Dr Tibi is a community pharmacist in Oxford, who has a D.Phil. in
the history of medicine
|
Much of what we now know about the medicinal value of opium
was already known in antiquity. Produced in Egypt, particularly in Thebes,
opium was exported all over the Mediterranean world as opium thebaicum and used medicinally by the ancient Egyptians, and in Hellenistic and Roman
times. With the spread of Islam in the seventh century, opium was introduced
into India and, much later, in the 13th century, into China, where it was
first used as a medicine.
Greeks and Romans
Papaver somniferum |
The benefits and dangers of opium were recorded by many Greek and Roman
medical authors such as Hippocrates, Dioscorides, Celsus, Galen and Paul
of Aegina. They knew, as we do, that nearly all parts of the white poppy,
Papaver somniferum L, are pharmacologically active, particularly the
unripe capsules, from which the juice or latex, opium, is extracted.
The word opium is from the Latin for poppy juice and from the Greek word,
opion, meaning juice of a plant. The Greek word diacodion means “the
drug from the poppy capsule”. In Arabic, the word for opium, taken
either immediately from Greek, or through the Persian word abyun, is
afyun, while poppy is called khashkhash — “that which rattles” referring,
presumably, to seeds in a dry capsule.
Knowledge of the Graeco-Roman use of opium passed to ninth century Baghdad
physicians mainly through translations of the works of Dioscorides and
Galen. Dioscorides, from Anazarbus in south-east Turkey, was the first
to write detailed accounts of the therapeutic uses of opium. He acquired
his name, Greek for “the dendrologist of God”, from his interest
in nature; he spent 40 years collecting information on over 1,000 plants,
animals and minerals and recorded this in the five books of ‘De
materia medica’, which became one of the most influential of medical writings,
forming a database of pharmacy for generations after him. Strangely enough,
the shield in the centre of the Royal Pharmaceutical Society’s coat
of arms, which is supported on the left by the 11th century Islamic physician
Ibn Sina (Avicenna) and on the right by Galen, does not feature Dioscorides
at all.
Illustration of a poppy from a 13th century Arabic manuscript of
a translation of Dioscorides’s De materia medica |
Way ahead of his times, Dioscorides arranged drugs according to their
physiological effect on the body. Herbs, for instance, are recorded in
different books
depending on their actions. Book IV, ‘Herbs and roots’, has
separate entries for the different species of poppy. ‘De materia
medica’ of Dioscorides was first translated from Greek into Arabic
in the ninth century and became the foundation for Islamic pharmacology.
The only translation into English was made by John Goodyer in the 17th
century.
Two Arabic manuscripts of De materia medica are held at the Bodleian
Library in Oxford. One is a 12th century, complete and unillustrated
copy and the
other is a 13th-century, illustrated copy which is incomplete but does
contain the book on herbs and roots. The latter was bought by Sir William
Osler (Regius Professor of Medicine at Oxford) in 1912 via the British
consul in Shiraz from a reluctant but needy Persian for the grand sum
of £25
plus tuppence ha’penny for postage. Much to his disgust, the consul
noted that the halo on Dioscorides at the beginning of the manuscript
had been changed by a pious former owner (as being idolatrous) to a turban.
Galen, who lived in the second century AD, was of even greater influence
in the Islamic medical world. According to Ibn Zuhr, the renowned 12th-century
Andalusian physician, “Jalinus [Galen] was unquestionably the master
of the science of medicine”. Like Dioscorides, Galen was a Greek
living in a Roman world and though he wrote in Greek, the titles of his
books are generally referred to by their Latin names. Born and educated
at Pergamum in Asia Minor, Galen went to Rome, where he excelled as a physician.
His most famous patient was Marcus Aurelius (161–80 AD), for whom
Galen prepared a daily dose of theriac (literally antidote). Theriac was
made up of many drugs and aromatics, including opium. According to Galen,
it cured everything from snakebites to epilepsy but, for Marcus Aurelius,
he adjusted the opium content depending on whether the Roman emperor wished
to feel good or simply wanted a good night’s sleep. Like Dioscorides,
Galen described the effect of opium as cooling because of the potentially
fatal loss of innate heat and sensitivity.
Baghdad in the ninth century
The Arabs played an important role in preserving Greek knowledge. They
studied and translated many of the Greek medical works, then built on
them with their own observations. The ninth century (the third, in the
Muslim calendar) was a particularly significant one in the Islamic world.
It was the golden age of the Abbasid caliphate (of Harun al-Rashid fame),
an age not only of power but also of learning and progress. The capital,
Baghdad, though only 50 years old, was at its peak and had become a centre
of academic activity. Caliphs sent scholars to distant places in search
of manuscripts; according to the historian R. A. Nicholson: “In
quest of knowledge men travelled over three continents and returned home,
like bees laden with honey, to impart the precious stores, which they
had accumulated to crowds of eager disciples.” As a result, many
Greek and Roman codices that would otherwise have been lost were copied,
translated and preserved. Owing in part to Muslim tolerance of other
religions, the translators were mainly Syriac-speaking Christians, who
were of the elite class before the arrival of Islam and therefore knew
the languages necessary. The translators of Greek works into Arabic were
not interested in Greek literature, so no close contact was established
between the Arab mind and Greek drama, poetry or history (influence in
this field remained Persian). It was Greek medicine, mathematics and
allied sciences, and philosophy that fascinated the Arabs most. Philosophy
(from which the Arabic word falsafa is derived) was new to them and Aristotle
was their “first teacher”. In medicine, Galen was quoted
most, but when it came to pharmacy and botany, Dioscorides took precedence. Opium and poppy in selected works
A number of well known physicians, who either originated from Baghdad
or went there to practise, flourished in the ninth century and were authors
of important medical and scientific treatises. Medical figures of the
time were not only polymaths, but also excelled in all that they knew.
Their livelihood and their lives were at the mercy of the ruling caliph,
yet they still managed to produce a vast amount of work not only on medicine
but also on a variety of subjects such as philosophy, mathematics, logic,
music and astronomy. Kindi, for example, wrote the earliest known description
of how the frequency with which various letters of the alphabet appear
in a text can be used to decipher codes.
Six of the most important figures were, in chronological order: Yaqub
ibn Ishaq al-Kindi, Sabur ibn Sahl, Hunayn ibn Ishaaq, Ali ibn Sahl Rabban
al-Tabari, Thabit ibn Qurra and Muhammad ibn Zakariyya al-Razi. Kindi and
Razi (so called after the place of his birth, Rayy, near Tehran) were Muslims,
while Thabit (from Harran in Mesopotamia) was a Sabian — a star worshipper.
Sabur (from Khuzistan), Hunayn (from al-Hira) and Tabari (from Tabaristan)
were Christians, although Tabari converted to Islam at the age of 70.
By the ninth century, the number of simple and compound remedies known
to the Arabs had risen from that recorded in Greek works, and medical formularies
or aqrabadhins were compiled according to the type of medicament, a form
of arrangement for an aqrabadhin favoured in early Islamic medicine. Kindi’s
medical formulary is one of the earliest written in Arabic. Each recipe
has a title, usually specifying the ailments it is intended to treat, followed
by a list of ingredients and their weights, a brief method of preparation
and, sometimes, the dosage. Most of the recipes end with the following,
or a similar invocation: “Beneficial, God willing.” Kindi’s
recipes that include opium or poppy are mainly for ocular complaints such
as cataracts and ophthalmia.
Like Kindi’s, the much larger medical formulary of Sabur, which continued
to be used by hospitals and pharmacies until the 12th century, is arranged
according to the type of medication in chapters with curious names such
as “theriacs and electuaries” and “divine remedies”.
Unlike Kindi, however, Sabur gives full instructions on preparation: the
ingredients are gathered, pounded and sieved (sometimes through a silk
cloth), then kneaded in honey. Other vehicles include wine that has been
boiled until two thirds of it has evaporated (muthallath wine). In one
recipe, Sabur stipulates that the medicine should be used six months after
its preparation and that it would be fatal if used before. There are about
300 substances that occur in Sabur’s opium and opium poppy recipes,
some of them quite bizarre. One remedy for angina includes dog’s
excrement while another, for miscarriage, requires a hyena that is “lame,
female, alive and old, with its front and back legs tied together”.
Oddly enough, the hyena features in remedies by a number of sources, including
Dioscorides, and is still used by African witch doctors. Sabur’s
400 opium or poppy recipes are for a range of remedies, including those
that are “good for old age” and one which, if given to a healthy
person, “will protect him from all pains and diseases”. Interestingly,
the recipe with the most opium is “useful for stupidity and lethargy,
and sharpens the brain”, while a recipe called “Food for sorrows”,
which contains henbane as well as opium, is, not surprisingly, used for
depression.
It is worth writing a few words about Hunayn, who was a particularly interesting
character. The son of a pharmacist, Hunayn, known in the Latin world as
Johannitus, was fluent in Greek, Syriac and Arabic and became the most
able and prolific of the translators. Besides making translations, Hunayn
wrote a number of original works on medicine and other subjects. Word of
Hunayn’s knowledge and expertise inevitably reached the ears of the
caliph who summoned him and made him chief of physicians at his court.
Knowing that Hunayn had been to Byzantium, and uncertain of his true allegiance,
the caliph decided to put him to the test. He asked Hunayn to concoct a
poison to kill an enemy but Hunayn flatly refused, saying he had only learnt
how to prepare cures, and that such a request went against both his profession
and his religion. As a result, he was imprisoned but continued to study,
apparently unperturbed by his surroundings. The caliph, impressed by Hunayn’s
conviction and learning, released him and had him reinstated. Later, however,
Hunayn fell out of favour again and was publicly flogged. Worse still,
like Kindi before him, he had his library confiscated. At the loss of a
library that had taken him a lifetime to build up, Hunayn is said to have
either died of sorrow or to have poisoned himself.
Hunayn’s ‘Ten treatises on the eye’ is the oldest existing
systematic textbook of ophthalmology. It contains a large number of remedies
that involve mainly opium. In the eighth treatise, for instance, opium
is described as “cold, dry and in the fourth degree [highest potency]”.
Horned poppy is described as having moderately astringent properties. Hunayn,
who was sceptical about the use of narcotics, gives the dangers of misusing
opium in an interesting passage: “With regard to drugs of the seventh
category, that is narcotics, they should be used when the pain is so acute
that the patient’s life is in danger, particularly when the pain
is sharp and comes with corrosion and ulcers. It is necessary to be cautious
in the use of these drugs because they weaken eyesight and could possibly
damage it. For this reason, one should be careful and avoid them except
in cases of extreme urgency. When needed, such drugs should be used sparingly
and for a short period, until the pain subsides. When this happens, one
should use ocular remedies that have a warming effect, such as the one
prepared with cinnamon. These [narcotic] drugs are opium, juice of mandrake
and the like.”
The tenth treatise contains 45 compound remedies by Greek authors; they
are mainly for collyria, involving opium or horned poppy, or both, used
to treat ophthalmia, ulcers and pain in the eye. Four recipes are for kuhl,
a compound ocular remedy ground to a fine powder and applied to the eyelids
with a probe (al-kuhl is the origin of the word alcohol — it came
to mean essence and spirit obtained by distillation). Hunayn says little
about preparation but, occasionally, gives instructions on how to use the
medicine, for example, mixed with egg white, woman’s milk or water,
then applied.
Tabari’s most famous work, Firdaws al-hikma (‘The paradise
of wisdom’), is a compendium that includes the anatomy of the human
body, its diseases and their treatment. Opium and poppy feature in 46 recipes
with titles such as “The great theriac”, “Caesar’s
recipe”, “God’s gift” and “Mithriditus” (an
antidote named after Mithridates VI, king of Pontus, who gave himself immunity
to poisons by gradually taking increased doses to the extent that when
he was defeated by Pompey, he was unable to commit suicide by poison and
had resort to the sword). Some of Tabari’s recipes show superstitious
belief. For example, some are used for epileptic fits that occur monthly
at half-moon, or for people under a spell, for the evil eye, or for evil
spirits. Tabari also had a recipe for weight gain in women (fatness in
women was, and probably still is, considered highly desirable by Arab males).
The Kitab al-dhakhira (Book of treasure) attributed to Thabit (famous mainly
as a mathematician) is a small compendium of diseases and their treatment
for use by general practitioners. It has some 60 references to opium or
poppy, many of which are not recipes, but contain interesting information
such as “opium can eradicate hair from the face and the body” or “eating
poppy with syrup of rose-water and syrup of grapes is useful for colds”.
For head lice, Thabit recommends a paste of horned poppy and borax. Although
they appear under the general heading, “Treatment for hangover”,
there are two recipes that would seem to precipitate rather than treat
the effects of intoxication. In addition to opium, one of them includes
black henbane and the other, henbane and mandrake. Perhaps, like many of
us, Thabit regarded intoxication as therapeutic in certain circumstances
(just as we might take the hair of the dog today).
The most important writer
The sixth and by far the most important medical writer in ninth century
Baghdad was Razi, known to Europeans as Rhazes. Physician, philosopher
and alchemist, he spent most of his life studying. Razi’s output
was phenomenal, the largest of his medical works being Kitab al-hawi
fi al-tibb (‘The comprehensive book of medicine’). In it,
Razi, who did not know Greek, quotes Hippocrates in the middle of the
first millennium BC and a range of Hellenic authors between the first
and the seventh centuries AD, Galen being his preferred choice. The Hawi is, therefore, an invaluable source of earlier work as well as a unique
record of the medical knowledge at the time, including remedies that
were used or at least tested. Translated into Latin in the 13th century
under the title ‘Continens’, the Hawi was repeatedly printed
in Europe in the 15th and 16th centuries. The medical science of Razi
had a major influence on the development of European medicine. Some of
his sayings, which have strong parallels with modern trends in medicine,
are worth noting:
• “The physician, even though he has his doubts, must always make
the patient believe that he will recover, for the state of the body is
linked to the state of the mind”
• “If the physician is able to treat with nutrients, not medication,
then he has succeeded. If, however, he must use medication, then it should
be simple remedies and not compound ones”
• “With a learned physician and an obedient patient, illness does
not linger long”
A medical encyclopedia of 23 volumes, two of them further divided into
two lengthy parts, the Hawi deals with diseases from the head and progresses
systematically through the rest of the body. It is a collection of medical
notes that Razi made for himself throughout his life from all he had read
(quoting each source), to which he added personal observations. These notes
were put together after Razi’s death by doctors who had been his
pupils.
Razi held strong views on the role of a physician and did not believe it
included that of a pharmacist. Introducing his discourse on pharmacy, he
states that he includes it in his work despite the fact that “knowledge
of medicines and the ability to distinguish the good from the bad and the
pure from the adulterated are not of necessity obligatory for a physician”.
As a result, there is no separate section on compound remedies and, for
a text this size, there are relatively few recipes. Both opium and poppy,
however, are mentioned frequently and are discussed at length in Volume
XX (‘On simple drugs), where the entries on opium and poppy in Dioscorides’s
Materia medica are reproduced. Volumes with more than 20 citations of opium,
poppy or horned poppy in descending order are: ‘Intestines’, ‘The
eye’, ‘Ear, nose and teeth’, ‘Sleep and wakefulness’, ‘Kidneys
and urinary tract’, ‘Evacuation and fattening’, ‘Piles
and gout’, ’Lungs’, ‘The head’, and ‘The
uterus and pregnancy’.
Razi evidently considered opium and poppy particularly effective for diseases
of the intestines and the eyes. He recommended opium orally for diarrhoea
and for intestinal ulcers; opium suppositories for tenesmus; opium suppositories
(attached to a thread, held at night and pulled out when necessary) for
colic; poppy seed enemas for intestinal ulcers and a poppy drink at all
times for what he called “a loathsome type of diarrhoea”, possibly
referring to ulcerative colitis or severe dysentery. Opium was also recommended
by Razi to stop the loss of blood in pregnancy, heavy periods and haemorrhoids.
An ointment for anal fissures, described by him as “very remarkable”,
consists only of camphor to which opium is added when the pain is severe.
Opium combined with colchicum occurs in oral recipes for “gout and
the joints”. Colchicum has been used to treat gout since the second
millennium BC and its active constituent, colchicine, still used today.
Gout was known and described by ancient Greek physicians under various
names that appear to have been applied to gout and rheumatism alike; this
might explain Razi’s reference to “gout and the joints”.
Poppy taken with kidneys of skink, brains and eggs of birds, or cockerel
testicles was the Viagra of the day, though which of the ingredients was
the aphrodisiac is anyone’s guess. Tabari’s version, which
reads more like a gourmet dish, was made with onions, garlic and male birds’ brains.
Opium or poppy appear in topical preparations for inflamed male and female
external genitalia. Razi, however, struck lucky and cured a swelling in
his right testicle simply with emetics! In the volume on leprosy and scabies,
Razi curiously includes treatment for whitlow (a paste of opium in vinegar)
which he declares to be the best.
Towards the end of his days, Razi suffered from cataracts and went blind
but refused treatment, saying that at his age it would be too painful and
that in any case he had seen enough of the world.
Conclusions
From the mass of material encountered in the six works discussed, it
appears that Baghdad physicians in the ninth century used opium for a variety
of ailments in every part of the body. Also used, but to a lesser extent,
were various species of poppy, which included the horned poppy and
a
variety of wild poppy. Recipes by the earlier authors, particularly
by Sabur and Tabari, have far more ingredients and were often used for
a
wide variety of disparate complaints. Recipes by the later authors,
in particular by Thabit and Razi, are short, to the point and say little
about preparation, weights or dosage. The invocations to God invariably
given by Kindi and Sabur are absent from recipes by the later authors. Terminology Opium, according to Razi, is the juice of the “black
poppy” and, according to Tabari, it is extracted from the juice of
poppy leaves. The combining of “heat-producing” drugs such
as castoreum and cinnamon with opium make it safer to use. The use of the
term khashkhash is not altogether clear. In theory it denotes the genus,
poppy, of which two specific varieties are identified and used, mamitha,
the horned poppy, and narkiwa, a wild variety. Khashkhash is sometimes
qualified as abyad (white), aswad (black) or barri (wild), but when unqualified
it seems to refer to the opium poppy.
Of the poppy varieties that are specifically mentioned, the black and the
white poppies, along with their seeds, feature most. What was meant by
black poppy is uncertain. Botanically, there is no such colour, so this
may have been a reference to poppies with dark red flowers, or to the seeds.
The relative potency of opium, poppy varieties and poppy parts were graded
in the following order, going from weak to strong: unripe poppy, poppy
seeds, poppy husks, black poppy and, the most potent, opium. As regards
formulation, poppy was made into a drink, a syrup or a confection, powdered,
roasted, fried or inhaled as a vapour.
Uses of opium and poppy There is no clear distinction between the functions
of opium, poppy, wild poppy or the horned poppy. In general, however, opium
was undoubtedly the drug of choice for pain or severe pain, and poppy was
often prescribed for coughs and colds, while horned poppy featured in many
ocular remedies. Razi even declares that “horned poppy maintains
the health of the eye”.
The medicaments take various forms and include: potions; pills, tablets
(round or triangular, taken as they are, or stored and mixed with a drink
when needed) and lozenges (placed under the tongue overnight), ocular remedies
(applied with a probe or in the form of collyria), pastes, dressings and
compresses, suppositories, snuffs, decoctions poured on the head for headaches,
fumigants and preparations shaped like apples and sniffed. Instructions,
however, on how to prepare or use these products are not always provided.
All six authors used saffron, gum arabic and myrrh in the recipes. Evidently
considered to be of therapeutic value, saffron is the substance that occurs
most frequently, although less so towards the end of the century. Starch,
which hardly features in recipes by the earlier physicians and is not mentioned
by Razi, is the excipient used most by Thabit in the middle of the century.
Dose and overdose The weight of ingredients and doses are not always given,
but in a number of oral recipes where they are, the percentage of opium
per recipe varies roughly between 2 and 13 per cent, and the weight of
opium taken per dose, depending on the patient, is between 0.03 and 0.42g.
The dangers associated with opium were generally known, and various figures
were given for the lethal dose, ranging from 3.125 to 6.25g. The main symptoms
of overdose were given as: dizziness, hiccups, dimmed vision, choking,
body chills, severe convulsions, deep sleep and the smell of opium when
the body was scratched. Treatment of overdose included: drinking water
with honey or absinth with vinegar; taking cinnamon (the antidote for opium
poisoning) or chicken broth and salt; sternutators, emetics, strong acid
enemas, smelling putrid matter and soaking in hot water to alleviate itching.
Razi states that, from experience, he found the best treatment of opium
poisoning was a potion prepared with a mithqal (4.46g) of asafoetida in
two uqiyyas (67.7g) of pure, strong wine.
A modern perspective Plants and other substances available to practitioners
1,000 years ago differed from area to area and from those of today, so
we cannot always be certain of what was meant by names and terms transcribed
in books through the centuries. Consequently, we do not know precisely
what was used or practised by the physicians. However, bearing this in
mind, a brief comparison of the use of opium as seen in the six works with
the use of its active components today, allows us to judge whether these
physicians were rational users of the opiate. It must be remembered that
Razi and the other physicians made the observations they did without the
help of modern methods.
The use of opium recommended by the six authors for moderate and severe
pain matches, in general, the oral use of codeine, dihydrocodeine and morphine
today, although they are not used topically now as some of the opium recipes
were by Baghdad physicians. Different varieties and forms of poppy were
recommended for coughs, as are codeine and its weaker derivative, pholcodine,
now. Both opium and poppy were recommended or intestinal disorders, especially
diarrhoea, and codeine is prescribed for acute diarrhoea today. On the
other hand, opiates are not used nowadays for eye problems, gout, insomnia,
to increase sexual desire or to eradicate head lice.
The delicate red flower that we tend to associate with wheat fields and
cornflowers on a balmy summer’s day belongs to a family of plants
that has served us well through the ages, so much so that Britain’s
first commercial crop of opium poppies was harvested at 20 secret locations
in August 2002. The poppy and its product, opium, have killed pain, induced
sleep, improved vision, counteracted gut complaints and treated depression.
These vital attributes and many more were noted by Baghdad physicians in
the ninth century and, though well aware that opium was a potentially toxic
drug, they considered its therapeutic usefulness outweighed its dangers,
and recommended its use extensively, but with caution. |
