From century to century: Diet at any cost? A glance at a few mentions of diet in the history of medical practices

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From century to century: diet at any cost? A glance at a few mentions of diet in the history of medical practices

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Diet is one of those recurrent themes that feeds theoretical literature like circumstantial press. The question of diet appears in medical and paramedical works, in books of history, of philosophy, but also in magazines (often those referred to as “feminine”). What is there to do with a notion that a philosopher like Paul Ricœur could qualify as a “catch-all concept” (as he does for the word crisis)? Articulating theory and practice, professional competence (the knowledge of a doctor, of a nutritionist) and personal experience (what each individual decides to do, the choices carried out), history and current events or even tradition and modernity, the diet offers an array of possible directions and invites ink to be spilled: yesterday’s quills as much as today’s printers.

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Our stance entails, in the form of a glance, revisiting some dimensions that are proper to this notion through several periods of the history of medicine, of illness and of health.

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Take care of yourself!

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“What you eat, what you drink, in addition to what is necessary for your health, also builds up additional credit toward the advancement of illness and of death.” This philosophy of life, that brings together diet and balance into a shared fate, is formulated by Luigi Cornaro in his 1558 book, Discourses on the Sober Life: How to Live 100 Years. This book will be a best seller, met with several re-editions up until the 18th century, recommended by generations of doctors even though the advice of this honest man who approached a hundred years of age – which was very rare at the time –] in aiming to turn each person who followed his recommendations into a doctor himself should have resulted in the unemployment of many members of this profession. Indeed, faultless care and shrewd judgment would exempt each individual from any recourse to a doctor. Both before and after Cornaro, an assortment of injunctions ranging from benevolence to threat by way of every shade of care never ceased to span the discourses of treatment, evolving in a moral and medical intertwining. Yet, what remains in common between Cornaro’s century and our own? The history of men is also that of their metamorphoses, and that is the case in in every domain of social life, of science, of politics; but, traversing all of these changes – those that are characteristic of the evolution of medicine from a humoral conception contemporary with Cornaro to an experimental approach three centuries later with Claude Bernard – a few constants scatter their occurrences within discourses of health and of illness, following the example of diet. Philosophy of existence, medical thought and practice, treatment practices, an arsenal of preventative and therapeutic measures, or even in the concern for preserving oneself in all circumstances: the diet imposes itself as a compass of existence from antiquity up until today. Dependent on balance, diet would not know, by itself, how to define any specificity of man. After all – and there are many researchers in ethology who have said it – every animal naturally determines the food that best suits it. In the same way that fleeing from pain and searching for pleasure are instinctively shared by a significant community of living species, diet, as aptitude for choosing a way of life and the most adequate food to one’s own nature cannot, at first glance, constitute a distinctive human attribute. However, it is a question of a notion at the intersection of several fields of knowledge and domains of activities: technique, science, physical effort, medicine, philosophy; it is a dynamic and fundamental component of selfknowledge. It is then permissible to state that this notion of diet forms unavoidable stimulus for all discourse on treatment, whether it sways toward the side of “care” or rather the side of “cure” to use current terminology that has recently come into fashion.

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Diet is an object of history of medicine – as, for example, Vigarello showed – what generations of doctors have shown in the context of a so-called pre-scientific medicine, a recurrent object in news media, as is shown by mainstream press in the summer… The goal of this article is therefore to evaluate how diet says something about the human: how its evolutions, its metamorphoses, summarize an evolution of man taken in his individuality, in his intimacy, toward the social man, how diet goes from the order of individual health as part of a formal relationship between the doctor and his patient to a relationship of public health, an issue of political and social regeneration. The metamorphoses of diet speak to the metamorphoses of man. The discourses that express an injunction to diet translate a progressive series of modalities aiming to actualize a humanity in man; here, being human is knowing how to behave, it is knowing how to face up to situations, it is knowing how to adapt. These evocations also communicate a periodization, leading us from Hippocratic antiquity to the beginning of the 19th century. Is that to say that the rest does not deserve to be taken into account? That contemporary evocations of diet only fall in line with fashion and with media-friendly displays? Why not take these periodic returns to diet seriously? Is it a question of a return to the old order, of a resurgence of the past dating to before medicine was marked by rationality and scientific distance? One of the issues linked to discourses of diet resides today in a constant push and pull between a situation where the patient is an object of medico-political recommendations (don’t smoke, don’t drink, and so on) and a process of constituting this same patient as a subject apt to be evaluated without resource to some doctor or institution, which is the best for him, like a “Cornaro” brought up to today’s tastes.

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We will therefore see, first of all, how diet expresses man’s aptitude to think about himself, to draw an internal force from himself, corollary to the virtue that was dear to the Stoics. Diet falls in line with an archaic medicine that is the most immediately human medicine: man, in this context, calls upon therapy and philosophy in order to choose the existence that best suits him. Nevertheless – and this will be the second point, thinking about the French word for diet, régime– leading one’s life as part of a set of practices falling in line with a political approach: self-governing. But the government of one’s self refers to an exterior, superior government, and interior law always refers to an exterior law. When the individual dietary regime of life meets with the political and institutional regime, one must ask the question of the ambivalence of its ends, a questioning that will feed the third point.

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The question for diet expresses a desire for self-sufficiency, likely catalyzed by a contemporary issue of the growing complexity of links, especially those links that are supposed to connect the patient with the doctor and the medical institution as a whole.

1 - Natura medicatrix

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Diet, since Antiquity, has been a notion situated at the intersection of human action and the power exercised by natural phenomenon. Such a notion requires one to think about man and nature at the same time, man taken in his natural environment. This approach surely finds one of its origins in the Hippocratic corpus and follows a meaning that sees very few changes until the 18th century. It is a matter of medicine, of philosophy and of grammar. If this meaning is not centrally maintained in our article, it should nevertheless be recalled. We can take as an example that a dictionary as substantial as Diderot and d’Alembert’s Encyclopedia continues to be so substantial and that, in the middle of the 18th century, it established itself as a true witness of the evolution of many terms, between signifiers coming from tradition and semantics linked to modernity. Such is the case for régime – the French word for “diet” – a term for which two entries are offered. A first entry belongs to the “grammar” rubric and is the object of a substantial article that begins by reminding us that régime “comes from the Latin regimen, government: it is employed in Grammar in a figurative sense, of which we can see the foundation in the article TO GOVERN. It is here a question of determining proper meaning with regard to grammatical language” (Beauzée, vol. XIV, p. 5). Here, régime asks the question of what is appropriate in the economy of relations between verbs, nouns and complements. This idea of appropriateness can be found again in the second entry of this same dictionary: “It is the practice that one must follow in order to use with order and in a regulated fashion, things said to belong to non-natural schools; i.e., of all that is necessary to animal life, and of all that is inseparable from it, in health as much as in sickness. See NON-NATURAL, things. This practice therefore has as its object to make the usage of things appropriate, to make the usage of things serve in the conservation of health; to substitute this regulated usage with the abuse of these things that could cause or that has caused health trouble, the state of illness; consequently, to direct the influence of these things in the animal economy, such that they contribute essentially to preserving the health of the alterations that it can experience, or to re-establish it when it has been altered. See HEALTH and ILLNESS” (vol. XIV, p. 11).

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Two ideas deserve to be highlighted: starting from the 5th century before our era, diet has brought about two sets of reflections and questions on the nature of man and man within nature. The first idea states that man cannot be medically understood outside of a milieu, not in the sense that Claude Bernard will impart for this term when speaking about “interior milieu,” but in the first and more general sense of natural milieu. The second idea bears on the distinction between the natural and the non-natural, whose successive re-readings – either Comtian, Durkheimian or Canguilhemian – would be translated by a distinction between the normal and the pathological. In what way does diet say something significant about the ascendency of milieu over man? And in what way does it support transformation and preservation?

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If anthropology is a notion that is only explicitly theorized and conceptualized beginning in the 18th century, coming from the Germanic lexicon and used by doctors (Ernst Platner) and philosophers (Kant), ancient medicine offers an archaic anthropology that is decisive for drawing up a portrait of man in health and in sickness. The Hippocratic corpus, which constitutes one of the most sizable from all of Greek and Roman Antiquity and that will then be translated and constantly discussed by the Arabs up until the classical age at least, engages in an extensive investigation of the physical and moral characteristics that are proper to man. Only one work, attributed to Hippocrates himself, deserves our attention since it will remain, until the middle of the 19th century, a true bedside book for doctors: Airs, Waters, Places. The author offers a study of men as they are marked by the natural milieu in which they live, profoundly affecting them both physically and morally. There emerges a doctrine of man and of illness that bestows the idea of milieu with a conceptual existence: climate, region, morals, customs…To be, to exist is therefore first to be steeped in a set of environmental factors. Juan Huarte, in his 1645 The Examination of Men’s Wits, in which by discovering the variety of natures, is showed for what protection each one is apt, and how far he shall profit therein, and Montesquieu in his 1748 The Spirit of the Laws, in which one of the foundational theses establishes that every law is always relative to a decided milieu, draw on this Hippocratic and neo-Hippocratic legacy. The guidelines of health take, for doctor de Cos, an aphoristic form that will inspire many successors resembling the 17th century Dutch doctor, Hermann Boerhaave. Yet, this presentation allows for the formulation of recommendations that are as short as they are sober, even if, sometimes, their conciseness lends itself to ambiguity in their interpretation. To be quite capable of grasping the origin and the nature of an affection, “One will notice that innate constitution, country, habits, age, season, the nature of the illness, its state and its remission, whether it ends or does not” (Aphorism 4). Such recommendations are addressed, of course, in the first place, to the doctor, but they also speak to the shrewd man, as well as to the sick man himself. Some rules are thus common to men, even if they are perfected by doctors, such as the art of observation, of analysis, of discernment and the sense of precaution.

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The primary model – primary in the arithmetic sense as well as the ontological sense – is that of nature: natura medicatrix. This attentiveness to nature is not solely the prerogative of doctors because knowledge does not know the borders that are distributed in the form of strictly delimited disciplinary fields: medical schools are also philosophy schools. Attested by the following words, from Seneca in De vita beata:

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Meantime, I follow the guidance of Nature – a doctrine upon which all Stoics are agreed. Not to stray from Nature and to mold ourselves according to her law and pattern – this is true wisdom. The happy life, therefore, is a life that is in harmony with its own nature, and it can be attained in only one way. First of all, we must have a sound mind and one that is in constant possession of its sanity; second, it must be courageous and energetic, and, too, capable of the noblest fortitude, ready for every emergency, careful of the body and of all that concerns it, but without anxiety; lastly, it must be attentive to all the advantages that adorn life, but with over-much love for none – the user, but not the slave, of the gifts of Fortune.

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Far from being entirely passive, following nature demands that one know nature, that one understand it by means of logos. It is therefore a constant quest for nature, widely available, allowing each individual to know himself while apprehending with full knowledge the phenomena that are proper to the milieu in which he is evolving: knowledge of climate dictates the opportunity for each activity, observation of the air provides information about the risk of epidemics, the study of plants opens the door to an adapted pharmacopeia, nothing should be left to chance. This medico-philosophical demand, taking up Jacky Pigeaud’s expression (Illnesses of the Soul in the Ancient Times), to conform to the model of nature goes together with the concern that is at the origin of all care-taking practice, of all medicine and of all diets, to distinguish between the natural and the non-natural, between health and illness or even between normal and pathological. What defines the conditions of an acceptable human life must correspond to the distinctions offered by Galen (De oculis) that ostensibly predate him and that will pervade practices of care from a medical point of view until the 18th century: natural things, non-natural things and unnatural things. Natural things correspond to elements, temperaments, parts, humors, spirits, faculties, everything that takes part in forming the physical man; in non-natural things, one finds air, the content of food and drink, movement and rest, sleep and waking, what is retained in the body and what comes out of it, and the soul’s affections: these things concern all of the actions of man with an aim of conserving health; when these actions are the object of improper uses, producing an effect to the contrary of what is good, one names them unnatural: diseases, their causes and their symptoms. One would need a broader development in order to rigorously examine how these distinctions are found in medical discourses and practices, but they definitely pervade a set of medico-philosophical conceptions describing in what a “good life” should consist for every human being, in connection with the idea of balance that, as Gadamer mentions, constitutes a plumb line for medicine, by regulating the “variation of events” (The Enigma of Health). What deserves to be remembered is an oscillation of medical discourse with regard to the very status of disease: what happens, what must happen, but that should not occur. The idea of the “unnatural,” here does not refer to an artificial dimension of disease, nor even a supernatural one (we will not make use of the idea of the generally irrelevant idea of divine punishment in order to characterize medical thought before the emergence of secular societies), it indicates human emergence within the natural order insofar as it is indeed man who, by making poor use of what is brought to him by nature, corrupts the natural order in some way. The “unnatural” is unbalance, and this comes from an improper management of the needs and demands of the body, generally more because of ignorance than because of vice. The doctor then gives himself the aim of restoring health, namely a return to balance, diet and practices of care that are connected, just as hygiene must warn about and anticipate any disturbance. Medical thought, even if it does not precede philosophy, informs the idea of free will since it is up to each individual, subject of himself, to assess what is most appropriate for his balance.

2 - Diet: a self-medicine?

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In what way would a demand for diet appear as the necessity to be one’s own doctor? One’s own doctor, the title of a significant work by Évelyne Aziza-Shyster (1975), is a theme that, since Antiquity, has scanned the relations of man to medicine and, more generally, to practices of care. Such an ambition has not disappeared today, but its motivations have, so to speak, been inverted. Until the middle of the 19th century, it was the insufficiency of mechanisms of prevention and of repair proper to the medical universe that could generate a self-medical approach. Distrust of doctors, immortalized by Voltaire who did not want to grant them the little health that remained in him, the obsessive fear of hospitals before their reform and their evolution into scientific structures (19th century), moreover the rarity of doctors on the scale of a country like France was, for as much, a favorable factor, through portable dictionaries of health, textbooks for taking care of oneself, in particular for ailments whose gravity was not proven. Beginning in the second half of the 20th century, another form of distrust surfaces, toward the cold monster that the medical institution has become, and the expression of a desire to return to nature, to not depend upon a society that was judged to be too technical, to refuse a logic of clientelism. But it is also in the middle of this century, in parallel with the emergence of an explicit medical ethics, that the claim to make every patient and every sick person into his own subject was formed and saw a significant upsurge. These are, for as much, facets that have contributed to giving a new body to the mention of being one’s own doctor.

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But, before becoming an ideal, a probable utopia, being “one’s own doctor” falls within a demand of a political nature. It is here that the very term régime fully shows its dual meaning: régime as government and régime as conduct of one’s health, as diet. It informs a philosophy of existence: knowing how to govern oneself in all circumstances. It contributes to making a form of autonomy effective, but this notion is the object of a considerable evolution between the 15th and 18th century. Antiquity prescribes régimes of life – medical and philosophical examples (the Stoics) – in order to perfect a conformity of man not only with nature, but also with society: the self-regulation of each individual participates in a social regulation that is vital for the balance of the entire city-state; on such a point, some unison is characteristic of a Hippocratico-Aristotelian structure. The modern era regenerates this demand, insisting upon a conformity with society and on a moral propriety: régime must police man. If the legacy of Antiquity prevails in the writing of many works that aim to advise men regarding the preservation of their health, the intervention of the term “government,” as will be the case a little bit later for “politics” of health, applied to an individual management of everyday life, tends to inflect discourse in the direction of a social and moral demand. One must look for a behavioral model; hence the success of Luigi Cornaro’s book, which I mentioned in the introduction. In this same trail, Nicolas-Abraham de La Framboisière writes a Government necessary for each individual to live long and in health, (1600). The author boasts a book written in French, which is intended for the “commoner” and that seeks to distinguish itself from a jargon-laden and abstruse literature; it justifies a practice that has been carried out since the dawn of time: the fact of borrowing wise and reasonable remarks from one’s predecessors. There, one finds the intersection of two temporalities. On the one hand, man is understood through distinctions inherited from Galen: natural, non-natural and unnatural things, and the temperaments linked to humors (sanguine, phlegmatic, choleric and melancholic). On the other hand, man is inserted into a context that has changed since Antiquity, a fact of renewed propriety and demands, following the example of the rules of beauty, of cleanliness and of hygiene (Book III, chap. 1 and 2).

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Health advice is in line with a logic of manners. Concern for oneself is a major component in the distribution of rules of appearance. The demand for care is often mixed with an aesthetic demand: health is on the side of beauty; what is pleasant to look at, to hear, undeniably contributes to elevating the spirit and fortifying the body’s defenses. One such piece of advice is given by La Framboisière to elderly people whose humor has a tendency to darken: “In order to give pleasure to the eyes, they will spend their time looking at beautiful women, gazing at the variety of flowers, the diversity of beautiful colors, and will always wear some precious ring, and, among others, sapphires and emeralds, for there exist no colors that better preserve vision than green and violet” (ibid., chap. VII). But the issues relative to the recommendation for governing oneself are not limited to this array of demands. It is at the end of the 17th century that the concern for public health is intermittently formulated, extended to a significant population, particularly motivated by economic stakes. The great inquiry into work-related illnesses, taking a census of different forms of plagues according to artisan corporations, is published by Bernardino Ramazzini in 1700. Such a preoccupation falls in line with a process of recognition, of growing valorization of work. The industrial arts make their entry into the circle of the sciences, of philosophy, especially with Diderot and d’Alembert’s Encyclopedia beginning in 1751. Before the Third Estate, coming from the “nothing” that it was for so long, aspires to become “everything,” to make use of Sieyès’s words from the end of this same century, the good health of production is certainly considered to be a determinant factor for the future of the economy; for this, one needs artisans that are in good health. It is in the framework of the debate over the reform of hospitals (the Tenon Report on the Hôtel-Dieu) that the demand for public health can be found explicitly formulated, and it is in this context that, without abandoning the idea of self-government, this aspiration reaches a perceptible shift. The modern hospital, dispensing of its function as a hospice hosting the ill, the destitute, the alienated and other “pariahs” from society, coming out of its image as skid row, would become, as Foucault renders it (The Birth of the Clinic), a place within which medicine becomes institutionalized as science and as a legally delimited professional body. This new hospital which, in fact, will not see the light of day until the end of the following century, especially with the creation of boarding schools, hosting only the “truly” sick, would contribute to separating people into those who are in good and in bad health. It would be this “machine” that directly distinguishes the positively normal from the pathological, leaving healthy people with the responsibility to actively contribute to the development and to the production of all of the forces of society. In this context, good health demands rigorous management: remaining in this state entails warning against any risk of deterioration.

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From the old to the new regime, doctors, scholars, philosophers and politicians sometimes join together in the project of creating a new man, a regenerated man. Knowing one’s self returns as an injunction for this precious resource to be researched and to be exploited, what in a time more contemporary with Aristotle one might have called virtue. Regeneration does not fall within a pure stylistic expression. The regenerated man is he who, through his way of life, is directly participating in the great movement of rupture with the corruption generated by the habits of the old regime. To this end, three objectives must be fulfilled by each citizen as Tissot shows in his famous Avis au peuple sur sa santé, as did Cabanis or even Lanthenas, theorists of the idea of the regeneration of man: coming out of poverty, of ignorance and of illness. Work, education and preventative medicine that are founded in part on hygiene and on diet are responses to these three issues. Government of oneself becomes from then on, a national imperative because the one whom it is a question of taking care of, beyond the individual himself, is the citizen. Echoing the logic that came from the Social Contract, he who transgresses the laws endangers himself as much as society in its entirety, in a reflexive dynamic that is established by the Contract; likewise, he who does not take proper care of his body, of his health, thereby endangers the health of the nation. One of the emblematic gestures of such a politics of regeneration paradoxically puts an ancestral and gruesome practice back at the center of therapeutic mechanisms of prevention: bloodletting. It is not yet a question of giving blood, since techniques of transfusion are from being mastered at this point in time, but a question of regulating it: temperance, temperament, a model for every citizen, for every individual, excludes blood that is too bright just as it excludes blood that is too pale, too fast or too slow.

3 - The regulatory demand

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Blood, this vital contribution to any physiology of life and of man, oscillating between Harveyan revolution, humoral resurgence, between science and myth, expresses, at its highest point, in this context, the regulatory demand that takes shape with the emergence of a new society. The good citizen is he who is going to spill his blood. Two occasions present themselves: war and bloodletting. If the former brings to mind the sacrifice of the citizen turned soldier, of the part for the whole, the latter returns to a logic of prevention and of balance. Bloodletting first appears as a question of physiology; it takes us back to the immense hydraulic circuit that makes up the animal economy – the surgical and therapeutic entryway of almost all doctors – it also becomes, over the course of the 18th century, a moral and political question, a question so serious that it tends to justify such a practice until at least the 19th century (some blood illnesses are still treated today through bloodletting, such as for hemochromatosis, a disease that is distinguished by an excess of iron in the blood, and for which some bloodletting is employed, in some cases up to once a week), in order to regulate blood. What virtues, at the dawn of the advent of experimental medicine, can be found in bloodletting? For tuberculosis, cancer, fevers or even epilepsy and hysteria, bloodletting would be highly recommended. It facilitates the movements of arteries and of the heart, whose contractions are more supple; it facilitates absorption, favors nutrition, lowers the heat of the skin and facilitates respiration…these are some of the arguments advanced by Guersent in favor of this practice (Adelon, Dictionnaire de médecine, 1827, vol. XIX, art. “saignée”). This argumentation is also brought up by Chantal Beauchamp (Le Champ et l’imaginaire médical, preface by Marc Ferro, Éditions Desclée de Brower, 2000).

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Bloodletting therefore intervenes in two dimensions of medicine, which are therapy and hygiene; it remains one of the most used medical acts in a considerable range of cases of disease. The interest of an epistemological questioning about the persistence of such a practice, well beyond the last breaths of humoral medicine, would be deserving of a full development on its own. What can already be remarked upon is that one part of the reasons for which bloodletting persists resides not in the medical sciences as they exist between the end of the 18th century and the first decades of the following century, in the context of a still pre-Bernardian medicine, but in the practices of care linked to habits, to cultures beyond medicine in the strict sense of the term.

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The 19th century is indisputably the moment of a break with an intimate conception of diet and of hygiene, wherein, as Michel Foucault shows (The History of Sexuality), politics of control become generalized. The body is an object of science within university hospitals, it is an object of control, in particular for women. The regulatory demand is multiform and varied: a medical, scientific, economic and political issue.

4 - What life choices?

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What behavior in life, what practices of care should be adopted? These are the questions that are provoked by the quest of a diet. Such questions are in no way relegated to a bygone past. Thus, one finds two motivations that were already present in the time of La Framboisière: aesthetic and therapeutic.

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If medicine – medical science, the practice of care, techniques – has not yet finished with the revolution now initiated almost two centuries ago, if the hygiene that is put in place at the end of the 19th century appears radically metamorphosed with regard to the discourses and the prescriptions that it previously supported, then what about diet? A much longer development that is not the object of the present article would lead to rendering this theme in a growing urban environment, in a time that is quite often that of haste, of the short term. In such a framework, the preceding mentions of an old regime could resonate in an approximative echo with the advice that regularly feeds, nostalgically, the pages of magazines, especially just before the summer, when advice for a healthy diet lives alongside a review of different philosophers from Antiquity; there one generally sees flat stomachs and glowing, sunlit faces neighboring the bust of one of our wise ancients…

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These few developments dealt with the original acceptance of diet and of its variations in the fields of morality and politics. This article can be read as a glance at some facets of the history of diet, a glance but also a wink, because what the history of a phenomenon or the history of a practice tells us can also contribute to feeding a critical regard on its present state. The state of diet is currently experiencing, as it appears, an oscillation between overconsumption and a return to nature, just as much excess, just as many flaws that hypothecate a balanced comprehension of what a diet could be, rid of all guilt-inducing discourses: diet should never be a priesthood, nor a luxury. Between the two, a range remains to be found, so long as the piano is in tune.


Bibliography

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Outline

  1. Natura medicatrix
  2. Diet: a self-medicine?
  3. The regulatory demand
  4. What life choices?