Legacy of the Mediterranean – Nutrition Past

Legacy of the Mediterranean – Nutrition Past – Nutrition Today; Prescientific Origins of Nutrition and Dietetics, part 2

Louis E. Grivetti

This article is the second of four on prescientific nutrition and dietetics. The series explores allopathy and the rich prescientific origins of nutrition and dietetics: Part One-the nutritional-dietary legacy of India; Part Two-the allopathic contributions from Greek-Roman-Byzantine, and Jewish-Christian-Moslem Mediterranean societies; Part Three-the allopathic works from China; and Part Four-the important Hispanic contributions to allopathy in the New World. The objectives are three: 1) to identify the ancient origins of allopathy as a medical-dietary system and trace it from antiquity into the 20th century; 2) to identify and describe allopathic principles using original accounts and important, readily available secondary sources; and 3) to explore how allopathy and scientific nutrition differ and where common-sense principles coincide. By the development and publication of this series the author and editor believe that nutrition education in the United States today can be improved, especially in American communities where allopathy is widely practiced and science is viewed skeptically.

Editor’s Note-Additional tables on Comparative Food Groups (Celsus of Verona, B.C. 27-A.D. 37, and Paul of Aegina, A.D. 625-690); Doctrines of Naturals and Nonnaturals; and Chronology: Mediterranean Writers on Nutrition, Diet and Food Patterns, B.C. 6th century-15th century A.D. are available from the editor upon receipt of a stamped ($1.16), self-addressed 8 1/2 by 11 envelope.

Ancient Indian contributions to the history of medicine and nutrition were explored in the February issue of Nutrition Today (Grivetti, 1991). Caraka, the Indian “Father of Medicine,” first developed allopathic medicine, circa 1500 B.C. Allopathy, a complex approach to medical-nutritional healing, was based upon concepts of elements, humors and various descriptive attributes assigned to foods and to diseases. At its heart was the principle of contraris contrariia, the doctrine of opposites, e.g., hot diseases were treated using cold foods, wet diseases with dry. Such concepts also characterized ancient Mediterranean medicine and are the subject of this article.

Part Two: Legacy of the Mediterranean

Diseases caused by overeating are cured by fasting; those caused by starvation are cured by feeding. Diseases caused by exertion are cured by rest; those caused by indolence are cured by exertion. To put it briefly; the physician should treat disease by the principle of opposition to the cause of the disease according to its form, its seasonal and age incidence.

Hippocrates, The Nature of Man, 9

ALLOPATHIC CONCEPTS IN GREEK AND ROMAN MEDICINE

The origins of Greek medical-nutritional practices-like those of ancient India-are shrouded in myth. The Greek god of medicine, Aesklepios, his physician-sons, Machaon and Podalirus, and his daughter Hygeia, are well described in Greek art, fables and texts. Aesklepios, son of Apollo, accompanied Jason on the quest for the golden fleece. Both Machaon and Podalirus fought in the Trojan war. Hygeia, the goddess of health, was worshiped as a component of the Trinity: Health, Peace and Wealth. According to Greek myths, descendants of Aesklepios, or Asclepidae, trained healers and ultimately formed a caste that specialized in the healing arts (Wright, 1963; Seyffert, 1966).

Contributions by Philosophers. The earliest surviving Greek texts related to medicine were written by philosophers. Thales of Miletus (639-544 B.C.) was the first known Mediterranean to propose the doctrine of Four Elements, that air, earth, fire, and water were required for human life. A contemporary of Thales, Anaximander of Miletus (611-547 B.C.), wrote that all living matter exhibited temperature and moisture attributes, specifically, qualities of hot or cold and wet or dry (Wright, 1981).

Other Greek philosophers expanded the doctrine of Four Elements and temperature-moisture attributes. Pythagoras of Samos (583-489 B.C.) suggested that nine descriptive terms characterized life: 1) limited-unlimited, 2) odd-even, 3) single-many, 4) right-left, 5) male-female, 6) straight-crooked, 7) light-dark, 8) good-evil, and 9) square-oblong (Moon, 1923). Alcmaeon of Croton (circa 540 B.C.), a student of Pythagoras, wrote that health represented equilibrium, a natural state when elements and attributes were balanced (Longrigg, 1963). Heracleitus of Ephesus (540-475 B.C.) proposed that fire, not air, was required for life. Empedicles of Agrigentum (502-443 B.C.), a noted thinker of the period, wrote that air, earth, fire and water existed as distinct, separate entities within the human body, and concluded that death resulted when innate body heat was extinguished (Baas, 1971).

Mediterranean Allopathy: Genesis of an Idea. Physicians may be philosophers, but philosophers are not physicians. Two important Greek physicians, contemporaries of Empedicles, emerged from the mythological cloak of Aesklepios. Both were celebrated during their lifetimes, but the fame of only one transcended geographical-time boundaries of the Mediterranean and reached the 20th century. Hippocrates, the first, has been called the “Father of Medicine,” and is widely known today. He was trained by his father who was a physician, and by another healer named Herodicus. The second physician, Ctesias, remains essentially unknown today. Both, however, were important to the history of medicine and nutrition.

The importance given Hippocrates in the 20th century is due directly to his medical writings. His texts have survived despite ravages of conquest and war, including the destruction of many libraries. Through his numerous, detailed and intricate texts we sense qualities of the man and his ethical values, and can appreciate his approach to healing. The importance of these cannot be overemphasized. His ideas, however, appear as if they developed de novo, without antecedent or reference to earlier physicians. When studied outside of their historical and geographical context, these works appear unique. They demonstrate well developed allopathic medical-nutritional approaches to treatment. They describe medical-nutritional concepts unlike those used by physicians in ancient Carthage, Egypt or Phoenicia. When the manuscripts of Hippocrates are reviewed and set within their historical and geographical context, a puzzle emerges that continues to challenge 20th century historical nutritionists: were his works the product of a unique, creative genius, or were they borrowed from others? What role, if any, might Ctesias have had in their formulation?

The Greek allopathic approach to medicine based on elements, humors and attributes assigned to both foods and diseases did not evolve from ancient Egyptian medical concepts. Egyptian medical practices, from 2700 B.C. through initial Greek contact with Egypt in the 5th century, a span of more than 2000 years, were based not upon allopathy but on religious-spiritual origins for disease (Ghalioungui, 1968, 1973; Darby et al., 1979).

While allopathic medicine was not practiced in the Mediterranean before the Greeks, this treatment system had been developed in India by at least 1500 B.C. The allopathic structure of both Indian and Greek medicine presents parallels so similar that a reasonable argument may be advanced that Greek Mediterranean concepts, attributed to Hippocrates, were influenced by an “Indian connection”. The puzzle has remained: was Hippocrates, the “Father of Western Medicine,” an innovator, or was he a borrower?

The Indian Connection. Hippocrates never visited India. One interesting report, however, states that he may have treated the Persian king, Artaxerxes (Jones, 1939). If true, the Persian king would not have traveled to Hippocrates’ hospital on the Mediterranean island of Cos; Hippocrates would have visited the king in Persia. Trade and cultural-economic exchanges existed between Persia and India for centuries before the reign of King Artaxerxes. If Hippocrates visited Persia, he probably would have met with Persian physicians. Might he have learned allopathic medical-nutritional concepts from the Persians, integrated these concepts of elemental-humoral medicine into his own medical perspectives, then introduced allopathy into the Mediterranean upon his return to Cos?

Hippocrates never visited India and his travels to Persia are suspect. Examination of the biographical record of Ctesias, in contrast, is enlightening. Ctesias (birth date unknown) practiced medicine between the years 416-384 B.C. He not only tended the wounded Persian king, Artaxerxes, at the battle of Cunaxa in 401 B.C., he visited and worked in India! Accounts reveal that Ctesias traveled to Persia and India in 416 B.C., and that he subsequently served as physician to the Persian royal court for 17 years. At an unknown date between 399 and 384 B.C., he returned to Greece and practiced medicine at the medical school of Cnidos on the Mediterranean coast of Asia Minor, (Wright, 1963; Seyffert, 1966; Baas, 1971).

Hippocrates never visited India, but his texts survived, and he is credited with “inventing” Mediterranean allopathic medicine. Ctesias visited India, his texts were lost through the ravages of war and time, and he has remained obscure. Does fame-or its mirror image obscurity-result from the chance survival of fragile texts? As a historical nutritionist, I find it curious that Hippocrates and Ctesias were contemporaries, and that their respective medical schools (Cos and Cnidos) were within 50 miles of each other. Did these contemporary competitors, both famous in their time, ever meet and exchange views? No one knows for certain, but I suspect that they did.

Perhaps Greek medical-nutritional texts authored by Ctesias may be discovered one day that will reveal who first introduced allopathic concepts into the Mediterranean region. Until then, Hippocrates must be credited as being the first, and it is to his important medical-nutritional texts that we now turn.

HIPPOCRATES OF COS (460-377 B.C.)

Hippocrates identified three categories of nutrients required for life: solid foods, beverages and air. Of the three, he considered air most important, since a patient could be deprived of solids and liquids for days and survive, but death always resulted if humans were deprived of air. He concluded that the human body was nourished by an innate heat; that humans were warmest on the day of their birth, and that they grew progressively colder with age, and were coldest immediately before death (Moon, 1923; Levine, 1971).

Hippocrates accepted the Four Element doctrine of Empedicles and stated that the body was controlled by four humors: blood, phlegm, yellow bile, and black bile. Health was the state of balance of elements and humors, while disease was imbalance. Hippocrates wrote that in addition to the effects of elements and humors, health was influenced favorably or adversely by the patient’s chronological age and by external factors such as climate and weather, season and individual lifestyle (Moon, 1923).

Regarding digestion Hippocrates stated that foods were mixed (crasis) inside the body, then “cooked” (pepsis) by body heat. As to nutrition, Hippocrates urged dietary moderation and recommended that diet reflect the appropriate season:

“[During Winter]: Eat as much as possible, drink as little as possible; eat bread; all meat and fish should be roasted; eat as few vegetables as possible. This regimen] will keep the body warm and dry.

[During Spring]: Take more to drink [than in winter], increasing quantity a little at a time; take softer cereals, substituting barley cake for bread; boiled meat should replace roasted; eat a few vegetables once Spring has begun, both raw and boiled.

[During Summer]: Live on soft barleycake, watered wine in large quantities, and all meat should be boiled; this will keep the body cool and soft.

[During Fall]: Cereals should be increased and made drier, and likewise the meat in the diet. Quantity of drink then should be decreased and less diluted; take in the smallest quantity of the least diluted drink and the largest quantity of cereals of the driest kind; this will keep the person in good health, he will feel less cold, for the season is cold and wet (Regimen in Health, 1).”

Hippocrates is the earliest known Mediterranean physician that integrated nutrition and dietetics with medicine:

A simple diet of food and drink, if it be preserved in without a break, is on the whole safer for health than a sudden violent change. Sudden changes cause harm and weaknesses, both to those who take one, and to those who take two full meals a day. Those who are not in the habit of lunching, if they have taken lunch, immediately become feeble, heavy in all the body, weak and sluggish. Should they also dine, they suffer from acid [indigestion]. Diarrhoea, too, may occur in some cases because the digestive organs have been loaded, contrary to habit, when they are accustomed to a period of dryness, and not to be twice distended with food and to digest food twice. It is beneficial, then, in these cases [to take] a slow, long walk without stopping. Such a man will suffer yet more if he eat three times a day to surfeit, and still more if he eats more often. But, indeed, those too who have the habit of taking two meals a day, should they omit lunch, find themselves weak, feeble, averse to all exertion, and the victims of heartburn. He, therefore, who has fasted strictly contrary to his custom is benefited if he compensate for the day of starvation in the following manner. He should avoid cold, heat and fatigue-all of which will distress him-and his dinner should be considerably less than usual, not dry, but of rather a liquid character (Regimen in Acute Diseases, 30-33).

Several of Hippocrates’ dietary recommendations stimulate comparison with modern approaches to patient care, but also serve as the basis for several 20th century dietary fads:

1. Those who eat only once a day become

exhausted and weak, and pass

warm urine on account of their abnormal

emptiness. Their mouth becomes

salty, or even bitter, and [they]

are unable to digest their dinner as

they would have if they had had a

breakfast. [Such persons] must eat

less at dinner than they are used to,

[they should] replace bread with

quite moist barley-cake and [from]

vegetables [select] dock, mallow,

peeled barley or beets. With their

food, let them drink wine in a reasonable

amount and quite dilute;

after dinner walk a little until urine

runs down and is passed. Let [such

people also] eat boiled fish.

2. Garlic produces flatus and heat

about the thorax, heaviness of the

head, and nausea; it is diuretic; it is

best of all to eat if one is about to go

drinking or is already drunk.

3. Cheese produces flatus, constipation

and heating of other foods; the worst

thing is for those already full to eat

it together with their drink.

4. All pulses produce flatulence; they

are not to be employed except together

with other foods; each has its

own particular dangers. Chick-pea,

both raw and roasted produces pain;

lentils contract and are laxative.

5. Goat’s meat is [as indigestible as]

beef, but produces belching and

choler [yellow bile]. Fresh goat’s

meat is best in summer, worst in

autumn.

6. Meat of a young pig is injurious

when either too raw or scorched,

since then it is likely to produce

choler [yellow bile] and to set the

[body] cavity in motion; pork is the

best of all meats; the most nutritious

is that which is neither very fat nor

very lean, and which has not the age

of an old slaughter-animal; eat it

without the skin, and slightly cooled.

7. The most important part of the dietetic

art is to observe and watch

closely during long illness for the

exacerbations of fevers and for their

remissions, so as carefully to avoid

the particular times when foods

must not be given, and to know

when they may be given with safety,

namely, when patients are furthest

from [their medical crisis] (Regimen

in Acute Disease Appendix, 44-47,

49-50, 54).

CELSUS OF VERONA (27 B.C.-37 A.D.)

The Roman, Celsus, practiced medicine more than 300 years after Hippocrates. He is recognized as one of the greatest writers on allopathic nutrition and dietetics:

The physician should [observe] evident causes: For what matters is this: whether fatigue or thirst, heat or cold, wakefulness or hunger, abundance in food or wine, has produced the disease; there should [not be] ignorance of the sick man’s temperament; whether his body is wet or dry, sinews strong or weak, frequently or rarely ill, and if so whether severely or slightly, for short or long [duration], the kind of life he has lived, [whether] laborious or quiet, accompanied by luxury or frugality. From such and similar [information] one may often deduce a novel mode of treatment (Prooemium, 52-52).

Celsus, familiar with common Mediterranean diseases, identified foods and drugs used to treat them. He observed that certain categories of food were medically stronger’ than others, an observation that hints at differences in caloric and protein content of foods.

All pluses and all breads-stuffs made from grain, form the strongest kind of food; to the same class belong: [meat from] all domesticated quadruped animals, all large game such as deer, wild boar, wild ass, all large birds such as crane, goose, and peacock, all sea monsters, among them which is the whale and such, also honey and cheese. Hence, it is [obvious why] pastry made of grain, lard, honey, and cheese is very strong food (On Medicine 2:18:2).

Celsus wrote that bread was more nutritious than any other food, that wheat bread was stronger than millet, and millet bread superior to barley. He wrote that beans and lentils were stronger than peas, that meat from domesticated animals provided different strength options to consumers: beef was the strongest and pork the weakest. He believed that cuts of meat from larger animals provided better nutrition to humans than similar cuts from smaller livestock (On Medicine 2:18:4-7).

A second category of foods, one that he called middle-strength, included items such as: pot-herbs with edible bulbs and roots, hare, all varieties of edible birds, and all fish except those that required salting for preservation. He wrote that flightless or walking birds’ were stronger foods than species that flew; large birds were better sources of nourishment than small; and meat from water fowl was weaker than that from avian species unable to swim. The strongest fish, he claimed, was mackerel, followed by tender/firm varieties such as sea bream, then softer species such as bass and mullet. Celsus suggested a third food category which he defined as weak, but still able to provide nourishment. Into this category he grouped: stalked vegetables, fruit-like vegetables (i.e., cucumber), orchard fruits including olives, edible land snails, and shellfish (On Medicine 2:18:3-7).

Having defined strong, middle-strength, and weak foods, Celsus wrote that the plants and animals of the same species had different abilities to nourish the human body due to age, seasonality, and climate/soil conditions where they grew and matured. Young plants and animals, he said, provided less nourishment to humans than older forms of the same species; that chickens raised in coops, for example, offered more tender meat than free-ranging chickens; that grain cultivated on hilly slopes was more nutritious than if raised on flatlands; that fish swimming among rocks were less nutritious than species living above sandy environments. He perceived, too, that foods could be classified according to relative ease of digestion. Cuts of meat from wild animals, for example, were considered lighter and easier to digest that similar cuts from domesticated or tamed forms; meats from animals living in wet, damp regions were deemed superior to those from the same species raised in dry or arid locations. He wrote that fatty meat provided more nutrition to the human body than lean; that fresh meats were better than salted; that stewed meats offered more nourishment and easier digestion than roasted, but he noted that roasted meats were consumed more because of better taste (On Medicine 2:18:8-10).

Celsus prescribed diets that balanced nine descriptive attributes assigned to foods. Foods: 1) produced “good juice or bad,” 2) were bland or acrid, 3) thickened or reduced phlegm, 4) were suitable or alien to the stomach, 5) were hot or cold, 6) were easily or poorly digested, 7) were evacuative (laxative) or retentive (constipating), 8) were diuretic, or 9) promoted sleep or excited the senses. Celsus’ nine food groups are important to the history of nutrition and dietetics because they identify the principal foods consumed by Greco-Roman citizens nearly 2000 years ago, and their respective allopathic roles.

PLUTARCHUS OF CHAERONEA (46-127 A.D.)

Plutarchus, Greek philosopher, traveler, and observer of human nature, was born in the Common Era, 9 years after Celsus’ death. Although untrained in medicine, he wrote extensively on food and dietary topics. In one tract, Plutarchus explored a wide range of food-related issues, including gluttony, simplicity in diet and vegetarianism, and proposed five dietary recommendations:

1. We ought especially to guard against

excess in eating and drinking, and

against all self-indulgence.

2. Let everybody [urge] himself not to

make his [food] more ample than

lentils, and by all means not to proceed

beyond cress and olives to croquettes

and fish, and by overeating

throw [the] body into discord, that is

to say, into derangements and diarrhoeas.

For the inexpensive things

keep the appetite to its natural limits

of moderation, but the arts of chefs

and their trained helpers, are constantly

advancing and enlarging the

bounds of [food] enjoyment, and altering

our ideas of what is good for

us.

3. Especially to be feared are indigestions

arising from meats; for they are

depressing at the outset, and a pernicious

residue from them remains

behind. It is best to accustom the

body not to require meat in addition

to other food. But while we may put

[meat] in as a sort of prop and support

of our diet, we should use other

foods and relishes which for the

body are more in accord with nature,

and less dulling to the reasoning

faculty, which, as it were, it kindled

from plain and light substances.

4. Milk ought not be used as a beverage

but as a food, [one that] possesses

solid and nourishing power; wine is

the most beneficial of beverages. In

the course of the daily routine [one

should drink] two or three glasses of

water.

5. In regard to food and drink it is

expedient to note what kinds are

wholesome rather than what are

pleasant, and to be better acquainted

with those that are good in the stomach

rather than in the mouth, and

those that do not disturb the digestion

rather than those that greatly

tickle the palate (Advice About Keeping

Well, 123:E-137:A).

GALEN OF PERGAMUM (131-201 A.D.)

Galen, born shortly after the death of Plutarchus, was the most influential Greek physician of the Common Era. He traveled extensively, visited Greece and Egypt, practiced medicine at Pergamum (where his hospital may be visited today), and retired in Rome. His medical texts, considered as a unit, provide a clear, rich exposition of Greek and Roman allopathic medicine and nutrition.

According to Galen the four elements (air, earth, fire and water) and moisture-temperature attributes assigned to foods and disease were central to healing. He perceived that digestion took place in the stomach, where food and beverages were “cooked” by natural heat, then transformed and differentiated into substances that ultimately produced four humors: blood, phlegm, yellow bile and black bile. Galen argued that health and therefore balance were protected if moderation in all things was practiced. Accordingly, he urged symmetry in eating and lifestyle (Dols, 1984).

Three concepts beyond the doctrine of the Four Elements, humors and moisture-temperature attributes characterize Galen’s writings. The first construct, the doctrine of the Nine Temperaments, described human health and personality. A balanced, even temperament, according to Galen, was ideal, but rare; the remaining eight temperaments reflected abnormal human conditions where one or more single temperature-moisture attributes dominated. The remaining eight temperaments were: hot, cold, wet, dry, hot-moist, hot-dry, cold-dry, or cold-moist. A second concept, doctrine of the Seven Naturals, was the basis for medical diagnosis. Physicians were required to understand: 1) elements 2) human temperaments, 3) humors, 4) organ shape, position and type, 5) impact of external forces on elements and humors, 6) specific body actions, and 7) impact of vital spirits. The third concept, doctrine of the Six NonNaturals, was a complementary diagnostic system used by physicians to systematically evaluate how the patient’s health was influenced and determined by: 1) qualities of air, 2) body activities, 3) actions during sleep and rest, 4) foods and beverages, 5) rates of retention or excretion of digestible products, and 6) effects of human passion and emotion (Dols, 1984).

Despite Galen’s contributions to medicine, his manner and attitude toward patients was not without bias. He described the ‘social disgrace” of contracting gout, kidney stones or an ulcerated bladder. His strongest words, however, were directed toward sufferers of arthritis, a disease he believed was caused by improper diet:

Is it not disgraceful that a person [with arthritis] be unable to use his own hands, and should need somebody else to bring food to his mouth, and to perform his toilet necessities for him? Unless one were an absolute weakling, one would prefer to die a thousand deaths rather than endure such a life (On the Preservation of Health, 5:1).

AFTER GALEN: CHRISTIAN, JEWISH, AND MOSLEM SOURCES

Galen died at the onset of the 3rd century of the Common Era; within 25 years, Christianity became the state religion of the Roman Empire. Little is known about Jewish or Christian medical-nutritional concepts and practices before Galen. After the 3rd century A.D., however, there emerged a vast body of medical, nutritional and dietary knowledge contributed by Jewish and Christian physicians and theologians. With the birth of the Prophet, Mohammed, and the rise of Islam, numerous Moslem physicians subsequently contributed to the corpus of post-Galenic allopathic nutritional literature.

Titus Flavius Clemens of Alexandria (150-220 A.D.). This early Christian theologian proposed that milk was the perfect food, since neonates received their required nourishment only from breast milk. Blood he called “the substance of the soul,” merely liquid flesh, a product changed by internal body heat into human milk. Clemens urged moderation in diet and stipulated that proper human food should be plain and ungarnished, that people should eat to maintain life, not to support self-indulgence. He concluded that humans required only simple, basic foods and argued that variety should be limited, since too many kinds of food upset the stomach, and led to taste perversions that turned people’s attention to pastries (The Instructor, 1:36-50; 2:2).

Other views on diet by Clemens, however, parallel modern nutritional advice:

We should shy away from foods that arouse the appetite and lead us to eat when we are not hungry. Even in moderate frugality, is there not a rich and wholesome variety [of food]? Roots, olives, all sorts of green vegetables, milk, cheese, fruits and cooked vegetables of all sorts, but without the sauces? And should there be a need for meat, boiled or dressed [served with condiments], let it be given. Surely, of all the foods available, the most convenient are those which can be used immediately without being cooked. Inexpensive foods come next in order (The Instructor, 2:15).

Gregory of Nyasa (330-395 A.D.). The Christian theologian Gregory of Nyasa wrote that three internal organs were essential to life: the brain, the heart and the liver. He said three forces controlled the body: the first moistened, the second warmed and the third regulated movement. He resurrected (or plagiarized?) the observation of Plato of Athens (430-347 B.C.) that the purpose of intestinal convolutions was to slow evacuation so appetite would not return rapidly (Gordon, 1959).

Gregory’s contributions to dietetics, outlined in his text Catechetica Magna, included notions that: All people [do] not need the same type of food, only a diet suited to their condition. Required is a combination of liquids and solids: solid parts of the body are nourished by solid foods, liquid portions by liquids. Staple diet is bread with water as beverage, sometimes sweetened with wine, to blend with internal body heat to form blood (Keenan, 1944).

Gregory reported the especially important observation that: “Starving people should not eat until their strength has been restored gradually, using limited food intake.” He also wrote that feverish patients should not be fed [i.e., feed a cold-starve a fever] (Keenan, 1944).

Paul of Aegina (Paulus Aegineta) (625-690 A.D.). Works by Paulus Aegineta frequently are overlooked, given the prominent writings of Hippocrates, Celsus and Galen. Nevertheless, Paulus made a significant contribution to Mediterranean allopathic medicine. He compiled numerous accounts of medical-nutritional practices and discussed a wide range of dietary conditions, among them pregnancy and how to manage morning sickness, food aversions and pica (eating clay). If vomiting was debilitating he recommended that his pregnant clients exercise, eat unsweetened foods and drink ample quantities of aged red wine. He wrote that pregnancy food aversions could be overcome using savory foods to stimulate the appetite, then eating large quantities of dry starch and mustard to restore the appetite. Paulus claimed that pica was the mother’s behavioral response to her weak fetus caused by the accumulation of various superfluities’ in the stomach leading to appetite for earth. In his view pica was an adverse medical condition to be eliminated through hard, exhausting work and long walks (Epitome, 1:1).

Paulus’s most important contribution, however, was his food classification system that identified the most common Mediterranean foods by their temperature-moisture categories. He organized the foods into 12 groups for easy medical reference.

Hunan Abu Zeid Ibn Ishaq Al-Ibadi of Al-Hira (813-873 A.D.). Ibn Ishaq, also called Johannitius Onan, was among the most important Christian medical contributors of the Middle Ages. He produced a translation, exposition and clear treatment of Galen’s doctrine of Seven Naturals and Six Non-Naturals that served as a model for medical care during succeeding centuries. Onan argued that all humans experienced one of three conditions: health, neutrality or disease. Health was normal; neutrality was represented by cases of blindness or old age; disease occurred when normal human activities were interrupted (Questions on Medicine, pp. 8-11).

In his view hot diseases were caused by five factors: 1) immoderate movement, 2) exposure to external heat, such as direct sunlight, 3) excessive warmth from ingesting too much food, 4) thickened skin pores, and 5) putrefaction inside the digestive system. Cold diseases, in contrast, were caused by eight factors: 1) exposure to external cold, such as ice, snow and wind, 2) excessive cold obtained from food, 3) ingestion of foods that extinguished innate heat of the body, 4) excessive fasting and refusal to drink to the point where innate body heat was nearly extinguished, 5) undue thickenings and related residues inside the body that smothered body heat, 6) displacement of innate heat by external applications to the body, 7) emotional state and excessive exercise/movement and 8) excessive sleep/rest (Questions on Medicine, pp. 14-15).

Dry diseases, according to Ibn Ishaq, were due to four factors: 1) exposure to external dryness, e.g., desiccating winds, 2) overconsumption of dry foods or beverages, 3) reduced intake of food and beverages, and 4) emotional state or excessive exercise. Wet diseases, in turn, were caused by four factors: 1) exposure to external wetness, for example, excessive bathing, 2) overconsumption of moist foods and beverages, 3) excessive intake of food and beverages and 4) an easy life and general weakness in character (Questions on Medicine, p. 15).

Abu Ali Husayn Ibn-Abdullah Ibn Sina of Afshena (93 7-103 7 A. D.). Ibn Sina (Avicenna), perhaps the most famous Medieval Moslem physician, made significant contributions to nutrition and dietetics. His texts provide the basis for many modern Mediterranean allopathic beliefs and practices:

1. In winter food should be hot; in

summer cold or only slightly warm.

2. Do not [eat] unless you have digested

your former meal entirely. A

person should not eat unless hungry.

Nothing is worse than to eat to

repletion during a time of plenty

after having been in a state of starvation

during a time of famine.

3. No meal should be bulky enough

to completely satisfy the appetite.

One should rise from the table

while some appetite or desire for

food is still present. If one [eats] to

excess one day, one should fast the

next.

4. One should not go to sleep immediately

after a meal, with the food

still swimming in the stomach, and

one should, as much as possible,

abstain from much exercise after a

meal, lest the food pass into the

blood before it is sufficiently digested,

or glide out of the stomach

without being digested at all.

5. Certain rules must be noted in regard

to combinations of food: milk

must not be taken with sour foods;

fish must not be taken with milk in

that case chronic ailments such as

leprosy may develop; pulses must

not be taken with cheese or radishes

or with the flesh of flying

birds; barley-meal should not follow

a dish of rice and sour milk.

6. To have several courses to a meal

is injurious, for the rate of digestion

is diverse, for the part that digests

more speedily is admixed with a

part which is not yet digested, and

a person may eat too much of one

dish.

7. It is proper to eat at least once in

the space of a day and night; at

most twice; the average being three

times in 2 days;

8. It is necessary to chew well to obtain

good digestion; everything that

is hard to chew is hard to digest;

when you eat an indigestible food,

wisely take something to neutralize

[it].

9. If you fear the unhealthfulness of

fat and its difficult digestion, add

some salt or acid to it; both will

make it digestible.

10. Do not drink during meals as this

separates the food from the walls

of the stomach. Never drink after

the meal or after a warm bath, or

after violent exercise, nor after sexual

intercourse. This is dangerous

(Cannon, 760-879; Poem On Medicine,

55-57, Kamal, 1975).

Musa Ibn Maymum of Cordova (1135-1208 A.D.). Musa Ibn Maymum (Maimoinides), the most famous Medieval Jewish philosopher-physitian, provided wonderful insights on medicine, nutrition and dietetics. Ibn Maymum examined Hippocrates’ allopathic medical treatments, added his own observations, then produced one of his most famous medical-dietary texts, On the Aphorisms of Hippocrates:

1. The more natural warmth of a person,

the more food he needs. The

digestive process in the bodies of

young people is more rapid. People

who are extremely old cannot tolerate

abstention from food, but require

small amounts at frequent intervals,

because their body warmth is near

extinction and they require constant

nourishment for its maintenance

(1:13).

2. The fundamental rule [when administering

food] depends on the state

of the strength of the patient and on

the type of illness. One should also

take into consideration the age of the

patient, [his] custom[s] and the climate.

A strong person requires that

his food intake be all at one time,

whereas a weak person needs to eat

small portions at intervals. A lean or

emaciated person needs to be fed a

generous amount of food, whereas

obese patients should be fed less. It

follows that a weak, lean patient

should be fed small amounts of food

at frequent intervals. When summer

approaches, it is proper to decrease

food intake and increase [the] interval

between meals, because at that

time the body may be full. This is

because the humors, which were

congealed during the winter, liquefy

and melt (1:17).

3. The most rapidly and suddenly

nourishing substance is wine (2:18).

4. Ravenous hunger is caused by either

the cold of the stomach alone, or

because of the sour humor which is

swallowed up by its substance. Wine

cures both conditions (2:21).

5. Elderly people have more control

over their diet than young people.

However, the strength in the bodies

of old people is weak [and they have

less resistance to disease] not only

because they are unable to cook the

illness, but also because when they

are affected with illness, the latter

are due to cold humors (2:39).

6. If you [classify] each and every illness,

you will note that [they] are

better or worse depending on the

particular age group of the patient

and the particular land or the particular

season of the year or the particular

dietary regimen. Someone suffering

from a cold illness in his youth

feels better in summer and in warm

countries and with a warming diet.

In general, opposites for opposites

are beneficial and a therapeutic approach

which deviates in the same

direction is detrimental (3:3).

7. Women do not become bald because

of the moistness of their constitution.

Gout is also rare in women because

they empty their superfluities in the

menstrual blood (6:28-29).

CONCLUDING COMMENTS

Allopathic medicine, nutrition and dietetics first appeared in the medical system of ancient India, circa 1500 B.C., possibly earlier, and did not become part of Mediterranean healing systems until the era of Hippocrates and Ctesias, circa 400 B.C. Given the relatively late, sudden emergence of the Mediterranean allopathy, and basic similarities of Greek to Indian systems of medicine-dietetics, it is tempting to assume an Indian origin for these practices.

Nutritional concepts and dietary recommendations reported in this article are still followed today in the Mediterranean region, and by many Americans as well. It is perhaps human nature to believe in the “collective wisdom” of ancient texts. Scientific nutritionists, however, do not accept the concept of “collective wisdom,” but insist, instead, that conclusions should be based upon demonstrated evidence. Some proponents of allopathy argue that older, traditional medicine is “better” than modern medicine and nutrition science, and because such systems are ancient, they automatically have merit. The remark by Hippocrates that people should eat “as few vegetables as possible during winter,” or the statement by Paul of Aegina that pregnant women should drink “aged red wine,” clearly are ancient-but are not recommended today by scientific nutritionists.

Some Mediterranean allopathic recommendations and concepts cited in this article have been adopted by various nonscientific nutrition-practitioners in the United States and elsewhere. Some nonscientific practitioners, for example, claim that “seasonal rhythms” should be followed and that eating foods “outside their natural season” is deleterious. Other nonscientific practitioners urge devotees to restrict intake of so-called phlegm-producing foods (i.e., raw eggs and milk), because Celsus, Galen or Paulus so prescribed. So-called phlegm-producing foods, however, do not produce phlegm. Other Americans attracted to the vegan “raw food movement” find support in the theological writings of Clemens who urged that people eat simple, uncooked foods. Still others attracted to recent proclamations by proponents of “food combining” see merit in the texts of Ibn Sina.

Several recommendations made by ancient Mediterranean physicians-nutritionists cited in this assay are logical and have withstood scientific scrutiny. More than one ancient contributor urged patients not to skip meals, since those who ate only once per day could expect to be exhausted and weak. Several Christian theologians, untrained in medicine or nutrition, recommended moderation in diet, and encouraged people to eat to support life, not “self-indulgence.” Their views, while laudable from a modern nutritional perspective, were stated to demonstrate religious self-denial, not medical wisdom. It is interesting to note that the Christian theologian, Gregory of Nyasa (4th century A.D.), wrote that malnourished, starving people should not eat to repletion, but be fed gradually so not to cause undue death. This view subsequently was echoed by the Moslem physician, Ibn Sina. Is there not a terrible irony to Gregory’s and Ibn Sina’s recommendations? How many times during 19th and 20th century wars and famines, has their sound advice been ignored by relief personnel who unintentionally overfed starving refugees and caused unnecessary deaths?

The study of medicine, nutrition and dietetics also reveals that both ancient and modern humans have shared common bonds throughout the centuries. Take, for example, the widespread human concern with obesity, the proliferation of treatment modalities, and confusion over which offered best results. Overweight clients who attended the Hippocratic “Weight-Loss Center,” for example, exercised, ate flavorful foods at one meal per day, slept on hard beds and discarded their clothes and walked about nude. Followers of the “Galen Diet System,” on the other hand, were provided non-nourishing food, then told to vomit, rest and refrain from exercise. Mediterraneans who entered “Paul’s Clinic” on the island of Aegina, were placed on an exercise program designed to “melt fat away,” then advised to eat once a day. Obese patients attracted to Ibn Sina’s successful “diet plan” were prescribed laxatives that reduced “contact-time with the intestines,” and assured “rapid descent of food from the stomach,” then told to eat bulky, “feebly nutritious” foods, and engage in strenuous exercise. Other overweight clients considered Musa Ibn Maymum’s “last-chance sea-side resort program” for weight loss, where patients “checked in,” then were told to walk leisurely along the sunny Mediterranean shore, bath in the sea, and inhale salt-spray air, so body fat would “melt away.” At such an idyllic Mediterranean setting, Maymum’s clients were served vegetables and fish, roasted nonfatty meats, and were required to perform as much physical exercise as possible.

History is a good instructor. From the past we learn that some ideas are sound, others baseless. Some medical concepts commonly used in antiquity have extended essentially unchanged into 20th century while others have been abandoned. We learn, too, that ancient and modern peoples both have been concerned about health, disease and how to choose sound diets.

It is also refreshing to realize that people in antiquity struggled to maintain ideal body weight. As a nutritionist I do my best to make proper food selections and I exercise regularly. Nevertheless, I continue to carry several “extra” kilograms. Sometime in the future I plan to lose those kilograms. Currently, I am in the process of searching for a coeducational weight-loss program in America that reflects the best of Musa Ibn Maymum’s reasonable approach to eating and exercise, but incorporates the dress code of Hippocrates. I am still looking….

POSTSCRIPT: A CONTRIBUTION FROM RENAISSANCE FLORENCE

This article closes with a Mediterranean diet prescribed in 1463 by four court physicians (Drs. Bartholommeo, Cesari [from Naples], Filippo Cenni, and Mingho) who attended the Florentine prince, Giovanni dei Medici. This interesting case represents allopathic concepts, humoral medicine, temperature and moisture classifications and presents the reader with a still unsolved mystery:

As to air, [the patient is to habituate] temperature air, that is neither hot nor cold, but including to dryness; [he] is to avoid air that is too hot or too cold [and] for this reason it is harmful [for him] to stay in the sun, or in overheated rooms. As to the quality of [his] food and drink, [he should] select food that is easy to digest, neither exceedingly hot nor exceedingly cold; and on no account use food that is gaseous, or salty or acid; [as for proper kinds of] flying flesh, use pheasants, partridges, chickens, robins, wood-peckers, larks. Of cereals use bran, chick-pea and especially flour from dark red chestnuts; avoid chicory, lentils, beans and rice; avoid all forms of fungi and especially truffles as they are of poorest nutrient; avoid fish from lakes or marshes or swamps, particularly oysters served with pepper or sharp spices. As to the quantity of food, eat comfortably and drink temperately; [the patient should] never eat until sated, and for this reason [he should] avoid a great diversity of food. As to the time of eating and drinking, [he should] eat when the appetite is good and not postpone meals. As to taking exercises or remaining quiet, we say that it is advisable for him to take exercise before each meal, that it must not last until he is tired and perspiring; and it is better to exercise in the morning rather than in the evening (Richards, 1939).”

Giovanni dei Medici died at the age of 42 in 1463, the same year his diet was prescribed. Giovanni’s mother wrote after her son’s death that he was terribly obese, suffered from severe catarrh and generally neglected his health. Severe sinus infections and accompanying respiratory infection rarely kill today because of the availability of antibiotics. Catarrh was, however, a serious condition in the Middle Ages. The question is, however, was the prescribed diet useful or not? Was Giovanni’s life prolonged or was his death hastened by this diet? Did, in fact, Giovanni follow his physicians’ dietary advice or not? Perhaps he disliked the recommended larks and woodpeckers, and maintained throughout his illness a secret passion for lentils, rice and other foods expressly denied by his physicians? Giovanni was told not to skip meals, and to engage in light morning exercise. Did he eat regularly or irregularly, exercise too little or too much? Answers are unknown.

There is also the question: What happened to the four physician-nutritionist-dietitians who bravely recommended this diet and signed their names to the bottom of the document. What thoughts went through their minds when informed that the prince had died? Were they summoned individually or collectively to explain their failure? Were they paid and rewarded for their efforts, or accused of foul play? If rewarded, did they continue their medical practice at court, or were they retired?’ If accused of foul play, did Giovanni’s mother speak out on their behalf? Richards searched the Florentine archives and concluded only that the four physicians had disappeared.

Disappeared? Did the physicians “retire,” leave Tuscany, or flee elsewhere, to resume their practice of medical dietetics under different names? Palace intrigues typified the dei Medici court and the word “disappeared” has an ominous ring. Disappearance or “termination?” If “terminated” because of their failure to cure Giovanni, were their bodies tossed into the silent, dark Arno river that flows through Florence past the dei Medici palace to ultimately join the Mediterranean? Answers are unknown.

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