Treating medieval plague: The wonderful virtues of theriac

Early Science and Medicine

Volumn 12, Issue 3, 2007, Pages 247-283

  Fabbri, Christiane Nockels ^a  

^a YALE UNIVERSITY   (United States)

Author keywords

Black Death; Composite medicines; Medieval medicine; Plague tracts; Therapeutic efficacy; Theriac

Indexed keywords

ANTIDOTE; OPIATE;

CONFERENCE PAPER; DRUG COMBINATION; EUROPE; HISTORY; HUMAN; PLAGUE;

ANTIDOTES; DRUG COMBINATIONS; EUROPE; HISTORY, 15TH CENTURY; HISTORY, 16TH CENTURY; HISTORY, 19TH CENTURY; HISTORY, ANCIENT; HISTORY, MEDIEVAL; HUMANS; OPIUM; PLAGUE;

EID: 34548137337     PISSN: 13837427     EISSN: 15733823     Source Type: Journal    
DOI: 10.1163/157338207X205115     Document Type: Conference Paper

References (140)

1. Plague remained endemic in Europe until the eighteenth century.
2. This paper is based on the author's 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 author's.
3. This 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 justification for pharmaceutical practices could even be found in the Bible, which taught that God created medicines from the earth for man's benefit; 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).
5. "Eat garlic with bread every morning; salvia and rue; and in early morning take some bayberry...," urged a fifteenth-century Göttingen pest tract: "... et des morgens knuflock 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 Göttingen MS hist. nat. 51," in Gerhard Eis and Gundolf Keil, Fachliteratur des Mittelalters: Festschrift für Gerhard Eis (Stuttgart, 1968), 457-467.
6. For Jacme d'Agramont, 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 àntrach ho mala busaynna); see Jacme d' Agramont, Regiment de preservació de pestilència (Lleida, 1348), Estudis introductoris i Glossari, ed. Jon Arrizabalaga, Luis García Ballester, Joan Veny (Lleida, 1998), 63. Gentile da Foligno advised rue, figs, 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");
7. see Karl Sudhoff, "Pestschriften aus den ersten 150 Jahren nach der Epidemie des "schwarzen Todes" 1348," Archiv für Geschichte der Medizin, (1907-1928), III, V.
8. See for example the discussion of the "hearbes Carduus Benedictus and Angelica," in Thomas Brasbridge, The 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. 882003res_id=xri:eebo&rft_id=xri:eebo:image:25153:21.
9. "... 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 fievre de pestilence et especialement en este." Rudolf Sies, Das 'Pariser Pestgutachten'von 1348 in altfranzösischer Fassung (Pattensen, 1977), 48, 51.
10. 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.
11. See also Lynn Thomdike, A History of Magic and Experimental Science, 2 vols. (New York, 1923), esp. 130-131.
12. 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 slaffen geht sollet nemen eyn leffel 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).
13. "...car elle a propriete merveilleuse a esleescier et conforter le cuer," see Sies, Das Pariser Pestgutachten', 49. In Galen's 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 Diana's 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;
14. see Karl H. Dannenfeldt, "The Introduction of a New Sixteenth-Century Drug: Terra Silesiaca," Medical History, 28 (1984), 174-188.
15. Most medicines derived from traditional medical authorities such as Galen, Avicenna, Rhazes, Averroes; see Jon Arrizabalaga, "Facing the Black Death," in Roger French, Luis García-Ballester, Jon Arrizabalaga, Andrew Cunningham, eds., Practical Medicine from Salerno to the Black Death (Cambridge, 1994), 237-288, at 281.
16. Electuaries were drugs usually mixed with honey, or sugar and water, into a pasty substance suitable for oral administration in the form of syrup.
17. Giovanni della Penna prescribed the latter to take once or twice a week in order to cast off not only plague but also worms; see Sudhoff, "Pestschriften," V: 345.
18. The word 'theriac' derived from the Greek for "pertaining to wild beasts or poisonous reptiles." The 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 Thorndike, History of Magic, I, passim.
19. Also Gilbert Watson, Theriac and Mithridatium: A Study in Therapeutics (London, 1966).
20. The principle of similia similibus curantur, or-paradoxically-that the cause of the disease will cure its result, was common in ancient and medieval medicine, and a notion that medicine shared with magic.
21. Excerpted from Nicander's Theriaca as cited by Martin Levey, "Medieval Arabic Toxicology: The 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.
22. "Metridatum id est mater omnium antidotorum/Sive a Metridato rege dictum"; see Paul Dorveaux, ed., L'Antidotaire Nicolas: deux traductions françaises de l'Antidotarium Nicolai (Paris, 1896), 20, note 9.
23. Celsus attributed Mithradates' immunity to his antidote only, whereas in Pliny it is attributed to the combination of both poison and antidote, see Laurence M.V. Totelin, "Mithradates' Antidote - a Pharmacological Ghost," Early Science and Medicine, 9 (2004), 1-19. Allegedly, Mithridates' immunization method was so effective that, when defeated by the Romans, he tried to commit suicide by drinking poison, but was unsuccessful.
24. Galen, De antidotis I, 1 in C.G. Kühn, Galeni Opera Omnia (Leipzig, 1827), XIV: 2-3.
25. 'Venice treacle' was reputed to be the best, and was exported to commercial centers throughout Europe.
26. 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.
27. Michael McVaugh has delineated the scholastic debate over the "Questiones de tiriaca" by William of Brescia, in M.R. McVaugh, "Theriac at Montpellier 1285-1325," Sudhoffs Archiv, 56 (1972), 113-144. McVaugh argued that this debate revealed the existence of a more general process by which academic medicine at Montpellier "moved from a still somewhat empirical to a markedly philosophical or theoretical orientation."
28. M.R. McVaugh, Medicine before the Plague: Practitioners and Their Patients in the Crown of Aragon, 1285-1345 (Cambridge, 1993), 153.
29. 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, The Medieval Health Handbook «Tacuinum sanitatis» (New York, 1976).
30. McVaugh, "Theriac at Montpellier," 114.
31. "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 Avie. V° sui canonis." Ibid., note 6.
32. Ibid., 114.
33. Even Gentile da Foligno's scholastic inquiry into the reasons for the use of theriac and Mithridatium was "not strikingly illuminating." See Watson, Theriac and Mithridatium: A Study in Therapeutics, 99-100.
34. For a short history of theriac in the Middle Ages with detailed primary source references, see Thomas Holste, Der Theriakkrämer: ein Beitrag zur Frühgeschichte der Arzneimittelwerbung (Pattensen, 1976). Holste acknowledges Watson's careful tracing of early theriac history from Alexandria to Galen.
35. Watson, Theriac and Mithridatium, 87.
36. John Scarborough, "The Opium Poppy in Hellenistic and Roman Medicine," in Roy Porter and Mikuláš Teich, eds., Drugs and Narcotics in History (Cambridge, 1995), 17. The analogy with modern antidepressants is debatable. However, if effective, they can generate energy, lift the mood, and even stimulate euphoria. On the whole, the psychotropic effects of any substance - whether opium, wine, or selective serotonin reuptake inhibitor - are difficult to assess, especially retrospectively, since they would depend on multiple factors: dosage, concomitant drugs, synergy, and individual patient.
37. "...les opiats sont une famille importante. Tous contiennent de l'opium et ont une consistance d'électuaire. La thériaque ... est le plus célèbre." Jean-Pierre Bénézet and Jean Flahaut, Pharmacie et médicament en Méditerranée occidentale (XIIIe-XVTe siècles) (Paris/Geneva, 1999), 641.
38. "La thériaque est la médication héroique des grands syndromes douloureux..." Bénézet notes that theriac was also used to counteract poisons and to prevent miscarriages. Ibid.
39. A compendium of composite medicines, the Antidotarium Nicolai first appeared in Salerno around 1150 and is attributed to Nicolaus Salernitanus; see Rudolf Schmitz, Geschichte der Pharmazie (Eschborn, 1998), 368ff. 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.
40. Lucia Fontanella, Un volgarizzamento tardo duecentesco fiorentino dell'«Antidotarium Nicolai», Montréal, McGill University, Osler Library 7628 (Alessandria, 2000), 48.
41. Ibid. Translations, unless otherwise noted, are mine.
42. 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., L'Antidotaire Nicolas, 20: "Metridatum vaut: à dolor de chef de fraidor, à dolor d'orailles, de denz, de palais, et à 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." The 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 significant dose.
43. In 40 commentaries on the subject of opiates, pain is only mentioned ten times; see Bénézet and Flahaut, Pharmacie et médicament. See also Bénézet's compound opiate inventories, p. 674.
44. See Levey, "Medieval Arabic Toxicology," 87. On the history of opium, see especially Scarborough, " Opium Poppy" Also Schafer et al., "Pain Treatment."
45. Cited by Scarborough, "Opium Poppy," 8.
46. Bénézet and Flahaut, Pharmacie et médicament, 672. Eastern opium was often termed "Theban," denoting its ancient Egyptian origins. The twelfth-century Salemitan Matthaeus Platearius' famous Book of Simple Medicines known as Circa Instans stated that "Opium is cold and dry in the fourth degree. Three kinds of medicines are made from it, which one calls properly opium... thabaic because it is made overseas in the country of Thebes. This is poppy juice... One collects it in the following way. Incisions are made in the poppy head and in its leaves, a milky liquid flows out, which is opium. The best kind is made in Thebes. It has a repulsive taste (Le meilleur celluy qui est fait a Thebes il a goust molt orible...)..." See Carmélia Opsomer-Halleux and William Stearn, Livre des simples médecines: Codex Bruxellensis IV. 1024: a 15th-century French Herbal (Antwerp, 1984), II, 224;
47. also ibid., I, 154v.
48. 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 l'en claime opium tranense: celui fait l'en en Puille en une cité que l'en apelle Trane; mès il ne valt mie tant. Opium tebaicum conoistrez en tel maneire quant il sera buens: il est molt orribles, nil n'est ne trop durs ne trop mox. Opium tranense est mox et atrait un poi à rouse color. Opium tebaicum peut l'en garder .xx. anz...)." See Matthaeus Platearius and Paul Dorveaux, Le livre des simples médecines. Traduction française du Liber de simplici medicina dictus Circa instans de Platearius tirée d'un manuscrit du XIIIe siècle (Paris, 1913), 143. See also the nearly identical text in the 2000 facsimile edition of a fifteenth-century French vernacular manuscript of Platearius' work, http://www.moleiro.com.
49. 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 Thirteenth Century Paris" (Ph.D. thesis, Johns Hopkins University, 1997), 448. Schalick's study of late thirteenth-century physician Jean de Saint Amand and the regulation of apothecary practice in Paris concerning specific 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).
50. Bénézet and Flahaut, Pharmacie et médicament, 672.
51. 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 jaçoit 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 offending cause, the other to eliminate sensation: "La douleur est appaisée en deux sortes: l'une est en ostant la cause contraire, l'autre en ostant le sens a la partie." See chapter V, "Des médicamens sedatifs de douleur, et de leurs operations," 618ff., in Guy and E. Nicaise, La grande chirurgie, composée en l'an 1363. Revue et collationnée sur les manuscrits et imprimés latins et français... (Paris, 1890).
52. "Or quand la douleur ne peut estre appaisée par la certaine et vraye maniere, et la necessité nous contraint, à 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 qu'un homme meure de douleur, ... Adonc il faut passer aux sedatifs, stupefactifs, qui n'appaisent pas la douleur vrayement, ains en apparence, comme si quelqu'un disoit, qu'un homme mort ne sent point de douleur... Et tels, sont fort contraires à ceux qui vrayement et essentiellement appaisent: Car ils sont froids, et contraires à nature, comme l'opion, la racine de mandragore, la morelle, l'hyoscyame, et le pavot. Mais ils sont plus salutaires secs que verds, et corrigez avec du saffran, myrrhe, styrax, et castorée, comme au Philonion et es opiates, aussi en suppositoires, et en collyres, ils sont plus seurs." See ibid.
53. "La quantité [d'opium] et le temps doivent estre opportuns... Et de ce furent suspects aux Medecins, les trochiscs que Monsieur l'Evesque de Rieges conseilla à Monsieur l'Evesque de Marseille, lequel enduroit une strangurie douloureuse, car il en mourut assoupy et endormy. Car ils avoient telle proprieté, qu'un seul prins appaisoit la douleur." Ibid. The 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., The 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.
54. "Des stupefactifs la forme est telle par tout le Continent" (Guy is referring to Rhazes' Liber Continens): "PR. De l'hyoscyame blanc, une drachme: opion, demy drachme: semence de citrouille et de laictue, de chacun quatre drachmes: graine de pourpier, deux drachmes. Qu'on en forme des trochiscs, avec de l'eau 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 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 & Gilman's The Pharmacologic Basis of Therapeutics, 11th ed. (New York, 2006), 508; also McGraw-Hill Access Medicine drug monograph.
55. 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.
56. 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 Cremona's translation of Avicenna's "Antidotarium" (Book V of the Canon medicinae), and Constantinus Africanus' Liberpantegni (the Liber decimuspractice qui Antidotarius dicitur). See McVaugh, Medicine before the Plague, esp. 153-158.
57. Apothecaries often kept receptarii of prescriptions received, and even small town apothecary shops inventoried large numbers of different drugs; see ibid., 155.
58. Nockels Fabbri, "Continuity and Change in Late Medieval Plague Medicine," Appendix I, 205-216. That 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 Defoe's Journal of the Plague Year,
59. 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.
60. According to Jon Arrizabalaga's study, the importance of such auxiliary measures increased over time, a phenomenon interpreted as a reflection 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 García- 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.
61. "Hon dich que pendre .III. vegades la setmana per lo matí una dragma ho .III. diners pesants de fina triaga és cosa molt proffitosa," Agramont, Regiment de preservado de pestilència, ed. Arrizabalaga et ai., 63.
62. "li grans triade 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 flairant souef... il resiste molt a la putrefaction de lepydimie... Et en tel maniere comme dit est de triade puet on dire de metridaton," Sies, Das 'Pariser Pestgutachten' von 1348, 50.
63. See also "Optimum [theriac]: The kind that frees the rooster from poison and has been aged for ten years," in Cogliati Arano, The Medieval Health Handbook «Tacuinum sanitatis», Plate XLI. Theriac (triacha).
64. "Sumatur bis in septimana de tiriaca ad quantitatem fabe um vino albo aquato vel cum aqua acetóse quae mihi plus placet..." See Johannes Jacobi in Sudhoff, "Pestschriften," XVII, 27.
65. "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 nenuffar ou buglose, en yver tout pur." See Jehan Guido, Briefve institution pour preserver & guerir de la peste (Paris, 1545), 9.
66. "Il est bon que les cras uscent de triade iii foiz de sepmaine," see Maistre Chretien in M. Pagart d'Hermansart, "Une ordonnance medicale contre la peste, vers 1400," Bulletin Historique de la Société des Antiquaires de la Morinie, 196 (1901), 8.
67. 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 Sudhoff, "Pestschriften," III.
68. "...ee daz er ausgeet sich waschen mit ezzig under den augen, dar inne ein wenig tryackers sey zergangen," see Sinn der höchsten Meister von Paris für die Sterbung der Drüsen ('Dise ercznei fur den gebrechen der druezz...), ibid.: II, IV.
69. See, for instance, Alfonso de Cordoba: "...uti ... ante omnem comestionem et bibitionem tiriaca de terra sigillata in quantitate unius nucis avellanae..., " ibid.: III.
70. See, for instance, Levey, "Medieval Arabic Toxicology."
71. Ibn 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 Ga'far Ahmed ibn 'Ali ibn Mohammed ibn 'Ali ibn Hatimah aus Almeriah über die Pest," Archiv für Geschichte der Medizin, 19 (1927), 27-81. Alfonso de Cordoba's 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 flux: "Caveatur a forti medicina et maligna, quia tales frequenter per fluxum ventris moriuntur. Sed cassia fistula, tamarindi, reubarbarum, viole, pruna, et quandoque clisteria possunt administran." See Johannes Jacobi in Sudhoff, "Pestschriften, " XVII, 28. Thick cooked quince juice with bolus rubra was effective against diarrhea; clysters (enemas) were used to relieve dangerous intestinal accumulations.
72. Ein weiteres deutsches Pest-Regiment aus dem 14. Jahrhundert und seine lateinische Vorlage, das Prager Sendschreiben "Missum Imperatori" vom Jahre 1371, see Sudhoff, "Pestschriften," III.
73. "... recepta tiriace per nos composite. " See R. Simonini, Maino de Maineri ed il suo Libellus depreservatione ab epydimia (Modena, 1923), 27.
74. Ein neues deutsches Pestblatt; see Sudhoff, "Pestschriften, " III.
75. "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.
76. "Semper medicus habeat mentem ad confortandum cor et istud pro alio remedio non dimittatur... Post apostema versus cor ponatur tyriaca, si possibile est, et fiat electuarium tale." Ibid.
77. 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, The Medieval Health Handbook «Tacuinum sanitatis», XLI. Clearly, medieval physicians recognized that the natural qualities of theriac had a complex therapeutic spectrum.
78. McVaugh, "Theriac at Montpellier." According to McVaugh's reading of the "Questiones de tiriaca" by William of Brescia, themselves drawing upon Averroës' commentary on Aristotle's 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, viper's flesh, being similar to viper's venom, acts on it by attraction; on the contrary, it repels all other poisonous humors. This is rationalized as "arising from an internal tendency towards self-perfection." Theriac thus was homeopathic and allopathic medicine rolled into one, both at the service of a perceived homeostatic milieu intérieur.
79. The 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-inflammatory agent very effective against gout, and an alkaloid of autumn crocus (meadow saffron, Colchicum autumnale), was a frequent constituent of medieval plague remedies.
80. See Goodman & Gilman's The Pharmacological Basis of Therapeutics, I.1.
81. See Jerry Stannard, "Medieval Reception of Classical Plant Names," Revue de Synthèse, 89 (1968), 153-162.
82. Also Yves Lefèvre, La Lexicographie du latin médiéval et ses rapports avec les recherches actuelles sur la civilisation du Moyen-Age (Paris, 1981). For fake opium, see for instance Radhi Jazi, "Contribution à l'étude de l'histoire de la pharmacie arabe: Falsification et contrôle des médicaments pendant la période arabe" (PhD thesis, University of Strasburg, 1966), 82ff.
83. 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. The 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 difficult (for this writer) to determine specific 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 effect considered preferable to plain opium.
84. Purgation, effected 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 fluid loss. Opiates also helped intestinal absorption, by slowing motility, thus promoting absorption of fluids, nutrients, and (other) medicines.
85. "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 gan, so machstu der süke wedderstan..." Anon., Incipit regimenpestilencie (Ein deutsches Pest-Regiment aus dem 14. Jahrhundert) in Sudhoff, "Pestschriften, " III.
86. "das aller kostlichest bulver dassoltu alle morgen niechter einnemen.. .es schat auch keiner frauwen." See Anon., Ein neues deutsches Pestblatt (Augsburg, ca. 1483) in ibid., IV.
87. "... quod nominatur Thesaurus et gloria inestimabilis. Cuius elcunarii compositionem ponit Aristoteles in sua episula ad Alexandrum..." Simonini, Maino de Maineri, 27.
88. 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 sçavant" 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, brouillant infinis mots Arabiques, & pervertissant en plusieurs endroits l'intention des bons autheurs Grecs: lesquels il na ni leu, ni suyvi, ni entendu...), see Nicolas de Nancel, Discours très ample de la Peste (Paris, 1581), 176ff. Reference is to Nicolaus Salernitanus, the compiler of the famous Antidotarium Nicolai.
89. Scarborough, "Opium Poppy," n. 33.
90. After scarification "pour vuyder le sang envenimé, qui est là autour & dedans le bubon... applicqueras medicaments suppuratifz & attractife en la forme suyvante. Prens un oignon blanc, & le cure par dedans avec le Cousteau, Y faysant une concavité 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 à ce qu'il soit mol: & tout chauld l'appliqueras sur le bubon. C'est un des meilleurs remedes que l'on y sçache appliquer." François Vallériole, Traicté de la Peste (Lyon, 1566), 152.
91. 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.
92. Charles LaWaIl, Four Thousand 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 official ointment bases.
93. Scarborough, "Opium Poppy," 17. In modern terms, the combination of gum arabic's 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, emulsifier, 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.
94. It should also be noted here that plague physicians were expert in
95. See for instance Peter Brain's argument regarding iron deficiency 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 Three Works (Cambridge, 1986), ch. 10.
96. See for example Jeff 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," 217ff. This paper does not begin to address all potential therapeutic effects 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.
97. See, for instance, the chapter "Antimicrobial Activities of Pomegranate" in Pomegranates: Ancient Roots to Modern Medicine (Boca Raton, 2006).
98. 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 effectiveness; see Anne Van Arsdall, Medieval Herbal Remedies: The Old English Herbarium and Anglo-Saxon Medicine (NewYork, 2002).
99. 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.
100. Ibid.
101. Hyoscyamus 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 effects) and scopolamine are widely used in modern medicine. See Goodman & Gilman's The Pharmacologic Basis of Therapeutics, II, 7;
102. also Bénézet and Flahaut, Pharmacie et médicament, 671, n. 53.
103. Paul Slack, The Impact of Plague in Tudor and Stuart England (London, 1985), 35.
104. See for example Ibn Khatimah's 1349 case report in Dinanah, "Die Schrift über die Pest," 62-63.
105. See Jean Noël Biraben, Les hommes et la peste en France et dans les pays européens et méditerranéens, 2 vols. (Paris, 1975), esp. vol. 2.
106. Bénézet and Flahaut, Pharmacie et médicament, 685-689.
107. Among 399 single deliveries even cupping candles were included, demonstrating also a persistent preoccupation with humoral evacuations.
108. Bénézet arrived at the same conclusion: "La thérapeutique de la peste, mise en jeu en cette fin du XVIe s., a peu évolué depuis le Moyen Age, Guy de Chauliac ne la désavouerait pas." Bénézet and Flahaut, Pharmacie et médicament, 687.
109. Bénézet, 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 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 at tenuation. Similarly, vermifuges, pediculicidals, and antipsorics were most likely used for the troubles they implied. Stavesacre, as Bénézet stated, may not have indicated the presence of lice at a certain moment in time, but does denote a specific therapeutic concern. See ibid., 18.
110. The 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 & Brookfield, VT, 1992).
111. "...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,
112. also in M.R McVaugh and Nancy G. Siraisi, eds., Renaissance Medical Learning: Evolution of a Tradition (Philadelphia, 1991). The 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." Their 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 defined and distinct.
113. The co-mingling of empiric, scholastic, and magical elements was not limited to the poor. Thus, 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 asp's head: "rubinus... similiter smaragdus, et corallus utriusque et lapis inventus in capite 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. This dichotomy held true into the seventeenth century, when English physician and astrologer Richard Napier hung on patients' doors a talisman to protect against plague.
114. Charles F. Mullett, The Bubonic Plague and England: An Essay in the History of Preventive Medicine (Lexington, 1956), 3.
115. The 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., The Regulation of Evil: Social and Cultural Attitudes to Epidemics in the Late Middle Ages (Florence, 1998), 7-39.
116. "C'est une pharmacopée bizarre où se heurtent les drogues les plus insolites; la valeur de ces recettes et de ces antidotes infaillibles est purement historique." See H. Émile Rébouis, Etude historique et critique sur la peste (Paris, 1888), 41. Nancy Siraisi's classic work cautions, that "in attempting to evaluate medieval and early Renaissance therapeutic knowledge and techniques, the measure cannot be that of physical effectiveness." Although the substances in use included some that would reliably produce consistent, perceptible results, the "ability of practitioners to produce predictable effects by medication was limited." This was due to their "rough and largely intuitive" means of dosing and preparation, which "more often suggest[ed] the kitchen than the laboratory."
117. See Nancy G. Siraisi, Medieval & Early Renaissance Medicine: an Introduction to Knowledge and Practice (Chicago, 1990), 148ff. 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.
118. See Anne Van Arsdall, "The 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 Scientific 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 fifteenth-century curricula of the branch known as practica testified to this. This growing interest for "the particular and the specific" was one the developments leading to new theories of disease, and the new anatomy of the sixteenth century;
119. see Siraisi, Medieval & Early Renaissance Medicine, 152.
120. paul Slack, "Mirrors of Health and Treasures of Poor Men: The 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.
121. Harold J. Cook, "Good Advice and Little Medicine: The Professional Authority of Early Modern English Physicians," The Journal of British Studies, 33 (1994), 1-31, at 31.
122. See "The Therapeutic 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 defining such change as an essentially intellectual process."
123. Keith Thomas, Religion and the Decline of Magic (NewYork, 1971), 185.
124. See also Slack, "Mirrors of Health," in Webster, ed., Health, Medicine, and Mortality, esp. 264-273.
125. Robert S. Gottfried, The Black Death: Natural and Human Disaster in Medieval Europe (NewYork, 1983), 104.
126. 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 effects; purges purged, emetics induced vomiting, opium soothed pain and moderated diarrhea." See Charles E. Rosenberg, "The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth-Century America," in Morris J. Vogel and Charles E. Rosenberg, The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia, 1979).
127. Also John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885 (Princeton, 1997).
128. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine, 12.
129. Arsdall, "The Medicines of Medieval and Renaissance Europe as a Source of Medicines for Today," 26.
130. "A typical medicine chest of an eighteenth-century physician was not very different from a thirteenth-century physician's 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 Warner's 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;
131. see Warner, Therapeutic Perspective, 160, and chapter 4, "Therapeutic Change."
132. Watson, Theriac and Mithridatium, 150.
133. See for example Jacalyn Duffin and Barbara G. Campling, "Therapy and Disease Concepts The History (and Future?) of Antimony in Cancer " Journal of the History of Medicine and Allied Sciences, 57 (2002), 61-78.
134. Holland, ed., Prospecting for Drugs, 1.
135. See ibid., and Bart K. Holland, "Prospecting for Drugs in Ancient Texts," Nature 369 (1994), 702.
136. John M. Riddle, Eve's Herbs: A History of Contraception and Abortion in the West (Cambridge, MA, 1997).
137. Also idem, Quid pro quo.
138. Arsdall's suggestion that pharmacologists investigate such concoctions was seen as extreme by one of the reviewers of her article in Holland, ed., Prospecting for Drugs;
139. see M.P. Earles, in Medical History, 42 (1998), 262.
140. Bénézet and Flahaut, Pharmacie et médicament.