by Laura Klasek
At the turn of the twentieth century, Thomas Edison predicted that “the doctor of the future will give no medicine, but will instruct his patient in the care of the human frame, in diet, and in the cause and prevention of disease.” Medicine, Edison claimed, was on the verge of understanding the origins of disease and how to prevent it without the use of drugs. He went on to say that “surgery, diet, antiseptics—these three are the vital things of the future in preserving the health of humanity.” Now in the twenty-first century, we’re nowhere close to understanding the causes of many diseases or escaping drugs, but merely walking into a bookstore or turning on the television in January bears witness to our obsession with diet not only as a means to fitness but also, increasingly, to health. Edison was right, and Edison was wrong, but Edison was perhaps most especially wrong at the opening of his statement: “the doctor of the future.”
What would we find if, instead of The South Beach Diet, we consulted the Regimen Sanitatis Salernitanum,[i] a twelfth century text of diet aphorisms in rhyming Latin verse? The Regimen claims to be written to the king of England by practitioners at Salerno, Italy, a center of medical expertise at that time. It covers a broad range of subjects, with titles as varied as “Of Figs” to “Of Bleeding, and of the Age for Bleeding,” most of which reflect the prevailing medical theory of the time: the Galenic humoral system.
According to this system, the body’s four fundamental substances were fluids called humors: blood, phlegm, yellow bile, and black bile. Specific organs produced each of these humors. Yellow bile, for example, came from the liver, blood plasma, and vitelline substances, while black bile consisted of “the dregs of the blood” which looked black when “flow[ing] out of the body from below or above.”[ii] These four substances, each corresponding to an Aristotelian element, combined to create the physical body. Each individual had their own humoral complexion, an ideal proportion for each humor within their body. But humors fluctuated in response to “non-naturals”—diet, environmental conditions, exercise, sleep, sex, and even thoughts. Scholarly medieval medicine devoted itself to studying the signs and symptoms that indicated a humor imbalance, and physicians intervened to restore or maintain the balance of their patients’ humors through diet, drugs, or surgery.
A regimen, or prescribed health regime, was primarily a method of preventative care aimed towards keeping the humors in balance. It regulated—or tried to regulate—all the non-naturals. Of critical importance was diet: for example, two-thirds of the Regimen’s recommendations deal with diet. A regimen was “the means par excellence not only for the preservation of health, but also for curing diseases.”[iii] As such, the Regimen contained simple treatments for conditions like over-drinking, seasickness, and catarrh.[iv] These treatments corrected the humoral imbalance with drugs that held the opposite properties of the malady: a hot, dry cough should respond to a cold, wet cucumber, for example. The Regimen recommended “repeat[ing] the dose at morn” for a hangover, mixing salty water with wine for seasickness, and eating hot food and breathing humid air for catarrh. In a way, the text can be thought of as an analogue to WebMD.com: it allowed patients to self-diagnose and self-medicate. An influential Persian physician and theorist named Avicenna “declared […] that the formal distinction between [food and medicine] was that food was assimilated by the body, whereas medicine assimilated the body to itself.”[v] Though many theorists discussed the divide created by Avicenna’s definition, in practice medieval pharmacology considered most food also medicine. Physicians conscripted herbs and edible substances that caused observable physical effects into use as drugs.
Leigh Chipman, an Israeli historian, analyzed cough remedies presented by a thirteenth century Arabic pharmacist and found that of the almost sixty ingredients mentioned, most common include four which modern research recommends to treat coughs (hyssop, fennel, licorice, and poppy), four which have been shown effective against the ailment (mucilages of gum arabic, quince, mallow, and marshmallow), and three which persist in homeopathic remedies, though with insufficient clinical support (maidenhair, almond oil, and gum tragacanth).[vi] Six, she notes, including cucumber, figs, jujube, raisins, rocket lettuce, and sebesten, have yet to be tested.[vii] We still use all seventeen ingredients in food of some sort: fennel is a common garden herb that my mother keeps in her spice cabinet, for example, and you’ll find gum arabic and gum tragacanth in candies like Mentos.[viii]
Of these seventeen ingredients, the Regimen says that “figs soothe the chest” and hyssop “frees from phlegm the overburdened chest,” but it does not mention treatment of coughs in the uses of mallows or fennel. “Fig-poultices,” the Regimen also claims, “will our bodies rid of tumors, scrofula, boils, and even peccant humors; ‘twill surely draw—add poppy-heads alone—the splintered fragments from a broken bone.” It continues to explain that the fruit “breed[s] lice and lust” while the root counteracts those properties. “Figs the bowels scour”—a statement validated by modern medical science, as ficin, a compound in figs, is thought to have some laxative effects—and relieve “every kind of swelling.” In addition to tastiness, figs, according to the Regimen, possess the ability to cure chronic disease, minor illness, and traumatic injury and to act as medieval Viagra. In the text, hyssop lays claim to a narrower range of abilities. Besides easing respiratory difficulties, it “is said to give the face the highest character of human grace.” Today, we use hyssop as a flavoring agent in liquor as well as in its traditional role of cough suppressant.
Other sections of the Regimen tie more directly to modern pharmaceuticals. For example, “Of the Willow” states that “its bark in vinegar of any sort, when macerated long, dissolves a wart.” Willow bark contains salicin (Figure 1), a molecule that consists of β-glucose bonded to an aromatic molecule. Breaking this bond, discarding glucose, and oxidizing the methyl alcohol substituent group which is attached to the aromatic molecule produces salicylic acid (Figure 2), the primary ingredient in over-the-counter wart medication as well as medication for many other skin conditions (some products released by Noxzema and Clearisil contain 1% and 2% salicylic acid respectively as their active ingredients). Searching for home remedies for warts via Google reveals treatments like crushing or dissolving aspirin (Figure 3) and applying it topically. Aspirin is acetylated salicylic acid, a “prodrug” which the body converts back into salicylic acid in the stomach, allowing the compound to reduce inflammation. These properties of willow bark come up in texts from ancient Greece and in Native American folk medicine.
As a culture, we see medieval texts that mention hyssop as a cough suppressant, note that willow bark can treat warts, and say, “Oh, look, there were some smart people around even when we were primitive and barbaric and handicapped by morons who believed in this system of humors.” Yes, the historical and persistent recommendation of these ingredients in medications indicates that physicians observed the drug’s effectiveness. Our modern scientific method enshrines observation as the foremost precept of science so those historical observations support our world view. But, “Hey, look, smart people existed, and we’re even smarter now,” fails as a philosophy. Why? Because modern medicine struggles with the same problem—how to treat—and uses the same tools—diet, drugs and surgery—and spawns as much quackery as its medieval predecessor.
To us, food means the stock on the shelves of the grocery store or the trays at the farmer’s market. We represent it with a pyramid or the Percentage Daily Value of a two-thousand Calorie diet or sometimes an equation. We obsess over its effect on our bodies: “I have three nutrition books on my nightstand. One says that wheat is making us fat, one says meat is making us fat, and one says sugar is making us fat. What the &;!?@ are we supposed to eat?” says a recent Facebook status. And to us, drugs typically mean pills and intravenous fluids. They contain mystical substances with names that require high level chemistry courses to understand—2-hydroxybenzenecarboxylic acid, for example, is salicylic acid—and have structures represented by bizarre pictograms and letters.
We understand that health ties to diet. The dietary requirements to manage some diseases, like diabetes and lactose intolerance, are common knowledge to us. We treat the problem with a drug—insulin or LACTAID—and maintain wellness by eating a restricted diet. Other diseases that we treat with heavy-duty drugs also depend on diet, including AIDS and cancer. Charities like Community Servings in Boston, God’s Love We Deliver in New York, and Food Outreach in Saint Louis provide meals to those living with chronic or debilitating illnesses. Patients benefit from these organizations, founded early in the AIDS epidemic to treat malnutrition in those wasting away from the disease, because drug therapies used to treat HIV/AIDS sometimes need to be taken with food. Additionally, the drugs do not alleviate the malnutrition that can accompany the disease, and patients may be too ill or disadvantaged to prepare food for themselves. Food Outreach provides meals to cancer patients because good nutrition increases the effectiveness of some cancer treatments and the dose of medication some patients can tolerate.
The hunt for new and better drugs sends both the fringes and the academic heart of the medical field chasing obscure but potentially helpful substances found in nature. We isolated penicillin from bread mold; other antibiotics come from sources as disgusting. The academic establishment subjects all of its potential drugs to rigorous scientific trials, though the fringe does not. “Complementary medicine”—anything and everything not recognized as valid by modern Western academic medicine—and its proponents believe that even “untested” medications help those who need them because “[treatment]’s about making people more comfortable,” not “purely about data” which “is rarely clean.”[ix] An example of an alternative treatment for which data has yet to be “clean” is arnica, an extract from the flower of Arnica montana. Arnica falls under the umbrella of homeopathic medicine. Natural food and supplement stores sell it in little vials of tiny pellets, which you dissolve underneath your tongue to reduce swelling. WebMD’s Vitamin and Supplement database lists it as “possibly ineffective” for “reducing pain, swelling, and complications from wisdom teeth removal,” but oral surgeons, including my own, readily recommend it to for exactly those purposes.
Despite testimony from those that swear by arnica, clinical trials fail to prove it has any significant, independent effect on pain and bruising. The American Cancer Society’s webpage on arnica notes that a 1998 review of eight arnica-placebo studies found that overall the studies failed to demonstrate arnica’s efficacy versus a placebo, and a later placebo-controlled study by the same researcher showed no significant difference between the pain and swelling of those taking arnica and those taking the placebo for carpal-tunnel surgery. The ACS lists four other studies for carpal tunnel surgery, knee surgery, laser surgery, and tonsil removal in which arnica failed to demonstrate significant reduction in bruising. Advocates of homeopathy like Roger Savage argue that a 2003 carpal tunnel study and those like it fail to follow the basic tenants of homeopathy—“the lower the dose, the more powerful the effect”—so they don’t properly test arnica[x]. Others argue more broadly that a placebo effect is still an effect. “Truth and lies aren’t [as] fundamentally different as we might think that they are,” says anthropologist Daniel Moerman on NPR’s Radiolab show entitled “Placebo,” which originally aired on May 18, 2007.[xi] If oral surgeons prescribe arnica, they must, on some level, believe in it. If patients take it, they buy in as well, which can arguably have an active effect on their health.
Dr. Mehmet Oz is a physician invested deeply in the power of belief. A talk show host and cardiologist known for endorsing “miracle cures” to treat obesity and cancer, Dr. Oz takes constant criticism from colleagues who profess to be “guided by evidence above all.”[xii] He drew particular ire for promoting the supplement raspberry ketone for weight loss. “Raspberry ketone” sounds like a tremendously intimidating molecule especially if one uses its official IUPAC name, 4-(4-hydroxyphenyl)butan-2-one, but it is actually a simple aromatic compound (Figure 4). You’ll recognize the benzene ring and hydroxyl group from salicylic acid above. Some researchers feel that the raspberry ketone may promote weight loss in part by affecting lipolysis, or fat-breakdown, in fat tissue through regulation of the norepinephrine signaling pathway. Raspberries as well as cranberries and blackberries contain raspberry ketones in low concentrations. But the concentrations necessary to affect rat lipolysis exceed those found naturally—“to get the same benefit from the whole fruit, you’d have to consume 90 pounds of raspberries” says Dr. Oz’s website—hence the supplements, which contain a vastly higher dose of the compound, manufactured synthetically. Dr. Oz and the supplement wholesalers endorsed the product for weight-loss based on a limited number of studies. To his critics, Dr. Oz responds that the potential to change lives by enabling patients to explore yet unproven drugs outweighs the fact that the data does not and may never exist to prove that the alternative treatment is truly “medicine.”
Other doctors take it further. In September 2010, Dr. Oz aired a show in which Dr. William W. Li claimed that certain foods, including green tea, strawberries, soybeans, and cinnamon, had “anti-angiogenesis” properties. Angiogenesis is the formation of blood vessels, which tumors promote in order to fuel their growth. The American Cancer Society has supported research into anti-angiogenesis treatments, and some, including the drug Avastin, have been approved by the FDA. Dr. Li’s treatment focuses on preventing undesirable angiogenesis through the diet. He claims that angiogenesis will “conquer cancer and more than 70 of life’s most threatening conditions.” Phrases like “revolution” and “expert voice and champion” litter the webpage of his Angiogenesis Foundation. The American Cancer Society mentions his foundation in their angiogenesis treatment page as another source of information, but they also state that being included on that list does not imply ACS endorsement. Most of Dr. Li’s dietary advice is on a separate website where members upload recipes for anti-angiogenesis meals. (That “Eat to Defeat Cancer” site does not list figs as a treatment option, sadly, despite the Regimen’s assurance that they rid us of tumors.)
Another doctor, Dr. Joel Fuhrman, advocates using his weight-loss advice to alleviate the symptoms of diseases such as arthritis, high blood pressure, diabetes, headaches and migraines, heart disease, osteoporosis, and stroke. He even has a handy-dandy formula: H=N/C, wherein the health of a particular food equals number of its micronutrients divided by its Calories. Micronutrients include vitamins, minerals, and phytochemicals. Vitamins are essential organic molecules the body cannot synthesize, and minerals are essential inorganic compounds. Phytochemicals consist of any compound produced by a plant that may affect human health. Niacin, for example, is a vitamin; iron is a mineral; antioxidants found in blueberries are phytochemicals. Consuming food high in micronutrients per calorie can, in Dr. Fuhrman’s view, reduce or even replace drug therapies for autoimmune conditions. His website contains testimonies from patients with type 2 diabetes, rheumatoid arthritis, and asthma whose symptoms eased on his diet.
All of these different treatments bring us to this question: what, really, is medication? Chemical compounds manufactured in pills and drips and creams, stamped with FDA approval? Food in combination with traditional pills? Homeopathic compounds that traditional medicine ignores, discards, or warns against? Foods high in chemicals known to have certain properties? Just food, any food, with high phytochemical content?
And if all of the above are medication, what does that say about modern medical treatment?
In the time of the Regimen Sanitatis Salernitanum, the limitations of medieval medicine altered the way physicians and patients considered prognosis and treatment. Nancy Siraisi writes, “A more vague and diffuse concept of recovery was the concomitant of the complexional interpretation of health and disease.”[xiii] To be healthy or to be cured is not simple when the health depends on a delicate, fluid mingling of humors which respond to everything you eat, drink, think, or do and everywhere you are. The Galenic humoral system defines health as a state of perfect balance and disease as imbalance, but it also included the concept of the “mean state,” a “neutral state between health and sickness”[xiv] as the body slipped toward illness or recovered health.
In the late Renaissance and early modern period, as scientific knowledge expanded, the concept of a cure—a panacea—entered our collective consciousness. This shift in attitude also changed our perception of medication. The split between food and medication grew wider when medication ceased to look like food and began to look more like pills, a shift which began with Paracelsus, a sixteenth century theorist who abandoned Galenic principles and championed “chemical” medicine that emphasized the effects of mercury, sulfur, and salt. To Paracelsus, an external agent caused disease, rather than an internal imbalance.[xv] Paracelsus attracted followers who were often involved in alchemy, and their influence on medicine created a greater emphasis on finding a cure-all—something along the lines of the Philosopher’s Tincture, reputed to have strong medicinal properties as well as the ability to transform any metal into gold—which was reflected in some advertisements in the seventeenth century.[xvi]
As our understanding of the chemical processes and compounds involved in drugs deepens, it begins to seem like there should be a dividing line. Food consists of that which nourishes the healthy body; drugs consist of that which affects a change in the sick body, calling to mind the Avicenna mentioned earlier: “Food [is] assimilated by the body, whereas medicine assimilate[s] the body to itself.”[xvii]
The difference is semantic at best and fuzzy at worst. Though Dr. Oz’s raspberry ketones and Dr. Li’s cinnamon will likely never be proven effective at burning fat or fighting off cancer, they still affect the body in some way. Is their effectiveness derived only from a placebo effect? Maybe. And maybe it doesn’t matter.
When Thomas Edison said that all future treatment would rest “in the care of the human frame, in diet, and in the cause and prevention of disease,” he stated nothing revolutionary. He was right when he called out these touchstones of medicine, but he was wrong when he claimed that we would be free of medication because diet itself can serve as medication. Truth be told, we all could take a lesson from the Regimen Sanitatis Salernitanum.
[i] All translations of the Regimen Sanitatis Salernitanum are from: Ordronaux, John. Code of Health of the School of Salernum. Philadelphia: Lippincott, 1870. Web. A second translation was consulted for clarification and may be found in: “Regimen sanitatis Salerni. The school of Salernes most learned and iuditious directorie, or methodicall instructions, for the guide and gouerning the health of man.” Medieval Medicine: a Reader. Trans. Philemon Holland. Ed. Faith Wallis. Toronto: University of Toronto Press, 2010. Print.
[ii] Joanittius. “Isagogue.” A Source Book in Medieval Science. Trans. H.P. Cholmeley and Michael McVaugh. Ed. Edward Grant. Cambridge: Harvard University Press, 1974.
[iii] Bos, Gerrit and Ivan Garofalo. “A Pseudo-Galenic Treatise on Regimen: The Hebrew and Latin Translations from Ḥunayn Ibn Isḥāq’s Arabic Version.”<Aleph 7. (2007): 43-95. Web.
[iv] A cough or cold
[v] Siraisi, Nancy. Medieval and Early Renaissance Medicine: an Introduction to Knowledge and Practice. Chicago: University of Chicago Press, 1990. Print.
[vi] Chipman, Leigh. “How Effective Were Cough Remedies Known to Medieval Egyptians?” Korot: the Israel Journal of the History of Medicine and Science 16 (2002): 135-157. Web.
[viii] Gum arabic on Mentos, in fact, disrupts the surface tension of Diet Coke, contributing to the famous exploding Diet-Coke-and-Mentos experiment.
[ix] Specter, Michael. “The Operator: Dr. Mehmet Oz.” The New Yorker. 4 Feb 2013: 40-49. Print.
[x] Stephens, Anatasia. “Does Arnica really work?” Daily Mail no date. Web.
[xi] This Radiolab episode is highly recommended for those interested in aspects of the placebo effect beyond the scope of this essay.
[xii] Specter, Michael. “The Operator: Dr. Mehmet Oz.” The New Yorker. 4 Feb 2013: 40-49. Print.
[xiii] Siraisi, Nancy. Medieval and Early Renaissance Medicine: an Introduction to Knowledge and Practice. Chicago: University of Chicago Press, 1990. Print.
[xv] Shackelford, Joel. “Early Reception of Paracelsian Theory: Severinus and Erastus.” The Sixteenth Century Journal 26.1 (1995): 123-135. Web.
[xvi] Wallis, Patrick. “Consumption, retailing, and medicine in early-modern London.” Economic History Review 61.1 (2008): 26-53. Web.
[xvii] Siraisi, Nancy. Medieval and Early Renaissance Medicine: an Introduction to Knowledge and Practice. Chicago: University of Chicago Press, 1990. Print.