Pain Management in the Greek and Roman Mediterranean

by Heidi Marx

Oct. 26, 2023

Heidi Marx is a professor in the Religion Department at the University of Manitoba (Winnipeg). Her main research is in the philosophy and medicine of Late Antiquity, and she has just published, along with Kristi Upson-Saia and Jared Secord, Medicine, Health, and Healing in the Ancient Mediterranean (500 BCE– 600 CE): A Sourcebook.

The first time I consciously encountered OxyContin was in the final month of my child’s father’s life, as he was dying a very painful, heart wrenching death from metastatic lung cancer. We went to be with him, and, as it turned out, to say goodbye to him. Without medication, his pain would have been unmanageably excruciating. During his final hours it was difficult and risky for him to swallow anything, so the palliative nurse switched him to liquid morphine, but she warned us that it was weaker than what he’d been taking orally. I thought to myself—naïve as I was—“what is stronger than morphine”? OxyContin, it turns out, by about 50%, while Fentanyl makes this look tiny, clocking in at about 100 times stronger than morphine. With the least potent of these drugs in his system, he passed with his pain eased, but not erased. A nurse came to pronounce the time of death and then helped us wash him and put him in silk pajamas.

As we gathered up his medications, I was surprised to find two large bottles of OxyContin sitting on his beside—hundreds of pills, surely the start of an addiction, if anyone had been interested in making off with even a portion of what was there. This past winter, this experience came back to me—the pain, the pills, and the attempt to erase suffering—as I watched the series “Dopesick,” a dramatization of the early days of the opioid crisis in the United States. The series follows how this public health disaster was kicked off and fueled by the creation and aggressive marketing of OxyContin by Purdue Pharma, owned and operated by the Sackler family whose involvement in the crisis has been widely publicized and criticized in the media worldwide. Not only did my encounter with the pills spring to mind, I was also struck by the stark difference between our pain management strategies today and those of the ancient past. We try to kill pain, even to the point of mass addiction. In the Greco-Roman past, pain was accepted as part of human existence, something that was ubiquitous, ever present, and hard to manage.

Terracotta pyxis (box)

Attributed to the Penthesilea Painter, Athens, Greece, ca. 465–460 BCE, MET Museum Accession No. 07.286.36a, b

To be fair, the ancient Mediterranean lacked truly effective analgesics (by modern standards) to treat chronic, everyday pain, and ancient practitioners did not possess anaesthetics to deal with acute situations. It was also an environment where pain and suffering were prevalent. So how did folks manage pain in this environment? A recent volume from Jacqueline Clarke, Daniel King, and Han Baltussen explores the narrative strategies and philosophical encounters with pain. Surgical manuals also offer a small glimpse into the pain involved in the dramatic situations of, say, amputating a gangrenous limb, or sliding a needle into a patient’s eye to move a cataract. If patients were fortunate, the physician or surgeon would have administered a sedative drug, such as opium, before the procedure began. Yet it is striking how little mention is made in surgical manuals of the extreme pain that must have been part and parcel of many severe injuries and efforts to repair them. Pharmacological authors do mention a few substances, but it is here where ancient drug-based approaches to pain management do not map onto our understandings or expectations.

Dioscorides of Anazarbus (modern Anavarza, Turkey) was a first century CE author of a massive ancient pharmacological handbook called De Materia Medica. This compendium, which shaped plant pharmaceuticals for the next 1500 years, mentions only two substances that may have functioned as actual anesthetics, namely mandrake (used as a general anesthetic, but more likely functioning as a sedative similar to opium) and memphitic stone (possibly resinasphalt). Mandrake was prepared by boiling the root down with wine into a concentrated tincture, while memphitic stone was crushed and spread on the area about to be operated on as a local anesthetic. Dioscorides mentions that both can be used for either surgery or cautery, which reminds us that patients often elected to undergo the very painful process of having their flesh burned with a hot iron instrument in the hopes of eliminating pathological pain.

Mandrake (gr. ΜΑΝΔΡΑΓΟΡΑ,). Naples Dioscurides, Fol. 90 (7th century CE), Dioscorides De Materia Medica (Naples, Biblioteca Nazionale, Cod. Gr. 1).

What of chronic pain or more moderate pain associated with lingering conditions? A comprehensive survey of all references to remedies for pain in Dioscorides shows there are very few references to substances that are identified as analgesics for any kind of pain. Opium, mandrake, and henbane are the main ones, but the entry for the opium poppy notes that its main characteristic (power or dynamis) is its soporific quality. That is, Dioscorides recommends opium to treat insomnia, not eliminate pain. Because opium was thought of as a cooling drug, and heat was associated with vitality and life, opium was considered a dangerous substance, because it could cool a patient to the point of plunging them into a coma—perhaps even to the point of death. Its analgesic properties are only mentioned in passing. As Theophrastus states:

Bronze statue of Eros sleeping, Greek, 3rd–2nd century BCE, MET Museum, Accession Number: 43.11.4

“And the juice, since it, too, cools a great deal, befuddles, and dries, and taken in an amount as small as a bitter vetch is analgesic, soporific, helpful for digestion, and comes to the aid of coughs and abdominal conditions” (Dioscorides, De Materia Medica 4.64, trans. Beck).

Rather than treat analgesics as general “pain killers” to manage discomfort, Dioscorides takes a different approach. That is, he tries to treat the underlying condition, while focusing on specific types of pain. He identifies plant substances, stones, minerals and animal/human products (such as whole insects and worms, livers, horn, hooves, testicles, milk, blood, bile, fat, urine, and dung) that can be used to treat pains of the side, chest, stomach, genitals, ears, womb, teeth, and head. Headaches are treated by plastering on various substances using either vinegar, wine or oil. Unguent of roses, a very costly and time-consuming preparation involving thousands of roses, is especially effective and often the medium for delivering other drugs to the temples and forehead for relief. Countless drugs were applied directly to infected and rotting teeth for relief and healing of inflammation. But sometimes toothache was treated by administering drugs into the ear or plastering them onto the face above the painful area. Heat, too, can treat discomfort. For example, for those suffering from hip pain, Dioscorides recommends using the “intense heat” that issues from goat droppings (ideally from wild mountain goats), placed over wool soaked in oil on the space between the thumb and index finger “until the sensation reaches the hip…and the pain stops” (Dioscorides, De Materia Medica 2.80, trans. Beck).

Similarly, mustard should be applied to the skin in order to cause a “counter-irritation” in cases of chronic pain, when the aim is to “transfer something from deep inside the body to the surface” (De Materia Medica 2.154, trans. Beck). Drawing the irritation from inside the body to the surface, should lead to relief at the original site of pain. Cautery, as mentioned earlier, was likewise thought to work by moving pain from one location in the body to another, or by containing disease in one area so that it would not spread to other parts of the body through its channels. This comprehensible, if foreign logic, underpins other remedies that most today would find strange. For example, Dioscorides reports that if you use a moist poultice of treacle clover to foment wounds caused by reptile bites and then transfer that poultice to a new patient, “the person will suffer as the bitten” (De Materia Medica 3.109, trans. Beck). In other words, the pain that was drawn off the wound by the initial fomentation is then transferred to another person if the same poultice is re-used.

Joaquín Sorolla y Bastida (Spanish, 1863 - 1923), The Wounded Foot, 1909. Oil on canvas. The J. Paul Getty Museum, Los Angeles, 78.PA.68

The idea that a substance could be applied to the surface of the body to draw off pain whether deep inside the body or on the surface and then be contained in that substance happens to be a basic principle of pain management grounded in ancient scientific theories of attraction, sympathy and antipathy. Indeed, we find similar ideas expressed in the works of Pliny the Elder, a first century CE contemporary of Dioscorides, who records in his Natural History that one can alleviate pain by attaching the tooth of a mole onto the inflamed tooth of a patient (Natural History 30.7). He also records that bladder stones evacuated from a suffering individual can be used to treat someone similarly afflicted (Natural History 28.9). And in cases of pains of the vital organs, a live, nursing puppy can be applied to the area, although this will likely lead to the death of the animal as the illness is transferred to it (Natural History 30.4). In other words, one strategy for managing pain was to draw it off into other areas of the body, or into other bodies, both animate and inanimate.

Attic Red-Figured Kylix, 490–480 BCE, Attributed to the Brygos Painter. Greece, Athens. The J. Paul Getty Museum, Villa Collection, Malibu, California, 86.AE.286.

I am struck that the logic of this approach to managing pain mirrors the wish many of us feel when a loved one is ill, namely to somehow take their suffering from them, bear it for them ourselves. I certainly wished this in the final months of my ex-husband’s life when I saw him in pain, not yet aware that he had cancer, and in the final days in those moments when there was a delay in administering Oxycontin by overworked hospital staff still trying to grapple with pandemic conditions. It’s no small miracle that we can eliminate pain in ways that ancient peoples could have only dreamed about (sometimes literally in an Asclepian temple). At the same time, we have to manage different pain on an unprecedented scale, the pain of grief over lives lost to addiction. Despite our differences, we continue to share one important similarity with the ancient world, namely that the kinds and levels of pain that our society creates and the way we manage them reflects our commitment to equality and social justice, and when we fail in this commitment, the need to manage pain is unequally distributed among social groups based on socio-economic class, gender, and race.

The Sources

Pedanius Dioscorides of Anazarbus, De Materia Medica, trans. Lily Beck. 3rd edition. New York: Georg Olms, 2017.

Pliny. Natural History, Volume VIII: Books 28-32. Translated by W. H. S. Jones. Loeb Classical Library 418. Cambridge, MA: Harvard University Press, 1963.

Discussion Questions

What do we currently expect from our analgesics and pain medications? What does managing pain mean for us? How much pain is acceptable?
How do ancient pharamacological theories of pain absorption and transfer coincide with your own experiences of non-pharamacological pain management techniques (cold compresses for headaches, bandaids, etc.)? What about the presence of other humans or animals as part of pain management strategies?
Does chronic pain differ from acute pain? Which type of pain are modern medicines best suited for? Which type do ancient pain remedies seem oriented towards?
What is pain? Is it different from discomfort? Irritation? Fear? Anxiety? What are the boundaries of the experience of pain, and how do medical treatments attend to them?

Pain Management in the Greek and Roman Mediterranean

by Heidi Marx

The Sources

Recommended Readings

Discussion Questions