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8. THE DOCTRINE OF HUMOURS.

The doctrine of the humours probably had its origin1 in superficial deductions from obvious facts of physiology, but it was strongly coloured by philosophic speculation, in particular by the doctrine of opposites. Indeed it is impossible to keep distinct the various influences which acted and reacted upon one another in the spheres of philosophy and medicine; only the main tendencies can be clearly distinguished.

Even the most superficial observer must notice (a) that the animal body requires air, fluid, and solid food; (b) that too great heat and cold are fatal to life, and that very many diseases are attended by fever; (c) that fluid is a necessary factor in digestion;2 (d) that blood is in a peculiar way connected with life and health.

These simple observations were reinforced by the speculations of philosophers, particularly when philosophy took a biological or physiological turn, and

[p. xlvii] became interested in the organs of man and their functions.3

The second of the Greek philosophers, Anaximander,4 taught that creation was made up of "opposites," though it is not clear how many he conceived these opposites to be. Many later thinkers, working on lines similar to those of Anaximander, made them four in number--the hot, the cold, the moist and the dry. These were the essential qualities of the four elements, fire, air, water, earth.

There was, however, no uniformity among thinkers as to the number of the opposites, and Alcmaeon, a younger contemporary of Pythagoras and a native of Croton, postulated an indefinite number.5 Alcmaeon was a physician rather than a philosopher, and asserted that health was an ἰς1ονομία of these opposites and disease a μοναρχία of one.6 This doctrine had a

[p. xlviii] strong influence upon the Coan school of medicine, and indeed upon medical theory generally.

But the opposites are not χυμοί: they are only δυνάμεις2. The humoral pathology was not fully developed until for δυνάμεις2 were substituted fluid substances.7 In tracing this development the historian is much helped by Ancient Medicine. It is here insisted that the hot, the cold, the moist and the dry are not substances; they are only "powers," and, what is more, powers of merely secondary importance.8 The body, it is maintained, has certain essential χυμοί, which χυμοί have properties or "powers" with greater influence upon health than temperature. The number of the χυμοί is left indefinite. If the body be composed of opposite humours, and if health be the harmonious mixture or blending (κρᾶς1ις) of them, we shall expect to see one or other "lording it over the others" (μοναρχία) in a state of disease.

The two commonest complaints in ancient Greece, chest troubles and malaria, suggested as chief of these humours four : phlegm, blood (suggested by hemorrhage in fevers), yellow bile and black bile (suggested by the vomits, etc., in remittent malaria).

That the humours are four is first clearly stated in Nature of Man, which Aristotle assigns to Polybus, though Menon quotes a portion of it as Hippocratic. The passage in question runs : τὸ δὲ ς1ῶμα τοῦ ἀνθρώπου

[p. xlix] ἔχει ἐν ἑωυτῷ αἷμα καὶ φλέγμα καὶ χολὴν ξανθήν τε καὶ μέλαιναν, καὶ ταῦτα ὲς1τὶν αὐτῷ φύς1ις . . . ὑγιαίνει μὲν οὖν μάλις1τα ὁκόταν μετρίως ἔχῃ ταῦτα τῆς πρὸς ἄλληλα κρής1ιος καὶ δυνάμιος καὶ τοῦ πλήθεος, καὶ μάλις1τα μεμιγμένα ἤ̂ κ.τ.λ. (Littré VI. 38 and 40).

Some thinkers, belonging to the school of Empedocles, and being more inclined towards philosophy than towards medicine, made the four chief opposites, materialized into fire, air, water and earth, the components of the body, and disease, or at any rate some of the chief diseases, an excess of one or other. We see this doctrine fairly plainly in Menon's account of Philistion,9 and it is copied by Plato in the Timaeus.10

The doctrines I have described admitted many variations, and in Menon's Iatrica, which is chiefly an account of the origins of disease as given by various physicians, the most diverse views are set forth. Petron of Aegina, while holding that the body is composed of the four opposites, stated that disease was due to faulty diet, and that bile was the result and not the cause of disease.11 Hippon thought that a suitable quantity of moisture was the cause of health ;12 Philolaus that disease was due to bile, blood and phlegm ;13 Thrasymachus of Sardis that blood, differentiated by excess of cold or heat into phlegm, bile, or τὸ ς1ες1ηπός (matter or pus), was

[p. l] the cause ;14 Menecrates that the body is composed of blood, bile, breath and phlegm, and that health is a harmony of these.15

The Hippocratic collection shows similar diversity of opinion. Diseases IV. 51, gives as the four humours bile, blood, phlegm and ὕδρωψ (not water, but a watery humour).16 Affections I. ascribes all diseases to bile and phlegm.17 Ancient Medicine recognizes an indefinite number of humours.

The great Hippocratic group imply the doctrine of humours in its phraseology and outlook on symptoms, but it is in the background, and nowhere are the humours described. It is clear, however, that bile and phlegm are the most prominent, and bilious and phlegmatic temperaments are often mentioned in Airs Waters Places and Epidemics I. and III. There are signs of subdivision in πικρόχολοι18 and λευκοφλεγματίαι.19

Amid all these differences, which by their very variety indicate that they belonged to theory without seriously affecting practice, there is one common principle--that health is a harmonious mingling of the constituents of the body. What these constituents are is not agreed, nor is it clear what exactly is meant by "mingling."

The word ἄκρητος, which I have translated "unmixed" or "uncompounded," is said by Galen to mean "consisting of one humour only." It is more

[p. li] likely that the word means properly "showing signs that crasis has not taken place."


Coction

The course of our inquiry has brought us to the doctrine of "coction" (πέψις). Familiar as a modern is with the difference between chemical blending and mechanical mixture, it is difficult for him to appreciate fairly theories put forward when this difference was unknown, and the human mind was struggling with phenomena it had not the power to analyse, and trying to express what was really beyond its reach. We must try to see things as the Greek physician saw them.

We have in Chapters XVIII and XIX of Ancient Medicine the most complete account of coction as the ancient physician conceived of it. It is really the process which leads to κρᾶς1ις as its result. It is neither purely mechanical nor yet what we should call chemical; it is the action which so combines the opposing humours that there results a perfect fusion of them all. No one is left in excess so as to cause trouble or pain to the human individual. The writer takes three types of illnesses--the common cold, ophthalmia and pneumonia--and shows that as they grow better the discharges become less acrid and thicker as the result of πέψις.

In one respect the writer of Ancient Medicine is not a trustworthy guide to the common conception of πέψις. He attached but little importance to heat, and it can scarcely be doubted that the action of heat upon the digestibility of foods, and the heat which accompanies the process of digestion itself,

[p. lii] must have coloured the notion of πέψις as generally held. It is true that we read little about innate heat in the Hippocratic collection, but that is an accident, and it certainly was thought to have a powerful influence upon the bodily functions.20

A disease was supposed to result when the equilibrium of the humours, from some "exciting cause" or other (πρόφας1ις), was disturbed, and then nature, that is the constitution of the individual (φύς1ις), made every effort she could through coction to restore the necessary κρᾶς1ις.


Crisis

The battle between nature and the disease was decided on the day that coction actually took place or failed to take place. The result was recovery, partial or complete, aggravation of the disease, or death. The crisis (κρίς1ις) is "the determination of the disease as it were by a judicial verdict."21

After a crisis there might, or might not, be a relapse (ὑπος1τροφή), which would be followed in due course by another crisis.

The crisis, if favourable, was accompanied by the expulsion of the residue remaining after coction and κρᾶς1ις of the humours had occurred. This expulsion

[p. liii] might take place through any of the ordinary means of evacuation--mouth, bowels, urine, pores--and the evacuated matters were said to be concocted (πέπονα), that is to say, they presented signs that coction had taken place.22

But nature was not always able to use the ordinary means of evacuation. In this case there would be an abscession (ἀπός1τας1ις). When the morbid residue failed to be normally evacuated, it was gathered together to one part of the body and eliminated, sometimes as an eruption or inflammation, sometimes as a gangrene or tumour, sometimes as a swelling at the joints.

An abscession did not necessarily mean recovery ; it might merely be a change from one disease to another. The Hippocratic writers are not clear about the point, but apparently the abscession might fail to accomplish its purpose, and so the disease continued in an altered form.23 In other words there was abscession without real crisis.

To trace the course of a disease through its various stages, and to be able to see what is portended by symptoms in different diseases and at different stages of those diseases, was an art upon which Hippocrates laid great stress. He called it πρόγνως1ις, and it included at least half of the physician's work.

[p. liv]


Critical Days

Crises took place on what were called critical days. It is a commonplace that a disease tends to reach a crisis on a fixed day from the commencement, although the day is not absolutely fixed, nor is it the same for all diseases. The writer of Prognostic and Epidemics I. lays it down as a general law that acute diseases have crises on one or more fixed days in a series.

In Prognostic Chapter XX the series for fevers is given thus:--4th day, 7th, 11th, 14th, 17th, 20th, 34th, 40th, 60th.

In Epidemics I. XXVI. two series are given:--

a) diseases which have exacerbations on even days have crises on these even days: 4th, 6th, 8th, 10th, 14th, 20th, 24th, 30th, 40th, 60th, 80th, 120th.

b) diseases which have exacerbations on odd days have crises on these odd days: 3rd, 5th, 7th, 9th, 11th, 17th, 21st, 27th, 31st.

A crisis on any other than a normal day was supposed to indicate a probably fatal relapse.

Galen thought that Hippocrates was the first to discuss the critical days, and there is no evidence against this view, though it seems more likely that it gradually grew up in the Coan school.24

What was the origin of this doctrine? Possibly it may in part be a survival of Pythagorean magic, numbers being supposed to have mystical powers, which affected medicine through the Sicilian-Italian

[p. lv] school. But a man so free from superstition as the author of Epidemics I. was unlikely to be influenced by mysticism, particularly by a mysticism which left his contemporaries apparently untouched. More probably there is an effort to express a medical truth. In malarious countries, all diseases, and not malaria only, tend to grow more severe periodically ; latent malaria, in fact, colours all other complaints. May it not be that severe exacerbations and normal crises were sometimes confused by Hippocrates, or perhaps a series of malarial exacerbations attracted the crisis to one of the days composing it? The sentence in Epidemics I. XXVI. is very definitely to the effect that when exacerbations are on even days, crises are on even days ; when exacerbations are on odd days, crises are on odd days. Evidently the critical days are not entirely independent of the periodicity of malaria.

1 It is supposed by some that the humoral pathology originated in Egypt. See Sir Clifford Allbutt, Greek Medicine in Rome, p. 133.

2 See Nutriment LV.: ὑγρας1ίη τροφῆς ὄχημα. See also Disenses IV., Littré VII. 568: τὸ ς1ῶμα . . . ἀπὸ τῶν βρωτῶν καὶ τῶν ποτῶν τῆς ἰκμάδος ἐπαυρίς1κεται.

3 Empedocles, Philistion and Pausanias were the chief pioneers in this union of philosophy with medicine which the writer of Ancient Medicine so much deplores. See Burnet, Early Greek Philosophy, pp. 234, 235 (also Galen X. 5, οἱ ἐκ τῆς Ἰταλίας ἰατροὶ Φιλις1τίων τε καὶ Ἐμπεδοκλῆς καὶ Παυς1ανίας καὶ οἱ τούτων ἑταῖροι.)

4 He was also interested in biology. See Burnet, pp. 72, 73.

5 Aristotle Meta. A 986 a 31 : φης1 γὰρ ἔναι δύο τὰ πολλὰ τῶν ἀνθρωπίνων, λέγων τὰς ἐναντιότητας οὐχ ὥς1περ οὗτοι [sc. οἱ Πυθαγόρειοι] διωρις1μένας ἀλλὰ τὰς τυχούς1ας, οἷον λευκὸν μέλαν, γλυκύ πικρόν, ἀγαθὸν κακόν, μέγα μικρόν.

6 Aétius V. 30. 1, and Galen (Kéhn) XIX. 343: Ἀλκμαίων τῆς μὲν ὑγείας ἔναι ς1υνεκτικὴν ἰς1ονομίαν τῶν δυνάμεων ὑγροῦ, θερμοῦ, ξηροῦ, ψυχροῦ, πικροῦ, γλυκέος καὶ τῶν λοιπῶν, τὴν δὲ ἐν αὐτοῖς μοναρχίαν νός1ου ποιητικήν. See also 344: τὴν δὲ ύγείαν ς1ύμμετρον τῶν ποιῶν τὴν κρᾶς1ιν. It would be interesting if the technical word κρᾶς1ις could be traced back to Alcmaeon himself.

7 It is a pity that the treatise Humours tells us so little about the humours themselves. It is merely a series of notes for lectures, heads of discourse to medical students.

8 See especially Chapters XIV-XVII, in particular XVII : ἀλλ ἔς1τικαὶ πικρὸν καὶ θερμὸν τὸ αὺτό, καὶ ὀξὺ καὶ θερμόν, καὶ ἁλμυρὸν καὶ θερμόν . . . τὰ μὲν οὖν λυμαινόμενα ταῦτ̓ ἐς1τί.

9 Iatrica XX. : Φιλις1τίων δ᾽ οἴεται ἐκ δ̂ ἰδεῶν ς1υνες1τάναι ἡμᾶς, τοῦτ̓ ἔς1τιν ἐκ δ_ ς1τοιχείων: πυρός, ἀέρος, ὕδατος, γῆς. εῖναι δὲ καὶ ἑκάς1του δυνάμεις, τοῦ μὲν πυρὸς τὸ θερμόν, τοῦ δὲ ὰέρος τὸ ψυχρόν κ.τ.λ.

10 86 A: τὸ μὲν οὖν ἐκ πυρὸς ὑπερβολῆς μάλις1τα νος1ῆς1αν ς1ῶμα ξυνεχῆ καύματα καὶ πυρετοὺς ἀπεργάζεται, τὸ δ᾽ ἐξ ἀέρος ἀμφημερινούς κ.τ.λ.

11 Iatrica, XX.

12 Ibid., XI.

13 Ibid., XVIII.

14 Iatrica, XI. (end).

15 Ibid., XIX.

16 Littré VII. 584.

17 Ibid., VI. 208.

18 Regimen in Acute Diseases, XXXIII. : οἱ πικ̣όχολοι τὰ ἄνω : Epidemics III. XIV. (end).

19 Epidemics III. XIV.

20 See Aphorisms, I. 14: τὰ αὐξανόυενα πλεῖς1τον ἔχει τὸ ἔμφυτον θερμόν: πλείς1της οὖν δεῖται τροφῆς: εἰ δὲ μή, τὸ ς1ῶμα ἀναλίς1κεται κ.τ.λ.

21 See Dr. E. T. Withington, Classical Review, May-June 1920, p. 65. There is a good definition of κρίς1ις in Affections VIII. (Littré VI. 216) : κρίνες1θαι δέ ἐς1τιν ἐν ταῖς νούς1οις, ὅταν αὔξωνται αἱ νοῦς1οι ματαίνωνται μεταπίπτως1ιν ἐς ἕτερον νός1ημα τελεντῶς1ιν.

22 The chief signs of coction were greater consistency, darker colour, and "ripeness" or "mellowness."

23 The most important passages are:-- (a) οὐδὲ γὰρ αἱ γιγνόμεναι τούτοις ὰπος1τάς1ιες ἔκρινον ὥς1περ ἐπὶ τοῖς ἄλλοις (Epidemics III. XII.).

b) ἀπος1τάς1ιες ἐγένοντο, μέζους ὥς1τε ὑποφέρειν μὴ δύνας1θαι, μείους ὥς1τε μηδὲν ὠφελεῖν ἀλλὰ ταχὺ παλινδρομεῖν κ.τ.λ. (Epidemics I. VIII.).

24 On the other hand, critical days are not discussed at all in Coan Prenotions, the supposed repository of pre-Hippocratic Coan medicine.

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