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.

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[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.

Dr. Crawford Long’s Remedy for Insect Bites – Another Use for Ether

By: Michelle DiMeo

On May 20, 1847, Dr. Crawford W. Long was called to see a child residing 6 miles outside of Jefferson, Georgia, who had been bitten by an insect four hours earlier. He was at least 100 yards away when he “distinctly heard her screams”. The child was in extreme pain and suffering from various symptoms, including stomach cramps, difficulty breathing, chest pain, and muscle spasms in the abdomen. The family had given her “about half pint of brandy … two portions of sen[e]ka snake root boiled in ^sweet^ milk and … two teaspoons full of Aqua ammonia, but all without the least benefit”. Dr. Long administered “eighty drops Tinct Opii, a teaspoonful of Hoffmans Anodyne, and the application of the strong Aqua ammonia on a pledget of cloth to the bitten part and retaining it until vesication was produced”. After seeing some improvement, he continued with doses of Hoffman’s Anodyne and the Tincture of Opium in thirty minute intervals, noting the patient was “greatly relieved”.[1]

Hoffman's Anodyne
With Permission from www.SureCureAntiques.com

The preferred remedy, primarily a combination of Hoffman’s Anodyne and opium tincture, worked as an anti-spasmodic and a pain-killer. Hoffman’s Anondyne was a compound sometimes known as “Spirit of Ether”, produced through a process of distillation. Though originally named after the German physician Friedrich Hoffmann (1660- 1742), the recipe was still popular across Europe and the US during the mid-19th century. One 1850s pharmaceutical study of the remedy’s chemical properties found that versions of it varied greatly between commercial manufacturers, between international pharmacopoeia, and from Hoffman’s original recipe.[2]

Dr. Crawford Williamson Long (1815-78), an American surgeon and anesthetist, is one of the first physicians to have administered ether as an anesthesia for surgery. After receiving his M.D. from the University of Pennsylvania in 1839, he practiced medicine in New York before returning to his home state, Georgia, in 1841. As early as 1842, Dr. Long used sulfuric ether during the surgical removal of a tumor. He continued to use ether in operations over the next few years, but he failed to publish his results until 1849, after anesthesia was already heralded as a major medical innovation.[3]

Dr. Long's Remedy for Insect Bites
The College of Physicians of Philadelphia, MSS 2/0093-01

While Dr. Long is celebrated today for his innovative use of ether in surgery, the double-sided single-page manuscript from which this story was taken shows that he was also using popular ether-based medical remedies to treat common household ailments, such as insect bites. After the turn of the nineteenth century, ether was drunk in medical remedies in the United States and Europe and became a popular recreational drug in many European countries.[4] In this manuscript, Dr. Long reports that he successfully administered this treatment a second time and he was writing this account specifically because “A great variety of Sovereign remedies have been recommendend [sic] ^as being usefullest^ for the treatment of bites of poisonous insects”, but there was “still great diversity of opinion among the Members of the Medical profession”.

Dr. Long’s narrative is also a good reminder to us that sub-divisions within the medical field were not as defined in the past as they are today: there was nothing wrong with a surgeon exploring pharmaceutical remedies. Further, the fact that he records in detail the household remedies his patient had already tried before he administered his own validates the possibility of their effectiveness, even if they were ineffective in this particular case, and it offers a good example of how diverse medical treatments were often intermingled.


[1] The College of Physicians of Philadelphia, MSS 2/0093-01, “Holograph remedy for poisonous insect bites, c. 1847”. This item also includes a typed donation letter from 1971 recording the provenance of the item.

[2] William Procter, Jr., “On Hoffman’s Anodyne Liquor”, American Journal of Pharmacy, 28, 1852, 213-18.

[3] W. M. Crawford, “An Account of the First Use of Sulphuric Ether by Inhalation as an Anaesthetic in Surgical Operations”, Southern Medical and Surgical Journal, 5, 1849, 705-713.

[4] Science Museum, “Ether”, http://www.sciencemuseum.org.uk/broughttolife/techniques/ether.aspx Accessed 11/9/2012.