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Four Humors

Hippocratic Method and the Four Humors in Medicine

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Hippocrates Statue

Hippocrates Statue

Flickr Creative Commons License by Epugachev
I do anatomize and cut up these poor beasts, he said to Hippocrates, to see the cause of these distempers, vanities, and follies, which are the burden of all creatures.
- Democritus - The History of Melancholy (1)

When today's doctor prescribes an antibiotic to fight infection, he is trying to put the patient's body back in balance. While the drugs and medical explanation may be new, this art of balancing bodily fluids has been practiced since Hippocrates' day.

In the Hippocratic corpus (believed not to be the work of a single man of that name) disease was thought to be caused by isonomia (2), the preponderance of one of the 4 bodily humors:

  • Yellow Bile
  • Black Bile
  • Phlegm
  • Blood

Four humors matched the four seasons

  • Autumn: black bile
  • Spring: blood
  • Winter: phlegm
  • Summer: yellow bile.

Each of the humors was (3) associated with one of the four equal and universal elements:

  • earth,
  • air,
  • fire, and
  • water
posited by Empedocles:
Aristotle, who used the image of wine to expose the nature of black bile. Black bile, just like the juice of grapes, contains pneuma, which provokes hypochondriac diseases like melancholia. Black bile like wine is prone to ferment and produce an alternation of depression and anger....
-From Linet's The History of Melancholy
  • Earth: black bile
  • Air: blood
  • Fire: yellow bile
  • Water: phlegm.

Too much earth made one melancholic;

Too much air, sanguine;

Too much fire, choleric;

Too much water, phlegmatic.

Finally, each element/humor/season was associated with certain qualities. Thus yellow bile was thought of as hot and dry. Its opposite, phlegm (the mucus of colds), was cold and moist. Black Bile was cold and dry, while its opposite, blood was hot and moist.

  • Black Bile: Cold and Dry
  • Blood: Hot and Moist
  • Phlegm: Cold and Moist
  • Yellow Bile: Hot and Dry.

As a first step, the prudent Hippocratic physician would prescribe a regimen of:

  • diet,
  • activity, and
  • exercise,
designed to [www.old.perseus.tufts.edu/GreekScience/Students/Chad/pre-soc.html] void the body of the imbalanced humor."

According to Gary Lindquester's "History of Human Disease," if it was a fever -- a hot, dry disease -- the culprit was yellow bile. So, the doctor would try to increase its opposite, phlegm, by prescribing cold baths. If the opposite situation prevailed (as in a cold), where there were obvious symptoms of excess phlegm production, the regimen would be to bundle up in bed and drink wine.

Resorting to Drugs

If the regimen didn't work the next course would be with drugs, often hellebore, a potent poison that would cause vomiting and diarrhea, "signs" the imbalanced humor was eliminated.

Observation of Anatomy

We might assume such Hippocratic ideas sprang from speculation (4) rather than experimentation, but observation played a key role. Furthermore, it would be simplistic to say ancient Greco-Roman doctors never practiced human dissection. If nothing else, doctors had anatomical experience dealing with war wounds. But especially during the Hellenistic period, there was extensive contact with the Egyptians whose embalming techniques involved removing bodily organs. In the third century B.C. (5) vivisection was permitted in (6) Alexandria where living criminals may have been put to the knife. Still, we believe Hippocrates, Aristotle, and Galen, among others, only dissected animal bodies, not human.

So man's internal structure was [old.perseus.tufts.edu/GreekScience/Students/Andrea/HippocratesOnHeart.html#intro] known primarily through analogy with animals, inferences from the externally visible structures, from natural philosophy, and from function.

Evaluating the Humoral Theory

Such ideas might seem far-fetched today, but Hippocratic medicine was a great advance over the supernatural model that had preceded it. Even if individuals had understood enough about contagion to realize rodents were involved somehow, it was still the Homeric Apollo, the mouse god, who caused it. The Hippocratic aetiology based on nature permitted diagnosis and treatment of symptoms with something other than prayer and sacrifice. Besides, we rely on similar analogies today, in Jungian personality types and ayurvedic medicine, to name two.

These men demonstrated that when the nutriment becomes altered in the veins by the innate heat, blood is produced when it is in moderation, and the other humours when it is not in proper proportion.
-Galen On the Natural Faculties Bk II

[(1) URL = www.umich.edu/~iinet/journal/vol2no2/v2n2_The_History_of_Melancholy.html accessed 02/02/99]
[(2) URL = www.astro.virginia.edu/~eww6n/bios/HippocratesofCos.html accessed 02/02/99]
[(3) URL = www.med.virginia.edu/hs-library/historical/antiqua/textn.htm accessed 02/02/99]
[(4) URL = viator.ucs.indiana.edu/~ancmed/foundations.htm]
[(5) URL = www.med.virginia.edu/hs-library/historical/antiqua/stexta.htm 02/02/99]
[(6) URL = www.med.virginia.edu/hs-library/historical/antiqua/stexta.htm 02/02/99]

Black Bile Cold and Dry Too much earth Melancholic Autumn
Blood Hot and Moist Too much air Sanguine Sping
Phlegm Cold and Moist Too much water Phlegmatic Winter
Yellow Bile Hot and Dry Too much fire Choleric Summer
Important Names in Greco-Roman Medicine > Four Humors

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