THERAPEUTIC MANAGEMENT OF MIXED TEMPERAMENTS
Introduction: Real Life is a Mixed Bag
In the previous four pages in this section, I have written about the therapeutic management of each one of the Four Temperaments, or constitutional bodymind types. However, in real life, most people have mixed temperaments when it comes to their own personal constitutional makeup, and those who are purely of a single temperament are relatively rare. Some people can be quite mixed when it comes to their constitutional makeup, having each of the Four Temperaments substantially represented. It could even be said that this fact of life is what eventually led modern medicine to discard the idea of the Four Temperaments. Nevertheless, since our constitutional nature and temperament has a lot to do with our vulnerabilities or predisposition to certain types of pathology and disease, modern physicians simply leave the whole question of temperament to nothing more than asking the patient what diseases run in the family. One’s temperament or constitutional makeup is generally inherited from one’s parents.
In the Basic Principles section of this website, I have written a page on The Four Temperaments, in which I give concise descriptions of each temperament, or constitutional bodymind type, according to some nineteen different vectors or parameters, involving such characteristics as physique, physiognomy, physiology, digestion, metabolism, urine, stool, etc… If you have not done so already, I highly urge you to go back and take a personal inventory on yourself in order to find out exactly what your own personal constitutional makeup is. Keep score for each vector or parameter, whether it is a “C” for Choleric, an “S” for Sanguine, an “M” for Melancholy, or a “P” for Phlegmatic. The relative scoring of C, S, M or P, tallied up at the bottom of the page, will give you a good idea of your constitutional makeup of humor and temperament.
In order to qualify purely as one of the Four Temperaments, you need to have the vast majority of the different parameters being scored with the same letter. As I said earlier, those who are pure types, or very nearly so, are relatively rare; these relatively pure types can follow the guidelines given in the one of the previous four pages that applies to their temperament in a simple, straightforward manner. However, most people tend to be of dual temperament, with one of the letters being the clear winner, with a strong secondary, and the other two getting left way down below somewhere; sometimes the primary and secondary temperaments can actually be quite close to each other in terms of their relative strength, or even tied with each other. Still a few others will have three of the four letters relatively even and balanced, with the fourth lagging way behind – then their constitutional makeup is not distinguished by any strength or preponderance, but rather by a deficiency or weakness. The rarest type of person is the one in whom all the Four Temperaments are relatively equal and balanced.
If you should be of a dual or mixed temperament, then there are basically three ways in which this can manifest. First, the characteristics of each temperament can be perfectly blended, either as a kind of midpoint on a polarity or continuum, or as two colors are blended together to yield a third. Secondly, you can have a kind of “patchwork quilt” blending of temperaments, in which your complexion will be of one temperament, and your digestive habits of another temperament, for example. And finally, the two dual temperaments within you can be battling for supremacy, with first one of them in the ascendancy, then the other, often determined by exogenous factors like dietary indiscretions, environmental influences, etc… Each of your dual temperaments, when provoked by the right factors, will come to the fore and assert itself.
Basic Guidelines for the Therapeutic Management of Mixed Temperaments
Since having a basic primary temperament and a strong secondary temperament is the most common situation or pattern for those of mixed temperaments, the basic guideline is to tailor one’s basic health regimen primarily to the needs of that temperament while making additional allowances for keeping the secondary temperament in line, and not unduly aggravating or provoking it. If one has two different temperaments fairly evenly or equally blended in one’s constitutional makeup, then the regimen to be followed should be a harmonious blending of therapeutic measures and considerations that are equally good or beneficial for each of the dual temperaments. These basic guidelines should be followed in each area of the overall health regimen: in diet, in exercise, in lifestyle, in herbs and supplements, etc… Above all, things that unduly provoke or aggravate either one of the dual temperaments should be avoided.
If you have three different temperaments pretty much equally represented in your self-inventory, and the remaining fourth temperament weak, the therapeutic focus then needs to be on supplementing, strengthening or shoring up the fourth weak element and its corresponding humor / temperament. If the Fire / Choleric element is weak, then work on strengthening the forces of pepsis and the digestive and metabolic fires of the body. If the Air / Sanguine element is weak, then work on tonifying Blood, as well as respiration, and the vital forces of cellular metabolism and immunity. If the Earth / Melancholic element is weak, work to strengthen mineral assimilation and metabolism, as well as bones, tendons, fascia and connective tissue. If the Water / Phlegmatic element is weak, then work to keep the body well hydrated and cleansed, and to nourish the deep Phlegmatic and Serous fluids of the body. It’s pretty much common sense, and these strengthening and tonification needs usually persist throughout a whole lifetime.
Avicenna’s System of Eight Mixed Temperaments
In the medical thinking of Avicenna, the father of Greco-Arabic or Unani Medicine, there could only be eight mixed or dual temperaments, even though, if you “do the math” and figure out all the possible combinations of two of the Four Temperaments, listing the primary temperament first and the secondary temperament second, you get the number twelve. Obviously, from this grand total of twelve possible mixtures, Avicenna cast out four as being basically unstable or ephemeral in nature, and those were the mixtures involving temperaments that had the same primary or active quality of either Hot or Cold. And so, Avicenna cast out any primary / secondary mixtures involving Choleric and Sanguine (both Hot), as well as Melancholic and Phlegmatic (both Cold). In the first pairing, the doubled heat would dry up the moisture of the Sanguine Temperament, resolving to purely Choleric. In the second pairing, the doubled Cold would condense the residual moisture of the Melancholic Temperament, resolving to purely Phlegmatic. Although this is the traditional Unani viewpoint, you don’t have to accept it.
So, let’s take a brief look at each one of Avicenna’s eight mixed temperaments, with the first or primary temperament in capital letters:
SANGUINE / Phlegmatic: In this pairing of temperaments, moisture or wetness is stronger than in the purely Sanguine temperament, and the level of heat or warmth is considerably reduced, although still slightly to moderately warm. Since the Wet quality is common to both of the mixed temperaments, not unduly aggravating excessive phlegm and dampness is more of a therapeutic consideration than it is for the purely Sanguine. Edema and venous congestion impeding the return of Blood to the heart can also be a consideration, since venous Blood is colder in temperament than arterial Blood. Digestion and pepsis are still basically good and hearty, but bogged down by more phlegm and dampness than in a purely Sanguine temperament. The vascular and vital functions of Blood are still robust and dominant, but not as strongly as in a purely Sanguine temperament, as secondary Phlegmatic concerns are also present.
PHLEGMATIC / Sanguine: In this pairing of temperaments, the coldness and wetness of the Phlegmatic Temperament have taken the upper hand over the warmth and moisture of the Sanguine Temperament. Phlegmatic issues such as phlegm congestion, digestive sluggishness, lymphatic congestion, water retention and edema will be primary concerns, even though they will not be as severe or pronounced as in a purely Phlegmatic temperament. Similarly, the digestive and metabolic fires will be low, but not quite as low as they are in a purely Phlegmatic temperament, tending to generate more phlegm than blood, but not as severely so as it would be in a purely Phlegmatic temperament.
In short, the previous two mixed temperaments can be thought of as pertaining to the Wetness or moisture continuum, since both the Sanguine and the Phlegmatic temperaments double down on the common quality of Wetness. The doubled or emphasized wetness of these mixed temperaments also gives them a certain flourishing robustness. The main difference is that warmth predominates in the first of these dual temperaments, whereas coldness prevails in the second. A common pattern for those on this continuum of mixed temperaments is to start out more towards the Sanguine end of the spectrum in one’s younger years, then go more towards the Phlegmatic later on in life, as the digestive and metabolic fires usually decline with age.
CHOLERIC / Melancholic: In this pairing of temperaments, the heat and dryness of the Choleric Temperament has the upper hand over the colder dryness of the Melancholic Temperament. Humorally speaking, this mixed temperament is characterized by excesses as well as pathological aggravations of both Black and Yellow Bile, with Yellow Bile predominating. Accordingly, hotter, more vehement symptoms of GI inflammation, hyperacidity, ulceration, etc… will predominate over the more chronic and indolent manifestations of these disorders, although the heat and choler will be slightly cooler than that of a purely Choleric temperament. When there aren’t any acute flareups, more chronic or indolent bilious disorders, of the Melancholic type, will linger in the background.
MELANCHOLIC / Choleric: In this pairing of temperaments, the relative coolness, chronicity and indolence of the Melancholic humor and temperament have the upper hand over the relative heat, acuteness and vehemence of the Choleric. Accordingly, acidity, ulceration and bilious upsets in the GI tract tend to be more towards the Melancholic end of the spectrum, although slightly more vehement and volatile than in a purely Melancholic temperament. Chronic bilious disorders are common in those of this mixed temperament, and digestive conditions may be quite difficult to resolve, involving pathological forms of both Black and Yellow Bile. This blending of temperaments is also more nervous, deficient and aesthenic in nature than the previous one, which tends to be more vehement and robust in its overall expression.
The previous two mixed temperaments are both part of the Dryness continuum, since their two constituent temperaments both have the Dry quality in common. This continuum between Choleric on the Hot end and Melancholic on the Cold end could also be called the Bilious continuum, since it commonly involves pathologies involving morbid, oxidized forms of Black and Yellow Bile – so bilious regulation and purification, and the eating of beneficial fats and the avoidance of pathogenic fats, is important. Because dryness predominates on this continuum, those who are of these mixed temperaments need to take care to stay well hydrated and replenish their vital fluids and electrolytes, as well as to nourish and replenish their moist, flourishing Sanguine and Phlegmatic humors with the right foods and nutrients. In addition, those who are of these mixed temperaments may start out closer towards the Choleric end of the spectrum in youth, but move towards the Melancholic end as they age, due to the dwindling of the vital digestive and metabolic fires of the organism; this is a common pattern.
All of the previous four pairings of dual temperaments involved temperaments that shared the same passive or secondary quality, either wetness or dryness. The next four pairings of dual temperaments involve temperaments that share no common qualities; and so, these pairings are inherently more volatile and dynamic than the first four, which can be seen merely as intermediary points on a polarity or continuum.
CHOLERIC / Phlegmatic: In this pairing of two contrary temperaments, the heat, expressiveness and volatility of the Choleric Temperament predominates, while the secondary Phlegmatic Temperament gives it more flourishing, fecund moisture than a purely Choleric temperament. Although the core digestive and metabolic characteristics of the Choleric Temperament predominate, phlegm congestion and Phlegmatic weight gain and sluggishness can be secondary issues. There can also be a propensity for morbid humoral accumulations involving both turbid dampness as well as putrefaction, purulence and pus formation, which can sometimes be discharged through the skin or a suitable orifice, such as the anus or the vagina. A chief concern is the purification and detoxification of the vital fluids – the blood and lymph, as well as other serous fluids. Psychologically, this mixed temperament can be particularly intense, combining Choleric expressiveness and volatility with Phlegmatic sentimentality and emotional depth.
PHLEGMATIC / Choleric: In this pairing of two contrary temperaments, the wetness, torpor and sluggishness of the Phlegmatic Temperament prevails over the heat and volatility of the Choleric. Although superficially, all seems to have a Phlegmatic placidity and stability, given the right conditions and provocation, Choleric flareups can come at any time, erupting from the watery depths of the dominant Phlegmatic nature. And so, for example, although the usual digestive predisposition is towards a slow, lethargic digestive fire and phlegm accumulation in the stomach and GI tract, this temperament is not immune from occasional flareups of hyperacidity, acid reflux, etc… The same goes for toxic or purulent conditions of the blood, lymph and other serous fluids – although eruptions and flareups are less frequent, they do happen under the right causes and conditions, and when they do, Phlegmatic dampness prevails over Choleric purulence and putrefaction. Psychologically, although this dual temperament may have some emotional intensity, it is usually more subdued and deep seated, and less apparent.
The previous two pairings of dual temperaments could be called the Cardinal or Extreme spectrum, since both of the temperaments concerned involve the extreme Cardinal elements of Fire and Water. Since these two Cardinal elements drive all change, manifestation and physiological processes in the human organism, this pairing of temperaments is inherently volatile and dynamic, and can even be unstable, with first one temperament provoked, then the other. There’s really no middle ground between Fire and Water, which represent the extremes of Yin and Yang according to the Greek system; combine them, and you produce steam, which is full of motive power and intensity. The typical pattern for those of this pairing of mixed temperaments is to start out life hotter and more Choleric dominant, and then have the Phlegmatic heaviness and sluggishness accumulate with increased weight gain as one ages, and the metabolism and its vital fires start to wane.
SANGUINE / Melancholic: In this pairing of temperaments, the Sanguine Temperament and its humor, Blood, which is the very essence of life, health and vitality, predominates, and the Melancholic Temperament and its humor, Black Bile, which is a sediment of Blood and the very antithesis of the Sanguine humor in its basic qualities and attributes, plays a secondary role. As the first humor to arise from the second digestion in the liver, Blood could be called the first and greatest product of the liver; Black Bile, or the Melancholic humor, is stored in the spleen. Therefore, this particular dual temperament is often characterized by digestive imbalances involving disharmonies between the liver (Blood) and the spleen (Black Bile). It can also be characterized by residues of morbid Black Bile in the blood, which often unduly thicken the Blood and can also cause certain chronic skin conditions. Balancing and harmonizing the digestive functions of the liver, spleen and stomach should be a key concern for those with this mixed temperament, as well as cleansing the Blood of residues of morbid Black Bile.
MELANCHOLIC / Sanguine: This pairing of mixed temperaments is closest to the Melancholic Temperament, with more Blood, and less of a tendency towards anemic and aesthenic conditions, than the purely Melancholic temperament. The tendency towards Melancholic type digestive upset and disharmony is greater in this mixed temperament than in the previous one. Also present is the Melancholic tendency towards arthritic and neuromuscular disorders, although not as severe as in the purely Melancholic Temperament. The tendency towards chronic Blood dyscrasias involving morbid residues of Black Bile is also there, with Black Bile predominating, with the same potential for chronic skin conditions. Psychologically, in the previous mixed temperament, a Sanguine sense of optimism and wellbeing prevails, but with Melancholic dominance, a moody, withdrawn and nervous temperament is in the ascendancy.
Since the previous two mixed temperaments both involve Blood, or the first humor to arise, which receives the richest, choicest share of nutrients from food and drink, as well as Black Bile, the last humor to arise, receiving the coarsest, poorest share of nutrients from food and drink, this pairing could be called the Nutritional polarity or spectrum. As long as a nutritionally sound and complete diet is eaten, and the organs of the Natural Faculty, which involve the digestion and assimilation of vital nutrients, are in decent shape, there will be good health and an adequate supply of Blood; but with nutritional deprivation and nervous stress, the Melancholic component will be provoked or gain the ascendancy. A common life pattern for those with this particular pairing of temperaments is to start out life towards the more robust, Sanguine end of the spectrum, and then as dietary and nutritional indiscretions, mounting worldly cares and stress, and the declining health and efficiency of the digestive organs increases past middle age, to move more towards the Melancholic end.
Other Mixed Temperaments: Thinking Outside the Avicennian Box
When Avicenna formulated his doctrine of eight mixed temperaments, he was working mainly from the angle or perspective of the Four Basic Qualities: Hot, Cold, Dry and Wet. And working from this perspective, it is perfectly clear why he thought certain possible combinations of temperaments were inherently unstable and untenable. But if one works from another perspective – say, of the temperament’s dominant humor, then other possibilities for mixed temperaments arise, and Avicenna’s “forbidden four” are once again back in play. So let’s briefly take a look at the possibilities offered by the pairings of temperaments that Avicenna omits:
CHOLERIC / Sanguine; SANGUINE / Choleric: This particular pairing of mixed temperaments involves Sanguine factors of Blood excess and congestion, as well as excessive heat and choler in the Blood, or both simultaneously. It can also predispose one to bleeding disorders, arising either from an excess of Blood, or an excess of heat and choler in the Blood, which causes it to “boil over” and run amok. They can also suffer from skin rashes and sensitivities, both acute and chronic, caused by excessive heat and choler in the Blood. Those who have these mixed temperaments will have a good, healthy level of metabolic heat, which is greater than the purely Sanguine, but less, and less prone to acute pathology and flareups, than the Choleric. As one ages, the typical pattern for those of these mixed temperaments would be to start out life towards the hotter, more vehement Choleric end of the spectrum, and move more towards the warmer Sanguine end past middle age.
MELANCHOLIC / Phlegmatic; PHLEGMATIC / Melancholic: This particular pairing of mixed temperaments involves both Melancholic dryness, roughness, stiffness and tightness as well as Phlegmatic wetness, softness and laxity. It would involve both Melancholic issues of nervousness, asthenia, malnutrition, arthritic and neuromuscular disorders, as well as a frail, finicky digestion, complicated by Phlegmatic fluid retention and edema. Or, it can involve rheumatic complaints and conditions that get worse with cold, damp weather. Chronic skin conditions, which alternate between Phlegmatic wetness and Melancholic dryness in their clinical manifestations, are another distinct possibility. Frankly speaking, this particular pairing of mixed temperaments seems to be less realistic and tenable than the previous one.
The bottom line, I suppose, is that every person is a unique individual. When you take a personal inventory of yourself as outlined in the page on The Four Temperaments in the Basic Principles section of this website, and as you look back over your life to see which health themes and issues have predominated over which others, a picture or pattern will gradually emerge, and the relative strengths or rankings of the Four Temperaments within your own constitutional makeup usually becomes clear. And from this emerging picture, you will be able to piece together a regimen of health that works best for you, taking care to listen to your body, and what it is telling you, as you do so.
A Common Sense Approach to Managing Mixed Temperaments
As with the simple temperaments – the basic four – these eight or more mixed temperaments are primarily constitutional states of being, and not, in and of themselves, pathological conditions. They are something you have to make adjustments and allowances for in designing your own personal health regimen for optimal wellbeing. Although these mixed temperaments, like the simple, basic four, indicate the potential for, or predisposition towards, certain types of pathology, these are potentials only, and can be remedied or prevented by a sound regimen of healthy diet, exercise, lifestyle, supplements, etc… Above all, we should take a pragmatic, common sense approach to managing our constitutional nature and temperament, whether it happens to be simple or mixed, and should not fall into the twin traps of undue pessimism or hypochondria on the one hand, nor of undue dogmatic rigidity on the other. We must learn to listen to our bodies, and to deal with health issues promptly, decisively and efficiently as they arise, without undue projection of our own hopes and fears regarding our health into the future.
If you should be of a certain dual or mixed temperament, it is erroneous to believe that you will be limited to experiencing only pathologies involving the dominant humors pertaining to each of your constituent temperaments. Although you will be predisposed towards a greater potential for experiencing pathologies involving these two humors, you can, if provoked by various dietary indiscretions or other pathogenic factors, as the environment or circumstances may dictate, experience pathologies involving humors that don’t directly pertain to your constitutional makeup, although these may be less probable. In real life, pathologies can arise and complicate themselves over the course of time, which can even wind up involving all four of the humors; resolving them can be like untangling the strands of some challenging Gordian knot.
Although I have indicated some common health issues and predispositions of the various mixed temperaments above, do not get overly fixated on them. You, as a unique individual, while being of a certain mixed temperament, may not share in these typical predispositions towards pathology – or, you may have some other ones of your own. Or, in addition to being blended together seamlessly and simultaneously like a painter blends his colors, the dual temperaments in your mixed constitutional makeup can vie for attention and manifestation, with one getting provoked or becoming active, then the other in its turn. Or, you can be the patchwork quilt, with a digestive system of one temperament, and a circulatory or musculoskeletal system of another – or yet another. Every one of us has his or her own unique health patterns, challenges and destiny to fulfill.
DISCLAIMER: The material contained on this page is for educational purposes only, and is not intended to substitute for personal diagnosis and treatment from a physician or licensed health care practitioner. The reader assumes all personal responsibility and liability for the application of the information contained herein, and is encouraged to consult with a physician or licensed healthcare practitioner should his or her symptoms or condition persist or worsen.