This article focuses on a key teaching or clinical precept of Greek Medicine, that Health is a harmony of the humors.
The Four Humors: A Universal Holistic Healing Concept
I remember having a conversation with the president of an acupuncture school in Tucson, Arizona once – I believe that this was before I put up my website, but during our conversation, he brought up the subject of the Four Humors. I don’t know if he intuited that I had leanings in that direction at the time, but he told me how the Four Humors are even present in the various Zang Fu organ syndromes of Chinese medicine – heck – they have all kinds of phlegm syndromes, for example. And Chinese Medicine is always talking about Qi and Blood, and how the former always follows the latter around, like a shadow – Greek Medicine describes this clinical reality as the vital function of Blood, or the Sanguine Humor. And the various Spleen syndromes, especially those involving deficiency, fall pretty neatly into the category of the Melancholic humor and temperament in Greek Medicine, with both pertaining to the Earth element in their respective systems. In Greek Medicine, the Spleen is the receptacle for Black Bile, or the Melancholic humor. And the parallels go on and on…
Ayurveda, or the ancient Vedic healing science, has three Doshas, or fundamental principles, or essences, whose harmony and balance defines health and whose disharmony and imbalance lead to disease. Although rough parallels are often drawn between the three Doshas of Ayurveda and the Four Temperaments of Greek Medicine, they are not exactly the same thing, in spite of their considerable overlap. Let’s see – Vata is Melancholic, Pitta is Choleric, and Kapha is Phlegmatic, with the most healthy and youthful Sanguine temperament corresponding to the state of Sama Dosha, or a healthy balance of all three Doshas. The main difference between the Four Humors and their respective temperaments of Greek Medicine and the three Doshas of Ayurveda is that the latter lean more towards the temperaments, or constitutional bodymind types of Greek Medicine than they do the humors per se, although there is some degree of overlap with the humors as well.
When it comes to the moist, flourishing humors of Greek Medicine, which are the Sanguine and Phlegmatic humors, if we delve into the seven Dhatus, or fundamental tissue types, we get more into the humoral side of things: Rasa Dhatu, or the vital sap or plasma of the organism, corresponds quite closely with the various fluids of the Phlegmatic Humor – and Rasa Dhatu is also called Poshaka Kapha, or that which nourishes or feeds the Kapha Dosha. When it comes to Blood or the Sanguine Humor, the waters get muddied considerably, and the connections are much more tenuous, with the humoral aspect of Blood being the Rakta Dhatu, which is the Dhatu that follows Rasa Dhatu in the generation process. But, oddly enough, Rakta Dhatu nourishes or feeds the Pitta Dosha, or the fiery bilious principle; it seems like Ayurveda keys into the warmth or Hot quality of Blood more than its wet or moist quality. And you might say that the Pitta Dosha, when we examine it more closely, seems to hopscotch back and forth between Yellow Bile, or the Choleric Humor, and Blood, or the Sanguine Humor in its warmer, more heating aspect. The real black sheep if we compare the two systems is Vata, which, in its overall clinical manifestations and symptomatology, corresponds quite closely with the Melancholic temperament of Greek Medicine. But when it comes to the theoretical underpinnings of Vata versus the Melancholic humor and its temperament – forget it – they are as different as night and day!
As you can see from the above discussion, weaving back and forth between these three systems – Greek Medicine, Chinese Medicine and Ayurveda – can be a tricky business, and can test the intellectual mettle of even the most astute medical or natural philosopher. One such medical sage and luminary was Ibn Sina, known in the West as Avicenna. Hailing from Persia and central Asia, Avicenna had a broad, panoramic and encyclopedic view of just about all the traditional healing systems of his day, of both East and West. And one of the truths that Avicenna saw and recognized is that some concept or notion of vital essences or fluids that permeate the human body, whose harmony and balance creates health, and whose imbalance and dysfunction create suffering and disease. Besides the notion of vital fluid essences or humors, a system of constitutional delineation and typology was another universal, or near universal principle that Avicenna recognized. Avicenna compiled his magnum opus, his Canon of Medicine, which was his great overview and synthesis of all the medical knowledge that existed in his day.
How Can We Define a Harmony of the Humors?
In human health and disease, within the rather broad parameters that are considered to be normal, different individuals have their own personal set-points that define more precisely what is normal and healthy for them. The way Greek Medicine looks at this phenomenon is from a humoral standpoint – that each person has their own precise balance or mixture of the vital fluids or humors. When an individual is enjoying precisely the right mixture and balance of humors that defines him or her, there is health, which the ancient Greeks called Eukrasia, or a “good mixture”; when that same individual got out of balance with their humors, and suffered debility or disease, the resulting state was called a Dyskrasia, which is a faulty or dysfunctional mixture of humors that was out of tune with their true self. Ayurveda looks at things in terms of a balance or mixture of their three Doshas, or constitutional types. Someone’s inherent nature, their own personal makeup of Doshas, is called their Prakriti, or Nature; when someone departs from their inherent state of natural balance and gets their Doshas out of balance, that is called Vikruti, or being thrown off of one’s inherently natural state of harmony and balance. The physician’s job then becomes leading the patient from their current out-of-balance state back towards their natural self, and its natural state of harmony and balance.
You might say that, quantitatively speaking, each one of us has their own personal set points when it comes to each of the Four Humors – both within the organism as a whole as well as in each of its individual organs or parts as well. Qualitatively speaking as well, each of the Four Humors within a person’s organism must have the right viscosity, the right qualities and temperament, and should be relatively pure and free from toxic or harmful residues, amalgamations or admixtures. And each of the Four Humors must also be in its place, or in the places that they belong, where they can do their job properly. And within the fairly broad range called “normal”, each individual will have his or her own distinctive mixture and distribution of humors that defines health for them. Although various organs and body parts can express symptomatic reactions when their humors are impure or out of balance, imbalance or disease is something that the entire organism experiences as a whole; when everything is right with the Four Humors, health is experienced by the whole organism, in body, mind and spirit. And during the recovery process, the entire organism, or Physis, recovers as a whole. From a state of disharmony and imbalance, the physician must know how to lead the person back to their original state of balance and health.
Inter-Relationships among the Four Humors
In order to bring the Four Humors back into a state of healthy harmony and balance, we must first have a good understanding of the various inter-relationships that exist amongst the Four Humors, as well as how the Four Humors relate to the larger framework of Nature. Like everything else in the material universe, the human body is composed of Four Elements: Fire, Air, Earth and Water. Each of these Four Elements is characterized by its own particular pairing of the Four Basic Qualities: Hot, Cold, Dry and Wet. As part of the Natural Faculty that is responsible for the nutrition, growth and feeding of the organism, each one of the Four Humors serves its associated element as its metabolic agent in the body:
Blood, or the Sanguine Humor, serves the Air element as the carrier of Pneuma, or the vital principles to every cell, organ and tissue of the body.
The Phlegmatic Humor, comprised of all the clear, watery fluids of the body, serves the Water element by cooling, moistening and nourishing the organism on a deep and fundamental level, as well as providing lubrication, transport and expulsion of substances.
The Choleric Humor, or Yellow Bile, is responsible for the transformation and distillation of nutritive substances and essences in the digestive process; it is also behind other manifestations of heat and fire in the organism, such as the inflammatory response.
The Melancholic Humor, or Black Bile, has a Retentive Virtue, as well as a thickening, solidifying, crystallizing influence on bodily digestion and metabolism; it is also responsible for the deposition of minerals from the Earth into the bones and connective tissue.
There are Four Basic Qualities, arranged in two pairs of complementary opposites: Hot versus Cold, and Dry versus Wet. These same Basic Qualities are also paired up and inherent in the Four Elements and their corresponding humors. On their own, the Four Basic Qualities are rather unstable and ephemeral in nature, but the Four Humors serve to hold the Four Basic Qualities in place, and give them some endurance and stability.
The moist, flourishing humors are Blood, or the Sanguine Humor, as well as the Phlegmatic Humor. Both of these humors serve elements that have the quality of wetness or moisture inherent in their nature: the Air and Water elements, respectively. Because these humors are moist and flourishing, they exist in the human body in the largest amounts, and the lion’s share of the proper nutrition of the human organism rests on their shoulders.
The dry, effete humors are Yellow Bile, or the Choleric Humor, and Black Bile, or the Melancholic Humor; they serve the Dry elements – Fire and Earth, respectively. They are only needed by the body in relatively small amounts, to perform certain specialized digestive and metabolic functions.
The Yin and the Yang of the Four Humors
Chinese philosophy and Chinese Medicine are most famous for their dualistic concept of Yin and Yang, or the two primal opposite polarities in the universe. Greek Medicine, with its Four Humors, is also a dualistic system of complementary opposites, with the Four Humors arranged into two different Yin / Yang polarities. Like the four directions of a compass, the Four Humors exist as two pairs of complementary opposites. Here are the two main polarities:
Blood, or the Sanguine Humor, is moderately warm and moist, with a moderate level of both warmth and moisture being essential for life; Blood is considered to be the very essence of life, youth and health. Black Bile, or the Melancholic Humor, is the polar opposite of Blood in its basic qualities: Cold and Dry, which are two qualities that are considered to be the very opposite or antithesis of life. While Blood is considered to be the very essence of life, youth and health, Black Bile, or the Melancholic Humor, is associated with many different chronic health problems, especially those that most characterize the aging process: arthritis, constipation, irritable bowel, chronic digestive issues, insomnia, and the like. In a way, an absence or a deficiency of Blood is a Melancholic condition, since, due to the relative lack or deficiency of Blood’s Warm and Moist qualities, the resulting anemic or ischemic condition can be seen as colder and dryer in nature. But this is not the same as an excess or aggravation of Black Bile itself. Proper discernment and differentiation of the two requires proper clinical judgment.
The two humors corresponding to the two extreme or cardinal elements, Fire and Water, are the Choleric Humor and the Phlegmatic Humor, respectively. The Fire and Water elements are the extreme elements because they represent the extremes of Yin and Yang, with Water, the greatest receiver of energy, being the most Yin element, with both of its basic qualities being Yin, and Fire, the greatest emitter of energy, being the most Yang element, or the most energetic and dynamic – needless to say, both its basic qualities are Yang in nature. Fire and Water are also considered to be the Cardinal elements because they are the primary or root drivers of all change and manifestation in the universe; they are also the prime drivers of digestion and metabolism in the human body. Fire and Water, being so extreme, are also the two elements that have the most destructive power if allowed to go unchecked by their polar opposite. The basic metaphor that describes all metabolic change in the human body in a nutshell is that of a steam engine or pressure cooker, with both the Fire and Water elements both keeping each other in check, as well as being the prime movers of change in the other, as the vital fires of the organism steam and circulate the vital fluid essences throughout the organism, distilling vital essences out of them when and where necessary.
Every traditional holistic healing system has its concept of the vital fire, or the vital fires of the organism; where exactly they are seated or located varies from system to system. In Greek Medicine, the primary seat of the metabolic fire in the body is in the heart; in Ayurvedic Medicine, the primary vital fire of the body is the Jatharagni, or the digestive fire located in the stomach. In Chinese Medicine, the main or root vital fire of the organism is the Ming Men Huo, or the Life Gate Fire located in the kidneys and adrenal glands; this is said to support and underlie all other metabolic fires of the body. Basically, these vital fires metabolize and transform, distill and concoct. Dr. Lad, my teacher of Ayurvedic Medicine, even went so far as to say that the very heart and soul of the art of internal medicine lay in the skillful adjustment and balancing of Agni, or the metabolic fire. These vital or metabolic fires of the human organism are distinguished from the various humoral manifestations of the Fire element in the body; simply put, the vital fires are mostly necessary and beneficial, whereas the humoral embodiments of the Fire element are dualistic in nature, have both their necessary and beneficial side as well as their destructive or pathological side. And so it is with the metabolic fire versus the Choleric Humor in Greek Medicine – the astrological symbol for the former is the Sun, whereas the astrological symbol for the latter is Mars.
With the Water element and the Phlegmatic Humor, there is not such a clear cut distinction between vital principle and humor; this is mainly because the Water element is, by its very nature, passive and receptive. In other words, it is the metabolic heat or fire that is driving the changes and distillations in the vital fluid essences of the body, which are most embodied in the Water element. So basically, with the Water element and its Phlegmatic humor, the distinction is mainly between a normal balance and excess or aggravation, and when it comes to the latter, it can be further specified which one of the Phlegmatic body fluids is in excess, or is causing the problem. Qualitative aberrations of the various Phlegmatic fluids of the body exist as well. And of course, when it comes to the Water element and its Phlegmatic Humor, deficiency and dehydration are also a distinct possibility.
When it comes to the Yin and Yang of the Four Humors, “cousin humors” in which only one of their two basic qualities differs is another possibility. Take the two dry, effete humors – Yellow Bile and Black Bile, for example – they differ only in their primary quality of Hot versus Cold, which you could say define Yang versus Yin. An excess or aggravation of Yellow Bile in the liver and gall bladder is called Yang jaundice in Chinese Medicine, and its overall symptom picture is more agitated and vehement in nature – in other words, hotter and more energetic. An excess or aggravation of Black Bile in the spleen is called Yin jaundice in Chinese Medicine, and the symptom picture here is definitely more passive and indolent in nature than it is for Yang jaundice. And of course, the complexion or skin color in Yang jaundice is brighter than in Yin jaundice, in which the complexion is a dark or dull yellow. The liver sits on the right side underneath the lower ribs, whereas the spleen sits on the left side underneath the lower ribs – between the two is the stomach, so both Yang and Yin forms of jaundice will negatively impact the digestive process as the liver and the spleen “duke it out”.
You can make a similar differentiation between the two moist, flourishing humors – Blood, or the Sanguine Humor, and the Phlegmatic Humor. Both nourish and moisten the organism, but Blood has the potential to power cellular metabolism, which the Phlegmatic Humor definitely lacks. From another perspective, a deficient metabolic heat or fire can produce too much of the Phlegmatic Humor and not enough Blood, or the blood will be too thin and watery in its viscosity. Or, there can also be pathological amalgamations of the Phlegmatic Humor admixed with Blood, or the Sanguine Humor. And so, anemia, or a deficiency of Blood, can either be an absolute quantitative deficiency of Blood, or the Blood can be deficient in its viscosity or its richness. In real life, or in clinical practice, there can be all kinds of shades or blendings of various conditions and syndromes, and nothing really exists in isolation. First, an aspiring physician learns the textbook cases and definitions as part of his didactic training, and then he is exposed to actual cases in real life, and in clinical practice.
Complexion, in Cosmetology and in Medicine
In Japan, a traditional doctor of Kampo Yaku, or traditional Chinese Herbal Medicine, will frequently ask about a patient’s Kao Iro, or face color. If the face color looks healthy, and is “in the pink” as they say, there is health and a harmony of the humors. In case you haven’t figured it out already, the different colors of the Four Humors show quite readily through the skin and facial color: red for Blood or the Sanguine Humor and white or pale for the Phlegmatic Humor; since these are the two dominant moist or flourishing humors, this rosy or pinkish hue dominates the complexion, at least in a white or Caucasian individual. In blacks and those of other races, or admixtures of races, we must rely on other qualities of the Four Humors expressing themselves through the skin, like a soft, creamy moisture for Blood and a cold or clammy moisture for the Phlegmatic Humor, for example. The two dry, effete humors also project their colors out through the skin: a yellowish tint for the Choleric Humor, or Yellow Bile, and a brown or olive colored hue for Black Bile, or the Melancholic Humor. Cachexia is a morbid greenish or ashen grey complexion that indicates a profound and chronic disharmony of the humors.
In Greek Medicine, the term “complexion” does not merely refer to skin color; the term can also be used to denote the complex and nuanced tempering or admixture of varied and contrasting qualities and humors present in any given clinical picture. In such clinical situations, it is not just the absolute quantitative vectors that the physician is concerned about, but their relative balance and proportion to each other within the system as a whole. Because the relative balance of these factors within the whole clinical picture is important, slight shifts in an absolute sense may make for substantial differences in the clinical situation and outcome. If we look at climate and meteorology, for example, slight temperature changes of just one or two degrees in the ocean or gulf waters may make all the difference between a terrible or extreme hurricane season and a relatively mild one, for example. And so it goes for the storms and tempests that might arise within the human body as well. The astute physician must develop his or her awareness of, and sensitivity to, these minute differences and changes in order to be an effective clinician.
Conclusion and Acknowledgements: Thank You, Hakim G. M. Chishti!
The great phrase or maxim, “Health is a harmony of the humors” is not original to me, but appears in The Traditional Healer’s Handbook by Hakim G. M. Chishti. This simple, short maxim sums up the heart and soul of Greek Medicine perhaps better than anything else, and it was one of my great “takeaways” from reading his book, which should definitely be in the library of everyone who is a student of Greek Medicine.