Adams
Adams
Adams
A
VAST LIBRARY OF WRITINGS exists on humoral theories,
including those originating from India, Egypt, and the
Middle East, and the variety of humors, their balance in
maintaining bodily homeostasis, diseases caused by their im-
balance, and therapies to restore balance have been perennially
popular topics. Some trace aspects of humoral theory back to
Empedocles who theorized there were four elements, indestruc-
tible, that composed all substances: water, fire, earth, and air.1
As a structural biological theory his four elements might be
interpreted as representing fluidity (water), energy/metabolism
(fire), tissue (earth), and oxygen (air or πνεῦµα pneuma). There is,
however, no logical progression from the elements of Em-
pedocles to a theory of health and disease. Instead, it is the fifth
century B.C. Hippocratic treatise Nature of Man that provides a
true humoral theory, one with characteristics inherent in man
and comprising bile, phlegm, black bile, and blood. Its compo-
nents were within the body, whereas the Empedoclean com-
ponents were the body. One of the supporting arguments for a
humoral theory is observational in that the author of Nature of
Man had seen a sequential change in vomitus as induced by a
potent (toxic) medicine: the initial appearance of the vomitus he
interpreted as being bile, followed by phlegm, then black bile,
pocratic treatises cited in this paper are from the twelve volumes of the Loeb
Classical Library edition. Nature of Man is at IV 3–41; chapters 1–8 discuss
aspects of humors.
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Greek, Roman, and Byzantine Studies 64 (2024) 195–207
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196 AN EARLY CONCEPTION OF INFLAMMATION
Paul Potter, who interprets the “imbalance” of four “moistures” (X 101 ff.) as
giving rise to disease.
5 W. H. Adams, The Natural State of Medical Practice: Hippocratic Evidence
Hippocratic terminology
As background: Hippocratic physicians had yet to apply avail-
able optics to the study of human tissues, and the cause of many
diseases therefore wanted explanation.6 A nosological frame-
work was required for them to initiate a systematic organization
of diseases that might be useful in prognostication and therapy.
Thus, despite the known importance of the association of certain
diseases with weather, season, and environment and in the ab-
sence of other obvious external physical threats, the idea of an
internal source of disease was entertained. They considered that
humans intrinsically carried what has been termed “promotors”
of disease, especially the classical components “bile” and
“phlegm,” these being translations applied by moderns to
represent Greek χολή khole and φλέγµα phlegma. But have these
translations been accurate?
Bile:
Bile is highly irritating, and its colors vary from dark green to
yellow. The word is derived from the Latin bilis, used by the
Roman playwright Plautus in attributing a personality trait (or
“temperament”) to “black bile” (atra bilis, Capt. 596). This indi-
cates that by the third century B.C. the Greek χολή as commonly
employed and understood by the general educated public
reflected one’s temperament. χολή finds its root meaning in
“wrath” and “bitter anger,” which also can be considered tem-
peraments. In the Iliad its anatomic location is repeatedly stated
to be in the chest (the source of Achilles’ wrath, 4.513) rather
sixth century B.C. quartz lenses probably used by jewelers, but similar lenses
could have (and I believe would have, given more time) been adapted for
histological study. Examination of lesions and excreta with a lens is merely
an observational extension of the physical examination, and lenses were at
hand. Stone (λίθος) and glass (ὕαλος) describe burning lenses that were avail-
able at apothecaries (Aristophanes Clouds 766–767), and Pliny comments that
physicians use crystals for cautery (HN 37.28 urenda corporum).
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198 AN EARLY CONCEPTION OF INFLAMMATION
Phlegm:
“Phlegm,” the modern term for mucoid expectoration derived
primarily from the respiratory tract, is the usual translation of
φλέγµα even though the Greek noun and its verb φλέγω signify
“fire/blaze.” The modern use of “phlegm,” however, comes
from Late Latin describing it as moist and cold, those being
classical characteristics of phlegm as one of the humors. Greek
synonyms of “phlegm” include µύξα muxa from which “mucus”
would later be derived, and βλέννα blenna. With such alternatives
why would the modern term “phlegm” be the translation of
φλέγµα, a word derived from fire? Homer had used φλέγµα to
describe an unquestionably fiery “evil flame” (Il. 21.337). Per-
haps φλέγµα was not like our “phlegm” and was perhaps not
even mucoid. There are inconsistencies. Herodotus (4.187.2)
describes it in children as draining from the head, and in Hip-
pocratic works it is described in Aphorisms (7.54) as re-absorbable,
in Nature of Man 5 as something to be vomited, and in Air, Waters,
Places (3, 10) as moist and flowing down from the head. Galen
states that Prodicus concluded there were two types of φλέγµα,
one that was like mucus and the other a denser “cooked” φλέγµα
called from πεφλέχθαι, “to be burned.”8 Aristotle describes it as
“viscous” (or “oily,” λιπαροῦ: Metaph. 1044a20).
It is proposed here that the “fiery” attribution refers to the
biting and bitter nature of, for example, a pathological postnasal
drip, one that is often associated in viral catarrhs with a sore
throat, with the acid reflux of gastric juice into the mouth, with
pharyngeal drainage, cystic fluids of various pathological states
and lesions including hydrocephalus and hydatid cysts, the non-
purulent fluid sometimes present in chronic abscesses and
pleural effusions, and transudates of wounds, blisters, and
eczemas. Thus, φλέγµα was a mix of exudates, transudates, and
Names: The Case of τέρψις, χαρά and εὐφροσύνη,” JHS 131 (2011) 131–
145.
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200 AN EARLY CONCEPTION OF INFLAMMATION
9 The Loeb edition of Paul Potter, V (1988) 94–183, is cited by section and
then page number.
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WILLIAM H. ADAMS 201
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WILLIAM H. ADAMS 203
states that the Hippocratics used the term φλεγµονή phlegmone as the equivalent
of his inflammatio, but see Adams, The Natural State 13, for an opinion to the
contrary, that φλεγµονή is properly translated as a “localized soft-tissue swell-
ing.”
11 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 (Leiden 2012) 335–359, at 335.
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204 AN EARLY CONCEPTION OF INFLAMMATION
theory see Vivian Nutton, Ancient Medicine (New York 2005), ch. 5, especially
for the concept of “black bile.” He also has documented the rise to prom-
inence of humoral theory following the writings of Galen (130–210 A.D.) in
“Humoralism,” in W. F. Bynum et al. (eds.), Companion Encyclopedia to the
History of Medicine (London 1993) 281–291.
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WILLIAM H. ADAMS 205
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