In Flux

The Fluid Body in Classical Greek Medicine

Brooke Holmes

A body awash in fluids.

If we go back to our earliest Greek medical texts, this is the body we find: a body imagined primarily as the hidden terrain of dynamic fluids. These fluids are often referred to in our medical texts as humours (chymoi) or, literally, juices.

Humours

Grey textured artistic depiction of turbulence

In the long-lived and widespread traditions of medicine and philosophy developed from the ancient Greek medical canon, the number of humours is firmly fixed at four: phlegm, blood, yellow bile and black bile.

From second-century CE Rome to ninth-century Baghdad to eighteenth-century Germany, people thought about health and disease in terms of how the four humours interacted with food and drink, with the seasons and the climate, and with one another inside the body.{{¹}}{{{For the reception of the quaternary model of the humours, see Jacques Jouanna, ‘The Legacy of the Hippocratic Treatise The Nature of Man: The Theory of the Four Humours’, in Greek Medicine from Hippocrates to Galen: Selected Papers by Jacques Jouanna, ed. Philip van der Eijk, trans. Neil Allies (Leiden: Brill, 2012), 335–59. For the reception of Hippocratic humoralism in the Arabic tradition, see Peter Pormann, ‘Arabo-Islamic Tradition’, in The Cambridge Companion to Hippocrates, ed. Peter Pormann (Cambridge: Cambridge University Press, 2018), 340–61. For the persistence of humoral theory into eighteenth-century Germany, see Barbara Duden, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany, trans. Thomas Dunlap, rev. ed. (Cambridge, MA: Harvard University Press, 1998).}}} Their ebbs and flows dictated not only health but also a person’s character or temperament, a word derived from the Latin temperamentum—literally, the mixture of humours determining one’s characteristic disposition.

So common are the four humours in medical traditions based on ancient Greek precedent that it comes as a surprise that the standard quaternary model appears in only one of the nearly 60 texts ascribed to the celebrated father of Greek medicine, Hippocrates of Cos, who lived in the fifth century BCE (and whose authorship of any surviving treatise remains unproven).{{²}}{{{For an introduction to the Hippocratic Corpus, see Jacques Jouanna, Hippocrates, trans. M. DeBevoise (Baltimore: The Johns Hopkins University Press, 1998).}}}

The text is called On the Nature of a Human Being. It was a favourite of the second-century CE physician Galen of Pergamum, whose impact on medical thinking and practice over the next 1,500 years—from Alexandria to Baghdad to Salerno to Paris—was unparalleled. By elevating On the Nature of a Human Being as the authoritative version of Hippocrates’ doctrine, he enshrined the four humours in later medical traditions.{{³}}{{{For Galen’s canonisation of the four-humour model, see Jacques Jouanna, ‘Galen’s Reading of the Hippocratic Treatise The Nature of Man: The Foundations of Hippocratism in Galen’, in Greek Medicine from Hippocrates to Galen: Selected Papers by Jacques Jouanna, ed. Philip van der Eijk, trans. Neil Allies (Leiden: Brill, 2012), 313–33.}}}

But, if we go back to our classical-era Hippocratic texts, it is clear that what matters more than the number or the type of humours—different texts offer different models—is their liquidity.{{⁴}}{{{On the fluid dynamic of the inside of the Hippocratic body, see Brooke Holmes, The Symptom and the Subject: The Emergence of the Physical Body in Ancient Greece (Princeton: Princeton University Press, 2010), 138–47. See also A. E. Hanson, ‘Conception, Gestation, and the Origin of Female Nature in the Corpus Hippocraticum’, Helios 19, no. 1–2 (1992): 31–71.}}}

Fluids flow. The humours are always moving and changing, always dynamic.

The humours are identified by most Hippocratic writers as constitutive elements of the human body. They also participate in a dynamics of power that extends throughout the non-human world—to the rhythms of the seasons and the shifting winds and the food we consume. The different humours wax and wane in response to the constant exchange of material inputs and outputs in the body. The human body is continuous with the physical world beyond its boundaries.

For this reason, what happens inside the body can be understood in terms of the principles governing the regularities of the entire physical world.{{⁵}}{{{See, for example, [Hippocrates], Generation; Nature of the Child, 1; [Hippocrates], The Sacred Disease, 16; [Hippocrates], Airs, Waters, Places, 15.}}} The flows of the body can in this way be controlled. But the humours can also be seen as exemplifying the very unruliness of matter. In the fourth century BCE, Plato speaks of matter as always going ‘to and fro’.{{⁶}}{{{See, for example, Plato, Philebus, 43a-d.}}} For Plato, bodies are by nature unlimited and unstable.

Bodies, from this perspective, are in perpetual flux: amorphous, labile, elusive.

Small wonder, then, that the fluid body that emerges in classical Greek medicine has often had such a bad reputation in the philosophical tradition, requiring the discipline of mind or soul—indeed, the discipline of philosophy itself.{{⁷}}{{{See Brooke Holmes, ‘Body, Soul, and Medical Analogy in Plato’, in When Worlds Elide: Classics, Politics, Culture, ed. Karen Bassi and J. Peter Euben (Lanham, MD: Rowman & Littlefield, 2010), 345–85, Holmes, The Symptom and the Subject, 192–227.}}}

*Yellow Bile, Pore; Blood, Pore; Phlegm, Pore; Black Bile, Pore*. Martha Friedman © 2015.

*Yellow Bile, Pore; Blood, Pore; Phlegm, Pore; Black Bile, Pore*. Martha Friedman © 2015.

Yellow Phelgm (from "Pore," Martha Friedman, 2015)

Even for the Hippocratic medical writers, humours are suspicious. Despite being our most basic elements, they often turn on us, behaving much like cancer cells do in the contemporary imagination. The physical body of the Hippocratic Corpus is an unruly terrain, populated by forces that are both necessary for life and capable of destroying it.

It is for this reason that the body must be the object of a technē: an art or science or craft.{{⁸}}{{{On the concept of technē in the Hippocratic Corpus, see Heinrich von Staden, ‘Physis and Technē in Greek Medicine’, in The Artificial and the Natural: An Evolving Polarity, ed. B. Bensaude-Vincent and W. R. Newman (Cambridge, MA: Harvard University Press, 2007), 21–49.}}} It requires control.

Control

Artist's evocation of liquified currencies

In Plato’s Republic, Socrates says that, if you asked him whether a body could survive on its own, he would reply:

Of course it needs something else. That’s the reason why the art of medicine has now been invented, because the body is defective.
Plato, Republic 1, 341e

In other words, if it were enough for bodies to be bodies, we wouldn’t need medicine. The very reason why medicine exists is because bodies are not self-sufficient.{{⁹}}{{{For this problem in Galen, see Brooke Holmes, ‘Galen on the Chances of Life’, in Eikos: Probabilities, Hypotheticals, and Counterfactuals in Ancient Greek Thought, ed. Victoria Wohl (Cambridge: Cambridge University Press, 2014), 230–50.}}}

The Hippocratic text Ancient Medicine gives us another version of this story.

In a virtuoso bit of speculative anthropology, written in the late fifth century BCE, the author argues that medicine was first set on its path when a group of early humans came to a startling realisation amid crushing pain.

All other animals are well fitted to the world. Only human nature is maladapted to raw food. The first human technology is, therefore, the art of cooking, through which the power of food is tamed.{{¹⁰}}{{{[Hippocrates], Ancient Medicine, 3. For an overview of, and background to, this text, see Mark Schiefsky, Hippocrates, On Ancient Medicine (Leiden: Brill, 2005), 1–71.}}}

But cooking is not enough. The problem with human natures lies not only outside the body, but also inside of it.{{¹¹}}{{{[Hippocrates], Ancient Medicine, 14.}}}

These early humans, by interpreting symptoms, learn that fluid substances within our own bodies can make us sick. Health requires an equilibrium among the different substances inside us.

But, all too often, we eat the wrong thing and one of these substances grows too strong, overpowering the others. The result is disease, and the treatment of disease requires doctors, not cooks.{{¹²}}{{{[Hippocrates], Ancient Medicine, 5.}}}

The health of the body is, therefore, always put at risk by a hidden liquidity that is unbound and unbalanced. Fluids flow. They are always moving and always changing, far below the threshold of what we can see and feel.

So what does medicine offer?

The first problem with human nature, as the author of Ancient Medicine describes it, is that the body is so easily hurt by the food that it needs to survive.

But the vulnerability of embodied life is compounded by the fact that we humans sense, and understand, so little of what goes on below the skin. The Hippocratic medical writers are fascinated by the domain of the body that escapes perception: the domain of the humours.

Because the humours inhabit a space deep within us, below the threshold of what we can feel, we know something is wrong only at the moment the symptom erupts into consciousness or visibility.{{¹³}}{{{See Holmes, The Symptom and the Subject, 121–47.}}}

Even then, sudden pain or unusual swelling gives little indication of the trouble within. We know only that something has gone wrong.

On this author’s story, the physician steps in, after the birth of medicine, with two critical skills. First, building on the collective knowledge of human nature and the body accumulated by medical science, he makes sense of the symptoms. Second, equipped with this expert knowledge, he can intervene in the body, primarily through drugs and food, to manage its fluid dynamics.

Together, these powers lie at the heart of what fifth-century BCE medical writers called the technē: the art or science of medicine.

Liquid Agency

Artist's evocation of disturbances and foam

And yet, the body is not entirely dependent on medicine.

In Hippocratic writings of the early fourth century BCE, we can track a growing interest among physicians in the body’s capacity for self-regulation.

One text, Epidemics VI, famously speaks of an ‘untaught nature’ that does what’s needed to fix a problem in the body—by crying, blinking, yawning, hiccupping, and so on.{{¹⁴}}{{{[Hippocrates], Epidemics VI, 5.1: ‘The body’s nature is the physician in disease. Nature finds the way for herself, not from thought. For example, blinking, and the tongue offers its assistance, and all similar things. Well trained, readily and without instruction, nature does what is needed. Tears, moistures of the nostrils, sneezing, ear wax, production of saliva in the mouth, the intake of breath, exhalation, yawning, coughing, hiccough, in a variety of ways’.}}} The idea of untaught nature (or ‘the healing power of nature’, vis medicatrix naturae) became a core tenet of the Hippocratic legacy.{{¹⁵}}{{{See, for example, Charles T. Wolfe and Motoichi Terada, ‘The Animal Economy as Object and Program in Montpellier Vitalism’, Science in Context 21, no. 4 (2008): 537–79.}}}

Galen again can claim credit for the later influence of this idea. For Galen, nature (physis) actively works to preserve the organism, showing a providential care for its health first observed, he insists, by Hippocrates himself.{{¹⁶}}{{{See R. J. Hankinson, ‘Galen on the Best of All Possible Worlds’, Classical Quarterly 39, no. 1 (1989): 206–27; Armelle Debru, Le corps respirant: la pensée physiologique chez Galien (Leiden: Brill, 1996); Mark Schiefsky, ‘Galen’s Teleology and Functional Explanation’, Oxford Studies in Ancient Philosophy 32 (2007): 369–400; Jacques Jouanna, ‘Galen’s Concept of Nature’, Greek Medicine from Hippocrates to Galen: Selected Papers by Jacques Jouanna, ed. Philip van der Eijk, trans. Neil Allies (Leiden: Brill, 2012), 287–311; Holmes, ‘Galen on the Chances of Life’.}}}

But, for the idea of a teleological—that is, ends-directed—nature within a living body, Galen owes more to Aristotle than to any Hippocratic text.{{¹⁷}}{{{Philip van der Eijk, ‘“Aristotle! What a Thing for You to Say”: Galen’s Engagement with Aristotle and Aristotelians’, in Galen and the World of Knowledge, ed. Christopher Gill, Tim Whitmarsh and John Wilkins (Cambridge: Cambridge University Press, 2009), 261–81.}}} In fact, Aristotle often imagines the physician imitating what nature does to sustain the life of an organism. What a nature does automatically, the physician does through reasoning and the resources of the technē, stepping in when nature is disrupted in its aims and restoring order.

For Aristotle and Galen, then, as in the earliest Greek medical texts, fluids represent something to be channelled and disciplined. Fluids also remain capable of overwhelming the order of the soul or medicine or philosophy.

In Aristotelian biology, form is male. By contrast, matter is female and fluid: it poses a constant threat to nature’s norms.{{¹⁸}}{{{Marguerite Deslauriers, ‘Sex and Essence in Aristotle’s Metaphysics and Biology’, in Feminist Interpretations of Aristotle, ed. Cynthia Freeland (University Park, PA: Pennsylvania State University Press, 1998), 138–67; Emanuela Bianchi, The Feminine Symptom: Aleatory Matter in the Aristotelian Cosmos (New York: Fordham University Press, 2014).}}}

In Galen, too, the functions so wisely crafted for the body by Nature are at constant risk of being undermined by the humours’ tumult.{{¹⁹}}{{{I capitalise Nature here to capture Galen’s sense of nature as transcendental, providential and demiurgic: see Jouanna, ‘Galen’s Concept of Nature’.}}}

Fluids, in short, can always undo.

But, if fluids can overturn order, it is not because they are purely destructive. For many Hippocratic writers, we have to remember, life depends on the humours.

Indeed, in Greek religion and philosophy, fluids are often imagined to be life-giving. Thales, the earliest Presocratic, made water his first principle, and many other Presocratics, influenced by earlier Greek and non-Greek cosmologies, thought life emerged from water.{{²⁰}}{{{See Aristotle, Metaphysics, Α3, 938b8-12 [=Thales D3], quoted in Thales, Fragments in Early Greek Philosophy, 233.}}} In civic cults, rivers were worshipped as nourishing the young (kourotrophic).{{²¹}}{{{Homer, Iliad, 23.141–51; Aeschylus, Libation Bearers, 6; Pausanius, Description of Greece, 1.37.3. See further J. A. Ostrowski, Personification of Rivers in Greek and Roman Art (Krakow: Nakładem Uniwersytetu Jagiellońskiego, 1991), 12; Jennifer Larson, Greek Nymphs: Myth, Cult, Lore (New York: Oxford University Press, 2001), 98; Brooke Holmes, ‘Situating Scamander: Natureculture in the Iliad’, Ramus 44, no. 1–2 (2015): 29–51.}}}

Nevertheless, the river that offers care could always turn turbulent and flood its banks.

One of the most famous representations of a river from ancient Greek literature is in Homer's Iliad, where the river Scamander surges into action late in the epic in anger at a rampaging Achilles. In an extended simile, the poet compares Scamander to water flowing through a channel that a gardener has made, running it from a nearby spring to irrigate his plants. But the water gets out control, tearing pebbles loose...

going too fast, even for the one who guides it...
Homer, Iliad 21.260-61

The Homeric simile's concerns about the unruly dynamics of water look forward to a moment in the Hippocratic Corpus. In the fourth-century BCE text On Places in a Human Being, we’re told that sometimes in a patient who needs to be purged, bile starts flowing on its own (automatē), without being triggered by the physician's drugs. The author warns us that a flow of bile that arises naturally, however beneficial, is hard to manage: it resists control.{{²²}}{{{[Hippocrates], On Places in a Human Being 33.}}}

Here, then, the flow within is neither an instrument nor an object of medical mastery: it expresses its own agency.

Rivers, liquids, flows.

These do not simply represent chaos to be set against the order of technē, a madness to be managed.

They have a logic of their own.

In the fluid dynamics of the humoral body, we glimpse not only what is codified by tradition, medical practice, and teleological aspiration, but also life unbound.

John Waterhouse painting of the Danaides pouring water

The Danaides. John William Waterhouse, 1906. Aberdeen Art Gallery and Museums Collections.

IMAGE CREDITS

Listed in the order in which images first appear in the essay.

Raphael, Scuola di Atene (The School of Athens), 1511. Public domain. Taken from Wikimedia.

Cave paintings. Prof saxx, Paintings in the Lascaux Caves (Montignac, Dordogne, France), 2006. Prof saxx © 2006. Taken from Wikipedia. Reproduced under a Creative Commons Attribution Share Alike Unported (CC BY-SA 3.0).

John William Waterhouse, Danaides, 1906. Out of copyright. Image © Aberdeen Art Galleries and Museums Collections. Reproduced by permission of Aberdeen Art Galleries and Museums Collections.

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