The year 1000: Pharmacy at the turn of the first millennium

Brother Cadfael, as television viewers will recall, is the hero of a medieval murder mystery set in 12th-century Shrewsbury. The plot of Ellis Peters’s novel, ?Monk’s hood’, revolves around the fact that aconite (monkshood) is both a deadly herbal poison and a beneficial drug. Brother Cadfael, the pharmacist for his monastic community, uses a mixture of the ground root of monkshood, mustard oil and flax seed oil to rub on the skin of an old monk, because, as he remarks, it “works wonders for creaking old joints”.

Martindale observes that aconite liniments were formerly used extensively in the treatment of neuralgia, sciatica, and rheumatism; so Cadfael’s elderly patient would have noticed the beneficial effect of this treatment. During the therapy, a young apprentice overhears Cadfael say that, if taken internally, the ointment is a deadly poison. Later the apprentice steals a small amount from the jar and adds it, in revenge, to the food of the man who had dispossessed his family.

There is no doubt that aconite was known as a poison by the end of the first millennium; it was added to bait for wolves, used to poison arrows and even to execute criminals. But were the beneficial effects of aconite known? Would a practitioner of pharmacy at the beginning of the second millennium have had monkshood in one of his liniment jars?

The underlying assumption of Ellis Peters’s story is that certain people in Anglo-Saxon Britain had a good knowledge of the medicinal usages of herbs and other substances, a knowledge that was later forgotten or suppressed, and whose existence is no longer recognised. But were Anglo-Saxon medicines effective? Did they produce results beneficial to patients?

Modern beliefs

Many pharmacists and most medical historians believe that, in such prescientific times, available therapies did more harm than good. Arthur K. Shapiro, an eminent pharmacologist, asserts that the only link between medieval and modern medicine is the placebo effect. J. Worth Estes concluded from his study of the clinical effectiveness of drugs used in colonial America that the majority of patients would have recovered “without any of the 225 preparations then commonly available.” Henry F. Dowling estimates that “less than two dozen effective drugs were known before the year 1700”. L. J. Henderson took the view that, prior to 1912, a random patient with a random disease had chances no better than 50:50 of benefiting from a consultation with a random physician. The fee, however, would certainly have benefited the physician.

Specialists in the history of Anglo-Saxon medicine confirm these opinions. Charles Singer, one of the most distinguished scholars to study early medieval herbals and related documents, held that “in thinking of the Middle Ages it is always necessary to remember that the knowledge of the day was not only perverted and corrupted in quality but that it was also extremely small in extent”. In his view, much of the medical literature of “the dark ages” was the product of “local ignorance and perversion”. Few people, he continued, “realise the degradation involved when the mind becomes saturated with such material and deluded with such hopes.” The “magical and superstitious practices” exhibited in these documents are “comparable to those of West African savages”.

Wilfrid Bonser, in his study, ?The medical background of Anglo-Saxon England’, supports Singer’s interpretation. He notes that the number of herbs that occur in prescriptions and glossaries is very great. “But the inability to make any practical use of this knowledge is shown by the fact that not one drug in a hundred has the physiological action attributed to it. Ill effects must have often resulted from remedies thus ignorantly, but none the less explicitly, prescribed.” The “overwhelming majority of substances used would have no beneficial effect save upon the mind of the sufferer.” But, as Bonser points out, “the medieval mind, like that of the savage before it, worked according to a logic of its own. It had not the benefit of modern science to assist it.”

Anthropological insights

While both Singer and Bonser allude to the thought and practices of “savages”, they do so in a dismissive way, without any suggestion that an understanding of “primitive” societies might assist in the interpretation of Anglo-Saxon documents. It does not require subscription to unilinear theories of social evolution to recognise the potential value of anthropological insights for the study of early medieval therapeutic practices.
The American physician Dr George Way Harley spent over 20 years as a medical missionary in Liberia. He learnt to speak six African languages and immersed himself in the culture of the Mano peoples. In his book, ?Native African medicine’, first published in 1941, he compares pathology and appropriate treatment as determined by scientific western medicine with native Liberian Mano categories, diagnosis and modes of treatment. Harley discerns a division in Mano medicine between empirically rational procedures and magical treatments. He reveals how these are applied in accordance with the Mano classification of diseases and their knowledge of anatomy, physiology and pathology.

Harley’s rare accomplishment is to bring his training in western medicine to elucidate the everyday experience of the Mano. Thus he illuminates not only the magical aspects of Mano medicine but also shows that they have a considerable knowledge of efficacious herbal remedies and a respectable range of empirically sound forms of treatment. The Liberian native doctor knows many valuable remedies, based on drugs growing in his own forest and discovered by his ancestors to be effective in curing his own diseases.

Many of the most rational treatments for common ailments are carried out, not by the doctor, but by the mothers who treat their own families with household remedies. This is an important observation, not least because it reminds us that most medicine was in the past, as it still is today, self or family administered. When judging a drug’s effectiveness historically, we judge the ability not only of the medical practitioner but also of the lay person to make rational decisions.

Challenge

No one has done more to challenge the established interpretation of therapeutic practice in early medieval Europe than the American scholar John M. Riddle. His published work since 1964 has demonstrated that a command of the languages of the original texts, the patience and determination to locate and scrutinise them in detail, and the judicious application of modern pharmacognosy are essential requirements for the historian of early pharmacy.

In an article published in 1974, Riddle mounted an incisive critique of those medical historians who regard the early middle ages (circa 500-1100) as the “dark ages”. Such a view derives from an excessive concentration upon medical theory and a neglect of medical practice; it stems from the habit of writing medical history from the point of view of the physician rather than from that of the pharmacist or the patient.

The standard histories of medicine postulate a decisive break between late Roman and early medieval medical practice. The absence of theory in the medical texts after the collapse of the Roman Empire is taken as incontrovertible evidence of medicine’s decline. “The curse of the science of medicine, as of all sciences,” wrote Singer and Underwood in 1962, “has always been the so-called practical man, who will consider only the immediate end of his art, without regard to the knowledge on which it is based. Monkish medicine had no thought save for the immediate relief of the patient. All theoretical knowledge was permitted to lapse.” It was not until the end of the 11th century that the School of Salerno and the Islamic translations brought about the return of rational speculation.

Riddle corrects this oversimplified view of medieval medical history by focusing upon pharmacy or drug therapy – in other words, by focusing upon the way most medicine was practised. He argues that, because both Roman and medieval medicine consisted of non-institutionalised, informal practice, there was no notable change in the practice of medicine, certainly in drug therapy, between the two eras.

Although speculative medical theory was almost totally abandoned, the records from the fifth to the 10th century show that medical progress was not solely dependent on written treatises. On the contrary, the records show that a medical practice existed based upon a pharmacy that not only preserved the older practical knowledge but also recognised and used new drugs. Moreover, there was no great leap forward at the end of the 11th century because the new drug theory was unworkable; the re-establishment of the pre-eminence of medical theory merely created a damaging gap between theory and practice.

Even though medical theory was virtually lost in Western Europe during the so-called dark ages, the ancient legacy of pharmaceutical prescriptions continued to be transmitted. John Riddle’s meticulous research has uncovered the process by which Dioscorides’s ?De materia medica’, which contains a description of around 900 items of pharmacy, was preserved for medieval use. It was translated into Latin from the original Greek before the sixth century and became the most complete authority for plants, animal products, and minerals in medicine. More popular than the full version was a Latin abridged edition known as ?Ex herbis femininis’, which was a more practical guide. It included only 71 herbs, each drawn for identification and all commonly known in Europe.

The fact that most of the early medieval pharmacy texts are copies of classical works does not mean that pharmacy was static. Many new early medieval recipes are derived from Germanic, Celtic, and Hispanic folk medicine. There was, moreover, a continous drug trade between the eastern and western Mediterranean worlds. Of the most frequently cited drugs in a Latin ninth-century antidotary, a majority could have come only from the Orient. Examples are aloes, myrrh, frankincense, pepper and mastic. Prescriptions dating from the ninth to the 11th centuries include ambergris, zedoary, and camphor, substances unknown in Graeco-Roman pharmacy. In short, early medieval medical practice was a continuously developing art, a partly empirical, partly traditional skill.

Rational drug use

John Riddle argues persuasively that there was rational drug use in early medieval pharmacy. The respected men of classical medicine, Galen, Hippocrates, Dioscorides, etc, had not themselves discovered the medicinal value of the herbs, minerals, and animal substances they prescribed. Many thousands of experiments in folk practice had separated out substances with pharmacological action from the inert and harmful.

Long before the rise of modern science, “primitive” societies in various parts of the globe had discovered the psychogenic properties in practically every plant possessing such properties, plants such as coffee, tea, tobacco, coca, yerba maté, peyote, marijuana, opium, alcohol and hallucinogenic mushrooms. The authors of classical medicine merely authenticated the results of this trial-and-error science.

Dioscorides’s aim in the first century AD was to impose order on scientific and traditional folk experiences with drugs. In the preface to ‘De materia medica’, he explains how he arrived at his science of drugs. First, he made direct and personal observations of drugs, identifying, harvesting, and preparing them in the field. Secondly, he carried out a literature search of pharmacy data. Thirdly, he measured the activities of drugs experimentally, that is, by clinical observation of drug trials on patients. And, finally, he made field inquiries of folk practices “in each botanical region”.

It is what drugs do when given to patients that really interests Dioscorides. Consequently, the organising principle of his magnum opus comes not from botanical morphology or an alphabetical listing of pharmaceuticals, but from what John Riddle has astutely recognised as a “drug affinity” system. This means that drugs are grouped by similar physiological effects, that is, by what happens when patients are given a particular drug in the treatment of particular complaints.

Fertility control

In his ‘Contraception and abortion from the ancient world to the Renaissance’, published in 1992, John Riddle develops the most sustained and subtly argued case yet made for the existence of a pre-modern rational drug usage. His thesis is that herbal drugs taken orally were an effective and widespread means of controlling fertility in certain ancient and medieval societies.

A systematic search of the major sources for the history of pharmacy reveals recipes for contraceptives and abortifacients as well as the occasional discussion of fertility control considered theoretically and practically. Over many centuries a small number of plant drugs, among them myrrh, cow parsley, juniper, wormwood, pennyroyal and rue, were used as contraceptives and early stage abortifacients. Riddle argues that from the time of the earliest societies women and sometimes erudite male herbalists had the knowledge to control fertility with drugs as well as the social and political freedom to do so. But both the knowledge and the freedom began to decline in Western Europe at the end of the Middle Ages.

John Riddle’s work raises many issues beyond the scope of this short article. On several occasions he has expressed his own doubts about the legitimacy of using modern science to validate past practices. Should the pharmacy of the past be evaluated on the basis of modern knowledge? His answer is that “if extreme care is used, the historian can find it useful to evaluate pharmaceutical records in the light of scientific studies, in order to learn whether early practitioners were, in our judgment, ?rational’ users of medicines… . the historian wishes to know… what the physical effects of given drug therapies might have been.”

His purpose, then, is not to glorify the present by discovering historical antecedents to modern discoveries, but rather to rescue our ancestors from the charge of being illogical and naive. “Far too long,” he reminds us, “we have believed that the past was filled more with superstition and stupidities than with experienced judgments about medicine.”

Bibliography

Singer C, Underwood EA. A short history of medicine (2nd ed). Oxford: Clarendon Press, 1962.