The four humors: Part of naturopathic training

The four humors: Part of naturopathic training

The ancient Greeks posited a system of health and disease based on the four humors: blood, phlegm, black bile and yellow bile. According to this system, health is defined as a harmony of these four humors and disease is caused by an imbalance among them. Restore the balance, and health is restored. Bleeding is a familiar example of humoral medical treatment based on a diagnosis of an “excess” of blood. Fortunately, the humoral system of diagnosis and treatment died out with the advent of modern scientific medicine.

But as David Gorski asked (sarcastically, of course) in his presentation on quackademic medicine at CSICon in October, if supposedly ancient philosophies of diagnosis and treatment such as Traditional Chinese Medicine and Ayurveda are so beloved by CAM proponents, despite their implausibility and lack of evidence of effectiveness, why not the humoral model of health and disease? Why not include humorism in the CAM practitioner armamentarium?

Who knew?

Well, as it turns out, humorism is alive and well in that most inclusive of all CAM practices, naturopathy. A full chapter on its “theory” and practice is right there in the Bible of naturopathy, the Textbook of Natural Medicine, Fourth Edition, 2013, Ch. 49, pp. 419-437. That’s right, the brand-spanking-new edition of the foundational text of naturopathy has a chapter on humorism.

But, you may ask, how did I come to possess a copy of the 2013 edition of the Textbook of Natural Medicine? The simple answer is that it arrived as a gift on my doorstep, via UPS, on Christmas Eve. Not a gift in the sense that someone gave it to me as a Christmas present – I ordered it myself – but in the sense that it is (per “something bestowed or acquired without any particular effort by the recipient or without its being earned.” All I did was pay $186.75 – a bargain compared to the book’s true worth.

Why? Because the American Association of Naturopathic Medicine has declared its intent to push for licensing of “naturopathic doctors” as primary care physicians in all 50 states. They’ve succeeded in 16, with 11 more targeted for 2013. This should be viewed with alarm by anyone who values science-based medicine. Or evidence-based medicine, for that matter.

Given the tendency of state legislatures to legitimate implausible and evidence-free CAM practices by giving their practitioners licenses to practice medicine, I feel it is important to oppose this effort. And I’ve discovered that there is nothing better to demonstrate the foibles of CAM than going to its source materials, especially when it comes to claims of being “science-based” or “evidence-based.” I am not the first to notice this, of course. Kimball Atwood in his SBM series on the cult of naturopathy (references collected here), and others, including additional SBM posts and Quackwatch articles, have done a splendid job of exposing naturopathy, including criticism of its literature. What I add here is simply that, in 2013, based on naturopathy’s latest, most “scientific,” most “evidence-based” effort, things have not improved much.

Exhibit A: Chapter 49

The inclusion of humorism in the Textbook of Natural Medicine is not immediately obvious, as the chapter covering the subject is named “Unani Medicine.” And for the chapter’s first couple of pages, the true content is only hinted at with statements like

there is no question that the initial, primary, and most honored textual sources were of Greek origin.

Unani apparently is a sort of Islamiscized version of Greek humorism, with a bit of folk medicine absorbed along the way,

from the traditional use of herbal remedies of ancient Palestine to the folkloric ore-based therapeutics of the people living on the high plateaus of the Himalayan Hindu-Kush mountains.

At the same time,

Unani medicine also shares medical theories, philosophies, cultural identity, and spiritual insights regarding human health and disease with ancient systems of medicine, such as Hindu India’s Ayurveda and Traditional Chinese Medicine, because its knowledge and wisdom hail from the traditional Eastern ‘Orient.’

No wonder unani medicine is a logical choice for inclusion in text on naturopathy, what with its being such a hodgepodge

But by page 421, the foundational elements of unani medicine are revealed to be none other than the familiar four humors, in the form of a chart (Table 49-1) “Comparing the Three Great Traditional Healing Systems with Modern Western Medicine,” identified by metrics such as “disease correlates,” “disease causes,” “primary treatment modalities,” “health care expenses,” “common medicines used,” and so forth. (The two other “Great Traditional Healing Systems” are Ayurveda and Traditional Chinese Medicine, both already beloved of naturopaths.)

Thus, in the column headed “Unani” we find this information:

Disease correlates: Humors

Disease causes: Imbalance of humoral elements

Basis of diagnosis: Restore balance to humors and organ systems

Chief diagnostic modality: . . . temperament assess for each of four humors

Pulse diagnosis: Reveals humoral imbalance in organ system. Taken with three fingers at radial pulse of wrist; more than 1,000 potential factors evaluated in seconds. [!]

Of course, take any chart in a CAM textbook comparing “Modern Western” medicine with “Great Traditional Healing Systems” and guess which system is going to come out looking less palatable? Right, modern Western medicine. Thus, for modern western medicine, the primary treatment modality listed in the chart is

Chemotherapy; radiation therapy; pharmaceutical drugs; surgery; rehabilitative physical therapy.

And the primary treatment objective of western medicine is

Symptom suppression, kill germs and bacteria; palliative end-of-life management.

Under the category “side effects,” the three “Great Traditional Healing Systems” all experience “very rare” side effects. In contrast, under modern western medicine, it is noted that

106,000 die annually from improper medications; severe and frequent drug reactions; very common.

And, for “Cancer rates,” supposedly based on “WHO rates out of 93 countries,” Unani and Ayurveda are both “6th lowest,” TCM is “30th lowest,” and modern western medicine is “”93rd lowest (worst of all).” No citation is given for this comparison. For “Annual per capita health care expenses,” Unani and Ayurveda are $9.45 each, and for TCM an amazingly low $3.96. For modern western medicine annual per capita expenses are $1,301. The source of these figures is listed as the World Bank but without further information on how to find this World Bank analysis.

Even the “deity of system” is catalogued. Unani’s deity is “Abrahamic monotheism,” while modern western medicine’s deity is

Secular atheism; agnosticism; modern evolutionary nihilism.

Elsewhere the chapter’s author (an ND and licensed acupuncturist) goes on to describe the “Seven Naturals,” which he describes as “the pillars and determinants of health.” Of these, five are based directly on humorism: the humors themselves, as well as temperaments (each named after a certain humor), forces (“the manifesting activities of the humoral and organ powers”), functions (“the by-products of the will or power of the humors and organs”) and pneumata (the “heavenly command” that acts upon the humors).

Over two pages are devoted to a description the traditional Greek humoral temperaments – sanguine (blood), choleric (yellow bile), melancholic (black bile), and phlegmatic (phlegm), with corresponding detailed descriptions of the physical manifestations of each temperament. Thus, while the urine of the sanguine temperament is “rich or bright yellow and thick,” that of the choleric is “scanty, dark, thin” and can be “hot or burning.” Melancholics are light sleepers, while phelgmatics are deep sleepers and tend to snore. And so on.

In addition to detailing the humoral basis of unani much of the chapter is an explanation of the religious basis of its practices, which the author often analogizes to the basic principles of naturopathy. To this point, naturopathy is described as “the offspring of the life and thought of the ‘prince of physicians,’ Avicenna,” the father of unani.

The official naturopathic seal of approval

Unani is a traditional medical system that borrows heavily from Greek humoral medicine. As is true of acupuncture, homeopathy and Ayurveda, it was a pre-scientific attempt to explain human functioning, including health and disease, appropriate to its time and culture. And like acupuncture, homeopathy and Ayurveda, its diagnostic methods and treatments are easily debunked. In fact, it’s been done already. As Wikipedia says, “modern medical science has thoroughly discredited humorism.” That it is “thoroughly discredited” is not what is interesting here. Most people already know that.

What should grab our attention is the way unani medicine is presented in the Textbook of Natural Medicine, 2013 edition. It is not just part of a larger history of various traditional medical practices. No, here it is part of “Section Three: Therapeutic Modalities,” right along with chapters on naturopathic standards like acupuncture, fasting, homeopathy, hydrotherapy, nutritional medicine, and soft-tissue manipulation. I’ll let the editors describe the purpose of the “Therapeutic Modalities” section in their own words:

This section presents a historic, scientific, and practical review of the schools of thought and modalities of natural medicine. We have compiled the work of experts in their fields into what we hope the reader will find a concise, yet useful, description of these practices and modalities. Because of the clinically oriented and alternative nature of these disciplines, the scientific evaluation of their theories and efficacy has been limited in the past. Happily, published research in natural medicine has increased dramatically since A Textbook of Natural Medicine was first published in 1985.

Although this textbook is strongly oriented to the scientific method and the use of the peer-reviewed literature for documentation of the efficacy of a therapy, these modalities’ widespread clinical use and long history of patient satisfaction demand that they be given a place here even though the mechanisms of action of several have yet to be elicited.

Allow me to translate: we have no idea how, or if, any of these therapies work, even though we’ve “dramatically” increased naturopathy research in the last 30 years. But, feel free to use them anyway because, well, they are being used anyway.

I might be called to task if I were to stand up in front of a legislative body and claim that naturopathic doctors still practice humorism, the long-discredited ancient Greek system of medicine based on the four humors – blood, yellow bile, black bile, and phlegm – and the theoretical basis for the practice of bleeding. But if I held up the Textbook of Natural Medicine and directed their attention to Chapter 49, the NDs would be hard pressed to disclaim it. As I said, there is no richer source for argument against CAM practices than the CAM literature itself. And this is a perfect example.





  • Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.    

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.