Byzantine suggestions and treatment on gout by Ioannis Komnenos Choumnos (1290-1338)

Abstract

This paper explores the insights of Ioannis Komnenos Choumnos (1290-1338), a Byzantine scholar, on gout management. Choumnos, combining his expertise in philosophy and medicine, emphasizes a holistic approach to preventing and treating gout. He advises avoiding foods like salty, smoked, and acidic items, dairy products, and excessive alcohol, recommending instead a diet of easily digestible foods and moderate exercise, such as walking and horseback riding. Choumnos also stresses the importance of regular bathing and overall hygiene. His philosophy of moderation underpins his advice, warning against overindulgence in food and drink, which he views as detrimental to health. While his recommendations resonate with modern practices, the historical reliance on wine due to unsafe water highlights unique challenges during the medieval times. Choumnos’s work offers timeless guidance on the impact of lifestyle choices on health and disease prevention.

Keywords: gout, statesman, philosophy, ethics, diet, podagra

Introduction

Ioannis Komnenos Choumnos (Greek: Ιωάννης Κομνηνός Χούμνος) was a Byzantine general, scholar, and statesman who lived from 1290 to 1338. As the eldest son of Nikephoros Choumnos (ca 1250/1255-1327), himself a noted scholar and statesman, John was significantly influenced by his father’s intellectual and political legacy. He quickly rose in the imperial hierarchy and was named “Parakoimomenos tou Koitonos” (a high-ranking court title). Ioannis Choumnos led the Byzantine forces against the Ottomans in Bithynia from 1300 to 1306, under the command of Michael IX Palaiologos (1277-1320). As a result, he gained a reputation for his military abilities and in 1307, was promoted to «Parakoimomenos tes Sphendones». Komnenos was a cultured man, having studied rhetoric, philosophy and medicine and his letters were preserved in historical manuscripts [1-2].

In ancient Greek medicine gout was called ‘’ποδάγρα’’ (podagra) [Figure 1] from the words “pous” meaning a foot and “agra’’: a seizure, to refer to the lesions involving the first metatarsophalangeal joint of the big toe followed by the other joints of the feet and later on of the hands [3]. Dominican monk Randolphus of Bocking (1197-1258) reinstated the name of gout as podagra eons later [4]. This historical vignette surveys the saved work of Ioannis Choumnos related to gout (Greek: ποδάγρα, podagra), unveiling some neglected philosophical and medical aspects on the matter.

Addressing gout management. In his eighth letter titled ‘’Prophylactic diet for gout’’ – (“Δίαιτα προφυλακτική εἰς ποδάγραν”) he focuses on the prevention of gout, analyzing three main points: proper diet, exercise and maintaining hygiene [5]. His work on proper diet for gout is significant as a medical treatise. The excerpt is as follows:

Figure 1. Venus, Podagra and Bacchus, engraving by Johann Andreas Schlegel (ca 1657-1681), in Scriptum apologetico-politicum de podagra, Joh. Brühl, Weisenfels, 1687, representing gout as a man with an inflicted right foot and hand

“Βρώματα ταριχευτά πάντα, κάν οποῖά ποτ’ άν εἴη και όπως ἐσκευασμένα, καθάπαξ φύλασσου, ὡσαύτως δη και δριμέα. Γάλα παν, και ὅσα πηγνυμένου τοῦ γάλακτος ειδιοποιεῖται, φυγῆ φεῦγε. Μὴ δίωκε ἰχθῦς ἐκ τηγάνου, ἤ άλλ’ άττα.

Τῶν ωῶν πάντων ἄπεχου. Ἄρτου μὴ ἐμφοροῦ. Εδηδοκώς, σκόπει μὴ ὑπερκορής γίγνη. Μὴ κενωθέντος σοι τοῦ στομάχου ὡστ’ ἐπιεικῶς ζητεῖν τροφήν, μὴ ποτε προσενέγκῃς. Μὴ χαῖρε ταῖς τῶν ὀψων ποικιλίαις ἤ καρυκείας. Ζήλου δὲ μᾶλλον τοὺς ἁπλοῖς βρώμασιν ἑφθοῖς καὶ ὁπτοῖς τερεφομένους. Λάχανα πάντα και ὅσα γε μὴν ἕτερα μὴ δεχομένων σοι τῶν σπλάγχνων, διά τὸ μὴ ἐρρῶσθαι, μηδέ τῷ στόματι δέχου. Σησαμοῦντας, ὡς σηπεδόνας αἵματος, τοῖς γαστριζομένοις χαρίζου, ἕτι γε μὴν καὶ τοὺς ἄρτους, ὄσοι μὴ ἐξ ἀλεύρου, ἀλλ’ ἐρεβίνθων, τήν ζύμην τυγχάνουσι κεκτημένοι. Οἴνῳ ἀκράτῳ μὴ χρῶ, μήτε μὴν νικῶντι τὸ ὕδωρ, ἀλλ’ ὑπ’ αὐτοῦ νικωμένῳ. Μὴ παραρρύῇς υπό δίψους, πέψεως γιγνομένης, εἰς πολυποσίαν, ὅπερ δῇτ’ ἐπηπείλησέ σοι, ἤν’ ὑφορώμενος νόσον, ταῦτα γράφεις. Ὕδατά σε λίαν ψυχρά μὴ ἐπισπάσητα, ὥρα θέρους, πολλοῦ γε δέω φάναι, χειμῶνος μὴδ’ ἐντρέπου βρωμάτων οὕτως ἐχόντων, μηδέ τούνατίον ὑπερζεόντων. Τὸ ήδύ τῶν όπωρῶν εἰ μή πασῶν τελέως διαδρᾱναί γε δυνηθείης, δίδου τινῶν ἑγκρατῶς σεαυτῶ τάς πλείστας δὲ τούτων ώς μή οὒσας ἀποστρέφου, ὅσαι γε μὴν ὑγρότεραι καὶ ψυχρότεραι καθεστᾱται. Πέμμασι τὸν νοῦν μὴ προσέχειν. Μήτε βαλάνους φοινίκων ἤ ἀκρόδρυ’ ἄττα περιποιῦ. Μήδ’ ἐξαπατάτω, μηδὲ παρασυρέτω σε ταῦται τῇ γαστρί χαρίζεσθαι. Μηδέ ζήτει φαγών τραγήματα, κλεπτομένος ὑφ’ ἡδονῇς τούτων, ἄλλην αὖθις τροφὴν οὐκ ἀναγκαίαν οὐδέ κατάλληλόν σοι. Τῶν σιτίων ἄπερ ἐδηδόκεις μὴ πεφθέντων, μη ποτ’ ἀφροδίσιων ήττηθῆς: ἀλλὰ καὶ οὖτω σαυτὸν τούτοις μὴ κατατείνης. Τα τήμερον βρωθέντα σοι και πεφθέντα αὔριον ἐξ ἐωθινοῦ ἐκκριθῇναι πρᾱξον, καὶ τοῦτ’ ἀεὶ ποίει.

Πρόσκεισο γυμνασίοις· γυμνάζου δ’ οὖχ ἥκιστα περιπάτοις ἤ ἱππασία. Θεράπευε σεαυτὸν λουτροῖς δίς ἡ ἄπαξ τοῦ μηνός. Τέμνου φλέβα ὀπόταν καὶ ὁποίαν ἂν οἱ Ἀσκληπιάδαι προστάξαιεν. Ἅν οὕτως γε σαυτὸν διαιτῲης, δυνήση, προγονικῆς ἴσως ἐπισειομένης σοι νόσου, ὑπέρτερος γενέσθαι, αὐτοῦ συναιρομένου τοῦ κρείττονος. Εἰ δὲ σε, ὡς ἂντ’ ἄλλον παπρῲου κλήρον ὀν ἕδει σοι περιγενθέσθαι ὡς πρωτοτόκω, ταύτην γε μὴν εἴμαρτα δῇτ’ ἐπανιμηκέναι, ἁλλ’ οὖν ῥᾷον οἲσεις  μετα τοιαύτης δίαιτης.

Ἀν δὲ κατὰ μῇνιν Θεοῦ ὑπέρσχη, οὕτε σύ σαυτὸν, οὔτ’ ἄλλος αἰτιάσεταί σε, ὡς βρωμάτων ἡττηθέντα μοχθηροτέρων τοῦτο παθόντα, καὶ ὑπ’ ὀρέξεως ἐνσχεθέντα τοσαύταις ἀφύκτοις παγῖσι. Καὶ γὰρ οἱ διὰ ταῦτα τούτῳ τῳ πάθει ἐνισχημένοι ἔοίκασί μοι καὶ τῆς μελλούσης κολάσεως ἀλογεῖν.

Ὁ γὰρ διά βρώμαθ ἑαυτὸν εἰς τοιαύτας περιωδυνίας καὶ ἀλγηδόνας ἐνσείων και, τὸ τῆς παροιμίας, ὂν καταβάλλεται καρπὸν θερίζων, καὶ οὐκ ἀφιστάμενους τούτων, προδήλου ὄντος τοῦ αἰτίου, καὶ παρά πόδας καὶ ἐξ ὑπογυίου τίσεως, σχολῇ γ’ ἂν ὂγε τοιοῦτος τὰς ἀπειρημένας ἡδονὰς ἀποσκορακίσοι διὰ τὴν μὴ φαινομένην μέλλουσαν τίσιν.’’[5].

1. do not eat everytome you are hungry
2. avoid spices
3. ρεβυθοψωμο
4. mediocrity fruits
5. blood letting in which vein needed

In this letter he recommends avoiding salt preserved foods, milk and spices. He also advocated to refrain from the consumption of fried foods, especially fish and eggs. Instead of normal bread he encourages the consumption of chickpea bread. He emphasizes that the consumption of wine should be done in moderation and with the addition of water, as was customary at ancient and to a lesser extent Byzantine times [6]. Also special preference is shown for boiled vegetables and easily digestible products. Furthermore, he refers to the practice of bloodletting to whichever vein the doctors (Asclepiads) seem fit, as this was an ancient practice for the treatment of several diseases. [7]

Choumnos also places a strong emphasis on lifestyle, advocating for regular physical activity, such as walking and horseback riding, to maintain physical health as was popular at the time [8]. Additionally, his advice on hygiene, specifically bathing once or twice a month, notes the importance of hygiene in a general healthy perspective. Most of his suggestions could be applied in contemporary times for management and treatment of podagra, but compared to today’s standards consuming wine is strongly discouraged. It is understandable that at that time, wine had a more widespread use and in some cases substituted a significant part of water consumption. This was due to the difficulty in gathering safe water and the many diseases that followed from drinking contaminated water. In contrast, wine consumption was more popular than it is today, as it was commonly used in church masses, which were much more influential and widely attended at the time. Additionally, wine presented fewer risks of infection compared to water [9].

In his sixth letter named “Τῼ ΦΙΛΟΣΟΦῼ.” (to the philosopher), he describes a drinking scene. Specifically, he mentions the following:

“ὑπισχνεῖσθαι πιεῖν, καὶ παραπαίουσι, καὶ όρθοεπεῖν οὐ δεδύνηνται, καὶ ἐπεγγελώντων ἄλλων καὶ αὐτοὶ ἐπεγγελῶσιν. αὑτοῖς, καὶ, πειρώμενοι ἀνίστασθαι, καταπίπτουσι, καὶ βαδίζειν ἐπιχειροῦντες, διολισθαίνουσι, καὶ κλονοῦνται τρομερῶν αὐτῶν τῶν γονάτων ὑπ’ ἀκράτου καθισταμένων, και βοῶσιν ἄσημα καὶ ἀλλόκοτα, καὶ μεμηνόσιν ἐοίκασιν ἀτεχνῶς. γὰρ πόσις οὐ μέχρι κόρου, ἀλλ᾽ ἄχρις ἐμέτου καὶ καταπτώσεως ἀναισθήτου. Καὶ τούτων πάντων τῶν κακῶν, οἷς ὑπ᾽ οἴνου ἐνίσχηνται, μία λύσις, ὕπνος, καὶ οὗτος θανάτου μικρὸν διενηνοχώς. ”[10]

He describes the consequences of excessive drinking, painting a picture of moral and physical degeneration. He illustrates a scene where individuals, having pledged to drink, find themselves unable to maintain their composure. They stagger, unable to stand upright and laugh along with others. Their attempts to rise end in failure as they collapse, and their efforts to walk end up in failure. Choumnos notes that the situation resembles madness in its most raw form. He describes this behavior as a result of drinking not to the point of satisfaction, but to the extreme of vomiting and senseless collapse. He depicts this state in a degenerative manner and concludes that the only remedy for these ills brought on by wine is sleep, a sleep that closely resembles death in its profound stillness. Choumnos’s portrayal of this scene serves as a warning against the dangers of abandoning moderation.

Conclusion

Choumnos died sometime between 1332 and 1338, while serving as governor of Chios [9]. Although Choumnos’ opinions on gout present some scientific interest, researchers reviewing the subject are neglecting to mention him [11], while Byzantine literature dedicated small fragments, categorizing him as an ecclesiastical figure [12]. This may be due to the fact that Choumnos prescribed a strict diet, eliminating salted and smoked foods, fried fish, eggs, milk and dairy products, following through and repeating Demetrius Pepagomenus’ (1200-1300) recommendations for the prevention of gout [13].

Ioannis Komnenos Choumnos’s contributions to the understanding and management of gout, as well as his observations on the consequences of excessive drinking, are a significant addition to byzantine medicine. His beliefs, rooted in moderation and preventive care, emphasize the importance of a balanced diet, regular exercise, and hygiene—principles that remain relevant in contemporary medical practice. Choumnos’s depiction of the degeneration caused by excessive drinking serves as a philosophical approach in moderation along with his other works and was dictated by Christian Eastern Roman ethics. His approach on gout also aligned with earlier scholars like Demetrius Pepagomenus and in part he repeated his work on gout. Nevertheless, his writings provide valuable insights into Byzantine medical practices and the enduring continuation of medical knowledge.

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