Hippocrates & Galen – The Four Humors

Few concepts in the history of ideas have touched as many human lives as the doctrine of the four humors. Its cultural and historical reach has been immense. From its development in ancient Greece, it spread throughout classical Rome and the Islamic world (Ullmann, 1978; Browne, 1962; Temkin, 1953; Harris, 1916). It dominated Western thinking throughout the Medieval and Renaissance periods (Mitchell, 2004; Filipczak, 1997; Siraisi, 1990; Draper, 1970). It was displaced as the primary framework for scientific medical practice only in the 18th century (Duffy, 1993). It still permeates folk medicinal practices throughout the world (Foster, 1979; Foster, 1953). Whatever the basis for its popularity, this idea has dominated human medical thinking like few other concepts. It has been productive in the definition and understanding of health for untold numbers of human beings.

While most often associated with Galen, the doctrine of humors received some development by Galen’s teacher and predecessor Hippocrates. This theory held that four humors or bodily fluids held the secret to health. These humors were, blood, phlegm, yellow bile and black bile. A proper mixing of these humors constituted good health. The undue preponderance of any one humor would result in characteristic patterns of disease (Miller, 1962; Temkin, 1953; Harris, 1916).

This theory can be seen as part of the larger Greek cultural movement – visible from Thales through Aristotle and beyond – away from supernatural modes of explanation towards naturalistic explanations. Galen accepted the output of this movement, including the Pythagorean, Empedoclean and Platonic accounts that matter is composed of four elements; fire, water, air and earth with their qualities of hot, moist, cold and dry, respectively. These natural elements do not exist as such in the body, but are characterized as blood, yellow bile, black bile and phlegm. From these antecedents, Galen formalized Hippocrates’ typology of the humors and gave it the clarity and parsimony that carried it through time (Sarton & Erhardt-Siebold, 1943).

Spread in ancient near east was immediate, across Arabic and Mediterranean cultures. A Galenist influence is clearly present in the Kit¬āb al-Malakī, a masterwork of classical Arabic medical literature, prepared by the important Islamic doctor al-Majūsī (Alī ibn-al-‘Abbās al-Majūsī). This book classified the universe in terms of the elements, defined as the properties of the hot, cold, wet and dry, exemplified by fire, air, water and earth. All living things are held to arise from these four elements, mixed in different amounts and proportions. The Arabic word Misáj (pl. Amzija) denoting ‘health’ in Arabic, Persian and Turkish, has its etymological roots in a verb meaning ‘to mix’, referring to the state of equilibrium between the four elements or properties. It also has the meaning of temperament or balancing, along with the word krāsis. A well-tempered system would be called balanced or even (mu’tadil). A deviation from equilibrium by the preponderance of any single element is called Inhiráfu’l – Mizáj, or khārij ‘an al-I’ tidāl (Ullmann, 1978; Browne, 1962).

In the body, the four Galenic humors are the bearers of the elemental properties. Determining the correct balance of humors during an intervention would not be a simple matter. The right mix for any one organ or person depends on the body system involved, the person’s age, the season and other such factors. Treatment of imbalances would significantly involve foods or drugs thought to contain the right balance of the four natural properties for that therapeutic situation. Ibn Sina (Avicenna) also reviewed doctrine and added secondary humors.

Jumping ahead to the Elizabethan period, we find that the theory of the humors had become what Michel Foucault has called a discipline or a practice of the body. A vast amount of how Elizabethans regulated themselves: their diet, their activities, their clothing, their bathing habits or lack thereof, can only be understood in terms of their massive preoccupation with the state and balance of their own humors. They would have inherited the view from the Middle Ages that bathing was more harmful for men than for women; masculinity being associated with the hot, dry humors and femininity with the cold wet humors. Artistic representations of females in the proximity of water with men keeping a certain distance were made with these distinctions in mind (Filipczak, 1997).

In a similar fashion, almost every aspect of comportment was informed by the theory of the humors. And it was not simply a preoccupation of the elites. Falstaff knew about Galen, referring to him in Henry IV, I. ii. 133, one of five references to Galen in Shakespeare. These explicit references prove what the whole opus demonstrates, which is the absolutely dominant role of Galenic doctrine in the popular understanding of the body during the Elizabethan era. Both Shakespeare and Chaucer make explicit use of the doctrine of the four humors (and related astrological lore) for characterization, including physical appearance, goals and motivations, social position and profession, behavior under stress and other components of characterization. The doctrine had become a primary metaphor for the understanding of human life (Draper, 1970).

Constitutional imbalance – a humors-based concept – remained the primary medical framework in the seventeenth century. Graduates of Oxford and Cambridge in the UK, members of the Royal College of Physicians, still practiced an essentially Galenic style of medicine, with heavy reliance on the ‘depletory regimen’, balance or cleansing the humors through bleeding, cupping and blistering, purging, vomiting and sweating (Duffy, 1993). This was a feature of American medicine into the early nineteenth century, and remains a part of the folk medicine tradition to this day (Foster, 1979). Furthermore, at the time of the conquest of America right down through to the late eighteenth century, Spanish medicine too was dominated by the humoral theory, as received from the Arabic medical tradition. Humoral theory thus remains part of the folk medicine in the Spanish-speaking world as well (Foster, 1953).

If nothing else, humoral theory forced physician to consider patients as a whole during diagnosis and treatment. However, it is also clear that humoral theory captured some aspects of the structure of concern, and so an understanding of broader regularities may have been involved. Galen’s theory of the humors has associated with it a theory of temperament, giving rise to a very famous typology of personalities, namely the choleric, melancholy, phlegmatic and sanguine. By the Elizabethan period, it was thought that the various humors gave off vapors which ascended to the brain, such that the state of a person’s humors would explain their temperament and comportment. The complete humoral theory is summarized below.


As this typology stands, the E style from PAEI is missing from the schema. However, as in the case with Aristotle’s rhetorical triangle and the three Gunas of Hindu philosophy, the missing style can be seen as assimilated to the context of the activity the typology supports. Medical diagnosis is a task that is very often Intuitive in the Jungian sense. It involves the inference of a pattern based on scattered cues and prior learning. Some people are better at it than others, because skill at diagnosis partly involves good instincts, or the tendency to have good hunches. Thus, a certain type does not appear within this framework – the type of person who goes around making universal theories of everything that help them see patterns where others might not. This producer of the model does not appear within the model as its own distinct type. E is thus the context within which PA and I (or the lack of all motivation styles) are identified.