Humorism

This article is about humors in ancient and medieval medicine. For the modern theory of temperament, see four temperaments. For humors in Ayurvedic medicine, see Ayurveda.

The four temperaments as depicted in an 18th century woodcut: phlegmatic, choleric, sanguine and melancholic.

Humorism, or humoralism, was a system of medicine detailing the makeup and workings of the human body, adopted by the Indian Ayurveda system of medicine, and Ancient Greek and Roman physicians and philosophers, positing that an excess or deficiency of any of four distinct bodily fluids in a person—known as humors or humours—directly influences their temperament and health.

The humoralist system of medicine was highly individualistic, for each individual patient was said to have their own unique humoral composition. Moreover, it resembled a holistic approach to medicine as the link between mental and physical processes were emphasized by this framework. From Hippocrates onward, the humoral theory was adopted by Greek, Roman and Islamic physicians, and became the most commonly held view of the human body among European physicians until the advent of modern medical research in the nineteenth century. The concept has not been used in medicine since then.

The four humors of Hippocratic medicine are black bile (Greek: µέλαινα χολή, melaina chole), yellow bile (Greek: χολή, chole), phlegm (Greek: φλέγμα, phlegma), and blood (Greek: αἷμα, haima), and each corresponds to one of the traditional four temperaments. A humor is also referred to as a cambium (pl. cambia or cambiums).

Four humors

Essentially, this theory holds that the human body is filled with four basic substances, called humors, which are in balance when a person is healthy. All diseases and disabilities supposedly resulted from an excess or deficit of one of these four humors. These deficits were thought to be caused by vapors inhaled or absorbed by the body. The four humors are black bile, yellow bile, phlegm, and blood. These terms only partly correspond to the modern medical terminology, in which there is no distinction between black and yellow bile, and in which phlegm has a very different meaning. These "humors" may have their roots in the appearance of a blood sedimentation test made in open air, which exhibits a dark clot at the bottom ("black bile"), a layer of unclotted erythrocytes ("blood"), a layer of white blood cells ("phlegm") and a layer of clear yellow serum ("yellow bile"). It was believed that these were the basic substances from which all liquids in the body were made.

Greeks and Romans, and the later Muslim and Western European medical establishments that adopted and adapted classical medical philosophy, believed that each of these humors would wax and wane in the body, depending on diet and activity. When a patient was suffering from a surplus or imbalance of one of these four fluids, then said patient's personality and or physical health could be negatively affected. This theory was closely related to the theory of the four elements: earth, fire, water and air; earth predominantly present in the black bile, fire in the yellow bile, water in the phlegm, and all four elements present in the blood.

Paired qualities were associated with each humor and its season. The word humor is a translation of Greek χυμός, chymos (literally juice or sap, metaphorically flavor). At around the same time, ancient Indian Ayurveda medicine had developed a theory of three humors, which they linked with the five Hindu elements.

The following table shows the four humors with their corresponding elements, seasons, sites of formation, and resulting temperaments alongside their modern equivalents:

Humour	Season	Element	Organ	Qualities	Ancient name	Temperament	Temperament characteristics
Blood	spring	air	liver	warm and moist	sanguis	sanguine	courageous, hopeful, playful, carefree
Yellow bile	summer	fire	spleen	warm and dry	kholé	choleric	ambitious, leader-like, restless, easily angered
Black bile	autumn	earth	gallbladder	cold and dry	melaina kholé	melancholic	despondent, quiet, analytical, serious
Phlegm	winter	water	brain/lungs	cold and moist	phlégma	phlegmatic	calm, thoughtful, patient, peaceful

Blood

The blood was believed to be produced exclusively by the liver.

Yellow bile

Excess of yellow bile were thought to produce aggression, and excess anger reciprocally gave rise to liver derangement and imbalances in the humors.

Black bile

The word "melancholy" derives from Greek μέλαινα χολή (melaina kholé) meaning 'black bile', from the belief that an excess of black bile caused depression.

Phlegm

Phlegm was thought to be associated with apathetic behavior, as preserved in the word "phlegmatic" /flɛgˈmatɪk/.

The phlegm of humorism is far from the same thing as phlegm as it is defined today. Nobel laureate Charles Richet MD, when describing humorism's "phlegm or pituitary secretion" in 1910 asked rhetorically "this strange liquid, which is the cause of tumours, of chlorosis, of rheumatism, and cacochymia - where is it? Who will ever see it? Who has ever seen it? What can we say of this fanciful classification of humours into four groups, of which two are absolutely imaginary?"

History

Although advances in cellular pathology and chemistry discredited humoralism by the nineteenth century, the theory had dominated Western medical thinking for more than 2,000 years. Only in some instances did the theory of humoralism wane into obscurity. One such instance occurred in the sixth and seventh centuries in the Byzantine Empire when traditional secular Greek culture gave way to Christian influences. Though the use of humoralist medicine continued during this time, its influence was diminished in favor of religion. The revival of Greek humoralism, owing in part to changing social and economic factors, did not begin until the early ninth century. Use of the practice in modern times is pseudoscience.

Origins

The concept of four humors may have origins in Ancient Egyptian medicine or Mesopotamia, though it was not systemized until ancient Greek thinkers around 400 BC directly linked it with the popular theory of the four elements: earth, fire, water and air (Empedocles).

Fåhræus (1921), a Swedish physician who devised the erythrocyte sedimentation rate, suggested that the four humours were based upon the observation of blood clotting in a transparent container. When blood is drawn in a glass container and left undisturbed for about an hour, four different layers can be seen. A dark clot forms at the bottom (the "black bile"). Above the clot is a layer of red blood cells (the "blood"). Above this is a whitish layer of white blood cells (the "phlegm"). The top layer is clear yellow serum (the "yellow bile").

Greek medicine

See also: Ancient Greek medicine

Hippocrates is the one usually credited with applying this idea to medicine. One of the treatises attributed to Hippocrates, On the Nature of Man, describes the theory as follows:

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.

Although the theory of the four humors does appear in some Hippocratic texts, some Hippocratic writers only accepted the existence of two humors, while some even refrained from discussing the humoral theory at all. Humoralism, or the doctrine of the four temperaments, as a medical theory retained its popularity for centuries largely through the influence of the writings of Galen (129–201 AD) and was decisively displaced only in 1858 by Rudolf Virchow's newly published theories of cellular pathology. While Galen thought that humors were formed in the body, rather than ingested, he believed that different foods had varying potential to be acted upon by the body to produce different humors. Warm foods, for example, tended to produce yellow bile, while cold foods tended to produce phlegm. Seasons of the year, periods of life, geographic regions and occupations also influenced the nature of the humors formed.

The imbalance of humors, or dyscrasia, was thought to be the direct cause of all diseases. Health was associated with a balance of humors, or eucrasia. The qualities of the humors, in turn, influenced the nature of the diseases they caused. Yellow bile caused warm diseases and phlegm caused cold diseases.

In On the Temperaments, Galen further emphasized the importance of the qualities. An ideal temperament involved a balanced mixture of the four qualities. Galen identified four temperaments in which one of the qualities, warm, cold, moist or dry, predominated and four more in which a combination of two, warm and moist, warm and dry, cold and dry or cold and moist, dominated. These last four, named for the humors with which they were associated—that is, sanguine, choleric, melancholic and phlegmatic, eventually became better known than the others. While the term temperament came to refer just to psychological dispositions, Galen used it to refer to bodily dispositions, which determined a person's susceptibility to particular diseases as well as behavioral and emotional inclinations.

Islamic medicine

See also: Medicine in medieval Islam and Unani

Medieval medical tradition in the "Golden Age of Islam" adopted the theory of humorism from Greco-Roman medicine, notably via the Persian polymath Avicenna's The Canon of Medicine (1025). Avicenna summarized the four humors and temperaments as follows:

Avicenna's four humors and temperaments
Evidence	Hot	Cold	Moist	Dry
Morbid states	Inflammations become febrile	Fevers related to serious humor, rheumatism	Lassitude	Loss of vigour
Functional power	Deficient energy	Deficient digestive power	Difficult digestion
Subjective sensations	Bitter taste, excessive thirst, burning at cardia	Lack of desire for fluids	Mucoid salivation, sleepiness	Insomnia, wakefulness
Physical signs	High pulse rate, lassitude	Flaccid joints	Diarrhea, swollen eyelids, rough skin, acquired habit	rough skin, acquired habit
Foods and medicines	Calefacients harmful, infrigidants beneficial	Infrigidants harmful, calefacients beneficial	Moist articles harmful	Dry regimen harmful, humectants beneficial
Relation to weather	Worse in summer	Worse in winter		Bad in autumn

Influence and legacy

Medicine

The four humors and their qualities

Typically "eighteenth-century" practices such as bleeding a sick person or applying hot cups to a person were, in fact, based on the humor theory of surpluses of fluids (blood and bile in those cases). Ben Jonson wrote humor plays, where types were based on their humoral complexion. Methods of treatment like bloodletting, emetics and purges were aimed at expelling a surfeit of a humor. Other methods used herbs and foods associated with a particular humor to counter symptoms of disease, for instance: people who had a fever and were sweating were considered hot and wet and therefore given substances associated with cold and dry. Paracelsus further developed the idea that beneficial medical substances could be found in herbs, minerals and various alchemical combinations thereof. These beliefs were the foundation of mainstream Western medicine well into the 1800s.

Central to the treatment of unbalanced humors was the use of herbs. Specific herbs were used to treat all ailments simple, common and complex etc., from an uncomplicated upper respiratory infection to the plague. For example, chamomile was used to decrease heat, and lower excessive bile humor. Also, arsenic was used in a poultice bag to 'draw out' the excess humor(s) that led to symptoms of the plague. Philip Moore, who wrote on the hope of health, and Edwards, who wrote Treatise concerning the Plague discuss how these herbs are helpful in curing physical disease. They also discuss the importance of maintaining an herb garden.

The Unani school of medicine, practiced in Perso-Arabic countries, and in India and Pakistan, is based on Galenic and Avicennian medicine in its emphasis on the four humors as a fundamental part of the methodologic paradigm.

There are still remnants of the theory of the four humors in the current medical language. For example, modern medicine refers to humoral immunity or humoral regulation when describing substances such as hormones and antibodies that circulate throughout the body. It also uses the term blood dyscrasia to refer to any blood disease or abnormality. The associated food classification survives in adjectives that are still used for food, as when some spices are described as "hot", and some wines as "dry". When the chili pepper was first introduced to Europe in the sixteenth century, dieticians disputed whether it was hot or cold.

Culture

Theophrastus and others developed a set of characters based on the humors. Those with too much blood were sanguine. Those with too much phlegm were phlegmatic. Those with too much yellow bile were choleric, and those with too much black bile were melancholic. The idea of human personality based on humors contributed to the character comedies of Menander and, later, Plautus. Through the neo-classical revival in Europe, the humor theory dominated medical practice, and the theory of humoral types made periodic appearances in drama.

Because people believed that the quantity of humors in the body could not be replenished, there were folk-medical beliefs that the loss of fluids was a form of death.

The humors can be found in Elizabethan works, such as in Taming of the Shrew, in which the character Petruchio pretends to be irritable and angry to show Katherina what it is like being around a disagreeable person. He yells at the servants for serving mutton, a "choleric" food, to two people who are already choleric.

Foods in Elizabethan times were all believed to have an affinity with one of these four humors. A person showing signs of phlegmatism might have been served wine (a choleric drink and the direct opposite humor to phlegmatic) to balance this.

The concept of balance in health, a key feature in the humoralist theory, is still prevalent in modern Western culture. The dietary guidelines put forth by the United States Department of Agriculture recommend finding a "balance between food and physical activity". The contemporary view of a healthy lifestyle in Western culture emphasizes the historically influential concept of balance.

See also

• Five Temperaments
• Three Doshas of Ayurveda
• Wu Xing (Five Elements of Chinese philosophy)

References

Notes

Bibliography

• Edwards. "A treatise concerning the plague and the pox discovering as well the meanes how to preserve from the danger of these infectious contagions, as also how to cure those which are infected with either of them". 1652.
• Moore, Philip. "The hope of health wherin is conteined a goodlie regimente of life: as medicine, good diet and the goodlie vertues of sonderie herbes, doen by Philip Moore." 1564.
• Burton, Robert. 1621. The Anatomy of Melancholy, Book I, New York 2001, p. 147: "The radical or innate is daily supplied by nourishment, which some call cambium, and make those secondary humours of ros and gluten to maintain it [...]".

External links

• BBC Radio4's In Our Time. Episode on the four humors in MP3 format, 45 minutes.
• Article from 'Phisick'. Humoral Theory