The principle of theriac

A paradoxical remedy

The effectiveness of theriac and its nature as a universal panacea depend on the great number of drugs with different effects that are included in the composition. They are all known for their therapeutic virtues, as is also confirmed in Dorvaut’s treatise, The Laboratory or General Repertoire of Practical Pharmacy, which is still used as a reference in pharmacopoeia even today. Galbanum is described in this learned work as a stimulant and antispasmodic, Dittany of Crete is a stimulant, a diuretic and anti-hysteric, wild rue seeds are inebriating, sleep inducing and poisonous, sweet flag is a stimulant, a tonic, stomachic, and so on.

It results that most of the drugs of theriac are classified as stimulants, excitants, tonics, diuretics, antispasmodics and expectorants, and this corresponds to the thermal and drying properties that Greek-Arab medicine attributed to theriac. The presence of opium (afyūn) certainly reinforced the effect since this milky juice of the unripe fruit of the poppy contains alkaloids, the most important of which is morphine, well known as a powerful painkiller. Besides these simple compounds, the theriac of Andromachus includes three complex elements: the tablets of scilla, of Hedychroum and of viper flesh.

The scilla tablets, already introduced into theriac by Proclus, according to the Book of Theriac (page 16/22), are based on scilla or sea onion, used in pharmacopoeia above all as a diuretic and a cardio tonic. The Hedychroum tablets take their name from the city of Udhrūkhurūn, situated on an island in Asia (see page 11/25), now called Andros. It was believed that their sweet perfume hid the bitter taste of some of the ingredients. With regard to the viper tablets, they were an essential element since it was for their virtues that theriac was known as an effective antidote to poison. Even today, poison antidotes are obtained from the blood of animals immunised with the poison of the specific snake whose bite must be neutralised.

Furthermore, the viper was considered effective against skin diseases, as illustrated by the anecdote of the man cured of elephantiasis. This curative property probably derives from a model based on the moult by which the snake renews its skin every year. However, this is not the principle of theriac. It depends on the theory developed by Galen in the De theriaca ad Pisonem: every drug has its own characteristic (for example, wild rue is hot and dry to the fourth degree), but when the drugs are mixed the result is not the simple sum of the properties of each, since a specific force derives from what they create together.

This theory was refused by certain Arab physicians and pharmacists, such as al-Kindī and Ibn Biklārish, who maintain that a medicinal compound is the accumulation of the forces and qualities of each element that is used in its preparation. However this is the theory on which the presumed effectiveness of theriac is based. It is magnificently represented in the double figure on pages 66-67/40-41 where the list of the drugs in the Andromachus theriac is given. But although the table on the previous page gives a therapeutic indication for each of the drugs, here the new effects of the drugs combined together are described. In the centre, a paragraph sums up, in terms similar to those of Galen, the modifications that are at the basis of this process. The theoretic importance of this double page, just like the balance of its composition, calls for deciphering and translation.

a: aqrāṣu l-afā‘ī (viper tablets)
b: aqrāṣu l-udhrūkhurūn (Hedychroun tablets)
c: aqrāṣu l-isqīl (scilla tablets)
d: aqrāṣu l-udhrūkhurūn (Hedychroun tablets)
e: qinna - dār ṣīnī - dūqū - al-ward - faw - bazru l-shaljum - al-wajj - ḥamāmā - thūm barrī - zāj mashwī – aṣlu l-sūs - ghārīqūn - ṭīn makhtūm - rubbu l-sūs - bazr rāziyānj – duhn balsān - jinṭiyān - murr
f: filfil aswad - salīkha - ḥirmil - sunbul - ṣamgh - ‘ūd balsān - sūrinjān - ja‘da – maṣṭakī - lubnī rummān – aṣlu l-kabar – muql - hūfāriqūn - ḥabbu l-balsān - qusṭ - bazru karafs
g: bazru l-karafsi l-jabalī - sasāliyūs - usṭūkhūdūs - ḥabbu l-ghār - ḥurf - farāsiyūn - kamādaryūs – fūdhanj jabalī - nānkhawāt - fanjankusht - kamāfīṭūs - rāwand – liḥyatu l-tīs - za‘farān – nārdīn – shīḥ jabalī - zanjabīl - maw
h: sikbīnaj - ṣamghu l-buṭm - ushshaq - fuqqāḥu l-idhkhir - anīsūn - kundur dhakar - aqāqiyā - mushkaṭarāmishīr - jāwashīr - dār filfil - qufaru l-yahūd - afyūn - qanṭūriyūn - zarāwand – jundbīdastar - filfil abyāḍ
[the therapeutic indications of the drugs when 2, 3 or 4 are combined are given outside and especially inside the frames containing the names of the drugs, not always with a clear explanation of which drugs are considered. We translate just three examples:]
i: these two (drugs) increase breast milk
j: these three (drugs) are indicated for pneumonia
k: these six (drugs) are indicated for verrucae on the body
l: There are also viper tablets
m: The combination of the drugs of this theriac and its tablets and the combination of its indications (manāfi‘) (are) as follows:

When the simple drugs (al-adwiya) are combined, the combination results in a new force [the Arabic word mizāj which currently means “constitution” here refers to the idea of the strength of the drugs, as described on page 71/47 “this force (quwwa) is called mizāj”] which differs from the typical force of each of the single drugs. Each of these drugs, when combined with the others, is drawn towards that most similar, it mixes with the latter, helps the body to heal, fights disease and brings the body back to the state of health that had abandoned it. One only of the simple drugs (dawā‘) included in the electuary (ma‘jūn) possesses its own characteristic (manfa‘a) but if it is associated with another drug, a new characteristic results, and yet more if other drugs are added. If it is the will of God. God is all, He cures and He gives health. I need only God.” These last three sentences, which, following Galen, sum up the triple effect of mixing the drugs, are placed in the centre of the figure, in a frame that plays on the types of writing and is full of arabesques.

This position is not by chance: the scholar had understood the importance of this passage, since it indicated what the “secret of theriac” was: not some obscure alchemy, but the strength of a cure by means of the action of the substances that, far from being weakened or annulled by the presence of other substances (today one would speak of a dilution or antagonistic effect) is increased and reinforced (today one speaks of potentiation or synergy). If theriac results from empiricism, Galen opened up the path of scientific thought to explain the action and its preparation. The Book of Theriac has a role in this Greek-Arab medicine that develops a rational approach to disease and to methods of cure. Contrary to what Meyerhof wrote, it is not at all “a mystical-magical preparation derived from the pseudo-scientific literature of the late Alexandrian age”.

A paradoxical remedy
In opposition to the eminent position that considers theriac as a universal panacea in the De theriaca ad Pisonem, in other treatises Galen gives a more reserved judgement on its effects. In De Simplicium Medicamentorum Temperamentis ac Facultatibus, he describes the alexipharmaca to which theriac belongs as a remedy against poisonous animals and deadly substances. The affinity with poison makes them noxious for man. This is why they must be used exclusively as a preventive measure, or for the purpose of healing, and why they must be administered in very precise dosages.

Although the use of theriac as an alexipharcon may have been admitted to protect humanity against poisons of animal or non-animal origin, its advantages and its uses have been diversely appreciated by Arab physicians. In fact, theriac is a paradoxical remedy, “at the same time, a healthy poison and a poisonous remedy” to quote the interesting expression used by Véronique Boudon. In Kitāb al-masā’il fī l-ṭibb, Ḥunayn ibn Isḥâq, a translator and physician who lived in Baghdad in the eleventh century, praised without reserve the double advantage of theriac, therapeutic and preventive: “Theriac is the best of compound remedies. It counteracts poisons and deadly substances, as well as the onset of illnesses. It protects the body not only from everything that comes from outside, but also from everything that arises within the body. It acts in advance against what could arise within the body.”

However, by no means does everyone share this opinion and recommend a generalised use of theriac. Ibn Sīnā, known in the west by the name of Avicenna (who died in 1037), author of the famous Canon, considers theriac “as the most sublime medicine for the multiplicity of its advantages”, however he reserves it for illnesses of a cold nature (since it is a hot medicine), caused by disorders due to black bile or phlegm, such as paralysis, epilepsy, madness, leprosy, kidney and bladder disease, diarrhoea and haemoptysis. He also attributes to it a stimulating and fortifying effect and recommends it, for example, in the case of anorexia. Also Ibn Rushd, the great Andalusian physician and philosopher (who died in 1198), holds forth on this antidote, in his Treatise on Theriac, claiming that it is stronger than a drug and not as strong as a poison, and concludes by stating that it must be excluded as a means of maintaining health and must only be used with care and only for certain illnesses. In spite of the reserves of the learned scholars, theriac was no less fascinating to the men who saw it as a universal panacea, but an inaccessible panacea since it was rare and costly.

Although some of the drugs included in its composition were commonly used, a certain number had to be imported. They were among those expensive “spices” from India and China, the trading of which was particularly flourishing in the Middle Ages. Their use for the preparation of theriac contributed to make it an expensive commodity. This could lead charlatans to use, for example, false cinnamon instead of the genuine substance, or to imitate the shape of long pepper; this is why, on pages 63-54/45-46, there are indications on how to check that the preparation had not been adulterated. In the Book of Poisons that he drafted in 1198 at the instigation of the Cadi al-Fāḍil, the famous Jewish physician Ibn Maymûn (Maïmonides) explains that the great theriac and mithridate are preparations that are difficult to produce in the city of Cairo since, of all the substances necessary for theriac, only the poppy is found there, which means that the drugs necessary must be obtained from distant countries. And he adds: “Since these two medicines are so rare that they cannot even be found in most of the treasures of the kings, how can you hope to find them on the market?” In fact: theriac belongs to the treasure of kings.

This complex compound is costly, rare and precious. That is where its magic lies: the magic of an inaccessible panacea, kept in phials and vases of rich manufacture, owned only by the powerful, shown and offered as a sign of wealth and fame. The Flemish traveller Van Ghistele, who arrived in Cairo in 1483, was given, among others present, a “good dose of theriac” by the interpreter of the Sultan of Cairo. The richly and elegantly written and illuminated manuscript of the Book of Theriac is certainly a collector’s item, commissioned by a very rich personage. However, its value also depends on its content: not that of a medical treatise destined to be used by practitioners, but that of a work that encloses, as in a phial, a precious potion. To own a similar manuscript must have been a sign of social distinction because of the luxury and beauty of the object, but also because of the imaginary world that emerges from the title and from the subject. In this case beauty and significance are combined.