Every now and then on a blog post I’ve mentioned humors or qualities and the time has come for us to delve into the muddled world of Hippocratic physiology. Geronimo!
I’m sure it’s something you all are vaguely familiar with: the historical idea that the body is composed of the four humors – blood, phlegm, yellow bile and black bile (or melancholy). While we now know that doesn’t happen to be the case, the idea is still woven pretty tightly into western culture. For example, if you are really fancy with your vocab, you might describe someone as sanguine. The ancient-mediciny-historicalness behind this is the idea that someone has a humoral make-up that is predominantly made of blood causing a ruddy complexion and a cheerful and optimistic temperament. But we’re getting ahead of ourselves here…
Although the origin of this idea is often attributed to Hippocrates, its roots reach farther back into the murky realm of ancient history – with whispers of the humors found in both ancient Egyptian and Mesopotamian cultures. It is fair to say, however, that the Greeks are the first instance (that is extant) wherein the humors are clearly systematized into their familiar form. This happens specifically in the Hippocratic text On the Nature of Man:
“The human body contains blood, phlegm, yellow bile and black bile. These are the things that make up its constitution and cause its pains and health. Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed. Pain occurs when one of the substances presents either a deficiency or an excess, or is separated in the body and not mixed with others.” (Hippocrates, Nature of Man, 4)
Again, assigning authorship to Hippocratic works is tricky business, but scholars tend to think that this text is actually the work of Hippocrates’ student and son-in-law, Polybus. But, potato-potato (really loses something in its written form) – what you need to know is that it was in the Hippocratic Corpus where this humors business really started to take shape.
But it didn’t stop there! Four humor physiology took on a life of its own and was interpreted in many different ways. In fact! Jacques Jouanna (who literally wrote the book on Hippocrates) writes of the Corpus: “There is no point in dwelling on the various humoral theories of the Hippocratic physicians… For the moment it is enough to indicate that there was no single theory to which all the Hippocratic physicians subscribed.” (Jouanna, Hippocrates, 316)
Enter: Galen. When this Pergamonian (Pergamonese? ugh – guy who hailed from Pergamon) entered the scene, it was swirling with humoral theory – so you know what he did? He decided to systematize it. He decided to systematize it, and then say it’s how Hippocrates had meant it, and then build himself a reputation as the best physician ever because he was the only one who followed the true Hippocratism. Clever bloke, that Galen.
Anyway, humoral physiology stayed pretty much in vogue until the 19th century. I mean, there were a few periods where contrasting theories popped up or other times when religious explanation became more important – but still, the longevity of humoralism is, to me, absolutely amazing.
And although Galen did a pretty solid job of systematizing things, the theory continued to advance and evolve and the humors began to mean more than just bodily fluids. In Alexandria in the 6th century CE (according to Jouanna’s estimate) a firm idea of humoral temperaments took shape. Again, this idea had whispers and roots scooting around in the medical literature, but we’re talking almost complete fruition here. This idea of ‘temperament’ is where we get the example about of the ‘sanguine’ person – one could also be choleric (having an abundance of yellow bile), or melancholic (of black bile), or phlegmatic (of phlegm). One’s disposition all depended on the natural mixture, or krasis, of the humors in the body.
So how does this humoral physiology apply to nosology? It’s all about balance, my friends. According to humoralism, someone gets sick when the krasis of their body is thrown outta whack – either in quality or in quantity. This is known as a dyskrasia and it is the basis for most of the remedies and pharmacology in the Hippocratic/Galenic medical tradition. A physician could cure a dyskrasia through diet or exercise of by physically removing the fluids from the body through bloodletting or the use of cupping glasses. And the best way to prevent such an imbalance was through a good regimen (diet, exercise, etc.), too. Better to prevent an illness than to cure it!
I know this seems crazy, but it actually makes more sense than you would think. Not more sense in a “let’s apply this to the modern body” sort of way, but hear me out. In antiquity there was a bit of a taboo about opening the human body. Dissections weren’t really a thing. Basically a physician had to learn whatever he can from external observation, from poking around in wounds and during rudimentary surgeries or from the things excreted by the body. And many different things can effect what you observe, particularly when it comes to excretions. For example, as argued by the Swedish physician Fåhræus, when a blood sample is left to settle in a glass container it separates into a dark clot, a layer of red blood cells, a layer of white blood cells and a clear yellow serum. Another example, and one of my favorites, what the use of hellebore as a cure for melancholic disease: hellebore, a nasty, nasty poison, was thought to expel black bile from the body – because it was a nasty, nasty poison you’re body would do a lot of expelling to get rid of it (from both ends!) and, as an added bonus, it would cause these excrements to take on a dark shade (from both ends!). And if you already think that black bile is causing the disease (because of everything you’ve read and been taught), this looks awesome, because you see lots of black matter exiting the body. You can kind of see how, from the outside, this seemed like a good idea. Disclaimer: it really wasn’t. Please don’t ingest hellebore.
I guess my point is that it’s easy to look back at the four humors and scoff, but I think that part of it’s longevity was down to the logic of the system. If you accept the basic principles, everything that follows makes absolute sense. There were even times during my PhD (fairly late on when my brain was turning to mush, I’ll admit) that I had to stop and remind myself that this was not how the human body works. I just got so deep into analyzing Renaissance medical texts and their logic was so clear… I was ready to cure my cold with cupping glasses (because clearly it stems from an overabundance of phlegm!).
Because of the nature of blogging and this post – and because I didn’t want to bore you too much with technicalities – this is only a short overview of the complex world of humors. However, if you want to learn a little bit more – a highly, highly, highly recommend this broadcast from BBC Radio 4’s program, In Our Time. It features four eminent scholars in the history of medicine talking about the humors and the lasting impact they’ve made on the history of medicine.
Image source: Colin McGuckin, Marcin Jurga, Hamad Ali, Marko Strbad & Nicolas Forraz, “Culture of embryonic-like stem cells from human umbilical cord blood and onward differentiation to neural cells in vitro”,
Nature Protocols 3, 1046 – 1055 (2008), figure 1.