Milk of Paradise

by Lucy Inglis

  The Sassanid Empire was short, but in the nation of Persia it had established an elegant, lucrative and educated centre of exchange between East and West. But a transformation was coming, one that heralded the end of the ancient world: Islam.

  Muhammad’s Triumph: Islam’s Golden Age of Learning

  Hundreds of years of sporadic war between Rome and the House of Sasan came to an end in 629, when Emperor Heraclius overthrew the last of the Persian kings. Despite their constant squabbles, these two empires had divided the Fertile Crescent between them, and created continuity, if not stability. Into the breach created by their collapse came the Prophet Muhammad.

  Born around 570 in Mecca, at the age of forty Muhammad was a merchant with a mediocre career behind him. He may or may not have been literate, and he was not rich. In short, he was the opposite of his wealthy and cultured Persian and Roman equivalents. Depressed, he went out and sought refuge in a cave, and was visited by the angel Gabriel. After three years, Muhammad began to reveal his revelations and preach publicly. The Arab tribes who worshipped hundreds of pagan idols, many of which adorned the Ka’aba in Mecca, had previously been regarded as the poor cousins of the East, ‘of all the nations of the earth, the most despised and insignificant’.19 Muhammad’s teachings were not popular with many in Mecca, and at one stage he was forced to flee; this flight, known as the Hijrah, remains one of the most symbolic events in Islam.

  Under Muhammad, the Arabs united in the worship of one god. In 629, just as Rome and the Sassanids had exhausted each other, the Prophet mustered an army to defeat the pagans of Mecca; by the time he died in 632, the majority of the Arabian Peninsula worshipped Allah. By 651 the Muslim conquest of Persia was complete. It was a gargantuan achievement: a religious event on a par with Alexander’s military sweep across a continent. Muhammad’s timing was perfect, and his legacy immense. His death allowed those men who had known him in life – the caliphs – to establish the first caliphate, and as the Prophet had left very few hard and fast rules for society, they quickly set about making their own. Muhammad’s communes with Allah were written down as the basis of the Qur’an, and Islamic scholars began work on the Hadiths, meant to explain these communications in terms of Muslim daily life, comparable to the Jewish tradition of the Torah and the Talmud. (A brief reference to opium appears in an early Palestinian Talmud, c.400.20)

  The Christian ascetic tradition, particularly the stylites who lived on top of pillars, mortifying their flesh in the name of God, was influential in the Middle East, especially Syria, and associated piety with godliness in the strongest terms. Muhammad – drawing perhaps on his life as a merchant, and his time in the cave, as well as his perilous Hijrah – left an idea that the rich should not cheat the poor, and that equality should be promoted. The Qur’an also banned alcohol and other intoxicants.21

  The first caliphs who succeeded Muhammad, the Rashidun caliphate, are often seen as overseeing a thirty-year golden era of both Muslim religion and government. Less successful were the Umayyads who followed them, who drank alcohol, and one of whom kept a pet monkey. Another Umayyad caliph hunted with a cheetah, which rode out sitting on the rump of its master’s horse; the caliph’s saluki dogs wore gold anklets and had personal human slaves. Things had gone horribly astray from the original preachings of Muhammad. After just under ninety years in power the Umayyad caliphate was toppled and replaced by the stricter Abbasids, who chose to create their own capital, Madīnat as-Salām or the City of Peace (now Baghdad), near the site of ancient Babylon.

  The end of the Umayyads is the beginning of what is known as the Islamic golden age, which lasted over 500 years and spread rapidly as far as Central Asia, known then as Transoxonia. The acquisition of Transoxonia in the middle of the eighth century is traditionally associated with the introduction of paper to the Middle East, through the skills of Chinese prisoners of war kept at Samarkand. The fall of Samarkand to the Muslims in 712 also marked the movement east to China of many migrants who did not want to live under the new rule. The Tang dynasty of 618–907 controlled an expanded version of the Han territories during the peak of the silk trade, and despite a reputation for insularity in terms of immigration, these peoples from the west were absorbed into the Chinese population. This movement of Arab Muslims to China coincides with the first appearances of opium in Chinese writing, most particularly by the author of A Supplement to the Pen Ts’ao, called Ch’en Ts’Ang Ch’i.22

  After Samarkand, Islam moved into the vanguard of science, medicine, civilization and thought. From the Iberian peninsula in the west, conquered in 711, to the Russian steppes in the east, the intellectual world was under Arab control. In Baghdad in 830, Abbasid Caliph Harun al-Rashid (c.795–809) created Bayt al-Hikma, the House of Wisdom, modelled on Gondeshapur, where scholars from all parts of the world were invited to come and translate all the knowledge that existed into Arabic. The intellectual and religious tolerance of the Abbasid court of Baghdad was an impressive testament to the new Islamic faith.

  A series of scholars emerged not only in Baghdad but across the Arab world, whose contribution to medical knowledge seems rather like a checklist of all of the things it was possible to discover at the time, in anaesthesia, analgesia, surgery and pharmacology. One of the earliest of these scholars associated with the House of Wisdom was al-Kindi, a Basra-born philosopher who also wrote on medicine, and devised a scale for the accurate concoction of medicines, many of which contain opium, namely that of the white, or Egyptian poppy.23

  Taking their lead from the Hippocratic corpus and Dioscorides, Muslim scholars combined them with Islamic instructions on healing the sick, and instructions for the afflicted to ‘Seek treatment, for God the Exalted did not create a disease for which He did not create a treatment, except senility.’24 Having access to so much written information, as well as the model of Gondeshapur and the Indian tradition of building hospitals, meant that medicine in the Arab world began to make strides forward, facilitated by the money brought in from a vast empire controlling much of the heartland of the Silk Roads. A Chinese visitor to the empire in this period could not believe the profusion of goods, where ‘everything produced from the earth is there. Carts carry countless goods to markets, where everything is available and cheap.’25

  From the ancient Silk Road trading city of Rey, near Tehran, Abū Bakr Muhammad ibn Zakariyyā al-Rāzī came to Baghdad. Known as Rhazes (865–925), he was one of the first recorded polymaths, and is often equated with Hippocrates in Arabic history. His two primary works were the Kitab al Mansuri, a ten-chapter book on temperament and physiognomy, and Kitab al-Hawi, ‘the greatest medical encyclopedia produced by a Moslem physician’, which was influential until the Renaissance.26 When Rhazes came to Baghdad and was working at the Muqtadari Hospital, there were three forms of medicine in operation: prophetic medicine, based largely on the teachings of the Qur’an; folkloric medicine with its roots in Arab and Zoroastrian traditions; and Greek medicine. Druggists were becoming respected professionals, and the state had stepped in to provide regulation on weights, measures and qualities in the form of an inspector, al-Muhtasib, and his assistants.

  In Baghdad, opium – afyūn in Arabic – was already in use, according to the methods of Dioscorides, in a decoction, a pill or an ointment, either on its own or with up to dozens of different ingredients for diseases such as leprosy. From these recipes, it often seems that the more terrifying the disease, the more elaborate the treatment. Greek texts in the Hippocratic tradition are patient-focussed and stress empathy as one of the foremost tools of the physician, so it is not surprising that such diseases merited ‘special’ medicines. Rhazes, however, was also an intuitive physician who wrote accurate and nuanced works on disorders as mundane yet distressing as bed-wetting in children, and understood that smallpox could only be contracted once. Like Galen, he continued with experimentation upon animals, including testing mercury on a monkey.

  Rhazes also wrote about surgery, on which the Arabic medical commun
ity was making significant advances, particularly in pelvic surgery. He is often credited as the first physician to use opium as a general anaesthetic, using the works of the prolific alchemist and chemist Abu Mūsā Jābir ibn Hayyān, or Geber (c.721–c.815), for guidance.27

  An indication of how extensive surgical methods, particularly those on the internal organs, had become is given by the works on suturing created at the time, especially by Rhazes. Debate among physicians was fierce: some recommended only cotton and silk to repair flesh, including notes by the Nestorian-Christian physician to the caliphs, Yūhannā ibn Māsawayh, known as Mesue Senior, about using strong silk to repair arteries.28 Rhazes preferred to use the catgut strings favoured by lute players to repair abdominal walls, and also used horsehair sutures, which remained popular for centuries.29 These writings suggest abdominal and arterial surgery was being performed, making anaesthesia of some kind compulsory. Although some simple, if relatively major, surgeries such as the removal of a bladder stone were achieved through heavy restraint of the patient, it seems highly unlikely that anyone could undergo abdominal or pelvic surgery, some of which details the joining of bowel sections, without having first been rendered insensible.

  As surgical techniques progressed, Baghdad founded its own guild for making surgical needles, and often the physicians gave their own specifications as to what their needles should look like and what they should be made from, with gold and silver particularly popular. The finest needles were used for eye surgery, and a woman’s hair used as sutures.30 Ophthalmology was a preoccupation of the early Arabian physicians, and opium was a common ingredient in topical recipes for eye medicines. Al-Kindi’s recipes contain a large number, proportionally, of eye remedies containing it, although Greek physicians had disagreed over whether it was helpful or harmful, because although it was a painkiller, it was also an irritant.

  The famous Persian scholar Ibn-Sīnā, known as Avicenna (980–1034), was responsible for condensing a large amount of the theories we take for granted today. He named the five external senses, and some internal, such as common sense, which allows us to process external information and to understand how it will affect our welfare. His primary work was the Kitab al-Shifa’ or The Book of Healing, a work not upon medicine but on science and philosophy, as well as early psychology. For Avicenna, as for many early polymaths, the separation between disciplines was tenuous, and he explored how we process thoughts and feelings, as well as astronomy. He was careful, with his medical works, to focus on the facts of his experiences as a physician rather than criticisms or opinions of other theories, representing an early and important move towards empiricism. Another of his works, Al-Qānūn fī aṭ-Ṭibb, or Canon of Medicine, was also central to the contemporary understanding of pain. Galen had described four different types of pain, and correctly located the brain as the organ which perceived it, but Avicenna identified fifteen different types.

  Pain theory is central to the history of opium: understanding why and how we feel pain dictates how we try to relieve it. To illustrate how advanced Avicenna’s understanding of pain was, the modern McGill Pain Questionnaire that is used throughout North America classifies twenty different types of pain, thirteen of which are in common with those in Avicenna’s Canon. To relieve pain, he writes of the taskin, or painkillers, and mukhaddar, anaesthetics. Opium is listed as both a taskin and a mukhaddar, and its use as an anaesthetic is mentioned along with preparations for amputation. The dose mentioned for a painkiller is the size of a ‘large lentil’, but to induce ‘a deeply unconscious state so as to enable the pain be borne’ a ‘half a dram’ dose of opium is recommended, along with other narcotics including henbane, a dose that would certainly have put the patient at risk, as indicated by Avicenna’s own terse warning of ‘can kill’.31 People with pain metabolize far higher doses of opium than people who are pain-free, something he had no doubt observed. He also found pigs’ bristle efficacious for closing large wounds, but they were later banned in surgery by the strict Shafi’i school of Islam in the ninth century.32

  Surgery was not the bulk of Avicenna’s work, though. Like Rhazes, he was deeply interested in treating the patient as a whole. He was particularly interested in chronic conditions such as gout, for which he prescribed opium. He too recommends opium for insomnia, taken either orally or rectally, and the Arabs call it abou-el-noum, ‘father of sleep’.33

  The Canon has a whole chapter entitled ‘Afion’ in Book Two, and details an extensive knowledge in the management of patients using opiates, for everything from coughs and diarrhoea to headaches, but is particularly interesting on the dangers of opium and overdose, listing symptoms and the need to be aware that the patient may also be drunk. It also offers equivalent dosages of other medicines to compare with opium, such as cannabis seed, ‘in triple weight’ to the equivalent amount of opium.34 The Canon advises, like the Ebers Papyrus, that opium can be used to stop a persistently crying baby. The seemingly endless list of ingredients for this infant medicine contains the key component in the last sentence:

  Take bugle seed, juniper berry, white poppy, yellow poppy, linseed, celandine seed, purslane, plantain seed, lettuce seed, fennel seed, aniseed, caraway; some of each is roasted little by little; then all are rubbed together. Add one part of fried flea-wort seed which is not powdered. Mix the whole with a like amount of sugar and give two ‘drams’ as a potion. If it is desired to make it still stronger, one should add an amount of opium equal to a third part of it or less.35

  Avicenna’s life outside his studies is equally interesting. Typically dressed in a brocaded robe, leather shoes and a linen turban, he enjoyed wine and female concubines, and a biographer noted that of all his ‘concupiscent faculties’, his sexual capacity was ‘the most powerful and predominant’ and he ‘indulged it often’.36 Bearing in mind his startling intellectual abilities, one can only imagine how powerful this capacity was. He never married, or recorded any children, and died in 1037, a few years after going on campaign with his emir Alā’-al-dawla MoḤammad, where he suffered a serious illness in unfortunate and mysterious circumstances. A bout of colic laid him low, just as he and the emir were retreating from oncoming troops. To try and cure himself, he allegedly gave himself eight enemas in a single day, and continued rigorous purging, but his physician put far too much celery seed into the mixture. When he became even sicker, a servant, who was perhaps also a conspirator in his master’s intended demise, brought him mithridate, which induced a seizure. Although he nursed himself slowly back to health, he was never the same again but continued to indulge in sexual excess, and later died of an opium overdose.

  Whatever the truth of his death, the truth of his career is that, in terms of practical medicine and medical philosophy, he – and the others like him of the Islamic golden age – provided the essential bridge between the basics laid down in the Graeco-Roman period and the Renaissance.

  From the Dark Ages to the Crusades

  Outside the Arab world and the Roman Empire, which had receded from western Europe, things were not so enlightened. After the Romans retreated from Britain in 409–10 and Christianity took hold, opium use also disappeared. This does not appear to be any kind of religious statement, as the Coptic Christians of Upper Egypt used opium, recorded by a papyrus of the seventh to eighth centuries requesting it for ‘brother Paule’, a poorly monk, but northern Europe had lost either the knowledge or the willingness to record the use of such a powerful drug.37

  Most medical knowledge in the Dark Ages centred around the religious houses, mainly monasteries, where the Graeco-Roman teachings were still followed, and medicine was still based upon the humours. Ordinary people relied upon folk medicines, often in the control of a female member of the community, working from oral traditions.

  Christianity arrived in Britain during the Roman occupation, and had mustered enough power to send a delegation to the Council of Arles in 314, and of Rimini in 353. But the Christians were under siege from the Picts, Scots and Britons, sendi
ng a message to Roman general Aetius c.446, begging for help: ‘the barbarians push us into the sea, the sea pushes us back into the barbarians’.38 ‘Barbarians’ is an appropriate term for some of these Celtic peoples, of whom the Greek historian Diodorus Siculus wrote: ‘They are very tall in stature, with rippling muscles under clear white skin. Their hair is blond, but not naturally so: they bleach it, to this day, artificially, washing it in lime and combing it back from their foreheads. They look like wood-demons, their hair thick and shaggy like a horse’s mane. Some of them are clean-shaven, but others – especially those of high rank – shave their cheeks but leave a moustache that covers the whole mouth.’39 Many of these British and northern European Dark Age tribes were beer or wine drinkers, but others avoided intoxicants completely. The Nervii of Gaul and the Germanic Suebii did not import alcohol. Julius Caesar asked why and he was told, ‘they allowed no wine nor any of the other appurtenances of luxury to be imported unto them, because they supposed that their spirit was like to be enfeebled and their courage relaxed thereby’.40

  Queen Boadicea addressed her soldiers in AD 61 with a condemnation of their drunken foes: ‘To us every herb and root are food, every juice is our oil, and water is our wine.’41 But with such limited written records until the Norman Conquest, it is hard to obtain a clear picture of Dark Ages Britain in comparison with what was happening in the Fertile Crescent. Even in France, where the courtly King Charlemagne (c.747–814) was an avid record-keeper, there is no mention of opium or the poppy. In contrast, the opium poppy and the horned poppy were being cultivated in the elegant Moorish gardens of southern Spain.42