684 SQUILL IN ANCIENT AND MEDIEVAL MATERIA MED ICA, WITH SPECIAL REFERENCE TO ITS EMPLOYMENT FOR DROPSY* JERRY STANNARD, Ph.D.t Professor, Department of History University of Kansas Lawrence, Kans. IT has long been recognized that in classical antiquity, as in the Middle Ages, plants and plant products were widely used for a variety of practical purposes including, of course, drug therapy. But, contrary to the impression gained by reading the more lurid accounts of mandragora, arbre sec, yggdrasil, spina christi, and the like, those uses were based on first-hand experience with the living plant known from and collected in its native habitat. While it is true that ancient and medieval writers did not make the taxonomic and nomenclatural distinctions which we are accustomed to make today, most of the plants mentioned in such writings can be identified satisfactorily to- day, at least to the generic rank. It is sometimes difficult, however, to explain in modern terms the rationale for their various uses, especially their therapeutic uses. Moreover, it is virtually impossible to deter- mine when and how a particular plant came to be used for a specific complaint. It is probably correct to imagine a long period of folk use proceeding by trial and error but there is, unhappily, little documen- tary evidence to support such a conjecture. These obstacles notwith- standing, ancient and medieval knowledge of plants and their uses can be reconstructed in some detail. A case in point concerns squill and its role in materia medica. The early history of the medicinal uses of squill is, however, by no means a simple story.' In the present study no attempt has been made to mention every writer who referred to squill or to paraphrase every reference to squill found in ancient and medieval texts. Rather, the most important texts have been chosen, along with a selection of *Presented as part of a Symposium on Squill. tNow Visiting Professor, Universitdt Marburg, Marburg/Lahn, Federal Republic of Germanv. SQUILL IN ANCIENT AND MEDIEVAL MATERIA MEDICA 6 8 5 texts of lesser importance, in order, first, to illustrate the complexities of a tradition which lasted two millennia and second, to illustrate the more specific uses of squill in the treatment of dropsy. In addition to a fragmentary record for the pre-Hippocratic pe- riod, the history of the therapeutic uses of squill is complicated by three other factors. I) Squill was used in the treatment of many com- plaints other than dropsy. 2) Dropsy was treated by operation and dietetic regimen as well as by drug therapy, which included many plants in addition to squill. 3) Literary diagnoses are notoriously un- safe and dropsy is no exception. But rather than try to avoid these difficulties by an oversimplification, I shall attempt to account for them within the context of ancient and medieval materia medica by the liberal use of passages from a wide range of contemporary documents. The word squill is an anglicized form of Latin scilla (late Latin squilla), and cognate to other modern European names derived ulti- mately from Greek oKdX~a (skilla) or OKLXAv, (skille). The pre-Greek etymology and Indo-European root are not certain, as the abundance of hypotheses testify.2 It is clear, however, that squill was known to the Greeks at an early period, perhaps borrowed from the Egyptians,3 although the first literary evidence is post-Homeric.4 Before we proceed further, a few remarks on the botanical de- scription, nomenclature, and taxonomy will provide a basis for com- parison with the ancient and medieval passages to follow. A nontechnical description will best convey the general appear- ance of the squill, Urginea maritima (L.) Baker: An unmistakable plant either in the spring with its broad strap- shaped leaves growing out of huge bulbs, or in the late sum- mer when the tall spikes of white flowers grow leafless from the dry ground. Bulbs up to IS cm. across with broad lance- shaped, more or less flat shining leaves, 3-6 cm. across, ap- pearing in the autumn and lasting till summer. Flowering stems robust, I-1i2 m. high, with very numerous stalked white flow- ers in a long dense cylindrical spike; the lower flowers open first and flowering continues gradually upwards. Petals white, blunt and green-nerved; anthers greenish. HABITAT: sands, rocks and dry hills; circum-Medit. August-October.5 Three further details, whose relevance will appear below, require Vol.50,No.6,June 1974 686 686J.J. SSTTAANNNNAARRDD only a brief mention. First: squill is not winter-hardy, though it makes a successful if somewhat uncommon house plant.6 Second: there are two color varieties of the squill bulb: red and white. There has been much difference of opinion as to their comparative physiological ac- tivity, but taxonomically the color variations appear to be of little significance.7 Third, the bulb will sprout and, it is reported, will occasionally blossom, without being placed in the soil.8 The accepted scientific name of the squill was created a century ago by John Gilbert Baker (i834-1920), for many years associated with the Royal Botanic Gardens at Kew. In i872 Baker published the second of his monographs on the genera of the lily family (Liliaceae).9 For the present purposes, it may be noted that he distinguished five genera of the tribe Scilleae of the Liliaceae and separated, on the basis of differences in the perianth and seed morphology, the two genera Urginea and Scilla. Up to the time of Baker's revision, these two genera were either not distinguished or only imperfectly distinguished, despite the creation of the new genus Urginea in I834 by Adolphe Steinheil (i8io-i839). 0 Prior to Steinheil's study, in which squill was termed U. Scilla Steinh., the plant was usually known by the older name Scilla maritima L., codified by Linnaeus in 1753.11 Other names have been proposed, but in the taxonomic literature the three most common names are U. maritima (L.) Baker, U. Scilla Steinh., and Scilla maritima L.12 The earliest references to squill in Greek are, for the most part, nonmedical. But, as we shall later observe, the nonmedical and para- medical uses of squill have a bearing on the medical uses and cannot easily be separated. There are, in addition, other reasons why the pre-Hippocratic references are important. For example, some significance attaches to the proverb "Neither rose nor hyacinth grow upon the squill.""1 This seemingly simple-line, attributed to Theognis (fl. Ca. 544-54i B.C.), establishes the fact that squill was well known. For had it been rare, or even uncommon, the proverb would have lost its point. At approximately the same time, squill is mentioned in some other verses whose meaning is, however, less obvious. The passage in ques- tion comes from Hipponax (fl. 540-537 B.C.), an iambic poet of Ephesus, known today principally for the fragments of what were, presumably, colloquial satires. The subject of the passage is unknown Bull.N.Y.Acad.Med. SQUILL IN ANCIENT AND MEDIEVAL MATERIA MEDICA 6 8 7 and the object is supplied solely on grammatical grounds: "Throwing [at him] in the winter [or, in the meadow] and beating [him] with twigs [? of the fig tree] and [leaves of] squills like a scapegoat.""4 There is no need here to enter into the metrical and orthographical questions that have beset scholars in their attempts to interpret this passage. From a botanical point of view, the facts, though not the context, are reasonably clear. First, the phrase "in the winter" makes better sense than the emendation "in the meadow" because the leaves appear after the blossom.'5 The plant, according to L. H. Bailey, flow- ers as early as July and August.16 The blossom is succeeded by the long and broad leaves described above, which are well suited to Hipponax' purpose. A second point again concerns the leaves. Whatever may have been the reason for beating, or perhaps whipping-a well-known cultic ritual-squill leaves and fig twigs were ideally suited.17 Several investigators have pointed out that contact with squill leaves may produce serious local irritation."8 This property was already recognized in antiquity.'9 Thus squill leaves and the supple, lactiferous twigs of the fig tree would lend themselves to the use described by Hipponax. The third of our early references adds further complexities but, at the same time, provides further evidence as to its use. Athenaeus (fi. ca. 200 A.D.), the learned author of the Deipnosophistae (The Dining Wisemen), was ever on the alert for poetical snippets illustrating the foods and drinks he and his colleagues enjoyed, though sometimes vicar- iously. In a gastronomic discussion foreshadowing Jean Anthelme Brillat-Savarin, the question arose concerning the identification of the plant known as kaktos (Cynara cardulculus L.). In order to settle the matter, several lines were cited from Epicharmus, a fifth century Sicilian writer of comedy and perhaps of medical treatises as well, who flour- ished during the reign of Hieron, king of Syracuse (478-467 B.C.). The Epicharmian verses run as follows: "Poppy . .. fennel, and rough cactuses to eat among other vegetables." "And again he says," Athe- naeus continues, "lettuce, palm buds, squills (axvvov) . . . radishes, cactuses."'* Two points are noteworthy. First, the alimentary use of squill is quite uncommon. But judging from the other vegetable prod- ucts, perhaps the leaves were employed as a salad.21 This interpreta- tion is confirmed by yet another reference to squill, also preserved by Athenaeus.22 In this case, two verses from Anaxandrides (fi. 382-349), a minor writer of the Middle Comedy, are apposite: Vol.50,No.6,June1974 6 8 8 ,JJ.. SSTTAANNNNAARRDD 688 Cutting some asparagus, squills (ox~vov) and marjoram, which, as everyone knows, when mixed with coriander, give distinction to smoked fish. The verses of Epicharmus, and Anaxandrides as well, are impor- tant for a second reason. The word squill, in those verses, is a trans- lation of Xtvos (schinos), rather than the more common uKdxxa. The con- text suggests that the synonymy aoikka/aX-vo' was well-established for otherwise, like the proverb noted above, it would be pointless. Usually oivos denoted mastic, the gum produced by the lentisk (Pistacia Lentiscus L.).23 Often known under the trade name of Chian mastic, from the island of Chios, mastic was chewed as a breath sweetener and entered into a variety of composita.24 Because of the presence of a bitter principle, it also served as an expectorant and stimulant, much as did squill. The synonymy ,dKt'Xa/uotvos was common in Greek but appar- ently it became archaic, for later writers made a point of recording their equivalence.25 At an earlier time, the synonymy was sufficiently common that it served as a base for a pun. Plutarch (ca. 46-I2o A.D.) reported that Pericles (ca. 495-429 B.C.) was dubbed "squill-head" (oXtvoKfSaXos) by Cratinus (fi. 484 B.C.), the Athenian comic poet and perhaps a critic of Periclean policy.26 It is still an open question whether that derisive term referred to Pericles' unusually shaped head or whether it was an opprobrious term, much like our "egg head," due to Pericles' association with sophists and "intellectuals." The sobriquet caught the public's fancy and was repeated later.27 An easy transition to the medicinal uses of squill is provided by Aristophanes (ca. 450-ca. 385 B.C.), the master of the old comedy. Though he was younger than Hippocrates, it will be convenient here to consider one passage from his Plutus. Produced in 388 B.C., this work contains a good-natured satire on Asclepius and the healing arts.28 The relevant passage is a description of the preparation of a medicament by the attendant priest of the Asclepeion. .first he set himself to mix a plaster . . . throwing in three . . cloves of Tenian garlic; and with these he mingled verjuice and squills (uxivov); and brayed them up together. Then drenched the mass with Sphettian vinegar, And turning up the eyelids of the man, plastered their innersides, to make the smart more painful.29 Bull. N.Y.Acad.Med. SQUILL IN ANCIENT AND MEDIEVAL MATERIA MEDICA 6 8 9 Before we turn to the explicit medicinal uses of squill note should be taken of two semi-legendary figures, each of whom played a minor role in later squill lore. Few factual data are recorded for Epimenides and even his dates are a matter of conjecture. But from the anecdotes preserved by later writers two pertinent items appear, although their connection is by no means clear. Near the end of Diogenes Laertius' biography of a typi- cal wonder-worker, he noted that Epimenides "withdrew [i.e., from political life] and engaged himself in the collecting of roots and sim- ples."30 Whether this is only an inference from Theophrastus' account (see below) or is based on independent evidence, Epimenides' name became associated with squill. Theophrastus, about whom more will be said later, wrote: Among edible roots are not only purse tassels and others which resemble them, but also the roots of asphodel and squill, though not of all kinds of the latter, but only the kind called "Epimeni- des" squill, which gets its name from its use.31 No further details are supplied by Theophrastus concerning its use. But from other sources it appears that that use was magical, and per- haps the apotropaic properties later attributed to squill go back, in fact, to Epimenides.32 Pythagoras (fi. ca. 53i B.C.), about whom an even larger number of legends centered, is involved in the early history of squill on some- what slender grounds. Were it not for a frequent misunderstanding of Pliny by later writers, he would not merit attention here. At the con- clusion of his account of squill, Pliny stated that Pythagoras devoted an entire book to squill. While it is remotely possible that he wrote such a book, as well as one on cabbage,33 it is equally possible that this attribution is nothing more than an example of ascribing useful dis- coveries and inventions to a "culture hero." It is significant that the earliest explicit reports of the medicinal uses of squill in classical antiquity are found in the Corpus Hippo- craticum. There are numerous references in Diseases of Women,-4 the Nature of Women,35 and elsewhere.36 But none of the passages men- tioning squill is concerned with dropsy nor in any of the more fre- quent references to dropsy and its treatment is squill mentioned.37 As it is not our purpose here to consider all the drugs of vegetable origin mentioned by the Hippocratic writers, it will suffice to note that Vol.50,No.6,June 1974 69 J. STANNARD J. STANNARD squill was recommended for various uterine complaints,38 as an emol- lient for open sores,39 and once as an ingredient in an ophthalmological prescription.40 As noted, references in the Corpus Hippocraticum to dropsy-or, to be more precise, to morbid conditions characterized by the collec- tion of fluids and edema, and hence translated as "dropsy," "dropsical," etc.-do not contain any reference to squill. However, the numerous references to dropsy sensu lato indicate that the symptom complex was not uncommon and that it had been observed sufficiently often that certain generalizations could be made. For example, a long-de- scription based on clinical evidence appears in On Sufferings,41 and other references are scattered throughout the Corpus.4 Finally, two of the Aphorisms help to define the later relations between dropsy and its therapy and the manifold uses of squill.43 In particular, the surgical treatment of dropsy, referred to in Aphorisms VI, 27, should be com- pared with drug and regiminary therapy, both of which are clearly alluded to but not specified in any extensive detail in his work On Sufferings. Turning now to the plant itself, the Hippocratic references con- tain an ambiguity of a type so common in late classical and medieval texts that it is worth pointing out here. Generally speaking, the mere mention of a plant name, a recommendation for its use-even its in- clusion in a list of ingredients for a compositum-is no guarantee that the plant was actually available to the physician, that he used, or had used it, or that he had any personal knowledge of the plant itself. In the present instance, there is no reason to doubt the integrity of the Hippocratic writer. For, as we have seen, squill was well known to the educated public and it is, and presumably was, widely distributed in Greece and the Aegean Islands.44 Still, the fact remains that there is no incontrovertible evidence that Hippocrates or the anonymous authors of the Hippocratic Corpus had any experience of squill be- yond its preparation for purposes of administration.45 While there may be some doubt as to the extent of Hippocrates' personal knowledge of squill, all doubt is removed when we consider the accounts of subsequent writers. Squill is mentioned but once in the genuine writings of Aristotle (384-322 B.C.) but his comment that locusts deposit their eggs "in the stalks of squill" bears witness to his powers of observation." In two other texts, both of which were Bull.N.Y.Acad.Med. SQUILL IN ANCIENT AND MEDIEVAL MATERIA MEDICA 6 9 I formerly attributed to Aristotle, there are descriptions which, despite some questionable plant physiology, unmistakably derive from ob- servation of the living plant.47 A more complete description was given by Theophrastus (ca. 370- ca. 286 B.C.), Aristotle's pupil and later his successor as head of the Lyceum. In both his History of Plants and Causes of Plants he fre- quently referred to squill as if it were a common plant. It belonged to the class of bulbous plants and possessed a large bulb with several layers of scales capable of being peeled off.48 Elsewhere Theophrastus describes the tunicate bulb in terms which will reappear in later writings: Now all bulbous plants are tenacious of life, but especially squill; for this even lives when hung up and continues to do so for a very long time; it is even able to keep other things that are stored, for instance the pomegranate, if the stalk of the fruit is set in it; and some cuttings strike more quickly if set in it; and it is said that, if planted before the entrance door of a house, it wards off mischief which threatens it.49 Regarding its habitat, he noted that there are some terrestrial plants which, "on occasion live in the sea" (7mof {V T7 OaXa'TTl /tOViV) such as palm, squill, and asphodel.50 The obvious translation suggests that Theophrastus was attempting to describe a strand plant. But if he was describing a locale where the plant was washed by wave action or submerged at high tide, no corroborating evidence has been found. It is rather more likely that this was a loose phrase, indicating nothing more than a maritime habitat, reflected in some of the many vernacu- lar names proposed for squill.5' There is one more Theophrastean reference to squill which de- serves comment. In his Characters, a series of life-like characterizations combined with embellished stereotypes, the description of the super- stitious man concludes thus: if ever he see one of the figures of Hecate at the crossroads wreathed with garlic, he is off home to wash his head and summon priestesses whom he bids purify him with the carrying around of asquill or a puppy-dog.52 After Theophrastus, evidence for the knowledge and uses, medi- cinal as well as nonmedicinal, becomes more frequent. Each of the strands of the interwoven history of squill touched an above-medical, Vol.50,No.6,June 1974 692 J. STANNARD 69 .SANR pharmacological, botanical, and magical-receives its share of attention. Caelius Aurelianus, a fifth century physician of the methodist sect, stated in his long account of dropsy that Erasistratus (early third century B.C.) and Asclepiades (d. ca. 40 B.C.) had each written De hydrope (On Dropsy).53 Unfortunately these books have been lost and with that loss, perhaps went information regarding the early post- Hippocratic use of squill.54 It is, in fact, not until the early first cen- tury A.D. that a pattern begins to emerge regarding the therapeutic uses of squill. Prior to that time the few references are of an inci- dental nature and play little role in subsequent times. It is otherwise, however, with the report of Aulus Cornelius Celsus, Roman encyclopedist and author of De Medicina, who flour- ished under the Emperor Tiberius (I4-37 A.D.). Whether he was an original writer or only the editor-translator of a now lost Greek text is of less moment than his clear and straightforward description of dropsy and its treatment.5 Following a tradition that extends back to Hippocrates, he recognized the value of a closely regulated regimen and a rigorous control of fluids, even to the extent of recording daily intake and output.56 Diuretics, he admitted, are beneficial but diure- sis, he thought, was better effected by diet and regimen than by drugs. Nevertheless, he enumerated some 25 diuretics, most of which will occur, for centuries to come, in treatment for dropsy.57 Toward the end of his account of dropsy he added, almost as an after- thought, "It is also useful to suck a boiled squill."58 Elsewhere in De Medicina other uses of squill are mentioned, including squill vinegar, which later played an important role in materia medica generally.69 Celsus' references to acetum scillinum are particularly interesting because he does not include a recipe for its preparation. Presumably he assumed that his readers knew how to prepare squill vinegar though, in fact, no recipe earlier than those of Dioscorides and Pliny seems to have been preserved. With the mention of Dioscorides and Pliny it is only fitting to consider their contributions at this point. Along with Galen, Dio- scorides (fi. Ca. so A.D.) and Pliny (23-79 A.D.) were the most influential of ancient writers on materia medica, though for some- what different reasons. Whereas Dioscorides' De materia medica was one of the greatest texts ever written on the subject, whose very name derived from his only publication, Pliny was essentially a com- Bull.N.Y.Acad.Med. SQUILL IN ANCIENT AND MEDIEVAL MATERIA MEDICA 6 9 3 piler, and not always too critical at that. But because Pliny wrote in Latin, his encyclopedic Historia naturalis was widely read, copied, abridged, and excerpted throughout western Christendom."° Dio- scorides' De materia medica, on the other hand, maintained a pre- carious existence in the West until the late Middle Ages.6' In the Byzantine East, on the other hand, it remained the fundamental text for the later physician-compilers. The relation between Dioscorides and Pliny-neither of whom men- tions the other by name-is still a matter of controversy.62 Whatever the ultimate answer regarding that relation may be, their respective statements on squill provide the most detailed reports in antiquity and supplied generations of later writers with data to be abridged or other- wise modified as occasion dictated. Because of its historical impor- tance I translate, in its entirety, Dioscorides' chapter on squill. Squill has a sharp, heating property, but when cooked it is very useful. Wrapped around with clay or spelt-dough, it is placed in an earthenware pot or in the ashes until the outer covering of dough is sufficiently baked. If it is not tender following removal of the covering, we apply another covering of dough or clay [and cook again]; for, if the squill is not sufficiently cooked, it is harmful when given, especially to the intestines if taken internally. It is also prepared by cooking in a jar, covered with a lid, placed inside an earthenware pot. In this process, the middle portion is used, the outside having been stripped off. After being cut in pieces, it is boiled. The water of the first boiling is poured off, and it is boiled again until the water is neither bitter nor sharp. Then it is cut into [smaller] pieces, strung on a thread so that the pieces do not touch one another, and dried in the shade. Those pieces we use as wine, vinegar, or oil of squills. For fissures of the feet, the inner portion of raw squill is boiled with oil or applied, mixed with pitch; and as a cataplasm, boiled with vinegar, for those bitten by a viper. For purposes of softening the belly, we give to a fasting patient one or two spoonfuls of [a preparation com- posed of] one part of roasted squill to eight parts of roasted, pulverized salt. It is given in drinks or in aromatic preparations when we wish to promote the flow of urine, to those with dropsy, or whose stomach is bloated with undigested food, or Vol.50,No.6,June 1974