Historical Perspective

The 4 Humors Erythrocyte Sedimentation: The Most Influential Observation in Medical History

HIPPOCRATES AND THE HUMORS

A modernized version of what they might have seen is shown in Figure 1. On the left is blood taken from a healthy person–almost all red–the color of blood. On the right is blood taken from a person dying of an acute infection, which displayed 4 components: from the top down, a yellow layer, a dirty gray plug, a red layer and, finally, a darkish red area. Fåhraeus characterized this observation: “There is probably no observation in the history of medicine which has played such a big part as has

GALEN AND AVICENNA

Approximately 600 years after Hippocrates, Galen (129 to ~ 200) elaborated on the humoral theory. He aggressively speculated about health and disease and boldly arrived at a body of conclusions—an elaborate edifice of dogma—which became the foundation of the Western medicine.⁹ He was perhaps the most influential physician of all time.

After Rome fell, Islam arose, and the locus of scholarship shifted to the Middle East. The work of Hippocrates and Galen was preserved by the translations of the

THE TEMPERAMENTS

In addition to their effect on physical health, the humors were felt to be responsible for different personality types. Galen felt that human moods, emotions and behaviors were caused by various mixtures of the humors and named the temperaments after them.¹³ Someone with a phlegmatic personality was apathetic, sluggish and dull. A sanguine personality was associated with laughter, music and a passionate disposition. (Today, this means cheerful and optimistic.) A choleric individual was

THE HUMORAL THEORY OF DISEASE AND MEDICAL TREATMENT

Medical treatment was designed to restore the balance of the humors. For example, if a patient had a fever (a hot dry condition), the culprit was yellow bile, and the doctor would try to increase its opposite humor, phlegm, with cold baths. A patient with a head cold with excess phlegm would be warmed—bundled up in bed and given wine. Because Galen believed that different foods influenced the humors produced by the body, other approaches employed herbs and foods associated with particular

BLOODLETTING IN AMERICA

The prominent Philadelphia physician Dr. Benjamin Rush (1746–1813), a signer of the Declaration of Independence, was an aggressive proponent of bloodletting.¹⁹ Unfortunately, it was believed at that time that the body contained 12 quarts of blood instead of 6. On December 13, 1799, George Washington developed a sore throat and hoarseness after a day spent riding on his farm. At 2 am, he awakened his wife complaining of ague (chills and fever). Difficulty in breathing then ensued, now thought to

THE VERY SLOW RETREAT OF THE HUMORAL THEORY AND BLOODLETTING

The humoral theory of medicine began its slow retreat in the early 1800s in Paris. Reliance on authorities such as Galen began to be abandoned, to be gradually replaced by observation and analysis.²¹ Physical examination made great strides. For example, the stethoscope was invented by René Laennec in 1816. In 1828, Pierre Charles Alexandre Louis introduced statistics into medicine—a revolutionary concept at that time— when he first reported what we now call an observational study of 77 patients

CONCLUSIONS

What stands out from this fascinating story is the enormous awesome power, throughout human history, of widely accepted unquestioned beliefs—what “everybody knows.” None of us is immune. It is extremely difficult not to be caught up in uncritical acquiescence to broadly accepted “truths.” (It seems that we are hard wired to rely on authority and on conventional wisdom rather than on critical evaluation of data.)

This story should also serve as a cautionary tale for us today. The history of

ACKNOWLEDGMENT

The author indebted to Professor PK Saha for his extremely helpful suggestions.