Medieval Medicine

Early Science and Medicine 12 (2007) 247-283
www.brill.nl/esm
Treating Medieval Plague: e Wonderful Virtues of eriac*

Christiane Nockels Fabbri
Yale University
Abstract is paper examines one of the most popular remedies in medieval plague medicine, namely theriac, and explores possible reasons for its remarkable continuity in the late medieval and early modern medical tradition. eriac, reputed as a universal antidote since ancient times, was a complex compound, composed of multiple ingredients, difcult to prepare, and subject to strict manufacturing and commercial controls. e paper centers on the therapeutic applications of theriac and on its relative pharmacologic ecacy in treating the symptoms of plague. e consistent use of theriac in plague medicine attests not only to the conservatism of medieval medical practice, but also to an underlying solidly founded rationale that combined humoral doctrine, empiric observation, and pharmacologic eect. Keywords medieval medicine, theriac, Black Death, plague tracts, composite medicines, therapeutic ecacy
e ravages of the Black Death aected all aspects of the late medieval world. e 1348 plague and its later epidemic outbreaks severely challenged late medieval and early modern medicine, yet, medical theory and practice were slow to transform.1 In the following centuries, neither prevention nor treatment of plague changed appreciably.
*) A rst version of this article was presented at the Holmes Workshop, Department of the History of Science and Medicine, Yale University, April 2006. I am very grateful for the valuable suggestions of Dr. Christoph Lthy and of three anonymous referees for Early Science and Medicine. I should also like to thank Professor Ann Ellis Hanson and Dr. Remo Fabbri, Jr. for their guidance. 1) Plague remained endemic in Europe until the eighteenth century.
Koninklijke Brill NV, Leiden, 2007 DOI: 10.1163/157338207X205115
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C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283
ere was little evolution in the antipestilential regimen as regarded diet, hygiene, medicines, or surgical procedures. On the contrary, late medieval physiciansin the face of what was by all accounts a terrible diseaseretained their long-established practices and remedies. Plague prophylaxis and the substance of plague therapies, both steeped in the principles of traditional Galenic therapeutics, remained the same. Prescriptions of medicinals together with measures such as purging and bleeding did not vary appreciably. roughout the period studied in this paperfrom 1348 to the close of the sixteenth centurythe treatment of plague, albeit in a tiered, costbased fashion, was strikingly continuous, attesting to an overarching conservatism of medical practice.2 is remarkable therapeutic continuity is clearly illustrated by the consistent use of theriac, the main focus of this study. Among plague medicines, theriac was one of the most popular. A complex compound, made of multiple ingredients, it had been famous as a universal antidote since ancient times. It was dicult to prepare and was subject to strict professional controls. Recipes could contain up to eighty dierent ingredients, among which weremost notablysignicant amounts of opium. In plague medicine, theriac was used as both a preventive and therapeutic drug, and was most likely benecial for a variety of disease complaints. Indeed, from a modern vantage point, the consistent and continued use of this specic remedy would suggest that plague medicine was not only pharmacologically informed but also oered signicant symptomatic relief. Medieval plague medicine embraced, rst and foremost, the principles of traditional Galenic therapeutics, placing strong emphasis on the regimen sanitatis, the art of maintaining moral and physical health. Prevention of disease and maintenance of health required not only the good ordering of the so-called naturals (elements, humors, parts of the body, and faculties), but also the regulation
2)
is paper is based on the authors survey of a sample of plague treatises dating from 1348 to 1599; see Christiane Nockels Fabbri, Continuity and Change in Late Medieval Plague Medicine: A Survey of 152 Plague Tracts from 1348 to 1599 (Ph.D. Dissertation, Yale, 2006). Translations, unless otherwise noted, are the authors.
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of the non-naturals (food and drink, movement and rest, evacuations and passions, or emotions). Disease resulted from imbalance of the four humorsblood, black bile, yellow bile, and phlegm and their respective qualitieshot, cold, wet, and dry, all of which were impacted directly or indirectly by individual and environmental naturals and non-naturals. e prevention of disease, together with the maintenance and promotion of health, was an important part of the physicians responsibility, and expertise in rectifying various imbalances of patient complexion was essential. Medical practice thus dealt with the proper management of patient regimen (management of naturals and non-naturals), with the administering of drugs, and with surgery.3 Of these, the administration of drugs appears to have dominated. Simple and composite, they were considered paramount in restoring the harmonious balance of the four humors. Underlying the whole of medieval medical and pharmacological practice was the ancient belief in the vis medicatrix naturae. On the one hand the healing powers of nature were harnessed through judicious use of the healthy regimen (moderate life style and proper nutrition), and on the other through what were mostly botanical medicines.4 e notion that nothing in nature was without power accounted in part for the many simples employed and for the complexities of composite formulations. Here, medieval physicians had a long pharmacologic tradition to draw upon: from the polypharmacy of Galen and Dioscorides, and the Latin translations of GrecoArabic pharmaceutical compendia, to the teachings of early medieval monastic botanicals, incorporating, along the way, their own indigenous Saxon, Celtic, Teutonic, or Gothic lore.
is was the teaching of the Isagoge of Johannitius, a component of the fundamental Ars parva or Articella, which was at the heart of the university medical curriculum after 1250. See Michael McVaugh, History of Medicine, in Joseph Reese Strayer, Dictionary of the Middle Ages, 13 vols. (New York, 1982), VIII: 248. 4) Aside from Aristotle and Galen, theoretical justication for pharmaceutical practices could even be found in the Bible, which taught that God created medicines from the earth for mans benet; see the discussion of medieval English pharmacy in Faye Marie Getz, Healing and Society in Medieval England: A Middle English Translation of the Pharmaceutical Writings of Gilbertus Anglicus (Madison, WI, 1991).
3)
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A large part of the plague physicians armamentarium was at the same time food and medicinal simple. us, vinegar, garlic, or onion, staples of the medieval medical cuisine, were frequently advocated as useful preservatives.5 Among herbs, rue, borage, blessed thistle, or angelica, were guaranteed to have protective virtues.6 Acidulous substances such as sorrel, sour pomegranate, citrus fruit and juice were considered to have both preservative and curative value against the apostumes of plague, and were also commonplace dietetics.7 Dry and cold in the humoral schema, such foodstus could engender the type of humors suitable to corroding and overcoming the pestilential poison, itself hot and moist. Other substances, like
Eat garlic with bread every morning; salvia and rue; and in early morning take some bayberry, urged a fteenth-century Gttingen pest tract: et des morgens knuock myt brode; salvie unde ruten; eyne lorbern des morgens vro See Hyrna volget j. remedium to ryme vor de pestilenciam, cited in Walter L. Wardale, Some Notes on the Stockholm MS X 113 and the Gttingen MS hist. nat. 51, in Gerhard Eis and Gundolf Keil, Fachliteratur des Mittelalters: Festschrift fr Gerhard Eis (Stuttgart, 1968), 457-467. For Jacme dAgramont, whose 1348 Regiment was only preventive, an infusion of scabious before breakfast, or the juice of dandelion, were superior antidotes against anthrax or bad buboes (contra ntrach ho mala busaynna); see Jacme d Agramont, Regiment de preservaci de pestilncia (Lleida, 1348). Estudis introductoris i Glossari, ed. Jon Arrizabalaga, Luis Garca Ballester, Joan Veny (Lleida, 1998), 63. Gentile da Foligno advised rue, gs, walnuts, and fruit preserved in vinegar as pest preservatives, whereas the Prague Missum imperatori advocated fresh, well-washed rue with salt (frischir rute, dy gewaschin sy, mit salcze); see Karl Sudho, Pestschriften aus den ersten 150 Jahren nach der Epidemie des schwarzen Todes 1348, Archiv fr Geschichte der Medizin, (1907-1928), III, V. 6) See for example the discussion of the hearbes Carduus Benedictus and Angelica, in omas Brasbridge, e poore mans ieuuel, that is to say, A treatise of the pestilence unto the which is annexed a declaration of the vertues of the hearbs Carduus Benedictus, and angelica, which are very medicinabl[e], both against the plague, and also against many other diseases (London, 1578), Microform. See also Early English Books Online, Yale University Library, 2005 and 2006, at http://gateway.proquest.com/openurl?ctx_ ver=Z39.882003&res_id=xri:eebo&rft_id=xri:eebo:image:25153:21. 7) toutes choses aigre en quelcunque maniere que elles soient prises sunt bonnes contre les apostumes de lepydimie, tant en gouvernement preservatif comme curatif Item syrop de ius de surrelle et de ius de citron et de ius de pommes grenates aigres sunt molt convenables contre la evre de pestilence et especialement en este. Rudolf Sies, Das Pariser Pestgutachten von 1348 in altfranzsischer Fassung (Pattensen, 1977), 48, 51.
5)
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Armenian bolus or terra sigillata (literally sealed earth), both simples prepared from natural clays, were strictly medicinals.8 Armenian bolus, rich in aluminium silicates and iron oxide, was used in the treatment of inammations, allergy and tumours. Terra sigillata (also known as Lemnian earth), a reddish clay originally mined on the island of Lemnos, was used as antidiarrheal and nutritional. e Paris masters had extolled the antipestilential virtues of both simples as early as 1348: Bol ayde merveilleusement contre lepydimie Item terre seelee preste grant ayde contre la pestilence de lair9 Simple or composite, medieval medicines generally fell into three categories according to their primary mechanism of action, or desired result: purgatives which desiccated and moisturized, by cleansing and purging superuous humors; cordials which strengthened the heart, brain, and liver, the three main bodily members of Galenic medicine; and antidotes, which operated by neutralizing poisons.10
8) Galen had used terra sigillata as a topical astringent for wounds and lacerations, and later prescribed it for internal use, see Galen, De simplicium medicamentorum temperamentis et facultatibus, ix, 1. See also Lynn orndike, A History of Magic and Experimental Science, 2 vols. (New York, 1923), esp. 130-131. Finely powdered Armenian bolus, to be taken at bedtime every night with one or two spoonfuls of wine mixed with rosewater, was a frequent prescription: alle nacht so ir slaen geht sollet nemen eyn leel weynes oder czwene gemischet mit rosenwasser mit ein wenig boli armeni aller kleynst gepulvert, see Anon., Arznei wider die Pestilenz (Erfurt, 1493; facsimile, Stevenson, Inventario Palat.Vat. II, 520, I). 9) car elle a propriete merveilleuse a esleescier et conforter le cuer, see Sies, Das Pariser Pestgutachten, 49. In Galens days, Lemnian clay was solemnly stamped into pellets or tablets with the sacred seal of the goddess Diana, an early equivalent to modern brand-name pharmaceuticals. Later on, terra sigillata tablets were available in various substitutes from other places. Ancient controversies over the authenticity of Dianas famous sealed earth pills are reminiscent of the brand-name vs. generic debates of modern-day drugs. Nevertheless, the simple was held in high esteem through the early modern period, and was included in European pharmacopeias until the nineteenth century. I am grateful to an anonymous reader for the reference to terra Silesiaca as a locally mined sixteenth-century antidote, to replace the expensive terra sigillata imported from Turkey; see Karl H. Dannenfeldt, e Introduction of a New Sixteenth-Century Drug: Terra Silesiaca, Medical History, 28 (1984), 174-188. 10) Most medicines derived from traditional medical authorities such as Galen, Avicenna, Rhazes, Averroes; see Jon Arrizabalaga, Facing the Black Death, in Roger
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e most valued remedies were composites, usually compounded in the form of pills, syrups or electuaries.11 Like general dietetic measures, and like other preservative or therapeutic drugs, they aimed to restore humoral balance by drying, cooling, warming, moisturizing, and fortifying the body. Examples were pills made of aloe, myrrh and saron; powders mixed of black pepper and cumin; tablets of aloe, lemon juice, rhubarb, and absinth juice, etc. Some of these had both antipestilential as well as other indications.12 Still, of all the composite medicines, the most famous and sought after was theriac, the ancient antidote believed to possess virtually magical powers. eriac had already been famous in Galens time. Originally a remedy for snakebites in which the esh of vipers was an important ingredient, the drug had later been developed as a universal alexipharmic or antidote, and was believed to be supremely eective against pestilential poisons.13 It was supposed to induce immunity according to the principle that like cures like, by gradually introducing into the body small amounts of poison.14 Of all the traditional antidotes, theriac was considered the most potent. It was compounded of multiple substances, and could include up to eighty dierent simples, such as cinnamon, saron, rhubarb, pepper, ginger, andsignicantlyopium; together with wine and honey these were mixed into a pulp to form a thick, syrupy theriac electuary.
French, Luis Garca-Ballester, Jon Arrizabalaga, Andrew Cunningham, eds., Practical Medicine from Salerno to the Black Death (Cambridge, 1994), 237-288, at 281. 11) Electuaries were drugs usually mixed with honey, or sugar and water, into a pasty substance suitable for oral administration in the form of syrup. 12) Giovanni della Penna prescribed the latter to take once or twice a week in order to cast o not only plague but also worms; see Sudho, Pestschriften, V: 345. 13) e word theriac derived from the Greek for pertaining to wild beasts or poisonous reptiles. e four ancient remedies against poison were theriac, mithridate, bolus armenicus, and terra sigillata; theriac and mithridatium were both composites in the form of electuaries. On the history of theriac and mithridate, see orndike, History of Magic, I, passim. Also Gilbert Watson, eriac and Mithridatium: A Study in erapeutics (London, 1966). 14) e principle of similia similibus curantur, orparadoxicallythat the cause of the disease will cure its result, was common in ancient and medieval medicine, and a notion that medicine shared with magic.
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e eriaca by Hellenist physician and botanist Nicander of Colophon (ca. 200 BC) provided one of the earliest detailed recipes:
you may with instruction compound a general panaceait will be very serviceable after you have mixed all the simples togetherlet these be birthwort, root of iris and spikenard, of valerian too with dried pellitory, of all-curing dried carrot, and of black bryony, and with them the spongy roots of a freshy dug peony, sprigs of the black hellebore, and mingled with them native sodium carbonate. Pour in too cumin and a sprig of eabane mixed with the husks of stavesacre; and grind down equal quantity of bayberry and tree-medick and the lowly horse-moss, and gather in some cyclamens. Cast in also the juice of the gleaming poppy, and over all the seeds of the agnus-castus, balsam too, and some cassia, and with them cow-parsnip and a bowlful of salt, mingling them with curd and a crab; but the former should come from a hare, the latter should be a dweller in pebbly streams. Now all these you should throw into the belly of a capacious mortar, kneading them with the blows of stone pestles. And on the dry ingredients pour at once the juice of cleavers and mix well together; then prepare round cakes of a drachm each, limiting the weight precisely with a balance; then shake them up in two cotylae of wine and drink.15
e idea of a universal antidote to counteract all poisons was ancient and can be found in many pharmaceutical treatises. In medieval Europe, formulations of theriac appeared in the Lorscher Arzneibuch as early as the eight century. eriac itself derived from mithridatium, the mother of all antidotes, named for Mithradates, King of Pontus (120-63 BC).16 Mithradates, an avid student of toxicology, had discovered a number of remedies by testing the eects of various drugs upon condemned criminals. To protect against the threat of poisons, he attempted to immunize himself by drinking a daily dose of poison and antidote, eventually combining the results of his research into one grand compound.17 In the rst century
15)
Excerpted from Nicanders eriaca as cited by Martin Levey, Medieval Arabic Toxicology: e Book on Poisons of ibn Wahshiya and Its Relation to Early Indian and Greek Texts, Transactions of the American Philosophical Society, 56 (7) (1966), 18. 16) Metridatum id est mater omnium antidotorum/Sive a Metridato rege dictum; see Paul Dorveaux, ed., LAntidotaire Nicolas: deux traductions franaises de lAntidotarium Nicolai (Paris, 1896), 20, note 9. 17) Celsus attributed Mithradates immunity to his antidote only, whereas in Pliny it
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AD, Andromachus the Elder, physician to Nero, modied Mithradates recipe by adding viper esh and by increasing the proportion of opium, thus formulating the famed theriac.18 Initially designed to counter poisons, both theriac and mithridatium were widely used as panaceas through the early modern era. Both gured in French, German, and Spanish pharmacopeias until the nineteenth century. eriac, however, from which derives the English word treacle, was considered the most valuable among all medieval remedies.19 It was said to cure fevers, prevent internal swellings and blockages, alleviate heart problems, treat epilepsy and palsy, induce sleep, improve digestion, strengthen limbs, heal wounds, and protect against the bite of snakes, scorpions, and other venomous insects, also against the bite of rabid dogs and poisons of all sorts. It could even prevent and cure the plague. Eectively employed to prevent or treat a variety of aictions, it eventually became synonymous with (universal) antidote.20 e therapeutic powers of theriac had been a subject of much interest to late thirteenth and early fourteenth-century scholastic physicians. Questions centering on its eectiveness, dosing, and on its specic properties, were the substance of argument in an academic discussion, which called attention to the problem of describing the strength of compound medicines.21 Composite medicines
is attributed to the combination of both poison and antidote, see Laurence M.V. Totelin, Mithradates Antidotea Pharmacological Ghost, Early Science and Medicine, 9 (2004), 1-19. Allegedly, Mithridates immunization method was so eective that, when defeated by the Romans, he tried to commit suicide by drinking poison, but was unsuccessful. 18) Galen, De antidotis I, 1 in C.G. Khn, Galeni Opera Omnia (Leipzig, 1827), XIV: 2-3. 19) Venice treacle was reputed to be the best, and was exported to commercial centers throughout Europe. 20) Totelin, Mithradates Antidote. For a broader historical overview of diverse analgesic therapies, including theriac, see D. Schafer, R. Sabatowski, S.M. Kasper, H. Brunsch, L. Radbruch, Pain Treatment: A Historical Overview, Current Pharmaceutical Design, 10 (2004), 701-716. 21) Michael McVaugh has delineated the scholastic debate over the Questiones de tiriaca by William of Brescia, in M.R. McVaugh, eriac at Montpellier 12851325, Sudhos Archiv, 56 (1972), 113-144. McVaugh argued that this debate revealed the existence of a more general process by which academic medicine at Montpellier
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were typically based on one or two primary simples; additional ingredients were included to reinforce or modulate eect. us, in theory, it was possible to create a compound targeted to a specic qualitative humoral imbalance, by combining simples of known qualities and strengths (degrees).22 Recipes made up of a dozen or more simples were commonplace. eriac, so remarkable among composites, was of special interest to scholastic physicians because of the peculiar origin of its eectiveness, which Avicenna had attributed to its specic form, ex tota sui substantia.23 It had been noted that when theriac was fresh, it constipated the bowels, for it contained opium and other constrictives; this eect was thought to be due to insucient aging. Only when it was nished and fully matured (perfected), it acquiredthrough the fermentation of all ingredientsits true form, namely the capacity to comfort the heart, and thereby to resist every poison24 e medicinal virtues of theriac were thus thought to derive not only from the complexions of its individual ingredients, but also from a unique act of combination, of fermentation, that was not rationally predictable and could be learned only by experience. is irrational, occult proprietas (similar to that of the magnet, for example) symbolized for physicians the strictly empirical element of natural phenomena.25 Modern scholarship has obscured the role of opium as a major ingredient in the famous theriacs of Antiquity, perhaps because of
moved from a still somewhat empirical to a markedly philosophical or theoretical orientation. 22) M.R. McVaugh, Medicine before the Plague: Practitioners and eir Patients in the Crown of Aragon, 1285-1345 (Cambridge, 1993), 153. Plants, minerals, seeds, and other simple medicines were described in terms of four qualities, hot, cold, dry and moist. For each quality there were four degrees, listed in books of simples or degrees, see for example the beautifully illuminated texts in Luisa Cogliati Arano, e Medieval Health Handbook Tacuinum sanitatis (New York, 1976). 23) McVaugh, eriac at Montpellier, 114. 24) Tyriaca quando est recens constringit ventrem, quia est in ipsa opium et alia constrictiva, et haec operatio non est a tota substantia quia nondum tyriaca est perfecta; cum enim perfecta est haec forma in tyriaca ex fermentatione miscibilum acquiritur ei forma, cujus operatio est cor confortare et idcirco resistit omni veneno, ut dicit Avic. V sui canonis. Ibid., note 6. 25) Ibid., 114.
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assumptions about its addictive nature. Gilbert Watsons well-known monograph on theriac and mithridatium dismissed its importance in plague medicine as scantily documented.26 Instead, Watson underscored Marcus Aurelius regular use of theriacs (recorded in Galens Antidotes) as a story of particular value, since it is the only caserecord of a patron or addict of these fortiers and remedies.27 eriac, to be sure, was not only considered eective against dierent types of poisons, but also appeared to have functioned as a kind of all-round, multi-ingredient preparation intended to promote a sense of well-being, comparable to modern anti-depressants.28 Historian Jean-Pierre Bnzet, in his analysis of Mediterranean apothecary practice, conrmed the important use of opiate electuaries including that of the famous theriac.29 According to Bnzet, theriac was primarily used for pain syndromes and as a sedative in neurologic conditions such as epilepsy and apoplexy.30
Even Gentile da Folignos scholastic inquiry into the reasons for the use of theriac and Mithridatium was not strikingly illuminating. See Watson, eriac and Mithridatium: A Study in erapeutics, 99-100. For a short history of theriac in the Middle Ages with detailed primary source references, see omas Holste, Der eriakkrmer: ein Beitrag zur Frhgeschichte der Arzneimittelwerbung (Pattensen, 1976). Holste acknowledges Watsons careful tracing of early theriac history from Alexandria to Galen. 27) Watson, eriac and Mithridatium, 87. 28) John Scarborough, e Opium Poppy in Hellenistic and Roman Medicine, in Roy Porter and Mikul Teich, eds., Drugs and Narcotics in History (Cambridge, 1995), 17. e analogy with modern antidepressants is debatable. However, if eective, they can generate energy, lift the mood, and even stimulate euphoria. On the whole, the psychotropic eects of any substancewhether opium, wine, or selective serotonin reuptake inhibitorare dicult to assess, especially retrospectively, since they would depend on multiple factors: dosage, concomitant drugs, synergy, and individual patient. 29) les opiats sont une famille importante. Tous contiennent de lopium et ont une consistance dlectuaire. La thriaque est le plus clbre. Jean-Pierre Bnzet and Jean Flahaut, Pharmacie et mdicament en Mditerrane occidentale (XIIIe-XVIe sicles) (Paris/Geneva, 1999), 641. 30) La thriaque est la mdication hroique des grands syndromes douloureux Bnzet notes that theriac was also used to counteract poisons and to prevent miscarriages. Ibid.
26)
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A late thirteenth-century vernacular manuscript of the widely used Antidotarium Nicolai31 recommended Galens Great eriac for an array of ailments:
Triaca mangna [sic] la quale puose Galieni detta donna dele medecine. Vale molto alle gravissime infermit del corpo humano, agli epilentici e catalentici e poplentici e scotomaci, cefalargici, e all magrana fa grandissimo prode; alla ocaggine dela boce ed al constringnimento del petto; ottima ali artetici a agli asmatici emottoici, iterici, idropici, epiplemonicis Recipe trociscorum sciliticorum lb. ii; piperis longi lb. i et s.; trociscorum tiri, trociscorum diacoralli, ana lb. i; xilobalsimo on. vii; oppei tebauci, agarici, oppi, rosarum, yrei, scordeon, seminis rape, salvie, cinamomi, opopobalsami, ana on. v; ...32
Nicolaus recipe was made up of seventy simples including, among other, vipers esh, ground coral, balsam, pepper, rose water, sage, cinnamon, saron, ginger, parsley, gum arabic, nasturtium, centaurea, storax, myrrh, and anis seed, as well as several ounces of opium; all ingredients were carefully weighed and measured, then ground in a mortar, after which they were steeped in wine for three days, boiled, cooled, and nally mixed with ne skimmed honey and stored. is Great eriac, wrote Nicolaus, Galens very own recipe, was called the primadonna, the rst lady of medicine. It was useful for the most serious illnesses of the human body, for epileptics and cataleptics for headaches, and for migraines also for sore throats, and for constriction of the chest; optimal for arthritics and asthmatics, icterics, hydropics, peripneumonics, also for kidney stones, and colics.33 e drug helped menstrual disturbances and diculties in elimination associated with older age; it
31)
A compendium of composite medicines, the Antidotarium Nicolai rst appeared in Salerno around 1150 and is attributed to Nicolaus Salernitanus; see Rudolf Schmitz, Geschichte der Pharmazie (Eschborn, 1998), 368. Widely accepted as a standard dispensatory as early as the thirteenth century, the text had been incorporated into the Paris medical curriculum by 1270; see McVaugh, Medicine before the Plague. It included over twenty compounds containing both opiate and solanaceous simples. 32) Lucia Fontanella, Un volgarizzamento tardo duecentesco orentino dellAntidotarium Nicolai, Montral, McGill University, Osler Library 7628 (Alessandria, 2000), 48. 33) Ibid. Translations, unless otherwise noted, are mine.
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was thought especially valuable for the treatment of venoms, snake bites and bites of other poisonous animals, but of greatest merit was its general utility in a wide variety of bodily ailments: it kept the heart, lungs, brain, liver and stomach healthy; it helped the entire body stay well Pain relief, except for headache and colic, was not mentioned as a specic indication.34 us, analgesia was likely not the primary objective of most antipestilential prescriptions, but an expected side eect along with other symptomatic treatment.35 Obviously, opium, as a major constituent of theriac, possessed specic therapeutic properties that would have been very eective against the prime disease manifestations: pain, cough, fever, and diarrhea, all of which were symptoms described in the medieval plague literature itself. e medicinal use of opium can be traced to pre-classical cultures in Asia Minor and Egypt. Obtained by incising the unripe capsules of the poppy Papaver somniferum, it was well known in ancient medicine. e ninth-century Arab physician Ibn Wahshiya wrote about the juice of the wild poppy and its properties as follows:
Opium has many uses. One of them is that it annuls pain in the limbs so that when they are struck no pain is felt. Another use is to retain remedies in the stomach when a little of it is mixed with them until their activity is completed so as to intensify their eectiveness. It stops excessive diarrhoea and a greater viscosity of the blood when one-half dirham in wine is taken. One of its uses is that
34)
Mithridatium, in another of Nicolaus recipes, was simpler in preparation but valued for pain, especially for headaches, earaches, toothaches, pain of palate and all mouth pain, and for topical relief at the site of pain. See Dorveaux, ed., LAntidotaire Nicolas, 20: Metridatum vaut: dolor de chef de fraidor, dolor dorailles, de denz, de palais, et tot dolor de bouche, mis sur le leu dolant. Pren: encens, chenilee, mire, genciane, ana dragme .vi.; opium, dragme, .iiii.; safran dragme .iii.; euforbe, aristologe longue, ana dragme .i.; miel sofeisant. e dose of opium in this compound was four drachms. At 3.88 g per drachm, this was equivalent to approximately 15.52 g. If morphine content was the standard 10%, this would have corresponded to 1550 mg, a signicant dose. 35) In 40 commentaries on the subject of opiates, pain is only mentioned ten times; see Bnzet and Flahaut, Pharmacie et mdicament. See also Bnzets compound opiate inventories, p. 674.
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if the temples are bandaged with it then sleeplessness and partial insomnia pass away. It has a wonderful and intense action in hot swellings, arrests and helps them to get better completely If its application is continued by repetition, then it annuls the pain and suering quickly. ere are more uses than those which have been discussed36
e multiple uses of the opium poppy, like much of the medieval pharmacopeia, had been re-introduced into Western Europe by the physicians of the Greco-Arabic school. Dioscorides Materia medica described various formulations, including a boiled down solution, a combination of whole poppy capsules and leaves for topical use, as well as the stronger pain-killing lozenge for coughs and tracheal discharges, and for conditions of the bowel.37 In medieval Europe, opium was imported from Asia Minor. It was also produced near the Apulian town of Trani, on the southern shores of the Adriatic; however, tranese was considered of lesser quality.38 e substance appears to have had a signicant presence
See Levey, Medieval Arabic Toxicology, 87. On the history of opium, see especially Scarborough, Opium Poppy Also Schafer et al., Pain Treatment. 37) Cited by Scarborough, Opium Poppy, 8. 38) Bnzet and Flahaut, Pharmacie et mdicament, 672. Eastern opium was often termed eban, denoting its ancient Egyptian origins. e twelfth-century Salernitan Matthaeus Platearius famous Book of Simple Medicines known as Circa Instans stated that Opium is cold and dry in the fourth degree. ree kinds of medicines are made from it, which one calls properly opium thabaic because it is made overseas in the country of ebes. is is poppy juice One collects it in the following way. Incisions are made in the poppy head and in its leaves, a milky liquid ows out, which is opium. e best kind is made in ebes. It has a repulsive taste (Le meilleur celluy qui est fait a ebes il a goust molt orible) See Carmlia Opsomer-Halleux and William Stearn, Livre des simples mdecines: Codex Bruxellensis IV. 1024: a 15th-Century French Herbal (Antwerp, 1984), II, 224; also ibid., I, 154v. Apart from opium tebaicum, there was another which is called opium tranense: this is produced in Apulia in a city called Trani; but it is not as good (Il en i a un autre que len claime opium tranense: celui fait len en Puille en une cit que len apelle Trane; ms il ne valt mie tant. Opium tebaicum conoistrez en tel maneire quant il sera buens: il est molt orribles, nil nest ne trop durs ne trop mox. Opium tranense est mox et atrait un poi rouse color. Opium tebaicum peut len garder .xx. anz). See Matthaeus Platearius and Paul Dorveaux, Le livre des simples mdecines. Traduction franaise du Liber de simplici medicina dictus Circa instans de Platearius tire dun manuscrit du XIIIe sicle (Paris, 1913), 143.
36)
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in medieval apothecary stores. In Paris, opium had already been highly regulated as early as the thirteenth century.39 Among analgesic simples in late medieval apothecary supplies, Bnzets Pharmacie et mdicament en Mditerrane occidentale recorded 14 instances of opium in 24 Provenal inventories, 3 in 5 Aragonese pharmacies, and 7 in 18 Italian, for a total of slightly over a third, thus demonstrating the drugs signicant presence.40 Black Death contemporary Guy de Chauliac was familiar with opiate drugs in the treatment of pain and other conditions; he included instructions for their use in the antidotary, which made up the last treatise of the Great Surgery.41 If humoral evacuation and topical remedies did not work, and necessity forced intervention, he wrote, it was preferable to introduce something harmful which could be corrected, rather than to permit that the patient die of pain.
See also the nearly identical text in the 2000 facsimile edition of a fteenth-century French vernacular manuscript of Platearius work, http://www.moleiro.com. 39) See Walton O. Schalick, III, Add One Part Pharmacy to One Part Surgery and One Part Medicine; Jean De St. Amand and the Development of Medical Pharmacology in irteenth Century Paris (Ph.D. thesis, Johns Hopkins University, 1997), 448. Schalicks study of late thirteenth-century physician Jean de Saint Amand and the regulation of apothecary practice in Paris concerning specic drugs centers on the controlled use of laxatives. Opiates were used to counteract excessive purgation; conversely, laxatives counteracted the constipation caused by opiate use (or abuse). 40) Bnzet and Flahaut, Pharmacie et mdicament, 672. 41) Pain, Guy wrote, was according to Avicenna a feeling arising from something contrary, such as change of nature through heat or cold, through violent stroke, and through other causes, which may break, cut, extend, or gnaw: Douleur, selon Avicenne, est un sentiment de chose contraire. Et jaoit que les choses contraires, selon Galen, soient changemens de nature par et par froid, par coup violent, et par autres choses qui peuvent rompre ou trancher ou estendre ou ronger. Pain was appeased in one of two ways: one was to remove the oending cause, the other to eliminate sensation: La douleur est appaise en deux sortes: lune est en ostant la cause contraire, lautre en ostant le sens a la partie. See chapter V, Des mdicamens sedatifs de douleur, et de leurs operations, 618., in Guy and E. Nicaise, La grande chirurgie, compose en lan 1363. Revue et collationne sur les manuscrits et imprims latins et franais... (Paris, 1890).
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In that case one must turn to sedatives and narcotics, which do not truly alleviate pain, but only in appearance, as if one were to say that a dead man does not feel pain ese are cold, and contrary to nature, such as opium, mandragore root, black nightshade, hyoscyamus, and poppy. ey are more salutary when dried, rather than fresh, and when corrected with saron, myrrh, styrax, and castoreum, such as in Philonion and other opiates, suppositories and collyria also are safer.42
e use of narcotics, particularly of opium, was thus not a rst choice for Guy, but a last resort, for it was un acte contre nature. Indeed, physicians were well aware that excessive use could be dangerous; Guy himself had known of at least one case of fatal overdose.43 His own recommended dose was a half drachm (equal to approximately 1.94 metric grams, or 1940 milligrams).44 If the
42)
Or quand la douleur ne peut estre appaise par la certaine et vraye maniere, et la necessit nous contraint, raison de quelque symptome qui peut amortir la vertu, il vaut mieux induire ou apporter quelque nuisance, laquelle on pourra corriger, plustost que de permettre quun homme meure de douleur, Adonc il faut passer aux sedatifs, stupefactifs, qui nappaisent pas la douleur vrayement, ains en apparence, comme si quelquun disoit, quun homme mort ne sent point de douleur Et tels, sont fort contraires ceux qui vrayement et essentiellement appaisent: Car ils sont froids, et contraires nature, comme lopion, la racine de mandragore, la morelle, lhyoscyame, et le pavot. Mais ils sont plus salutaires secs que verds, et corrigez avec du saran, myrrhe, styrax, et castore, comme au Philonion et s opiates, aussi en suppositoires, et en collyres, ils sont plus seurs. See ibid. 43) La quantit [dopium] et le temps doivent estre opportuns Et de ce furent suspects aux Medecins, les trochiscs que Monsieur lEvesque de Rieges conseilla Monsieur lEvesque de Marseille, lequel enduroit une strangurie douloureuse, car il en mourut assoupy et endormy. Car ils avoient telle propriet, quun seul prins appaisoit la douleur. Ibid. e anonymous Grete Herball states that the blacke [poppy] is perylous & caused to fall in lytargye & may mortyfye or slee. See De papavere. Poppy, CCC, xxix in Anon., e grete herball whiche geueth parfyt knowlege and vnderstandyng of all maner of herbes [and] there gracyous vertues whiche god hath ordeyned for our prosperous welfare and helth,... (London, 1526); available from http://eebo.chadwyck. com. 44) Des stupefactifs la forme est telle par tout le Continent (Guy is referring to Rhazes Liber Continens): PR. De lhyoscyame blanc, une drachme: opion, demy drachme: semence de citrouille et de laictue, de chacun quatre drachmes: graine de pourpier, deux drachmes. Quon en forme des trochiscs, avec de leau de regalice. Guy and Nicaise, La grande chirurgie. Drachm, or dram, is a unit of the avoirdupois system of apothecary weights; one drachm, or dram, equals approximately 3.89 metric grams (60 grains, or 1/8 ounce). Today the usual adult dose of morphine, taken orally, is 10 to
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quantity of morphine in Guys opium was similar to the ocial morphine content of todays powdered opium, estimated at 10 to 10.5% by weight, this dosing would have provided a hefty 194 mg of morphine. Together with the parasympathetic inhibitor henbane, another one of the ingredients, Guys recipe would have had a powerful narcotic and anaesthetic eect.45 In plague medicine, opiates, mostly in the form of theriac, were of paramount importance. e advent of the Black Death provided ample opportunity to make use of the expanded pharmacopeias of Arabic tradition, which had replaced many of the early monastic recipe books.46 Recipes for theriac and other opiates were available in such texts as the popular Antidotarium Nicolai, although some plague writers chose to make up their own proprietary formulations.47 eriac became a major component of the medieval physicians antipestilential armamentarium, topping the list of composite remedies. As a remedy to protect against the disease and to treat its multiple symptoms, theriac had no equal. e earliest plague writers recommended its liberal use. Indeed, among the sample tracts of the Pestschriften literature reviewed by this author, there is hardly
30 mg (milligrams) every three to four hours. Newer extended release morphine formulations recommend not exceeding a maximum of 1600 mg/day, although for adults, with appropriate titration, there is theoretically no maximum dose. See Louis Sanford Goodman, Alfred Goodman Gilman et al., Goodman & Gilmans e Pharmacologic Basis of erapeutics, 11th ed. (New York, 2006), 508; also McGraw-Hill Access Medicine drug monograph. 45) Henbane (Hyoscyamus niger), and deadly nightshade (Atropa belladonna), were known as psychoactive agents and poisons since ancient times. Part of the family of solanaceous plants, they have a variety of anticholinergic and potentially deadly effects. 46) Starting in the eleventh century, the early medieval monastic libri antidotarii or libri receptarii (e.g. the Lorscher Arzneibuch) were gradually enlarged and superseded by the newer Arabic pharmacopeias, notably Gerard de Cremonas translation of Avicennas Antidotarium (Book V of the Canon medicinae), and Constantinus Africanus Liber pantegni (the Liber decimus practice qui Antidotarius dicitur). See McVaugh, Medicine before the Plague, esp. 153-158. 47) Apothecaries often kept receptarii of prescriptions received, and even small town apothecary shops inventoried large numbers of dierent drugs; see ibid., 155.
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one that does not extol its antipestilential virtues.48 As a preservative, theriac would reinforce the healthy regimen, strengthen the body, and increase its resistance against the pestilence.49 As a therapeutic, the drug would alleviate the suering of those stricken by the disease. e oldest surviving plague treatise, Jacme dAgramonts 1348 Regiment de preservacio a epidimia o pestilencia e mortaldats, advised its readers to take one drachm of ne theriac three times a week, in order to ward o the pestilence.50 e 1348 Consultation composed for the King of France by the Paris Faculty stressed the importance of using high quality theriac for plague prophylaxis; the best, often designated as theriaca magna or maior, was that which had been aged ten years.51 eriac could be diluted in wine, vinegar, or acidic fruit juice.52 In summer, it could be taken with honey,
48)
Nockels Fabbri, Continuity and Change in Late Medieval Plague Medicine, Appendix I, 205-216. at theriac continued to be a drug of choice for the treatment of plague through the seventeenth century is attested by numerous contemporaries; see, for instance, the references to Venice treacle in Pepys Diary, and Defoes Journal of the Plague Year; also Bart K. Holland, Treatments for Bubonic Plague: Reports from Seventeenth-century British Epidemics, Journal of the Royal Society of Medicine, 93 (2000), 322-324. 49) According to Jon Arrizabalagas study, the importance of such auxiliary measures increased over time, a phenomenon interpreted as a reection of the increasing technical control of the physician, the rise of community health, and the growing economic gains of medical professionals in post-plague Europe; see Arrizabalaga, Facing the Black Death, in Luis Garca-Ballester, ed., Practical Medicine from Salerno to the Black Death, 237-288, esp. 280-281. My data do not corroborate this view; there was some variability among individual practitioners, but there was no appreciable increase in the use of prophylactic measures between 1348 and 1600. 50) Hon dich que pendre .III. vegades la setmana per lo mat una dragma ho .III. diners pesants de na triaga s cosa molt protosa, Agramont, Regiment de preservaci de pestilncia, ed. Arrizabalaga et al., 63. 51) li grans triacle fait de x ans, duquel on doit prendre de .xv. iours en .xv. iors ou de mois en mois, avec .ij. onches de bon vin airant souef il resiste molt a la putrefaction de lepydimie Et en tel maniere comme dit est de triacle puet on dire de metridaton, Sies, Das Pariser Pestgutachten von 1348, 50. See also Optimum [theriac]: e kind that frees the rooster from poison and has been aged for ten years, in Cogliati Arano, e Medieval Health Handbook Tacuinum sanitatis, Plate XLI. eriac (triacha). 52) Sumatur bis in septimana de tiriaca ad quantitatem fabe um vino albo aquato vel
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in winter, unmixed and full-strength.53 As a prophylactic, it was considered especially useful for stout, plethoric individuals.54 eriac served to settle the stomach, and would neutralize the ill eects of tainted food or drink.55 A little theriac diluted in vinegar was a good tonic with which to wash the face prior to leaving ones house.56 For maximum protective eect, the medicine had to be taken regularly, at least two or three times a week, if not daily, before every meal.57 Once disease had set in, theriac appeared to be equally unsurpassed. Traditional scholastic therapy against particular poisons, borrowing from the Greco-Arabic medical tradition, had called for both internal and external treatments to be carried out at the same time, or in quick succession; this could involve alternate or simultaneous use of emetics or cathartics, carminatives, cordials, pain relievers, or just plain external massage.58 In plague medicine, too, there were systemic remedies comprising a variety of electuaries, powders, infusions, cordials, and digestives, as well as a whole host of fortifying herbal and mineral potions in various formulations. ey served to alleviate nausea, diarrhea, constipation, thirst, headaches, fever, pain,
cum aqua acetose quae mihi plus placet... See Johannes Jacobi in Sudho, Pestschriften, XVII, 27. 53) Item il sera bon de prendre deux fois la sepmaine la grosseur dune noix de theriaque de galien ou de metridat au matin a quatre heures avant menger en este avec conserves de Roses de violes, de nenuar ou buglose, en yver tout pur. See Jehan Guido, Briefve institution pour preserver & guerir de la peste (Paris, 1545), 9. 54) Il est bon que les cras uscent de triacle iii foiz de sepmaine, see Maistre Chretien in M. Pagart dHermansart, Une ordonnance medicale contre la peste, vers 1400, Bulletin Historique de la Socit des Antiquaires de la Morinie, 196 (1901), 8. 55) In that case, the patient was instructed to vomit until all the evil had been ejected, then was to swallow a potion of good wine with tiriaca maior: et post hoc sumatur tiriaca maior cum decoctione salviae, rutae, encianae, aristologiae, baccarum lauri et tormentilla et herba cimini... in vino bono et cum tale vino sic decocto; see Epistola et Regimen Alphontii Cordubensis de pestilentia in Sudho, Pestschriften, III. 56) ee daz er ausgeet sich waschen mit ezzig under den augen, dar inne ein wenig tryackers sey zergangen, see Sinn der hchsten Meister von Paris fr die Sterbung der Drsen (Dise ercznei fur den gebrechen der druezz), ibid.: II, IV. 57) See, for instance, Alfonso de Cordoba: uti ante omnem comestionem et bibitionem tiriaca de terra sigillata in quantitate unius nucis avellanae, ibid.: III. 58) See, for instance, Levey, Medieval Arabic Toxicology.
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weakness and anxiety. Warm water and vinegar helped avert vomiting; pomegranate juice with peppermint leaves helped settle the stomach. Purgation was vital for ghting the dyscrasias of pestilence, and could be accomplished before or after the letting of blood, another mainstay of treatment.59 Favored above all interventions, however, was the use of theriac, the traditional remedy against poison. Analgesic, sudoric, antitussive, antidiarrheal, and sedative, theriac was ubiquitous. Most physicians prized its regular dosing in a variety of formulations. us, after venesection, a fourteenth-century Prague practitioner urged his patients to take a little dryakel with warm wine or beer, then to get into a hot bed and cover up well to promote sweating.60 Alternatively, for adults who did not want to be bled, or for children, the treatment of choice was a dose of theriac administered with warm wine, followed by bedrest. e fourteenth-century Maynus de Maineriis recommended either tyriaca magna, or else a theriac of his own compounding.61 A fteenth-century treatise advised liniments of roasted eggshell lled with saron, powdered and mixed with theriac.62 A rare writer warned against putting theriac plasIbn Khatimah, for example, used a decoction of prunes and breastberries with sugar and tamarind; this could be taken on an empty stomach and would both purge and soothe. See Taha Dinanah, Die Schrift von Aba Gafar Ahmed ibn Ali ibn Mohammed ibn Ali ibn Hatimah aus Almeriah ber die Pest, Archiv fr Geschichte der Medizin, 19 (1927), 27-81. Alfonso de Cordobas recipe was purgetur cum pillulis magistri Nicolai et cum teriaca dissoluata. Cum aqua scabiosae purgatur saepius locus cordis et hoc reiterari, quotiens necesse fuit, quosque perfect curetur. However, any laxatives employed must be mild to guard against excessive dehydration; otherwise the patient could die of intestinal ux: Caveatur a forti medicina et maligna, quia tales frequenter per uxum ventris moriuntur. Sed cassia stula, tamarindi, reubarbarum, viole, pruna, et quandoque clisteria possunt administrari. See Johannes Jacobi in Sudho, Pestschriften, XVII, 28. ick cooked quince juice with bolus rubra was eective against diarrhea; clysters (enemas) were used to relieve dangerous intestinal accumulations. 60) Ein weiteres deutsches Pest-Regiment aus dem 14. Jahrhundert und seine lateinische Vorlage, das Prager Sendschreiben Missum Imperatori vom Jahre 1371, see Sudho, Pestschriften, III. 61) recepta tiriace per nos composite. See R. Simonini, Maino de Maineri ed il suo Libellus de preservatione ab epydimia (Modena, 1923), 27. 62) Ein neues deutsches Pestblatt; see Sudho, Pestschriften, III.
59)
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ters on the plague bubo for this might propel the pestilential poison inward;63 even so, the physician must always aim to comfort the heart, and therefore, if possible, apply theriac near to the heart, past the [plague] apostume.64 e exact mechanism by which the drug counteracted the pestilential venom was, as noted above, a matter of speculation. Nevertheless, theriac was employed both as prophylactic and as therapeutic in various formulations. Moreover, both physicians and their patients seemed to have been fully aware of the physiologic eects of its powerful ingredients and the fatal consequences of overdosing. ey used it judiciously. Warm and dry in the humoral medicinal schema, theriac, properly aged, was known to be eective against poisons, and both warm and cold illnesses, rheums, and uxes.65 Its most important activity, however, was due to its unique proprietas, dened by Galen as the operation of a medicine that proceeded from the totality of its substance. is could only be known through experience, hence precise dosing (all the more dicult since the stronger the medicine, the less should be given) was essential and must be based on an empiric standard.66 Proprietas was what certain articial compounds acquired when mixed, namely, special properties
Supra locum apostematis non ponatur tyriaca, quia ipsa propellit venenum ante se et eciam faceret ipsum profundari ut declarat Arnoldua de Villa nova in speculo in caseo recenti intoxicato. See Jacobi, Tractatus de pestilencia, in ibid.: XVII. 64) Semper medicus habeat mentem ad confortandum cor et istud pro alio remedio non dimittatur Post apostema versus cor ponatur tyriaca, si possibile est, et at electuarium tale. Ibid. 65) It was also considered primarily good for cold temperaments, for old people, in winter, in cold regions and, if necessary, anywhere else. See Cogliati Arano, e Medieval Health Handbook Tacuinum sanitatis, XLI. Clearly, medieval physicians recognized that the natural qualities of theriac had a complex therapeutic spectrum. 66) McVaugh, eriac at Montpellier. According to McVaughs reading of the Questiones de tiriaca by William of Brescia, themselves drawing upon Averros commentary on Aristotles Physics, the similitude between theriac and poison is analogous to that of magnet towards iron, or of nutriment towards a part of the body: in the case of theriac, vipers esh, being similar to vipers venom, acts on it by attraction; on the contrary, it repels all other poisonous humors. is is rationalized as arising from an internal tendency towards self-perfection. eriac thus was homeopathic and allopathic medicine rolled into one, both at the service of a perceived homeostatic milieu intrieur.
63)
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dierent from those of their individual components. Present-day physicians and pharmacists struggle with similar predicaments. e notion that the whole is greater than the sum of its parts is a concept alive and well in modern pharmacology, where the mechanism of action of numerous drugs remains unknown,67 and the complexity of chemical interactions, resulting in alteration of the eects of some agents when coadministered with another, dees memorization.68 e eect of theriac on reported plague symptoms is dicult to assess. Multiple ingredients, together with lack of standardization and disputes about proper constituents, as well as possible chemical interactions, make this a challenging, if not impossible, task. Historians of pharmacy have generally shied away from studying medicaments, especially in the medieval era. Prejudice against supposedly ineective therapies together with a rationalist bias may explain this lack of interest. Lexicography in the study of ancient drugs presents additional obstacles. Medieval botanical terminology is not easily reduced to modern scientic taxonomies, and the array of both exotic and indigenous plants encountered compounds researchers diculties. Scholars such as Jerry Stannard, Danielle Jacquart, and, more recently, Jean-Pierre Bnzet, have pointed to the complexities in the transmission of pharmacologic vocabularies. Western translations of Arabic pharmacopeias, themselves based on Greek, Persian, and Arabic terms, were often but transliterations; glossaries and lists of synonyms were helpful, but without universal scientic criteria, linguistic, geographic, or functional confusion was easy. Furthermore, in the absence of microscopic plant anatomy, plant identication itself was prone to errors. Pulverisation as well as fraud (a frequent accusation levelled against grocers and apothecaries) pre-
67)
e exact mode of action of important drugs such as digitalis, quinine, and colchicine, for example, remains poorly understood or unknown; the same is true for the pharmacodynamics of many newer medicines, especially anticonvulsants and psychotropics. It is noted that colchicine, a unique anti-inammatory agent very eective against gout, and an alkaloid of autumn crocus (meadow saron, Colchicum autumnale), was a frequent constituent of medieval plague remedies. 68) See Goodman & Gilmans e Pharmacological Basis of erapeutics, I.1.
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sented additional pitfalls in product identication.69 Nevertheless, it is notable that all of the most prized composites contained powerful ingredients each one eective against a number of plague symptoms. eriac and mithridatium, the classic antidotes, both included opium. is may well explain their longlasting appeal.70 It is probably safe to assume that in plague medicine, this one ingredient would have been valued for its three major indications: relief of pain and anxiety, suppression of cough, and suppression of diarrhea.71 Not many plague authors discussed the ingredients of theriac. e secret of its manufacture was closely guarded, and the reader referred to the local apothecary. What writers did not provide in recipes, however, they made up for in promotional rhetoric, praising the merits of their medicaments. Fine herbs, hearty syrops, splendid remedies, and priceless powders competed for the attention of the reader, promising immunity.72 Authors pointed out their
See Jerry Stannard, Medieval Reception of Classical Plant Names, Revue de Synthse, 89 (1968), 153-162. Also Yves Lefvre, La Lexicographie du latin mdival et ses rapports avec les recherches actuelles sur la civilisation du Moyen-Age (Paris, 1981). For fake opium, see for instance Radhi Jazi, Contribution ltude de lhistoire de la pharmacie arabe: Falsication et contrle des mdicaments pendant la priode arabe (PhD thesis, University of Strasburg, 1966), 82. 70) It is unclear whether the opiate laudanum was in use during the fourteenth century. Most sources credit Paracelsus for coining the term for this compound which, according to the OED, he formulated using gold leaf, crushed pearls, etc. It was, however, suspected early on that opium was the real active agent of Paracelsus costly cures. e gum resin ladanum, or labdanum (from plants of the genus Cistus, esp. C. ladaniferus and C. creticus) used for fumigation and in perfumery, adds to the etymologic confusion. Laudanum, ladanum, labdanum, and lapdanum appear in plague recipes in various applications, and it has been dicult (for this writer) to determine specic therapeutic usage. Modern pharmacopeias include laudanum as tincture of Opium; made of opium and equal parts of distilled water and alcohol, it is for immediate eect considered preferable to plain opium. 71) Purgation, eected early in the course of disease, served to cleanse the body of bad humors. Any subsequent constipation, resulting from the use of opiates, would have slowed dysentery and uid loss. Opiates also helped intestinal absorption, by slowing motility, thus promoting absorption of uids, nutrients, and (other) medicines. 72) eyn creftig syrop; one was to take one drop morning and evening, with a spoonful of warm beer; also sluck pestule(nci)e iij. Pillen, dat do, wen du wult slapen
69)
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drugs safety for women and children,73 or invoked the fame of purported discoverers. Maynus de Maineriis, for example, had a special opiate electuary called Inestimable Treasure and Glory, a recipe straight out of the so-called letter of Aristotle to Alexander the Great.74 e sixteenth-century Nicolas de Nancel, very particular about compounding and formulation, stressed that certain tried and true remedies should only be bought at the apothecaries shops, and only at the most reputable ones...75 All the same, many plague doctors demonstrated a sophisticated knowledge of active ingredients. eir systematic use of theriac together with cautious dosing could hardly have been inadvertent. Moreover, their use of multiple types of preparations and routes of administration was further evidence of their pharmacologic expertise. eriac and theriac-like opiates were not only given in oral form as electuaries and syrups, but also in rectal, topical, transmucosal, and inhalable preparations. ere were theriacal powders, salves, and ointments, which could be applied to the skin, or lozenges, which could be given sublingually. Camphored opiate pomanders and sponges could be snied or inhaled with almost certainly observable benecial eects. Fomentations of decocted poppy leaves and poppy capsules were spread over the face and chest to bring
gan, so machstu der ske wedderstan Anon., Incipit regimen pestilencie (Ein deutsches Pest-Regiment aus dem 14. Jahrhundert) in Sudho, Pestschriften, III. 73) das aller kostlichest bulver dassoltu alle morgen niechter einnemenes schat auch keiner frauwen. See Anon., Ein neues deutsches Pestblatt (Augsburg, ca. 1483) in ibid., IV. 74) quod nominatur esaurus et gloria inestimabilis. Cuius elcunarii compositionem ponit Aristoteles in sua episula ad Alexandrum... Simonini, Maino de Maineri, 27. 75) Nancel, in true sixteenth-century humanist vein, prided himself on following the teachings of Dioscorides, and not those of le Nicolas des apothicaires homme grossier & peu savant who followed, as in all else, the description of the Arabs, muddling innumerable Arabic words, and perverting in a number of places the intent of the good Greek authors: whom he neither had read, nor followed, nor understood (a suyvi la description des Arabes, comme il fait partout, broullant innis mots Arabiques, & pervertissant en plusieurs endroits lintention des bons autheurs Grecs: lesquels il na ni leu, ni suyvi, ni entendu...), see Nicolas de Nancel, Discours trs ample de la Peste (Paris, 1581), 176. Reference is to Nicolaus Salernitanus, the compiler of the famous Antidotarium Nicolai.
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on sleep.76 Opium latex was combined with rose oil, almond oil, saron, myrrh, egg yolk and even womans milk, as an external remedy for a variety of complaints. Warm poultices made of hollowed cooked onion lled with good theriac, or with Guys theriacal powder, were considered one of the best topical remedies.77 It is therefore unlikely that the consistent use of theriac was accidental, or did not have the desired pharmacologic eect. Presumably, the wide diversity of delivery techniques simply reected a need for various methods of achieving symptomatic relief. Modern medicine has, indeed, similarly perfected inhalable, oral, transdermal, and transmucosal sustained release preparations for a variety of drugs, including narcotic analgesics.78 Another measure of plague physicians pharmaceutical sophistication was their prociency in formulating, storing, and preserving techniques, all very important in the manufacture and conservation of theriacal drugs. For example, goose grease or pork lard were favorite ointment bases into which could be mixed liquid or powdered medicinals. Both have long served as carriers of antiseptic or analgesic remedies for skin swellings, boils, and ulcers; they are known to have exceptional penetrating power and, as late as the twentieth century, were still vehicles of choice for transdermal delivery.79 Likewise, acacia, or gum arabic, an additive frequently combined with
Scarborough, Opium Poppy, n. 33. After scarication pour vuyder le sang envenim, qui est l autour & dedans le bubon applicqueras medicaments suppuratifz & attractifz en la forme suyvante. Prens un oignon blanc, & le cure par dedans avec le cousteau, Y faysant une concavit assez grande, laquelle rempliras de fort bonne theriaque, ou de la pouldre theriacale de Guidon, & le couvriras de son couvercle, & feras cuyre soubz la brase iusques ce quil soit mol: & tout chauld lappliqueras sur le bubon. Cest un des meilleurs remedes que lon y sache appliquer. Franois Vallriole, Traict de la Peste (Lyon, 1566), 152. 78) In 2007, administration routes for opioids include transmucosal application via lollipops, as well as other intranasal, transdermal, or sublingual delivery systems. Fentanyl, a synthetic narcotic forty times more active than morphine, and buprenorphine are administered this way; see, for example, Schafer et al., Pain Treatment, 9. 79) Charles LaWall, Four ousand Years of Pharmacy (Philadelphia and London, 1927). According to the U.S. Dispensatory, where maximum absorption is desired lard is probably the best of the ocial ointment bases.
77) 76)
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decoctions of opium, known to extend the eectiveness of any medicine, was a careful choice, especially in the case of theriac where long shelf life and compound stability were important.80 From a modern vantage point, some of the general recommendations, procedures, and remedies of plague practitioners were eminently sensible.81 To be sure, pharmacologic eects of preparations based on simples containing one single active ingredient, such as rue, vinegar, or aloe, can be assessed relatively easily, for they remain readily available and are part of present-day natural medicine pharmacopeias. Likewise, the physiologic results of bloodletting, and its attendant risks and benets, can to a certain extent be extrapolated from medieval descriptions: modern cardiovascular medicine can explain the hemodynamic eects on the heart and lungs of reducing preload and afterload; hematology, cell biology, and general medicine can predict the potential consequences of signicant iron depletion and volume loss.82 At the peril of being branded pre80)
Scarborough, Opium Poppy, 17. In modern terms, the combination of gum arabics constituents (a natural gum of acacia and colloid glycoprotein, containing arabin, arabic acid, calcium, and traces of magnesium and potassium) explains its pharmaceutical properties; highly nutritious and an excellent mucilage, excipient, emulsier, and thickener, gum arabic is still used as a pharmaceutical demulcent in various syrups (especially cough syrups), pastes and pastilles. Gum arabic still has many applications in the confectionery and beverage industries. 81) It should also be noted here that plague physicians were expert in supportive treatment during patient recovery or deterioration. Both hydration and nutrition were administered judiciously, in order to strengthen debilitated patients during convalescence, or to comfort the dying in their last days. Meals and potions were composed to provide necessary uids and electrolytes, vitamins and minerals, and easily digestible nutrients. Chicken broth, lemon and pomegranate juices, rose syrup and honey were among the most popular. Servings were frequent and small. Body temperature, rest, and sleep were carefully monitored. Dietetic and therapeutic governance of the non-naturals were just as intrinsic to plague therapy as they were to prophylaxis, and as important as any pharmaceutical or surgical ministrations. For a detailed discussion of preventive and therapeutic plague medicine, see Nockels Fabbri, Continuity and Change in Late Medieval Plague Medicine, III. 82) See for instance Peter Brains argument regarding iron deciency anemia in bacterial diseases, in Peter Brain, Galen on Bloodletting: A Study of the Origins, Development, and Validity of His Opinions, with a Translation of the ree Works (Cambridge, 1986), ch. 10.
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sentist, one may in the same way infer from current biochemistry and pharmacology the possible eects of more complex botanical substances and herbal extracts; all this, even though the specic historical actors in playdisease, patient, and remedyare not at hand, and may have diered from later historiographic interpretations. Given these constraints, one can engage in a number of speculative exercises in order to shed light onto the potential eects, and eectiveness, of medieval plague medicine and its seemingly quaint practices. Table 1 correlates the most common plague symptoms described by many authors with several typical plague tract remedies, using present-day medical criteria.
Table 1. Eect of selected plague remedies on reported plague symptoms
Absinth (Wormwood) Fever + antipyretic, diaphoretic ++ mild local anaesthetic + antispasmodic + + stomachic + + + topical antiinammatory, anaesthetic antibacterial antifungal diuretic ++ +++ +++ +++ +++ + + ++ ++ Camphor eriac (Opium) Pomegranate Rue
Pain Cough Diarrhea Vomiting Dyspnea, pulmonary congestion
Abscess, Boils, ulcers
wound healing
++ topical pain relief, cooling
++ topical pain relief sedative, hypnotic, weak bactericidal
+ astringent
General Properties
antioxidant antimicrobial antifungal, anthelmintic
antibacterial antioxidant
+ - mild eect ++ - moderate eect +++ - strong eect
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Each of the remedies in this table possesses specic therapeutic properties that would have been eective for one or more of the listed symptoms.83 In the case of theriac, its analgesic action would result in part from the eects of raw opium on the central nervous system. Opium and its two principal alkaloids, morphine and codeine, are powerful pain relievers, and are to this day unsurpassed both as hypnotics and sedatives. e drug has additional astringent and antispasmodic properties, making it also an eective remedy for diarrhea and cough.84 Known to exert its action more slowly than pure morphine, opium isby modern pharmacological standardspreferable in certain cases, such as the control of diarrhea, yet another millennial-deep reection of Dioscorides recommendation that poppy capsules be used for conditions of the bowels.85 In the treatment of plague, theriac and other opiates such as mithridatium, philonium magnum, requies magna, and athanasia, were
See for example Je M. Jellin, Forrest Batz, and Kathy Hitchens, Natural Medicines Comprehensive Database (Stockton, CA, 1999). A list of simple medicines, based on their frequency of occurrence in plague tracts, and their medicinal uses derived from medieval, early modern, and modern sources is included in Appendix II: Selected Simples in Plague Medicine, in Nockels Fabbri, Continuity and Change in Late Medieval Plague Medicine, 217. is paper does not begin to address all potential therapeutic eects of the numerous substances used in medieval plague medicine. Recent work on the antimicrobial properties of pomegranates, rich in vitamins and minerals, is but one example of the empirical good sense of plague prescriptions. See, for instance, the chapter Antimicrobial Activities of Pomegranate in Pomegranates: Ancient Roots to Modern Medicine (Boca Raton, 2006). For this reference, I am indebted to an anonymous referee; the same referee also directed me to recent work on medieval Anglo-Saxon medicines and their therapeutic eectiveness; see Anne Van Arsdall, Medieval Herbal Remedies: e Old English Herbarium and Anglo-Saxon Medicine (New York, 2002). 84) Morphine, the main active component of opium, depresses the thalamus, the sensory cortex, and the respiratory and cough centers; other opiate alkaloids (especially codeine, papaverine, narceine, noscapine, and thebaine) stimulate the medulla and the spinal cord; papaverine and noscapine relax intestinal muscle, thus the historical use of opium in the treatment of diarrheas. See Scarborough, Opium Poppy, 13. In the 1970s, the demonstration of opioid receptors in the human brain as well as the discovery of endogenous opioid substances (endorphins and enkephalines) further contributed to the understanding of opium in the process of nociception and internal pain modulation; see Schafer et al., Pain Treatment, 9. 85) Ibid.
83)
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thus probably prized for their sedative, antitussive, and antispasmodic properties, the latter potentiated by the addition of solanaceous substances such as henbane (hyoscyamus), or mandrake (mandragora). Both act primarily at the level of the autonomic nervous system by inhibiting smooth muscle contraction. e simultaneous use of solanaceous drugs and opium, a central analgesic, is synergistic in acute pain syndromes, but eectiveness is also strongly correlated with toxicity.86 No one could argue, had deemed Paul Slack in his discussion of plague medicine in sixteenth-century England, that the appeal of contemporary medical knowledge lay in its instrumental success.87 True, theriac, like alcohol, opium, or various other herbal remedies, only brought relief, not cure. eriac and other opiates only alleviated nausea or diarrhea, soothed cough and sore throat, and calmed anxiety. Yet, like many treatments, whether based on humoral theory or rooted in older magical traditions, the manifold applications of theriac were carefully selected and would have been, if not curative, at least helpful. Many plague remedies were supremely palliative; others were undoubtedly restorative, and some were probably protective. ere were even, on occasion, reports of cures.88 Few records remain to document the actual operation and dispensation of specic drugs in the treatment of plague at the local level. Rather than reporting individual case histories, or detailing apothecary stores, the Pestschriften literature conveys the details of fumigation, isolation, and other sanitary measures. Archives record various religious practices, processions, and devotions.89 NevertheHyoscyamus and mandragora, both solanaceae, contain the anticholinergics atropine and scopolamine. Both atropine (a mixture of d- and l-hyoscyamine, also known as belladonna because of its mydriatic eects) and scopolamine are widely used in modern medicine. See Goodman & Gilmans e Pharmacologic Basis of erapeutics, II, 7; also Bnzet and Flahaut, Pharmacie et mdicament, 671, n. 53. 87) Paul Slack, e Impact of Plague in Tudor and Stuart England (London, 1985), 35. 88) See for example Ibn Khatimahs 1349 case report in Dinanah, Die Schrift ber die Pest, 62-63. 89) See Jean Nol Biraben, Les hommes et la peste en France et dans les pays europens et mditerranens, 2 vols. (Paris, 1975), esp. vol. 2.
86)
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less, a 1587 municipal register of Signes, a small Provenal town of population one thousand, conrmed the standard antipestilential treatment regimen. Here, the local apothecary, at a cost to the municipality of 1,150 orins, provisioned the sick at the plague inrmary with approximately forty dierent simple and compound medicines.90 Most of the items supplied corresponded to the classic remedies of the medieval plague pharmacopeias: diachylum plasters, basilicum ointments, rose honey and rose oil, lemon and poppy syrups, wine and spice cordials, and, of course, theriac.91 e vast majority of prescriptions, composites for topical or oral use, veried that opiates and solanaceae were the fundamental therapeutic agents. From March to September 1587, the roster of individual therapeutic measures at the Signes inrmary also substantiated the general principles of plague medicine: cleanse the humors, strengthen the vital parts, and neutralize poisons. ese prescriptions for the mallades ateintz de contagion in 1587 Signes are indicative of the same conservatism as that evidenced by countless plague tracts: that plague therapy, by the end of the sixteenth century, had evolved little, if at all, since the time of the rst pandemic.92 However, both sources also conrm the preponderant role of theriac and theriac-like opiates in the treatment of plague symptoms. Even if inferring disease through the on-going use of these agents might be considered problematic, the presence of theriac in times of plague nonetheless denotes well-dened therapeutic preoccupations, and validates the retrospective analysis of broader pharmacologic categories.93
90) 91)
Bnzet and Flahaut, Pharmacie et mdicament, 685-689. Among 399 single deliveries even cupping candles were included, demonstrating also a persistent preoccupation with humoral evacuations. 92) Bnzet arrived at the same conclusion: La thrapeutique de la peste, mise en jeu en cette n du XVIe s., a peu volu depuis le Moyen Age, Guy de Chauliac ne la dsavouerait pas. Bnzet and Flahaut, Pharmacie et mdicament, 687. 93) Bnzet, who used this approach to trace medieval pathologies, concluded that humoral pharmacotherapy does not necessarily permit the same extrapolations as modern-day consumption of drugs, and cautioned against overrating particular medicines as markers of disease. In the Middle Ages, drastic purgatives aimed to eliminate vitiated humors as much as to stimulate lazy intestines. A rubefying plaster might have
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Examined through a pragmatic lens, plague medicine was unquestionably based on an intricate rationale. Much of it derived from classic humoral therapy and bore the stamp of Galenic thought, yet, equally frequent were contemporary practical observations and nonscientic, folkloric, or empiric accretions.94 Scholastic medicine itself was not entirely deductive. Rather, it was characterized by the indefinite integration of new material, within a closed doctrinal and disciplinary framework; and by a lively dynamism that did not involve radical changes.95 us plague medicine was a product of empirical and observational usage, underpinned by theory and tradition. At the same time, many of its recipes exhibited magical features, and popular responses to the plague often combined crude magic with the cheaper natural remedies such as vinegar and rue.96
served to relieve rhumatism rather than to ripen a bubo, etc. Nonetheless, the retrospective study of broader therapeutic categories retains validity. Opiates and solanaceae were fundamental in humoral analgesia. Colchicum, for example (still used in 2006), was part of the treatment of gout just as much as was purgation and humoral attenuation. Similarly, vermifuges, pediculicidals, and antipsorics were most likely used for the troubles they implied. Stavesacre, as Bnzet stated, may not have indicated the presence of lice at a certain moment in time, but does denote a specic therapeutic concern. See ibid., 18. 94) e medicinal usage of many botanical substances had been discovered by folk medicine long before modern chemistry isolated their active compounds. For instance, the juice of poplar trees and the bark of the willow, containing salicylates, were already in use by the Hippocratic physicians for treating fever and pain. See John M. Riddle, Quid pro quo: Studies in the History of Drugs (Hampshire & Brookeld, VT, 1992). 95) a concept of increment that was not progressive in the sense of continual accumulation. Chiara Crisciani, History, Novelty and Progress in Scholastic Medicine, Osiris, 6 (1990), 118-139, also in M.R. McVaugh and Nancy G. Siraisi, eds., Renaissance Medical Learning: Evolution of a Tradition (Philadelphia, 1991). e fourteenth-century scholastic physician-surgeons Henri de Mondeville and Guy de Chauliac had invoked an artisanal metaphor to describe the accretions and improvements called for in science. eir image was that of a house, where workers continually labor to repair things that are broken, to replace parts, and to straighten the walls yet the structure of this house was already well dened and distinct. 96) e co-mingling of empiric, scholastic, and magical elements was not limited to the poor. us, the learned fourteenth-century Maynus de Maineriis, for example, advised not only a variety of herbs and his own proprietary theriac, but also a compound made of ground rubies, emeralds, coral and a special stone found in the asps head: rubinus similiter smaragdus, et corallus utriusque et lapis inventus in capite
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is harmonious plurality of therapeutic approaches was underscored by the parallel coexistence of humoralism, homeopathy, Christian metaphysics (as expressed in the doctrine of signatures), and magical beliefs. Yet, even though preventive medicine rubbed shoulders with folklore, quackery with science, acquaintance with plague medicine forces a warning against oversimplication.97 e inuence of the Black Death on medical doctrine and therapeutic practice has been a matter of historical debate. Some authors, considering that traditional remedies were soon found useless to combat the dire sickness, focused on the search for new universal remedies, such as the alchemical quests for the quintessence of certain substances, for instance, gold or wine.98 Others, while noting that therapies typically resisted change, have been content to point out the apparent general lack of therapeutic merit of medieval medicine. Its fanciful recipes might be of historical interest but they had little if any benecial value.99 Some went so far as to suggest that
aspidis Historian Paul Slack deemed that it would be a mistake to assume that there was any real social or cultural divide in medical treatments or medical attitudes. See Slack, Impact of Plague, 34. is dichotomy held true into the seventeenth century, when English physician and astrologer Richard Napier hung on patients doors a talisman to protect against plague. 97) Charles F. Mullett, e Bubonic Plague and England: An Essay in the History of Preventive Medicine (Lexington, 1956), 3. 98) e quest for the elixir, an agent of perfection for metals and human bodies deemed to have miraculous healing powers, had been started by thirteenth-century alchemists. Plague physicians such as Gentile da Foligno and Maynus de Maineriis were among those who endorsed alchemical compounds in their therapies. See Chiara Crisciani and Michela Pereira, Black Death and Golden Remedies. Some Remarks on Alchemy and the Plague, in Agostino Paravicini Bagliani and Francesco Santi, eds., e Regulation of Evil: Social and Cultural Attitudes to Epidemics in the Late Middle Ages (Florence, 1998), 7-39. 99) Cest une pharmacope bizarre o se heurtent les drogues les plus insolites; la valeur de ces recettes et de ces antidotes infaillibles est purement historique. See H. mile Rbouis, Etude historique et critique sur la peste (Paris, 1888), 41. Nancy Siraisis classic work cautions, that in attempting to evaluate medieval and early Renaissance therapeutic knowledge and techniques, the measure cannot be that of physical eectiveness. Although the substances in use included some that would reliably produce consistent, perceptible results, the ability of practitioners to produce predictable eects by medication was limited. is was due to their rough and
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the very profusion of medicines suggested for each complaint indicated that they could not have been of much practical help.100 Instead of interventionist remedies, scholastic medicine was seen to emphasize moral advice from men of learning and discernment.101 e physicians role was understood as essentially consolatory and psychological, and past therapeutic practices were construed as a mixture of ritual and placebo.102 Moreover, the rationale behind many old popular remedies was never articulated; for they represented the debris of so many dierent systems of
largely intuitive means of dosing and preparation, which more often suggest[ed] the kitchen than the laboratory. See Nancy G. Siraisi, Medieval & Early Renaissance Medicine: an Introduction to Knowledge and Practice (Chicago, 1990), 148. Anne Van Arsdall has pointed to the continuity of Galenic pharmaceuticals from the time of the Roman Empire to at least the seventeenth century; challenges to ancient prescriptive practices began only with the challenges to ancient theories of anatomy and physiology in the sixteenth century. See Anne Van Arsdall, e Medicines of Medieval and Renaissance Europe as a Source of Medicines for Today, in Bart K. Holland, ed., Prospecting for Drugs in Ancient and Medieval European Texts: A Scientic Approach (Amsterdam, 1996), 20. Siraisi, for whom the experience of plague brought little change in medical practice, nonetheless called attention to the increasing intellectual focus on practica (the branch of medical knowledge which dealt with particulars of disease and treatment); the outpouring of plague literature and the appearance in fteenth-century curricula of the branch known as practica testied to this. is growing interest for the particular and the specic was one the developments leading to new theories of disease, and the new anatomy of the sixteenth century; see Siraisi, Medieval & Early Renaissance Medicine, 152. 100) Paul Slack, Mirrors of Health and Treasures of Poor Men: e Uses of Vernacular Medical Literature of Tudor England, in Charles Webster, ed., Health, Medicine, and Mortality in the Sixteenth Century, Cambridge Monographs on the History of Medicine (Cambridge, 1979), 237-273, at 264. 101) Harold J. Cook, Good Advice and Little Medicine: e Professional Authority of Early Modern English Physicians, e Journal of British Studies, 33 (1994), 1-31, at 31. 102) See e erapeutic Revolution: Medicine, meaning, and social change in nineteenth-century America, in Charles E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge, 1992), 9. Indeed, Rosenberg observed that, on the whole, medical historians ignored past therapeutics and that if they did not, they were most often obsessed with change as progress and concerned with dening such change as an essentially intellectual process.
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thought that their genealogies would be dicult to trace.103 Black Death historian Robert Gottfried, one of plague medicines harshest critics, denounced the members of Europes fourteenth-century medical community as rigid and generally inept, unable to respond to new diseases with eective treatments, because they lacked expertise in clinical research and observation.104 In more recent years, medical historians have been largely concerned with contextualizing, or historicizing, interpretations of past medical practices, including therapeutic ecacy. Such scholarship has pointed to social, intellectual, cultural, and economic forces that sanctioned the utility and the employ of various therapies.105 erapeutic choices are seen to be subject to a wide variety of determinants, perceived eectiveness being but one of the factors inuencing treatment decisions. Equally important might also be the prevailing ideas about disease causes, disposition of the patient, practitioner experience, or economic motive. us, the key to understanding therapeutics lies in recognizing that all treatment strategies are part of a system of belief and behavior participated in by physician and layman alike.106
Keith omas, Religion and the Decline of Magic (New York, 1971), 185. See also Slack, Mirrors of Health, in Webster, ed., Health, Medicine, and Mortality, esp. 264273. 104) Robert S. Gottfried, e Black Death: Natural and Human Disaster in Medieval Europe (New York, 1983), 104. 105) Charles Rosenberg and John Harley Warner notably argued that therapeutic behaviors and practices, central components in any medical system, could be properly understood only within their own local and temporal contexts, and as part of a social and cultural pattern. Measures utilized to ameliorate or cure certain disease symptoms worked not because they acted according to modern physiological criteria but because they provided visible and predictable physiologic eects; purges purged, emetics induced vomiting, opium soothed pain and moderated diarrhea. See Charles E. Rosenberg, e erapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth-Century America, in Morris J. Vogel and Charles E. Rosenberg, e erapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia, 1979). Also John Harley Warner, e erapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885 (Princeton, 1997). 106) Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine, 12.
103)
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Other scholars, however, have called for systematic scientic examination of the therapeutic claims of ancient and medieval medical texts, in order to explain the persistence and popularity of traditional remedies. Medievalist Anne Van Arsdall has pointed out that the recipe for theriaca, also called theriac, or Venice treacle, is a good example of what moderns disdain in ancient medicinesbut what was in it and why it was popular for centuries, until as late as the nineteenth century, is not understood.107 Indeed, there is a core pharmacopeia that constantly appeared in ancient medical literature. Until the nineteenth century, the drugs used were remarkably consistent, and change was resisted.108 In fact, theriac itself remained part of the German Pharmacopeia until 1872, and was still included in the 1884 edition of the Pharmacope franaise.109 e present discussion does not reject the view that historical truth may be relative to a given historical moment. However, the fact that such cognitive relativism is also intimately bound to physical, physiological, and pharmacological constraints must be considered. us, for instance, the ecacy of bloodletting in removing accumulated bad humors, historicized as a cultural practice at a particular historical moment, does not preclude the physiologic eects necessarily attendant to the procedure. In the same way, the therapeutic eects of theriacdemonstrated by observable benecial outcomesnot only attest to the persistence of magical beliefs that like cures like, but also t neatly into an allopathic humoral epistemology of contraria contrariis curantur; yet, above all, they are explained by the pharmacokinetics of opiumassuming, of course, that fourteenth-century poppy juice was similar to that of the
Arsdall, e Medicines of Medieval and Renaissance Europe as a Source of Medicines for Today, 26. 108) A typical medicine chest of an eighteenth-century physician was not very different from a thirteenth-century physicians chest except the medieval physician would not have had the drugs from the New World, such as balsam of Peru, guaiacum, sasparilla, and tobacco; see Riddle, Quid pro quo. John Harley Warners landmark study of therapeutic change in nineteenth-century American medicine also demonstrated that once established, medical therapies showed remarkable tenacity and that most changes were very gradual; see Warner, erapeutic Perspective, 160, and chapter 4, erapeutic Change. 109) Watson, eriac and Mithridatium, 150.
107)
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Fig. 1. An assuredly good electuary for the pestilence and how to make it... From Hieronymus Brunschwig, Liber pestilentialis de venenis epidemie. Pestbuch, oder Das buch der vergift der pestilentz (Strasburg, 1500) (by permission of the Herzog-AugustBibliothek, Wolfenbttel: [456.17 eol. 2(2)]).
twenty-rst. In this vein, the interpretations of relativist historians are complemented, rather than contradicted, by the studies of socalled absolutist empiricists like Jerry Stannard and John Riddle, or, more recently, Jacalyn Dun.110
110)
See for example Jacalyn Dun and Barbara G. Campling, erapy and Disease
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Against this backdrop of competing historiographic interpretations, the question of pharmacologic eect and therapeutic ecacy of plague medicines in general, and of theriac specically, merits investigation. In the treatment of plague, where scholastic humoralism and practical experience combined to combat the disease, many key measureswhile not curativewere nevertheless restorative and/ or palliative. Moreover, from a modern vantage point, the continued and consistent use of certain specic remedies suggests that plague medicine was not only pharmacologically informed but also that it oered signicant symptomatic relief. eriac in particular, ubiquitous in plague prescriptions, was most likely benecial in the treatment of a variety of disease complaints. Clearly the routine usage of theriac and its relative ecacy in treating plague have been under-appreciated by traditional historiography. In recent decades, a renewed interest in herbal medicines and ethnobotany has led to an increasing role for premodern western medical knowledge as a guide to discovery.111 Researchers like John M. Riddle, Bart K. Holland, and Anne Van Arsdall have underscored the value of studying traditional medicinal plants in the quest for pharmacologically active compounds, and have cautioned against modern rationalist bias in assessing the eect of old remedies.112 According to Holland, a systematic, interdisciplinary re-examination of ancient and medieval medical texts by pharmacologists, classicists, medievalists, and historians of medicine, linked with modern standards of testing, would be less expensive and perhaps more productive than prospecting for phytochemicals in tropical rainforests. Above and beyond, John Riddles work has provided concrete examples of early herbal remedies whose use has been validated by modern pharmacologic science. Not everyone agrees that studying the scientic basis for the long life of theriac requires the investigation
Concepts: e History (and Future?) of Antimony in Cancer, Journal of the History of Medicine and Allied Sciences, 57 (2002), 61-78. 111) Holland, ed., Prospecting for Drugs, 1. 112) See ibid., and Bart K. Holland, Prospecting for Drugs in Ancient Texts, Nature 369 (1994), 702. John M. Riddle, Eves Herbs: A History of Contraception and Abortion in the West (Cambridge, MA, 1997). Also idem, Quid pro quo.
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of messy polypharmaceutical concoctions of this kind.113 Nevertheless, perhaps the time has come, not only for close comparative scrutiny of ancient theriac recipes, but also for brewing some modern-day, laboratory-standard treacle, in order to document by controlled qualitative and quantitative analysis any positive therapeutic eects of this complex substance.. In conclusion, theriac was fundamental to plague medicine. e drug itself was obviously not a marker of specic disease. Its presence in medieval apothecary stores did not translate into individual disease cartographies; nonetheless, it did connect with certain symptomatologies.114 Together with cordials, pomanders, and fumigants, the enduring use of theriacs constituted an indisputable index of plague therapeutics, conrmed by multiple plague tracts and recipes. A paradigm of the remarkable continuity of medical tradition, the healing powers of theriac became part of the framework of modern pharmacologic palliation. In the absence of denitive antibiotic therapy (for presumptive bacterial disease of whatever microbial etiology), plague medicinealthough unable to extirpate the underlying disease causeknew how to oer signicant symptomatic relief. From a presentist standpoint, therefore, the prescription of theriac for plague made eminent good sense.
Arsdalls suggestion that pharmacologists investigate such concoctions was seen as extreme by one of the reviewers of her article in Holland, ed., Prospecting for Drugs; see M.P. Earles, in Medical History, 42 (1998), 262. 114) Bnzet and Flahaut, Pharmacie et mdicament.
113)
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Early Science and Medicine 12 (2007) 247-283

Treating Medieval Plague: e Wonderful Virtues of eriac*

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

Pain Cough Diarrhea Vomiting Dyspnea, pulmonary congestion

Abscess, Boils, ulcers

++ topical pain relief, cooling

++ topical pain relief sedative, hypnotic, weak bactericidal

antioxidant antimicrobial antifungal, anthelmintic

+ - mild eect ++ - moderate eect +++ - strong eect

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

C. Nockels Fabbri / Early Science and Medicine 12 (2007) 247-283

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