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Pain, poison, and surgery in fourteenth-century China

Yi-Li Wu

It’s hard to set a compound fracture when the patient is in so much pain that he won’t let you touch him. For such situations, the Chinese doctor Wei Yilin (1277-1347) recommended giving the patient a dose of “numbing medicine” (ma yao).  This would make him “fall into a stupor,” after which the doctor could carry out the needed surgical procedures: “using a knife to cut open [flesh], or using scissors to cut away the sharp ends of bone.” Numbing medicine was also useful when extracting arrowheads from bones, Wei said, enabling the practitioner to “use iron tongs to pull it out, or use an auger to bore open [the bone] and thus extract it.” More generally, Wei recommended using numbing medicines for all fractures and dislocation, for it would allow the doctor to manipulate the patient’s body at will.

Wei’s preferred numbing medicine was “Wild Aconite Powder” (cao wu san), and he detailed the recipe in his influential compendium, Efficacious Formulas of a Hereditary Medical Family (Shiyi dexiao fang), completed in 1337 and printed by the Imperial Medical Academy of the Yuan dynasty (1271-1368). In his preface, Wei affirmed that medical formulas were the foundation of medicine and that a doctor’s ability to cure depended on his ability to use these tools skillfully. Wei’s family had practiced medicine for five generations, and he synthesized their knowledge with that of other doctors to produce a comprehensive treatise encompassing internal medicine; the diseases of women and children; eye diseases; illnesses of the mouth, teeth, and throat; ulcers and swellings; and diseases caused by invasions of “wind” (ailments with sudden onset, including febrile epidemics and paralytic strokes). Numbing medicine appeared in Wei’s chapters on bone setting and weapon wounds.

Wei’s Wild Aconite Powder is the earliest datable recipe that I have found for surgical anesthesia in a Chinese text, and it is a valuable window onto practices that were largely transmitted orally, whether in medical families or from master to disciple.  Dynastic histories relate that the legendary doctor Hua Tuo (110-207) employed a formula called mafeisan  to render his patients insensible prior to cutting them, even opening up their abdomens to excise rotting flesh and noxious accumulations. Some scholars have hypothesized that mafeisan (literally “hemp-boil-powder) may have contained morphine or cannabis (ma), but its ingredients remain a mystery.  A text attributed to the twelfth-century physician Dou Cai (ca. 1146) recommended using a mixture of powdered cannabis and datura flowers (shan qie zi, also called man tuo luo hua) to put patients to sleep prior to moxibustion treatments, which in this text could involve a hundred or more cones of burning mugwort placed directly on the patient’s skin.  Wei Yilin’s recipe provides important additional textual evidence for a tradition of anesthetic formulas based on toxic plants, one that was clearly in circulation long before he wrote it down.

At least as far back as the Divine Farmer’s Classic of Materia Medica (3rd c.), medical authors had described aconite as highly toxic (for contemporary Roman views of aconite, see blogpost by Molly Jones-Lewis). In the right hands, however, aconite was a powerful drug, and part of the Chinese practice of using poisons to cure (see blogpost by Yan Liu).  Warm and acrid, aconite could drive out pathogenic wind and cold from the body, break up stagnant accumulations, and invigorate the body’s vitalities. In the language of Chinese yin-yang cosmology, it nourished yang—all that was active, heating, external, and ascending. The main aconite root was considered more toxic than the subsidiary roots (designated by the separate name fu zi, “appended offspring”), and the wild form was more potent than the cultivated variety.

Images of toxic medicinal plants from China’s most celebrated pharmacological work, Li Shizhen (1518-93), Compendium of Materia Medica (author’s preface dated 1590). Woodblock edition of 1603. Wild aconite is the middle image in the top row. Cultivated aconite (main and subsidiary roots) are in the bottom right corner. Image credit: National Library of China. Posted on-line at the World Digital Library.
Images of toxic medicinal plants from China’s most celebrated pharmacological work, Li Shizhen (1518-93), Compendium of Materia Medica (author’s preface dated 1590). Woodblock edition of 1603. Wild aconite is the middle image in the top row. Cultivated aconite (main and subsidiary roots) are in the bottom right corner. Image credit: National Library of China. Posted on-line at the World Digital Library.

Wei’s numbing recipe consisted of 13 plant ingredients, including the main roots of both wild and cultivated (Sichuanese) aconite, along with drugs known as good for treating wounds:

Young fruit of the honey locust (zhu yao zao jiao)
Momordica seeds (mu bie zi)
Tripterygium (zi jin pi)
Dahurian angelica (bai zhi)
Pinellia (ban xia)
Lindera (wu yao)
Sichuanese lovage (chuan xiong)
Aralia (tu dang gui)
Sichuanese aconite (chuan wu)
Five taels each[1]

Star anise (bo shang hui xiang)
“Sit-grasp” plant (zuo ru), simmered in wine until hot
Wild aconite (cao wu)
Two taels each

Costus (mu xiang), three mace

Combine the above ingredients. Without pre-roasting, make into a powder. In all cases of crushed or broken or dislocated bones, use two mace, mixed into high quality red liquor.

Wei most likely learned this formula from his great-uncle Zimei, a specialist in bonesetting and wounds. Its local origins are also suggested by its use of zuo ru, literally “sit-grasp”, a toxic plant whose botanical identity is unclear. However, according to the eighteenth-century Gazetteer of Jiangxi (Jiangxi tong zhi), sit-grasp was native to Jiangxi, Wei’s home province, and was used by indigenes to treat injuries from blows and falls.  While classical pharmacology focused on the curative effects of aconite, Wei’s anesthetic relied on aconite’s ability to stupefy and numb, while curbing its ability to kill. If an initial dose failed to make the patient go under, Wei said, the doctor could carefully administer additional doses of wild aconite, sit-grasp herb and the datura flower.

Additional images of toxic medicinal plants from Li Shizhen, Compendium of Materia Medica. Sit-grasp herb is in the middle of the top row, and datura flower in the middle of the bottom. Image credit: National Library of China. Posted on-line at the World Digital Library.
Additional images of toxic medicinal plants from Li Shizhen, Compendium of Materia Medica. Sit-grasp herb is in the middle of the top row, and datura flower in the middle of the bottom. Image credit: National Library of China. Posted on-line at the World Digital Library.

In subsequent centuries, as medical texts proliferated, we find additional examples of numbing medicines that employed aconite, datura, and other toxic plants, employed when setting bones and draining abscesses, and to numb injured flesh before repairing tears and lacerations to ears, noses, lips, and scrotums.  Such manual and surgical therapies are an integral part of the history of healing in China.

Yi-Li Wu is a Center Associate of the Lieberthal-Rogel Center for Chinese Studies at the University of Michigan, Ann Arbor (US) and an affiliated researcher of EASTmedicine, University of Westminster, London (UK).  She earned a Ph.D. in history from Yale University and was previously a history professor at Albion College (USA) for 13 years.  Her publications include Reproducing Women: Medicine, Metaphor, and Childbirth in Late Imperial China (University of California Press, 2010) and articles on medical illustration, forensic medicine, and Chinese views of Western anatomical science.  She is currently completing a book on the history of wound medicine in China.

Acknowledgements
This research was funded by the Wellcome Trust Medical Humanities Award “Beyond Tradition: Ways of Knowing and Styles of Practice in East Asian Medicines, 1000 to the present” (097918/Z/11/Z). I am also grateful to Lorraine Wilcox for directing me to the work of Dou Cai.

*****

[1] The weight of the tael (Ch. liang) has varied over time, but during Wei’s lifetime would have been equivalent to 40 grams.  A mace (Ch. qian) is one-tenth of a tael.

Living in Seasons: Mulberry Wine, or the Moral Perils of Recipes in Times of Austerity

By He Bian

April and May on the US east coast = temperature swings = confusing and sickly weather. This year especially reminds me of the sobering admonition from the ancient Chinese classic of medicine, <The Yellow Emperor’s Inner Canon>: “when there is damage from cold in winter, one suffers from warm diseases in spring (Dong shang yu han, chun bi bing wen)” (see Marta Hanson’s insightful book on this subject). Seasonality is well known as a central preoccupation in the Chinese medical tradition: the cosmic resonance of the body and the larger world according to the quadruple division of the solar year – the cyclic fluctuation of temperature, directionality of wind, and the loci of corporal vulnerability that furnished essential cues for a master practitioner of medicine.

But if etiology in Chinese medicine is classically understood as seasonal, surely the therapeutics should also follow a seasonal rhythm? To my surprise, a search for pre-modern monographs that contain the keyword “four seasons” (sishi) yielded few results. In addition, they tend to focus on agriculture (which of course also follows a seasonal rhythm) or popular festivities around the year. I decide to take a closer look at the latest text that featured “four seasons” in its title – a title attributed to Qu You (1341-1427), Si shi yi ji (Auspicious and Inauspicious Deeds in Four Seasons). I thought this text might teach me something about how a learned scholar approached the notion of seasonality in the early fifteenth century, and how that might align or depart from the canonical medical model of seasonality.

The book consists of twelve chapters, each describing the dos and don’ts for a specific month. I flipped to the chapter on the fourth month (which corresponded roughly to this present moment in Western calendar). I learned, to my surprise and delight, a ton of practical advice with specific recipes: how to properly dry and insulate book and painting cases before the advent of rainy season; “use eels that have been sun-dried, burn them inside the house to thwart the thirst of mosquitoes” (seems appropriate for New Jersey habitat); “wrap your battle gears along with Sichuanese peppers (huajiao) or powder of Daphne flowers (yuanhua) to prevent worm damage… wrap windshield collars and earmuffs and store them in a vat, tightly seal it up, so as the fur will not fall off.” After the first full moon this month, one “should drink mulberry wine” to prevent “wind heat” illnesses (see Shigehisa Kuriyama’s discussion of wind in classical Chinese and Greek medicines). The recipe goes as follows:

Use Mulberries, get its juice of three dou (1 dou ~ 18 liter). White Honey four ounces (liang); Butter (suyou) one ounce; raw ginger juice two ounces.

Bring mulberry juice to a boil in a pot, and reduce its volume to three sheng (1 sheng = 1/10 dou), and then add honey, butter, and ginger juice. Add three drachm (qian) of salt and keep boiling till the texture is thick.

Store in porcelain utensils. Each time, take a small cup with wine. This effectively cures various wind-induced illnesses.

Not only does this sound completely delicious and doable to me, I also realize how recipes like this are in fact completely grounded in the seasonal rhythm of biological life (I just saw a friend posting the harvest of fresh mulberries in her backyard in China).

In sum, what Qu You did in this book was to cull from a wide range of medical and non-medical sources (a rough count yielded over 60 different titles) for hints and tips on how to live according to the seasons. Some of his references were archaic almanacs that offered divinations on the most auspicious dates to travel, have sex, trim your nails, or remove grey hair, as well as dates one should abstain from such activities. Some were quasi-ethnographic accounts of “customs” (fengsu) in ancient cities that still lend to a viable reading as practical guides to festivities. Still others draw from esoteric Daoist literature on the preservation of vital essence (I have blogged on a related topic here), a decision on Qu You’s part that raised many eyebrows both during his lifetime as well as centuries later.

A Daoist talisman in Qu You, Si shi yi ji (1920 reprint of an 1836 edition).

We must remember that Qu lived through the Ming dynasty’s founder, Hongwu emperor’s reign (1368-1398) – a period known for its austere message of moral purity and simplicity. His fourth son, who usurped the throne shortly after Hongwu’s death to become the Yongle emperor (r. 1404-1424), was not exactly friend of the letters either. Those were not easy times for a literary aficionado with keen interests in morally dubious subjects, and yet Qu You continued to compose and comment on poetry, wrote short stories featuring ghosts and women, and collected esoteric recipes. He even managed to publish those works, prefacing them with loud self-defense of his moral stature. Qu eventually got into trouble, endured decades of exile in the north, and yet again outlived the Yongle emperor, who threw many a undisciplined scholars like him into jail, by three years.

Perhaps the seasonal recipes did work well for him after all?

Transmission of drug knowledge in medieval China: A case of Gelsemium

By Yan Liu

Figure 1. Illustration of gouwen (Gelsemium) in an early sixteenth-century materia medica text (Bencao pinhui jingyao, 1505). Image from Zhonghua dadian, ed. Zheng Jinsheng, 2008.
Figure 1. Illustration of gouwen (Gelsemium) in an early sixteenth-century materia medica text (Bencao pinhui jingyao, 1505). Image from Zhonghua dadian, ed. Zheng Jinsheng, 2008.

One striking feature of classical Chinese pharmacology is the abundant use of toxic substances. Prominent examples are aconite, arsenic, and bezoar. Fully aware of the toxicity, or du, of these materials, Chinese doctors developed a variety of methods to prepare and deploy them for therapy. How was such knowledge produced in traditional China? And how did it migrate from one space to another? Here I use several medical documents from the seventh century to explore these questions, focusing on gouwen 鈎吻 (Gelsemium), a toxic herb growing in southern China (Fig. 1).

The seventh century is a crucial moment in the history of Chinese medicine. The favorable political environment of early Tang dynasty (618-755) fostered the flourishing of medical ideas and the formation of a number of influential texts. One of them is the Newly Revised Materia Medica (Xinxiu bencao 新修本草, 659), the first state-sponsored pharmacopeia produced in China. Compiled by more than twenty court scholars, the text reflects the government’s effort to standardize medical knowledge. Gelsemium is one of the 850 drugs in the book (Fig. 2). Defined as warming, pungent, and highly toxic, the root of the herb could cure, among others, wounds inflicted by metal weapons ulcers, swelling, and convulsion. The authors also stressed the great danger of the herb by showing that drips squeezed from one or two leaves would suffice to kill a person. But not a goat. Quite the contrary, its sprouts could make the animal grow large. It must be, the authors mused, the case that everything in the world submits to something else.

Figure 2. The entry of gouwen (Gelsemium) in the Newly Revised Materia Medica (659). This copy of the text is from Dunhuang (P. 3714), dated to 667. Image courtesy of Bibliothèque nationale de France (Gallica).
Figure 2. The entry of gouwen (Gelsemium) in the Newly Revised Materia Medica (659).
This copy of the text is from Dunhuang (P. 3714), dated to 667. Image courtesy of Bibliothèque nationale de France (Gallica).

Gelsemium was also embraced by contemporary doctors. Sun Simiao 孫思邈 (?-682), one of the most famous doctors in Chinese history, incorporated the drug into his Essential Recipes of A Thousand Gold Worth (Qianjin yaofang 千金要方, mid-seventh century). The toxic herb appears in nineteen prescriptions in the text, primarily for topical treatment. In one case, Sun presented a recipe called “Ointment of Gelsemium” to treat toxic swelling, pain and numbness in the limbs, ulcers, weak feet, among other conditions. At the end, Sun warned: “This recipe should not be given to vulgar people. Be cautious.”

Why did Sun keep the recipe away from vulgar people, a term referring to commoners? Two possible reasons. First, handling Gelsemium was a delicate matter. Due to its high toxicity, any misuse of the herb could result in devastating, if not lethal, consequences. Commoners may not possess the proper knowledge of deploying the herb, hence they should refrain from taking this recipe. Second, because Gelsemium straddled medicine and poison, laymen might easily use it to harm others. By restricting its access, Sun tried to prevent such malicious misuse. Contemporary sources echoed Sun’s concern. According to an eighth-century statute of medical practice, private families were forbidden to possess Gelsemium. The government tightly controlled the access of the toxic herb to prevent it from falling into the wrong hands.

Figure 3. Gelsemium root preserved in the house of Shosoin in the Todaiji  Temple in Nara, dated to the eighth century. The roots are 0.5-2.0 cm in diameter and 17-24 cm in length. Image courtesy of the Imperial Household Agency website.
Figure 3. Gelsemium root preserved in the house of Shosoin in the Todaiji
Temple in Nara, dated to the eighth century. The roots are 0.5-2.0 cm in diameter and 17-24 cm in length. Image courtesy of the Imperial Household Agency website.

This begs the question whether the plant was actually used as a medicine. At the high level of the society, this is likely the case. The evidence came from a precious collection of medicines preserved in the Todaiji Temple in Nara , donated by the Empress Dowager Komyo in 756 as a gesture of benevolence. Because of the vibrant cultural interaction between China and Japan at the time, many drugs of Chinese origin travelled eastward. Gelsemium was one of them (Fig. 3). It is possible that the herb reached Japan as an item of exchange between the two imperial courts that appreciated its medicinal value.

Figure 4. Drug substitution in a seventh-century manuscript from Dunhuang (P. 3731). The recipe of the “Ointment of Illicium” is highlighted by the blue box. The arrow points to the note, written in small characters, that specifies the substitution of Phytolacca for Gelsemium. Image courtesy of Bibliothèque nationale de France (Gallica).
Figure 4. Drug substitution in a seventh-century manuscript from Dunhuang (P. 3731). The recipe of the “Ointment of Illicium” is highlighted by the blue box. The arrow points to the note, written in small characters, that specifies the substitution of Phytolacca for Gelsemium. Image courtesy of Bibliothèque nationale de France (Gallica).

In the local community, the situation is different. We get a clue from a seventh-century manuscript from Dunhuang, a town located in the far west of the Tang Empire on the Silk Road. The manuscript contains miscellaneous recipes, many for external application. One, called “Ointment of Illicium,” merits our attention (Fig. 4). It closely resembles Sun Simiao’s recipe that I showed above, but with an important variation: it doesn’t use Gelsemium. Underneath the ingredient Phytolacca (danglu 當陸), we find an explanation: “The original recipe uses Gelsemium. Nowadays it cannot be obtained, so one uses Phytolacca to replace it.” We can posit why this happened, given Gelsemium’s habitat in southern China, that is, far away from Dunhuang and its restricted access to commoners, as explained earlier. By contrast, Phytolacca was a local herb whose medical function substantially overlapped with that of Gelsemium, making it a reasonable substitute for the distant, unattainable plant.

This example of drug substitution is telling. Compared to social elites, lay people in local communities faced the challenge of limited medical resources. Consequently, they sought alternative options. The rise of authoritative texts at the imperial center thus went hand in hand with its fluid transformation as it moved in various geographical and social domains. Medical knowledge, upon transmission, was destabilized, begetting varied practices in society.

Situating Drug Knowledge in China: A Digital Humanities Solution

By Michael Stanley-Baker

Mandala of Medicine Buddha surrounded by medicinal plants, animals and minerals
Mandala of Medicine Buddha surrounded by medicinal plants, animals and minerals – Blue Beryl Thangka reproduction, author’s collection

Drugs, be they plant, animal or mineral, were important objects for trade, cure and even spiritual salvation throughout Chinese history even until today.  They appear in all sorts of diverse sources, from poems and diaries to scriptures, pharmacopoeias and recipe books. The historical record for the early imperial period (221 BCE – 589 CE) indicates that the majority of health care was provided by religious specialists– Daoists, Buddhists and mediums–and that doctors were in a very small minority.

Knowledge of a particular signature drug could mark a certain group’s identity, forming a means through which they showed their own therapeutic knowledge, while also distinguishing them from other players in the medico-religious marketplace. Knowledge of what drugs did, and access to them, either through physical access in the regions from which came, or through knowledge of how to identify them, could play an important part in religious identity.

Thus, simply having a drug “name” leaves a lot untold.  Unifying projects, like state-sponsored pharmacopoeias, as well as modern botanical dictionaries that make equations between traditional Chinese names and modern botanical identities, do a lot to conceal the diverse processes by which drugs circulated in pre-modern China.  Substitution, modification and the use of alternate names were common practices in this period (and still are today). The geographic origins of a plant or animal product also had an impact on its efficacy, and also on the fact that it could under different names in different regions.

However, the history of Chinese pharmacology has largely been devoted to tracking changes in different pharmacopoeic editions over time–the editorial staff on each project, increases in quantities of drugs, and development of plant knowledge, such as the identification of new species or sub-species of plants.  This approach works within the normative limits of the state-recognized and medically authorised knowledge, but studies outside of this domain are largely limited to anecdotal stories of Daoists revealing isolated recipes, or Buddhists providing healing to the laity. There have been few overall, systematic studies of drug lore in other domains – like the Buddhist or Daoist canons, for example. To what extent does the data in the Daoist canon back up the anecdotal claim that Daoists were the major stake-holders in early drug lore?  Which sects, in which periods and times, were most active in drug lore, and were they actively competing with other sects from the same time and places?

This image plots out the locations described for 36 drugs in the Daoist text, the Zhen'gao 真誥 DZ 1016.
This image plots out the locations described for 36 drugs in the Daoist text, the Zhen’gao 真誥 DZ 1016.

At the Max Planck Institute for the History of Science, Shi-Pei Chen and I are developing a digital solution to help answer such questions. This will better situate early Chinese drug knowledge within the multiple contexts, times and places in which drugs took on new meanings and interpretations. We will expand the study of Chinese drug lore into what has normally been considered “religious” literature, and perform a variety of analyses on digital transcriptions of early materia medica. A detailed description of this project can be found here.

We are considering the following open access repositories for transcribed, digital editions of the Buddhist  (see the repository here) and Daoist canons. We will do statistical analysis of the texts in the Daoist and Buddhist canons to establish the frequency of drug terms in the texts, to see how much of the pharmacopoeia figured for these actors. Based on general metadata about those texts (as available/reliable), such as date (or date range) and place of composition, author or sectarian affiliation, we can better analyse the circulation of drug lore across time, space and community.  Using GIS place name authority databases (CHGIS, CCTS and DDBC) we will associate historical place names with GIS points.  This will enable us to use time-space displays to show the distribution of drug knowledge across time and space (we are considering PLATIN, see sample applications here).

This image plots out the locations for the same 36 drugs, as they appear in the Bencao jing jizhu 本草經集注. Both texts were edited by the same person, Tao Hongjing 陶弘景, between 492 and 500.
This image plots out the locations for the same 36 drugs, as they appear in the Bencao jing jizhu 本草經集注. Both texts were edited by the same person, Tao Hongjing 陶弘景, between 492 and 500. – Both maps were made with QGIS, and appear in Stanley-Baker, 2013, p. 172.

We will then select interesting or important texts for closer study, and use an automated text-marking system, MARKUS, to markup individual texts in detail. We will focus initially on DRUG NAMES, DRUG FUNCTIONS, LOCATION NAMES, and PEOPLE. This will enable us to compare regional associations about drugs in Daoist and Buddhist texts against those in the pharmacopoeic tradition. For example, whether and how recipes vary across texts, whether the same places are identified as centres for drug supply or transcendent use, which drugs or sets of drugs circulated through which communities.

The pilot study is limited to the Six Dynasties period (220-589), a time which had the most formative influence on religious institutions, and the conclusion of which saw the establishment of the first imperial medical academy.  In later stages of the project, we hope to invite scholars working in other periods, regions, and languages to collaborate with us.  If there is enough interest from the medical history community, perhaps together we could create a research infrastructure to study drugs across the pre-modern world.  If you would like to join this venture in its future stages, please contact us!

References Cited:
Stanley-Baker, Michael. 2013, Daoists and Doctors: The Role of Medicine in Six Dynasties Shangqing Daoism PhD Thesis, London: University College London.