Tag Archives: Poison

Pain, poison, and surgery in fourteenth-century China

Yi-Li Wu

It’s hard to set a compound fracture when the patient is in so much pain that he won’t let you touch him. For such situations, the Chinese doctor Wei Yilin (1277-1347) recommended giving the patient a dose of “numbing medicine” (ma yao).  This would make him “fall into a stupor,” after which the doctor could carry out the needed surgical procedures: “using a knife to cut open [flesh], or using scissors to cut away the sharp ends of bone.” Numbing medicine was also useful when extracting arrowheads from bones, Wei said, enabling the practitioner to “use iron tongs to pull it out, or use an auger to bore open [the bone] and thus extract it.” More generally, Wei recommended using numbing medicines for all fractures and dislocation, for it would allow the doctor to manipulate the patient’s body at will.

Wei’s preferred numbing medicine was “Wild Aconite Powder” (cao wu san), and he detailed the recipe in his influential compendium, Efficacious Formulas of a Hereditary Medical Family (Shiyi dexiao fang), completed in 1337 and printed by the Imperial Medical Academy of the Yuan dynasty (1271-1368). In his preface, Wei affirmed that medical formulas were the foundation of medicine and that a doctor’s ability to cure depended on his ability to use these tools skillfully. Wei’s family had practiced medicine for five generations, and he synthesized their knowledge with that of other doctors to produce a comprehensive treatise encompassing internal medicine; the diseases of women and children; eye diseases; illnesses of the mouth, teeth, and throat; ulcers and swellings; and diseases caused by invasions of “wind” (ailments with sudden onset, including febrile epidemics and paralytic strokes). Numbing medicine appeared in Wei’s chapters on bone setting and weapon wounds.

Wei’s Wild Aconite Powder is the earliest datable recipe that I have found for surgical anesthesia in a Chinese text, and it is a valuable window onto practices that were largely transmitted orally, whether in medical families or from master to disciple.  Dynastic histories relate that the legendary doctor Hua Tuo (110-207) employed a formula called mafeisan  to render his patients insensible prior to cutting them, even opening up their abdomens to excise rotting flesh and noxious accumulations. Some scholars have hypothesized that mafeisan (literally “hemp-boil-powder) may have contained morphine or cannabis (ma), but its ingredients remain a mystery.  A text attributed to the twelfth-century physician Dou Cai (ca. 1146) recommended using a mixture of powdered cannabis and datura flowers (shan qie zi, also called man tuo luo hua) to put patients to sleep prior to moxibustion treatments, which in this text could involve a hundred or more cones of burning mugwort placed directly on the patient’s skin.  Wei Yilin’s recipe provides important additional textual evidence for a tradition of anesthetic formulas based on toxic plants, one that was clearly in circulation long before he wrote it down.

At least as far back as the Divine Farmer’s Classic of Materia Medica (3rd c.), medical authors had described aconite as highly toxic (for contemporary Roman views of aconite, see blogpost by Molly Jones-Lewis). In the right hands, however, aconite was a powerful drug, and part of the Chinese practice of using poisons to cure (see blogpost by Yan Liu).  Warm and acrid, aconite could drive out pathogenic wind and cold from the body, break up stagnant accumulations, and invigorate the body’s vitalities. In the language of Chinese yin-yang cosmology, it nourished yang—all that was active, heating, external, and ascending. The main aconite root was considered more toxic than the subsidiary roots (designated by the separate name fu zi, “appended offspring”), and the wild form was more potent than the cultivated variety.

Images of toxic medicinal plants from China’s most celebrated pharmacological work, Li Shizhen (1518-93), Compendium of Materia Medica (author’s preface dated 1590). Woodblock edition of 1603. Wild aconite is the middle image in the top row. Cultivated aconite (main and subsidiary roots) are in the bottom right corner. Image credit: National Library of China. Posted on-line at the World Digital Library.
Images of toxic medicinal plants from China’s most celebrated pharmacological work, Li Shizhen (1518-93), Compendium of Materia Medica (author’s preface dated 1590). Woodblock edition of 1603. Wild aconite is the middle image in the top row. Cultivated aconite (main and subsidiary roots) are in the bottom right corner. Image credit: National Library of China. Posted on-line at the World Digital Library.

Wei’s numbing recipe consisted of 13 plant ingredients, including the main roots of both wild and cultivated (Sichuanese) aconite, along with drugs known as good for treating wounds:

Young fruit of the honey locust (zhu yao zao jiao)
Momordica seeds (mu bie zi)
Tripterygium (zi jin pi)
Dahurian angelica (bai zhi)
Pinellia (ban xia)
Lindera (wu yao)
Sichuanese lovage (chuan xiong)
Aralia (tu dang gui)
Sichuanese aconite (chuan wu)
Five taels each[1]

Star anise (bo shang hui xiang)
“Sit-grasp” plant (zuo ru), simmered in wine until hot
Wild aconite (cao wu)
Two taels each

Costus (mu xiang), three mace

Combine the above ingredients. Without pre-roasting, make into a powder. In all cases of crushed or broken or dislocated bones, use two mace, mixed into high quality red liquor.

Wei most likely learned this formula from his great-uncle Zimei, a specialist in bonesetting and wounds. Its local origins are also suggested by its use of zuo ru, literally “sit-grasp”, a toxic plant whose botanical identity is unclear. However, according to the eighteenth-century Gazetteer of Jiangxi (Jiangxi tong zhi), sit-grasp was native to Jiangxi, Wei’s home province, and was used by indigenes to treat injuries from blows and falls.  While classical pharmacology focused on the curative effects of aconite, Wei’s anesthetic relied on aconite’s ability to stupefy and numb, while curbing its ability to kill. If an initial dose failed to make the patient go under, Wei said, the doctor could carefully administer additional doses of wild aconite, sit-grasp herb and the datura flower.

Additional images of toxic medicinal plants from Li Shizhen, Compendium of Materia Medica. Sit-grasp herb is in the middle of the top row, and datura flower in the middle of the bottom. Image credit: National Library of China. Posted on-line at the World Digital Library.
Additional images of toxic medicinal plants from Li Shizhen, Compendium of Materia Medica. Sit-grasp herb is in the middle of the top row, and datura flower in the middle of the bottom. Image credit: National Library of China. Posted on-line at the World Digital Library.

In subsequent centuries, as medical texts proliferated, we find additional examples of numbing medicines that employed aconite, datura, and other toxic plants, employed when setting bones and draining abscesses, and to numb injured flesh before repairing tears and lacerations to ears, noses, lips, and scrotums.  Such manual and surgical therapies are an integral part of the history of healing in China.

Yi-Li Wu is a Center Associate of the Lieberthal-Rogel Center for Chinese Studies at the University of Michigan, Ann Arbor (US) and an affiliated researcher of EASTmedicine, University of Westminster, London (UK).  She earned a Ph.D. in history from Yale University and was previously a history professor at Albion College (USA) for 13 years.  Her publications include Reproducing Women: Medicine, Metaphor, and Childbirth in Late Imperial China (University of California Press, 2010) and articles on medical illustration, forensic medicine, and Chinese views of Western anatomical science.  She is currently completing a book on the history of wound medicine in China.

Acknowledgements
This research was funded by the Wellcome Trust Medical Humanities Award “Beyond Tradition: Ways of Knowing and Styles of Practice in East Asian Medicines, 1000 to the present” (097918/Z/11/Z). I am also grateful to Lorraine Wilcox for directing me to the work of Dou Cai.

*****

[1] The weight of the tael (Ch. liang) has varied over time, but during Wei’s lifetime would have been equivalent to 40 grams.  A mace (Ch. qian) is one-tenth of a tael.

Anecdotes and Antidotes

By Alisha Rankin

How did early modern individuals test and try their recipes and cures? This question is at the heart of the special issue of the Bulletin of the History of Medicine, “Testing Drugs and Trying Cures in Medieval and Early Modern Europe,” in which I participated as both a co-editor and an author. My article, “On Anecdote and Antidotes: Poison Trials in Early Modern Europe,” examines the ways in which early modern practitioners tested a specific kind of cure: antidotes to poison. It contains some information I discussed in earlier posts on this blog – here and here – but adds many details and thoughts about testing in general. Most cures, I argue, tended to be tested in the course of regular clinical experience. A patient got sick; a practitioner tried a particular remedy, observed the results, and frequently shared anecdotes of success or failure. The scale of this kind of testing could be small or large, but in most cases it involved patients who were already sick.

Poison antidotes were a little different, because practitioners could actually create the condition of illness by giving poison to a test subject. In 1563, for example, the royal surgeon to Holy Roman Emperor Ferdinand I, Claudius Richardus, wrote a letter describing the marvellous virtues of bezoar stone. As avid Harry Potter readers will know, bezoar was an animal byproduct prized as a poison antidote and cure-all. Richardus recounted a series of marvellously successful tests he had conducted on bezoar at the Emperor’s behest. In two of them, patients received bezoar in the midst of a serious illness – the usual practice. In the other two, bezoar was tested in contrived trials on condemned criminals.[1]

Bezoar stones from the imperial Kunstkammer, Kunsthistorisches Museum Vienna. Photo by Alisha Rankin.

This second kind of test – which I call a poison trial – has a long history dating back to antiquity. Many ancient kings, most famously Mithridates VI of Pontos (135-63 BCE), used condemned criminals to test poison antidotes, from which he developed his famous antidote and cure-all, mithridatium. The Greco-Roman physician Galen reportedly tested theriac, a derivative of mithridatium, on roosters, and versions of this test appeared in the writings of several Arabic physicians, including Avicenna’s highly influential Canon of Medicine.[2] Medieval physicians repeated the description of Galen’s test as well. However, poison trials tended to be described as theoretical tests that one could conduct rather than as anecdotes about tests that had actually taken place, and they were mainly suggested as a means to test whether a batch of theriac was inferior, fraudulent, or old – not whether theriac actually worked. From the time of Galen, moreover, poison trials were conducted exclusively on animals, not humans. The dominant argument for the efficacy of these drugs remained anecdotal reports of their use on sick patients.

In the Renaissance, poison trials expanded significantly, as did their role in medical communication. From the 1520s, powerful rulers began to revive the gruesome tradition of using condemned criminals to test a variety of poison antidotes – not just theriac. In addition, these tests were reported and circulated as anecdotes rather than being described as theoretical suggestions. The first known example comes from Rome in August 1524, when Pope Clement VII directed his medical personnel to test an antidote oil created by the surgeon Gregorio Caravita. He granted the medics two Corsican criminals who had been condemned to death by beheading. Both prisoners were given a strong dose of the deadly herb wolfsbane (aconitum napellus). Caravita then anointed one prisoner with the oil. The other, a “savage spirit,” was given no antidote. The first man survived; the other died in much agony.

Testimonium de verissima ac admirabili virtute olei compositi contra pestem & omnia venena (Rome, 1524), BNF.

A second successful test was conducted on a Mantuan prisoner given arsenic. Soon thereafter, the medical personnel published a public service pamphlet describing these trials in detail.[3]

A shorter version of this anecdote also appeared in the famous herbal published by Italian physician Pietro Andrea Mattioli in 1544 (with a Latin version in 1554). Mattioli’s influence helped spread poison trials around Europe. From 1561-67, a number of contrived trials on condemned criminals took place under powerful princes, including Emperor Ferdinand I, King Charles IX of France, and Duke Cosimo II de’Medici. Significantly, royal physicians and surgeons spearheaded these poison trials, and they communicated the results in anecdotes that appeared both in private documents and printed books. Claudius Richardus’s bezoar trials were part of a series of such events.

These anecdotes demonstrated careful thought in how the trials were devised and conducted. They described the trials in in excruciating detail, including the number of times a prisoner had vomited and defecated as well as the hour at which these events had occurred. In some cases, physicians attempted to created conditions that would lead to a useful outcome. Richardus’s letter described how food was withheld from a prisoner before the test, “so that one could be more certain of the trial.” This step came in response to a previous case in which the physicians had trouble getting the poison to work. Finally, physicians took care in reporting and circulating their reports about the trials, clearly imbuing them with significance. A series of poison trials on dogs conducted in 1580 by a German prince circulated in both manuscript and print as a detailed Observatio, a report intended to be shared.

Poison trials represented only a miniscule part of drug testing in early modern Europe. Indeed, anecdotes about drugs used successfully on sick people helped drive the interest in new drugs from around the globe, as described in this post by R.A. Kashanipour. Nevertheless, the anecdotes about antidotes demonstrated significant developments in both testing practices and medical communication. To find out more, read my article!

 

[1] Richardus’s letter, to Archbishop Nicholas Olahus, was later published in Latin and German. Thomas Jordan, Pestis phaenomena (Frankfurt, 1576), 621–630; Johann Wittich, Bericht von der wunderbaren bezoardischen Steinen (Leipzig, 1592), 21.

[2] Galen’s poison trial appeared in the treatise On Theriac to Piso, which may be spurious. However, scholars in the Islamic world and Europe assumed it was authentic. See Robert Leigh, On Theriac to Piso, Attributed to Galen: A Critical Edition with Translation and Commentary (Leiden: Brill, 2016).

[3] The pamphlet was signed by the physician Paolo Giovio, the apothecary Tomasso Bigliotti, and the senator Pietro Borghese. Testimonium de verissima ac admirabili virtute olei compositi contra pestem & omnia venena (Rome, 1524).

Writing Early Modern Medicine for Medical Readers

Poison trials on dogs conducted by Landgrave Wilhelm IV of Hesse-Kassel in 1580. Universitätsbibliothek Heidelberg, Cod. Pal. germ. 177
Poison trials on dogs conducted by Landgrave Wilhelm IV of Hesse-Kassel in 1580. Universitätsbibliothek Heidelberg, Cod. Pal. germ. 177

By Alisha Rankin

Years ago, in a recipe collection belonging to Countess Elisabeth of the Palatinate (1552-90), I found a fascinating entry: a copy of an official document that described trials of a poison antidote on dogs, which I described in a post on this blog. My interest in that document has expanded into an entire book project on poison trials. Because these trials feel vaguely like an antecedent to modern clinical trials (with many twists and turns along the way), I’ve found that this project has provided an exciting opportunity to introduce early modern medicine to a medical audience. Last month Justin Rivest and I had the privilege of publishing a short piece, “Medicine, Monopoly, and the Pre-Modern State: Early Clinical Trials,” in the New England Journal of Medicine. Just a few days later, I published a blog post titled “Poison Trials on Condemned Criminals under Pope Clement VII: A Medical and Moral Testimonial” for the Sperimento blog, run by the Medici Archive Project. The juxtaposition of these two pieces, of similar length and on similar topics but in two very different venues, led me to reflect on writing history for non-experts, and on how different it is to write for doctors than for historians. Because the Recipes Project blog intends to reach a wide audience, I thought it might be interesting to jot down some thoughts on the experience here.

Testimonium de verissima ac admirabili virtute olei compositi contra pestem & omnia venena (Rome, 1524), BNF.
Testimonium de verissima ac admirabili virtute olei compositi contra pestem & omnia venena (Rome, 1524), BNF.

Writing the Sperimento piece felt very familiar. The blog is intended to introduce a specific document in early modern Italian science and/or medicine, so I picked a Latin pamphlet published in 1524 on the authority of Pope Clement VII. The pamphlet described three poison trials conducted on condemned criminals and was intended to show the wondrous workings of an antidote oil created by a surgeon named Gregorio Caravita. I reflected on the religious and moral undertones of the document, and I included several footnotes with the original Latin. It was a pretty typical blog piece – fun to work on and quite helpful to write, as it forced me to sit down and meticulously make my way through the pamphlet. (I had hoped to find a recipe for the oil at the end of the pamphlet, but sadly the recipe remained Caravita’s secret – although Jo Wheeler included a later Medici version in his book.)

The NEJM piece, on the other hand, was far harder. We had to plan the article out very carefully. The word limit was officially 1,200 (although they happily ended up being a little flexible!), and it needed a lot of framing on each end. Justin is an expert in seventeenth- and eighteenth-century France, and I was highlighting work from sixteenth-century Germany. That left each of us just a couple of short paragraphs to present our case from our own research and to tie everything together. This is apparently the first time the NEJM has published a piece on early modern medicine, so we tried our best to make it fit into categories that medical readers would find familiar. That meant keeping modern medicine as the standard against which we compared our historical case. It also – helpfully – forced Justin and me to come up with a coherent narrative over a long period of time.

The hardest part – for me at least – was the footnotes. The journal allowed only five references, which was very hard for two historians with two completely different sets of research that drew on archives as well as printed sources. Justin and I worked and worked to get it down to the requisite number and felt pretty good about the result. Then the peer reviews came back – and the editor clarified that five references meant individual references, not footnotes. Because some of our footnotes contained multiple sources, we had to cut out an additional six references. Uff. We simply had to give up on documenting everything, and I learned how uncomfortable that made me. Would historians think that the article was shoddily researched? Maybe, but I kept reminding myself that historians were not the main audience, an important distinction when I had to choose between my archive and an important English-language journal article. Were I writing for historians, I almost certainly would have picked the archive, to show all the great (hard!) research I’d done. In this case, I went with the article, on the theory that an interested reader could follow up with it more easily.

The fun part of writing for the NEJM was thinking about how to make early modern medicine seem something other than “wrong.” We went for the basic takeaway point that trials (even in a very, very early form) have been used to assess drugs for a really long time. I also did a short podcast with the journal, to expand on certain points. I didn’t have the questions in advance, and I couldn’t help but cringe a bit when the interviewer straightforwardly referred to our historical actors as “scientists” and “researchers,” but in some ways that was validating, as it suggested he was treating our subject with respect.

A truly interesting coda was what happened afterwards. Both the NEJM article and the Sperimento post made the rounds on social media. Interestingly, the latter appears to have been of more interest to early modernists, at least judging by the re-tweets I saw on my Twitter feed (perhaps those footnotes mattered after all!). The NEJM piece, in contrast, really did reach physicians. While we did not receive any major press attention, Tweets came literally from all over the world. Looking at this metrics map of where the article was read was really fascinating:

NEJM page views

I hadn’t quite thought about how far-reaching a top medical journal is – that short essay may well be the most widely read thing I ever write. Most gratifyingly, I received a lovely e-mail from a former student – now a doctor – who was delighted to see his old professor pop up in an unexpected place. But overall, the consensus from Twitter appeared to be “Wow! I had no idea that people were testing drugs that early!” In some ways, that is exactly why we do public history – to make people look at the past a little bit differently and, hopefully, to put modern trends in context. Being forced out of your comfort zone (footnotes!) also makes you think carefully about what message you really want to share. And of course readers of this blog will not be surprised to learn that recipes can lead you to all sorts of unexpected places!

Controlled substances in Roman law and pharmacy?

By Molly Jones-Lewis

Let me begin with a passage from the Digest of Roman Law within the section on the Lex Cornelia on murderers and poisoners (D.48.8.3.3):

It is laid down by another decree of the senate that dealers in cosmetics[1] are liable to the penalty of this law (the Lex Cornelia on murderers and poisoners) if they recklessly hand over to anyone hemlock (cicuta), salamander, aconite, pine-worms (pituocampae), or buprestis,[2] mandragora, or, except for the purpose of purification, cantharis beetles.

This particular decree of the senate was preserved by the jurist Marcian (active c. 200 and 222 CE), but the actual decree could date from any time between 81BCE, when it was passed, and Marcian’s own day. The main test of the law was not whether or not a murder had been committed, as it is with most modern legal systems, but the intent to murder. Penalties ranged from relegation (temporary exile) to death by wild animals.

Negligence should not have exposed someone to its penalties, but there is evidence in both the legal and literary record of medical professionals who unwittingly aided in a murder being prosecuted under the Lex Cornelia. Galen, for instance, mentions one unfortunate doctor who was executed when a wicked stepmother (of course) claimed a drug was for her own use, only to have her slaves slip it into her stepson’s food.

Other examples preserved in the Digest involve gynecologists, aphrodisiacs, and abortifacients; gender bias very likely accounts for the departure from the intent-test. Add to that the demographics of medical professionals in the Roman Empire–many of them were slaves and freedmen–and the pattern becomes even more clear. Elite moral panic likely drove the legislative policy in this decree of the senate, with chilling effects. Under it, suppliers are held liable for selling commonly used pharmaceutical ingredients.

So would these highly toxic items that an ancient pharmacist would carry? Absolutely! Dioskourides, author of a first century CE pharmacy manual (and standard reference for Roman pharmacists), listed several uses for them.[3]

“Spanish Fly” continues to enjoy an unfortunate reputation as a “natural” aphrodisiac, even in this age of safer alternatives. Image credit: Nuvalife.
“Spanish Fly” continues to enjoy an unfortunate reputation as a “natural” aphrodisiac, even in this age of safer alternatives. Image credit: Nuvalife.

We begin at the end with Blister Beetles (Cantharis, buprestis, pituocampae): Here, I am grouping three similar insects, just as Dioskourides did (2.61). These insects are more popularly known as “Spanish Fly.” The oil produced by these beetles causes the skin to blister, and this made it a useful item for removing growths.

But Dioskourides does not mention its most famous application, and most dangerous–blister beetle poisoning irritates the urogenital tract, causing an erection. It was, in essence, ancient Viagra. It seems to have been responsible for quite a few accidental and embarrassing deaths, and likely accounts for the general anxiety surrounding the use of aphrodisiacs in Roman law and armchair scientists like Pliny the Elder.[4] It also shows up in some cringe-worthy gynecological recipes, and must have caused many a woman severe discomfort.

Cosmetics sellers would stock it for people with warts, women would keep it handy, and Roman legislators were concerned. It is hardly surprising that this class of insect dominates the senate’s decree.

The shape of the flower resembles the hood of a monk, hence the English common name. Image credit: Wikimedia Commons.
The shape of the flower resembles the hood of a monk, hence the English common name. Image credit: Wikimedia Commons.

Aconite, also known as monkshood, wolfsbane, and the “queen of poisons,” is best known today as Professor Snape’s go-to icebreaker question for Potions class. It is deadly–strong enough to cause numbness when it comes in contact with the skin–and that is precisely what put it on the senate’s list. Dioskourides 4.77 declares it useful for killing wolves, and nothing else, but urban sales were almost certainly aimed at eliminating human nuisances like abusive slaveowners and inconvenient husbands, at least in the minds of lawmakers.

The English name reflects the long history of identifying the somewhat anthropomorphic form of this root. Dioskourides differentiates between a “Male” and “Female” form – this one is the female variety. Image credit: http://fa13ethnobotany.providence.wikispaces.net/Mandrake.
The English name reflects the long history of identifying the somewhat anthropomorphic form of this root. Dioskourides differentiates between a “Male” and “Female” form – this one is the female variety. Image credit: http://fa13ethnobotany.providence.wikispaces.net/Mandrake.

Another alumna of Harry Potter, the mandrake is best known for its use in magic. However, it also has a strong effect as a sedative and anesthetic; it was used as such into the early 1900s. But too much could cause death, as Dioskourides warns in his lengthy list of applications (4.75). It’s hallucinogenic properties, too, combined with its sedative effects, would have made it a prime candidate for abuse and accidental death. No wonder it makes the senate’s list!

Even today, Hemlock remains infamous for its role in the death of Socrates. So why on earth would a pharmacy sell it? Dioscorides 4.78 recommends it for topical applications only, first as a cure for shingles and erysipelas, both common and painful skin conditions. He goes on to prescribe it to stop lactation, to keep youthful breasts small, and, alarmingly, to cause a boy’s testicles to shrivel. The most shocking suggestion, though, is that it be applied to the testicles to prevent nocturnal emissions – surely a recipe for disaster if the man in question failed to wash his hands carefully.

Small jars excavated in the prison in the Athenian Agora, possibly used for the executioner’s Hemlock. Author’s image, 2006.
Small jars excavated in the prison in the Athenian Agora, possibly used for the executioner’s Hemlock. Author’s image, 2006.

So we have in this list a number of items common in recipes and associated with women and medical professionals, both of whom might respond to their systemic oppression with the covert violence of poisoning. If you were to open a pharmacy in the bustling streets of the Roman empire–especially if you were a woman, freedman, or both– it would be best to think twice about why your patient is so keen to buy his cantharis in bulk.

[1] The ingredients in cosmetics and pharmacy were often similar, and likewise cosmetics were made to also have medical benefits.

[2] J. B. Rives rightly suggests (n. 22) that the word “bubrostis” is a misspelling of “buprestis.”

[3] See Lily Beck’s excellent translation and commentary for the most likely identification of the species involved. Taxonomy and nomenclature in antiquity is imprecise by modern standards; it can be difficult to link ancient names to known species.

[4] For example, Natural History 25.25: “I do not include abortifacients in my account, and not even love potions, remembering that Lucullus the most famous general perished from such a potion.”