and focused monograph seeks to explain the details of, and resolve some questions about, Galen's characterization of black bile and the mechanisms by which it causes disease. With admirable clarity, Stewart states explicitly at the beginning of the book both the shortcomings of the (considerable) prior scholarship on black bile he seeks to remedy (5) and his plan for doing so (6). The shortcomings outlined here are attributed to scholars (most centrally Jacques Jouanna 1) who exaggerate the influence of the Hippocratic Nature of Man on Galen's theory of black bile, consequently find inconsistencies among Galen's several accounts of its production and bodily effects, and end up sweeping those inconsistencies under the rug in an effort to "save the phenomena" of Galen's dependence on the single Hippocratic text.

The remedy Stewart proposes here is a four-part plan. He begins by demonstrating that Nature of Man is but one influence on Galen's theory, then moves on to study the features of Galen's theory of black bile in more detail, and shows how Galen manipulates evidence from the Hippocratic corpus and elsewhere. He finishes by demonstrating how Galen's opinions on the authenticity of various texts (and parts of texts) in the Hippocratic corpus influenced his theory-making. Stewart does not follow this plan in chapter-by-chapter order, but rather incorporates elements of each of his four steps into several of the chapters in the book; the first, third, and fourth steps are most thoroughly explored in the first two chapters, while the remaining five chapters are more completely dedicated to explaining Galen's own theory.

The book begins with a brief history of humoral theory, unsurprisingly with a particular focus on black bile. Stewart is keen here to emphasize the importance of the Aristotelian distinction between "elements" and "residues" for Galen's discussion of black bile (8), and categorizes Galen's use of Aristotelian language in On the Elements According to Hippocrates as one of the titular "manipulations" (18), though he notes further that "Aristotle is relegated by Galen to being someone who has continued the work of Hippocrates on elements by providing some demonstrations of Hippocrates' theoretical framework" (16). A quick review of a few other authors (e.g. Diocles and Theophrastus), who might have participated in the debate about humoral theories versus theories predicated on elements or qualities, rounds out the first chapter.

The second chapter reviews the most important influences on Galen's theory of black bile. Stewart argues that philosophical authors may have served as implicit influences on Galen's logical argumentative structures and his teleological views, but the early influences on Galen are dominated by the Hippocratic corpus, notwithstanding Galen's retrospective "manipulation" of those texts to make them appear to share his teleological commitments (28). A brisk history of the fortunes of the Hippocratic corpus at Alexandria and elsewhere in the late Hellenistic period and the first century CE, with a particular focus on earlier assessments of the authenticity of the various Hippocratic texts, paves the way for a more detailed consideration of Galen's own opinions about the authenticity of the various relevant Hippocratic texts (notably Nature of Man) in the second half of the chapter.

The remaining chapters take up Galen's own theory of black bile in more detail, beginning in the third chapter with his explanations of its essential structural properties. Galen draws much of this material from Nature of Man, but Stewart takes care to point out where he expands on the Hippocratic theory to label black bile "earth-like" (63) or compare it to wine-lees or other sediment (67), physical features which will turn out to be important for black bile's physiological effects in causing disease. The fourth chapter furnishes the heart of Stewart's innovation on past scholarship on black bile; Stewart draws not only on Galen's On Black Bile and On the Natural Faculties, the texts of interest in Jouanna's discussion of the problem, 1 but also some of his Hippocratic commentaries, On the Causes of Symptoms and others. Jouanna finds inconsistencies in Galen's theory, notably that whereas black bile is associated in Nature of Man with the qualities "cold" and "dry," Galen reports in On Black Bile that it can be aggravated by hot and dry conditions. Stewart, on the other hand, suggests on the basis of his wider sample of Galen's texts a threefold distinction between different types of black bile, namely ideal natural, non-ideal natural, and unnatural or altered forms (75). Differences in the constitution and physiological effects of black bile can then be explained by recourse to the differences between the various types, rather than attributing them to inconsistency on Galen's part.

The remaining chapters of the book examine the properties of harmful black bile, the ways it can be cleansed from the body, and the diseases it causes. The fifth chapter, which is a brief 10 pages, examines the properties of altered black bile that make it harmful for the body. The sixth focuses on the generation of non-ideal natural black bile by the liver and of ideal natural black bile in the blood vessels, and its removal by the spleen under non-pathological circumstances. The chapter concludes with a concession that Galen might not always deploy clearly the neat differentiation developed earlier, that instead Galen uses language situationally "without having a systematic framework of nomenclature that could hinder his use of different sources for his refutation of the theories of his rivals" (128). While this might seem disappointing after the attractive neatness of the threefold division proposed in the fourth chapter, Stewart demonstrates that it is necessary in light of the complexity and variety of the treatises in which Galen analyzes black bile. Finally, the last chapter looks at the familiar diseases associated with black bile: melancholy in its various forms, epilepsy, and quartan fever.

The book builds on the author's 2016 University of Exeter dissertation, What factors influence Galen's development of a theory of black bile for his explanation of health and disease in the body? In general, modifications are few, and mainly involve moving some chapter headings around, while the samples I examined suggest the text has largely remained the same. The introduction has been slightly modified, but the conclusion has not. The stability of the project from dissertation to book is not so much a flaw as a feature that readers should keep in mind when building expectations for the work: this is a highly focused study, as dissertations often are. The subtitle "Hippocratic Tradition, Manipulation, Innovation" might be taken to indicate a broader engagement with questions of how medical authors in antiquity transformed the traditions in which they worked, such as is found in the papers collected in the 1999 volume edited by van der Eijk. 2 In fact, however, when it comes to "tradition and manipulation," Stewart is intently focused on the specific question of which Hippocratic treatises (and, to a lesser extent, other medical and philosophical texts) seem to have furnished concepts adopted by Galen in his own explanations of black bile and its effects on the body.

Stewart argues that Galen constructs the three varieties of black bile in a self-conscious manipulation of the Hippocratic tradition, but that he does not advertise himself as creating a brand-new theory (149-150). The resulting blend of old and new theory, and the creation of a new typology to reconcile possible theoretical inconsistencies, is perhaps a fair reflection of Stewart's own work. Readers already interested in the subject will find Stewart's treatment clear and ecumenical, while those new to the questions surrounding black bile will benefit from the introductory literature review.


1.   Jouanna, Jacques. "Bile Noire et Mélancolie Chez Galien : Le Traité Sur La Bile Noire Est-Il Authentique?" In Antike Medizin im Schnittpunkt von Geistes- und Naturwissenschaften: Internationale Fachtagung aus Anlass des 100-Jährigen Bestehens des Akademievorhabens "Corpus Medicorum Graecorum/Latinorum", edited by Christian Brockmann, Carl Wolfram Brunschön, and Oliver Overwien, 235–57. Berlin: De Gruyter, 2009.
2.   van der Eijk, Philip. Ancient histories of medicine : essays in medical doxography and historiography in classical antiquity. Leiden; Boston: Brill, 1999.

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