The preference of foods by Islamic physicians out of compassion towards their patients.
The ancients difffered in their appraisal of the comparative values of foods and drugs in the preservationofhealth and the cure of disease. To our knowledge, this started with Hippocrates who gave prime importance to diet and, not only wrote Peri Diaiotae where he described the individual qualities of foods, but permeated with the same notions allhis writings, even those dealing with conditions, like fractures, seemingly unrelated to diet. Hippocrates recognized, however, the difficulty of making absolute statements and setting rigid rules owing to the varations existing in human temperaments, ages, countries, winds, and composition of food substances. What attracts attention is that in chapter LXVIII, 1 of this same work he declared that he wrote it to benefit those who lead strenuous live sin order to gain a living, and eat irregularly and at hazard.
It is indeed impossible to overestimate the importance given by classical Greek medicine to diet. Food was – apart from air – the only external thing to enter the body and to be assimilated by it. It was, therefore, befoere the role of micro-organisms was discovered, the only foreign agency tow hich disease could be attributed.
But, owing to ignorance of the chemical composition of foods, of the laws of assimilation and metabolism, and of the caloric and body needs,knwoledge of food was based, on the one hand on empirical experience and, on the other, on religious and analogical cosniderations inherited from the Pythagoreans who maintained – belief shared by Plato, that science is concerned with the purification of the soul and that the health of the soul depends on the health of the body.
Egyptian physicians (also) held that food, if subjected to insufficient or faulty digestion, could be transformed into morbid entities, and they influenced the shcool of Cnidos and, possibly, the school of Co who professed smilar theories.
Arab physicians, although they recognized that foods anddxrugs constitute the pillars of therapy, differed in the importance they accorded to each.
The importance of diet was, however, stressed by many, of whom Avicenna who expressed it in several verse of his Canticum: “To preserve health, medicien acts in two ways. To maintain the temperament give a similar diet. To alter the nature of the body, give its contrary (verses 791-798).
“Having dealth with the preservationof health, start to deal with disease according to a single principle. Meet anything with its contrary: heat with cold, cold with its contrary; moisture with dryness; dryness with its contrary (verse 989-992).”
Avicenna apears here to have adopted the Galenic principle of treatment by contraries, opposed by Averroes, who took the view that medicines merely triggter the natural healing forces.
But the relation between diet and drugs was more than being one of mutual support, for they were regarded as comparable in quality and nature according to some simple principles:
- The action of any substance introduced into the body is the result of a reciprocal action/interaction between its nature and that of the body.
- The nature of all beings, animal, vegetal, and mineral, is the result of the proprtionate faculties of the lements, fire, air, earth, and water that compose it.
- There are four faculties, two opposed to two: heat and cold; moisture and dryness.
- The mixture of the faculties constitutes the temperament.
- Temperaments are of two kinds: a first temperament amde of the addition of the faculties; a second temperament resulting from the combination of the constituent faculties creating a new, different temperament.
The animal body, like foods and drugs, was also said to be made of the four elements, that are transformed into the four humors (blood, phlegm, and the two biles) from which arise the organs, each credited with the temperament created by the combination of the humors that compose it.
This elegant construction, that put the body, foods, and drugs in the same frame, permitted the classical physicians to imagine their interactions, that Avicenna summarized by saying that everything eaten or drunk acts in the body either by its faculty, or by its elements, or by the totality of its substance. What acts by its faculty cools or heats by its cold or heat, without being assimilated.
What acts by its elements is transformed into the form of the organ but keeps its faculty. Thus blood engendered by lettuce is cold, while blood engendered by garlic is hot. What acts by the totality of its substance acts by the resultant of the mixture (we would say today by the combination) of its simples if anything different results from it8.
There was thus no essential difference between the actions of the three. Any difference was of degree:
In the first degree, the action was imperceptible.
In the second, action was perceptible but harmless.
In the third, action was harmful, but short of lethal.
In the fourth it was lethal. This was the nature of poisons9.
Owing to this haziness of frontiers, scientists, like Avicenna in book 11 of the Canon7. that deals with simples, discussed consecutively minerals, food substances, drugs and poisons, e.g. mandrake, storak, and lapis-lazuli; or lentils, honey, Calotropis gigantea, and scorpions; or iron pigeons, poplars, the terebinth tree, chameleons, vipers, and donkeys.
This is also clear in the gradation Avicenna establishes between what were called foods, medicinal foods, nutritional medicines, and poisons. if a substance is transformed and assimilated by the body without altering it, it is a food. If it is not assimilated by the body, it is a moderate medicine. If it is transformed by the body and transforms it: if it is assimilated by it, it is a nutritional medicine; if it is not assimilated it is a medicine sensus strictu. But if it afters the body without its being transformed, it is a poison9.
In other words, what is completely mastered by the body is a food; what masters the body is a medicine; what masters the body at first and is later mastered is a medicinal food.
In the absence of any correct knowledge of chemistry and pharmacology, the faculties were deduced either from the rapidity of their alteration, or by their effects on the senses, or by inference from known actions. Thus substances that are easily heated or burnt were regarded as hot, and substances that easily solidify, as cold.
Taste was considered the most reliable of the senses. Nine tastes were recognized: insipid, astringent, acrid, salty, bitter, pungent, acid, sweet, and fatty. To each, specific actions were attributed.
Odours were less reliable because, although the vapours that are perceived by smell affect taste as well, they emanate from only part of the examined body whereas the organ of taste obtains contact with the whole.
Other sensations, like colour, touch, thickness, lightness, viscosity, fluidity, friability, solidity, dryness, fatness, and heaviness, were also taken into account.
In addition, unknown qualities were inferred from known ones, but Avicenna and his peers insisted that they should be subjected to trial as the surest test for, otherwise, they were at best, guesse trials should, however, comply with strict conditions: the drugs should be devoid of accidental qualities; they should be equal in force to the illness; they should be tried on single illnesses and on opposed illnesses; their actions should be reproducible; and the timing of the response should be noted. In that way, Avicenna10 listed no less than 49 different qualities.
It is worthy of note that these actions were not thought to be limited to the sense organs; t represented the actual action of these substances on the internal organs.
We have somewhat insisted on the lack of any absolute distinction between foods and drugs. This was the reason why some physicians preferred treating by diet and avoided drugs whenever they could. This was tersely expressed in a saying attributed by Ibn Abi Usaybica11 to Rhazes: 1f the physician can heal with foods without using any drugs, he accedes to felicity”.
Ibn al-Nafis professed the same principles. 1n spite of his wide knowledge of medicine and his perfection in all its branches, said one historian12, he was not an able therapist. When he prescribed he never changed anybody’s customary regimen; he did not prescribe any drugs if he could prescribe a diet, nor any compound medicine whenever he could do with a simple one. He would prescribe wheat gruel (qamieh) for ulcers, meat stew for flatulence and carob for diarrhoea… until the druggist at whose shop he used to sit told him: If you wish to prescribe such remedies, go and sit at the butcher’s shop. But if you sit with me prescribe nothing but sugar, syrups, and drugs”.
Although one suspects this to be a mere quip, it does illustrate, albeit in a caricatural way, the inclinations of this great physician whose therapies we cannot but condone, for gruel is an admirable dressing and carob is an effective astringent.
Another tale that confirms his intellectual honesty is his answer to someone who asked him with what he could treat a nodule. “By Allah, he answered, 1 do not know with what a nodule can be treated12.
If the avoidance of side-effects were the only motive of Islamic Physicians, it would be ample reason to praise them. But the prevention of “iatrogenic” illnesses was not the only reason for the avoidance of drugs.. Physicians in the Islamic world received huge rewards from rulers and sovereigns, and they were accustomed to prescribe to their wealthy clients expensive drugs, imported at high cost from remote countries, China, India, etc.. Some, like Avicenna, prided in being too expensive to buy13.
No doubt, some of them were more interested in amassing fortunes by any means. Bagdady14 found Yassin el-Sinia’i to be an impostor and a quack, and Mussa lbn-cUmran to be extremely meritorious but inclined to serve rulers.
Many, however, were known for their generosity and charity, which they expressed in many sayings, like Rhazes’s: A physician must be moderate, not entirely attracted by this world nor entirely turning away from the other, following a middle course between desire and awe.
Rhazes was said to be generous and obliging, benevolent to people, charitable to the poor and ill, appointing to them lavish rations and sparing no effort to treat and heal them by all means available to him16.
In the same way Aly ibn-Radwan wrote in his autobiographical notes: 1 always try to be humble in my dealings, keen to help grief, to discover the distress of the afflicted, and to assist the needy, my aim being to enjoy the pleasure of good deeds”. He added: “There must come out of this some gain to be spent… and what remains 1 spend on parents, comrades, and neighbours.
Another of his notes runs as follows. “A physician, according to Hippocrates, is one with seven qualities, of which the desire to cure patients stronger than the desire of gain, and the wish to treat the poor stronger than the wish to treat the rich18.
This is the reason why many Islamic physicians expressed their concern over needy patients by writing on therapy by diet and cheap drugs.
In a recent article, Dr.S. Catahier19 mentioned some of these treatises, of which a work by Rhazes “Man la iahdaruhu el tabib” (Who is not assisted by a physician), also called “Tibb al Fuqara” (Medicine of the poor), and another by Ibn al-Jazzar al-Qayruwanc “Tibb al fuqara ‘wal-masakin ” (The medicine of the poor and destitute) which was criticlly edited by Catahier who judged that its contents were inspired from Rhazes.
The purpose of Ibn al-Jazzar’s work is clearly stated by him in his assertion that when he found that many poor and destitute failed to gain any benefit from his books owing to their poverty, he thought of relying on foods and drinks in treating his patients. This intention is stressed by the fact that he was also the author of a book on simple drugs and another on compound drugs20.
In fact, Ibn al-Jazzar seems to have been a man of high principles. “Nobody could reproach him for any slip in Qayruan, and he never gave himself to pleasure, wrote Ibn Abu Usaybia21. When he4 attended weddings or funerals, he never ate there anything, and he wrote a treatise to warn against drawing blood when there was no need for it”.
A similar work was another “Tibb al-Fuqari’ (The Medicine of the poor) also mentioned by Catahier (loc. cit.) written by Jamal al-Din Yussuf al-Hambali22, who noticed that the bodies of the rich are teeming with ailments because of their pleasure-filled lives and their rich fare, whereas illnesses are less common among the poor because they eat little and do not heap foods on foods, and remarked that if a poor man is taken ill, he needs cheap easily available drug.
There thus seems to have been formed what we might call a ‘corpus” of works aiming at curing poor people with cheap drugs or with foods rather than drugs, to make treatment easily available to them.
1. HIPPOCRATE: “Du Regime”. Texte etabli et traduit par Robert Joly, Paris: Les belies Lettres, 196/.
2. PLATO: “Timaeus”, in vol. 7 of Plato, translated by R.G. Bury, London: Heinemann, 86, d-e.
3. GHALIOUNGUI, P.: ” Lanotion de maladie dans les textes egyptiens et ses rapports avec la theorie humorale Bull. Inst Grangais d’Archeol Orientale”, XIII, 4, 383 1969.
4. STEUER, R.O. and J.B. DE C.M. SAUNDERS, “Ancient Egypt and Cnidian Medicine”, Univ. of California Press, 1959.
5. AVICENNE: “Pobme de la. medecine etabli et presente par H. Jahier et A. Noureddine.”. Paris: Les Belies Lettres, 1956.
6. ANAWATI, G. and P. GHALIOUNGUL: “TheDevice of Healing in: The Medical Treatises of Averroes at E1 Escorial,” Cairo: AI-Ahram, 1983.
7. AVICENNA: “The Canon”, reprint of the Bulaq edition. Beyrouth: Dar Saar, vol. 1. p. 223
8. Ibid., vol. 1, p.95
9. Ibid, vol. 1, p.96
10. Ibid., pp 232-235
11. IBN ABI-USAYBIA. “Uyun al-anba fi tabaqat al-atiba”, Beyrouth: AI Hayat Press, 1965, P. 421.
12. SH1HAB AL-DINE AHMED IBN FADL EL EMARI. “Masalek al Absar fi akhbar muluk al amsar ” MS. 99 M. History, part 7, p. 225, Cairo: National Library.
13. IBN ABl-‘USAYBIA (117), p.439
14. Ibid p.687
15. Ibid p.521
16. Ibid p.416
17. Ibid p.561-562
18. Ibid pp 564-565
19. CATAHIER, S: “Tibb AI-Fuqara’Wa Lmasakin.” The Journ. of the Eg. Med. Assoc., Special number of the Egyptian Soc. of the Hist. of Med., Vol. 1, in the Press, 1983
20. IBN ABI-USAYBIOA (10) p.482
21. Ibid. p.481
22. GAMAL AL-DINE YLISSUIF IBN cABD AL-HADY AL-MAQDISI AL-HAMBALI. “MS. 3155 Medicine 3. Introduction. ” Damascus: Zahiriyeh Library.
Prof. Paul Ghalioungui, EGYPT