Category Archives: Premodern

When Does a Drug Trial End?

By Justin Rivest

An eighteenth-century proprietary medicine vendor. Detail from “Le Charlatan, 1785.” Hand coloured etching and aquatint. Antoine Borel after J. Augustin L’Eveillé. Source: Wellcome Images.

The question I’d like to begin this post by asking is, When does a drug enter “normal use”? Is a trial a “provisional” phase, that reaches a definitive end, say when “proof” is found, or when the relevant authorities are convinced? Or in an age where drug monopolies were insecure and difficult to enforce, was the state of trial—l’épreuve—always ongoing?

This question first crossed my mind while preparing my contribution for the recent special issue of the Bulletin of the History of Medicine, “Testing drugs and trying cures,” edited by Elaine Leong and Alisha Rankin. My article focuses on the role of patient trials in granting monopoly privileges for proprietary drugs in eighteenth-century France. These royally-granted privileges were the distant ancestors of modern drug patents. They gave their inventors a legally enforceable monopoly over the drug in question by enabling them to fine counterfeiters.

Even after they were granted monopoly privileges, drug vendors continued, almost compulsively, to gather further evidence of the effectiveness of their drugs. This evidence often took the form of an attestation or certificat. These documents could take several forms: some were notarized statements, made by a patient declaring that he or she had been cured of this or that condition. Others were endorsements signed by an expert practitioner—a famous doctor, a representative of a local college or guild—who had personally witnessed the drug’s effects.

In this post, I will use the practice of what we might call “cure attestation collection” to question whether “trials” (épreuves) of a drug really had an end from the perspective of early modern drug monopolists.

The most important reason to continue gathering documentation of the effectiveness of their drug was to convince authorities to renew their privilege at a later date, as most monopoly privileges had fixed terms of three, ten, or fifteen years. But even within these term limits, they did not have perfect guarantees. Early modern drug monopolies were tenuous. Vendors knew that they might even have to re-submit both their drugs and their documentation for arbitrary re-examination by the authorities.

Even barring arbitrary re-examinations, the multi-generational duration of many early modern monopolies meant that they would be evaluated more than once by the authorities. The drug monopoly I studied in my article, the poudre fébrifuge of the Chevalier de Guiller, was particularly long-standing, extending across four generations. As a febrifuge, the drug was targeted at “intermittent fevers,” an important cause of mortality in the French army in this period. The drug was first awarded a monopoly privilege in 1713, at the end of the reign of Louis XIV. Its inheritors faced various challenges in exploiting it over the coming decades, but they consistently managed to get the privilege renewed. By the 1770s, in fact, the latest inheritors, the sisters Marie-Thérèse and Marie-Victoire de La Jutais, had accumulated a veritable archive of attestations in favour of their drug, spanning over sixty years.

Most of these documents were cure attestations and endorsements from patients, and prominent medical practitioners. A signed personal endorsement of the drug from the supervising practitioner was often the most important result of a hospital trial. Vendors who sold drugs in bulk to the state, especially to the military, could appeal to a special type of attestation. The La Jutais sisters, for instance, did not just rely on the documents that had been handed down to them through their family. They also went to government archives—much as historians do today—looking to collect documentation that might endorse their drug. They paid the navy office to make official copies of fifty-year-old correspondence concerning their drug so that they could submit it with their petition to renew their monopoly.

Monopolists were not, however, impartial researchers. The La Jutais sisters seem not to have collected any documentation which might cast their drug in a negative light—or at least, if they came across such evidence, they avoided disseminating it. Indeed, during my research I came across several documented cases of ambiguous or negative patient trial results of the poudre fébrifuge. In one 1714 trial involving “twenty or thirty” patients at a navy hospital, the drug was deemed to be too inconsistent in its effects and was dismissed as a violent purgative rather than a true febrifuge. It seems at least plausible that the La Jutais sisters’ archival searches might have drawn up this material as well. Nonetheless this report is notably absent from their petitions for monopoly renewal in the 1770s.

The “selective archive” of positive attestations that the La Jutais sisters assembled helped them to renew their monopoly privilege in 1775. We can see from their case that early modern drug monopolists had good reasons to keep collecting cure attestations wherever they could get them. They had the effect of turning the drug’s everyday use into a form of legally acceptable evidence, making a successful trial out of every cure.

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Justin is a postdoctoral researcher at the University of Cambridge and his work focuses on early drug monopolies and the role of bulk drug producers and consumers in the early modern medical marketplace. He recently co-wrote a short piece in The New England Journal of Medicine with Alisha Rankin on this topic, as well as an article in the Canadian Journal of History on one particularly successful drug entrepreneur, Adrien Helvétius (1662-1727), who sold massive quantities of his drug against dysentery to the French state for use in the army and rural poor relief efforts. His research has shown that trials on patients played a critical role in licensing early drug monopolies as well as in helping entrepreneurs secure lucrative supply contracts with the state.

Testing Drugs and Trying Cures

By Elaine Leong and Alisha Rankin

Miniature (no. 37.181) from 15th century manuscript in Dresden: Galen, and assistant with a pestle and mortar, and a scribe in an apothecary’s shop. © Wellcome Images

As readers of this blog well know, early modern Europe was aflood with recipes and drugs. One central question has long preoccupied many of us –  just how did our historical actors assess, test and try out recipes, drugs and materia medica? A few summers ago, a group of historians of science and medicine gathered to discuss just this question. This month, we present our ideas and findings in a special issue of the Bulletin of the History of Medicine. To celebrate the launch of the special issue, several authors of the volume will share their work on The Recipes Project. Tuesday’s post revisited Ashley Buchanan and Tillmann Taape‘s report on the original 2014 conference. Over the next few weeks, we’ll learn more about the research of Erik Heinrichs, Valentina Pugliano, Alisha Rankin and Justin Rivest. Finally, Tillmann Taape, who just completed his PhD at the University Cambridge (congrats!) also adds his voice to the series by reflecting on how theme of drug testing features in his doctoral dissertation.

To get us started on our month of ‘Testing Drugs and Trying Cures’, we wanted to say a few words as the organizers and editors of the project. First, you might ask, what do we mean by ‘Testing Drugs and Trying Cures’? Over the course of the project, we found that it was useful to view ‘testing drugs’ and ‘trying cures’ as two overlapping but distinct phenomena.

As the essays in the special issue show, physicians and apothecaries developed clear rules and practices for testing drugs as materials – from sensory analysis of materia medica to chemical analysis of substances like mineral waters or alchemical medicines. This kind of ‘testing drugs’ largely focused on gaining knowledge on the substances’ medicinal properties and played a particularly significant role in the discovery and adoption of materia medica from the New World and in assessing and establishing authenticity of exotic and/or expensive medicaments.

Paolo Antonio Barbieri, The Spice Shop, 1637. Image from Wikimedia.

‘Trying cures’, on the other hand, describes the widespread practice of trying remedies and other kinds of cures on human bodies. If ‘testing drugs’ was mainly conducted by learned physicians and apothecaries, ‘trying cures’ was performed by a broad range of healers. Within the home, women and men applied and observed the effects of remedies on family and household members. Likewise, physicians and other practitioners prescribed diets, medicines and other cures to their patients, again observing and recording the effects. Ample evidence of this kind of ‘trying cures’ survive in a range historical sources from the use of ‘probatum est’ to expressions of personal experience, customisation and rejection of recipes in household recipe collections (for more on this, see posts here and here).

For us, these two categories ‘testing drugs and ‘trying cures’ serve as helpful heuristic tools to untangle the assessment practices used by early modern practitioners. We see the two categories not as separate boxes but rather as overlapping and often intertwined practices. Many healers merged testing and trying by using patient tests to determine a substance’s properties or to refine methodologies in both drug production and application. These themes of testing and trying occupied a central place in the making of medical knowledge across a vast chronological span and broad geographical regions and social contexts. The essays in the special issue examine these crucial knowledge practices in Europe c. 1300-1800 (go here for a table of contents).

Several main themes emerged from this collaborative project. First, medicine was always an experiential art and the essays in the special issue demonstrate clear continuities between the learned physicians’ uses of experience/experiment in the Middle Ages and early modern experimental interests. Learned medicine made deliberate use of experience from a very early date and pharmacy was an area where the gathering of experiential knowledge was particularly pronounced. The senses – touch, taste, smell, sight and hearing – played vital roles in determining the properties of drugs and their effects on the human body.

Concurrently, as many essays in the volume demonstrate, structured drug testing had a long history. Medieval physicians developed meticulous rules for drug testing, as Michael McVaugh’s essay shows, although they left no record of actual medical trials. This focus on establishing protocols for drug testing continues throughout the medieval and early modern period, with significant expansion in scale and scope. By the eighteenth century, the testing of mineral spa waters (in Michael Bycroft’s essay) or proprietary drugs (in Justin Rivest’s essay) became large-scale undertakings situated in learned academies and hospitals.

When taken together, the essays in the ‘Testing Drugs and Trying Cures’ special issue collectively argue that ‘experimental thinking’ played a crucial role in learned assessments of medicine and drugs throughout the Middle Ages and early modern period. From the time of Galen, drug testing was structured and evidence-based with an aim to produce transferable results. For us, this fascinating and multifaceted story of premodern drug testing enriches and extends current histories of experimentation and we hope that our explorations into topic will inspire others to join us too!

Further Reading and Acknowledgements:

This post is a very condensed version of Elaine Leong and Alisha Rankin’s ‘Testing Drugs and Trying Cures: Experiment and Medicine in Medieval and Early Modern Europe’, Bulletin of the History of Medicine, 91 (2017), 157-182. The full version of the article is available here. The entire special issue is available here.

The ‘Testing Drugs and Trying Cures’ project was funded by the Max Planck Society as part of the Minerva Research Group’s ‘Reading and Writing Nature in Early Modern Europe’.  We also extend our grateful thanks to all the participants of the 2014 workshop, the editors of the BHM and the anonymous reviewers of the articles in this special issue.

Tales from the Archives: Testing Drugs and Trying Cures Workshop Summary

In September 2016, The Recipes Project celebrated its fourth birthday. We now have over 500 posts in our archives and over 120 pages for readers to sift through. That’s a lot of material! (And thank you so much to our contributors for sharing such a wealth of knowledge on recipes.) But with so much material on the site, it’s easy for earlier pieces to be forgotten. So, the editors have decided that, every now and then, we’ll pull something out of the archives to share with our readers anew.

Over the next few weeks, The Recipes Project will feature a selection of case studies from the current issue of the Bulletin of the History of Medicine on “‘Testing Drugs and Trying Cures”. This special issue grew out of a 2014 workshop held at Max Planck Institute for the History of Science in Berlin. We were very lucky to have two then graduate students Ashley Buchanan and Tillman Taape, join us for and grateful that they took the time to pen the post below. It seems fitting to begin this month on testing drugs and trying cures with a revisit to their post. Elaine (editor).

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By Ashley Buchanan and Tillman Taape

What did it mean to test a drug or try a cure in the early modern world? This was the central question for a group of scholars who gathered for a workshop at Max Planck Institute for the History of Science in Berlin, Germany.  Since recipes emerged as one of the key themes throughout the workshop, and because the conference’s location in Berlin made it difficult for scholars outside of Europe to attend, we thought we might share a brief summary of the “Testing Drugs and Trying Cures” papers, in the hopes that we could bring the workshop’s key ideas and discussions to a larger audience.  What emerged from an exhilarating two days of discussion and debate was the conclusion that historians of science and medicine should not privilege experiment and experimentation as fixed categories, but should understand the multiple ways in which physicians, apothecaries, artisans, institutions, and individuals in the early modern world tested, tried, investigated, experienced, modified, observed, and measured medicinal remedies and materiae medicae.

As written forms of medical and pharmaceutical knowledge and practice, recipes played an important part in the testing of drugs and cures, and our discussion raised larger questions surrounding the nature and purpose of an early modern recipe.

705px-ScuolaMedicaMiniatura
A miniature depicting the Schola Medica Salernitana from a copy of Avicenna’s Canons.  From Wikimedia Commons.

Michael McVaugh’s paper opened the discussion by exploring how medieval physicians went about testing drugs. Learned doctors in the Middle Ages might appear helplessly hidebound, and inclined to follow ancient authorities over experimentation. In contrast, McVaugh showed how a group of Montpellier physicians in the fourteenth century established something of an experimental program. Medieval physicians, however, were not testing to find a cure, but to determine the quality, strength, and effectiveness of a drug as it pertained to a particular person’s complexion. McVaugh underscored an important difference in the purpose of medieval drug testing. Physicians tested not for universal effectiveness, but to determine the quality of a drug – was it hot, cold, moist, or dry.

Duclos-title-page
Title page of the Academy’s Observations sur les eaux minérales (1675). From http://cures.hypotheses.org/the-workshop/programme-2/bycroft-michael

Although it became clear in our roundtable discussion that we should be wary of labeling such practices as obvious precursors to the experimental philosophies of the Scientific Revolution, many of the papers showed that the importance of specific tests resonated throughout the early modern period. Evan Ragland’s paper, for example, traced the use of the phrase periculum facere (‘to make a trial’) in physicians’ writings on medicine, anatomy and chemistry. Similarly, Michael Bycroft showed that French physicians and chemical experts of the Académie des Sciences became increasingly interested in the exact composition of mineral waters. Contrived tests such as color indicators or the analysis of residues after evaporation increasingly became the touchstone of proper inquiry.

McVaugh, Ragland, and Bycroft’s papers all underscored the need to understand the specific nature and purpose of testing in each historical context. Continuing to emphasize the importance of historical context, Francesco Paulo de Ceglia’s paper showed just how different the purpose of testing could be in the context of seventeenth century blood miracles in the Kingdom of Naples. Catholics tested the liquefaction of the blood of their patron saint to explore the limits of nature. By discovering nature’s limits, you could then determine what was truly miraculous. Protestants, on the other hand, tested various materials and recipes to recreate the liquefaction of blood to cast doubt on the alleged miracle.

san-gennaro
Reliquary containing a glass ampoule of San Gennaro’s blood. From La Repubblica.

In the context of testing, drugs and cures are often under scrutiny in the form of recipes detailing their production and administration. While recipes emerged from many of the papers as very important forms of knowledge, it proved virtually impossible to define exactly what a recipe was. Recipes can be very short or very detailed, ranging from a mere list of ingredients to careful step-by-step instructions. If there is one thing recipes have in common, it is the need for testing, trying, modifying and adapting to different conditions. While constructing an all-encompassing definition of a recipe proved futile, all agreed that it was fruitful to understand recipes as an important genre in early modern science and medicine.

apotheke_enhausen_l
From http://www.gn.geschichte.uni-muenchen.de/aktuelles/archiv_2011/archiv_2013/science_and_medicine/index.html

For her investigation on the testing practices of Venetian apothecaries, Valentina Pugliano emphasized the difference between experiment and experience. Venetian apothecaries were less concerned with testing drugs (in a traditional sense) than they were with the experience or truthfulness of their ingredients. Testing by inspection, smell and taste was also important in this pharmaceutical context, to ensure that the ingredients were what the merchant had promised them to be, and not a cheap substitute with inferior properties. For Pugliano’s apothecaries, the important issue that required testing was the authenticity of the ingredients rather than the efficacy of the finished product; after all, most preparations had proved their worth since antiquity. Like McVaugh, Pugliano questioned traditional “Baconian” understandings of what it meant to experiment and test and argued for more nuanced notions of testing and trying, which included observing, measuring, evaluating, and experiencing.

Image_Samir
Title page of Johannes Christophorus Homann’s Dissertatio inauguralis medica de medicinae cum geosophia nexu quam auspice deo prpitio (Hala Madgeburica, Hendelius, 1725). From http://cures.hypotheses.org/the-workshop/programme-2/boumediene-samir

With early modern Europeans’ increasing forays into the New World, however, more and more materiae medicae were found which were absent from ancient medical writings. Pliny and Dioscorides were silent on such substances as guaiacum wood, Peruvian bark or New World balsam, so their medicinal properties had to be newly investigated. Antonio Barrera-Osorio and Samir Boumediene’s papers added America, or the New World, into the discussion. Both emphasized the role of new drugs and materia medica in the rise of European experimental practices. New drugs and new medicinal recipes required new ways of testing.

Antonio Barrera-Osorio’s paper argued for an empirical culture in the Spanish empire, which was well suited to respond to these challenges. He showed how his protagonists gathered information about New World remedies from natives or travellers and experimented with ways of preparing them. Some of these drugs and recipes were deemed so important for the economy and health of the empire that the Spanish crown ordered tests in hospitals all over Castile. Samir Boumediene’s paper elaborated on the issue of making workable recipes for newly discovered drugs. Once more, taste and smell were important assays, but drugs such as guaiacum and Peruvian bark were also tested on a larger scale. Dispensing them to the poor inmates of charitable hospitals (as happened in France and Germany) helped to determine their effect, and to establish recipes, which indicated how to adjust the treatment in individual cases.

books
Andreas Cleyer, Specimen Medicinae Sinicae (Frankfurt, 1682). From http://cures.hypotheses.org/the-workshop/programme-2/hanson-marta-and-pomata-gianna

Gianna Pomata and Marta Hanson’s paper showed how recipes also functioned as vehicles of knowledge between different cultures. Recipes, as either formula or prescription, were both found in European and Chinese medical cultures. According to Pomata and Hanson, it was the familiar genre of the recipe that facilitated the transmission of Chinese pharmacology to Europe in the second half of the seventeenth century. Similarly, Carla Nappi argued that the Manchu medicinal recipes of the Qing court were spaces of encounter and medical translation in the early modern world. Pomata, Hanson, and Nappi demonstrated how the recipe served as the common ground between European and Chinese medicine and made the translation of Chinese pulse medicine and the transmission of Chinese materia medica possible in the seventeenth and eighteenth centuries.

Although recipes are difficult to characterize as a genre, it is clear that they are fascinating objects of historical study. More often than not, they are fluid rather than fixed forms of knowledge, requiring adaptation at every turn. They bring together ingredients, practices and often practitioners from all over the world, and themselves have a tendency to aggregate into larger collections. As written manifestations of gestures and processes, they play an important part in testing, assessing and modifying drugs and cures.

Henri’s kitchen: 4. Boeuf Bourguignon

Harry Hayfield, a resident of Ceredigion in Wales, has long had an interest in the stories of the Musketeers which are set in early 17th century France, this led in turn to an interest in the Stuart period of history and joining a living history group. However, as a registered carer for his grandparents, he is unable to get to many of the events and yet wanted to do something to help. One day he was watching “The Little Paris Kitchen” broadcast on the BBC and thought “These are recipes designed by the French, therefore could they be converted in the 17th century versions of themselves?”. Doing some research he found that they could. Harry will therefore contribute four of the recipes as shown in the programme as if cooked by Henri de Ceredigion (Harry’s Stuart persona) a cadet member of the Musketeers, with able assistance from Planchet, his manservant cum stable lad.

Picture the scene for a moment, you open the door to your house and find a person who blows a bugle in your face. Once you have finished twiddling with your eyes he declares “Henri de Ceredigion, Musketeer Cadet, you are hereby summoned to attend His Majesty at once. God Save the King!” That is precisely what happened to me a week before my first Christmas in Paris, and let me tell you, it was not an invitation you could ignore. So what had I done to warrant such a meeting? I had been challenged by no less a personage than the King himself to, as he put it himself, “on the day of the celebration of the birth of our Lord, the King commands that you give your Captain, Musketeers Porthos, Athos, Aramis and your manservant a present to be given at the end of a meal for those aforementioned!”. After bowing so meekly I wondered if I would ever get back up again, I reversed out of the throne room, leant against a wall and just gasped with disbelief. I had to make a full-blown meal for six people, including someone with the most voracious appetite possible, in just a week! Needless to say when Planchet got back from his trip to the market he found me absolutely in a state of panic. Thankfully he managed to calm me down a bit and set a plan in action. It would be a combination of all the things I had cooked up to that moment in time, which I have told you about, plus something from the Planchet school of cookery, Boeuf Bourguignon with Baguette Dumplings. 

Needless to say, the following day I was rushing around the market like a man about to face execution, so the fact that just as was about to return home Jussac, the captain of the Cardinal’s guards, decided to interfere was not welcome. He and I have a bit of a history, that I shall not go into, and fearing the worst I was about to draw my sword when he thrust a small envelope into my face. I cautiously opened it and found a card with the message: “This month is a month of peace to all men, be they living in the moors or the fen, and so I wish to say to you, Joyeux Noel and god speed too.” This took me a little by surprise, but as he explained being employed by a Cardinal of Rome, Christmas is the one time when normality reigns. Thus with the ingredients bought, it was time to make everything. The ingredients were: beef shin cut into six large chunks, some flour, oil, a small collection of lardons, peeled onions, a bay leaf, some parsley, thyme and rosemary, peppercorns, red wine, a small amount of sugar and salt and some mushrooms and then we got to work with Planchet doing the rest of the meal and me tackling this monster of a dish.

You will need a good wine for this dish! Credit: Agne27, Wikipedia

First, I dusted the beef with flour, and then placed them into a hot pan until they browned, and when they had done I added the lardons, onions, one of cloves of garlic, and some of the peppercorns. Now, whilst I was doing all this, there was a knock at the door. My Englishness came to the fore and I answered it. It was the butcher’s son from down the lane asking for something for the family for Christmas but as I found him a coin I smelt something burning and rushed back to find the bottom of the pan burnt. I was devastated, the meal ruined before it had begun, but Planchet placed a friendly hand on my shoulder and reassured me that it was a good thing. I knew he would never tell me a lie so I carried on by adding the meat back to the pan. Next I went to add the red wine, the usual bottle that I serve for Athos, but as I went to pour it in, Planchet grasped my hand firmly and said “Use a wine that you can drink” and with that handed me a bottle of wine I was going to give to Aramis for Christmas. Again, I knew he was in the right and so added the wine, followed by the same amount of water (rainwater, before you raise any eyebrows) and with that put the lid on and placed it in the oven, where it stayed for three hours. As I said, this was a mammoth task, and so during that time we made up all the things that I have mentioned earlier, the cheese and potato nests, the croque madames and the chouquettes and just in time too, because an hour before the meal was due to start in walked Athos, and demanded feeding. Thankfully, Aramis arrived a short while later and put a stop to his devouring, followed by Porthos and then the Captain, during which time I had to act like a host.

About fifteen minutes before the meal was due to be served, Planchet asked me to attend him in the kitchen and gave me some very bad news. We had forgotten to make the dumplings that go with the dish, mainly due to having so much to do anyway. I immediately panicked and when I do I sometimes have flashes of inspiration. And that’s what happened here. I grabbed a very old baguette and sliced it into large cubes, placed it in a bowl with some herbs, poured over some milk, added an egg and gave the whole thing a good mash together, then added some flour mixed it all up, grabbed a large handful, squeezed in my hand and said to Planchet, “Remind you of anything?” to which he declared “Dumplings, master!”. We then quickly made up six of them, fried them in a pan with some oil and just as they cooked I heard a voice saying “Henri, time to serve!”.

Taking a deep breath I pulled the pot out of the oven, placed the dumpling replacements on top and carried it to the table declaring “Henri has completed his task!” From the looks on their faces they were very impressed indeed with the end result, so much so that, and I don’t like to sound too boastful about this, the King declared me to be “un gentilhomme” which Aramis explained was a very high title for someone like me to hold and I will admit that for the rest of that Christmas I did rather have my nose up in the air on a large number of occasions, but it was all in the name of fun.