MHGCJ – 2020

Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

The Hippocratic account of Mental Health: Humors

and Human Temperament

Konstantinos Kalachanis

, Christos Tsagkaris

New York College, Athens, Greece,

University of Crete, Faculty of Medicine, Heraklion, Greece

Abstract

Introduction: A quintessential element of Hippocratic medicine is treatment of mental diseases

which was based on a detailed examination of the symptoms as well as the study of human

physiology and final outcome of the diseases which is based on humoral theory.

Purpose: The aim of the work is to highlight the contribution of Hippocrates to the study of

mental illness based on his theory of humors

Methodology: Our study consists of interpretations of the original text of Hippocrates including

extensive observations of anatomy and physiology of human body based on humoral theory.

Then the information was evaluated on the basis of modern literature in order to establish their

validity. A major limitation of the research is the lack of a systemic methodology to screen the

Hippocratic corpus for relevant passages which actually requires interdisciplinary research in

order to determine which aspects of Hippocratic medicine can be developed.

Results: In Corpus Hippocraticum, it is highlighting that maintaining a relative proportion of

humors in human body (apart from maintaining health) regulates the human temperament and

its behavioral manifestations. Hippocrates, has included in his work observations not only on

human physiology and diseases but also studies the environmental and geographical impact

on them, thus setting the stage for holistic approaches

Conclusion: Summarizing, Hippocratic medicine and particularly his observations on mental

disorders provides a clear picture of the methodology used by Hippocrates which can be a

guide for the adoption of good practices for contemporary scholars and clinicians on their

everyday practice.

Keywords

theory of humors, environment, temperament, eucrasia, Hippocrates.

Address for correspondence:

Konstantinos Kalachanis, MSc, PhD, New York College, Athens, Greece,. e-mail:

kkalachan@phys.uoa.gr

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: Kalachanis, Tsagkaris, 2020

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

DOI: http://doi.org/10.32437/mhgcj.v3i1.83

Submitted for publication: 15

June 2020

Received: 15 June 2020

Accepted for publication: 19

September 2020

MHGCJ – 2020

Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

Introduction

Hippocrates was a Greek physician if the 5th

century BC, who is often referred to as the "Father

of Medicine”. A descendant of a priests –

physicians family himself, Hippocrates was a

pioneer in the scientification of Medicine.

Founding the Hippocratic School of Medicine, he

established medicine as an art with a scientific

approach, gradually distinguishing it from theurgy

(Kleisiaris et al., 1995).

Medicine at the time of Hippocrates had

close ties with philosophy. Hippocrates and his

disciples emphasized on detecting etiological

correlations through keen observation of patients

and diseases. Apart from putting together the

Hippocratic Oath, a standard of ethics, which is

still relevant and in use today, the Hippocratic

Corpus, a collective work of Hippocrates and his

disciples is credited for promoting the systematic

study of clinical medicine, summarizing the

medical knowledge of previous schools, and

establishing good practices for physicians

(Kalachanis, 2011).

Among others, the Hippocratic Corpus

includes an account of humors and human

temperament, depicting the scientific perception

of mental health at the time.

Purpose

The purpose of this article is to summarize the

Hippocratic account of mental health discussing

humors and human temperament.

Methodology

We studied the Hippocratic Corpus focusing

on temperament and mental health. We worked

on the original text of Hippocrates and retrieved

information from Aristotelian Corpus where there

are extensive observations of anatomy and

physiology of human body. The information

extracted from the texts was subsequently

evaluated on the basis of modern literature in

order to establish their validity.

Results

Impact of the humors on human behavior

A basic concept of Hippocratic medicine was

was the attempt to identify the causes of

diseases in the physiology of the human body

(Galen, Quod optimus medicus sit quoque

philosophus, 54, 2-4) but also in the influence of

harmful factors of the environment such as air,

water and nutrtion (Kalachanis, 2011;).

Hippocrates considers Medicine as a pure

scientific discipline that aiming at treating illnesses

thus setting the basis of modern Medicine (Kirsten

et al. 2009) In order to understand the causes of

illnesses he had to understand apart from the

anatomy of human body he had to determine

the basic elements from which is consisted. It is

worth to mention that Hippocrates was taught

Philosophy by Democritus (Soranus, Vita

Hippocratis, 1) whose (along with Leucippus)

major whose cosmological views referred to the

atoms (not divisible) as the fundamental

elements of the world (Simplicius De caelo 242,

18-21). In the same context Hippocrates

claimed the existence of four fundamental

elements or humors (χυμοί) which indeed

correspond to the basic elements of the Universe

as described in ancient philosophy. Each humors

is secreted from a specific organ (Nemesius De

natura homini 4, 8-12) and also differ from each

other (Galen, In Hippocratis de natura hominis

librum commentarii iii 15, 66, 1-3). When the

proportion of the four humors as well as their

mixing is the proper, a state similar to equilibrium

and called by Aristotle eucrasia (De partibus

animalium, 673b, 26) health in human body is

maintained thus introducing a more

mathematical approach of medicine (Eftichiadis

1995). In case the condition of the body deviates

to the pathological one, a corresponding

therapeutic intervention is required, depending of

course on its nature (Galen, 17a 98, 25).

HUMOR

ELEMENT

ORGAN

YELLOW BILE

FIRE

LIVER

BLACK BILE

EARTH

SPLEEN

PHLEGM

WATER

BRAIN

BLOOD

AIR

HEART

Table 1: Human behavior is not an effect that

comes only from the mixture of the humors but

includes also the place of residence, air, water and

generally climatic conditions (See Hippocrates, De

aëre aquis et locis,)

Moreover, a basic attribute of the humors is

that the predominance of everyone in man also

creates a typology of characters (Table 1) (Kiersey

1998). Human behavior is not an effect that

comes only from the mixture of the humors but

includes also the place of residence, air, water

and generally climatic conditions (See

Hippocrates, De aëre aquis et locis,)

HUMO

ORGA

TEMPERAMEN

ATTRIBUTE

S OF

CHARACTE

Blood

Heart

Sanguine

courageous,

hopeful,

playful, care-

free

Yellow

Bile

Liver

Choleric

ambitious,

leader-like,

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Mental Health: Global Challenges Journal

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restless, easily

angered

Black

Bile

Spleen

Melancholic

despondent,

quiet,

analytical,

serious

Phlegm

Brain

Phlegmatic

calm,

thoughtful,

patient,

peaceful

Table 2: Humors, organa and typology of human

behavior

Galenus having interpreted the typology of

human character makes some interesting

observations thus saying that when the

melancholic (black bile) humor exceeds then

then the human character is malignant,

indigestible and generally a repulsive case for all.

On the other hand sanguine character (with

blood exceeding) identified as the most forgiving

and sweet character (Galenus, De constitutione

artis medicae ad Patrophilum, 1, 280, 1-9).

Hippocrates' work includes a large number

of case studies where he provides data on the

symptoms, the treatment and the final outcome

of the patients. Also apart from detailed

observation he used methods of palpation, and

auscultation in order to determine the patients

condition (Rektor et al. 2013) and study in detail

the symptoms. His experience in managing many

medical cases also allowed him to observe

environmental conditions such the place of

residence that affect not only diseases but also

human temperament diseases, thus observing

that “Tribes living in countries rugged, elevated,

and well-watered, and where the changes of the

seasons are very great, are likely to have great

variety of shapes among them, and to be

naturally of an enterprising and warlike disposition;

and such persons are apt to have no little of the

savage and ferocious in their nature;” On the

other hand, people living in low-lying places

which are not properly ventilated and exposed

into warm winds instead of cold, are not

courageous and also are not capable of

performing laborious enterprises (Hippocrates, De

aëre aquis et locis 24, 4-10).

Humoral theory and mental disorders

Mental illnesses was of major interest for

Hippocrates who was the first one to recognize

their different types using a terminology which is

used even in modern science such as Mania,

Melancholy, Phrenitis, Insanity, Disobedience,

Paranoia, Panic, Epilepsy and Hysteria (Kleisiaris et

al. 2014). His methodology apart from managing

case studies was to explain their causes to the

physiology of the human body and at the same

time to reject any divine intervention. A typical

case is the issue of epilepsy which the people of

his time called sacred, that is, they considered it

as sent by God which the people of his time

called sacred, that is, they considered it sent by

God because of its strange symptoms. This tactic

was established according to Hippocrates by

various magicians and purists who, although they

show reverence in reality, deceive people and to

hide their ignorance about the causes of the

disease they used God as an excuse. God also

according to Hippocrates could never infect a

body (Hippocrates, De morbo sacro, I, 2-24).

Currently, it is established that the onset of

epilepsy is linked to a paroxysmal alteration of

brain function. Excessive and hypersynchronous

discharge of neurons in the brain results to an

“epileptic seizure”. “Epilepsy” is the condition of

recurrent, unprovoked seizures. Epilepsy has

numerous causes – genetic and environmental,

intrinsic and extrinsic, but its onset indicates a

pattern of brain dysfunction (Shorvon et al. 2011;

Stafstrom & Carmant, 2015) as well as brain

injuries and ischemic damages (Reid & Roberts,

2005).

Actually in ancient Greek literature there are

many mentions that match the symptoms not

only of epilepsy but of mental illnesses. Such a

case is narrated by Herodotus about the Persian

king Cambyses, who went mad thus killing his

brother Smerdis, (Historiae, III, 30 ) and also

committed many other atrocities and crimes. The

cause for these actions was the sacred illness

since he was born (Historiae, III, 33). Hippocrates

although considers brain physiology as the cause

for this disease (De morbo sacro, VI).

Apart from the explanation of epilepsy

Hippocrates tries to explain melancholia which is

directly related to black bile and people who

suffer from this illness have symptoms of bad

mood (Aphorismi VI, 23, line 2) as well as

dangerous symptoms such as instillation of liquids

inside the body (ἀποσκήψιες) and apoplexies

(mania) while their lingual expression becomes

more interperate (ἀκρατὴς) (Aphorismi VII, 40, 1).

Also in a modern interpretation Hippocratic theory

on melancholia is mentioned that patients with

an excess of black bile may suffer from epilepsy,

seizures and depression in epilepsy and

depression. The clinical phenotype of black bile

excess depends on the “direction” of the malady;

if it bears upon the body, epilepsy, if upon the

intelligence, depression”. Hippocrates' claim that

“epileptics become melancholics” resonates with

contemporary knowledge, given that depression

is the most frequent psychiatric comorbidity

epilepsy (Rektor et al. 2013). Also Galen

mentions several cases of phrenitis (φρενίτις) and

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insanity (παραφροσύνη) a disease similar to μανία

(mania) which also interpreted as insanity (Sani et

al. 2017) or as a furious attitude, an acute mental

condition in the absence of fever (Routh, 1988).

These situations may result from yellow bile and

black bile (Galenus, De locis affectis libri vi VIII,

178, 5-9 and In Hippocratis prorrheticum i

commentaria XVI, 545)

Discussion

Despite its scientific methodology, Medicine

at the era of Hippocrates lacked the technical

means necessary to conduct research,

investigate and establish diagnoses. The

methodology of communicating science was

also different taking into account the negative

views of major intellectuals of the era such as

Socrates on books. The Hippocratic account of

temperament contributed to rationalizing mental

health and illnesses. At that time, conditions such

as epilepsy were considered as “sacred illnesses”

indicating the popular belief in their divine causes

and the – equally – popular disbelief in the ability

of physicians to diagnose and treat them.

Nowadays, mental health is facing a wealth of

controversies attributed to intrinsic and extrinsic

factors of the field. Scholars of the field have

pointed out the lack of funding, the gap between

basic and translational research, the limited

access to appropriate mental health care as well

as the widespread stigma of mental illnesses in

modern societies. Rationalizing mental illness and

establishing a trust between specialized

healthcare practitioners and the public is a

challenge that contemporary scientists face

(Wainberg et al., 2017).

It appears that this challenge is what

medicine today has in common with Hippocratic

medicine in terms of mental health. Although

humors are no more relevant, the interaction

between environmental factors and mental

wellbeing is still puzzling scientists. Despite the fact

that black bile is not the cause of depression, the

comorbidity of depression with seizures or mania

are quite relevant not only with regard to

treatment but also with regard to prevention and

early diagnosis.

Limitations of the study\Strengths of the

study

The potential of this study is limited due to the

lack of a systemic methodology to screen the

Hippocratic corpus for relevant passages. In a

broader sense, the fact that ancient texts might

have been lost weakens our assessment of the

Hippocratic account of mental health. On the

other hand, the fact that native Greek speakers

with backgrounds in Classics and Medicine share

authorship enhances the comprehension and

interpretation of these passages.

Conclusions (and Future Work)

Revisiting the Hippocratic account of mental

health can be a source of inspiration and good

practices for contemporary scholars and

clinicians. Such good practices include but are

not limited to empathetic communication with

patients, thorough history taking and

communication of patients’ narratives with

colleagues. Future studies may identify such

practices and investigate their feasibility and

efficacy in contemporary mental health facilities.

Conflict of interest

The authors declare no conflict of interest with

regard to this study.

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