Pretend it’s 500 BCE and you know nothing about modern, scientific medicine. You know nothing about anatomy or biochemistry or microbes. How would you approach the art of healing your loved ones when they became ill? How would you identify what’s wrong with them and offer them the supportive care they needed, their best chance of survival? You’d probably keep track of any events like vomiting, diarrhea, urination, wounds that are weeping or orifices that are secreting. Is pus or wax flowing out of their ear? Are they urinating way more or way less than normal? Is their urine super dark or smelly? Is that cut on their ankle looking crusty and gooey? Note your experience of trying to heal this loved one is shaped entirely by fluids. This is one of the reasons why, for millennia, the practice of healing followed a comprehensive, rational, and holistic explanation for disease based on vital fluids (or humors). This week, for the last episode in our Continuity series, we are discussing the millennias-long strangle-hold humoral medicine had on natural philosophy and medicinal healing. And… plot twist… we may be head back in this direction.

Transcript for: The Leaky Body: Fluids, Disease, and the Millennias-Long Endurance of Humoral Medicine

Written and researched by Marissa Rhodes, PhD

Recorded by Marissa Rhodes and Sarah Handley-Cousins, PhD

Marissa: Pretend it’s 500 BCE and you know nothing about modern, scientific medicine. You know nothing about anatomy or biochemistry or microbes. How would you approach the art of healing your loved ones when they became ill? How would you identify what’s wrong with them and offer them the supportive care they needed, their best chance of survival? 

Sarah: You’d observe them for signs (which are the outward, measurable presentations of disease) and ask them about their symptoms (which refer to how the sick person is experiencing the illness.) You’d feel their piping hot foreheads and try to cool them down, assuming something within their body is out of balance, something is wrong that is heating up the body. You’d assess their coloration and try to reduce their redness if they were flushed or improve their coloration if they looked pale. If your loved one was flushed, their face and forehead were warm and red, you’d (very rationally) come to the conclusion that there might be too much blood in their body. What else could be causing warmth and redness to collect in certain areas? So you’d bleed them. If they were pale, you might assume they LACKED blood so you’d feed them herbs and foods that have the warming and moistening properties of blood to try to perk them up a bit. 

Marissa: Most of all (and this might resonate with those of you who have cared for sick babies and children), you’d keep track of any events like vomiting, diarrhea, urination, wounds that are weeping or orifices that are secreting. Is pus or wax flowing out of their ear? Are they urinating way more or way less than normal? Is their urine super dark or smelly? Is that cut on their ankle looking crusty and gooey? Note your experience of trying to heal this loved one is shaped entirely by fluids. This is one of the reasons why, for millennia, the practice of healing followed a comprehensive, rational, and holistic explanation for disease based on vital fluids (or humors). This week, for the last episode in our Continuity series, we are discussing the millennias-long strangle-hold humoral medicine had on natural philosophy and medicinal healing. And… plot twist… we may be head back in this direction. 

I’m Marissa

And I’m Sarah.

Marissa: and we are your historians for this episode of Dig. 

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Marissa: For most of recorded human history, this has been the experience of healers and carers the world over. Medicine was all about viewing the body as a vessel filled with various fluids (or humors) but a vessel with leaky orifices that ebb and flow as a matter of course. Women lactate when they have a baby to feed. People bleed when they are cut. Men ejaculate as a result of sexual stimulation. Women menstruate on a regular cycle. These are all normal instances of bodily leakage. The ancient Greeks understood these as part of the normal functioning of a body and necessary for the body to maintain homeostasis. If the body had too much bile, it would typically vomit up bile and be experienced as heartburn or a stomach ache by the patient. Disruptions in these cyclical events (eg. a missed period, a very mucousy nose, a wound seeping with pus, blood in the stool, or even changes in the skin tone that suggest excessive blood (flush) or excessive yellow bile (jaundice) could be signs of a stoppage or blockage somewhere in that leaky body. Blockages, or “congestion” or “inflammation” as it was often called were signs of a humoral imbalance, or what the Greeks called dyscrasia, that was making the body malfunction. 

Sarah: The beginnings of humoral medicine are not entirely clear. There is record of humoral theories dating as far back as 3,000 BCE in ancient Sumeria. But humoral theory did not become a dominant, organized medical system until about 500 BCE in classical Greece. The theory was first systematized and recorded in the Hippocratic Corpus during the 400s BCE. This is a collection of treatises that are attributed to Hippocrates but were almost certainly not all written by one person. It’s likely that Hippocrates wrote only a few (or perhaps even none) of the Hippocratic treatises. But it’s probable that he conceptualized humoral medicine and taught this system to his many pupils, who then wrote it down in an organized way with or without his guidance and approval. So it’s more accurate to think of an amorphous, Hippocratic intellectual tradition than to think of this as one medical doctor who wrote down everything he knew. (Hundreds of years later, another scholar, Galen of Pergamum, will revolutionize the way that Hippocratic ideas were understood so stay tuned for that.)

an engraving of a bust of a bearded bald white skinned man in black and white.
An engraving of Hippocrates by Peter Paul Rubens, 1638 | Public Domain / Wikimedia Commons

Marissa: For whatever reason, several cultures systematized and recorded humoral theories around the same time as the Greeks: roughly 500 BCE. In India, the three doshas (in English roughly translate to wind, bile, and phlegm) were theorized and recorded at this time as part of ayurvedic medicine. In the Tibetan and Mongolian Uyghur system of medicine, their theory of humors developed around 500 BCE along the same lines as Ayurvedas, with the three humors. Traditional Chinese Medicine (TCM) has roots just as old as Ayurvedas but it wasn’t recorded and systematized until around 200 BCE. TCM theorizes two humor-like substances: yin and yang. 

While different medical systems disagree about the humber of humors and their qualities, the continuity of vital fluids in ancient medicine is remarkable. And most of these medical systems were holistic, meaning they viewed the body as an ecosystem and disease as an imbalance of that ecosystem. They also viewed the humors as intimately connected with a constellation of natural elements such as wind, space, earth, air, water, or fire. Each humor has a special relationship with each element. Furthermore, each humor and each element are associated with other natural phenomena like planetary movement, lunar cycles, or star charts. All humoral systems have these features in common which says something about either (1) their mutual influence on each other, or (2) some continuity within the human experience that produces similar types of systems.

Sarah: Greek humoral medicine á la Hippocrates, the iteration we will focus on here, conceives of four vital fluids or humors: Blood was wet and warm like the humid, Mediterranean air. It was thought to nourish the flesh, deliver heat around the body, and act as a transporter for other humors; Phlegm was wet and cold like water. It was thought to nourish the brain and act as a check to the heat delivered by the blood. It was also thought to be the substance that lubricated joints; Yellow bile was hot and dry like fire. This humor was thought to accumulate in the gall bladder and its main function was to keep food moving through the gut; Black bile was cold and dry like earth. It was thought to promote appetite and to nourish the bones and spleen. 

Marissa: Note the associations with the qualities of moisture content and temperature and how these have a one-on-one correspondence to one of the four major elements (air, water, fire, earth). The Greeks had an absolute obsession with the number four. It will keep popping up. But, you ask, aren’t there so many other bodily fluids one could think of? What about feces, urine, milk, etc.) They don’t mean to say that these are the ONLY fluids your body makes but, rather, that these are the VITAL fluids. The ones that keep your body working. But all other fluids in your body hold important clues as to the balance of your humors. For instance according to the Hippocratic corpus: “Colourless urine is bad; it is especially common in those with disease on the brain” and “The presence of particles like coarse meal in the urine of patients with fever signifies a long illness.”

Each of the humors was associated with an organ: blood and the heart, phlegm with the brain, yellow bile with the liver, and black bile with the spleen. So colorless urine would suggest brain problems and since phlegm is associated with the brain, we can be sure that the imbalance is of THAT humor. So even though it was understood that all four of the humors traveled throughout the entire body, some imbalances could be ascribed to specific malfunctioning organs. This made sense, since tenderness and swelling around the liver area would often result in jaundice in the patient (with our modern minds we might think of fatty liver disease or liver failure.) Jaundice is yellow… like yellow bile. So Jaundice would have been understood as an excess (or “plethora”) of yellow bile. 

Sarah: Ideally, these humors would maintain an equilibrium of sorts, what the Greeks called eucrasia. Each body was unique and had its own humoral ideal. A single person’s ideal balance would change depending on the season (in summer folks were more likely to deal with an excess of yellow bile), their age (youth were more prone to an excess of blood while the elderly were more impacted by the dryer humors), their lifestyle (someone with a sedentary job might function better with more phlegm than someone who did extensive physical labor), and their sex. Women tended to be more prone to excesses of blood or black bile while men were more vulnerable to excess yellow bile and phlegm. It was only when an imbalance went beyond a natural threshold that disease appeared. 

This way of understanding the body coincided with a principle the Greeks called vix meditrix naturae or “the healing power of nature.” This idea holds that bodies WANT to be healthy, the humors WANT to be in balance. That’s their natural way of being. So when bodies encounter a blockage, or a plethora or some other unexpected dysregulation, they, naturally, work to counteract the imbalance and restore regular functioning. So most symptoms: vomiting, fever, diarrhea, etc. could be interpreted as either (1) evidence of the humor that is imbalanced or (2) evidence of the body’s attempts to reach homeostasis. The physician’s job, then, was to prescribe therapies that would help the body (and soothe the patient’s lived experience) as their bodies sought that homeostasis. 

Marissa: Greek physicians were trained by experienced physicians in their youth. They read all of the Hippocratic texts and combined their academic learning with experiential learning. Greek medicine was what historians of medicine call “bedside medicine.” There was not typically clinics that sick people attended (though some temples did practice healing.) More often, local physicians were called to patients’ homes where they sat at their bedside, evaluated them, treated them, and checked in regularly to monitor their progress. Physicians spoke to patients themselves to learn about how they were experiencing their symptoms, but they also spoke to relatives and neighbors, got to know their diets, exercise regimens, and living and working environments. A humoral imbalance could be triggered by environmental, dietary, hygienic, or even psychological factors. 

This holistic approach was necessary BECAUSE the humoral system necessitated it. There had to be something that was causing an imbalance in the patient’s humors and it was the physicians job to address whatever was causing this dysregulation. During these investigations, physicians prescribed emetics (which caused patients to vomit- if they had too much bile for example), purgatives (which caused patients to move their bowels), bloodletting, and a whole cornucopia of herbal remedies that supported the patient as their body worked toward equilibrium again. Prescriptions often included recommendations for diet changes and exercise. So this was not heroic medicine where the physician is prescribing risky or elaborate medicines or surgeries. Since the Hippocratic tradition believed illness was natural; physicians viewed themselves as crucial in offering supportive care as the body did its thing. So their prognoses were very practical and their expectations for what they could achieve were modest. 

Sarah: We’re not accustomed to understanding medicine outside of the scientific framework that dominates now but we want to challenge you to think about how reasonable these humor/organ associations are. Where do you typically experience phlegm? Nose, sinuses, maybe eyes, mouth or ears if you’re lucky. All surrounding the brain. Also, the Greeks had seen enough warfare and accidental deaths to know what it looks like when someone gets their brains bashed in. They knew brains were wet and cold…. What else is wet and cold? Phlegm! At least phlegm is wet and it seems to happen more when it’s cold out. They also knew that blood was wet and warm because that’s how they would have experienced it. They also knew that blood had something to do with the heart since when an artery was opened (in war or in an accident) the blood spewed out to the rhythm of the patient’s heartbeat. 

Therefore, in a world where dissections were prohibited and anatomical knowledge as rudimentary, this system of understanding the body is very rational and based on external scientific observation. So don’t make the mistake of assuming that these people were idiots or that this system was irrational or even unscientific. It’s just that our scientific paradigm has shifted.This is a phenomenon that was first defined by Thomas Kuhns in his book Structure of Scientific Revolutions. Kuhn argues that science undergoes periodic “paradigm shifts” that profoundly transform scientific worldviews. He introduces the concept of “normal science,” where scientists work within an established paradigm, and “revolutionary science,” which occurs when anomalies accumulate, leading to a crisis that precipitates a paradigm shift. This shift replaces the old paradigm with an incompatible new one, a process Kuhn likens to a “gestalt switch.” His work fundamentally questioned the objectivity and rationality of scientific progress.

Marissa: So in classical Greece (and for two millennia thereafter in the Western world) humoral medicine was normal science. All experimental results were interpreted assuming that humoral medicine was a given– established, proven science. So their experiments, diagnoses, and treatments weren’t “wrong.” They were based on a different paradigm from ours. One day, we may establish a new paradigm that makes our 21st-century scientific medicine look hopelessly antiquated. This doesn’t mean there is no truth in science, just that we can only know what we can know. And sometimes knowledge is lost, and then found again (like the existence of the clitoris which is its own episode). It’s cyclical rather than straightforwardly linear. And to those questioning, but how could it have been good science if it “didn’t work?” The answer is, it did! At least as far as the ancients were concerned. As historian Frank Snowden writes: “How could a medical philosophy survive for millennia unless it was therapeutically useful?” 

Sarah: The Hippocratic tradition and the practice of humoral medicine remained relatively unchanged until Galen of Pergamon’s career in the late 100s CE. Even then, Galen accepted the Hippocratic corpus as gospel, Romanizing and promoting it, and adding on to it but never challenging it. Galen was a master of academic medicine, meaning he was the most highly educated physician in the Roman Empire. As such, he approached medicine from the place of an academic: studying and commenting on texts, delivering lectures, and guiding pupils. This is not to say he didn’t practice medicine. We have evidence that he did. Some of his Latin treatises which were lost still survive in Arabic (thank you Islamic Golden Age for being you). One of these works contains over 300 descriptions of Galen tending to his patients. He describes tending to patients with malaria, madness, smallpox, anxiety with minute attention. He visited their houses several times per day, and bathed, bled, and fed them himself. 

Marissa: Still, under Galen’s command, medicine became a scholastic enterprise rather than a bedside practice. He worshiped Hippocrates and, unlike most scientists today, Galen did not see science as ever-changing. He believed that the Hippocratic tradition was indisputable, unassailable truth and that it would forever remain so. Galen, therefore, built his scholarship on this solid foundation, positing that there were four temperaments, each corresponding to a different humoral balance. Remember we said that humoral balance, or eucrasia, could be slightly different for each person (often at different stages in life but also because each body is unique.) Galen took this a step further and categorized people whose bodies tended toward an excess of one of the humors. Buckle up because this will give you online personality test vibes. 

Folks who naturally had a plethora of blood were called sanguine. They tended to have a ruddy complexion and an affable, energetic, and pliable disposition. People whose bodies tended toward an excess in yellow bile had the choleric temperament. Their bodies were thin and sinewy, bad-tempered, restless, quarrelsome. A natural plethora of black bile meant you had a melancholic temperament. These people had dark hair and they tended to be restless, anxious, and introverted. The last temperament was phlegmatic and, you guessed it, this one resulted from an excess of phlegm. These folks were typically pale and obese, and they had an apathetic, calm, humble and sluggish demeanor. So, based on the temperaments, the humors took on even more importance in the Roman period. Their balance determined your health but also your physical appearance and personality. 

Sarah: Galen’s systematization and enhancement of humoral medicine was critical to humoralism’s longevity in the Western world. But, British historian Vivian Nutton writes, “Not only did [Galen’s] ideas constitute the basis of formal medicine in Europe at least until the seventeenth century, and arguably until the nineteenth, but… they constitute a major medical tradition in the modern Muslim world.” Galen died in 216 CE. But by the end of that same century, Rome was in turmoil (check out our episode on the Fall of Rome), and the Western World was descending into what scholars now call “late antiquity.” This period used to be called the Dark Ages or the early medieval period. This decline coincided with the rise of the Islamic world, which became an incredibly powerful force. 

Marissa: These times were generally much less stagnant that ordinary people think. But there is some truth to Dark Ages stereotypes. Galen’s humoral medicine quickly became the gold standard od medical scholarship in Europe, especially in areas colonized by (or formally colonized by) Rome. Still, Germanic folk medicines existed alongside classical Greco-Roman medicine for much of the medieval period. Christianity, adopted as the official religion of Rome in 313 CE, further solidified Galen’s hold on Western medicine. By about 550 CE, the Christian Church had gained access to limited Greek and Roman works. The Church favored Galen over other Greco-Roman scholars for a few reasons: (1) he very obviously believed in the soul which was compatible with Christian doctrine, (2) they approved of the academic approach to medicine that became his legacy; the Church discouraged dissection and experimentation, and (3) the Church had a monopoly on academia; the only literate, learned people within all of Europe were clergy and all studying and scholarship were happening within religious communities. 

Sarah: So Galen’s corpus was non-threatening, perhaps even advantageous for them. Most clergy used combinations of folk medicine and humoral theory to treat their parishioners. They planted and tended herb gardens, compounded herbal remedies, nursed ill and elderly parishioners, and prescribed dietary and exercise regimes to stave off that pesky humoral dyscrasia that cropped up every now and then. Though this treatment was often done in an institution, such as in the monastery itself, or some attached dwelling, this kind of practice resembled Hippocratic bedside medicine slightly more than the erudite, academic medicine of Galen. Though medieval medicine retained the humoral system, it deemphasized the secular and naturalistic elements of Hippocratic medicine, preferring moral and demonic explanations for disease. Still, they interpreted the impact of sin and demonic activity on the body through humoral lenses. 

Muslim scholars continued to study, comment, and publish on Hippocratic and Galenic medicine in Timbuktu, Grenada, Fez, Cairo, and the center of the Muslim world, Baghdad. By the 900s CE, Baghdad was the center of the Islamic Golden Age and waves of brilliant and famous physicians, such as al-Razi (known as Rhazes in Latin), Ibn Sina (Latinized as Avicenna), and Ibn Rushd(Averroes in the West), trained there. Medicine advanced rapidly in Baghdad. Unlike the Christian Church which, for various reasons, discouraged experimentation and advancement during this time, the Abassid Caliphate sought to remain the culture and scientific center of the world. 

a colorful medieval  image of an arabic man mixing medicine in a large pot with a long spoon
“Preparing Medicine from Honey”, from a Dispersed Manuscript of an Arabic Translation of De Materia Medica of Dioscorides | Public Domain / Wikimedia Commons

Marissa: Baghdad was home to the world’s first known secular hospitals. They had departmental specializations, on-call specialists, dedicated administrators, a Chief Pharmacist and Physician, specialty facilities for lepers and the mentally ill, and even outpatient and mobile clinics. All physicians and pharmacists were required to earn medical degrees and to obtain licensure. The hospitals underwent regular sanitary inspections. These hospitals were administered by a board and funded by both the state and waqfs which were Islamic charitable organizations. During the 1280s, Qalawun hospital treated 4,000 patients per day. Not to mention, Islamic physicians made great strides in many areas, including surgery, ophthalmology, and pharmacology. But still, they worked within the framework of Hippocratic and Galen humoral medicine.

Islamic scholars arranged surviving classical Greco-Roman works (many more than Europe inherited) as well as works from India and West Asia, into medical canons. The Abassid Caliphate also poured funding into a large-scale translation movement in Baghdad. Academics worked for two centuries translating and preserving works from Pahlavi, Sanskrit, Syriac, and Greek into Arabic. Many of the Greco-Roman works we have today were preserved only in Arabic. This is one of many reasons why we (and many other scholars) consider the Islamic world to be part of the Western World. Islamic scholars highly valued Greco-Roman scholarship and used it to build their own medical tradition, which they then shared with European Christendom. Though this was hardly the happy, friendly cooperation that one might prefer. 

Sarah: The Crusades, that centuries-long violent conflict between Islam and Christendom, changed the medical establishment in Europe forever. The constant movement of peoples between Europe and the Levant quickly added to the trickle of Greco-Roman medical treatises that were already available to medieval monks in Christendom. As Crusaders traveled to the Middle East between the 1090s and 1300 CE, they encountered advanced Islamic hospitals, universities, and scholars. During their travels, or upon the return of their co-religionists, European monks and scholars studied Arabic texts on medicine, astronomy, and mathematics, translating works by luminaries like Ibn-Sina and Al-Razi. 

Yes, while the Islamic Golden Age was raging in Baghdad, medical science was blossoming in southern Europe. This was partly due to its early exposure to the Islamic world. As we’ve discussed in other episodes, (Battle of Tours) Islamic armies conquered much of the Levant, North Africa, Mediterranean islands, and southern Europe during the 6 and 700s CE. In some areas, like Al-Andalus in Spain, they remained, setting up their own successor states. In other areas, such as Sicily, the Caliphate had lost possession of the area but Muslims and social connections to Baghdad remained. So in Southern Europe, Islamic medicine was introduced much earlier. 

Marissa: It should come as no surprise, then, that the first university in Europe, the University of Bologna, was erected in 1001. Dozens of Spanish and Italian universities, and those in Paris and Oxford soon followed. These universities used the new medical canon so carefully translated, arranged, and enhanced by Islamic scholars. All students were taught in Latin which had become the lingua franca of Christendom in the 4th century. While medieval scholars greatly admired and emulated physicians like Ibn-Sina and Al-Razi, it would have helped that they saw themselves as the heirs to the Greco-Roman tradition. Medieval church physicians like Albertus Magnus (1200-1280), and scholastic physicians like Arnold of Villanova (1240-1311) spent their days studying and commenting on this medical corpus rather than practicing clinical medicine. Medieval medicine was very much an academic endeavor. 

Sarah: Let’s take a look at how Greco-Roman humoral medicine functioned in the high middle ages in Europe, after the Crusades. Learned physicians essentially critiqued and debated the medical cannon, occasionally using anecdotal evidence to support their theories. For example, Hippocrates’s Aphorism 5.40 reads: “In women, blood collected in the breasts indicates madness.” On first inspection, this seems bizarre. Whose breasts fill with blood? And what does it have to do with madness? But through the lens of humoral medicine, this aphorism makes complete sense. Breast milk was believed to be menstrual blood that was re-routed from the womb that was cooked and filtered until it was milky white. To ancients with little anatomical or physiological knowledge, this made sense. When a woman becomes pregnant, she stops menstruating. Hippocrates and Galen theorized that this was because the womb blood had either been used as raw material for the fetus or it was used to nourish the fetus as it grew (there was some disagreement here). 

Marissa: Physicians noticed that once women gave birth, their breasts filled with milk to nourish the baby. And they still did not menstruate most of the time while they were breastfeeding. It logically followed that the womb blood, which had nourished the fetus in the womb, continued to do so from the breast. So Greek physicians theorized that after birth, the used up or toxic womb blood was excreted in the form of lochia (vaginal bleeding after birth) but the wholesome blood that was left, was rerouted to the breasts where it underwent a transformative process to become milk which was more appropriate food for a baby that had been born (rather than an unborn fetus). Some physicians even drew anatomical drawings that showed a theoretical vein connecting mammary tissue to the uterus. In the 1620s (when dissection became common), Italian physician Gaspare Aselli would discover milk veins or lacteals which appeared to confirm this theory.

Sarah: But physicians were faced with a problem. What if this process did not go smoothly? What if the new mother’s breast never secreted milk? Physicians had witnessed these problems first-hand so they looked for reasons why this might happen so they could perhaps prevent the malfunction. For this, they turned to Hippocrates’s somewhat confusing aphorism and concluded that when the transformation process goes awry (most blamed humoral imbalances that meant the woman’s breasts failed to convert the blood to milk) that the result is a toxic fume that damages the brain, hence, madness. This would have been easy enough for them to confirm with anecdotal evidence. Breastfeeding malfunctions can be deeply troubling and are perhaps more common when the mother is already suffering from mental illness. Breastfeeding problems like bleeding nipples appeared to confirm this theory, suggesting that the womb blood was not being fully converted to milk by the woman’s breasts. While this is not the only path to madness, it is one of many gendered pathologies that resulted from humoral medicine. 

Marissa: Intertwined with this medical misogyny, humoral theory also fueled medieval anti-Semitism. Jews were perceived as physically distinct from other groups, due to their distinctive religion but also due to their custom of circumcision. There was a widespread belief that Jews suffered from hemorrhoids and bleeding tendencies. In his 1219 history of the Holy Land, Bishop Jacque de Vitry wrote: “[Jews] have become unwarlike and weak as women, and it is said that they have a flux of blood every month.” Soon after, physician Albertus Magnus wrote: “Hemorrhoids are caused as a purging of melancholic blood from the veins around the anus… this happened, mostly to those who live off gross food and salted food, such as the Jews, and this happened according to nature.” Another shot at the masculinity of male Jews, melancholic dispositions are typically expected of women, not men, because of its cold nature. 

Sarah: Some physicians believed that Jews were prone to hemorrhoidal bleeding as a punishment for their rejection of Jesus Christ’s divinity and their role in his crucifixion. Bernard de Gordon, professor at Montpellier in the 13th century, wrote: “The Jews suffer from immoderate flow of blood from hemorrhoids, for three reasons: generally, because they are in idleness and for that reason the melancholy superfluidities are gathered. Second, they are generally in fear and anxiety, and for this reason melancholic blood is increased, according to this saying of Hippocrates: ‘Fear and timidity, if they have a lot of time [to work], generate the melancholic humor.’” Third, this occurs as a divine punishment, according to [scripture]: ‘And he struck them in their posteriors and gave them over to perpetual opprobrium.’”

Marissa: This idea was associated with the theory of the four bodily humors needing to be balanced. According to the Hippocratic corpus, men were viewed as generating more internal heat, while women were considered cooler in their bodily constitution. This was one of the primary reasons why physicians believed that women menstruated, to expel from their body toxins that men could expel via sweat and heat through their skin. The perception arose that “effeminate” Jewish men could not naturally dispel this excess heat, so they required a form of “menstruation” (bleeding) to achieve humoral equilibrium. This belief persisted for centuries, leading to very real consequences for European Jewry. The humoral economy of Jewish males’ bodies was explicitly mentioned in orders for their expulsion from Thuringia which cited Jews’ “need for human blood to heal a wound that flowed in them perpetually.” In Tyrnau, Austria, 14 Jews were accused of murdering a Christian child. Under torture, they confessed that “men and women among then suffer equally from menstruation… The blood of a Christian is the specific medicine for it, when drunk.” Despite their confessions, all 14 were burned at the stake. 

Sarah: Something similar happened during the early modern period (1500-1750) when European explorers fanned out around the globe looking for gold, conquest, trade routes, and souls to convert. Travelers accounts included stories of faraway lands and new, exotic peoples. Some of these narratives told stories of lactating men. These stories were, naturally, of interest to physicians and the anecdotes made their way into medical treatises. Helkiah Crooke, court physician to James I of England, wrote in 1615, “almost all the [indigenous] men have a great quantity of milk in their breasts.” This concept was even recorded in 18th-century encyclopedias as indisputable fact, using humoral medicine to explain the physiology. Therefore, these ideas about indigenous American bodies used humoral theory to explain human difference as Europeans were encountering it on a new scale. But it also allowed Europeans to make self-serving claims about their superior bodies, climates, and cultures.

Marissa: Nevermind that Hippocrates and Galen themselves recorded instances of Greek and Roman lactating men. So did 16th-century Italian polymath Gerolamo Cardano who purportedly “writeth that hee knew one Antonie Buzus at Genua, who being thirtie years of age, had so much milk in his breasts as was sufficient to nurse a childe.” There was even a revered Christian tradition of painting a lactating Jesus who, figuratively, suckled the Church at his teet. This gender-bendery is an interesting feature of humoral medicine that was written about by historian Thomas Laqueur in the 1990s. 

Laqueur argued that in pre-Enlightenment Western culture, there was a “one-sex” model of human reproductive biology. According to Laqueuer, males and females were seen as having the same fundamental reproductive structures, with the male being the perfect form and the female being an inverted version. This is an Aristotelian premise that women are merely imperfect men. Indeed, within humoral medicine, female reproductive organs were thought to be male ones that failed to emerge and descend during development. The ovaries were merely internal testes, the vaginal canal merely a hollow, internal penis, and so on. This was based on the humoral understanding that male fetuses experience more (aka the correct amount of) heat in the womb, which pushes their genitalia outward. Female fetuses suffer from a lack of heat (their first of many womanly failures) which results in internal genitalia. Laqueuer argues that the one-sex conception prevailed until the 18th century, when a “two-sex” model emerged that viewed male and female bodies as fundamentally distinct. Laqueur contended this ideological shift reflected changing gender politics rather than new scientific discoveries. His theory is not without fault but it’s useful in understanding what was going on with humoral theory in the late medieval and early modern world.

Sarah: Laqueur’s theory is based on the fungibility of fluids. This refers to the fact that within humoralism, one fluid could be transformed into another (like womb blood into breast milk) and that they often were. Due to this feature of humoralism, Laqueur writes: “blood, semen, milk, and the various excrements are fungible in that they turn into one another and whose processes– digestion and generation, menstruation, and other bleeding– are not so easily assignable to one sex or another as they become after the eighteenth century.” This does fit well with out earlier discussions about Jewish male menstruation and indigenous American male lactation. The fact that these phenomena are explainable via humoral medicine is, itself, an admission that humors could transform secondary sex characteristics. 

There are mountains of evidence that practitioners applied this idea in clinical settings. Barbara Duden’s book Woman Beneath the Skin demonstrates this well. Using the patient records of early 18th-century German physician Johann Storch, Duden discovered that “no morphological element nor any process such as the flow of semen or the monthly bleeding has been seen at all times and everywhere as unique to a specific gender.” Storch wrote about seeing women who only menstruated DURING pregnancy, and not otherwise. Or women who menstruated from the nose or anus rather than from the vagina. Still other women did not menstruate at all but were able to bear children. Storch also attended several babies and children who menstruated. Based on this clinical experience, Storch, and most other physicians, concluded that monthly bleeds were not necessarily connected to fertility so, therefore, they were not necessarily confined to women. Men often suffered from “flow of the piles” or bleeding hemorrhoids. Any periodic evacuation of blood: whether from the vagina, anus, nose, or any orifice, was categorized as “menstruation” and perceived as the body’s natural attempts as maintaining eucrasia (or equilibrium). 

Marissa: Viewed in this light, menstruating Jewish men and lactating indigenous men were less absurd to early modern physicians than they are to us. It may have seemed unusual to the general public but they were looking for reasons to justify their anti-Semitism and European exceptionalism anyway. They wouldn’t let humoral facts get in the way of that. Some physicians objected entirely. Nineteenth-century scientist Alexander Humboldt rejected the idea that Jewish or indigenous men were extraordinary or even particularly prone to menstruation or lactation. He wrote: “I can affirm, that at present, [male lactation] is not more common in the new continent, than in the old.” He continued: “In every age examples are cited of young girls not marriageable, or women withered by age, who have suckled children. Among men these examples are infinitely more rare; after numerous researches, I have not found above two or three.” 

Humboldt used humoral theory to argue that male menstruation and lactation were rare but natural and humorally explainable instances of human variation. Remember that these male menstruation and lactation myths were ALSO based on humoral theory. This is a great example of how humoral medicine was “normal science” according to Thomas Kuhn. Everything, even observations that seemed to contradict humoralism, were eventually explained away in humoral terms. Their brains were unable to conceive of a context wherein humoralism did not reign. This remained the case until well into the 19th century (remember by now humoralism has been the dominant paradigm for over 2,000 years.) This is even after the anatomical revolution, the scientific revolution, William Harvey’s mapping of the circulatory system, the discovery of vaccination, the advent of medical school and professionalization of medical doctors and licensure, and even the invention of anesthesia. 

Sarah: This continuity is only disrupted by the advent of modern medicine. Some people use the work “scientific medicine” but it’s not very precise because, surely, the Greeks, Romans, medievals, early moderns, and Enlightenment-era folks were all doing science. But somewhere in the middle of the nineteenth century, there was a paradigm shift or “revolution” as Thomas Kuh would call it. The 19th century saw a series of discoveries that challenged the old ideas. 

Germ Theory as conceived of in 1861 by Louis Pasteur proved that microorganisms cause disease. Though folks were not always quick to support his work. Still, further experimentation revealed how effective it was to protect the body against microbes. By the late 19th century, the weight of evidence for germ theory and the success of new treatments led to a revolution in medical practice. The old paradigm was no longer dominant, and a new one based on microbial understanding of disease became the norm.

Marissa: But this doesn’t mean humoralism just ended abruptly. British surgeon, Joseph Lister, introduced the concept of anti-sepsis to surgical practice in the 1890s. Anti-sepsis refers to the use of chemicals (he favored carbolic acid) to sterilize surgical instruments and prevent infection. Lister was a fully modern physician. He had broken completely with the humoral tradition. Contrary to popular belief, humoralism encouraged basic hygiene- clean-smelling air (free from miasma), clean hands (free from dirt), clean linens (free of noxious stains), etc. These practices were thought to protect the patient’s humors from corruption. They also are responsible for all of the medieval and early modern public health policies (there are many but that’s a whole other episode). 

a black and white image of a white man standing in front of a padded table. A scepter is laying in front of him and a very ornate chair behind. Above him hangs a portrait of a scientist of a previous generation.
Joseph Lister | Public Domain / Wikimedia Commons

Sarah: “Clean” according to humoralists was the kind of clean one might strive for knowing nothing about microbes. But Lister was less concerned about this kind of cleanliness and more concerned with killing the microbes that caused infection.  Lister had a decades-long conflict with a competing surgical hygiene system called “asepsis” championed by Ignaz Semmelweis. Surgical asepsis refers to the attempt to achieve a completely sterile environment by preventing the introduction of bacteria, fungi, etc. from entering the surgical suite to begin with. Semmelweis encouraged the extensive hand-washing surgeons do today when they “scrub in.” Asepsis actually was consistent with humoral medicine. Eventually, the modern medical establishment came to realize that antisepsis and asepsis need not be at odds: they could complement one another. Today, we use a combination of antiseptic and aseptic techniques. 

Marissa: The historical importance of humoral theory cannot be overstated. According to Professor Frank Snowden at Yale, “the Hippocratic writings stress a central claim: that disease is a purely naturalistic event that can be explained only by secular causes and that can be treated only by rational means.” This was revolutionary because up to this point, most interpretations of medicine had spiritual aspects to it. There were certainly rational elements of ancient Mesopotamian and Egyptian medicine but they were blended with spirituality. For most of human history, people looked to the spirit world when practicing healing. Ancient Jews, for example, interpreted disease and death as the “wages of sin.” Even archaic Greeks interpreted epidemic disease as the scourge of angry and vengeful gods. Medieval and early modern Europeans often sought demonic explanations of disease, believing that rooting out witches would cure epidemic and chronic disease. 

Sarah: It’s important to keep in mind, however, that medical progress is not linear and paradigms can and should overlap. The supernatural model of disease did not disappear with the advent of the Hippocratic corpus; It didn’t even disappear with the advent of modern medicine! John Humphrey Noyes, the 19th-century religious radical of the Oneida community who we’ve mentioned many times before, believed that their community could stave off disease and claim immortality by eliminating sin. Even as late as the 1980s, evangelicals like Jerry Falwell celebrated the HIV/AIDs crisis as proof of God’s disapproval of homosexuality.

Marissa: And we encounter remnants of humoral theory in popular medicine today. We draw from it every time we aspire to balance and harmony within our bodies and when we prescribe all things in moderation. We have also inherited Galen’s ideas of temperaments; we refer to “fiery red-heads” and “melancholic dispositions.” Even the connection between womb blood and breast milk is not entirely severe. New mothers worry about how stress might impact their milk supply or we may find it unnatural for someone to breastfeed another woman’s baby, joking that their child might imbibe some of their nurse’s personality or disposition in the milk. 

Recent scientific research has even suggested that humoral physiology was not all wrong. For example, in 2018 scientists discovered a new organ that had never been documented in medical literature. The interstitium is a network of fluid-filled spaces that permeates almost every organ in the body. It actually resembled the networks of pores that Hippocrates and Galen asserted were responsible for exchanging fluids within the body. Humoral theory emphasized the importance of bodily fluids, the interstitium is a vast network filled with fluid. This fluid plays a crucial role in communication and waste removal within the body. Humoral theory also proposed that fluids carried messages and influenced health. The interstitium facilitates communication between cells and organs by transporting hormones, immune cells, and signaling molecules. 

Sarah: That being said, we would choose modern medicine over humoral medicine any day of the week. But it’s still interesting, especially in the history of medicine which is all about progress and discovery, to note how LITTLE things changed for so long. We hope you enjoyed this last installment in our 5, no 6!, Cs of history: Continuity. 


Cabre, Monserrat, and Fernando Salmon. “Bloody Milk and Tender Meat: Ethnography of Breastfeeding and the Origin of People in a Mapuche Community.” Journal of the Society for the Anthropology of Lowland South America 7, no. 2 (2009): 85-104.

Duden, Barbara. Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany. Harvard University Press, 1991.

Kuhn, Thomas S. The Structure of Scientific Revolutions. University of Chicago Press, 1962.

Laqueur, Thomas. Making Sex: Body and Gender from the Greeks to Freud. Harvard University Press, 1990.

Maor, Hannah. “Medieval Roots of the Myth of Jewish Male Menses.” In Drawing the Line: The Anatomy of Sex and Body Pollution, 109-134. Routledge, 2021.

Nutton, Vivian. “Humoralism.” In Companion Encyclopedia of the History of Medicine, edited by W. F. Bynum and Roy Porter, 281-291. Routledge, 1993.

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Orland, Barbara. Lactation and Menstruation in the Galenic-Hippocratic Synthesis. Ashgate, 2014.

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Snowden, Frank M. “Introduction: The Greek Medical Writers and Their Intellectual Context.” In The Ancient Greek Medical Writers, Loeb Classical Library, edited by Frank M. Snowden, vii-xxvii. Harvard University Press, 2022.

Tuke, John Batty. “Hippocrates.” In Encyclopædia Britannica, 11th ed., vol. 13, 517-519. Cambridge University Press, 1911.

Hippocratic Writings, edited by G. E. R. Lloyd. Penguin, 1983.

“Galen and the Condition of Individual Scholarly Greatness.” The Lancet 377, no. 9773 (2011): 1253-1255.


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