After the theory of coction and crisis, that which prevails the most in the Hippocratic books, is the doctrine of the four elements, or the four elementary qualities, heat, cold, dryness and moisture, and the four cardinal humors, blood, bile, atrabile and phlegm. This doctrine was supposed to be an invention of the father of Greek medicine. Such is the opinion of all the commentators and historiographers, among others Galen, who extended and perfected it in his manner, and it reigned, exclusively, after him. The theory of four elements and four humors, harmonizes very well with
that of coction and crisis, of which it appears to be the complement.
Empedocles, of Agrigentum, who has been mentioned heretofore, was the first who introduced into physics, the consideration of four elementary forms, the first termed terrestrial or solid, the second aqueous or liquid, the third aerial or gaseous, the fourth igneous or ethereal. The latter, of which the ancients had only a vague notion, corresponds to what is termed an imponderable fluid, in modern physics.
Empedocles admitted, according to the doctrine of his master, Pythagoras, two principles in every thing : the one active, intelligent and impalpable, which is God ; the other passive, and devoid of properties, having no definite form, but susceptible of assuming any that the Creator might give it, named amorphous matter. The philosopher of Agrigentum, conceived, also, that amorphous matter had received from the Supreme Intelligence, four fundamental or elementary modes of existence, and these four principal modalities of matter, variously combined, constituted all the bodies in nature ; so that, according to this system, there is no material substance which does not include four elements, united in variable proportions.
The element which constitutes the largest proportion in a body, determines its permanent form : thus, the terrestial element predominates in solids ; the aqueous in liquids ; the aerial in vapours or gases ; the igneous in the ether or imponderable fluid. In this way, this philosopher explained the varieties of bodies, at the same time preserving the Pythagorean doctrine of homogenity in matter.
The assumption of four elementary or primitive forms was not, as may be thought, the dream of an exalted imagination ; the attentive observation of some very remarkable phenomena had suggested the idea, and gave it the appearance of reality ; thus, water can pass from a liquid to a solid or gaseous state, without changing its nature ; so, also, in the phenomenon of combustion, the wood, especially when it is green, oozes out water from its surface, exhales smoke, which the ancients regarded as crude air, deposits ashes, the terrestrial element, and lastly, gives off light and heat, or fire, the most subtle of the elements, which ascends, and is dissipated in the ethereal regions. Here the chemical analysis of the ancients stopped.
I will not carry farther this exposition of the four elements, or four primitive forms which served to explain the infinite diversity of the body without destroying the dogma of the homogeneity of matter. It is sufficient to have shown that it was neither ridiculous nor absurd before the discoveries of modern chemistry. I will add that the chemists themselves, after having augmented indefinitely the number of elements, now tend to limit them, and are not far from returning to the dogma of the homogeneity of matter, by the theory of equivalents.
Such was, at its origin, the doctrine of the four elements, which Plato and Aristotle adopted, and sustained by new and extremely subtle considerations, as we shall see hereafter. This doctrine, when Hippocrates appeared, had all the force and attraction of freshness, and it is not astonishing that that philosopher made it the basis and model of his medical theory. We now proceed to show by what course of reasoning he was led to it.
He commences by saying, that to properly understand man, it is necessary to study him with the lights of Medicine, *. e., in a state of health, and disease. He refutes the opinion of the philosophers who pretend that man is formed of a single element, and relies especially upon the little accord that exists among them, as to the nature of that unique element - some affirming that it is air, others water, others fire, and others earth. " Now," says he, " since they all contend for the same principle, and yet all come to different conclusions about it, it shows that they do not properly understand each other."
" In regard to physicians," he adds, " some contend that man is all blood, others that he is all bile, others all phlegm, and some all gas. Each one adopts the same mode of reasoning ; they insist that the being is one, whatever name may be given to it, and that this unique substance changes its form and its powers accordingly as it is affected by heat or cold. As for my views : I say, that if man were a simple element or being, he would never feel pain ; for what could excite pain in him if he is only of one substance? Suppose that he was susceptible to it : the remedy must be single also ; but we know that there are various remedies for pain. He who affirms that man is all blood, ought to show himself unchangeable, or at least, he should assign a season, or an epoch of life, in which we can see in man nothing but blood ; for in order to be sure that his opinion is correct, we should be able to see, at some time or other, at least, that only in man which exclusively constitutes him, viz : blood ; these remarks are applicable also to the assertions of those who pretend that he is all bile or phlegm.
" At first the generation of man can not proceed from a single substance, for how can a single substance be developed without a union with something else ? If it does not mingle with other different beings, of the same nature, there could be no generation of an economy like ours. Moreover if the heat and cold, the dry and humid, are not pro-
- And especially is this further illustrated in the correlation of the physical and vital forces. -.
Transperly tempered together, if one predominates too much, the generation could not take place. In like manner when a man dies, each of the elements of which he is composed takes a different direction, according to its nature - the humid to the humid, the dry to the dry, the heat to the heat, and the cold to the cold.
" The human body contains blood, phlegm, and two sorts of bile, yellow and black. Such is its nature, and their condition determines the state of health. It is healthy when each of these fluids is in due proportion to the other as to quantity and character, and especially when they are well mixed ; it is diseased when any one is in excess, or lacks its due proportion to the rest, or is evacuated without being properly mixed - for when it is thus evacuated, not only the region where the admixture should take place must be affected, but still more, the organ through which it passes off, becomes surcharged and suffers painful struggles.
" I have said that I would show that the things of which man is composed always remain the same. This is generally admitted, and is proved by the examination of his nature. Now the blood, phlegm, yellow or black bile, by common consent, are always the same, for neither of these words has an equivocal or doubtful meaning. Again, these elements are very distinct in their nature ; the phlegm has no resemblance to the blood, nor the blood to the bile, nor the bile to the phlegm. How then can they be confounded ? - for these differences are recognized by the sight alone, as they differ very much in color. So, if they are touched, there are manifest differences in the sensations they impart. So also, are they unlike in temperature and consistence. If a remedy is taken that acts on the phlegm, it is phlegm that is discharged ; if it acts on the bile, that is cast off ; or if the body is wounded, it is blood that flows out. These results occur at all seasons, all periods of life, and at all times. Thus man is really constituted of four humors, which are manifest to our senses, and there is no need of special arguments to prove it." (De la Nature de l'Homme ; Gardeil)
The author, after having established his doctrine by unquestionable arguments and observations, and having refuted the objections of those who professed contrary views, continues thus the exposition of his own : " The phlegm augments in man during the winter, and this humor is more analogous in its nature to that season ; for it is the coldest of all, as can be readily proved. If the phlegm, blood, and bile, are touched successively, it will be found that the first is the coldest. In the spring the blood augments ; for there is an affinity in its nature with the constitution of that part of the year - it is hot and moist. The bile increases in summer for the same reason, and the atrabile becomes most abundant and strongest in autumn."
Hippocrates then explains summarily, how diseases are engendered, namely, by the influence of the seasons, or by the regimen, the temperament, or the air that is breathed. Finally, he establishes a general rule for their cures, which consist, according to him, in inducing action in the system contrary to that produced by the cause of the diseases.
Whatever view may be formed of this system, comparing it with our present knowledge, we are forced to admit that united to the doctrine of coction and crisis, with which it perfectly affiliates, it offers an interpretation, sufficiently reasonable, of the physiological phenomena which had attracted the attention of the observers of that epoch. In fact, all phenomena, of whatever character, can only result from the combined action of vital and physico-chemical forces, that act simultaneously on the animal economy. Now, the theory of coction explains the laws by which the vital principle is supposed to exercise its influence ; that on the elements and humors exhibits the influence of the inorganic forces. and the laws according to which that influence is applied to organized bodies.
These two theories united, constitute the ancient Dogmatism - a doctrine originally of the school of Cos, and of which Hippocrates is regarded as the principal author. In that doctrine the humors play the part of secondary or physiological elements ; they are agents endowed with diverse, or even contrary properties, placed at the disposal of the vital principle, which alone gives to them a good or evil direction. But these agents can contract, sometimes, deleterious properties, in consequence of external forces not controlled by the vital principle.
The external forces admitted by the ancients, as we have seen, are of four kinds, heat, cold, dryness, and moisture, which may be easily reduced to two by the augmentation or diminution of caloric and moisture. This shows the poverty of the physics and chemistry of the ancients. They had no idea either of atmospheric pressure or its composition ; neither of electricity, the chemical phenomena of respiration. nor a multitude of other phenomena and influences. They possessed even on the effects of caloric and moisture, but vague and superficial perceptions, and considered their actions only in relation to the humors of the human body, without taking any account of the not less important modifications which they produce upon the solids. Besides, they attributed to the humors imaginary qualities, derived from the elements that were supposed to predominate in their composition. They
128 PHILOSOPHIC PERIOD.
also conceived relations to exist between these humors and the seasons of the year, which were more poetic than real.
The Asclepiadae, imbued with the same dogmas as Pythagoras, believed in a perfect harmony between the universe, or the macrocosm, and man, or the microcosm. Tor this reason they admitted four humors in their physiology; though observation could only distinctly demonstrate three - the blood, bile, and phlegm. The fourth humor was an object of much uncertainty and obscurity, among the Hippocratic authors. Some assimilated it to the terrestrial element, and called it atrabile, attributing to it extremely active properties, and regarding it as the cause of the gravest affections ; others assimilated it to the liquid clement, gave it the name of water, and regarded it nearly as a nullity, in the production of diseases. It was said, by one : the heart is the reservoir of the blood, the head of the phlegm, the liver of the bile, and the spleen of the water.
If the physicians had been less subjected to their philosophic prejudices, and relied more upon observation, they would have been able to discover more reasonable relations between the humors of the body and the seasons of the year ; they would have found, for example, that the prolonged action of cold, damp weather, at the close of autumn and the commencement of winter, in the temperate climate of Greece, developed the lymphatic or pituitary temperament and humor, as well as catarrhal affections ; that the damp, warm constitution of the weather at the end of winter, and in spring, disposed to open inflammatory diseases and hemorrhages ; and lastly, that the dry heat of summer and the beginning of autumn, increased the secretion of bile, and favored the prevalence of inflammatory bilious and putrid bilious fevers ; but to see this they would have had to renounce the Pythagorian harmony of the four humors with the four elements and four seasons.
Notwithstanding its errors and imperfections, the doctrine of Dogmatism is the most ingenious and the most complete of all the medical doctrines of antiquity ; it responds better than any other to the wants and tendencies of antique science, and it was received and adopted with admiration, not only by the generality of physicians, but also by the greatest philosophers. We shall have occasion to speak of it more than once, in considering the modifications it has undergone in its long reign.
What shall be said now of those who attributed to Hippocrates the glory of having separated Medicine from philosophy ; and of those, on the contrary, who attributed to him the glory of uniting philosophy with Medicine ? It must be said of them, what Hippocrates says of those who saw only one element in man : they do not well understand themselves.
It is certain that Medicine had been philosophized upon before Hippocrates ; it is also equally certain that Hippocrates philosophized as others, and that he shared the prejudices of his age in many particulars ; but in some respects his philosophy is distinguished from that of his contemporaries by greater and more profound wisdom. He reminds the philosophers and physicians, continually, of the maxim too often neglected by them, and even by himself, that the nature of man can not be well known without the aid of medical observation, and that nothing should be affirmed concerning that nature, until after having acquired a certainty of it, by the aid of the senses ; a maxim diametrically opposed to the dogmas of Pythagoras, and which includes the germ of an entirely new philosophy, that Plato misconceived, and of which Aristotle had only a glimpse, as I shall show hereafter.
The other theories that are found in the Hippocratic collection, have not now the importance of the two preceding ; they are only met with in a small number of works, sometimes in one alone. They were never adopted by a large number of physicians, and must be considered as the individual or particular opinions of some writers. A few of them, however, have furnished the first suggestions of the great systems invented at later periods, and on this account they merit special attention ; for they show us the origin and connection of the prevalent ideas of past ages.
From History os Medicine by P.V. Renouard M.D.