Where Some Ideas Are Stranger Than Others...
HELLEBORE, HENBANE, AND THE TREATMENT OF MADNESS
An ancient physician called to the aid of a person suffering from insanity faced an unenviable task. In the best case scenario, the physician would find someone ill with phrenitis, mania, or melancholia, illnesses with relatively specific and consistent symptoms and a time-tested approach to treatment. In the case of mania and melancholia especially, the premiere treatment regime started with hellebore, a strong purgative with a mythological license for the role. The physician had two hellebores to choose from: black hellebore and white hellebore. But in the unfortunate event that he couldn't acquire either hellebore, and the patient resisted helping the purging process along, he had reluctant recourse to two other plants: henbane and mandrake. Better known as ingredients in maddening love potions or as causes of temporary madness in people who ate them by accident, their potential use, even reluctantly, may seem quite surprising. A perusal of the ancient writers on medicine, primarily doctors, demonstrates genuine connections between all four plants, not all of them based on a "scientific" or "medical" viewpoint. An examination of the nature of these four plants in modern botanical terms, followed by consideration of the ancient perspective on them according to mythology, use in treating madness, and how the different ancient medical schools explained their use reiterates two key points made by Murphy in her 2013 MA thesis. Ancient doctors generally used the same treatment regimes for the same illnesses because those regimes were found to work, and they were practical and creative enough to find ways to implement those regimes under adverse conditions.
A Modern Overview of the Plants
Black Hellebore (Helleborus niger, Ranunculaceae)
Black hellebore is now better known as the Christmas rose, an evergreen perennial now found all over northern Europe although it is native to the western Mediterranean. It is a low growing plant with broad leaves of a dark shiny green and large white flowers when in bloom (Bevan Jones 2009: 61). The entire plant is poisonous if eaten (Nelson et al. 2007: 176), though its sap may not be as corrosive as that of stinking hellebore, which can cause chemical burns (Bevan Jones 2009: 62-63). Its fruit is a capsule full of shiny black seeds (Nelson et al. 2007: 176). The "black" parts of black hellebore are its rhizome and roots. The former has a gnarled, twisted shape and spreads horizontally under the soil, sprouting additional plants (Greenish 1909: 340-341). The roots sprout from the rhizome, and are relatively thick and numerous while leaving the rhizome mainly uncovered. In cross section the rhizome has a thick, dull black outer bark and a yellow coloured interior. It is this rhizome that was used in medicinal preparations from Graeco-Roman times right into the early twentieth century (Ibid).
In his own description of hellebores generally, Bevan Jones notes wryly that, "Fatal poisoning [by black hellebore] is unknown, but poisoning can be very unpleasant." This is at minimum an understatement in view of the effects of black hellebore ingestion reported by Nelson et al., including: mouth pain, nausea, vomiting, abdominal pain and cramping, diarrhea, and heartbeat irregularities. Nevertheless, consistent with Bevan Jones' comment, Nelson et al. do not mention any risk of coma or death due to ingestion of black hellebore.
March 2010 photograph of a black hellebore plant by User:Syp, released into the public domain, via wikimedia commons
White Hellebore (Veratrum album, Liliaceae (formerly called Melanthiaceae))
As Girard comments in her 1990 paper on the medicinal uses of hellebore, "On sait qu'il n'existe absolument aucune [extérieur] ressemblance entre l'hellébore noir et l'hellébore blanc." (1990: 397). Where the former is a low growing, dark green plant, the latter is tall (up to 1 m in height) and a much lighter green. White hellebore plants are made up of tall stalks with alternating leaves and brachts of white flowers all along their length. They are perennials and their fruit consists of pods full of winged seeds (Nelson et al. 2007: 296). The white hellebore rhizome is nearly cylindrical at its top, conical toward its base, and coloured dull black underneath a complete covering of its own grey roots. In cross section the rhizome is "whitish, firm, compact, and starchy" (Greenish 1909: 448-449). The whole white hellebore plant is poisonous. Greenish states its poisons are concentrated in the roots that are usually trimmed away (Ibid), but no modern source I have consulted on poisonous plants declares the rhizome harmless or relatively harmless compared to the roots. The difference in the accounts may be due to the fact that Greenish' hellebores were imported from abroad (Ibid: 341, 448), while the poisonous plant handbooks are dealing with exposure to fresh plant material.
Should a person ingest any white hellebore, Nelson et al. report the following likely symptoms: burning sensation in the mouth just after eating, then after several hours increased salivation, vomiting, diarrhea, prickling of the skin, and potentially headache, weak muscles, and dimmed sight. It also causes heartbeat irregularities, but of much greater severity than black hellebore, with a risk of coma if not death (2007: 296-297). The similarity of symptoms in the case of a minor poisoning probably contributed to the ancient designation of this plant as white hellebore.
Henbane (Hyoscyamus niger, Solanaceae)
Henbane is an annual from the same family of plants as the nightshades. It is a hairy plant that can grow up to 1 m high, with flowers ranging from yellow to white with purple veins and centres (Bevan Jones 2009: 76). The leaves are large, medium green in colour, and have a roughly triangular shape with indented edges (Nelson et al. 2007: 185). On fruiting henbane plants produce capsules full of small, brown-greyish seeds. They have a thick tap root with many smaller rootlets extending from it (CDFA 2014). The whole plant is poisonous, a feature of many members of its family of plants, though many others are poisonous only in their stems and leaves, producing safely edible fruit or rhizomes.
The ancient Greeks and Romans knew henbane contained a potent narcotic, burning its leaves or seeds for that purpose (Bevan Jones 2009: 78-79). It may be that medicinal use of henbane smoke would be less dangerous than eating any portion of the plant outright. Effects of ingestion include: dry mouth, difficulty swallowing or speaking, tachycardia, pupil dilation and blurred vision, elevated body temperature, excitement, delirium, headache, and confusion (Nelson et al. 2007: 185).
Public domain scan of W.O. Müller's illustration of immaure and mature henbane fruit, circa 1887, via wikimedia commons
Mandrake (Mandragora officinarum, Solanaceae)
Like the previous three plants, mandrake is wholly poisonous. It is low growing plant with broad, dark green leaves, making it generally similar to black hellebore. However, mandrake is an annual, and its leaves are lettuce-like in shape and texture. The flowers are small and cup-shaped, ranging in colour from white to purple, while the fruits are orange-yellow berries often referred to as "apples" in ancient and medieval literature (Bevan Jones 2009: 99). The flowers cluster around the main stem and central tap root. The mandrake's tap root may be its most (in)famous feature due to its thick, two or three branched, occasionally humanoid shape and acutely poisonous nature. The root is the most poisonous part of the plant (Ibid: 100).
Since it is such a close relative of henbane, mandrake has the same effects on ingestion, and was used with henbane in ancient and medieval anaesthetic mixtures (Bevan Jones 2009: 100). In fact, these two plants may have been conflated despite their different appearance in a manner similar to black and white hellebore. Dioscurides refers to henbane as having flowers ranging in colour from white through yellow to purple (Osbaldeston 2000: 615), a description that fits mandrake flowers more accurately than those of henbane, which is otherwise never reported to have white flowers.
An Ancient Overview of the Plants I: Mythology and Ritual
The descriptions given above are very much in the modern style, focussing on describing the plants in a way that enables the reader to visualize and identify them. All four being poisonous by nature, the summaries include information on the effects of consuming them. The ancient writers hardly describe the plants themselves at all, apparently taking for granted their readers would know what the referenced plant would look like. Instead they begin from a modern perspective in media res, turning directly to uses and any mythological bases for them. This is especially true for black hellebore, which is identified universally as a treatment for madness, and associated with madness in several different myths. Henbane and mandrake are usually identified as madness-causing plants, although they are occasionally suggested as drugs useful for at least calming a mad patient. They lack myths to emphasize or justify their use, although mandrake is linked to hellebore by one of the rituals reported for gathering it by Pliny the Elder.
Pliny briefly recounts how black hellebore was identified as a treatment for madness in Book 25 (21.47) of his Natural History:
Melampus is well known for his skill in the arts of divination. From him one kind of hellebore is called melampodion. Some hold that the discovery is due to a shepherd called Melampus, who noticed that his she-goats were purged after browsing upon the plant, and by administering the milk of these goats cured the daughters of Proetus of their madness [furentes]. Wherefore it is well to give here together an account of every kind of hellebore. (Translation Jones 1980: 171)
melampodis fama divinationis artibus nota est. ab hoc appellatur unum hellebori genus melampodion. aliqui pastorem eodem nomine invenisse tradunt, capras purgari pasto illo animadvertentem, datoque lacte earum sanasse proetidas furentes ... quam ob rem de omnibus eius generibus dici simul convenit. (25.20 in the latin at the Perseus Project)
"Melampodion" means "black-foot" and as noted above, black hellebore has black roots and a black rhizome, which were typically used for medicinal purposes. The connections to madness in this story extend further. Proetus is also the king of Argos who hosts Bellerophon, and Bellerophon himself eventually goes mad. Girard identifies a third myth connecting hellebore to curing madness:
Un second mythe veut qu'Héraclès lui-même ait été guéri de sa "fuereur" à l'aide de l'hellébore. Le mythe est rapporté dans la lettre apocryphe d'Hippocrate à Cratéras. (Girard 1990: 394)
This is not the only connection to Heracles. According to Pliny, the best white hellebore grew on no less than Mount Oeta near Pyra – that is, on the mountain and around the very spot where Heracles eventually immolated himself (Natural History Book 25, 21.49, 25.21 in latin at the Perseus Project). On the other hand, the best black hellebore came from Mount Helicon, haunt of the Muses (Ibid). Though never depicted as insane themselves, the Muses would not have escaped association with the concept of poetic madness.
Given such a mythological reputation and the powerful effects of hellebore ingestion on the body, it is not so surprising that there would be rituals and precautions for gathering both hellebores. Here again our source is Pliny (Natural History Book 25, 21.49-50):
Of these [hellebores] they call the black kind melampodium... This kind is gathered with even greater formalities. First a circle is drawn round it with a sword; then the man who is going to cut it looks at the East with a prayer that the gods will grant him permission to do so. He also keeps on the look out for a flying eagle – for generally one is present when men cut – and if an eagle flies near, it is a sign that the gatherer will die in that year. The white too is not easy to gather: it is very oppressive to the head unless garlic is eaten beforehand, wine swallowed every now and then and the plant dug up quickly. (Translation Jones 1980: 173)
nigrum ex his melampodium vocant... hoc et religiosius colligitur, primum enim gladio circumscribitur, dein qui succisurus est ortum spectat et precatur, ut id liceat sibi concedentibus diis facere observatque aquilae volatus; fere enim secantibus interest, et, si prope advolavit, moriturum illo anno qui succidat augurium est. nec album facile colligitur, caput adgravans maxime, nisi praesumatur alium et subinde vinum sorbeatur celeriterque fodiatur. (25.21 in latin at the Perseus Project)
A surprisingly similar ritual pertained to gathering mandrake. "The diggers avoid facing the wind, first trace round the plant three circles with a sword, and then do their digging facing the west." "effossuri cavent contrarium ventum et iii circulis ante gladio circumscribunt, postea fodiunt ad occasum spectantes." (Natural History Book 25, Chapter 94.148; translation Jones 1980: 194; 25.77 in atin at the Perseus Project)
An Ancient Overview of the Plants II: Treating Madness
In Graeco-Roman times, six main forms of madness were recognized, and three of these have a reasonably consistent set of recognized symptoms: phrenitis, mania, and melancholia (Murphy 2013: 16). Of these three, mania and melancholy were treated with hellebore (as part of a more extensive regime) and will be focussed on here. The doctors Caelius and Aretaeus define mania as "delirium without fever that affects the understanding," Aretaeus noting that mania involves errors of judgement rather than perception. He also considers mania and melancholia to be two states of the same disease (Ibid: 85-86). Caelius views melancholia and mania as two different diseases even though he recommends the same treatment for both. Nonetheless, he agrees with Aretaeus that a person suffering from melancholia is "dejected, fearful, delusional, and sorrowful without cause" (Ibid: 119). Celsus, who is generally considered a doctor as well as a medical encyclopedist, is not as specific, but his descriptions of mania and melancholia are at least not inconsistent with these descriptions. Pliny is not a doctor but a reporter and general encyclopedist whose accounts can vary significantly in terms of their accuracy and detail. Nonetheless, he doesn't deviate significantly from these descriptions either, although he says little about mania as such.
While the cause of mania and melancholia might be identified differently depending on the medical school a doctor subscribed to, the actual treatment applied did not vary significantly, as Murphy found in her 2013 study. Evidently doctors and reporters like Pliny focussed on what was understood to work based on experience and widely accepted accounts rather than privileging theory over all else. Although accusations of privileging theory over practice were made, as can be seen in Galen's discussions of methodist doctors (e.g. see Leith 2008), they are not borne out by other sources.
All the ancient medical writers report the use of emetics and purgatives to treat mania and melancholy, favouring white hellebore especially with black hellebore coming a close second. Henbane and mandrake make appearances as distant third choices for use in this role, unsurprising in view of the much higher risk of death from small doses of those plants in any form noted above.
A good place to begin is with Pliny, who is helpful for an overview of the topic, although he cannot be used to gauge real dosages in any way. Despite the high potencies of the four plants discussed here, the doses he records as transmitted in the manuscript tradition are dangerously high (dosage will be discussed further below).
Black hellebore is a cure for paralysis, madness [insanientibus], dropsy without fever, chronic gout and diseases of the joints; it draws from the belly bile, phlegms, and morbid fluids. (Natural History Book 25, Chapter 23.54; translation Jones 1980: 173)
nigrum medetur paralyticis, insanientibus, hydropicis, dum citra febrim, podagris veteribus, articulariis morbis. trahit ex alvo bilem, pituitas, aquas. (25.23 in latin at the Perseus Project)
Further along in the same book, Pliny adds:
Care must be taken, even with happy treatment, not to administer hellebore on a cloudy day; for to do so is followed by unbearable torture. Indeed, there is no doubt that summer is a better season to give it than winter. For seven days previously the body must be prepared by acid foods and by abstinence from wine; on the fourth and third days before, an emetic must be taken, and on the preceding day there should be abstinence from dinner. (Natural History Book 25, Chapter 25.59; translation Jones 1980: 179-181)
cavendum est felici quoque cura, ne nubilo die detur, inpetibiles quippe cruciatus existunt. nam aestate potius quam hieme dandum non est in dubio. corpus vii diebus ante praeparandum cibis acribus, abstinentia vini, quarto et tertio die vomitionibus, pridie cenae abstinentia. (25.25 in latin at the Perseus Project)
He also mentions mandrake as an alternative, though not preferred, treatment:
A dose of two oboli of mandrake is also taken in honey wine instead of hellebore – but hellebore is more efficacious – as an emetic and to purge away black bile. (Natural History Book 25, Chapter 94.150; translation Jones 1980: 243)
bibitur et pro helleboro ii obolis in mulso - efficacius helleborum - ad vomitiones et ad bilem nigram extrahendam. (25.77 in latin at the Perseus Project)
Pliny's overview is consistent with Celsus except for which hellebore is favoured in the treatment. Celsus identifies white hellebore as a useful treatment for "chronic and violent diseases without fever" including "insanity [insantientibus] accompanied by a kind of hilarity" "omnibus etiam cum quadam hilaritate insanientibus" (Book 2, 13.2; translation Spencer 1971: 173). However, he also states, "black hellebore root is given either to those with black bile [atra bile] and those suffering from insanity [insantientibus] with melancholy [tristitia]" "ut cum veratrum nigrum aut atra bile vexatis aut cum tristitia insanientibus aut iis" (Book 2, 12.1; Ibid: 169). This is rather confusing, but Celsus helps us by differentiating hellebore usage by the symptoms a manic patient manifests:
If phantoms mislead, we must note in the first place whether the patients are depressed [tristes] or hilarious [hilares]. For depression black hellebore should be given as a purge, for hilarity white hellebore as an emetic; and if the patient will not take the hellebore in a draught, it should be put in his bread to deceive him the more easily; for if he has well purged himself, he will in great measure relieve himself of his malady. Therefore even if one dose of the hellebore has little effect, after an interval another should be given. It should be known that a madman's illness is less serious when accompanied by laughter than by gravity. (Book 3, Chapter 18.20; translation Spencer 1971: 301)
Si imagines fallunt, ante omnia videndum est, tristes an hilares sint. In tristitia nigrum veratrum deiectionis causa, in hilaritate album ad vomitum excitandum dari debet; idque si in potione non accepit, in pane adiciendum est, quo facilius fallat: nam si bene se purgaverit, ex magna parte morbum levabit. Ergo etiamsi semel datum veratrum parum profecerit, interposito tempore iterum dari debet. Neque ignorare oportet leviorem esse morbum cum risu quam cum serio insanientium. (3.18 in latin at the Perseus Project)
A purge is a substance that causes diarrhea, while an emetic causes vomiting. Black and white hellebore cause both, so this implies that black hellebore is more diarrhetic than emetic, and indeed this matches its somewhat lower level of noxiousness compared to white hellebore.
Finally, Celsus reports that "some endeavour to induce sleep [in mad patients]" "Si nihilo minus vigilant, quidam somnum moliuntur potui dando aquam, in qua papaver aut hyoscyamos decocta sint, alii mandragorae mala pulvino subiciunt, alii vel amomum vel sycamini lacrimam fronti inducunt." by using henbane in solution (Book 3, 18.12; translation Spencer 1971: 297). His attribution of this practice to "some" people implies disagreement if not outright disapproval, perhaps because he is aware that a liquid essence of henbane is more dangerous than its fumes or smoke.
Caelius only refers to white hellebore specifically, and that for treatment of a manic patient (Acute Diseases I, Chapter X.169). He notes specifically that the white hellebore should be inserted in a radish and given to the patient to eat (Ibid). This is an unpleasantly clever ruse since its rhizome is of similar colour and texture, and any burning it caused in the mouth could be attributed to the strength of the radish. Conversely, Aretaeus recommends black hellebore for treating melancholia (Murphy 2013: 133) but can only be surmised to use hellebore in general to treat mania (Ibid: 101) due to lacunae in his preserved works.
So there is overall agreement that mania and melancholia are best treated by purgatives, whether they cause vomiting, diarrhea, or both. Aretaeus positively identifies purgatives as an outright cure, or at least a cure for a few years (Murphy 2013: 133). It seems clear that doctors were willing to use henbane or mandrake as purgatives if no hellebore of either type was available, but if they used them at all preferred to exploit their narcotic qualities to ease insomnia or restlessness. However, even then these were risky options, because henbane and mandrake were better known as causes of temporary madness, and henbane is more likely to cause delirium and manic behaviour when ingested.
An Ancient Overview of the Plants III: Explanation of Efficacy by Medical School
The doctors whose writings have been cited or quoted here, Caelius Aurelianus, Aulus Cornelius Celsus, Aretaeus, and Galen, are representatives of three different ancient medical schools: methodism (Caelius), empiricism (Celsus), and dogmatism (Aretaeus and Galen). Murphy's study focussed on Caelius and Aretaeus, and therefore compared the treatment regimens of a methodist and a dogmatist. She found no substantial differences in their treatments of mania, melancholia or phrenitis, and this is reinforced by Celsus' empiricist views as well at least for mania and melancholia. Overall this is to be expected on a practical basis, since a physician who refused to use treatments that worked and were known to work would soon be out of a job. This didn't stop them from having very different explanations for why purgative substances like the four plants considered here worked to cure specific illnesses, or failed to work as well as might be expected.
The founder of the methodist school of medicine according to tradition is the Greek Themison. The school's next great theoretician was Thessalus, who worked during Nero's reign. Galen was specially scandalized by Thessalus' claim that anyone could be a doctor in six months, but as Leith points out, this made perfect sense for a methodist physician to say because they were seeking general rules that could be applied universally (Leith 2008: 584). A doctor acting on the basis of general rules doesn't need to know what causes illness, how or why a treatment works, or even about the nature of the body. All such a doctor needs is the basic information on the patient's symptoms to select and apply a treatment (Ibid: 584; Murphy 2013: 13). The methodist doctor may not have brought much theory to a patient's bedside, yet this in no way limited the range of treatments he might consider and apply. So he might prescribe changes in diet or environment, specific ointments or oral medicines, or exercise (Leith 2008: 594). All of these treatment options might be guided by the concept of diatritus, treating on the third day with the patient fasting between treatments (Ibid: 585, 589, 592). Not bringing much theory is not the same as bringing none, however. He had at least one explanatory principle: illness comes from tightness, looseness, or a combination of both in the body's pores. When faced with a disease combining both tightness and looseness, the methodist physician dealt with the most acute symptoms first (Murphy 2013: 13-14).
As already noted, Caelius considered mania and melancholia to be two different forms of madness, yet treated them similarly. As could be expected, his attempt to explain their cause and the effectiveness of hellebore for treating them in terms of looseness and tightness is not consistent in the way the description of methodism given above would lead us to expect. In part he may have been caught between the popular belief that black bile is both cause and symptom of melancholia. By inclination he would want to keep causes and symptoms strictly separated because causes are not observable and he doesn't need to know them. So he refers to mania as a disease caused by stricture while emphasizing that black bile is an effect of melancholia rather than its cause. Then he declares that melancholia sufferers have a combination of tightness with periods of looseness (Murphy 2013: 90, 125). No doubt it was cruces of just this sort that encouraged methodist distrust of attempts to explain the cause of illness: it was nearly impossible to find an absolutely consistent explanation. Today we can explain this issue by pointing to many illnesses with similar symptoms, though this still leads to a methodist sort of approach in itself: treat the symptoms.
Empiricists denied that any unobservable elements were required to understand or explain illness, so humours were at best beside the point. They took the methodist critique of the humoural theory used by many dogmatists a step further by rejecting the use of any justification by specific signs or argument for a given practice (Matthen 1988: 109-111). Instead, they insisted that why or how a treatment worked didn't matter so long as it worked. Furthermore, what worked could be identified by means of correlation (Ibid: 109). If therapy x was known to cure illness y, then it can be applied to treat an illness z that is similar to illness y. In the case that a treatment didn't work, then the doctor should stop using it, even if it was the usual treatment x for illness y (Ibid: 110).
Celsus is an interesting representative of this school. True to its eschewal of explanation or speculation on cause, he doesn't give any. Yet it could be argued that at least when it came to the treatment of madness, Celsus was less inclined to dismiss a treatment that doesn't seem to be working. In the previous quote on treating madness, Celsus suggests dosing with hellebore repeatedly even if it doesn't seem to be doing much good. To be fair, this is probably because he is discussing treatment of a difficult to manage and deeply distressing illness, mania in which the sufferer is experiencing hallucinations. Apart from restraining a person in this condition, there was little else any physician could do in his time, and this is sometimes still the case even today.
Dogmatism, Better Known as the Hippocratic School of Medicine
Today the dogmatist school is still the best known of all ancient schools of medicine due to the extensive Hippocratic corpus and its place as the first professionalized, cult-independent medical practice. It is the source of the conceptualization of disease as an imbalance of the four humours, listed as hot, dry, wet, and cold; yellow bile, black bile, blood, and phlegm; or some complex combination of these depending on the illness. Its key departure from the priests of Asclepius was the idea that the conditions that encourage health or disease can be observed and adjusted, even if the specific causes of a disease cannot (Grant 2000: 61). In illness the imbalance needs to be treated above all else, and it may happen that the patient does not respond to treatment because some illnesses are inexorable (Matthen 1988: 103, 106). Reasoning can and should be used to choose and apply therapies and regimens, and information about the body can be reasoned out even if they can't be sensed directly (Ibid: 108).
Of the medical writers quoted directly above, Pliny reflects precisely this school of medicine. He doesn't fully differentiate mania and melancholia, referring simply to hellebore in the treatment of madness and as a means to purge black bile. This is consistent with Aretaeus' views in that he considers them two stages of the same disease, and its cause is an excess of black bile. The different directions of purging correlated to specific confluences of manic symptoms by Celsus is not necessarily inconsistent with this idea. According to the dogmatists, black bile could collect to excess in the head, throat, or bowels, with different attendant symptoms accordingly. For example, depression or delusion, vomiting a black substance, or constipation, all symptoms referenced by Celsus as well. It may be these parallels between Aretaeus and Celsus that have led to a questioning of whether he was an empiricist or not.
A Curious Absence: Dosage Information
Considering the powerful effects of all four of the plants considered here, and the regular and preferred uses of the hellebores among them, it is a real surprise how little information these writers provide on dosage. Even the doctors merely state, "give white/black hellebore to purge the patient up/downwards." Celsus recommends putting white hellebore in radishes and giving them to a mad patient to eat if he refuses to make himself vomit, which suggests a slip of material that can be pushed into a slit made in the vegetable. Yet radishes can range anywhere from 3 to 10 cm in length and 2 to 5 cm in greatest circumference. For his part, Pliny suggests a maximum black hellebore dose of one drachma for a milder diarrhea, and four oboli for a stronger effect (Natural History Book 25, Chapter 22.54). On consulting the weights and measures tables in the Loeb edition of Pliny's encyclopaedia, a drachma weight is approximately 4-6 g and an obol just over 1 g. Since 1 gram is roughly the mass of a single regular sized paperclip, it is clear the dose should be small, and there is a small difference between a "mild" dose and a strong one. This is still not enough information to feel at all confident in prescribing a poisonous plant to treat illness. Perhaps doctors only shared the specifics of dosage with their own pupils directly, rather than writing them down.
The exception to the lack of dosage details is Dioscurides, except not for hellebores. Concerning mandrake he reports that
Twenty grains of the juice (taken as a drink with honey and water) expel phlegm and black bile upward like hellebore, but when too much is taken as a drink it kills. (De Materia Medica, Book 4.76; translation Osbaldeston 2000: 624)
He also verifies the suggestion above as to why white and black hellebore were the preferred purgatives: mandrake is too dangerous. When he turns to hellebore specifically, he says it can be given heavily diluted or baked into bread, or even as a suppository in which case it can still cause vomiting as well as a diarrhea (Book 4.150-151). Unfortunately, he provides no further information to suggest what the proportion of hellebore to diluent should be, nor whether the hellebore is used in the form of a pulp or juice.
Graeco-Roman physicians endeavouring to treat and cure mania and melancholia had few effective tools at their disposal, a situation that still persists to this day. They made use of the most powerful drugs available to them in an effort to help their patients, in this case four of the most acutely poisonous plants humans can encounter. Even if they subscribed to different medical schools, based on practical experience they were in agreement that purging by vomiting and/or diarrhea was an important aspect of treating mania and melancholia. This did not preclude other prescriptions and changes such as exercise, adjustments to the patient's environment and diet, or the application of ointments or compresses. Most of these things still play a role in treating the modern understandings of these diseases as disorders including bipolar disorder, depression, and schizophrenia. Nevertheless, purgation as a treatment has fallen by the wayside along with the hellebores, henbane and mandrake. This change seems to parallel the curious disappearance of phrenitis from the ranks of modern mental illness. Parallel, though not otherwise similar. Purgation except in cases of poisoning by non-caustic substances may have been dropped from the doctor's repertoire not least because the purgatives were so dangerous as to potentially kill the patient. Pliny and Caelius both briefly refer to not purging a patient who is too weak to withstand the treatment, or to applying only a light purge, a real challenge when concocting medicines from plants.
The ancient doctors themselves not only shared a corpus of accepted therapies for mania and melancholia. They also used considerable botanical knowledge, as evidenced by their ready use of four such poisonous plants as well as the over three hundred plants mentioned in the Hippocratic corpus (Moison 1990: 381). The lack of specific dosage information provided for the plants discussed here suggests such information may have been treated as a sort of trade secret, sharing recipes between teacher and pupil directly rather than writing them down. On going to treat a mad patient, ancient doctors would have had to be ready to use alternatives and gauge safe dosages quickly under difficult circumstances. The materials considered in this paper suggest that more often than not, the ancient doctors met those challenges successfully, even if they could not always cure their melancholy or manic patients.
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