390456 HPYXXX10.

1177/0957154X10390456PellHistory of Psychiatry

Article
History of Psychiatry

‘Him Bid- Sona Sel’: psychiatry

22(4) 434­–447
© The Author(s) 2011
Reprints and permission: sagepub.
in the Anglo-Saxon Leechbooks co.uk/journalsPermissions.nav
DOI: 10.1177/0957154X10390456
hpy.sagepub.com

Christopher Pell
NHS Tayside

Abstract
Classical Greek and Roman writers documented the diagnosis and treatment of psychiatric illness in ancient
times. Following the fall of the Western Roman Empire however, we find little writing on the topic in early
Medieval Europe. Yet in Britain, medical texts survived and were complemented by local traditions and
treatments. This article explores the best-known Anglo-Saxon medical texts, the Leechbooks and Lacnunga,
for evidence of psychiatric illness and the treatments employed by physicians in the tenth century. The
difficulties encountered when working with sources translated from Old English and speculations about the
supernatural aetiology ascribed to these illnesses are detailed. The efficacy of the leechdoms (treatments)
described are also investigated for both their placebo and potential pharmacological effects.

Keywords
Anglo-Saxon, elf, herb, leechbook, placebo, supernatural

From Britannia to Ænglaland1

With the collapse of the Roman frontier in the late fourth and early fifth centuries, the Roman pres-
ence in Britain was gradually diminished, as legions were recalled to defend the Roman heartlands.
Evidence from forts along Hadrian’s Wall shows changes to the barracks, with fewer rooms and
more married quarters indicating reduced troop numbers. The decline was such that when British
tribes staged a revolt against Roman rule in 409, the embattled Emperor Honorius could only
respond that the Romano-British civitates appealing to Rome for aid must look to their own defence
and government from now on (Morris, 2004). What ensued was previously known as the Dark
Ages, characterized by a decline in civic infrastructure, and an ecclesiastical monopoly over learn-
ing and scientific progress lasting the best part of a millennium. Britain fragmented into separate
kingdoms with endemic warfare and pillaging as local rulers fought for dominance over their
neighbours. Into this fractious mix – whether opportunistically or, as Gildas writing around the
540s would attest, invited by King Vortigern as protection against Pictish and Irish raiding – came
the Saxons. Arriving in 449 as mercenaries, they soon established their own kingdoms across much
of southern Britain, pushing the indigenous British into the corners of Wales, Cornwall and

Corresponding author:
Christopher Pell, c/o Sunnyside Royal Hospital, Hillside, Montrose, Angus, DD10 9JP, UK.
Email: chris.pell@nhs.net
Pell 435

Strathclyde (Gildas, c.540; Bede, c.731). In the same period, efforts to re-Christianize the island by
missionaries from Ireland such as Palladius (431), Kentigern (or Mungo d. 614) and Columba
(c.521–597) paved the way for the establishment of ecclesiastical centres such as Iona, Lindisfarne
and Canterbury. Often these were closely affiliated with particular kingdoms, and it was in these
ecclesiastical and royal centres that the few surviving written documents from this age were penned
(MacQuarrie, 2004).
The seventh and eighth centuries saw a phase of hegemonization as regional powers vied for
dominance over their neighbouring kingdoms. Northumbria assimilated the Bernician and Deiran
kingdoms and, along with the Picts and Dal Riata in what is now Scotland, came to control the
northern half of the island. In the South, Mercia, Wessex and East Anglia consolidated their own
kingdoms by taking land from their neighbours, capturing important trading centres (such as
Lundenwic – now London), arranging strategic foreign marriages and building ecclesiastical links
with Rome.
This process was derailed, however, by the arrival of another wave of raiders and settlers from
Scandinavia. Beginning with isolated raids on monastic centres in the 790s, Viking settlers eventu-
ally occupied an area encompassing Shetland, Orkney, northwest Scotland, eastern Ireland and
much of northern England, with large centres at York and Dublin (Woolfe, 2007). Consolidating
the remaining Saxon Kingdoms in the South into the kingdom of Wessex, Alfred (the Great) was
able to recapture London by 886 and draw a halt to Viking expansion. It would be another 60 years
before Ælthelstan finally ousted the Danes from the North, to appoint himself the first King of all
England. However, renewed attacks from Danish rulers continued to threaten the stability of Anglo-
Saxon England. In the end, following the long reign of Edward (the Confessor, d.1066), it was
Harold Godwinson’s sovereignty that saw the fall of the Saxon world. Marching his troops from
London to defeat and kill Harald Hardrada’s forces at the Battle of Stamford Bridge, then immedi-
ately turning south to meet William of Normandy’s invasion force at Hastings proved a stretch too
far. The last of the Saxon kings of England died in the battle and was buried at Waltham Abbey,
near London. The crowning of William I on Christmas Day 1066 marks the end of Anglo-Saxon
dominance in British culture (Starkey, 2004).
It is no surprise that little written material has survived from these troubled and changeable
times. Shifting kingships, raids on monastic repositories of written material by pagan invaders
and poor literacy levels all play a part. Nevertheless the words of some writers of the age have
survived into the present and offer us a valuable insight into the events, beliefs and practices of
the Early English period. Manuscripts written on a variety of topics were penned, often in the
vernacular Old English rather than Latin, and poetry, religious commentary, saints lives and King-
lists all provide glimpses into Dark Age life. A number of medical texts have been discovered,
collected and translated, and the evidence of psychiatric practice contained within these is the
subject of the rest of the article.

Anglo-Saxon materia medica

Little reference to medical practice is made in the early sources, and the difference between lay and
clerical medics is often unclear. Few physicians are named, and described medical practice includes
many instances of prayer being used rather than practical treatments. One early exception comes
from the writings of Bede (672–735), a monk at St Peter’s monastery in Northumbria, and the most
prolific author of his day. He describes Cynefrith who treated St Æthethrith, Abbess of Ely by lanc-
ing a swelling during the plague year of 679 (Bede, c.731). Bede, himself a survivor of a plague,
also recounts how a Brother Baduthegn suffered a stroke:
436 History of Psychiatry 22(4)

When at last he got up, he felt one half of his body, from the head to the foot, struck with palsy, and with
much difficulty got home by the help of a staff. The distemper increased by degrees, and as night
approached, became still worse, so that when day returned, he could scarcely rise or go alone.

Following such a vivid description of the symptoms, Bede then recalls how the Brother had been
cured by praying to St Cuthbert. However, more practical cures were known to Bede, as his descrip-
tion of an eye swelling mentions surgical treatments.

In that monastery was a youth whose eyelid had a great swelling on it, which growing daily, threatened the
loss of the eye. The surgeons applied their medicines to ripen it, but in vain. Some said it ought to be cut
off; others opposed it, for fear of worse consequences. The brother having long laboured under this malady,
and seeing no human means likely to save his eye, but that, on the contrary, it grew daily worse, was cured
on a sudden, through the Divine Goodness, by the relics of the holy father, Cuthbert.

Other circumstantial medical information can be gathered from epic poems and the King-lists and
chronicles of the time, but little of substance. Fortunately for modern scholars, Oswald Cockayne,
working in the 1880s, was commissioned by the Crown to collect and translate the surviving
scientific and medical works of the Anglo-Saxons. His three-volume work entitled Leechdoms,
Wortcunning and Starcraft of Early England remains an invaluable compilation of Anglo-Saxon
medical texts (Cockayne, 1864).
As well as including Classical works, and works translated from Greek and Latin into Old
English, there are four books which represent the closest equivalent to Anglo-Saxon medical text-
books of the time. These texts are generally described as Leechbooks, because they contain primar-
ily descriptions of treatments or leechdoms (from the noun ‘læce’, Old English for ‘healer’ and not
to be confused with the bloodsucking annelid Hirudo medicinalis). The books translated by
Cockayne are known as Leechbooks I, II and III and the Lacnunga. Leechbooks I and II are col-
lectively called Bald’s Leechbook from a Latin colophon at the end, which begins: ‘Bald owns this
book, which he ordered Cild to write.’ The texts have been dated to around 950 ad, possibly copied
from a now lost original penned at the court of Alfred (Cameron, 1993). Written in vernacular Old
English, these books describe numerous leechdoms for a range of illnesses. They systematically
detail how a physician should concoct and treat everything from epilepsy to constipation. Many
remedies, particularly in Bald’s Leechbook, borrow and adapt treatments from earlier Greek and
Roman medical texts, and as such provide insights into how English physicians substituted rarer
Mediterranean ingredients with more easily obtained local herbs. The diagnostic skill of the physi-
cian is assumed, and descriptions of the illness are scarce, reading more like a modern-day formu-
lary than a diagnostic handbook. Leechbook III is felt to give a more authentic British collection of
treatments and is freer from classical influence than Bald’s Leechbook. The Lacnunga is the least
well ordered of the four and relies more heavily on supernatural treatments than the other texts
(Cameron, 1993).
Making sense of the remedies described presents difficulties to the modern reader. While writ-
ten English is continuously evolving, many forget the extent of the drift over long time periods.
Shakespeare: ‘But soft, what light through yonder window breaks?’ (Shakespeare, 2005) and even
Chaucer (2005): ‘But every thyng which schyneth as the gold, Nis nat gold, as that I have herd it
told’, writing in the sixteenth and thirteenth centuries, respectively, are still intelligible. However,
venturing back before the Latinization of English brought by the Normans reveals a very different
language with strong Germanic and Scandinavian influences. Few now would be able to discern
the meaning of the opening lines of Beowulf: ‘Hwæt! We Gar-Dena in geardagum, þeodcyninga
þrym gefrunon, hu ða æþelingas ellen fremedon.’2
Pell 437

Due to the relative scarcity of texts from the period, complete glosses for all Old English vocab-
ulary do not exist and some rarer words have no comparators to aid translation. Nor does the con-
text always allow the exact meanings to be discerned, and some elements of supposition must be
employed. This is a particular problem when looking for descriptions of psychiatric illness: while
some illnesses are clearly identifiable, there are many words for which the translation into modern
English is unclear. Some meaning can be gathered from the context, or from identifying sections
of text in the Leechbooks that has been appropriated from Latin and Greek texts, but there are
many words which still have uncertain meaning.
Scholars must be wary of implying too much from the literal breakdown of the words, particularly
those that imply supernatural causation. A number of illnesses are attributed to the malign influence of
elves and demons. While the described symptoms can provide clues as to the modern diagnoses in
some cases, a level of supposition is unavoidable when trying to establish the meaning of words such
as ‘deofelseoc’ or ‘devil sickness.’ There is also a need for caution in attempting to infer what the Saxon
physicians may have believed about the causation, supernatural or otherwise, of these illnesses. A
parallel today would be the continued use of ’flu to describe a common viral illness; very few people
would attribute astrological causation, even though the word originates from the Italian for ‘influence
of the stars’. Hence, although an illness has a name hinting at aetiological hypotheses, it does not neces-
sarily follow that this was the preferred scientific explanation of causation at the time. Therefore one
must exercise caution before concluding that feondes costunga or ælf seoc (temptation of the fiend or
elf sick) were truly attributed by the Saxon physician to the work of malign sprites (Hall, 2005, 2007).

Psychiatric illness in the Leechbooks

When reviewing the texts one finds a number of chapters which may refer to psychiatric illnesses.
There was certainly a long-standing recognition that mental illness could affect individuals, and
classical texts give descriptions of mania, psychosis, depression and dementia (Berrios and Porter,
1995; Marneros and Goodwin, 2005). The brain was known to be the seat of emotions and reason-
ing; Isidore of Seville (c.560–636) connected the two in his Eymologiae saying:

The primary part of the body is the head, and it was given this name because from there all senses and
nerves originate, and every source of activity arises from it. In it, all sensations become evident. Whence
it plays the role, so to speak, of the soul itself, which watches over the body. (Barney, Lewis, Beach and
Berghof, 2006: 232)

Although this work is likely to have been available to Early Medieval compilers of the Leechbooks
and Lacnunga, there is less evidence that they recognized this connection in practice (McIlwain,
2006). Certain caveats must be noted when attempting to identify psychiatric illnesses in these early
texts, particularly when thinking about the language used. Several chapters refer to illnesses that are
recognized in Classical works, the translations of which may be taken as valid. Illnesses such as
dementia, lunacy, phrenesis (frenzy, or delirium), idiocy (intellectual impairment) are good exam-
ples of this. However, there are a number of other chapters which describe remedies for less well-
defined maladies, or treatments for isolated symptoms that could represent features of mental illness.
These include many of the chapters dealing with supernatural-sounding ailments: temptation of the
fiend, elfin tricks and devil sickness. These names and their translations gathered from both
Cockayne’s (1864) work and the online Old English Made Easy dictionary3 have been collected and
are summarized in Table 1.
As can be seen, there is mention of madness with and without fever – frenzy and lunacy – as
well as dementia and depression or ‘heaviness of the mind’. There are also remedies for symptoms
438 History of Psychiatry 22(4)

Table 1.  Old and Modern English terms used in the Leechbooks and Lacnunga to describe mental illness

Book Chapter Old English Translations

Leechbook 1 63 Feond seocum Fiend sick
  63 Deoful fede Devil possessed
  63 Bræcseocum Lunatic / Epileptic
  63 Weden heorte Frenzied (lit. Mad heart)
Leechbook 1 64 Yfelre leodrunan Evil sorcery
  64 Ælfsidenne Elvish influence
  64 Mare ride Nightmare
Leechbook 1 66 Ungemynde Dementia
  66 Dyrgunge Idiocy
Leechbook 1 70 Wræne Lustful
  70 Unwræne Un-lustful
Leechbook 1 78 Unlust sie getenge Loss of appetite
Leechbook 1 80 Fordrince Drunkenness
Leechbook 1 82 Micel wæce Insomnia
Leechbook 1 85 Fundige wiþ his feond Aggression (lit. Fighting with his foe)
Leechbook 3 40 Monaþ seoc Moon sick (i.e. Lunacy)
Leechbook 3 41 Feondes costungum Temptation of the Devil
  41 Feondes costunga Temptation of the Devil
  41 Ælfsidenne Elvish influence
  41 Gewitseocne Wit sick
Leechbook 3 54 Nihtgengan Night goblins
Leechbook 3 58 Feondes costunge Temptation of the Devil
Leechbook 3 61 Ælfcynne Elven kind
  61 Nihtgengan Night goblins
  61 Þam mannum þe deofol mid hæmð Women with whom the devil has intercourse
Leechbook 3 62 Ælfadl Elf disease
  62 Ælfsogoþa Elf hiccough
  62 Feondes costunge Temptation of the Devil
Leechbook 3 64 Deofle Devil
  64 Ungemynde Dementia
  64 Deofler costunga Temptation of the Devil
Leechbook 3 67 Deofol seoc Devil sick
  67 Deofle Devil
Leechbook 3 68 Weden heorte Frenzied (lit. mad heart)
Lacnunga 11 Ælfsidene Elvish tricks
  11 Feondes costungum Temptation of the Devil
Lacnunga 73 Mnoðes (modes) hefignesse Heaviness of mind
Lacnunga 88 Wif færunga adumbige Woman suddenly struck dumb

such as aggression, and lustfulness which could be an indicator of mania. Mutism, insomnia and
loss of libido could also represent symptoms of depressive disorder.
The ordering of the Leechbooks generally follows a traditional system running from head to
foot. Each book begins with remedies for headache, eye and ear problems and toothache, and the
Pell 439

chapters detailing mental illness tend to be clustered together as a collection of remedies towards
the end of each book. This may suggest that these illnesses were seen as distinct and, given the
numerous references to demons and elves, more supernatural in origin. There are also chapters of
interest to be found in or near to the sections on fevers. Certainly in such cases the overlapping
symptoms of psychosis seen in both delirium and psychiatric illnesses could have caused the phy-
sicians to classify them, mistakenly, together. This would account for descriptions of feond seocum
being placed next to treatments for typhoid fever.
If we accept this overlap, then we have a plausible case for the demonic and elven illnesses
which form the bulk of the above table representing illnesses characterized by confusion and
behavioural disturbance. This is likely to include functional psychiatric illness as well as those
where fever is present, and hence it is reasonable to include them when looking at the types of
leechdom that were used to remedy them.

Treatments available
The range of treatments available within the Leechbooks and Lacnunga can be categorized into
three groups. Those with purely physical elements, those that rely solely on supernatural compo-
nents and those that combine both physical and magical aspects.
Purely physical treatments are fewer in number, and involve the concoction of salves or drinks
for use as emetics and purgatives. Some are very straightforward such as in Lacnunga Chapter 73
‘for heaviness of mind, give to eat radish with salt and vinegar, soon the mood will be lighter’, while
others require more and rarer ingredients. A typical example would be Leechbook 1, Chapter 63:

For a fiend sick man, or demoniac, when a devil possesses the man or controls him from within with
disease; a spew drink, or emetic: lupin, bishopwort, henbane, cropleek; pound these together, add ale for a
liquid. Let it stand for a night, add fifty libcorns, or cathartic grains, and holy water.

In these it seems clear that the components are intended to have curative physical properties, even
though the illness is given a demonological origin. The addition of holy water shows that even with
a simple emetic, supernatural and religious elements are very often included. Other remedies were
less humane. Leechbook 3, Chapter 40 explains that: ‘in case a man be a lunatic; take the skin of a
mereswine or porpoise, work it into a whip, swinge (thrash) the man therewith, soon he will be
well’. Although this one instance of beating is recommended in the texts, there are no references to
other forms of punitive measures for the treatment of mental illness. Neither restraint nor confine-
ment of disturbed individuals is mentioned in these books. This is not to say that it did not occur,
simply that there is insufficient evidence of the practical day-to-day management of the mentally
ill to be found in these compilations of treatments.
Purely magical remedies also exist, often in the form of charms and amulets. Charms are words,
songs or incantations that are generally said or sung over the ingredients to imbue them with magical
properties. Amulets are objects which when carried by or placed on the patient have a curative
action. These often take the form of holy words written on parchment, but could be other objects,
usually to be tied around the person’s neck. Examples of amulets in the Leechbooks include using a
live crab amulet to alleviate swollen eyes and a plantain dug up before sunrise to cure a sore throat.
The only clear example of amulet use in psychiatric illness is given in Leechbook 3, Chapter 58, and
is another remedy for one who is suffering from the temptations of the fiend. It suggests: ‘a wort
height of red niolin, which grows by running water. If thou hast it on thee and under thy head bolster
(pillow), and over thy house doors, the devil may not scathe thee, within nor without.’
The most common remedies are those using a combination of elements. A typical example
includes using traditional herbal ingredients but imbuing them with religious significance and
440 History of Psychiatry 22(4)

ritualistic preparation. Using holy water as a base for potions, or having masses and psalms sung
over the medicine appear commonly in the sources. Many remedies require specific prayers such as
the ‘Pater Noster’, ‘Pro Infirmis’ and ‘Contra Tribulationem’ (‘Our Father’, ‘For the sick’ and
‘Against tribulations’) to be sung at different times during the preparation of ingredients, and often
each recipe will have several charms attached to it. There are also often instructions about who
should gather the ingredients, in what manner and at what time of day. Gathering elements from
consecrated sources also features, with moss growing on crosses a common example. The delivery
of the treatments might also be enhanced by magical ritual. Patients could be asked to drink the
mixture from out of a church bell, or have liturgical passages read, and psalms sung while taking the
treatments; certain words or phrases could be incanted while dispensing the medication. One gets a
sense of the solemnity and faith being placed in the expected curative effects of the lecedomas.
A typical example highlighted later in Leechbook 1, Chapter 63, contains the following
instructions:

For the phrenzied; bishopwort, lupin, bonewort, everfern, githrife, elecampane. When day and night divide
then sing thou in the church litanies, that is the names of the hallows or saints, and the Pater Noster. With
the songs go thou that thou mayest be near the worts and go thrice about them, and when thou takest them
go again to church with the same song and sing twelve masses over them, and over all drinks that belong
to the disease, in honour of the twelve apostles.

Interestingly, this implies that the physician will have sufficient knowledge of church practice to
complete the various litanies and prayers required. Does this suggest that the physician is also a
cleric? Perhaps. However, Lacnunga, Chapter 11, describes a similar treatment which allows for
the physician to ‘get masses sung over it’, along with a number of other prayers. This allows for
the possibility that some physicians were members of the laity.

Effectiveness of remedies
Would these treatments have had any curative or alleviating properties for psychiatric illnesses?
For these remedies to find their way into the equivalent of a medical textbook, their use must have
been well established. One might assume some benefits had been achieved by them to justify their
continued inclusion in such compendia. But in an era well before the concept of clinical trials, it is
probable that any reported benefits were based upon anecdotal evidence and tradition, rather than
more rigorous forms of data.
When cataloguing the most common ingredients used to treat psychiatric illnesses in the Leech­
books, we find the frequencies of the 30 most popular elements are as shown in the ‘word cloud’
in Fig. 1. Charms form the most common ‘ingredient’ across all treatments, mainly because of their
use alongside different herbal ingredients and because many recipes call for several different
charms to be used in their preparation. ‘Charm’ in this context includes all types of spoken or sung
elements, such as masses, psalms, prayers and song. Holy water also ranks very highly on this list,
acting as a base for many of the potions. Given this weighting of magical elements, is it conceiv-
able that any benefit derived was simply a form of placebo effect, or would the active elements in
the herbs also have given some symptomatic treatment for the illnesses?

The power of placebo

It seems clear that significant placebo effects would have been produced by these treatments. It was
known in the time of Socrates that saying a charm while taking a remedy was more effective than
Pell 441

Figure 1. Word cloud showing the relative frequencies of ingredients found in treatments for mental
illnesses in the Leechbooks and Lacnunga

using the remedy by itself, and the ability of placebos to effect improvements in symptoms contin-
ues to fascinate physicians today. The modern definition is often given as: ‘A placebo is a
substance or procedure … that is objectively without specific activity for the condition being
treated … The placebo effect is the … therapeutic effect produced by a placebo.’ (Moerman and
Jonas, 2002). In a review of the placebo effect in alternative medicine, Kaptchuk (2002) identified
five factors that could enhance the effectiveness of placebo treatments, as summarized in Table 2
(Kaptchuk, 2002).
Many of the treatments described in the Anglo-Saxon texts contain elements that would have
greatly enhanced the placebo response. A theological and spiritual framework that allowed for the
direct and personal intervention of Christian powers was shared by both patient and physician.
Ritual elements such as incanting and scribing holy words and phrases both during the preparation
of the medicine and during its dispensing to the patient would have served to further convince
those involved of its healing properties. Many such words and phrases served to promote the expec-
tation of a cure, giving direct assurances that the treatment would be effective. Invoking the power
of Christ to expel illness or calling on the protection of particular saints or requiring the patient to
attend church services again harness these beliefs. Patients may also have been convinced by the
elaborate nature of the treatments, and by the fact that they probably had to pay for the services of
the doctor.
The physician too was minded from the texts that these were tried and tested remedies. For
example, Leechbook 3, Chapter 62, tells how ‘this craft is very powerful against every tempta-
tion of the fiend’. Even the stock phrase: ‘him biđ sona sel’ or ‘he biđ sona hal’ which serves
as a closing remark for many leechdoms contained assurances that the patient would ‘soon be
well’ or ‘soon be healthy’. The physician may have held the leechdoms in high regard, thereby
enhancing his own confidence that the remedies would be successful, and boosting the placebo
responses obtained. This could perhaps have set up a positive feedback cycle, in that the better
a response he obtained, the more faith he had in his craft when treating the next patient. This in
442 History of Psychiatry 22(4)

Table 2.  Summary of factors influencing the placebo effect, adapted from Kaptchuk (2002)

Factor
Patient characteristics
 
 
 
 
 
Physician characteristics
 
 
Patient-physician interaction
 
 
Nature of the illness
 
 
 
Treatment and setting
 
 
 
 
Details
Patient expectations of a cure
Belief in the treatment
Patient preference and choice
Belief in benevolent forces at work
Lack of faith in other treatments in chronic conditions
Commitment to the treatment, e.g. requiring patient to pay,
daily lifestyle regimens
Optimistic or enthusiastic
Gives positive information about the treatment
Belief in the treatment
Mutually credible beliefs in treatment and illness models
Clear diagnosis
Assurance of recovery
Highly subjective symptoms
Few physical signs
Chronic and fluctuant conditions
Self-limiting (or episodic) illness
Frequency of dosage
‘Brand-name’ therapy
Active effects (i.e. causes noticeable side effects)
Use of mystery in explaining effects
Active engagement in therapy

turn would improve his reputation and status as a gifted healer, and further increase patient
confidence in his abilities.
The psychiatric illnesses in question have characteristics matching several of the factors detailed
in Table 2. Few objective physical signs and relapsing-remitting natural histories are the hallmark of
many mental illnesses. These types of illness have been shown in modern times to respond partially
to placebo treatments, so similar improvements may have been seen in Anglo-Saxon times.
Finally the treatments themselves and the setting in which they were employed might have
worked to increase the placebo effects obtained. Some treatments involved the giving of regular
drinks or applying salves which had been endorsed by learned earlier doctors such as Oxa and Dun,
and which contained herbal components that would have caused physical effects. Appeals were
also made to the mysteries of the Christian faith, and the patient and his family were actively
engaged in the therapy through joining in with the saying of charms or the singing of psalms. All
these factors share similarities with the findings of Kaptchuk.

Active herbal ingredients

While the placebo function of these treatments is significant, most contained a mixture of magical
and herbal elements. Could there have been any active treatment effects from the physical ingredi-
ents used to formulate the remedies? We know that some herbs can function in similar ways to
modern psychotropic drugs. St John’s wort (Hypericum perforatum), a plant with antidepressant
Pell 443

effectiveness similar to selective serotonin reuptake inhibitor medications, is probably the best
known example (Linde, Berner and Kriston, 2008). Additionally, many modern anti-dementia
drugs, the acetylcholine-esterase inhibitors, are ultimately derived from chemicals found in snow-
drops and daffodils (Amaryllis spp.). Did any of the remedies contained in the Leechbooks include
ingredients that are now known to have medicinal effects?
The identification of plant names has been aided by the preservation and translation into Old
English of early medical herbal catalogues such as the Herbarium Pseudo-Appuleius. This fourth-
century Roman text is included in Cockayne’s (1864) work and forms part of a long tradition of her-
baria which yield translations from Old English through to modern botanical names. Although herbaria
contain descriptions and illustrations of some of the plants described, other species have been more
difficult to identify. Online resources drawing on many Anglo-Saxon texts are therefore underway
using multiple primary sources to catalogue and translate more accurately the plants listed in the his-
torical texts into their current Latin taxonomic names (Bierbaumer et al., 2007; Biggam, 1999).
Similarly, modern herbal texts bring together the putative medicinal effects of plants and
describe their usage in herbal practice (Grieve, 1931). For some species, work has been taken
further through surveys of the chemical components of traditional medicinal plants. Some stud-
ies have focused on mining historical herbal texts to identify plant sources with the potential for
yielding novel pharmacological compounds. Through these efforts, more rigorous scientific
research into the pharmacological effects of specific plant chemicals that are most likely to have
biological effects on humans can be conducted (Buenz et al., 2004; Pengelly, 2004). For the
purposes of the present study, these various strands of research enable us to tabulate the pur-
ported medicinal properties of herbs used in Anglo-Saxon England for treating psychiatric prob-
lems; see Table 3.
Despite this renewed research interest, plant-derived treatments for psychiatric illness generally
lack any strong evidence base. Often only anecdotal accounts and tradition are used to justify the
continued use of these treatments. Carefully designed trials with randomization and placebo con-
trol for the plants used in these texts are still lacking, and it is not possible to comment with any
certainty on the effects of remedies prescribed and administered by tenth-century physicians. The
picture is further clouded by the absence of knowledge about the specific active chemicals con-
tained within the plants, and the possibility of synergism between the separate herbal ingredients
used in the decoctions. Where systematic reviews have been performed for herbal treatments of
psychiatric disorder, there has been no strong evidence for any of the plants detailed in the
Leechbooks (Gardner, 2002; Morgan and Jorm, 2008).
Further difficulties arise in that even the properties of the plants used in herbal practice appear
to be unrelated to psychiatric treatment. Diuresis, diaphoresis, expectoration and purgation awaited
those who were prescribed many of these remedies. Although this may have enhanced the placebo
effect by convincing the patient and physician that the herbs were physiologically active, they are
unlikely to have modified any of the major psychiatric illnesses.
Some reported effects of the remedies do have plausible roles in the management of psychiatric
disturbance. Several plants including Solanum and Stachys spp. are held to effect sedation and
narcosis which could reduce agitation caused by psychiatric symptoms. Solanum has been investi-
gated and shown to cause central nervous system depression in one animal study (Perez, Perez,
Garcia and Sossa, 1998). Rue, elecampane, wormwood and Allium species are held to be stimulant
or tonic with a plausible role in improving energy levels. However, the most useful effects could
be to alleviate pyrexia and pain. In an age where infectious disease was rife, delirium must have
been commonplace. The antipyrexial, analgesic and anti-inflammatory properties of plants such as
Alliums, wormwood, hind heal, gallium and the like, may have helped to ameliorate the psychiatric
symptoms associated with delirium.
444 History of Psychiatry 22(4)

Table 3. Translation and medicinal properties of Old English plant names found in the treatments for
mental illness described in the Leechbooks and Lacnunga

Old English Modern English Latin taxonomic Traditionally reported medicinal properties
Ælfþone bittersweet Solanum dulcamara alterative; anodyne; cancer; depurative;
nightshade diuretic; emetic; expectorant; hepatic;
narcotic; purgative
Alexandran alexanders Smyrnium olusatrum bitter; digestive
Attorlaþe ?cyclamen ?Cyclamen purpurascens emetic; purgative
  ?black nightshade ?Solanum nigrum antiperiodic; antiphlogistic; diaphoretic;
diuretic; emollient; febrifuge; narcotic;
purgative; sedative
  ?betony ?Stachys officinalis see below
Betonice betony Stachys officinalis anthelmintic; antiseptic; astringent;
carminative; cathartic; cholagogue; digestive;
diuretic; emetic; emmenagogue; expectorant;
nervine; sedative; sternutatory; tonic;
vulnerary
Bishopwort betony ?Stachys officinalis see above
  marsh mallow ?Althaea officinalis anti-inflammatory, antitussive; demulcent;
diuretic; emollient; laxative; odontalgic
Cassuc tussock grass ?Deschampsia cespitosa not known
Cropleac ?common leek Allium spp. antimicrobial, aphrodisiac, diaphoretic,
diuretic, expectorant, stimulant
Elehtre lupins Lupinus spp. antihelmintic, diuretic, emmenagogue, topical
anti-inflamatory
Finol fennel Foeniculum vulgare antispasmodic, analgesic, anti-inflammatory
Garleac garlic Allium sativum anthelmintic; antiasthmatic;
anticholesterolemic; antiseptic;
antispasmodic; cancer; cholagogue;
diaphoretic; diuretic; expectorant;
febrifuge; stimulant; stings; stomachic; tonic;
vasodilator
Gearwe yarrow Achillea millefolium anti-inflammatory; antiseptic; antispasmodic;
aromatic; astringent; carminative; cholagogue;
diaphoretic; digestive; emmenagogue;
odontalgic; stimulant; tonic; vasodilator;
vulnerary
Githrife corn cockle Agrostemma githago considered a cure for dropsy and jaundice;
diuretic; expectorant; vermifuge
Haran viper’s bugloss Echium vulgaris antianxiety; antidepressant; antitussive;
sprecel aphrodisiac; demulcent; diaphoretic; diuretic;
emollient; pectoral; vulnerary
Hedgerife clivers / Galium aparine alterative; antiphlogistic; aperient;
goosegrass astringent; cancer; depurative; diaphoretic;
diuretic; febrifuge; sedative; skin; tonic;
vulnerary
heoloþe elecampane Inula helenium diuretic, tonic, diaphoretic, expectorant,
alterative, antiseptic, astringent,
stimulant

(continued)
Pell 445

Table 3 (continued)
Old English Modern English Latin taxonomic Traditionally reported medicinal properties
Hind hindheal Eupatorium cannabinum alterative; antitumor; cholagogue; depurative;
heoloþe diaphoretic; diuretic; emetic; expectorant;
febrifuge; laxative; purgative; tonic
Lybcorn spurge/milkwort Euphorbia lathyris abortifacient; antiseptic; cancer; diuretic;
emetic; purgative; vulnerary, warts
MageÞe chamomile Chamaemelum nobile anodyne, anti-inflammatory, antispasmodic,
nervine, stomachic, tonic, vasodilator
Rude common rue Ruta graveolens abortifactant, anthelmintic, antidote,
antispasmodic, carminative, emetic,
emmenagogue, expectorant, haemostatic,
ophthalmic, rubefacient, stimulant, stomachic;
uterotonic
Wermod wormwood Artemisia absinthium anthelmintic, anti-inflammatory, antiseptic,
antispasmodic, antitumor, carminative,
cholagogue, emmenagogue, febrifuge,
hypnotic, stimulant, stomachic, tonic;
vermifuge

Overall there is simply insufficient evidence to comment on whether these putative claims for
the medicinal properties of the plants are true. Further research into the efficacy of the plants used
by Anglo-Saxon physicians is needed before any conclusions can be drawn. This would have to
include adequately powered, well-designed, randomized and placebo-controlled trials of the plants
and concoctions described.

Conclusion
The Leechbooks and Lacnunga complied and translated by Cockayne offer a rare glimpse into the
lives of patients and physicians living in the Anglo-Saxon era. The modern reader is presented with
many problems in the accurate translation of the medical terms used, but it appears that psychiatric
illness was recognized by the authors of the Leechbooks. Moreover, it was recognized that treatments
were required, and that remedies were available specifically to treat the symptoms of several such
maladies. The belief in the role of ælfs and demons as the causative agents of these illnesses is sug-
gested, and many treatments contain magical elements designed to exorcise these malign entities.
As to the effectiveness of the leechdoms prescribed, a shared cultural belief in the ability of
supernatural entities to affect illness and strong commitments to the treatment from both patient
and physician would have enhanced their placebo effects. This may have given the impression of
improvement or cure in many episodic mental illnesses. Many of the non-magical treatments used
would have had effects upon the patient, but this is likely to have been a nocebo effect as many
caused vomiting or had laxative effects. There is insufficient evidence to comment on any benefi-
cial or disease-modifying effects of the herbs used in the leechdoms, as high-quality randomized
controlled studies investigating these have yet to be conducted. Further research is needed to iden-
tify accurately all the plants used in Anglo-Saxon treatments and to validate their traditionally
reported medicinal claims against placebo.
The Anglo-Saxon doctor had a clear range of skills, from the identification of signs and symp-
toms to the diagnosis and treatment of illness. He would have required knowledge to identify the
446 History of Psychiatry 22(4)

correct medicinal plants, and practical skills in the preparation and administration of the remedies
concocted from them. Whether a member of the clergy or laity, he would also have needed a
knowledge of scripture and church practices in order to prepare the treatments described.
The Leechbooks and Lacnunga provide the instructions to prepare and dispense treatments, but
perhaps the real value of these early medical textbooks lay in the clear and confident message that
treatments did exist. They inspire hope that illness can be treated, in an age when mortality rates
were high and knowledge of the causes of disease were extremely rudimentary. The Leechbooks
allowed physicians to provide a variety of well-established treatments that combined both lay trad­
ition, classical medical wisdom, spiritual care and psychological elements to achieve synergistic
benefits for the patient. Perhaps this is not so different from our basic approach more than a mil-
lennium later in our synergistic use of physical treatments alongside a psychological or psycho-
therapeutic approach to help our patients achieve the best possible recovery.

Notes
1 Pronunciation: Æ/æ (‘ash’): ‘a’ as in cat; Þ/þ (‘thorn’) and Ð/đ (‘eth’): both used to stand for ‘th’ as in
three when at the beginning or end of a word, and ‘th’ as in brother when in the middle of a word.
2 Anon (n.d.), translated by Seamus Heaney (2000) as: ‘So. The Spear-Danes in days gone by and the kings
who ruled them had courage and greatness. We have heard of those princes’ heroic campaigns.’
3 Dictionaries page on website for Old English Made Easy. Retrieved (8 Dec. 2009) from: http://home.
comcast.net/~modean52/oeme_dictionaries.htm

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