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Balancing Your Humors

Does classical Greek medicine provide any insights today about mental health?

This week, on Halloween, I gave my second-year history students the entire history of psychiatry in 50 minutes. Well, it was actually 55 minutes—I went over, I admit. Starting in about 5000BC and continuing on right until 2013, with some discussion about future predictions of mental illness epidemiology, it was what you might call a barnstorming blast through the past.

As I was preparing the lecture, the number of different treatments and explanations for mental illness really struck me. Since I study the history of psychiatry, this shouldn't have been much of a shock, but when you go from year dot to the present day, covering all the highlights and lowlights, the sheer volume of approaches does boggle the mind. From exorcism and shutting people up in asylums to aquatherapy and lobotomy (which won its inventor the Nobel Prize in Medicine!), pretty much everything has been tried. While some treatments have truly been relegated to the history books, others have made comebacks over the years, only to be replaced with something else.

One of the most enduring approaches, in a way, may also appear the furthest removed from Western medicine, namely, humoral medicine. Starting with the classical Greek physician Hippocrates (460-377 BC) and disseminated even wider by the Roman Galen (129-216 AD), the basic idea behind humoralism was balance, and what needed to be balanced were the four humors, the four fluids found in the human body.

The four humors—black bile, yellow bile, blood, and phlegm—represented different qualities: while black bile was cold and dry and yellow bile was hot and dry, blood was hot and wet and phlegm was cold and wet. Given these combinations, the humors could be matched onto the four seasons, the four elements, and—here's the mental health bit—four different emotional characteristics. The ancient names for these humor—melancholic (black bile), choleric (yellow bile), sanguine (blood), and phlegmatic (phlegm)—represented different temperaments, and still do. Melancholic people are despondent and gloomy. Choleric people are bad-tempered. Sanguine people are courageous, hopeful, and amorous. Phlegmatic people are calm, cool, and unemotional.

Classical medicine was all about balancing these humors by changing diet, lifestyle, occupation, climate, or by administering medicine. A cold and wet cucumber might help to redress the balance in a feverish individual, as might bloodletting. This was as true for mental illness as it was for somatic diseases. So, if someone was melancholic, they suffered from an excess of black bile; if they were manic, it was either too much blood or yellow bile that was the problem. Balancing one's lifestyle, therefore, was central to one's emotional well-being.

On the one hand, it is easy to scoff at such ideas from our 21st-century vantage point. Antibiotics (at least usually) tend to work better than cucumbers in fighting feverish bacterial infections and many swear by antidepressant drugs, rather than trying to reduce a patient's excess black bile.

But, on the other hand, the idea of balance continues to be an attractive one. We often speak of having a balanced diet in terms of physical health, or having a good work-life balance when it comes to mental health, but how central is this to the advice we get from GPs or even psychiatrists? If we are coming down with all sorts of infections, we typically put all the blame on the bug and not on ourselves; perhaps it is the lack of balance in lives that wears down our immune systems and leaves us susceptible? Similarly, in many instances of mental illness, the focus is often only on the patient's flawed neurological system, and how to redress it pharmacologically, rather than what is going on in their lives. Perhaps, we need to re-think balance and its role in health more generally.

Humoralism as a medical philosophy persisted right up until the 19th century. Although cracks in classical medicine were occurring by the Renaissance, it remained a powerful way of understanding human health and disease for many physicians. It was replaced in the 19th century by ideas of disease specificity; as the germs for tuberculosis, cholera, yellow fever, and other diseases were identified, the notion that all diseases had a specific cause became predominant.

We may acknowledge that many diseases have multiple causes today in theory, but in practice, disease specificity tends to influence us the most, with genetics being the primary "specific" cause. Unfortunately, thinking in this way, especially when it comes to mental health, is not always very effective, because no disease exists in a vacuum. There are always a host of contexts that shape the outcome. Perhaps thinking of disease more in terms of balance would be more useful. Of course, then, other problems arise. It's one thing to "re-balance" your life if you are a wealthy Greek merchant; it's quite another if you are a single mother struggling to get by as it is. This being the case, maybe what we really need is a more "balanced" society.

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