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Naturopathy Embraces the Four Humors

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 dictionary.com) “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 “diety of system” is catalogued. Unani’s diety is “Abrahamic monotheism,” while modern western medicine’s diety 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.

Posted in: Faith Healing & Spirituality, History, Naturopathy, Politics and Regulation, Religion, Traditional Chinese Medicine

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33 thoughts on “Naturopathy Embraces the Four Humors

  1. PernilleN says:

    The figures about how many patients die from being treated with “allopathic” medicine: It’s really hard to find credible statistics. Numbers from the alternative proponents is one thing, and probably can’t be trusted, but according to American Association for Justice, http://www.justice.org/cps/rde/xchg/justice/hs.xsl/8677.htm
    almost 100,000 Americans die from medical errors each year, making it the sixth most common cause of death. Among their references ar this report: http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx and statistics from CDC: http://www.cdc.gov/nchs/fastats/deaths.htm.

    I’ve looked at CDC’s article about causes of death from 2009, where “Accidents (unintentional injuries)” ranks as number 5 with 118,021. AAAJ has the same number, but rank medical errors as number 6 with 98,000. Their number seems to come from the article from IOM, where the number is estimated as “at least 44,000, maybe as many as 98,000).

    In CDC’s statistics there is no specific number for medical errors.

    This is rather confusing. Anyone know more?

    Pernille Nylehn
    Norway

  2. Ben Kavoussi says:

    @ Jann,

    This is an excellent article that highlights the archaic nature of the ideas that underlie naturopathy and many other CAM modalities. Sadly, what you describe here applies directly to acupuncture and Oriental medicine. My article Oriental Medicine: a Tall Tale of Outdated Lore gives some details about the connection between humoriam and acupuncture.

    I would like to add a detail about Unani medicine: the word “Unani” (or Yunani), means “Ionian” in Arabic and Persian, it refers to Greeks in general. As you pertinantly state, Unani medicine is simply Islamized Greek humorism. This was done through the works of Avicenna and other medieval physicians along the Silk Road. Contrary to what most CAM providers want us to believe, there is nothing exotic and non-Western in any of their modalities. Actually, Unani medicine is something we gradually abandoned through discoveries between 16th and 19th centuries.

    As you state “there is no richer source for argument against CAM practices than the CAM literature itself.” However, most lawmakers are not aware of the fact that the same humorism that killed George Washington through bloodletting to purge excess “heat” (whatever that means) also underlines naturopathy, acupuncture, Oriental medicine, and other such archaic nonsense.

    Going back to medieval ignorance in the name of exotism and techophobia is outrageously irresponsible and needs to come to an end for the sake of public safety.

  3. Jann Bellamy says:

    @PernilleN:

    Medical errors are an important issue and one that is being addressed by the medical profession. Perhaps I should have come right out and made the point clearly, but in the context of the naturopath’s chart it is simply a means of trying to imply that “allopathic” medicine is dangerous and that one should instead see a naturopath. Of course, “allopathic” medical errors are completely irrelevant to the safety and efficacy of unani/humorism, for which this book provides no convincing evidence. This is a common tactic of CAM promoters when faced with the deficiencies of their own methods of treatment.

  4. FulfilledDeer says:

    Every time I read something like 16 states allowing naturopaths to be primary care physicians, I panic a little bit inside. What are we supposed to do? Because clearly being logical, correct, and quick with simple deconstructions does not seem to help.

  5. InvincibleIronyMan says:

    I thought all of alternative medicine had the four humours. Giggle, chuckle, guffaw and ROFL!

  6. Janet says:

    @FulfilledDeer

    I’m with you, but was somewhat heartened by yesterday’s post from Dr. Novella. I’m starting to think that CAM is somewhat self-limiting in its appeal to those who find a philosophical “fit” with it.

    I’m sure it’s just a co-incidence that I have been personally plagued by constantly running into these people. Of course, we have to continue to be “logical, correct, and quick with simple deconstructions”, in order to try to limit the spread of Carl Sagan’s Demon-Haunted World–the one book I most often recommend to the superstitious.

  7. WilliamLawrenceUtridge says:

    @FulfilledDeer

    What are we supposed to do?

    I’ve always been in favour of embracing the “Secular atheism; agnosticism; modern evolutionary nihilism” ascribed to us by the book. We let people choose the medical intervention they want to pursue, and over the course of hundreds of years, a particular strain of human thought should be weeded out by evolutionary pressures.

  8. Harriet Hall says:

    I wrote about the common accusation of “Death by Medicine” at
    http://www.sciencebasedmedicine.org/index.php/death-by-medicine/

    I would argue that effective medicine with a relatively small rate of human errors is superior to ineffective medicine with no errors at all.

  9. PernilleN says:

    Jann Bellamy, I totally agree, and I’m so sick of naturopaths saying medical errors are a reason in itself to go faulty practitioners.

    But I still wonder about the numbers. Is there any way of finding which numbers are the best approximation to the truth? NB I know it’s difficult.

  10. daijiyobu says:

    This too may be humorous!

    The principle ND editor of the TNM 4th edition (and previous) is Joe Pizzorno, whose Bastyr-centered empire was / is build on the moniker:

    “one of the world’s leading authorities on science based natural medicine” and
    “leading the forefront of science based natural medicine” (see http://drpizzorno.com/dr-joseph-pizzorno/ ).

    Yet, it’s a strange kind of science that permits nonscience within its locus. It’s quite a bogus locus.

    I enjoy the ‘junk though’ label that Susan Jacoby uses otherwheres.

    In 2006, I’d posted a review of the ‘philosophy’ chapter from the 3rd edition on Amazon and it’s still there

    (see http://www.amazon.com/review/R3O3Y1LGUXC0Y9/ref=cm_cr_pr_perm?ie=UTF8&ASIN=0443073007&linkCode=&nodeID=&tag= ) .

    Boy, oh boy it is not liked by the crowd that goes there for that book: 15 of 109 people found the review helpful and I do wonder how many requests were made to have it removed.

    That ‘philosophy’ chapter hasn’t changed in the 4th edition. The only difference is that the author has changed genders, actually: Randall is now Rachelle, and the chapter number moved from chapter number 6 to chapter number 5.

    I know too much about this nonsense, and I wouldn’t change a thing in that review.

    -r.c.

  11. FulfilledDeer says:

    @Janet

    That is a fantastic book, I haven’t read it in a while. I think I’ll break it out tonight (metaphorically – it will be the digital copy) and hopefully calm down. And while I certainly agree with your take on yesterday’s article and the self-limiting nature of the beast, the issue as I see it is more than people deciding to get un-medical care. It’s the erosion of the medical, medical education, governmental (not the least of which in the form of grants), and scientific institutions that really worries me. Many times when talking about CAM I find myself musing that if something like acupuncture touted itself as is – a religion – I wouldn’t be nearly as incensed. I absolutely draw the line when CAM dilutes actual science (and no, that does not make science even more potent). In the vein of Hitchens I have to conclude that CAM poisons everything.

    Along those same lines @WilliamLawrenceUtridge, as callous as your (satirical?) suggestion is, I have to point out that the CAM does not likely exert enough of an evolutionary pressure to provide for differential reproduction. Now if people had to choose CAM emergency treatment vs. real emergency treatment, maybe things would be different….but that world only exists in sketch shows.

  12. mho says:

    @daijiyobu
    there are now 16 people who found the review helpful ;-)

  13. DevoutCatalyst says:

    @大丈夫
    Way to go, Ron.

  14. Quill says:

    As I said, there is no richer source for argument against CAM practices than the CAM literature itself. And this is a perfect example.

    Indeed it is and indeed this is. I don’t know much about naturopathy yet I’d no idea it would be all Greek to me.

    And to contemplate the fact, the strange fact, that humors are actually being used in a modern textbook that is not satire, a work of fiction (well, this book -could- fall into that category) or poetry is amazing. Amazing in much the same way I would be amazed if I were to come across someone getting ready to go to France by sailing the atlantic in a brig with only the stars go guide them by. They might get there, they might not, but with a GPS available, why not use it? Or skip the brig and get on the Queen Mary II. Or just take a plane.

  15. daijiyobu says:

    @mho

    Thanks for being helpful.

    日本語は難しいです

    -r.c.

  16. geack says:

    Quill,

    Navigating by the stars is completely scientific and works fine if you know how to do it. There might be easier ways to find France, but knowing the stars will get you there.

    Using the humours as a basis for medicine is like trying to find France with your magic amulet and the ashes of a Parisian homing pigeon. It’s not just old-fashioned, it’s complete fantasy.

  17. Quill says:

    @ geack: Thanks for pointing out my analogy is not very good. Yours is better and much more naturopathic. :-)

    That being said, the “if you know how to do it” is the big problem with most things these days, education being what it is. Or no longer is, to be more precise. The fact this book that is the subject of the post could be considered a textbook of modern practicality is quite amazing, being as it is apparently printed with such magical ashes.

  18. bs king says:

    @PernilleN

    This blog post has very good resources for different numbers of medical errors and some links to methodologies
    http://www.leanblog.org/2009/08/statistics-on-healthcare-quality-and/

    I completely agree with Jann….this tactic completely disregards the reality of error reporting and tries to move attention away from the issue at hand.

    When considering medical errors, you really can’t compare naturopaths and allopathic medicine. For example, many of the deaths counted each year as being preventable errors are from hospital acquired infections….there is no comparable statistic for naturopaths, since there are no naturopathic hospitals (or at least I hope there aren’t).

    The more well regulated an industry, the more errors are going to be counted. You have to have a certain baseline infrastructure to even begin to count errors appropriately…things like standards of care etc. that naturopaths simply don’t have. Additionally, if a naturopath makes a mistake, the patient can still return to “normal” medicine to fix it….and naturopaths don’t tend to be nearly as attractive for lawsuits as MDs and hospital systems are.

    Also, is there anyone in naturopathic medicine who even claims to be tracking their practitioners errors? Just because no one’s counting the errors doesn’t mean they’re not happening (leaving aside the fact that the whole method of treatment is itself an error).

  19. PernilleN says:

    Bs king, the blog you linked to, is that some kind of joke? He just throws out dozens of completely different number, ranging from 44,000 to 195,000 … and 380,000 dying in nursing home because of infections. I haven’t looked through all his links, but the sheer absurdity of the blog post put me off trying to find out more.

    As for the alleged 380,000 deaths from infections in nursing homes, does he mean they were preventable? Old people get pneumonia and influenza and UTIs like everyone else, and often they die from them. But it’s not because they are in a nursing home. They are in a nursing home because they are sick, and since they are sick and fragile they contract infections.

    If he means they would have survived if they were at home instead, I think he and I live on different planets. And if he’s right, I’m a mass murderer: I’ve been a consultant in several nursing homes, and lots of my patients have died from infections. I didn’t realize it was my fault. :(

  20. bs king says:

    Sorry, wasn’t trying to be funny, just thought it was interesting how many wildly different numbers there were when the methodology was changed slightly. I thought it spoke a bit to your point about good data being hard to find. It seemed that malpractice lawyers and websites that give physician referrals reported very high numbers. I just thought it was interesting to see all the different numbers in one spot…but it definitely did get messy.

    I’ll admit, I didn’t read all the way down the page. The one about the nursing home infections is interesting….I couldn’t actually find that particular stat on the CMS website, and the only thing I could find about infections clarified that it included UTIs and pneumonia, and was talking about infectious agents in general and how it was a requirement that nursing homes have an infection control program.

    No reference to nursing home consultants being mass murderers, so I think you’re off the hook :).

    Sorry for the crazy link…

  21. bs king says:

    To make up for that link, here’s one to a paper that highlights the potential problems with the 44,000-98,000 number you originally mentioned:

    http://uwf.edu/sahls/medicalinformatics/docfiles/debates%20usa%20death%20rates.pdf

    Apparently the studies those were derived from did not include a baseline estimate of how many of those patients might have died anyway.

  22. PernilleN says:

    Thanks! :)

  23. daijiyobu says:

    Not to prattle on about naturopathy, but, to corrupt Samuel Beckett from 1954:

    “I can’t prattle on, so I’ll prattle on…”

    re: “”the American Association of Naturopathic Medicine [...and] licensing of ‘naturopathic doctors’ [...] more [are] targeted for 2013″,

    in my state of Connecticut, where they are already licensed under a long-standing drugless practitioner act, they’ve requested scope changes for 2013, which will include all schedule I-V pharmaceutical, injections and IVs, and changing their title to NMD from ND [drugless no more!]

    (see http://www.ct.gov/dph/lib/dph/practitioner_licensing_and_investigations/_2013_scope_of_practice/natureopaths_9-12.pdf ) [check out how many times the root 'scien' is in that letter, and the word "effective"!].

    My January posts at Naturocrit will include something regarding that ND Aresco letter, and excerpts from a few chapters from the new TNM, which I’ve been scanning and OCRing, so I can better search it. [Could they make the font size any smaller? It's like reading a PDR. Thank goodness for a hobby knife and Omnipage.]

    -r.c.

  24. NYUDDS says:

    @FulfilledDeer…You asked what we can do to deny licensure to naturopaths and other CAM stylists. One answer is to engage CAM legislatively. Local, regional, county and state medical societies must work, personally and collectively, in concert with their legislators and lobbyists, to refute licensure applications at every turn. It doesn’t matter what you or I think; if the state says they are allowed to practice “medicine” as “naturopathic physicians,” the horse is out of the barn forever. Note an earlier DAIJIYOBU post re: naturopathic efforts to expand their scope of practice in CT. And it will never end! I am enclosing a 2011 letter from the Mass. Medical Society that successfully stopped one such attempt vs. naturopaths:
    https://www.massmed.org/AM/Template.cfm?Section=MMS_Testimony&CONTENTID=52754&TEMPLATE=/CM/ContentDisplay.cfm

  25. DevoutCatalyst says:

    @NYUDDS
    That 2011 letter is great reading.

  26. FulfilledDeer says:

    @NYUDDS

    Side question: are you at NYU?

    Back to the point: how to do that? I’m totally willing to give of my time (such that it is), but I’m just not sure how to go about it. The only idea I have had so far is to create a SBM club at my med school (though I despise “clubs”). Also, is “SBM” copyrighted? Could I use it for the club name, or would that be a violation?

  27. DW says:

    Anthroposophic medicine (from Rudolf Steiner) also relies on the notion of the “four humors.” This link will give you the general idea:

    http://www.anthromed.org/Article.aspx?artpk=452

    Dr. Gorski wrote about anthroposophic medicine here:

    http://www.sciencebasedmedicine.org/index.php/a-university-of-michigan-medical-school-alumnus-confronts-anthroposophic-medicine-at-his-alma-mater/

  28. DW says:

    Anthroposophy, for those who don’t know, is the basis of the Waldorf schools, also called Steiner schools. Steiner/Waldorf families are often referred to anthroposophic physicians.

  29. rainORshine says:

    funny how that thread stopped so abruptly after someone brought up anthroposophical medicine – essentially a ‘humorism’ based philosophy of medicine for MDs. probably important to include ever-expanding number of MDs who practice ‘SCAM’ in these kind of discussions

    BTW, aside from anthroposophical MDs has anyone actually seen direct reference (such as an NDs website) to a naturopath who talks about their use of ‘humorism’ and what it actually means to them?

    seems kind of ‘unscientific’ to site this one excerpt from one book and generalize about how this influences the entire practice of natural medicine and everyone who practices it.

    im sure i can find more ‘evidence based’ discussion about how natural medicine is a peril to our society. ill keep looking

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