The Historical Context of the Huihui Yaofang, a Yuan Medical Encyclopedia
“A table without vegetables is like an old man devoid of wisdom.”
–Medieval Arab proverb, quoted Ahsan 1979:13
Some general reflections
Medical practice is part of culture, and thus influenced by all the factors that influence culture. Everyone knows this now, but evaluating the relative influences is difficult.
The general view taken in the present work is that medicine is the result of a great number of people trying their best to fix perceived individual, personal, and demographic problems of living and functioning.
One question concerns “normal” versus pathological or “abnormal” (Canguilhem 1991). A given culture, or its medical establishment, establishes ideas of what is normal, what is healthy, what is acceptable, and what curing is possible. These may define, or may be defined by, the “pathological” and the “abnormal.” Statistical norms may be quite different from health goals. We generally accept the fact that the average life expectancy is below the potential life expectancy. In preindustrial societies, the average life expectancy was around 30. Human potential life expectancy is over 80 (possibly 90-100). Which is normal? What, therefore, is pathological? Obviously a person dying at 80 in a preindustrial society would be far from “normal” for that society, but would be less “pathological” than the normal!
Statistical norms are not health. All cultures realize that there are deeper issues here. Let us briefly consider universal human experience. All persons, at some time, rather suddenly begins to feel awful in one way or another, and to find they have trouble doing what they usually do with ease. They then usually recover after a few days, weeks, or months; sometimes they never recover; often they decline and die. Among the commonest problems, worldwide, are respiratory difficulties; digestive and eliminative problems; sudden pains; rashes; sores; disabled limbs; wounds and other traumas; and bites, stings, and poisonings. The causes of many of these are obvious; an arrow in the leg, a dog bite, or a bruise from a fallen rock are easy to explain. (The victim may add a belief that someone bewitched the rock to fall on her, but that is a different question.) Genetic conditions were less easy to spot, but following family genealogies for any length of time demonstrated the existence thereof. The causes of respiratory and digestive upsets and sudden internal pains are less obvious. Psychologists have shown that humans feel a need to understand and explain what is happening to them (it gives some sense of control, or at least some hope), and thus it is no surprise that most cultures have theories of illness. No one imagined anything like bacteria or protozoa before Leeuwenhoek, and even then it was not till centuries later that people imagined such organisms could cause disease, so cultural theories in the days before laboratory science had to do without such causal agents. The obvioius suspects included, in the classic Hippocratic formulation, “airs, waters, places”; as well as witchcraft, invisible miasmas and contagions, obscure poisons and things that potentiated poisons, and similar abstract entities. Humans have been astonishingly creative in explaining disease, because they were desperate to find cures, and one reasonable way to find a cure for something is to figure out what causes it and then block that cause. Unfortunately, this led to treatments based on logical deduction from inevitably flawed premises. The history of medieval coping with bubonic plague epidemics is instructive: usually the first recourse was to kill unpopular minorities (they must have been performing evil magic), followed by prayer and ritual. Then came various herbal and spice cures, some of which actually had some effect. Finally, truly effective methods—notably quarantine—were invented. Plague was quite well controlled long before Pasteur and Yersin identified the true causative agent (the bacterium Yersinia pestis).
The main alternative—trying all kinds of plants, animals, minerals, and manipulations in hopes that something might do some good—is what actually worked, and so a wide range of highly effective biological and mineral drugs were known many millennia before science could explain why these worked. Thus traditional medicine had its causal theories, usually far from biomedical findings, but also had a vast range of empirical remedies, usually founded on something related to biomedical realities.
In talking about illness and health, we are talking about set-points culturally defined, and not always agreed on even within one culture. My idea of health may be less ambitious than my wife’s. Some humanistic psychologists of the 1960s had serious goals for mental health beyond the wildest dreams of the psychiatrists of today. We have greatly tempered our expectations as experience has taught us that we cannot fix everything.
This line of thought is most relevant to the HHYF when we consider what was meant, in those days, by “treating” or “curing” a condition. With the medicines available then, few illnesses could be “cured” in the modern biomedical sense. People had to be satisfied with symptomatic relief, or even with nothing beyond counterirritation to make them forget their initial problem. (Acupuncture may do no more than that.) Many herbal drugs of medieval times work well, but most are greatly inferior to modern drugs in actual healing power. Persons of that time might then say they were “cured” when a biomedical doctor of today would say only that they had had symptomatic relief, or that their condition was improved enough to let nature do the rest.
The “normal” would have included a good deal more grief than we think is normal today. On the other hand, the many folk and traditional remedies for things we now find very difficult to treat—from cancer to infertility—show that hope was very much alive. People did not give in. They refused to bow to the repeated failure of their remedies, and they refused to regard such conditions as too “normal” to be treated.
My experience with traditional Chinese and Maya medicine is that many or most common remedies work appreciably, in biomedical terms, but are usually less effective than biomedical drugs. The Maya learned to use large quantities of many herbals, knowing that sooner or later something would probably help. In the small area I study, some 350 species of plants and animals are used medicinally. The common ones have almost all been shown to work, at least a tiny bit, in biomedical terms (Anderson 2003). This medicine was far less effective than modern biomedicine, but was a great deal better than nothing. To give some figures (see Anderson 2003, 2005), infant mortality in rural Quintana Roo in the 1930s ranged up to 50% in remote communities. It is now around 5-10% and falling fast. Without even Maya medicine, it would almost certainly have been well over 50%. So traditional medicine brought it down to 50% or a bit less, and certainly did better than that, before the Spanish brought in new diseases (notably malaria) against which the Maya had no defense. Modern medicine has almost eliminated the other 50%. Traditional Maya medicine for adults was more effective than for infants.
The medieval Chinese and Near Eastern cases were probably comparable. One remembers a cautionary note: many observations in the Middle Ages suggested that prayer worked better than doctors’ medicines. This is less a comment on the power of God than on the kind of medicine purveyed.
Christianity, Islam, and Daoism alike taught that one should endure suffering as nature’s or God’s way, but practically no one seems to have lived by that fatalistic rule if they could avoid it. The Muslim medical books in particular are full of justifications for treating what some might consider to be Allah’s will. Muhammad himself, according to reliable traditions, advised practicing medicine. He or his followers pointed out that God may have made the illnesses but He made the remedies too, and they were presumably made to be used.
A fascinating insight into how people viewed traditional Galenic medicine and its rivals is found in Robert Burton’s Anatomy of Melancholy (1932, orig. 1651). Burton compares Galenic cures of all sorts with philosophy, religion, and other disciplines, admitting that none cured his lifelong depression. Some helped more than others. He maintained an open but rather skeptical mind. He discusses at length not only these treatment modalities but the ways they were viewed at the time. One suspects that Near Eastern and Chinese patients had similar thoughts.
In this book and all my work in medical anthropology, I use the term “western medicine” correctly: to cover the medicine of the western world, including the Hippocratic-Galenic tradition and its relatives, often blended with magic and faith-healing, that have dominated the west for almost all of history.
The use of the phrase “western medicine” to mean modern laboratory-based biomedicine is a serious mistake. Western medicine is, by all standards of linguistic usage, the medicine of the west—i.e., the above. Biomedicine was international from the beginning. It resulted from the confrontation of European medicine—itself largely derived from the Near East—with the different but obviously valuable traditions of Native America, East Asia, South Asia, and Africa in the Age of Discovery and later. It developed largely in France and Germany, but with international teams. Both Pasteur and Koch had Asian students. Europeans based in or widely experienced in overseas colonial locations were also important from the beginning, and they drew on local expertise wherever they were. It was and is a truly international field. There is nothing particularly “western” about it, except for the unthinking tendency within it to propagate western ideas of “man vs. nature” and “man the machine.” These two attitudes are not really part of biomedicine in the way that laboratories and chemistry are; rather, they are pathologies that it has had to overcome (and it has a way to go). The rather authoritarian doctor-patient relations characteristic of biomedical practice, and sometimes blamed on “the west,” are actually fairly characteristic of all medicine everywhere, including shamanic healing in ancient North America.
This being the case, calling biomedicine “western” is obviously an outrageous bit of racism and colonialism.
Going Back in Time: Early history of the medical traditions in the HHYF
The history of Near Eastern medicine begins in Sumer and Egypt. What little is known of early Mesopotamian medicine consists largely of religious formulas and texts, including magical spells, though contagion was recognized and many herbal and other remedies—some at least effective—were known (Bottéro 2001; Potts 1997). Many of the foods later used in healing were already known (see Potts 1997:56-90), and at least some were used medicinally. Egypt is better known, through about a dozen detailed and important papyri ranging from over 1500 BC to around 200 AD. Unfortunately, major problems with understanding the disease and drug names prevent full incorporation of these very ancient traditions in medical history. Egyptian herbal drugs, however, can often be identified (Manniche 1989; Nunn 1996).
Ancient Mesopotamian and Egyptian medicine has been accused of being largely magical. This seems broadly true for the former. Most of what we have from Mesopotamia is prayers and spells. We have some herbal lore, and excellent editions of rather late culinary texts (Bottéro 1995). All these are empirical enough. Several Babylonian and even Sumerian drug names carry over into Arabic (Sumerian TAR.MUSH for lupine, Arabic turmus; Sum. A.BAR for lead, Arabic abār; Akkadian bis.ru, Arabic bas.al for “onion,” and so on; Levey and Al-Khaledy 1967:29). Wormwood was already used in Akkadian medicine, plantain in ancient India and Egypt, and of course cannabis has been used for various reasons since time immemorial in India and Central Asia (Levey and Al-Khaledy 1967:43).
One of the greatest archaeological discoveries of all time was Henry Layard’s 19th-century find of the library of the Assyrian kings at Nineveh (see Van De Mieroop 2007:261-265). Thousands of cuneiform tablets were neatly ranked on shelves, arranged by topic, from the Epic of Gilgamesh to religious texts to economic documents. This is the earliest true archive and the earliest true library that is well known (although certainly far from the first in history). The importance of the invention of archiving cannot be exaggerated; archives and libraries made civilization possible (Posner 1972). But the medicine reflected in the vast Nineveh library is of the magical kind.
The dominance of magic in Egypt has been exaggerated. Many medical papryi exist, and reveal an extensive and generally pragmatic pharmacopoeia (Manniche 1989; Nunn 1996). Minerals and herbs were important, and many of the identifiable ones are medically significant, usually being carried over into later practice. Most are effective for the stated purposes.
These problems of interpretation also make it impossible to calculate the influence of Mespotamian and Egyptian medicine on the development of Greek medicine. Estimates of influence range from overwhelming to near zero. In regard to Egypt, it is probably best to trust Herodotus, who was there and knew what he was talking about. He saw major influences on practice, especially pharmacopoiea and (proto-)epidemiology, but does not seem to have detected much influence on theory per se. This may be an accident of preservation, however, for there is no surviving evidence for Egyptian medical theory; the medical papyri are practical manuals or magical spells. Theophrastus also tells us a great deal about Egyptian plant use, and surely the Greeks—always quick learners—adopted whatever knowledge they found useful (cf. Craik 1998:6).
No Greek stepped forward to provide a similar account of dependence on Babylonia. Major influence surely occurred, but we have little idea what it was, beyond knowledge of herbal drugs, magical spells, and general considerations of pathogenic entities. Influences from these ancient realms did not clearly shape the Hippocratic-Galenic medicine that appears in the HHYF, and thus need not be addressed in detail here.
Ancient Greek medicine achieved highly sophisticated scientific status at a quite early time (Phillips 1973). Most of our knowledge is, naturally, of the Hippocratic tradition (Craik 1998; Hippocrates et al. 1978) which eventually triumphed over all competitors, but we are aware of many other related traditions that vied for place. (For some of these, in relation to Chinese medicine, with possibility of mutual influence not totally ruled out, see Unschuld 2009.) Medicine seems to have been especially developed on the coasts and islands of the Aegean Sea. Hippocrates came from Cos, an island otherwise noted largely for its superior variety of lettuce, which he no doubt enjoyed. (Now called “Romaine,” it is said to be the oldest variety of vegetable in the western world, having been good enough to hold its own against all later comers.)
Hippocrates, and, in general, the doctors of his time, worked with “regimen”: diet and lifestyle. They advised on food, exercise, rest, exposure to airs and places, and the like. They used drugs only when necessary. Surgery was left to specialists; ordinary doctors did not do it. The original Hippocratic oath included a clause that the doctor should not poach on the surgeon’s territory by attempting to operate. We will meet this emphasis on regimen again. It is very clearly shown even as far afield as the Mongol Empire (see Buell, Anderson and Perry 2000).
We do not know how much of the humoral tradition is owed to Hippocrates, but by very early times the Greek medical system became based on the wider idea—found in Aristotle and elsewhere—that there were four elements: earth, air, fire, and water, and four qualities: hot, cold, wet and dry. Earth is cold and dry, fire hot and dry, water cold and wet, air hot and wet. This was to be applied to medicine, the final synthesis being effected by Galen (see below).
Among competitors to the Hippocratic-Galenic tradition, Soranus stands out. He was a methodist, meaning that he preferred to stick to meticulous observation rather than to received wisdom or to the theoretical speculations that were becoming dominant in the Hippocratic school and would soon triumph in the work of Galen. Soranus used lower-level hypotheses and midrange theory, but sedulously avoided grand theorizing.
Soranus’ work on gynecology survives (Soranus 1956), and is an amazing document. Most of the descriptions and recommendations would do credit to a modern text. Received wisdom falls to observation in almost every section of the book. Soranus disproves folklore about how to tell if an unborn child will be male or female, if a freckled woman is an unfit mother, and on and on. Only a few wrong-headed ideas get grudging provisional acceptance. One was the belief that a baby can be marked by what the woman sees or eats at conception, or during pregnancy. It is still worldwide; Soranus reported it without enthusiasm but without denial. One can only wonder what would have happened if methodism had triumphed. We would have been spared a vast amount of nonsense. On the other hand, it seems that the human mind needs theories and explanatory models as surely as the eye needs light. In any case, Soranus’ meticulous attention to observation of detail and recording of fact clearly influenced the future course of medicine, not least in the Near East.
Another, less medical, tradition that died from Galen’s attacks was Asclepides of Bithynia’s corpuscular theory (Unschuld 2009; Vallance 1990). This held that the particles of being were not indivisible, but could be subdivided, presumably indefinitely (like space or distance). Atomic theories tended to prevail instead.
Greek medicine was imperfect enough to lead Cato the Censor to claim it was “a Greek conspiracy to murder foreigners,” and Pliny to quote a common epitaph “He died of a crowd of doctors” (Parsons 2007:178). Medieval observations that praying over a sick person was more effective than doctors’ medicine were probably all too true. One could survive the prayers, but the medical treatments were often enough to kill the healthiest and strongest.
The problem was not so much the Hippocratic-Galenic tradition itself, with its sensible directions about food and exercise. The problem was the increasing elaboration of toxic drug mixes, bleeding, cupping, and other damaging therapies. Europe, with its tradition of driving devils from the sick, was worse served, and one wonders today how anyone survived premodern doctoring there. However, the Near Eastern world was spared the worst of this by the Arab and Persian medical emphasis on comfort and enjoyment. Thus the medicine transmitted to China in the HHYF was a fairly “heroic” sort, but not downright deadly.
Greece to Near East
We sometimes forget that much of Greek medical research and development took place in what we would now call the “Middle East,” specifically Asia Minor. Both the two physicians who most influenced Near Eastern medicine came from there. Rufus—by far the less important of the two, but still a presence seen in the HHYF—came from Ephesus. Galen (130-200), the overwhelmingly dominant, hailed from Pergamon (modern Bergama), where for a time he served in a huge medical academy. Much of it still stands. The skyline of Bergama is dominated by the enormous marble columns of the Aesculapius temple, which became the core of what would even today be an impressively large medical school. Photographs are found in Susan Mattern’s excellent biography of Galen (2013, following p. 168). It lies downslope from the old Roman hilltop town, but above the modern town, which developed around the market. One can imagine Galen walking down the hill to that huge, raucous market at the hill’s foot, and revelling in the incredible variety of foods and herbs there. (Alas, he would not have found the unexcelled tomatoes, green beans, chiles, and squash that abound there now; they came long after his time, from a continent unimaginable to him.)
Galen was a contentious, intensely proud man, but also a caring and responsible doctor, who apparently healed effectively (Mattern provides a wonderful picture of the man). He upheld his view of Hippocratic medicine against rival schools, notably the Methodists and Empiricists, who were much less theory-conscious. (He was also aware of Christianity, interestingly; he thought its ideas rather silly but its lifestyle commendable; Mattern 2013: 171-172). He was a superb anatomist, used to dissecting animals (even live ones) and also defunct humans; he may have once vivisected a human criminal. However, he is notorious for having assumed that humans had certain features we now know to be restricted to pigs; the Renaissance anatomist Vesalius caught him out in several mistakes of this sort (Mattern 2013).
Though Galen spent most of his life in Rome and other Italian venues, he remains a link to the East. Later figures often came from or lived in what is now Turkey and Syria. So to a large extent the transfer from “Greece” to “Islam” consisted of Islamic takeover of formerly Greek lands. Teachings were still alive. Moreover, ancient manuscripts (possibly forgotten by the Greeks) often turned up as buildings were redeveloped. North Africa, specifically Alexandria, was also a great center of medicine. Egypt’s very extensive medical knowledge had already influenced Greek learning for centuries (as Herodotus noted in the 5th century BC). Euclid wrote his Elements in Alexandria, with the benefit of Egyptian surveying knowledge.
Under the later Roman Empire the traditions essentially fused. The famous library contained at least 400,000 books at peak around 48 B.C., after which the wars of Caesar and then Octavian versus Mark Antony began to take a toll. Roman wars destroyed the library, and the famous Arab destruction in the 600s A.D. merely finished off a small remnant (see e.g. Kamal 1975:37-38). The role of Egypt in Greek knowledge, and of southward parts of Africa in Egyptian knowledge, is still extremely controversial. Suffice it to say that the Greeks themselves admitted freely to learning much from Egypt, and that Egypt’s southward connections are thoroughly proved by archaeology. The extreme Eurocentric theories of Greek knowledge are wrong. Exaggerated claims for Egypt’s centrality (going back to Grafton Elliott Smith’s [in]famous “heliocentrism” and more recently exemplified by Martin Bernal’s Black Athena, 1987), however, do not stand up, nor do W. Perry’s claims for Mesopotamia as origin of everything (Lowie 1937).
Galen is most famous for his thorough systematization of the theory that the most basic need in the body is balance between heat, cold, wetness, and dryness. He argues for this in terms similar to those I have heard today from folk practitioners of traditional humoral medicine. Excessive sun or fire damage the body, so similar illnesses (fevers, rashes, sores) seem to be from excessive heat. Moreover, putrefaction generates heat, as in piles of “seeds [presumably, decaying fruit is meant] or faeces” (Galen 2006:160), and of course in infected wounds. And of course “passion [is] a seething of the heat around the heart” (Galen 2006:161). Excessive cold damages the body—Galen describes hypothermia well (Galen 2006:165). So illnesses that look like the effects of hypothermia seem to be from excessive cold; such things would be weakness, pallor, inaction, failure to move actively, and low body temperature. Similarly for wet and dry.
His theory of humors has influenced medicine for almost 2000 years, and thus is worth quoting in his original formulation: “…yellow bile is hot and dry in capacity, black bile is dry and cold, blood is moist and hot, and phlegm is cold and moist. And sometimes each of these humours flows unmixed, but sometimes mixed with others, and the conditions of swollen, indurated and inflamed parts, in consequence, vary still more” (Galen 2006:169). Cooking or burning could change one humor to another: phlegm to blood, blood to yellow bile, yellow bile to black bile (a final endpoint, like black charcoal from wood; see Dols 1992:19). Black bile was added late to the system—early texts have only three—but black bile was needed to fill the cells in the grid (Mattern 2013:53).
Yellow bile is ordinary bile or choler, and excess of it leads to the physical and behavioral signs we still call “choleric.” Black bile is the foul mess of dead blood and other such effluvia that collects in the bile duct and nearby intestine in severe cases of malaria, hepatitis, and similar conditions. Contrary to some claims in the literature, it is not imaginary. It was all too common and visible in the malarial old days. Excess of it made one melancholy, a term used more widely than today. A melancholy person was thin, pale, weak, sad or even mentally disturbed, and despondent about activity. This would certainly be true of anyone with such severe hepatitis or malaria that they accumulated black “bile,” and it could also cover the effects of chronic tuberculosis or viral infection just as well as simple mental illness.
Excess of blood made one “sanguine,” and in greater excess downright manic. Phlegm—which was not only mucus but, at least in later times, any watery discharge—made one, of course, phlegmatic. Carl Jung correctly pointed out that these conditions may be bad physiology, but they are pretty good psychology. Galen and his followers knew personalities well. Not for nothing do we still talk about sanguine, phlegmatic, and melancholy personalities.
Galen’s medicine was by no means limited to hot, cold, wet and dry. He saw any imbalance as important. He was, of course, acutely aware of simple physical accidents—broken bones, bruises, cut-wounds, and so on. He was an expert on digestion, and was fully aware of the relative digestibility of many foods and the obvious inadequacy of the hot-cold-wet-dry model to explain this fully (Galen 2000, 2003). His experience, as well as older theories, taught him that excess or deficiency of flow or openness was as bad. Overdilation and overconstriction could come from humoral imbalance, but could come from physical damage or other factors. Overgrowth or undergrowth of tissues was also of obvious etiological significance.
Like Hippocrates, he recognized contagion, but gave it a minor place, apparently seeing it as occurring only when corrupted airs affected a susceptible body. He saw, or at least Muslim Galenists thought he saw, the spirit as divided into a hot dry vital spirit; a cold and wet psychic spirit; and a hot and wet natural spirit, as well as animal, vegetable, and rational components to the intellect (Nasr 1976:161). He also recognized “semitertian” and tertian fevers, i.e. malaria—identifiable by their climaxes every second or third day. Tuberculosis and leprosy also are fairly clearly described in his writings (Mattern 2013:119-121). He fled from—but described—the horrific plague of 168, which may have been smallpox (Mattern 2013:200). He recognized that the womb did not wander around the body (as in classical ideas of “hysteria”) but did give it a certain mind of its own, as well as recognizing it could become inflamed and infected (Mattern 2013:233); later Arabic medicine, following Galenic tradition, used effective treatments for these conditions.
In general, his theory was one of balance along many dimensions. This idea may have come from the ideas of the mysterious Alcmaeon of Croton (Johnston in Galen 2006:15), and, even farther back, from ancient Egyptian ideas of superfluity and corruption (Dols 1984). Later ages simplified it, often cutting out all but the hot/cold dimension.
It is important to note that this was a theory based on the total body, and on a global imbalance of its normal components (Canguilhem 1991:40)—as opposed to, for example, a theory of medicine based on alien “germs” that invade the body and secrete poisons there. Galen’s “normal” is a perfectly balanced set-point—the set-point differs for individuals according to their humoral consistency, the climate and land they inhabit, and their immediate environment. It is a personal ecology. Today’s“germ theory” normal is a body without alien invaders. We now see normality as defined in a whole community ecosystem.
Galen’s enormously extensive writings cover common foods and their values, all common symptoms of bodily problems of any sort, anatomy, physiology, illness classification, and everything else a working doctor might need in the 2nd century. He also spent a great deal of effort attacking other schools for their oversimplification, naivete, and failure to speculate about causes. He himself was fascinated (almost obsessed) with cause, following Aristotle in differentiating various meanings of the word (Galen 2006, including Johnston’s introductory and concluding materials). In particular, he concerned himself with ultimate causes and proximate ones. Just as a sword cut was caused immediately by the sword but ultimately by the anger of the sword-wielder, so an illness could be the result of a whole chain of causation. Galen’s thinking on this was incisive, wide-ranging, and fascinating (Galen 1997, 2006).
George Foster distinguished between “naturalistic” and “personalistic” theories of medicine. The former ascribe illness to natural, impersonal forces. The latter blame it on persons: often human sorcerers, but more often on supernatural persons. Biblical medicine, and thus much of the medical lore in the Judeo-Christian world, notoriously blamed illness on devils or unclean spirits, or saw it as God’s punishment for sin. Devils and witchcraft rose in popularity in the European Medieval period; the peak of belief in these was in the 15th and 16th centuries, not in the middle ages.
To all these, Galen’s eminently naturalistic medicine was a wonderful counterfoil (see e.g. Dols 1984:23), saving the Near East (and, to a much lesser extent, Europe) from the full horrors of a medicine that led only to judgmental attitudes toward the sick, beating the “possessed,” and praying over the “punished.” Galenic medicine was never eclipsed by personalistic theories, even at the folk level, though it was almost eclipsed by religious healing in Europe and had to compete with it in the East (Nutton 1985). Significantly, some medieval European commentators actually compared prayer with doctors and found prayer more effective—a telling comment on the level of doctoring. It is also significant that recovery from illness was often seen as a “miracle” in that age, and that many were sainted simply because patients sometimes failed to die under their care.
Paul Unschuld (2009) has stressed the scientific nature of ancient Greek medicine, notably the Hippocratic-Galenic tradition. This medicine early rejected supernatural explanations, especially the idea that sickenss was due to the arbitrary will of a god or spirit. Instead, the Hippocratics, climaxing with Galen, developed a medicine based on actual natural laws or principles, thought to be unchanging and all-prevailing. This contrasted with both supernatural healing and the mere empiricism of many (if not most) of Galen’s rivals. Unschuld (like many others) sees systematization and lawfulness as the true definition of science, including medical science. One might argue that even assembling empirically tested remedies is a bsic activity, and usually implies some knowledge of medical science, but certainly the development of a systematic medicine based on fundamental principles is a major achievement. It had influence in proportion.
Another advantage of Hippocratic-Galenic medicine was put in direct form by the Arab Galenist al-Rāzī (d. 925): “If the physician is able to treat with foodstuffs, not medication, then he has succeeded. If, however, he must use medication, then it should [as much as possible] be simple remedies and not compound ones” (cited Pormann and Savage-Smith 2007:115). This was excellent advice then. It is excellent advice now. Indeed, advice to this effect is very common today, and is demonstrably continuous with Hippocrates’ advice as transmitted through Galen and the Near East.
Unfortunately for medicine over the succeeding centuries, Galen was systematically wrong. Galen’s conclusions about ultimate causes are best typified by his speculations about balance of hot, cold, wet, and dry. He did the best he could with the material at hand. Faced with the formidable task of explaining physiology (and psychology) without microscopes, chemical analyses, or any other modern technologies, he made the best guesses possible. Indeed, rashes, burns, sores, and irritated membranes do look like burns, and so for the rest. Alas, all that was proved is that, in the words of H. L. Mencken, “there is always a well-known solution to every human problem—neat, plausible and wrong” (Mencken 1920:158).
Galen’s other causal speculations are closer to truth, because closer to direct observation. Inference, especially the most seductively plausible, is a necessary step but a dangerous guide. Galen was also so dogmatic that he helped give the word its modern meaning; he called himself a Dogmatist, meaning a theorist as opposed to a mere empiric, but he was indeed dogmatic about his positions.
Yet, reading his works on causes (Galen 2006), one is extremely impressed by their scientific spirit. He tried to build on existing theory and test it against his enormously rich and thorough clinical and experimental observations. He tested and rejected most of the theories of his time. He did not mindlessly accept even the work of his idealized forebear Hippocrates. His work on lovesickness also seems rather modern (Wack 1990); it was carried forward and augmented, with the rest of his medical lore, through succeeding nations and centuries, and influences us still. (Lovesickness continued to be important in Arabic medicine, and thence to Europe; Vilanova 2011; Wack 1990. But it never reached China, where similar ideas of excessive romantic passion existed but were conceptualized and treated quite differently.)
Galenic medicine is the greatest proof of Thomas Kuhn’s point (Kuhn 1962) that a theory never dies until superseded by a better theory. Galenic medicine was seen to be shakier and shakier as centuries rolled on, but nothing better offered itself. Galen had provided a comprehensive, rational, naturalistic, thorough, and beautifully organized system, extremely valuable for organizing, remembering, and systematizing medical knowledge of all kinds. No one could do without it until Koch and Pasteur in the 19th century radically changed the medical world for all time.
One may wonder, today, what would have happened without Galen. Western medicine would not have had comprehensive theories; it would have been left largely to religion, secondarily to the “methodics” and “empirics” who tied together systematically-recorded observations with a minimum of theorizing. Asian medical traditions would have developed without the powerful Greek influence. Only recently has the full impact of Galen’s medicine on Asia become clear. I have noted the fact that the court doctor to the king of Tibet in the 8th century was a doctor from “Rom” (i.e., the Byzantine empire) calling himself “Galenos” (Garrett 2007)! Galenic medicine continued to flourish in the Indian subcontinent, and still does today, under the name “Unani” (from Arabic and Persian yūnānī, “Ionian,” i.e. Greek). It is officially recognized in India and Pakistan, and has a large literature, including many of the medicinals added long after Galen’s time.
So Galen’s naturalism survived, and eventually had much to do with the triumph of a scientific medicine in and after the 17th century. It saved Europe from falling into personalistic religious theories. In fact, and somewhat ironically, modern biomedicine is actually more personalistic, since it puts so much emphasis on contagion—allowing people to blame friends for colds, lovers for STD’s, and enemies for biowarfare. Biomedicine also finds place for “stress,” typically blamed on spouses or coworkers or “modern life,” although the actual scientific evidence for social stress as illness-causer is, to say the least, equivocal. Later Galenic medicine also had a place for imbalance brought on by stressful interpersonal situations.
Galenic medicine spread throughout Asia and eventually throughout Europe, Latin America, and most of the world (Anderson 1987, 1996; Foster 1993). Cold (sardi), hot (garmi), wet and dry continue in modern Iranian folk medicine (see e.g. Benham 1986), as they do in Mexico, China, and almost everywhere between. It even influenced music. In the European Renaissance, melancholy was identified with the bass voice, phlegm with tenor, sanguine humor with alto, and choleric with soprano. Masses were written accordingly—the sad parts in bass, for example (Boccadoro 2005).
Many Galenic ideas persist today even in biomedicine-drenched Western society. Most of us, worldwide (literally!), were told in childhood not to get our feet wet, because we would get a cold, or a headache if the cold in the feet drove heat upwards to the head. Most of us learned not to go out with wet hair, so as not to “catch our death of cold.” Also, Galenic medicine led to the belief that seafood and dairy products cannot be eaten together, both being very cold. This belief existed by the time of Jahiz in the 9th century and was propagated by Avicenna (Avicenna 1999:404-405). He notes that “Indian observers and others” taught us also to avoid milk with sour foods and sour milk-rice following barley meal. The belief about dairy and sea foods was taken very seriously by my school friends in Nebraska in the 1950s, and in Italy in 1988 a waiter refused—with dramatic gestures—to bring cheese for my wife to put on her seafood pasta. Others have had this experience too.
Even today, psychology continues the Galenic tradition. The current personality theories (four-factor or five-factor) are straight out of Galen’s four temperaments. The “pathological” is a set of extremes derived from ordinary brain functioning, just as Galen said, and we still use his words for some of them. Depression, for instance, is now popularly seen as “melancholy” gone out of control due to oversecretion, not of black bile, but of serotonin, with undersecretion of dopamine. And we still call them “neurohumors”! Truly, Galen has a long reach.
The other great tradition in Greek medicine was herbal pharmacology. The first herbal we know is that of Aristotle’s student Theophrastus (1926, orig. 4th century BC). It is concerned mostly with food and wood, but has a long section on medicinal plants. More serious was the work of Dioscorides (Dioscorides 1937; Pavord 2005; Riddle 1985). Pedianos Dioskurides, said to come from Anazarba in Cilicia, was a soldier who saw service widely in the Roman Empire. During his soldiering career in the 1st century AD, much of it apparently as a medic, he collected herbal lore. Eventually he wrote it up, producing one of the most amazing botanical achievements in history.
Galen had also been a fine herbalist, good at identifying counterfeits as well as at identifying and using real medicines (Mattern 2013, esp p. 100). He advises doctors to know rural and village remedies thoroughly, and to know what to do on a sea voyage, in case they were caught far from home without medicines and needed to treat someone (Mattern 2013:110). He used theriac, which already included dozens of ingredients, ranging from vipers to opium.
Dioscorides classified the plants by form, within that by general use, and within that tended to put obviously similar plants (e.g. Ferula and relatives) together. He also classified plants by function—by the particular healing qualities they exhibited—as pointed out some years ago by John Riddle (1985). Thus plants that look and taste very different, and are far apart in Linnaean taxonomy, were placed together if they had similar action on the body. It was an Aristotelian mode, echoing and drawing on Theophrastus—useful and folk-like rather than formal or theory-driven. Dioscorides remained the standard herbal for centuries, and is the ultimate fons et origo for the herbalism of the HHYF, as Galen is for much for its medical theory. Surely few, if any, men have influenced humanity more than these two. Their systems reached beyond bounds of religion, ethnicity, time, and geography; virtually everyone on the planet today has been at least indirectly influenced by their collections of medical knowledge.
Unlike early Chinese herbals, his herbal is soloidly empirical, with clear, demonstrable, well-grounded effects specified for the plants. In many—possibly most—cases, he was right, or at least plausible, in his recommendations. In many, he was wrong, but his mistakes can often be explained by the resemblance of the plant to a more effective one, or by simple, plausible assumptions, such as the idea (nearly universal in the world) that yellow-flowering or yellow-leaved plants cure jaundice. He uses Galenic humoral classification, but only occasionally does he fall back on deducing from it the presumable curative value of a plant. By contrast, Chinese herbals routinely classified plants according to yang and yin, fivefold correspondences, and magical qualities, and tended to deduce curative value from these.
Many of Dioscorides’ remedies remained officinal well into the 20th century, and are still used in folk and household medicine—as in my household and millions of others.
A rather dramatic example of the closeness Greek and Chinese medicine is the argument between Dioscorides and Galen about coriander. Dioscorides, active around 40-80 CE, argued that it is cooling, being a bit astringent. Galen, however, later held that it is warming, because it feels warming in the mouth and is carminative and digestive—spicy, in fact. Galen certainly has the best of this argument, but mouthfeel standards. In any case, the Chinese had exactly the same argument over time—and I have heard it myself, when I asked Chinese consultants about the plant! Both the fruits and the leaves are up for discussion. Most Chinese herbals follow Galen and use the same arguments. It is extremely hard to believe this is not direct influence; the medical uses surely spread with the plant.
Galen also wrote much about pharmacology, and did not indulge in Dioscorides’ flights of taxonomic speculation; Galen therefore proved more useful in immediately succeeding centuries, though Dioscorides triumphed hands down in the Arab centuries. Galen classified plants by qualities, and indicated the strength. Plants ranged from hot, cold, wet, or dry to the first degree—barely perceptible in effect—to the fourth, dangerous to all but the strongest constitutions.
Another early source, differing considerably in detail from Dioscorides and Galen but covering plants found in those books, is the Alphabet of Galen. In spite of the name, it has nothing to do with Galen, and may actually be earlier or at least draw from earlier traditions. It is highly empirical, including even less magic than Dioscorides. The entries are very brief, and many of them say the plant or drug in question is “known to everyone,” so it is evidently a memory-prompt for practitioners, not a useful general field manual like Dioscorides’ book. There are no detailed recipes. This book has now been issued in a superb modern bilingual edition by Nicholas Everett (2012), and it is actually a cheap paperback. An affordable first scholarly edition of a medieval text is an amazing innovation in medical literature! Unfortunately it is of little use to us here, since the entries are too brief for much comparison with the HHYF.
Herbal wisdom shows lukewarm Byzantine and Syriac interest followed by very active Islamic interest. Byzantine pharmacology, like its medicine, was fairly stagnant. At least the great Greek sources, and their scientific attitude, were preserved and even somewhat supplemented (Scarborough 1985a). Its best was exemplified by Oribasius (325-403; like Galen, from Pergamon, and naturally a total Galenist), Alexander of Tralles (525-605), and especially Paul of Aegina (625-690)
Dioscorides’ herbal (Greek, 1st century CE) contained a few hundred plants—over 1000 substances in the expanded edition of the early middle ages. Oribasius took about 600 from Galen (largely On the Powers of Simple Drugs) and added a few more. Arab versions eventually included thousands. Near and Middle Eastern folk medicine, based largely on Greek in recent centuries, contains thousands more.
Around 854 AD, Dioscorides was translated into Arabic, supposedly by a Christian Syrian named Stephanos working under the great translator Hunayn ib Ishāq (Pavord 2005:94). (There were already herbals in Arabic, recording more indigenous traditions; see Nasr 1976:187.) In 948 A.D. the Byzantine emperor presented a beautiful Dioscorides edition to the caliph in Cordova, and later a Greek monk, Nicholas, came to help translate it into Arabic; this allowed translation of plant names not familiar to Stephanos. Derivative works from this were made by Ibn Juljul of Cordova in 982 and ca. 987 A.D. and Ibn al-Nadim of Baghdad, also around 987 A.D. (Sadek 1983). Both built on the Stephanos-Ishāq version. Further translation efforts were made from time to time (see Sadek 1983). Countless books were made based on these; virtually every medical writer in Islam seems to have felt it necessary to do yet another offtake. Many of these added local herbs.
Such important medicines as camphor, musk, senna (cassia, the laxative), myrobalan (from India), and sal ammoniac entered the pharmacopoeia (Pormann and Savage-Smith 2007:120). Greek narcotics such as opium and henbane remained in use (Pormann and Savage-Smith 2007:128-129).
Antiseptics included wine and later—probably—distilled alcohol; rose oil (a surprisingly effective antiseptic); herbal preparations including many members of the laurel and mint families; and resins like frankincense and myrrh. All these are quite effective, if not usually up to modern levels of effectiveness. Some, such as thyme, are still with us; thyme oil has been used recently in some hospitals where staphylococcus and streptococcus strains resist everything else. Note their common use in food, which clearly had at least as much to do with preventing spoilage as with adding good flavors. (The ridiculous myth that spices were added to cover up the taste of spoiled food has it exactly wrong; spices were added to prevent the spoilage of food, and worked very well indeed. They also improve nutrition; see Anderson 2005).
The herbal tradition climaxed in the enormous section on materia medica in Ibn Sīnā’s Canon, and in “the manual by Ibn al-Bayt.ār, which ws an alphabetical guide to over 1,400 medicaments in 2,324 separate entries, taken from his own observations as well as over 260 written sources which he quotes” (Savage-Smith et al. 2011:214).
Longer and more impressive than herbals were actual guides for compounding drugs; herbals listed simples. The books on compounding, aimed at physicians and pharmacists, were known in Greek as graphidia, “little pieces of writing.” The word graphidion became aqrābādhīn in Arabic. The HHYF is basically a giant aqrābādhīn, but nothing could be farther from a “little” piece of writing. The three chapters we have fill 500 pages (in the Chinese), and they are only 1/12 of the total. Thus the original may well have run 6000 pages.
Kamal’s dictionary of traditional Islamic medicine (1975) cites a number of relevant items. Kamal cites Avicenna on fattening foods, for instance: Almonds, hazelnuts, nigella, camphor, pistachios, cannabis (presumably the seeds), and pine seeds. Make into pills and take with wine. These are not only fattening but aphrodisiac! (Kamal 1975:117). Conversely, slimming can be aided by centaury, birthwort, gentian, germander, parsley, sumac, and other herbs (p. 118). He gives a whole section on compounds (pp. 164-189), as well as sections on diseases, cauterization, and other relevant matters.
The Near Eastern Connection
During the western “Dark Ages,” the Near East was anything but dark. Of the medieval Near East, Strohmaier (1998:148) says: “It is significant that the many-faceted scholars who took up medicine never seem to have done so in a superficial manner.” Philosophers, statesmen, theologians like Moses Maimonides, and even slave girls (if we are to trust the Arabian Nights), knew medicine in detail.
Galenic medicine naturally centered from the beginning in Alexandria and the Greek east. Alexandria was home to Paul of Aegina, the 7th-century doctor who was most important in preserving the Galenic legacy in Byzantine times. But Alexandria declined after Christianity entered the area and eventually was eclipsed. Byzantium and Syria continued to be pivotal. The Byzantines were less than innovative, and preserved Galenic medicine virtually unchanged. Never has such a powerful and mighty civilization contributed less to humanity, especially in the areas of medicine and similar sciences (on this and related points, Gibbon 1995 [1776-1788] is still the best). The few studies of Byzantine medicine turn up little that is new. The one good comprehensive volume in English is a collection of papers edited by John Scarborough (ed., 1985); some of the papers attempted a revisionist critique of the classic Gibbonian position, but the data in the book are all too clearly in accord with Gibbon. Medicine continued to be practised, and in some areas (notably veterinary; Scarborough 1985b) it flourished and advanced. But Galen and his forebears still reigned supreme.
Worse, Christianity influenced by Neo-Platonism taught stoical acceptance of disease and reliance on God rather than medicine (Nutton 1985), leading to a relative decline of medicine in much of the western world. Islam, in spite of its counsel of “surrender” (islām) to God’s will, was to provide a contrast that could not have been more dramatic. Muhammad and his followers made it clear that surrendering to God’s will meant making use of His provisions for us, including curative ones. It did not mean giving up. This led the caliph Al-Ma’mūn in the 8th? Century to stress the cultural superiority of the Arabs to the Byzantines, credit it to religion, and hold—not without reason—that “the Byzantines had turned their back to ancient science because of Christianity, while the Muslims had welcomed it because of Islam” (Gutas 2011:204).
Galenic medicine thus became the established medicine in Syria, a major center of Byzantine life and thought. Galenic texts were translated into Syriac, and Syriac doctors became the elite practitioners all over the Semitic Near East.
Greek penetration in the Near East was very long and deep. With the decline of the Roman Empire, Galenic medicine nested in Syria, Anatolia, and Arabia. Greek was always the core language, since Galen himself was Greek and wrote largely in that medium, but by the 6th century Syriac was important. Syriac is close to Arabic, and thus translations could easily be made when the rise of Islam made Arabic the chief language of the Near East. Greek and Syriac civilizations slowly interpenetrated after Alexander the Great’s time. Eventually they fused. Greek science, philosophy, and theology was translated into Syriac. From at least the mid-6th century onward, Greek medicine was transferred eastward to Arabia and Iran via Syrian practitioners (Nasr 1976:173 lists some of these). Syriac was the initial language of transfer, but Greek, Iranian, and Arabic became common.
Hospitals evolved in the Byzantine world after 200 or 300 AD. Called nosocomia, “sick-houses” (whence our term “nosocomial infections”), they were the first true hospitals in the world. It was this which the Arabs discovered when they conquered northward from the desert. (Syriac medicine is little known and less translated; see Budge 1976 —it is revealing that a source from 1913 is still standard.) The Arabs adopted this tradition, including the hospital, and greatly added to it; “it is evident that the medieval Islamic hospital was a more elaborate institution with a wider range of functions” (Savage-Smith et al. 2011:212).
Rufus of Ephesus, Soranus, and even obscure Greek magic-and-charm doctors were well known. The great Byzantine encyclopedist Paul of Aegina lived long enough to hear of the rise of Islam—assuming he was well posted on the news. His work was to exert a major influence on Near Eastern medicine and thence on the world.
After Nestorianism was condemned as heresy in 431 AD, Nestorians moved from Constantinople and Syria to Iran, and were instrumental in founding the Jundishapur (Gundeshapor; “beautiful garden”) medical university near what is now the Iraq-Iran border (Elgood 1951:45-50; Foster 1993). This medical university had Christian, Jewish, Zoroastrian and other faculty, and of course Islamic ones after Islam rose to power in the 7th century. Teaching was through lectures, readings, and clinical sessions, with apprenticeships similar to modern internships.
This has often been claimed as one of the greatest medical schools in the history of the world, but it seems actually to have been a minor station; it owes its subsequent fame to legends, reinforced by the Bukhtīshū’, a Nestorian family who came from there to Baghdad and became leading medical writers and practitioners. It now appears that Gondeshapor was only one center among many, and that hospitals, medical schools, and translation activities were widespread in the Greek and Syriac east (Pormann and Savage-Smith 2007:20). However, it was clearly important; Pormann and Savage-Smith (2007:80) quote a ninth-century book and other sources that speak of it as the most prestigious source of physicians. Supposedly Muhammad’s own personal physician was trained there (Isaacs 1990:342). Besides the Bukhtīshū’, the great doctor al-Masawayh had roots there.
From this time on, odd bits of Greek lore drifted into Near Eastern languages and sources, as what Ullman (1978:24) called “erratic blocks.” (We use this concept to deal with the same phenomenon in medieval China; see Buell, Anderson and Perry 2000.) Often these were incomprehensible, because the Greek terms were not understood, or useless, because the Near Easterners lacked Greek items or institutions; instructions for how to exercise in the gymnasium, for instance, were wasted. This did not mean there was no exercise; the Iranian “house of strength,” a comparable institution, probably had its ancestral forms by this time, and the Arabs had their field exercises. More useful were Greek works on wine and its value, which managed to get translated in spite of Islamic rules!
Repeating the many good histories of Near Eastern science and medicine is unnecessary here (see Campbell 1926; Elgood 1951, 1970; Freely 2009; Goodman 1990; Iqbal 2007; Isaacs 1990; Meyerhof 1984; Nasr 1976; Pormann and Savage-Smith 2007; Ullmann 1978). We need only pick out themes, including the spectacular internationalization of Near Eastern medicine after 600 A.D., which obviously set the stage for the Mongol transfers of medical knowledge.
Arab medicine before the rise of the Islamic caliphates was a rather chancy affair, if one is to believe Manfred Ullman (1978). Ullman records such remedies as camel urine, and says that “a woman who has only produced still-births” should trample “the naked corpse of a noble man killed either by treachery or the result of a blood feud” (Ullman 1978:2). One sees why the Arabs were so quick to adopt state-of-the-art medicine, i.e. Greek medicine, when they met it in Syria during their imperial expansion. Some of the depressing folk cures were later fathered on Muhammad, but, very fortunately for humanity, Muhammad was actually of a quite scientific and inquiring turn of mind, and established high standards of cleanliness, sanitation, empirical medical practice, and above all the direction to “seek knowledge even as far as China.” (This hadīth is not the best attested, but fits the character of the man, and I see no reason to doubt it.) The Arabs had a large body of excellent instructions on hygeine from the Quran and from the traditions (hadīth) of Muhammad (see e.g. Moinuddin 1985:54-55).
The Prophet was an astonishingly health-aware man for his time and place, and his words provided a solid framework for medical science. His direction about China opened the door for Greek, Iranian, and, of course, Chinese medical knowledge. (A sidelight on him, and on Islam, is his hadith “In the sight of Allah, the best food is food shared by many. To eat…alone is to eat with Satan; to eat with one other person is to eat with a tyrant; to eat with two other persons is to eat with the prophets (peace be upon them all)” (Moinuddin 1985:54). A related proverb, “when you sit in good company, sit long, for Allah does not count against your life the time spent in good company,” has recently been essentially confirmed by medical science; people live longer if they have enjoyed warm sociability, and the life extension actually is proportional to the time spent involved in pleasant socializing. This accurate observation, along with the Arab realization that pleasing tastes and sensations aided healing, should be remembered in all that follows.
Pre-Islamic Persian medicine was apparently a good deal more organized and developed. Zoroastrianism involved many purification rituals, some more pragmatically useful than others. Filth and putrefaction were banned from human presence. Hospitals and medical schools apparently existed (Elgood 1951:12). On the other hand, washing with urine was typical (Elgood 1951:15). Dogs were considered pure, and contact with them could cleanse defiled humans (Boyce 1979; Elgood 1951:9), but the danger of rabies was well recognized.
Fortunately, Muhammad had spoken favorably of medical practice, so the Near East was generally—but not always—spared from the Christian advice not to go against God’s will by treating illness (see Nutton 1985). Nor did Muhammad look favorably on the wonderful wandering community of gyrovagues, holy fools, divine madmen, drifting magicians and charm-dealers, qalandars, and other roving and demented healers who seem to have populated the Greek and post-Greek East in uniquely large numbers (Caner 2002; Dols 1985, 1992; both give delightful anecdotes). They continued in Islamic times, fusing with the Sufi movement, but were never viewed with enthusiasm. Medicine was serious, scientific business. After the Mongol period, magic and religious healing increased at the expense of scientific medicine in the Islamic world, but Muhammad’s relatively high standards still held in much of Islam.
On the other hand, in the Near East, as in the Roman Empire, Galenism had to compete with the fatalistic belief that God sent illness and was the only one who could properly cure it.
Serious appropriation of Greek science, including medicine, into the Islamic world began when the Ummayad caliphate consolidated control with a capital in Damascus. Contrary to some accounts, a major interest in science developed by the early 700s in the Ummayad realms (Dallal 2010:14). Individuals began to sponsor translations from Greek, usually via Syriac. The Syriac-speaking population of greater Syria had absorbed Greek civilization from long centuries of Byzantine rule. Doctors were highly literate and sophisticated—apparently fully integrated into the Greek cultural world. They soon found that the job of translatiing from Syriac to Arabic was easy compared to going from Greek to Syriac, and set to work. Multilingual scholars included at least some who also knew the Persian languages (Dallal 2010:15; Gutas 1998).
With the triumph of the Abbasids and their establishment of a capital in Baghdad, medical activity centered thither. Baghdad was a central location. It was founded around 760 A.D. by Caliph Al-Mansur. The famous Harun al-Rashid ruled there 786-809. He founded a great hospital, with live music to soothe the inmates and even—wonder of wonders—carefully prepared and supposedly excellent food. Good food was believed to be medically important, since soothing and delighting the senses was held to be curative—a point confirmed by modern medical research, if to a lesser extent than the Arabs believed. Modern hospitals should certainly take note. (On the sophisticated and excellent cuisine of the age, see Ahsan 1979; Rodinson et al. 2001.)
Music, too, was properly seen as therapeutic. One medical work—supposedly a Greek one, but probably a Syriac or Arab creation—is known from an Arab version in 815 AD. It recommends music for mental conditions (and evidently others), for reasons that go back to Pythagorean ideas: “…music…convey[s] to the soul…the harmonious souinds…of the heavenly spheres in their natural motion…. [W]hen the harmony of earthly music is perfect or, in other words, approaches the nearest to the harmony of the spheres, the human soul is stirred up and becomes joyful and strong” (Dols 1992:168-169). This reached to our Central Asian focal area of interest. By the 10th century, music was seen as part of metaphysics and important at cosmic, physical, and spiritual scales. “Here, the Greek notion of the harmony of the spheres meets the Iranian concept of the influence of the celestial bodies and the impact of sound on the individual” (Lawergren et al. 2000:598). Musicians were among the craftspersons moved all over the empire by the Mongols, and popular musical styles and usages must have diffused widely.
Hospitals—which abounded by the 900s and 1000s and were excellently appointed—continued to have high-quality live music at least into the 17th century, where the Turkish writer Evliya Chelebi observed it along with flowers used for visual relief and aromatherapy (Dols 1992:173). While not mentioned in the HHYF, this strong tradition of sensory therapy is vitally important to understanding Near Eastern medicine, and is echoed in at least the taste values of the HHYF. While the medical theories go back to Pythagoras, the development of a full sensory-therapy medicine seems to be an Arab and Persian creation.
Also noteworthy is the singular lack of blaming the victim in Islamic tradition and medicine. Illness is a test by God, often to challenge the strongest and most faithful to display their faith. It is not usually a punishment for sin or a result of foolish personal choices—though the results of excessive eating and drinking were all too well known, and inevitably led to some victim-blaming. (Both sensory therapy and “innocent until proven guilty” attitudes deserve more serious consideration today. Western medicine is heavily influenced by the belief that medicine was punishment by devils for sin, and had to be as unpleasant as possible, to punish the sinner and/or drive devils out of the body. This has carried over, far too often, into contemporary biomedicine and psychotherapy.)
Valuable in the rise of medical knowledge was Islam’s adoption of paper, said to have been learned from Chinese prisoners of war taken at the Battle of the Talas River in 751 (Hill 2000:273). This famous Arab victory stopped China’s expansion in Central Asia and contributed to the decline of the Tang Dynasty. By around 1000 A.D., water mills were being used for papermaking (as noted by Al-Bīrūnī, of whom more below; Hill 2000:273-274). This was the first known use of watermills for any purpose other than grain-milling.
Much of the transfer of Greek knowledge into Near Eastern civilization took place under the Abbasid dynasty (Al-Khalili 2010; Freely 2009; Goodman 1990; Kennedy 2004:253-260). The Abbasids were of Iranic origin, and thoroughly eclectic in their learning, wanting to counter the dominance of Arab culture as advocated by stern traditionalists (Pormann and Savage-Smith 2007).
Jabir ibn Hayyan (fl. 721-776) developed alchemy from Greek roots, and we trace modern terms like “alkali,” “antimony,” “alembic” and “aludel” (the last two being the upper and lower parts of a simple laborator still, respectively) to his usage.
A Christian Baghdadi, Yuhannā ibn Māsawayh, was instrumental in founding the Arab tradition. He was famous in Europe in later times as Mesue (from the Spanish Arabic pronunciation of his patronym; alternatively Mesue Senior, to distinguish him from a somewhat less eminent descendent). His father had been trained at Gundeshapor and emigrated to Baghdad. Mesue wrote original books as well as translating from Greek.
One who studied with Mesue was Hunayn ibn Ishāq, another Christian (Nestorian) Arab. He became a major translator of Greek texts in the early 9th century (Goodman 1990; ibn Ishāq 1980). He translated through Syriac, because it had a long history of developing scientific terms based on Greek; one assumes that his influence led, in turn, to development of scientific Arabic. Most of his translations were into Syriac alone, but he translated many into Arabic, with extreme care and detail (Isaacs 1990); his students, and eventually other medical writers eventually finished the latter task. He also wrote introductory texts in a question-and-answer framework to introduce Greek ideas to the Arab world. These have a certain amount of information about herbals and compounds, including the famous theriac, a mysterious and hotly debated Greek compound.
The philosopher Al-Kindī (9th century) had much to do with this, translating and writing treatises on much of the Greek learning, which led to his title “the Arab Philosopher.” (To the Arabs of that time, the Philosopher, par excellence, was Aristotle, so the phrase means “the Arab Aristotle.”). He supposedly produced 265 works. The Hippocratic-Galenic view was harmonious enough with Islamic cosmology and worldview to be accepted enthusiastically (Nasr 1976:159). Most of the translators were apparently Christian or Jewish (Lewis 1982).
Translation continued on a large scale, and the results were distributed widely. Many works from the Hippocratic-Galenic tradition, as well as other Greek scientific traditions, survive only in Arabic. (Many, but not all, exist in modern editions; several were published by Cambridge University in the 1970s).
Local medical works soon followed, such as the famous medical formulary of Al-Kindī (800-870; Levey 1966).
Baghdad was a truly international city, not least in its intellectual reach. Thus, many other medical traditions fed into the stream. Many scholars summarized classical Indian medicine (Al-Khalili 2010; Hamarneh 1973; Ullman 1978:20), as well as other Indian influences coming via Persia. Native medicine of the northern and northwestern Near East, including that of the Nabataeans (Hamarneh 1973:104), was also incorporated into the growing tradition. None of these displaced Greek thinking from primacy, but they progressively added to it and reshaped it. The role of Indian thinking, in particular, needs reassessment. Africa played into the mix in ways as yet hardly touched by historians.
Outlying areas were not neglected. An early “where there is no doctor” work was that of the Christian physician Qust.ā ibn Lūqā (820-912; Bos 1992), whose medical guide for pilgrims to Mecca indicates how well-integrated Christians and Muslims were in that time. In proper Hippocratic-Galenic fashion, he provides diet and regimen instructions, including directions for sexual health. Meal, barley, biscuits, sugar, and fruit are recommended, as well as easily-digested protein foods. Oils such as rose oil are valuable for the body (indeed they are, in the desert). The traveler is directed to be careful to avoid fatigue, which could compromise resistance to illness. The book is famous for providing an early discussion of the guinea worm (Dracunculus medinensis), then identified with Madina, now with Africa, where it is being rapidly eliminated today. Bos provides comparsions with Greek sources that show the author often simply carried the Greek straight over into Arabic.
Popular works made medicine widely available; such things generally disappear from the record and we never know they existed, but we have the keepers of the amazing Cairo Genizah to thank for saving a few scraps of Hebrew popular medicine along with the tens of thousands of other documents there (see below, and Isaacs 1990:348-351). The Thousand and One Nights tales also include popular medical lore along with so much else from the popular urban world of medieval Islam.
After this, however, translation of medical or any other materials from the Greek (and, indeed, all foreign languages) almost stopped. There are few major translations of scholarly lore into Arabic from 1000, and virtually none after 1200, until post-medieval centuries (Goodman 1990; Lewis 1982:76). Al-Ghazälī gets too much of the credit for checking the progress of Arab rationalism through his conversion to mysticism and traditionism and his consequent argument against rational philosophy (see e.g. Diyäb 1990; Goodman 1990); he merely happened to be the greatest thinker of the last great period of medieval Islamic thought.
The flow reversed; a trickle through Moorish Spain and Sicily quickly became a flood, and Arab works—including Arab translations of Greek texts—swept into Europe, reshaping its culture dramatically. The Muslim world, however, isolated itself for some time, with translations rare and translators mostly of Christian or Jewish background—often immigrants or captives (Lewis 1982).
The High Tradition in the Near East and Central Asia
All this led to a spectacular period of medical activity from 800 to 1300. It was overwhelmingly Greek in background, but Syriac, Arab, Persian, Indian, and even more remote influences were incorporated. Baghdad gradually lost leadership; Egypt, Iran, and Central Asia became important. A grand and unified tradition arose. After 1200 it declined, with little new being added. Europe took over the mantle of leadership, as the region reeled under the blows of invasion, war, plague, and other factors.
Iran rapidly grew as a medical source area, though Iranian medical men often had to go west to flourish. Haly Abbas—Ali ibnul-Abbas al-Majusi “the Magus,” 10th century—was one such. He wrote a huge treatise on medicine that remained standard until Avicenna’s Canon appeared; Haly Abbas’ work was still considered valuable enough to be translated into Latin, and it had much influence on Europe.
Central Asia for a while was actually the leading intellectual center of the entire world (Beckwith 2013; Starr 2012). A center of Buddhist thought and science, its conversion to Islam led to an intellectual explosion, as Greco-Arab science from the west met Indian, Chinese and indigenous science in Central Asia. From Buddhism came the organized, rigorous recursive arguments that later became standard scholastic method in the western world, and also the idea of the college—the Buddhist vīhāra became the Islamic madrasa (sometimes a building was simply converted from one to the other) and eventually reached Europe as the college, an institution first seen in the late 1100s after intense Islamic contacts (Beckwith 2013). Indian science entered in several forms, including translations of major Indian astronomical and mathematical works (see Beckwith 2013:81-85). Among worldwide benefits from this, perhaps the most important and well-known is the borrowing of the Indian numbering system, including zero, and the conversion of Indian written numbers into Arabic and then modern numerals. More to our task in the present book is the translation of several Indian medical works, including the great and basic Caraka-samhitā and Suśruta samhitā, into Arabic in the eighth century (Beckwith 2013:82). The epochal mathematician Al-Khwārizmi had much to do with this; as his name suggest, he came from Khwārazm, roughly modern Uzbekistan.
Through these central Asian contacts, the Arabs drew on Indian civilization with enthusiasm, picking up everything from the concept of zero to medical treatises on, for example, the “404 diseases” recognized by Mahayana Buddhism (Martin 2006). Indian and Chinese medicine somewhat influenced Near Eastern, but remained almost invisible compared to the Greek heritage.
Central Asia is of obvious special concern to us in this work. Its great doctors generally went to Baghdad, or at least to the Near East, in early times; thus ‘Ali b. Sahl Rabbān al-Tabarī (d. ca. 864), author of the Paradise of Wisdom (a notably early medical text), went west to seek his career. After the glory days of the Abbasid peak, medicine flourished in Central Asia with such leaders as Abū Bakr al-Rāzī (865-925). Al-Rāzī (Rhazes, 850-923) stands out as a judicious critic, who wrote on everything medical or related thereto. His work on measles and smallpox was still read in Europe in the 19th century, having been translated early (Turner 1995:135-136). The great polymath Al-Kindī also wrote on medicine (Beckwith 2013:86). A large number of other medical writers flourished under the Samanid dynasty in the region (Richter-Bernburg and Said 2000). Medical writings were appearing in the New Persian language by 980 (Richter-Bernburg and Said 2000:303).
Most famous of Central Asian medical writers was the polymath Avicenna (Abū ‘Ali Ibn Sīnā), the “Prince of Physicians” (980-1037; see Avicenna 1999, 2012, 2013). He was probably the greatest of all medieval medical and philosophical synthesists. He was also responsible for propagating the Buddhist recursive argument form in the Islamic world (Beckwith 2013). He was so revered that one of his personal copies of Galen (in Arabic) has been preserved (see illustration, Pormann and Savage-Smith 2007:42). His enormous literary corpus includes the Canon of Medicine (1999), which defined medicine not only in the Islamic world but, later, in Europe also, for centuries. It was a straightforward reworking of Galen, Paul of Aegina, and their tradition. He considerably extended the humoral medical tradition, mostly from logical extension; the book is notably lacking in case studies, and there is little evidence of his having been a working physician on any scale; he was a scholar and theorist (Álvarez Millán 2010; though for a less negative take see Starr 2012). The book is in five parts, dealing with general principles and definitions; simple drugs; illnesses; other conditions (from fevers and tumors to wounds, fractures, and poisons); and compound drugs. It will be noted that this organization is not dissimilar to that of the HHYF. We have, for instance, the HHYF section on wounds and fractures.
Relevant to the HHYF are passages on the differences of constitution and temperament caused by different climes; people of damp countries are “obese and have a soft and smooth complexion” and are easily tired (Avicenna 1999:210), mountaineers are “brave, strong, and have a long life” (Avicenna 1999:211). He contributed importantly to the theory of sulphur and mercury as basic chemicals, and he saw that transmutation of base metals into gold did not work (Abdurazakov and Haidav 2000:235). More specifically, his directions for treating ulcers (Avicenna 1999:537-540) are related to those in the HHYF, but quite different in detail; the HHYF is not drawing directly on him. He treated 590 medicinal plant substances involving 400 species, essentially the same as Dioscorides’ total (Abdurazakov and Haidav 2000:236) and with a very similar list of plants. Some are Chinese or Indian in origin (Richter-Bernburg and Said 2000:318); he was quite willing to add to the Greek pharmacopoeia.
Avicenna shows concern especially over food. A theoretical question concerns how food is digested and converted into human form (Avicenna 1999:220). This question exercised many great minds in ancient times; it was not obvious how a growing young person changed bread, meat and wine into bone, muscles and nerves. Avicenna did not pretend to know, but thought that the abstract qualities and character of the food were what mattered, allowing direct translation of the mere material substance. He classified foods not only as hot, cold, wet, and dry, but—following Galen—as rich or poor, light or heavy, wholesome and unwholesome. Interesting is his focus on wine; he discusses its values, qualities, and uses at enormous length in many parts of the book. This, of course, is purely Greek; Muslims in those days drank a great deal of wine, but were not supposed to admit it, let alone to talk about the many virtues of the drink! (It is true that Iranians like Avicenna had the Zoroastrian wine-loving tradition to draw on, and that is probably relevant here, but the specific instructions in the Canon are, as usual, Galenic.) Avicenna knew a good deal about anaesthetics such as opium (Avicenna 2013:403-404), and other effective herbal remedies, and had good advice on regimen, including regimen for travelers under harsh circumstances. He seems to have been more theorist than clinician, but well aware of clinical realities.
Al-Bīrūnī (Abū Rayhān Muhammad b. Ahmad al-Bīrūnī, 973-1048), another Central Asian polymath (from Khwarazm, his original language being the Iranic Khwarazmi), produced a medical formulary with 1116 drugs discussed; 880 were medicinal plants, 117 minerals, 101 animals, and 30 compound remedies (Abdurazakov and Haidav 2000:236). It was in alphabetic order by drug name in Arabic, and provided synonyms in Syriac, Greek, Sanskrit, Hebrew, Persian, Soghdian and sometimes other tongues, as well as description, literary references, uses, and varieties (Saliba 1990:420). He is much better known for his works on mathematics and geography (Al-Khalili 2010), but his work on medicine was influential and important (see also Beckwith 2013; Starr 2012).
Ibn al-Haytham (965-1039), another Central Asian, contributed to optics, understanding that vision depends on emanations from objects that define the form of the latter (rather than emanations from the eye, reflected from the object, as Aristotle and his followers thought). This understanding led to considerable development of scientific optics, including understanding of the rainbow, and was eventually influential in medieval Europe, where Roger Bacon and others knew Ibn al-Haytham’s work at some remove (Al-Khalili 2010; Hill 2000:260).
The Bakhtishu’ family of physicians contributed much to herbals. Ibn Bakhtishu’ (d. 1058) wrote a book “on the usefulness of animals,” following Aristotle’s zoology. It survives in a beautifully illustrated 13th century edition of a Persian translation (see Komaroff and Carboni 2002:142, 244). The illustrations, like other art of the time, were greatly influenced by Chinese art; this was the period of the Mongol information superhighway, and art styles flowed even more readily than medical knowledge.
Among the many later medical writers in the area, we may single out Zayn al-Dīn Ismā’īl b. al-Husayn al-Juzjānī (c. 1042-c. 1140). He has been called “Ibn Sina’s most influential follower” (Freely 2009:90). Writing in both Persian and Arabic, he made Khwarazm a center of medicine after 1100. His work was highly influential on medicine in Europe and the west as well as central Asia. He compiled an encyclopedia, the Treasury Dedicated to the King of Khwarazm, based on Ibn Sina’s Canon (Freely 2009:90). This work may very well be particularly important as an ancestor to the HHYF.
Related to medicine in that it shows a major knowledge of biological technology is the early use of oils in painting in Central Asia; the earliest use of oil paints in that area is at Bamiyan. European use of oil paint (not counting animal marrow in prehistoric cave art) came later (Holden 2008).
Unfortunately, Central Asia, world leader for half a millennium in almost all intellectual pursuits, declined in the 1100s and was utterly devastated by war and disease in the 1200s and 1300s. The Turks and then the Mongols did a thorough job of ravaging a land that had never been very well governed. The rulers of Central Asia were rarely equal to their philosophers and scientists, and in any case a realm consisting of far-scattered oases in a vast desert is not easy to hold together.
After the 1200s, the Little Ice Age hit the formerly flourishing economy very hard, and the Silk Road—already declining after the fall of Tang in 907—was eclipsed by the steady rise in sea trade, of which the Portuguese explosion in the 1400s was only the final culmination, not the origin. Central Asia was never to rise again, and remains, of all places on earth, the one that has fallen farthest. Afghanistan, once one of the most brilliant regions, now ranks at or near the top on lists of the world’s most troubled nations.
Frederick Starr (2012) and Christopher Beckwith (2013) agree that much of this was due to resurgent puritanical right-wing Islam, especially as advocated by the brilliant and troubled Central Asian theologial Al-Ghazālī (1058-1111). I find it hard to believe that an ideology, and especially a single ideologist, can devastate a region for centuries—though we have the baneful effect of Marxism in Russia and China as modern exemplars. I would respectfully point to the other factors, especially the decline in Silk Road trade as China and India went through waves of war and conquest (often—ironically—by Central Asians). The brilliant ferment that came from Greco-Arab and Buddhist civilizations meeting was lost forever. In Europe, however, it began at the same time Central Asia fell; Beckwith (2013) rightly compares the effect of Arabic and Islamic civilization on Europe with the effect that western culture had on Japan after the Meiji Restoration. But that is largely outside our purview here.
Moving back from Central Asia to the Near East, among many important works by Muslim Arabs we may single out Ibn al-Jazzār’s Provisions for the Traveller and Nourishment for the Sedentary (10th c?), because it is now well-known in English thanks to the exemplary work of Gerrit Bos (e.g. 1997, 2000).
Abd al-Latīf al Baghdādī (1162-1231) traveled from Baghdad to Egypt, observing it in 1200-1202, during a time of plenty followed by a low Nile flood that led to massive famine. Perhaps a third of the population died. His great book The Eastern Key (1964) describes the enormous feasts of the good years, when a recipe for a light picnic lunch requires four whole sheep baked into three pies. It then describes the horrific deaths of the year of Nile failure in what is still one of the best descriptions of famine in all literature. The mass death allowed al-Latīf to observe that the jawbone is one bone, not made up on two bones as Galen held. This was a rare triumph of observation over dogma in Arab medicine.
Ibn Rid.wān also wrote of Egypt, noting, among other things, that wheat and other grains grew quickly there but also quickly rotted in storage. He correctly realized that this was due to the hot, damp climate, and assumed that humans would do the same, since they not only lived in the same climate but lived on the grain and thus absorbed its nature (Mikhail 2011:204). The principle of “early ripe, early rot” was well established in medicine of the time. He and other doctors were also aware, in spite of the Islamic dubiety about “contagion” (see below), that Nile water could carry disease if dead animals and sewage were thrown in it (Mikhail 2011:204-212). Ibn Rid.wān also anticipated modern good sense in advising peopple to “choose foods that were new, fresh, firm, and solid,” including “the most recently caught fish” and meat from “young animals that had been allowed to graze freely on fresh grass” (Mikhail 2011:213).
Other triumphs included clear descriptions of diseases. Hippocrates and Galen were still struggling to figure out which symptoms were significant and which were not, leaving us puzzled today at their descriptions of epidemics. The Arabic literature thus gives us the first identifiable descriptions of smallpox, measles, hemophilia, and other clinical entities (Pormann and Savage-Smith 2007:56).
Syriac Christian medicine continued to flourish and developed as part of the same stream. Oddly, our only complete translation of an encyclopedic medieval Near Eastern medical work is Wallis Budge’s translation, now over 100 years old, of an anonymous and obscure Syriac manuscript he found in Mosul (Budge 1913). He thought it was from the 12th century, but the medicine seems more similar to that of the 13th and 14th—at least the prescriptions are very similar to those of the HHYF and its Near Eastern contemporaries. The manuscript consists mostly of an excellent, thorough summary of medieval Galenic medicine, to which was added a long astrological and meteorological treatise and a short section of folk cures. The latter are strikingly different from the first section. The first section is typical of the elite Galenic tradition of the time. The last section runs heavily to outright magic and to brief cures based on dung, carcasses, urine, menstrual fluid, and other classic ingredients of magical folkloric healing. Descriptions of conditions and cures are very brief. We are evidently dealing with an uneducated, unlettered tradition transmitted largely by word of mouth, and rarely reflected in writings.
Islamic medicine had shunned the concept of contagion (Stearns 2011), because Muhammad said in a famous hadith that contagion, ghouls, evil omens, and similar magical things do not exist. This makes it appear that Muhammad was speaking of something like sympathetic magic or magical pollution, especially since he also gave a great deal of good public-health advice, ranging from hand-washing and other personal sanitation issues to saying that one should not water sick camels with healthy ones. The ambiguity allowed the more liberal and medically-experienced Muslim, such as ibn Rushd, to bring in contagion through the back door (so to speak; see Stearns 2011). And of course pragmatic administrators acted as if contagion were real, not worrying too much about the official position (see e.g. Mikhail 2011:215-217). In hospitals, for instance, “special sections were reserved for the treatment of contagious diseases” (Dallal 2010:22). In general, however, even after the great plague of 1346-48, Islamic medicine did not allow much exploration of the idea; the plague was ascribed to jinns piercing people with darts. Christians were much more receptive to the contagion idea, but tended to think of it more as a metaphor for sin and heresy than as a scientific way to deal with disease; however, their openness allowed them to invent and invoke quarantines and other ways of dealing with the plague, as well as leprosy and other matters (Stearns 2011). Plague returned often—every nine years, on the average, in Egypt (Mikhail 2011:215)—and had much to do with keeping the Near East from developing along with the western Mediterranean (Dols 1977).
The plague itself spread west with the Mongol armies, and supposedly it was transmitted to Europe via Mongol-held Kaffa (near modern Odessa), where the Mongols used defunct plague victims as missiles to hurl into the city while besieging it (May 2012:200ff.). Genoese ships then carried it to Europe. The Mongols had lived with it in central Asia, where it is endemic among rodents. It spread to black rats, and with them it spread throughout the world; as is well known, fleas, especially the rat flea Xenopsylla cheopis, transmit it to humans. In China, it never became epidemic in the way it did in the west, for several reasons: different strains of plague, different rat ecologies (Benedict `1996), long exposure and thus adaptation, and probably other factors (Buell 2012).
Spain and North Africa soon followed Baghdad into scholarship and the arts. They soon took on central roles (see e.g. Álvarez Millán 2010). Spanish Islam produced its first medical works in the mid-tenth century. These were rather ordinary Galenic offerings. also a Greek manuscript of Dioscorides became available then, and was translated (not fully; Castells 1998; Fierro and Samsó 1998:xliv). In the latter half of the 10th century, medicine developed fast, climaxing in the work of Abulcasis—Abū l-Qasim al-Zahrāwī (936-1013)—who produced a huge encyclopedia of medicine that remained standard in the west for centuries and is still a basic source on Arab medicine (Fierro and Samsó 1998). Medicine continued to flourish, with further herbal work, influences from astrology, and local influences from the Christian realms of Spain. Again, this marginal region produced one of the truly great figures: ibn Rushd (Averroes, 1126-1198), from Cordova. An Aristotelian, he influenced medieval European thought profoundly (Leaman 1988). He discovered the fact that “the retina rather than the lens is the sensitive element in the eye” (Freely 2009:117). Many of the Spanish doctors, unlike Avicenna, were active clinicians (Álvarez Millán 2010).
Sicily and south Italy also became major players (see e.g. Skinner 1997), especially as the tolerant Normans conquered the area and enthusiastically propagated Arab learning in the 11th through 13th centuries. The most durable example of this has been the Taqwin, an Arab health manual written by the Christian physician ibn Butlān (d. 1066, just as the Normans were conquering England). It was translated, as the Tacuinum Sanitatis, at the court of King Manfred of Sicily (r. 1257-1266). A more complete version and a shorter but well-illustrated version eventually circulated (Sotres 1998); eventually there were six major Latin translations. An excellent introduction to the work, by Loren Mendelsohn (2013), shows that several differences between the Arab and the Latin versions appeared. Most of these involved leaving out rare and complex Arab foods and adding common European ones.
Versions of the Tacuinum are still in print. It became enshrined as almost sacred writ when a great school of Arab-Italian medicine developed at Salerno, just south of Naples. The School of Salerno remained the center of medicine for Europee through the medieval period. Legend has it that the school was founded by an Italian, a Greek, an Arab, and a Jew. It circulated the Tacuinum, which in turn evolved into the Salernitan rule, or Regimen sanitatis salernitanum, which appears actually too recent to have been written at Salerno. The Salernitan rule was famously translated by Sir John Harington in Elizabethan times. He set it in doggerel, and some of his lines are still famous, especially
“Use three Physicions still; first Doctor Quiet,
Next Doctor Merryman, and Doctor Dyet.” (Harington 1966:22.)
Still the best medical advice. The Tacuinum and its offshoots also advised moderation in all things and regular, vigorous, but not excessive exercise. These counsels are still with us, delivered by almost every health care provider. The Tacuinum remains influential.
Another thing that has not changed is the university student: “as the contemporary saying went, [students learned] liberal arts at Paris, law at Orleans, medicine at Salerno, magic at Toledo, and manners and morals nowhere” (Whicher 1949:3). This proverb gives a good concise guide to the top universities in medieval Europe.
Jews contributed greatly to medieval medicine throughout the western world. The Cairo Genizah, a vast collection of papers from a largely Palestinian Jewish congregation, has thousands of medical lists, books and scraps (Lev and Amar 2008). It reveals an incredibly rich and full medieval world (far more sophisticated and complex than the history books had previously allowed with their stereotypes of simple faith, dirt, and backwardness). This applies with full force to medicine. There were countless Jewish doctors, and they were well aware of materia medica. The Genizah held remnants of 35 medical books, to say nothing of countless letters, lists, deeds, and so on; the books break out about a third Greek (translated; Galen and Hippocrates feature heavily), a third Arabic, and a third medieval Jewish (Lev and Amar 2008:16).
Greatest of them all was Mūsā ibn Maymūn, Maimonides (1135-1204), was born in Cordova, but had to flee the Almohads, settling in Egypt as physician to the ruler. Here he wrote some of the greatest medical works of the entire medieval period, as well as some of the greatest philosophical works of all time. Joel Kraemer (2008) has provided an excellent summary of his life, drawing heavily on actual surviving letters, rulings, and other texts, often in Maimonides’ own hand, that survived in the Cairo Genizah. Unlike the other writers discussed here, Maimonides has not been relegated to “history”; his medicine is largely out of date, but his works on Judaism and Jewish law are still used as authoritative sources, and his philosophical writings are still read with great profit.
Even his medicine is inspiring (Rosner 1998); its common sense, reasonable advice on regimen, and thoroughly enlightened attitude toward practice are still useful. Most of it is available in English, thanks especially to the intrepid Jewish medical doctor and translator Fred Rosner, and Maimonides’ drug glossary has been especially useful in the present work (Maimonides 1979; see also Maimonides 1970-1971, Maimonides 1997). His advice on wine is worth quoting. Finding it the best of medicine but banned by Islam, he told Muslim rulers: “The legislators have known, as have the physicians, that wine is beneficial to mankind…. [T]he law [shari‘a] commands what is beneficial and prohibits what is harmful in the next world, whereas the physician gives counsel about what benefits the body and warns against what harms it in this world” (as translated by Joel Kraemer, 2008:455).
Contrary to the general case of Islamic science’s decline after 1200, medicine continued to flourish, grow, and incorporate more traditions in Islamic lands, perhaps most especially in the Indian subcontinent, where Hippocratic-Galenic traditions interfaced with Ayurvedic ones. The more Galenic (and thus more Islamic) side of the resultant fusion became known as Yunani, from “Ionian”; the Ayurvedic remained more Indian.
However, the Mongol invasions, the bubonic plague epidemics from 1346 on, and the expansion of Turkish and Persian imperial power all devastated the old Islamic core areas of Central Asia, Egypt, Syria, the Levant, and Mesopotamia—the areas where science had most flourished. This, as well as the slow shift of economic and political dynamism to Europe, led to a relative stagnation of Islamic science after 1350. However, one should emphasize the word relative here. Islamic regions fell farther and farther behind Europe after 1600, but, as with China (at least through Ming; see below), this is a matter of relatively slower advance in research activity, not of actual Dark Ages. Many medical works continued to appear.
Medical practice ran largely to regimen management, with foods blending into drugs via what we would now call nutraceuticals: poppy seed, nuts, honey, rose petals, and other things that were foods but were often (or even largely) eaten for medical effects. Bleeding and cupping were common, but the obsessive bleeding that characterized European medicine in the 18th century was not found. Surgery was frequent, but avoided when possible; in those pre-antiseptic days, it was highly dangerous. Some doctors, such as al-Rāzī, kept careful records and even experimented, resulting in important innovations in knowledge. Others did not, and in general the Galenic tradition persisted. Knowledge was added—slowly—but dramatic changes were few.
Infant rearing was quite enlightened by modern standards. Islamic law directs breastfeeding for two years, and interestingly equates milk kinship with blood kinship, a point strongly developed by Muhammad (Gilani 1999). Otherwise unrelated children nursed by a woman are siblings for life, and the woman remains a mother to them. Drawing from Galen and Soranus, medieval doctors gave good instructions on nursing babies, choosing wet-nurses, weaning, and regimen in general (Gilani 1999). As so often, Ibn al-Jazzār was notable for particularly sensible directions. The instructions for choosing a wet-nurse remain quite similar over time and space.
Islam has a strong and significant environmental ethic; the Quran and hadith both emphasize taking care of animals, plants, and nature (Dien 2000; Foltz et al. 2003). Relations with medicine are indirect but significant; the Muslims took care to preserve their environments, including medicinal herbs. However, playing against this went the imperative and immediate needs of herders, who inevitably overgrazed their pastures and overcut firewood whenever populations expanded or were limited by threat or harsh conditions. With modern times, traditional controls have weakened while popoulations have exploded, leading to rapidly worsening ecological situations in most of the Middle East. This should not be taken as a failing of traditional cultural patterns.
The Galenist Ibn Ridwān wrote in Egypt in the Fatimid period (that rare period when Egypt ruled the west). He believed in miasmas affecting variously susceptible bodies. He followed the classical view in discussing six conditions to examine: “ (1) air…;(2) food and drink; (3) movement and rest; (4) sleep and waking; (4) retention and evacuation; and (6) psychic events [mental states]” (Dols 1984:89). He evaluated Egypt in all these ways, and found it rather wanting in many respects; food spoils incredibly fast, imported animals get sick, and Nile water is good but polluted with sweage (still true today). Egyptians themselves are “feeble, quick to change, and lacking patience and endurance” and even prone to “timidity and cowardice, discouragement and doubt, impatience, lack of desire for knowledge and decisiveness, envy and calumny,” and so on (Dols 1984:93). He admits that there are exceptions, but even claims that the land is so coward-making that “lions do not live in this country; if lions are brought to Egypt, they become meek” (ibid.).
He has startlingly modern-sounding strictures on water and air pollution. He provided enormously detailed instructions for counteracting these by heavy use of herbs, scents, and other environmental amendments; many of the herbs rrecommended are strongly antiseptic, and would, in a word, work. Each season and each type of personal temperament required a different amendment, but, for instance, most of the amendments to the dirty Nile water actually involved cleansing and antibiotic agents. He also provides many complex remedies for illnesses.
For instance, irascible (choleric) people should use tabashir (a chalky substance), Armenian (red) clay, red earth, jujube, hawthorn, and vinegar. Placid (presumably phlegmatic) people should use bitter almonds and apricot pits with thyme and dill (Dols 1984:135). The former mix seems more heavy and sour, the latter more bitter and astringent. Evidently this was necessary to accommodate the different humoral makeups in question.
He also sounds quite modern in his long section telling the doctor to examine the environment and the patient, taking into account every aspect of the latter and his or her condition. It is worth giving the whole list (Dols 1984:120-121): “(1) the temperament of the country; (2) the indigenous illnesses; (3) the current season; (4) the temperament of this season; (5) the epidemic illnesses; (6) the diseases existing in the body and in what limb; (7) the cause of the illness; (8) the degree of strength of the illness; (9) the symptoms of the illness; (10) the intensity of the symptoms; (11) the strength of the patient; (12) the temperament of the patient; (13) the age of the patient; (14) the temperament of the limb affected by the illness and the limb’s functioning, form, and position; (15) the external appearance of the patient; (16) the nature of the patient, whether male or female; (17) his habits in times of health; (18) the nature of the foods and medicines; (19) his usage of them in times of health and illness; (20) the foods and medicines that are desirable for the doctor to select at times of health and illness; (21) what the treatment should be ;(22) what is the proper time for treatment; (23) what is the porpoer limb for administering treatment; (24) the patient and whoever cares for him should follow the instructions of the doctor; and (25) the cirucmstances of the patient should be conducive to recovery.” That should do it! The patient of a doctor conscientious enough to do all that was in good shape, even given the awful realities of medieval Egypt. Alas, some doctors were more concerned with looking distinguished—growing long gray beards and having fine steeds—than with medical care; again, the world can still well heed Ibn Ridwān’s advice about that.
Hospitals, public health, medical examinations and certification, care of the mentally ill, women doctors, and many other modern phenomena all had their start or reached high levels of development in the Muslim Near East (see Pormann and Savage-Smith 2007 for accounts).
Especially now, when Islam is accused of all manner of innate flaws and sins, it is well to remember that Islamic medicine was a world leader for centuries, while Europe stagnated, and that Islam spread a broadly scientific, naturalistic, and rational medicine throughout millions of square miles and thousands of diverse peoples.
Noteworthy was the relatively high level of secularism and religious tolerance of the age. Christians, Jews, and others, as well as Muslims, practiced medicine, shared in scholarship, and taught each other. People from all regions of the Middle East, Central Asia, and North Africa met and worked together harmoniously. The famous “convivencia” of Moorish Spain was only the best-known example of a widespread tolerance. That tolerance was never perfect, but it was comparable to the west today, and far different from so much of the modern Middle East.
Admittedly, the basis, including the basic scientific and rational spirit, was Greek, so one might speak of Greco-Islamicate medicine. But the influence, development, and propagation of the tradition belong to the Islamic world, especially the Arab and Iranic authorities. One recalls that not only did the Islamic world follow this path; it spread far beyond Islam in India, as the “Yunani” (=”Ionian”) tradition, and also swept almost all before it in Europe in the Renaissance. Thence it was carried to the New World, where hundreds of millions of ordinary people still live in some measure by the teachings of Galen and Hippocrates as reflected through Avicenna and his peers and followers. No religion, no political philosophy, no body of belief, no modern scientific teaching has influenced so many people so much.
Along with Greek medicine came vast amounts of local traditions (including herbal ones), magic, faith-healing, and other folk-medical forms (Dols 1992). These remain poorly studied and documented, but are not particularly relevant to our purposes herein.
A good idea of the closeness with which the HHYF followed Near Eastern practice comes from its recommendations for treating wounds in which the intestines have partially come out of the body. They are to be replaced and the wound sewn up, of course, but the HHYF goes further in recommending use of black grape liquor (juan 34, p. 18), as does Maimonides (Bos and Langermann 2012:247), though both the HHYF and Maimonides are confused enough to make it hard ot know exactly what is being done. As nearly as I can understand, the liquor—possibly distilled—is being used to wipe and clean the wound. Maimonides says it is “to alleviate pain,” but it is unclear whether it is drunk as an anaesthetic, used in a clyster (discussed just previously), or used on the wound, as the HHYF states.
Near Eastern medicine was incorporated in European medicine progressively after 1000, and especially after 1200. By 1300, Europe had caught up, using both translations of Arabic sources and translations of the actual original Greek ones. Use of cadavers in teaching came back into vogue about that time (Siraisi 1997:188). However, Europe simply followed the greats of the past until around 1500, when the dramatic breakthroughs that gave us modern science began. Andreas Vesalius questioned antiquity and developed modern anatomical research; Ambroise Paré found that treating wounds with boiling oil was a bad idea, and started using ordinary salves; and Paracelsus (1493-1541) threw out the whole Greco-Arabic system, from the Four Elements to traditional medicine, and invented a whole new system—itself far from perfect, but the start of a trend that was not to stop (Siraisi 1997:193).
Most interesting of all was the realization that diseases were actual entities with their own characteristics—they were not just various forms of humoral imbalance. Paracelsus realized this, but the major credit for changing the paradigm is generally given to the English doctor Thomas Sydenham (1624-1689). This is stunningly late for such a major breakthrough. The bubonic plague of 1346-50 (on which see Buell 2012) had been a disease so new and unique that no one could fail to see it as an utterly alien and incomprehensible force that could not be easily accommodated in Galenic medicine. An even bigger shock to the Galenic system was the explosion of epidemic syphilis after 1492. Columbus’ men almost certainly introduced it from the New World. In any case, it was not only a new disease, but was transmitted by an unusual route; in spite of gonorrhea (apparently not common), sexually transmitted diseases were not salient in European medical thought. Girolamo Fracastoro described and named it in 1530, and thus made it clear that a new and distinctive disease could appear; everyone should have realized that the old paradigms were dead. It is more than interesting that this did not happen. The time was simply not ripe to question the ancients.
All this coincided in time with China’s stagnation (and later decline) in learning, innovation, exploration, and other early scientific activity. China’s greatest herbal, Li Shizhen’s Bencao Gangmu, was to be its last truly innovative and brilliant one; ironically, it appeared at almost exactly the same time as the first great European herbals, by Rembert Dodoens, John Gerard, and others. Similarly, Paracelsus’ new system, aggressively and self-consciously grounded in new materialist and experimental views of the world, coincided with Wang Yangming’s definitive retreat into mysticism and meditation—Confucianism’s final flight from the real world. Late Ming was the last flowering of Chinese science; the Qing Dynasty ran on momentum for a while, then declined into the tradition-bound obscurantism that European observers of the Qing world wrongly thought typical of all Chinese history.
Finally, “an example of knowledge flow from the Near East to Europe may be of interest. The idea of circulation of the blood seems to have started in Islamic lands. Bernard Lewis (2001:79-80) records that “a thirteenth-century Syrian physician called Ibn al-Nafīs” (d. 1288) worked out the concept (see also Kamal 1975:154). His knowledge spread to Europe, via “a Renaissance scholar called Andrea Alpago (died ca. 1520) who spent many years in Syria collecting and translating Arabic medical manuscripts” (Lewis 2001:80). Michael Servetus picked up the idea, including Ibn al-Nafīs’ demonstration of the circulation from the heart to the lungs and back. William Harvey (1578-1657) learned of this, and worked out—with stunning innovative brilliance—the whole circulation pattern, publishing the discovery of circulation in 1628 (Pormann and Savage-Smith 2007:47). Claims that al Nafīs’ observation was a mere lucky accident, and that Harvey’s discovery was quite independent of it, have been disproved (Dallal 2010:179). Galen and the Arabs thought the blood was entirely consumed by the body, and renewed constantly in the liver. They did not realize that the veins held a return flow; they thought the arteries carried pneuma, the veins carried nutrients. Harvey’s genius was to see that blood actually circulates continually, ferrying nutrients to and from the whole body in a closed circuit.” (quoted from my paper “Science and Ethnoscience,” posted on my website, www.krazykioti.com).
Simples, as noted above, followed Dioscorides. The path of transmission went from Greece to Rome to Byzantium, where Princess Juliana Anicia was gifted with a spectacularly beautiful illustrated one, a real work of art, around 512. It is now the oldest surviving illustrated herbal in the world (Collins 2000:39).
The thread then went to the Muslims, as the Byzantine Empire began to decline. Compound formulations were recorded in aqrābādhīn works (the word is Greek, graphidion, “prescription,” as transliterated into Arabic). The first was that of Sābūr ibn Sahl, written in the 850s under the Abbasids (Hamarneh 1973:56), but the most important early one was by “the Philosopher” al-Kindī (ca. 800-870); it has been translated by Martin Levey (1966). Levey finds that in it “31 per cent of the materia medica comes from Persian-Indian soiurces, 33 per cent from Mesopotamia, 25 per cent from Greek origins, 5 per cent from Arabic, and 3 per cent from ancient Egyptian origins” (Levey and al-Khaledy 1967:28), so the Arabs did not slavishly follow the Greeks—though one must point out that many of the drugs from other regions reached the Arabs via Greek sources. After that, formularies flourished throughout the Islamic world, and of course Rhazes, Avicenna, and other famous medical writers had a hand in compiling them. They display a considerable sophistication in chemistry; for instance, experts knew the differentiation of milk into water, butter, and protein (known as the “cheese forming” fraction of the milk; Hamarneh 1973:78).
Perhaps the greatest was produced by al-Bīrūnī (973-1048), of Khwarizm, famous also for his great work on India (Alberuni 1973). His pharmacology lists 850 drugs, with names in several languages. Amazingly, this incredible work has been edited and translated (al-Bīrūnī 1973), with identifications of biota—a job rivaling the compilation of the original! Thus it can be drawn on for our purposes here. It is important to observe how many leading scientists and medical persons of this period were Central Asians: al-Bīrūnī, Jūzjānī, al-Samarqāndī, and many others, including of course the greatest of all, Avicenna. Central Asia had a real leadership position in the world at this time. This point has not been made often enough in explaining the rise and success of the Mongols. It is obviously critical to the HHYF and similar cultural exchanges.
Ibn Jazlah, whose work we draw on below, followed a century later.
That of ibn al-Tilmidh (of Baghdad; d. 1165) is representative of the best of the aqrābādhīn tradition (Hamarneh 1973:57-64). It had 20 chapters, covering troches (tablets; 42 recipes), pills and cough medicines (27), powders (28), confections with spices and flavors (26), electuaries (20), lohocks (from the Arabic for “lick”; 21); syrups (from the Arabic root shrb, “drink”; 27); robs (rubb, thick syrups; 10); medicated food decoctions (20), ophthalmic medicine (10), anointing oils (10), ointments (12), dressings (13), enemas and suppositories (15), oral medications including dentifrices (15); fattening aids (11); sternatatories, gargles, fumigators (5); bleeding-stoppers (5); emetics (5); sudorifics and antisudorifics (3+).
A good example of a remedy is one from Ibn al-Jazzār (d. 980):
“A recipe for a pastille which I have composed that will increase sexual desire, refresh the soul, warm the body, expel gas from the stomach, put and end to coldness of the kidneys and bladder, and incrase memory: Taken in the winter, it will warm the limbs. Its uses are many, and it is one of the ‘royal electuaries,’ and I have named it ‘reliable against calamities’…. Take seven mithqāls each of chinese cinnamon, sweet cost, Indian spikenard, saffron, fennel seeds, ginger, dried mint leaves, wild mountain thyme, mountain mint, cinnamon bark; of Indian’malabathron,’ long pepper, white peopper, black pepper, asarabacca, plum seeds, cultivated caraway, cloves, galingale, and wild carrot, four mithqāls each; and of hulled sesame, shelled walnuts, shelled pistachios, shelled fresh almonds, pinenuts, and sugar candy, eleven mithqāls each. Pulverise the ingredients, sieve vigorously, combine, and knead with honey of wild thyme, from which the froth has been skimmed, until the remedy is well mixed. Store in a vessel that is smooth on the inside, fumigated with Indian aloes [a standard fumigant to sterilise the jar as much as possible]. An amount the size of a walnut is to be taken before and after meals. And it will be efficacious, God willing” (quoted Pormann and Savage-Smith 2007:51). This combines all the common warming and nourishing agents that were also pleasant-tasting. Recall that the latter quality was considered very important in curing. The recipe would produce a candy rather like those still used throughout the region for exactly the same purposes, such as Turkish delight, Moroccan argan-almond-honey paste, and the more elaborate halvah mixes.
To some extent, this is medicine for the rich. Only a very rich man (this recipe is for the male) could afford to accumulate all these drugs, some exotic and expensive. Only a rich man could comfort himself with the fountains, aromatics, and live music prescribed in other books. On the other hand, almost anyone could get at least some of the medicinals listed. One assumes that buyers were quite aware that even a few of these would make a perfectly acceptable product.
A golden age of botany climaxed in the 12th and early 13th centuries (Idrisi 2005), informing the Mongols but paradoxically being impacted negatively by their conquests. Several books appeared, including one on the sex of plants, long before the European “discovery” thereof around 1700.
Again, Spain was a leader, and its pharmacology influenced the Near East (Meyerhof 1984). The Byzantine emperor presented the Ummayyad caliph ‘Abd al-Rahmän III with an edition of Dioscorides around 950, and this was translated from the Greek, introducing it to the western Arab world (Goodman 1990:494; Lewis 2008:331). The Spanish Arab Ibn al-Baytār (d. 1248; lived in Malaga) produced a Comprehensive Book on Simple Drugs and Foodstuffs with over 1400 medicaments in 2324 entries, reviewing almost everything in the literature (Pormann and Savage-Smith 2007:53). Of course, Spanish pharmacognosy influenced Europe; transmission through Spain and Italy were the routes by which all this material reached Europe in the medieval and Renaissance periods. The Reconquista led to a lapse, however, with plants like bananas, sugar cane and eggplants going into relative oblivion for a while (Idrisi 2005).
Following Galen, doctors designed drug and diet regimes for specific persons, according to individual temperament and environment. Nasr wisely remarks: “It is paradoxical that in the highly individualistic modern civilization there is a crass uniformity in medicine which assumes that the reaction of all bodies to a drug is the same or nearly so, whereas in traditional medicine belonging to a civilization in which the individual order is always subservient to the universal order each patient is treated invidiually and his temperament taken to be a unique blend of the humours never to be fouind in exactly the esame balance in another individual” (Nasr 1976:162). This is as true of China as of the Near East.
Unlike the main Galenic works and the great medical encyclopedias, these pharmacological works did not travel. They never made it to Europe, until very late, when they became part of the Dioscorides-related material that entered with the Renaissance. Even today, very few Arab or Persian pharmacologies, folk-medical works (e.g. Moinuddin 1985), or other pharmacognostic materials are known in the western world.
The tradition climaxed soon after, in time to be available for the Mongols. Contemporary, and close to their homeland in origin, were the Central Asian herbalists Badr al-Dīn Muhammad b. Bahrām al-Qalānisī, author of a huge aqrābādhīn (c. 1194; see Richter-Bernburg and Said 2000:310), and Najīb al-Dīn al-Samarqandī (d. 1222). The latter was author of many medical works including an aqrābādhīn that has been translated and studied by Martin Levey and Noury al-Khaledy (1967). It incorporates substantially more Indian remedies than earlier works, showing that the HHYF’s strong Indian influence was not unique. More specifically, Al-Samarqandī and the HHYF make heavy use of myrobalans, turpeth, Persian and Indian minerals, and other Perso-Indian remedies.
Levey and al-Khaledy note a number of Indian loanwords in the medicinal vocabulary, contrasting with the almost purely Greek and Arabic language of early works. (Levey and al-Khaledy exaggerate the Indian presence, however, by including many herbs known to Greek medicine and transmitted by Greek texts to the Arabs; sometimes, as perhaps with kinnamon and certainly with kardamon, the original reference was probably to a Greek plant and only later came to refer to an Asian one.) It seems almost certain that this herbal directly influenced the HHYF. None of the recipes seems exactly the same, but many are extremely similar. Both share a constant recursion to the same few herbs: dodder, turpeth, myrobalans, saffron, sarcocol, pomegranate rind, myrrh and frankincense, and others. (They also share a fondness for mint, thyme, and rose, but so did most other herbals in the Old World, so this is not significant.)
From the 1200s, Europe overtook and quickly passed the Arabs, and the great herbal tradition of European art and medicine grew rapidly (Collins 2000). By the early 1600s, it was far ahead of anything else in the world—but that is another story.
This makes the HHYF a truly key text, since it embodies so much sophisticated pharmacology. It too seems to have owed more to encyclopedias than to any specific pharmacological work, however.
A Comparison Case: Astronomy
Medicine spread along with other sciences, and it is instructive to look at another well-documented case, because it is suggestive in this context. Scott Montgomery (2000) and John Steele (2008) have chronicled the transfer of astronomic knowledge from ancient Mesopotamia to Greece to Rome and the Near East. It was a long and fascinating process. Mesopotamia perfected an amazing range of astronomical observations and plans, and developed astrology, a high science until its slow fall from grace after the Renaissance in Europe. Greece quickly learned from Babylon and Syria, and added both scientific astronomy and detailed, carefully calculated, extremely extensive astrology to its scientific repertoire (Steele 2008).
The transfer to Rome was fairly automatic; Rome took over first Magna Graeca and then Greece itself, enslaved many Greek scholars, and learned assiduously from the Greeks and their books. It remains ever fascinating that the Romans, almost alone in world history, were not only willing but eager to learn from people they had conquered and enslaved.
Those other empire-builders the Arabs were the only other group to do this on a large scale. Quickly realizing the value of such learning, they propagated it, especially under the Ummayad and Abbasid Caliphates. The Arabs showed more interest than the Syriac or even Byzantine scholars had (Saliba 2007). In fact, very little astronomical or other learned lore survives from those cultures (except, fortunately, in medicine; Scarborough 1984; note in particular that the Byzantines preserved the Dioscorides pharmacopoeia). Much more survives from the Islamic world. In the 9th century, the Abbasids caliphs supported astronomy based on Ptolemy but improving his observations; meanwhile, mathematics flourished, as translations of the foundational work of Diophantos stimulated the work of al-Kwārizmī and many others (Herrin 2008:126).
The Greek astronomers’ observations were supplemented more and more by Arab observations. Instrumentation steadily improved (Montgomery 2000; Nasr 1976; Steele 2008). Alhasan ibn al-Haitham (Alhazen), for instance, discovered that light rays reflect from objects and return to the eye, where they project an inverted image. He devised the camera obscura to study this (Covington 2007:6). Astrology, then still considered a science, spread with astronomy (Nasr 1976). Only since the Renaissance in Europe did astrology fail so obviously that it lost its scientific standing.
It is, incidentally, important to note that Nasr’s writings and his publication venue would both be unthinkable today. Islam has changed. It is clear from history that the keepers of genuine Islamic tradition are Nasr and his colleagues, not today’s lunatic bigots and killers.
Knowledge spread onward to Persia, Central Asia, and India. Contrary to some conventional wisdom, Islamic astronomy did not die in the Middle Ages. Al-Ghazālī’s famous conversion to mysticism and consequent attacks on science and philosophy, in the early 12th century, did have some deadening effect, though it has been greatly exaggerated in many book. More seriouis were later, similar attacks by less-known but important scholars. Their Ash’arite creed fell to an increasingly sour and reactionary anti-rationalism, in contrast to the liberal, enlightened views previously characteristic of Central Asian Islam (see Bosworth and Asimov 2000, passim, notably Paket-Chy and Gilliot 2000:129-131). However, Al-Ghazālī advocated science and rationalism to the last, and did not see it as incompatible with Islam (Dallal 2010:142-143). Thus science continued to flourish after his time. It should be noted that Islam never saw science as an enemy of religion; indeed, the whole idea of “science vs. religion” is a product of 19th-century Europe, and is very much a recent hothouse flower in the Islamic world, propagated largely via Christian missionary colleges (Dallal 2010:149-176).
Astronomy (and other sciences) continued to flourish and develop, albeit slowly and sporadically (Saliba 2007). The great polymath Nasīr al-Dīn al-Tusī, for instance, served the Mongols, getting a reputation for shaky loyalty to his ancestral homeland and his Assassin patrons, but giving himself an unrivalled platform for research and writing; his work included not only astronomy but the brilliant “Nasirean Ethics” (Nasīr al-Dīn al-Tusī 1964). He commuted regularly between Syria and Khorasan in northeast Iran, showing how peaceful and integrated his world was. Producing some 100 books, he also established the great astronomical observatory at Marāghā, one of the leading observatories of the pre-telescope age, and there he and his colleagues made observations that later would be used by Copernicus and Galileo in establishing modern cosmology. (On this and other matters, see the rather breathless introduction to Islamic science by Covington, 2007, which manages to cram an encyclopedic history into 16 pages; also Dallal 2010:23-26.)
Tusī thus influenced not only the Near East and China, but Europe too, quite profoundly. (This connection is annoyingly neglected; Eurocentric historians hate to admit anything valuable came from Islam, and Islamicists have until recently asserted that nothing happened after Tusī, or even after al-Ghazaālī, thus writing off the later science that bridged from them to Copernicus. Dallal 2010 has demolished these delusions.) He is overdue for a biography. His Ethics may still be read with great profit, however out-of-date his science may be.
Even after his time, with all its Mongol disturbances, Islamic science cranked along, continuing to develop locally (Saliba 2007), as Chinese science did. (We have long abandoned the delusion that Chinese science stagnated; it simply grew more slowly than European science did after 1400. See e.g. Elman 2003.) The Mongol conquest, however, began a decline greatly exacerbated by the bubonic plague in the 14th century. Then the Little Ice Age sorely affected the steppes and the Silk Road, and thus gave an advantage to sea trade and its European leaders. Finally, the rise of the “gunpowder empires” in the Near East and of predatory European expansion worldwide put an end to a separate Islamic science.
However, even then, theoretical, practical, and instrumental progress in astronomy continued, although in isolation from Europe, and falling sadly farther behind Europe as time went on. The final glory of premodern astronomy was the 18th-century Delhi observatory that may still be visited today.
The Indian connection
Much of Indian medicine is explicitly Greek in origin: the yūnanī (“Ionian,” i.e. Greek) tradition. This is our familiar Near Eastern development from Galenic and Dioscoridean roots. India’s own tradition, ayurveda, is at least 2500 years old—though not similar to the medicine in the earlier vedas (Wujastyk 2003; for a vast survey of Indian medicine, see Meulenbeld 1999-2002). It emphasizes balance and moderation, like the Greek traditions and also like Buddhism. It is based on three dosas: vāta “wind,” pitta “bile,” and kapha “phlegm.” These are related to the abstract qualities sattva, rajas, and tamas—respectively, the intellectual and bright aspect of life; the militant and emotional side; and the sleepy or sluggish side. These two triads correspond vaguely to the sanguine, choleric, and phlegmatic (plus melancholic) humors of Galenic medicine, and might have influenced those, but the influence—if any—is indirect and hard to trace. Several authorities have pointed out that this means the simple, neat balance called for in folk Galenic medicine (in both the Near East and China) is emphatically not a part of Indian medicine (Wujastyk 2003:xviii ff; Mark Nichter, Kenneth Zysk, pers. comm.). Rather, a dynamic equilibrium or accommodation must be maintained.
On the other hand, Vāghbhata’s standard ayurvedic compilation says: “The under-use, wrong use, or overuse of time, the objects of sense,and action, are known to be the one and only cause of illness. Their proper use is the one and only cause of health.” (Wujastyk 2003:207. Wujastyk correctly points out that the older Hippocratic texts are also a good deal more subtle; conversely, ENA can testify from much experience that Chinese folk medicine does make a major issue of bing “balanced, level,” as well as of ho “harmonized,” with bingho or hobing being a frequently-stated goal of medication. An apparently more dynamic and complex relationship between yin and yang in early medicine has been replaced by a somewhat complex, but basically fairly simple, notion of balance in much folk practice. The issue of balance in the HHYF is complex and requires further attention.)
Ayurveda is conservative; it relies on very old documents and traditions. Innovation, however, clearly occurred and was apparently very important. Much of it was influence from the Near East, presumably via yunani medicine. Opium and its use was first mentioned in the late Middle Ages, and the narcotic effects of marijuana did not make it into the medical books till around 1300 (Wujastyk 2003:256-257), though they were obviously known before. The extent of innovation remains to be determined. There seems to be no volume comparable to the collection of studies of innovation in Chinese medicine edited by Elisabeth Hsu (2001).
As in other ancient medical traditions, treatment is largely herbal. Poisons are a significant concern, indicating an elite patronage; a world of courts with poison-wielding assassins is implied (see e.g. Wujastyk 2003:78ff.). As in Hippocratic and Near Eastern medicine, there are explicit directions for regimen season by season, with diet, exercise, sex, and health care appropriate to the seasonal conditions.
Influence of ayurvedic medicine on the HHYF seems to have been mediated through the Persian world (including Iranic Central Asia) and possibly—to a lesser extent—through Tibet. Very significant is the fact that a large number of major ayurvedic works were discovered in Chinese Central Asia (Kucha, Dunhuang) or are known only from Chinese translations. Thus, the astonishing paean of praise for garlic written by the Buddhist monk Yaśomitra in the early 6th century AD (Wujastyk 2003:154-160) was discovered in Kucha. A gynecological work attributed to Kaśyapa is known only from a Chinese translation by a Buddhist monk in the late 10th century.
Relationships of ayurvedic medicine to the HHYF include a number of herbal drugs that are surely from India, and in some cases are barely even mentioned in the medieval Near Eastern sources. Also, there are early passages that seem to lie behind some HHYF material, such as passages from Suśruta (before 250 BC) concerning removal of splinters and arrows (Wujastyk 2003:107 ff.) Suśruta also describes tetanus, stroke, and what appears to be beriberi (Wujastyk 2003:121-122) in terms that seem broadly similar to those in the HHYF, allowing for the difference in medical rhetoric.
Yunani medicine and Ayurvedic medicine influenced each other throughout their careers in India (see Alter 2008), and of course Chinese and Tibetan medicine influenced them over the centuries.
The Tibetan connection
Then and earlier, Tibetan medicine in the Middle Ages seems to have been incredibly eclectic and comprehensive—one of the great medical traditions of the world (Clifford 1984). In the 8th century, when the Tibetan kingdom was first taking shape as a major regional power, physicians from all over the old world—nine regions are reported—gathered at the court. Histories relate that there were three especially prominent royal physicians, one from China, one from India, and one from the Byzantine Empire (Hrom, i.e. Rome). This last became head royal physician, under the name of Galen (Ga Le Nos)! (See Garrett 2007.) One suspects that this tradition is true, and that the wandering Roman had taken this prominent pseudonym in the same spirit that led Dr. E. Schoenfeld to byline his newspaper medical column “Dr. Hip Pocrates” in San Francisco in the 1960s. Unfortunately, we know little of what “Galen” brought from the Eastern Rome, but we know that Tibetan medicine remained an eclectic mixture enriched by Byzantine, Arab, Persian, Indian, Chinese, and other traditions as well as by its own formidable base of pragmatic and herbal lore. Its three humors (hii “wind,” shar “fire/bile” and badkan “phlegm”; Abdurazakov and Haidav 2000:243-248) are the sattva, rajas and tamas of Ayurveda. Its five elements (earth, water, fire, air and space) owe much to China, and indeed the Chinese five are sometimes used. Medicines derive in large part from Ayurvedic practice, but the Tibetans added a great deal, both from Chinese and Central Asian practice and from their own enormous resources (Dash 1994; Glover 2005). Tibet partakes, at the margins, of the fantastic diversity of plants and animals found in west China and northern Southeast Asia—by far the most biodiverse of the warm temperate and subtropical parts of the world.
Naturally, Tibetan tantrism was incorporated in the medicine. The medicine goddess known as the Nectar Mother has a wrathful form as the Diamond Sow, Vajravarahi. This female deity is shown in a wild and terrifying sexual embrace (standing, usually on a corpse) with the Black Horse-headed Demon, one of the demonlike beings converted to good in Tibetan Buddhism. Their sexual embrace symbolizes “the union of wisdom and skilful means,” which among other things is used to quell disease (Clifford 1984:51). A huge amount of healing ritual exists. This is totally absent from the HHYF, which is as rational as most Near Eastern medicine.
Tibetan medicine today is still eclectic, as shown in Denise Glover’s brilliant, comprehensive, and pathbreaking study (2005). Tibetan doctors know something of their culturally mixed heritage. In the PRC they are quite familiar with the Chinese five-phase system. Tibet’s Buddhist element appears in ascribing illness to desire or illusion. Tibet’s influence on China is still locally visible in the spread of medicinal herbs into Chinese practice (Glover 2005 and personal communication; Jan Salick, personal communication over several years). Tibetan medicine had been established as early as the 700s (Garrett 2007) but was significantly written down in manuscripts from around 1200 (Dash 1994; Martin 2007).
Presumably, a great deal of the Ayurvedic medicine (on which see Dash and Laliteshkashyap 1980; Nadkarny 1976) in the HHYF came via Tibet (cf. Dash 1976). We have no other indications of direct links to India.
The great Ayurvedic Yogaśataka was translated early into Tibetan (supposedly by Bu-ston). Vaidya Bhagwan Dash (1976) reproduced and studied the translation, assembling a number of mistaken or shaky word-equivalencies (this would help get a sense of whether Ayurveda was filtered through Tibet, but the differences are not great enough to allow a decision). He provides an English translation, with drug and disease names left in Sanskrit but explained in a glossary. The Yogaśataka derived from a time before there was much Near Eastern influence on India, so the plants in it are basically Indian. (Only cumin and saffron seem unequivocally Near Eastern; they spread very early to India as cultivated plants.) The commonly used ones get into the HHYF, but the specialized ones do not. Diseases follow the dosa theory. Unfortunately, most of them are ones not treated in surviving parts of the HHYF.
On the other hand, the lack of Tibetan influence on HHYF materia medica is rather astonishing, when one compares Dash (1976, 1994) and Glover (2005) with the HHYF materia. They share almost nothing except for the universal or very widespread ayurvedic remedies, especially those derived from the Near East. Most of Tibet’s local medicinal flora derives from the south and east of the country and does not grow in Mongolia.
Chinese medicine, meanwhile, had not been standing still. (On Chinese medical history, Unschuld 1985 and 1986 remain the best sources, and are followed broadly below; useful for further details and sources are the various chapters in Hinrichs and Barnes 2012.)
The first direct evidence we have for Chinese medicine comes from questions and answers on Shang oracle bones. These largely refer to illnesses supposedly caused by royal ancestors; the questions inscribed on the bones and shells ask which ancestor has been neglected in recent sacrifices and is therefore visiting illness on the survivors. I found exactly the same idea current in the New Territories of Hong Kong in the 1960s. It also survives among the Akha minority in south China and Thailand: “a man who had a stroke made the connection that his stroke was caused by not offering the correctly colored chicken at his ancestral offerings” (Tooker 2012:38).
In the late Warring States period, evidence for herbal medicine and other more secular approaches begins to appear in tomb texts. In early Han, many tomb texts exist, covering many of the later branches of medicine: pharmacopoeia, sexual medicine, surgery, needling (probably not true “acupuncture” but more pragmatic lancing of boils), etc. (see Harper 1998). From the very beginning, we can recognize the cardinal principle of Chinese medicine: strengthening the patient is more important than fighting the illness. Above all, nutrition was vital. Dealing with foods was always the first recourse. The highest in prestige of court physicians was the court nutritionist (at least according to a Han reconstruction of the Rites of Zhou). This was still true when Hu Sihui, Court Nutritionist to the Yuan, compiled the Mongol court nutrition manual in the 14th century (Buell et al. 2010).
Though contagion was always recognized (and even the dangers of “insects… crawling over food,” Needham 2004:38), Chinese medicine always focused on strengthening the person, not fighting the disease. This was known as yang sheng “strengthening inborn nature,” bu shen “supplementing the body [and its natural strength],” and similar phrases. Foods that built blood, for instance, were bu xue “supplementing the blood.” Many of these were indeed iron-rich and thus cured the anemia so sadly pervasive in old China (as I know from much personal observation). Orhers, like port wine (adopted in modern times), simply looked like blood, and were thought to work because of the the “doctrine of signatures” (a belief system very likely transmitted to China very early, if not independently invented).
Having lived for three years in traditional Chinese households and shared their problems and more than a few of their illnesses, I can understand how this developed. China’s biggest medical problem, throughout history, has been lack of nutrients—absolute lack of food, or, when food was available, frequent reduction of the diet to bulk starch. Desperate shortages of vitamins and minerals was the rule, not the exception. Moreover, the worst contagious disease problem—in recent centuries at least—has been tuberculosis, which tends to be chronic and to respond to better food and sunlight. The Chinese had no other way to treat it. Many other conditions were also chronic and also relieved by better regimen.
By contrast, infectious disease other than TB was less a problem in China than in early Europe, partly because the Chinese were more careful about sanitation, cooking food, boiling water, and so on. There was thus every reason to concentrate on strengthening the patient, especially through food, and little hope of doing much more about infectious disease until Koch and Pasteur began to train East Asian students (as they did from early on). All medical systems are accommodations between the prevailing illnesses and the available treatment methods. People deal as best they can with their worst problems. Native Americans dealt best with psychological ailments, having good psychological concepts but little hope of developing medical science; early 20th-century Americans dealt superbly with infectious disease but failed totally with psychological problems. The Chinese, like the ancient Greeks, dealt best with regimen, worst with epidemics.
Paul Unschuld (2009) traces scientific medicine to the early Han dynasty or just before. At this time a number of treads came together (Lo and Li 2010). Yin-yang theory was well established. Early needling—not the same as modern acupuncture, but probably ancestral—was already present, as shown by the Mawangdui tomb finds. Herbal medicine began to be codified. Surgery was supposedly well-developed, but we have only legendary accounts. Sexual hygeine and medicine were well established, as shown, again, by the Mawangdui finds. An important and sophisticated ecological science, focused on landscape and agriculture, also developed in Han, and is clearly related via the yang-yin and correspondence theories. We are handicapped in this and in all subsequent periods by the secrecy of the medical profession; they kept their trade secrets very close to their chests (Lo and Li 2010; I can attest to the persistence of this view into the late 20th century). However, people apparently felt they would need medical knowledge in the other world, so texts were buried with them. Tomb finds are thus important.
Most interesting was the rise of cosmological and “correspondence” theories. These depended on the concept of ganying, literally “stimulus and response.” This sounds like Pavlovian psychology, but referrred to cosmic resonances, sometimes exemplified by the sounding of a suspended lute when a lute tuned to it is played (see e.g. Salguero 2014:26). Humanity resonated to the rhythms and music of the cosmos. (This is why music has always been such an extremely important part of Chinese governance—seen most recently in Mao’s and Lee Kuan Yew’s insistence on proper, narrow ranges of music in their realms.) Flow of qi created music, as seen in the sounds of the wind, of waves on rocks, and of the earth ringing or sounding in earthquakes.
The correspondence theory that dominated, and emerged as the sole survivor of what was once a diverse set (Nylan 2010), was the fivefold correspondence system. This system involved an elaborate and highly schematized analysis of virtually everything in the world into sets of fives, the wu xing, “five phases.” Xing literally means “going” or “street,” and implies a dynamic, transformative view of the world. Apparently the Han thinkers understood the world as made up of subtle transformative processes or forces that appear in the fivefold nature of things—rather as modern physics sees an elaborate system of quarks and other forms of energy as basic to existence.
The fivefold classification apparently began with the five planets and five directions (the center being a direction). Then colors were assigned to the directions, then flavors and scents, and at some point the major bodily organs were added to the mix: Heart, liver, spleen, kidneys, and brain. Then five minor organs came into the picture (which involved regarding the metabolism as a virtual organ system). There were also five staple grains, five major trees, and so on (and on and on). This system was elaborated in Han, though it has earlier antecedents in the thinking of Cao Yin and others in the Warring States period.
This cosmology was very old at the time, going back to the Zhou Dynasty. It was put in shape during the glory days of the Former Han dynasty, especially by Dong Zhongshu (179-104 BCE) and the scholars clustered around Liu An, King of Huainan (179-122 BCE; see Liu 2010). It had been considerably extended and updated according to the best current science by Zhang Zai in the 11th century, and then built on in the moral philosophy of Zhu Xi (see Schäfer 2010).
Applied to medicine, this cosmology of correspondences led to a theory that has been so well stated by Pierce Salguedo (2014:27-28) that I can do better than quote him:
“Medicine, like governance, was about discovering the natural order of the univrse and adjusting one’s behavior to accord with it. Illness meant nott hat the gods or spirits had been offended by one’s moral failing, but that the natural cycles had been interrupted, impeded, or disturbed by an external agent or by one’s own improper regimen. Healing involved the restoration of systemic balance through the manipulation of the body’s qi…. Even more important than cure, however, was prevention.” Salguedo points out that the beliefs in gods and spirits did not die out. In practice, people combined those beliefs with rational correspondence medicine, to varying degrees (see below). As official religions were merely the tip of a vast iceberg of popular and folk religion, so official medicine—whether Daoist charms or rationalist drugs and exercise—rose from a vast range of folk practices (Salguedo 2014:28-29). This was still perfectly true in rural Hong Kong when I lived there in the 1960s.
Its major early medical statement of it is the famous Yellow Emperor’s Inner Canon. This great medical classic defined Chinese medical theory, and does so to this day. Marta Hanson summarizes it: “Incisive scholars now concur that the three extant recensions of the Inner Canon were from the beginning a collection of interrelated short essays form different lineages at different times, compiled most likely from sourcew written no more than a century before the first century BCE when it was made into a two-part book” (Hanson 2011:12). A theoretically final text was finished around 100 CE (Unschuld 2003), but has been variously revised since. Elisabeth Hsu calls the Yellow Emperor physiology the “body ecologic” (see below). How much this medicine influenced the Mongols is unclear, but the qi-based cosmology developed in Han and perfected in Song was most definitely in the head of Hu Sihui.
This fivefold path served the same systematizing function that Greek (especially Hippocratic-Galenic) medicine did in the west, and Unschuld is inclined to see these as the only two original scientific medicines in the world. (One might well add Ayurvedic, in spite of some supernatural elements.) Only these two absolutely eliminated supernaturals and their arbitrary will. Only these two based their teachings on a few simple basic principles. Only these two (plus Ayurvedic) led to serious medical science in the future. Unschuld refers only to the two traditions as “medicine,” other medical traditions being “healing”; this is an idiosyncratic usage that will not be followed here. I might want to add Native American traditions, such as the Maya one I studied, because these do have basic principles of a scientific nature, but even the highly pragmatic Maya system includes a great deal of supernatural and magical healing, not systematically separated from the strongly empirical and systematic herbal tradition.
However, it now appears that China had a serious nonmagical medical system before the fivefold correspondences took over. The brilliant medical anthropologist Elisabeth Hsu (2009, 2010b) has recently analyzed early documents, including ones newly discovered through archaeology. She finds that the “body ecologic” was preceded by a general notion of the body as produced by or influenced by yin and yang, and by being seriously affected by its natural emotions and emotionality. The body (xing) was animated by qi, which involved “feelings and emotions” (2010b:349; see also 357ff.). This she calls a “sentimental body.” Its upper and outer zones were more yang, lower and inner more yin. Joy and anger were particularly important and influential emotions. (I would assume that this is because of their very obvious effects on one’s physical sensations.) She finds that “early Han physicians paid [attention] to…feelings and emotions…they took individual psychology seriously, and in their view it affected visceral processes” (2010b:109). This view of life carried over into the Yellow Emperor’s Classic:
“Grief and worry harms the heart;
A double coldness harms the lungs;
Rage and anger harm the liver;
Drunkenness and sexual indulgence, and encountering the winds while sweating, harm the spleen;
If one uses force excessiveliy, such as after sexual intercourse, when sweat is exuded such that one can bathe in it, then one harms the kidneys” (Hsu 2009:108-109). Again, the feelings of heart palpitation from grief, and the dehydration and weakness and cold (from electrolyte imbalance) following excessive sweating (which really can harm the kidneys), are the actual clinical signs attended to. Hsu correctly emphasizes the strong difference between this psychologized medicine and the absolute separation of bodily medicine from psychological medicine that characterized much of western biomedicine until recently (and still does in some quarters). She also notes the awareness that early thinkers had of the value of music and ritual for “modulation of emotion and morality” (p. 358) or at least the Durkheimian function of getting people’s emotional lives coordinated and engaged with state morals. In general, over the centuries, Chinese have often tended to somatize what most westerners would consider psychological problems, but also to see the emotional roots of what westerners would tend to consider physical problems. Of course, readers of medical literature from Osler to Oliver Sacks will know the separation is not so absolute in the west either. In any case, we are well advised to recall that one cannot project the western separation of “body” and “mind” on Chinese medicine.
Hsu has also analyzed a text transmitted by Sima Qian in his great Han Dynasty history, Shi Ji (Hsu 2010b). This is a document purportedly written by one Chunyu Yi, who lived in the earliest part of Han but would have composed the book in the 150s BCE. The transmitted text, consisting largely of 25 case studies, is so augmented and overedited (by Sima and probably others) that it is impossible to tell if Yi even existed, but at least it shows that extremely sophisticated pulse analysis was done at that time. Pulse in Chinese medicine refers to a much more complex, subtle, and multiply tested process than the simple pulse of western medicine. It is an early example of featuring qi as all-important, and specifically dealing with the qi of each internal organ-field.
Many of his cases were made ill by overindulgence in women and wine. One woman got sick “because she desired a man and could not get one” (p., 84). One individual was noted as being unable to urinate because he had been overactive, after heavy drinking, in the “inner quarters,” which may suggest gonorrhea. It was cured with a succession of herbal teas, presumably diuretic and antibiotic. Hsu thinks several cases that do not refer explicitly to sex are actually about it, Yi being a delicate speaker when discussing the nobility. If she (and other commentators) are right, most of Yi’s main cases involved overindulgence in sex with either drinking before or cooling too fast afterward.
More interesting, however, are the many who got sick from falling in cold water and then getting overheated, or became sweaty and then got chilled or stressed by wind or other influences while drying out. This belief is exactly the same among the Maya of Mexico that I have lived with, and indeed my wife and I were raised with versions of it in the midwestern United States. It seems to be worldwide. Yi treated one case by making him drink 60 litres of medicated ale—quite a heroic measure but probably pleasant enough (Hsu 2010b:78). Another patient (p. 83) got sick from washing his hair and then going to sleep before it dried. My wife remembers being counseled not to go out or do anything with wet hair, and so do my Maya friends. In their cases, we can trace the idea back to Galen, but Yi was writing well before Galen—evidently this idea occurs to doctors worldwide.
In general, a large percentage of the problems were caused by or associated with “wind,” meaning not only literal wind but also intangible disruptive airs or influences in general (again, just as in Maya medicine). The leading authority Shigehisu Kitayama sees wind as “the unregulated and irregular,” leading to madness and seizures (Hsu 2010b:213). It remains important in Chinese medicine today.
Another individual strained his back lifting a heavy stone, and was cured with a softening decoction (p. 84). He also had difficulty urinating (Yi thought kidneys were involved; a biomedical doctor would probably think “muscular spasm”). This is a straightforward case. Another straightforward case (19, p. 84) involved diagnosis of intestinal worms by symptoms immediately recognizable to a medically experienced writer today, and they were treated with daphne, a convulsive systemic poison that would indeed clean out the worms (though an overdose would have killed the patient too). Another was clearly cystitis (p. 204), and treated accordingly, with a medicinal tea that was presumably diuretic, astringent and antibiotic.
The Chinese were already well aware of all these qualities, and knew effective herbs. Yet another ate horse liver, considered poisonous in old China (possibly because horses ate plants poisonous to humans and the toxins concentrated in the liver). Several other cases are less clear, but all cases seem to involve diseases that start from a specific causal event or event sequence.
Hsu contrasts the Chinese approach, focusing on the ongoing physical condition that appears as illness, with the western focus on a defined cause leading to a subsequent effect. However, Yi’s cases actually read exactly like biomedical cases: a specific event leads to an illness, which then produces symptoms and sometimes death. Hsu lists these specific causal events (p. 114). Chill aftrer overheating can create ongoing symptoms in both Chinese and western traditions. When it comes to death from overindulgence in alcohol, there is literally no difference in approach or causal theory between Yi and a modern doctor, except that the modern doctor would have more accurate knowledge of the physiology involved—and even there Yi knew that damage to internal organs was involved. Hsu is attending not to a real difference in causal theory so much as to a difference in the intervening variables assumed to be operating. Of course there are differences in the causal theories too, with the Chinese indeed attending more to ongoing states than some western researchers do, but the contrast is not a simple open-and-shut one.
Westerners may prefer to look at those very cause-effect relationships. Chinese do not ignore them. However, Hsu finds that Chinese may prefer to look at intervening variables, and finds great differences between east and west. Indeed, cultures tend to differ more in the black-box variables they infer than in observed relationships. It is easier to see that overindulgence in alcohol causes problems, or that catching a chill is bad for health, than to understand why (in physiological terms).
Acupuncture, so famous now in the west, suddenly appears in the Han Dynasty. Earlier references to needling seem to be merely lancing boils and other things for which needles are used worldwide. Acupuncture is totally different. It involves needling at strategic points of the body, where flows of blood and qi can be stimulated, blocked, cleaned, dispersed, drained, or corrected; hollowness is solidified, overflowing drained, stagnation removed, and so on (see Wu 1993:16). Several different types of needles are used. Most are very fine; the bigger ones tend to be the ones used for lancing boils and other less arcane purposes.
The earliest major treatise on acupuncture is the Ling Shu, “Spiritual Pivot,” the second part of the Yellow Emperor’s Classic (following the Su Wen, “Basic Questions”). The Ling Shu certainly confirms Elisabeth Hsu’s choice of “the body ecologic” for the body described in the Yellow Emperor medical tradition. A great deal of the book is a discussion and extension of the parallels between the individual body, the body politic, and the cosmos. In fact, the book makes it obvious that a great deal of acupuncture treatment is specifically derived from assuming “resonance” between these. The Ling Shu explains resonance about as clearly as anyone could: “The sun resonates with the moon, the water with mirrors, the durm with drumming sounds. For the sun and moon are bright…water and mirrors reflect…drums and drumming sounds resonate in time [i.e. rhythm],” and so on (p. 158). We are talking about real similarities in basic qualities here, and even about resonance in the most literal sense of the (English) word, in drumming. The extension of this to the resonance of Heaven, Earth and Humanity, and of cosmos, politics, and individual, is a natural logical step, however wildly overextended by Han thinkers.
Han cosmology and philosophy were based to a great extent on actual essential uniformities; the human body is a microcosm not just metaphorically or symbolically, but quite literally.
Note, for instance, that the above list of things to do to manage the qi channels bears no resemblace to anything biomedically effective, but an uncanny and very clear resemblance to the management of water in irrigation. Similar water and irrigation metaphors, or rather essential identities, occur throughout the book (e.g. p. 139).
Qi received from food is muddy or turbulent; clear qi comes from the air. The clear qi flows upward and into yin organs, the muddy goes down and into yang organs. They can get into opposition, a disordered state (see p. 148). “Debauched qi swirls and flows” (154), resulting in imbalances, which show themselves in ominous dreams.
Also, “The protective qi and the sun travel in the yang during the day. At midnight, the travel is in the yin…” (p. 119). The valley qi and other geographical qi’s are described. As to the body politic, “To cure the state is to cure the household,” followed by a repetition of the ancient Chinese proverb: “Enter a country and [ask about] the customs. Enter a household and [ask about household rules]” (p. 123). Rebellions in a country make medical treatment difficult; rebellions within the body are the same. Lustful and unregulated behavior of elites ruins not only their health but the realm’s; and much more. Some of the parallelism is directly mediated through good government making it possible for people to have adequate food and clothing, but some is clearly resonance again (see p. 124).
Finally, in a stunning passage, the entire macrocosm/microcosm is laid out in concise and comprehensive terms. This passage bears quoting in extenso, because it seems to be one true distillate of all Han thinking. (I am leaving out, however, several resonances so forced or so purely abstract that they add little.)
“Heaven is round. Earth is flat. Man’s head is round and his feet are flat, making the correspondences and resonances. Heaven has the sun and moon. Man has two eyes. Earth has the nine regions. Man has the nine orifices. Heaven has wind and rain. Man has joy and anger. Heaven has thunder and lightning. Man has tones and sounds. Heaven has the four seasons. Man has the four limbs…. Heaven has winter and summer. Man has chills and fevers. Heaven has the ten days of the celestial stems. Man’s hands have ten figers. The earthly branches are twelve. Man’s feet have ten toes, plus the penis and testicles make the correspondence. Women lack these latter two sections but can enwomb the human body [i.e., the female genitalia correspond to the male and thus make up twelve]. Heaven has yin and yang. Man has male and female. …Earth has high mountains. Man has shoulder and knee caps. Earth has deep valleys. Man has armpits and the crease of the knee…. Earth has grass and greens. Man has fine hairs. Heaven has day and night. Man has sleeping and waking…. Earth in the fourth month cannot produce grass. Man in later years does not produce children….” (227). “Man” here is ren, “person of either sex”; note that women are specifically mentioned. As if this were not enough, a great deal more listing of resonances occurs throughout the book, with a glorious finale at the climax (pp. 249-257). Seasonal directions and warnings throughout the book show that the Han obsession with seansonality and proper seasonal activities was fully present in acupuncture; other texts, such as the Guanzi and Huainanzi, ground these in agriculture and forestry, where they are largely practical and rational. Their extension to medicine is not without some justice—everyone in the world seems to have figured out that we get fevers in summer and colds in winter—but the Yellow Emperor’s medical tradition took it far beyond pragmatics (see e.g. p. 267, which bears comparison with Hippocrates on airs).
The fivefold set of phases seen in the Su Wen are, naturally, present here too, with the Five Viscera—heart, lungs, stomach, spleen and kidneys—emphasized. They have their proper colors,flavors, musical tones, and so on (pp. 156-157). The five wei, flavors, are extremely important, and remained so. They are still vitally imporant in Chinese medicine today.
Heat and cold are major causative entities, and their effects must be dealt with in countless ways (see e.g. many kinds of hot illnesses, and treatments, pp. 105 ff.). The book tells the student about conditions beyond treatment, when death is certain; these as seen on p. 107 are a good description of acute terminal phases of more or less typical infectious diseases in general; and on p. 111 are warnings about the frequent inability of acupuncture to deal with intestinal worms. There are also many of the warnings that every medical book in history, especially in China, must have in it somewhere: treat the illness as soon as possible—even before it arises if you can catch the prodromal signs.
Elisabeth Hsu’s emotional body survives in the book, too, and emotions cause illness. So do the other problems noted above in the Shi Ji text. “Worry and fear can strain the heart. Chilling the body and cold drinks can injure the lungs…. When there is great anger, the qi ascends and does not descend…. When one is struck or hit, or has sexual intercourse while drunk, or is exposed to wind while sweating, it can injure the spleen.When one uses effort in lifting heavy objects, or has unlimited sexual intercourse, or bathes while sweating, it can injure the kidneys” (p. 20). Similar warnings about excessive emotion and emotion-bearing activities (drinking, sex, fighting) occur throughout the book. In more general terms, “all [illnesses] are born in wind, rain, winter’s cold, summer’s heat, clearness and humidity, or joy and anger. When joy and anger cannot be controlled, it causes injury to the viscera. Wind and rain cause injury to the top. Clearness and humidity cause injury to the bottom…” and much more on causation (p. 216).
Several entire classifications of people according to their qi weaknesses and strengths occur in the book (pp. 161f-162; 205-211; 251 ff.). One classification of human types involves resonance with the winds: each human physiotype is particularly endangered by the wind of a particular season (177).
Closely related to the work Hsu analyzes, but several centuries later, is the Mai Jing, “Pulse Classic.” This amazing work, which runs to almost 400 pages in translation, was written by Wang Shuhe around 300 CE, during the Jin Dynasty. Thanks to careful collating and editing not too many centuries later, it survives as a fairly coherent work, though it is surely not quite the way Wang Shuhe left it. It describes many types of pulse and the countless medical indications that are provided by different pulse patterns in combination with other symptoms. The illness picture given in this book is incredibly rich, detailed, systematic, and scientific The science has not stood up well under modern biomedicine, but is still under investigation; clearly the end is not yet, and valuable insights may yet emerge. Chinese doctors still believe firmly in the significance of qi and blood flow, cold and heat, and pulse diagnosis.
The point, though, is that this is a fully scientific text: it is based on the very best objective observation and recording Wang could muster, the theories are free from supernatural beliefs, and the work is systematized according to the theories. These theories are those of the medicine of the time, basically those of the Yellow Emperor. As with the earlier works, much of the science involves cautious, controlled inference on the basis of the axiom that the human body is a microcosm of the world. Thus, observations of earthly conditions can be generalized—but only if carefully tested against clinical observation. Whether the results hold up to modern investigation or not, they were arrived at by the scientific method of the time.
Illness is due to the problems with qi and blood as stressed by heat, cold, wet, dry, and related environmental conditions. Illness progresses from exterior to interior, affecting progressively the organ systems once it strikes deeply into the interior and nests there. Different types of pulse correlate with different conditions in different organ fields. One can tell whether and when a person is going to die, from the pulse and other signs.
Seasonality matters, and so does food. The most important aspect of food in modern Chinese folk medicine, and important throughout the past as well, is the positioning in the Hippocratic-Galenic hot-cold-wet-dry quadrilateral. Rice is neutral; wheat is cool and wet; shrimps are hot and wet; and so on through the thousands of foods and drugs in Chinese herbals. Sweets are wetting, hence their damage to the body (see e.g. Flaws 1995:10).
The fivefold system is also important—much more so at times in the past than the hot/cold system was. Liver disease can occur in autumn from eating chicken; eating pheasant or hare can make spleen disease start in spring; the heart needs care abvout eating pork or fish, and winter is its danger season; lungs suffer from horse or deep meat, and summer; kidney disease follows from carelessness about beef in late summer (Wang 1997:26-27). Even specific times of day are part of this fivefold correlation scheme (p. 62). The microcosm/macrocosm resonances are invoked. Spleen, for instance, is associated with earth. “Earth is bountiful and rich by nature. It breeds and nourishes the tens of thousands of living things” (71). Thus the spleen is a beneficent, richly yielding organ, and associated with the stomach. The lungs, on the other hand, are asssociated with metal, and are with the large intestine. And so it goes, for the other organs. Pulses have to be appropriate to all this.
Pathogens are familiar conditions: wind, wind dampness, summerheat, excessive heat of any kind, and the various deficiencies, blockages, and overflows of qi and other humors.
Long sections tell when sweating is desirable (and should be induced) and when sweating must be avoided, and so for other treatments including acupuncture and moxibustion.
Some diseases involve major mental inolvement, including lily disease and fox disease (p. 272). These are both physical and mental in symptomatology, and seem to involve fevers that lead to mental confusion. Stroke is described, a point to which we will return (p. 274).
Herbal medicine began, so far as we have records, with the Shen Nong Bencao of the later Han. Bencao means “basic herbal.” (It was, originally, probably a deliberate pun, since it can also be translated “roots and herbs.” Ben still had its “root” meaning at the time; it was evolving into its more usual later meaning of “basic” or “origin,” with gen taking up the function of describing a botanical root.) Shen Nong was the god of agriculture, supposedly living around 2737 B.C., but the herbal is pure Han in its theories, and the name was evidently used in about the same spirit that made Dr. Eugene Schoenfeld name his medical column for young people “Dr. Hip Pocrates.” The herbal does not survive in its Han form; it was edited and put in definitive form by the great polymath of the 6th century, Tao Hongjing (452-536). Even his edition survives only in various quoted and abstracted forms, though it has been ably reconstructed, and we can be fairly confident we have something like his work. Sun Simiao reproduced large parts of it, and is an especially valuable source. What survives has been translated by Yang Shou-zhong (Yang 1998). Tao wrote his own augmented herbal with 730 (365 x 2) simples.
The Shen Nong Bencao contains treatments of 365 simples (one for each day of the year), listed as Ruler, Minister, and Servant drugs, i.e. basic major drugs, adjunct drugs that help or balance or mollify the effects of the master drugs, and adjuvants that merely add soothing or other minor qualities. In general, ruler drugs strengthen the patient—they are tonics and supplements. They are not toxic (or only trivially so). Minister drugs fight the illness, and thus may be toxic at times. Servant drugs add or balance. This political classification tended to disappear over time, as more and more “minor” drugs grew into major ones. In the Song Dynasty, the government herbal reports: “It is difficult to meticulously categorize the newly supplemented drugs” (Goldschmidt 2009) according to this system, so they downgraded it. It is absent from what survives of the HHYF. Evidently the flood of new drugs from both China and the outside world caused the system to break down. (On bencao history, see Needham 1986; Unschuld 1986; Goldschmidt 2009 provides some useful additional notes.)
Drugs are also coded according to the five-flavors system and the heating-cooling-balanced system. The latter may be already influenced by Greek medicine, but it is impossible to tell, because almost all the drugs are strictly Chinese and thus were not coded by early Western physicians or druggists. The few foods treated are largely coded as balanced; most of them would be today too. Sesame is balanced; authorities later have disagreed considerably on its position. Red beans are balanced too; they are now warm (in modern Chinese practice), but were still balanced in the medieval texts.
Drugs are noted as treating the “three worms,” identified by Yang Shou-zhong, following Chao Yuan-fang of the 5th-6th century, as pinworms, roundworms and “red worms” (1998:3). The “five evils” are also mentioned, and variously interpreted (p. 17); there are several lists of evils in the literature. Marijuana is described as acrid and balanced. In a very oft-quoted line, the Shen Nong says: “Taking much of it may make one behold ghosts and frenetidcally run about. Protracted taking may enable one to communicate with the spirit light and make the body light [in weight]” (p. 148).
In an early supplement to this work, a vast number of incompatibilities are noted; we shall meet such things again.
However, there may have been some earlier western influence. The term huoluan in the Yellow Emperor’s Classic (ca. 100 AD) may be from Greek cholera (Unschuld 2003). This would put a major Greek borrowing as early as the late Han Dynasty.
Late in Han, Zhang Zhongjing (a.k.a. Zhang Ji; 150-219 CE) wrote the now-lost original edition of the Shang-Han Lun (“Discourse on Damaging Cold,” i.e. coldness that damages the person). Zhang was from Changsha, not far from the Mawangdui tombs or from the court of Huainan, where Liu An and his staff had edited many major philosophic works a few centuries earlier. Long lost, the Discourse on Damaging Cold was re-edited from Tang reconstructions (Goldschmidt 2009:99-100). The rather modern cast to its medicine—it describes beriberi and oral rehydration for diarrhea—may therefore be Tang or even Song interpellations. Zhong’s theory was that coldness was damaging the patients. This referred to humoral cold, not literal cold wind, and thus it would seem possible that Hippocratic-Galenic ideas had become part of the basic medical axiom set, though it could equally well be parallel evolution; every culture realizes that physical coldness can be a problem, and many have independently extended it to something like a humoral theory. Marta Hanson contrasts this book with the Inner Canon: “The Inner Canon offered yin-yang and Five Phases doctrines, macro-microcosm models, and a type of correlative thought that related multiple registers of experience in a system of correspondences. Zhang…is non-theoretical by comparison and deeply clinical in focus. Zhang…described symptoms during the courses of disease, gave their underlying physiological and temporal patterns, and listed formulas iuseful as disease patterns changed” (Hanson 2011:12).
Shang-han was a general term for serious forms of diseases caused by or characterized by imbalance of yang and yin. These came in six general varieties, referred to as jing “warps,” i.e. “basic strands.” First was tai yang “greater yang” illness. The other five were sunlight yang, lesser yang, and three types of yin disease. The last of the yin diseases is the above-mentioned huo luan, and the symptoms described are exactly those of cholera (there is a theory that huo luan is actually a transcription of the Greek word). In general, yin diseases are characterized by more weakness and less fever than yang diseases. All descriptions are circumstantial and concise; someone was a very good clinical observer and recorder. Unfortunately, it is usually impossible to correlate symptom lists with modern disease categories (though see below). The problem is that so many infectious diseases call forth the same set of human defenses and vulnerabilities (deranged temperature control, vomiting, diarrhea, weakness, etc.).
Shang-han came in many forms, each form corresponding to a whole class of conditions. (One wonders whether Zhang saw all these as separate illnesses, or simply as severe, cold-worsened forms of the yang and yin conditions.) It was not necessarily febrile but involved severe coldness, general aching, vomiting, and hiccoughs (Zhang 1981). Related conditions or variant forms involve sweating, stiffness, chills, congestion, difficulty in urination, and cramps. In biomedical terms, the symptoms are basically those of flu, but could also apply to almost any infectious disease. Some forms involve alternating fever and cold, which can only apply to malaria. Some types include diarrhea, some do not. (It is denied for the condition in paragraph 20, which seems to refer to stomach flu and similar conditions; but present in the condition in paragraph 21, which appears to be acute salmonellosis including typhoid, but could also be any kind of dysentery, or even cholera; also in paragraph 25, which seems like a protozoan dysentery. And so throughout the book.) Zhang saw warm (febrile) disorders as transformations of cold damage, and did not explore them in detail, though he gave many recipes. The Shang-Han Lun focuses on what we now recognize as infectious disease, lacks discussion of stroke or the other conditions discussed in juan 12 of the HHYF, nor does it cover wounds and bites (HHYF’s juan 34).
Zhang’s book was the major fount of drug formulas. He gave concise but often effective recipes for every condition. These survive today, and indeed fully a fourth of the medical recipes in the great modern collection Chinese Herbal Medicine: Formulas and Strategies (Scheid et al. 2009) are from the work. Zhang and/or his editors were quite aware that diarrhea should be treated by teas with sweetness and with nutrient-rich and mineral-rich herbs. He anticipated modern oral rehydration therapy by 1800 years or so, if the material is truly Han; at the very least, by the 900 years since the Song editions. He also has a good description of beriberi, which was successfully cured with fresh herbs. The book mentions about 90 herbs, many of which are in the HHYF but many of which are not.
Extremely notable is the almost total lack of discussion of organ systems (as opposed to actual organs), fivefold taxonomies, or any of the other theories so vitally important in much of Chinese medicine. As Michael Nylan (2013) points out, fivefold correspondence theory was still under heavy debate in Han times, and there was not general agreement on it. Qi plays an important role, but only as the source of the damaging cold. This lack of connection with other theories did not escape Song medical writers: “Zhongjing’s book’s meaning is deep and it principles are profound. It does not [however] clarify the [role of the] circulation tracts, it does not explain the transformation of qi…” (Wang Wei—not the poet, but a Song doctor—quoted in Goldschmidt 2009:170).
Not long after Han, in the 3rd century CE, the alchemist and herbalist Ge Hong recorded in his book Emergency Prepararations Held Up One’s Sleeve that extract of qinghao (Artemisia annua) cured malaria (Marks 2012:111). It has, of course, recently gone worldwide for that purpose, and is the drug of choice in many areas of the world today. Meanwhile, plant exploration increased, marked by—among other things—what may be the world’s first true ethnobotany: the Nanfang Caomu Juan of 304 CE (updated since; see H. Li 1979, and cf. H. Li 1977 for other early medicinal plants). This book described useful plants of southeast Asia, including what is now south China.
Early in the Tang Dynasty, the great doctor Sun Simiao wrote Recipes Worth a Thousand Gold (651), a major work of synthesis and organization. He consciously interfaced Hippocratic-Galenic ideas with the Five Phases and yin-yang concepts of earlier Chinese tradition (Sun 2007). His work was influenced by Buddhism, not only in its western cast but in its argument for purity of mind in the physician (Scheid 2007:41). Sun was one of the geniuses of Chinese culture, and was duly elevated to the position of God of Medicine and Longevity.
At this time, foreign plants, especially those that came with Buddhist medicine and medical missionaries, started to appear in numbers in Chinese herbals (Laufer 1919; Salguero 2014). Sun has many, including eight common medicinal foods newly come from the west. The Newly Revised materia Medica (Xinxiu bencao) and the Supplement to the Materia Medica (Bencao shiyi) written in 739…both included largte numbers of new foreign drugs” (Salguero 2014:40).
Soon after, the Tang Bencao appeared under the editorship of Su Jing, with 984 simples. A Hu Bencao (“Iranian Herbal”) was compiled by one Zheng Qian around 740. The story of exotics in Chinese medicine has been told by Berthold Laufer (1919) and Shiu Ying Hu (1990, reprinted in the 1996 Huihui Yaofang edition).
A Persian who settled in China in the 9th-10th centuries and used the Chinese name Li Xun wrote a book in Chinese on western medicine, the Haiyao Bencao, “Basic Herbs from the Ocean Route” around 756 (Hu 1990; Kong et al. 1996; Liu and Shaffer 2007:217; Savage-Smith et al. 2011:217; Salguero 2014:40 thinks it was “ninth or tenth century”). Arab and Persian traders were well established in China by then; in the 9th century there was an Arab quarter with 200,000 residents (probably mostly locals, but many Near Eastern merchants) in Canton and with major establishments and trade at Quanzhou in Fujian (the main port in the next couple of dynasties). They brought foods and herbs as well as other products. Frankincense and myrrh entered Chinese practice.
Buddhist medicine brought in the Greek four-element theory, with earth, wind, fire and water as the elements; Chinese accepted these in Buddhist contexts (Salguero 2014). The Buddhist tridoṣa—Three Humors—of wind, bile and phlegm proved very hard to deal with. Wind was important in Chinese medicine, but the understanding of it was quite different from the Indian. Choler (bile) is almost unmentioned and melancholia was not a concept in China. The Chinese tried to deal with bile by invoking “hot” and “yellow” medical concepts (Salguero 2014:80), but clearly these remained alien to Chinese traditions, and are notably absent in the HHYF, where “hot” (re) has its usual Chinese meanings.
Chinese medicine also makes no obvious use of the four Greek humors—blood, phlegm, bile, and black bile—as such, but it does attach great importance to blood, and it also makes a major issue of phlegm (see Scheid et al. 2009, esp. 773ff. for phlegm).
Commentaries on the Sutra of Golden Light recommend against eating too much or little, waiting too long or not long enough; forbidden foods; and eating meat with milk. They also cautioned Southern people not to eat jiang (whatever that was), and northerners to avoid milk honey (obviously a hopeless counsel). Buddhist works taught that eating bitter vegetables with honey prevents conceiving a male child, and that consuming alcohol, wheat or raw meat when one has a Fire Illness would lead to blindness or worse. White heron fried in lard causes leprosy (lai). Oily Flavor (ni) can treat various conditions (Salguero 2014:99). The Chinese were disgusted by some aspects of Indian medicine (drinking cow urine…) and conversely the Indians found nothing to praise in similar Chinese practices, and, on a more important doctrinal level, traditional and Confucian Chinese were horrified by the Buddhist emphasis on loathing the body and abhorring it and all its products. The strong affirmation of the body and of physical life and activity in Chinese tradition certainly stands in dramatic and marked contrast to the hatred of the flesh that is central not only to Buddhist but also to traditional Christian (see e.g. Romans 7-8) and certain other western religions and philosophies. Chinese may have many traditional disciplines of the body, but they did not oppose flesh and spirit as savagely as the west, at least until Buddhism taught them to; even then, Chinese ascetics seem much less prone to excesses of “enthusiasm” than western ones.
Both Chinese and western medicine focused heavily on hot, cold, wet, and dry, but the question of whether the Chinese obsession with hot, warm, balanced, cool and cold is of Western origin is too simple. All major medical traditions in the world recognize that getting overheated or chilled is not a good thing. Chinese knew this long before they knew of western medicine. However, the Galenic tradition obviously influenced codings and beliefs; working with folk medicine in many Chinese communities, I found very few differences from what I know from Mediterranean and Latin American experience.
The Song Dynasty deserves major consideration here, because it profoundly changed Chinese medicine and set the stage for the HHYF. In Song, bencao literature grew, with up to 1748 simples described in the Zhenghe Bencao (“regulating harmony” or “regulation and harmony” bencao) of 1116 (Goldschmidt 2009; Hsu 2010a, 2010b; Hsu and Harris 2010; Unschuld 1986). In 1076, the Song government started an imperial pharmacy to standardize drugs and enforce quality and honesty (Goldscmidt 2009:124ff). Printing became common, greatly increasing the number of medical books and making nonscholarly sources widely available for the first time. More herbs from the west are recorded in the Song Hui Yao (Historical Records of the Song Dynasty; Savage-Smith et al. 2011:217). New classifications of herbal drugs appeared (see e.g. Scheid et al. 2009:xx).
Volker Scheid (2007) reports that “Song…was a time of rapid economic and social change based on the development of new technologies of agricultural production. Commoners were released from quasiserfdom and became independent landholders. Commercializaation of life and urbanization increased. The hereditary aristocracy…was replaced by a more fluid gentry elite…book printing facilitated intellectual exchange…. This stimulated scholars to systematize knowledge, which had previously circulated in smaller social networks, on a grander scale” (Scheid 2007:37). These trends all began in Tang and continued through Ming (see Mote 1999), but certainly they were prominent in Song. Population grew, leading to economic growth but also more disease. Foreign contacts increased, and presumably some diseases came with them.
Scholars, partly because there were too many of them for the imperial bureaucracies, turned to medicine in large numbers (Scheid 2007:42). They tended to displace downward the traditional professionals, who often followed local family traditions. Song philosophers and moralists argued that medicine was an ideal way for a scholar to use his knowledge if he could not manage to fulfill his ideal role as government servant.
The rise of scholarly medicine was so rapidly and strikingly effective that the emperors themselves became involved. The brilliant (if feckless; Kuhn 2009; Mote 1999) polymath emperor Huizong contributed a preface to the official medical encyclopedia and then went on to write a major theoretical work on medicine (see Goldschmidt 2009:183-6).
In contrast to earlier body-respecting medicine, Song medicine introduced autopsies, largely for forensic reasons (McKnight 1981; McKnight and Liu 1999). Dissection became acceptable, though still not common.
However, the rapid rise of the scholarly physicians led to more arcane and textual medicine (Scheid 2007). Meanwhile, the Five Circuit Phases (wuyun) and Six Qi’s (liuqi) added themselves to the picture. This new theory was called yunqi, and it had a long reach, affecting the leading medical writers of the time. We are not totally clear what these five and six entities were, but they apparently added a dynamic, environmentally grounded quality to the medicine. The five circuit phases—not the same as the classic Five Phases (wu xing)—seem to have been terrestrial, the six qi atmospheric (Leung 2003; cf. Goldschmidt 2009:183ff).
The doctor Lu Wansu concentrated on cooling; Zhang Congzheng on purging; Li Dongyuan on bu tu (lit. “supplementing the earth”), and Zhu Danxi on enriching yin (Scheid et al. 2009:xx-xxi).
Colder or warmer environments and personal temperaments were taken into account, no doubt partly inspired by Galenic influences. Older ideas of the five phases and flavors, “poison” (du, which means “poison-potentiating” as well as poisonous), and strengthening or supplementing (bu), were key concepts already (as they are to this day). After this, herbals continued to increase in coverage, climaxing in the great Bencao Gangmu, finished in 1593 and published in 1596, probably the greatest herbal in the world in its time (cf. Nappi 2009; Needham 2004:142). The west soon had fuller and better herbals, though actual theoretic advances in botany had to wait until John Ray in the mid-17th century, or—Needham thinks—even Tournefort in the late 18th century (Needham 2004:144.)
One major influence was a revival of a text from the past. In Song, many works derivative of the Shang-Han Lun were created. Song doctors made a major industry out of trying to square Zhang’s cold-focused medicine with the new emphasis on warm or heat problems (Goldschmidt 2009:157ff). Song doctors, and doctors in later dynasties, focused increasingly on these warm disorders (Scheid 2007), perhaps because fevers increased over time in the polluted Chinese environment. In Ming and Qing, heat disorders were to become even more prominent.
Combining Zhang’s medicine with other traditions may have cost China a chance to develop a scientific medicine, because Zhang’s sober clinical eye was an invaluable corrective to the arid, unrealistic logical paradigm of the correspondence school. The more the Song scholars integrated it with the latter, the more they diluted its value. All too predictable was the Song emperor Huizong’s espousal of the correspondence theory, which fits so well with the bureaucratic mind and so poorly with the mind of a real-world medical agent.
The same spirit animated too much of the government encyclopedia, which, for instance, spun the old story (known in the west too) that the body has 365 bones, corresponding to the number of days in the year. Just as Song’s so-called “sprouts of capitalism” withered over time (Mote 1999), the hard-science tradition from Zhang to Sun to the Song forensic investigators could easily have developed into a scientific empirical medicine, but failed to do so. The situation is a perfect reversal of that which took place in western Europe, where beginnings of observational medicine at the same time went on growing, eventually to culminate in the 17th century, with Sydenham, Harvey, and others replacing book-driven schemes by observation and experiment.
Zhang, Sun Simiao, and other books established a canonical set of prescriptions for any and all disorders. These could be varied, often by adding more and more drugs to balance out the original set. Doctors came to rely on published formularies as opposed to earlier, more individualized or familial, practices (Scheid 2007:39).
Many of the Song doctors, however, acquired a sense of clinical practice and awareness from their own practice and from Zhang. They could develop or modify their own formulas. They reported good descriptions of actual symptoms in actual patients. Shen Gua, who among his other achievements wrote a medical work, began it by pointing out that a good doctor will examine everything—the symptoms stressed by Zhang and those stressed by the correspondence school (Goldschmidt 2009:175 quotes him extensively). If history had been only slightly different, the Chinese would have anticipated the west in realizing that the old idea that illness is a weakness in the patient—caused by cold and heat, or by diet, or by environmental trauma, or by fear or other emotions—had to be supplemented by serious attention to the different kinds of diseases. (Of course, ironically, we are now learning that biomedicine’s focus on diseases has to be supplemented by concern for environment and emotion!)
Li Dong-yuan, a leading Song doctor, emphasized the importance of the spleen and stomach, and the ease of damage to the spleen by fire (medical, not literal) and other environmental influences. This seems to me a response to the southward movement of Chinese culture and the consequent familiarity to malaria. Chronic malaria enlarges the spleen and makes it tender and easily injured; I heard on the Hong Kong waterfront in the 1960s that one way of killing a person was to hit him hard in the spleen, which would rupture and lead to death. This assumes that the person was extremely malarious, an all too safe assumption in the old days. In any case, the spleen remains important in Chinese medicine out of all proportion to its biomedical role.
Li Dong-yuan was the first to describe and stress yin fire, “upward heat associated with damp heat below…[that] causes chaos…in the clear and turbid qi” (Flaws 1995:12). This in connection with the spleen is a fair description of the feeling of chronic malaria. (Clear qi should rise and energize the body; turbid qi remain below, partly in the form of the digestive process that separates nutrients from wastes.) Bob Flaws (1995) also points out—from his practice, and certainly correctly—that in milder forms it is a fine description of the results on the stomach and associated organs of the modern junk-food diet. (He follows Chinese folk and traditional practice in recommending a qing dan, “purifying and blanding,” diet, i.e. one high in neutral foods like grains and beans and low in high-calorie, hard-to-digest, and pungent foods. This makes perfect sense biomedically as well as Sinologically.) Once again, we have to recall that these doctors are talking about real conditions, however strange their language and classification system may be to biomedically-trained readers.
In spite of all this, epidemics swept China, especially in the 1040s. The government responded by publishing more manuals as well as through the hospital program. In 1057, the government established a Bureau for Revising Medical Texts (Scheid 2007:38). In 1089, when prefect of Hangzhou, the great poet Su Shi founded China’s first charity hospital. This inspired state hospitals on a large scale, beginning around 1100; these were independent from reief homes. Under Huizong, the empire soon followed, beginning a program of hospital and poorhouse building in 1102. It soon ran out of money, but not before innovating isolation wards to prevent contagion—a new idea in China, where strengthening the patient always took precedence over worrying about the illness. It seems more than possible that the idea of the hospital and above all the ideas on contagion and isolation came from the Near East. Wards were separated to reduce contagion—showing it was well recognized—and “salaried physicians were awarded bonuses on the basis of positive treatment outcomes” (Levine 2009:597). This brings us closer to the ancient goal of paying the doctor when one is healthy, and not when one is sick (a Zhou or Han Dynasty idea that anticipated medical insurance by a couple of millennia).
In connection with all this, Song, under Huizong, estabished a medical school (Yixue) in 1103, “designed to raise the stats of imperially licensed physicians to parallel that of Imperial University graduates” (Levine 2009:588). This involved clinical experience as well as learning texts. It was under the Directorate of Education, which also ran a mathematical school (founded 1104) and other technical enterprises (Levine 2009).
Acupuncture and moxibustion flourished, but largely among the nonscholarly practitioners (Leung 2003). The separation of working physicians and healers from scholarly practitioners—theoretically, scholars who practised medicine on the side, for families and friends, rather than for profit—was established strongly in this period. Such enlightened amateurs raised the status of medicine greatly. Professional doctors were, and remained, low in the social hierarchy.
A fascinating insight into Song medical thinking is provided in a brilliant essay by Cong Ellen Zhang (2011; could she be a descendant of Zhang Zhongqing?). She studied the belief in a miasma called zhang (a totally different character from her name, of course). This illness-causing and pervasive problem existed in the deep south, especially lowland tropical Lingnan (Guangdong and Guangxi). It was a product of the heat, wetness, intense sun, and possibly the lush vegetation (or, alternatively, the lush vegetation and the miasma were both produced by the wet heat). It was a general term for the sicknesses and misery provoked in northern Chinese in that climate. It seems especially to have targeted the many exiles sent down to that dismal and remote location, there to suffer boredom, isolation, humiliation, and fear. At least one account of the time explicitly differentiates it from malaria. Song accounts of it are strikingly reminiscent of 19th-century English accounts of the horrors and dangers of the tropics.
There were green-grass miasma in spring, yellow-plum ones in summer, new grain ones in late summer, and yellow-flossgrass ones in fall, the last being the worst (Zhang 2011:200, from Fan Chengda). Su Shi, who died of it (i.e., probably of some tropical-acquired chronic disease), treated it with ginger, onion and fermented black beans (Zhang 2011:215); others used Pinellia, Atractylodes and Agastache (Zhang 2011:216), herbal curealls that probably did little to help. It was a medically recognized regional miasma, a general aerial force or condition, dangerous or outright deadly.
What emerges from the Song texts is the critically important point that the doctors were genuinely interested in clinical treatment, not primarily in abstract theory. However much they may have diligently labored to theorize their practice, they were more interested in the patients’ recovery. This goes against the received wisdom in western studies of Chinese medical history, which is heavily reliant on theoretical texts and thus tends to see Chinese medicine solely in terms of theory. The result is the claim that Chinese medicine is incommensurable with Western, and could not relate to it. This is the claim we disprove in our work on the HHYF, and the disproof rests on the perception that Yuan doctors were interested in curing patients rather than in keeping their theories pure, and therefore could adopt Near Eastern medicine and make some sense of it. However wrong—in biomedical terms—were the accommodations of shang-han and correspondence medicine, they prove that Chinese doctors were more than willing to mix and blend paradigms if they thought it could help suffering clients.
With the Jin Dynasty, stronger medications, such as purges, became common also (Leung 2003:378). New ideas and practices were established widely. As in agriculture and other realms, new ideas and practices arose dramatically in the Song Dynasty (Unschuld 1985, 1986) but were developed more in later dynasties than in Song itself.
An important later Song work is Wang Zhi Zhong’s work Zhen Jiu Zi Sheng Jing (2011), a 12th-century manual of acupuncture and moxibustion. It is incredibly detailed, with names, treatments, and often descriptions of hundreds of illnesses. These range from clear-cut, straightforward conditions to arcane and complex ones. Perhaps the most clear-cut is back pain, blamed on too much physical work or activity and treated by simple needling and moxibustion (p. 221). At the other extreme are diseases due towinds, which tend to have complicated, detailed, and highly overlapping symptomatologies. One wonders how the Song Dynasty doctors figured out which was which. The book gives treatments for conditions ranging from nightmares and madness to deafness and lumbago. Male and female problems are detailed. Relating to what we have left of the HHYF are brief sections on hemiplegia (partial paralysis usually due to stroke), which is blamed on winds (171-172, 279). It is worse if on the left side in males, on the right in females. Tendon spasms (159) described in terms similar to the HHYF description, but much more simply. They are due to winds.
Overall, causes are usually attacks or influences by winds. These may strike the whole body or particular organs or body parts. Often disturbances of qi are the problem. At other times—but surprisingly rarely for a Chinese doctor—he blames overdoing alcohol, hot food, and sex. Following Zhang Zhongjing in looking at shang han and han re (“cold-and-heat”), he sees excessive cold and heat as often causative. At other times, as with the back pains, overexertion is the problem; he blames eye troubles on the classic causes, such reading in dim light, standing in smoke, going outdoors in the wind, and doing too much fine detail work, but also drinking too much alcohol and eating too much hot food.
Even for a Chinese doctor, Wang is notable for clear, systematic, naturalistic presentation. There is nothing mystical about his work—no demons, no obsessive fivefold correlations, no incomprehensible references to different sorts of qi. He seems to have a definite affinity for Sun Simiao, whom he cites frequently. His only fault is not distinguishing clearly between wind conditions, or between these and other illnesses due to cold, heat, and other factors. He seems to have simply summarized earlier descriptions; he was, after all, interested in the acupuncture and moxibustion treatments, not in the causation.
In contrast with the HHYF, his descriptions are clear, simple, and comprehensible. He seems typical of the Song period’s emphasis on getting rid of excessively complex and aridly schematic medicine and focusing on wind, qi, heat, cold, pathogenic energy, and physical causes (weakness, overexertion).
Overall, this is broadly similar to the HHYF, which is equally concerned with those variables. The details, however, are very different, making it appear that the HHYF does indeed draw heavily on Near Eastern tradition.
By the time of the HHYF, Chinese medicine was based firmly on a conceptual framework of considerable subtlety and elaboeration. It was based on:
The fivefold correspondences, including organ-fields, viscera, flavors, seasons, and much more;
The five degrees of hot and cold;
The vital importance of qi and blood as the circulatory systems of the body, and their dynamics, including stagnation, depletion, turbidity, overflow, and other irrigation-paralleling dynamics;
The yang and yin, and their complicated dynamics—they could be depleted, weakened, overproduced, and otherwise disarranged;
Related, but variously conceptualized, internal forces such as “fire”; yang and yin fires exist and can be damaging.
The dangers of external conditions including wind (both real and inferred) and heat, cold, wet (or damp) and dryness;
Personal problems that weaken the body, from worry and anxiety to fear, anger, excessive sex, and excessive eating and drinking (especially alcohol);
And miscellaneous other, less theoretical, conditions such as childbirth, injuries and traumas of all kinds, poisons, bites, stings, and the like.
Finally, a vast amount of magical, folk-religious, and folkloric practice continued, though it had no excuse in terms of the above system of medicine. Charms, exorcisms, taboos, credulous beliefs in longevity, and other such practices continue today. “A massive encyclopedia of medicine compiled at imperial behest at the height of the Song dynasty contains three fascicles (juan) cataloging talismans, rituals, and other interdictions, an indication of the continiuing high value placed on spirit-based medicine in the loftier echelons of society” (Salguero 2014:26; the work is the Zhenghe shengji zonglu of 1122). A stunning compilation of this bizarre and arcane lore has recently appeared in Shih-Shan Susan Huang’s study of Daoist art, Picturing the True Form (2012). It contains a vast number of medieval pictures of real and imagined parasites, real and imagined anatomy, charms, gods and spirits of the human body, and other strange medical apparitions (see esp. pp. 52-85).
It is likely that a few Chinese of the time made a distinction between the more scientific, theory-grounded, realistic medicine and this lore of spirits and demons, but one suspects that the vast majority of the people saw them all as equally true—just as medieval Europeans did. The more rational theories and therapies were, after all, far from biomedical reality, and probably gave no better cure rates than the magical ones did. And there was a vast space in between where the traditions fused, as I saw in east Asia 50 years ago, when spirit-mediums wrote herbal prescriptions or even told patients to buy aspirins and antibiotics medicines at the drug store. Huang’s illustrations include plates that have imaginary demons posed next to fairly accurate renderings of internal parasites (pp. 53, 62; Ming Dynasty pictures but from older sources).
Perfectly empirical methods for lengthening life (meditation, good diet, moderate drinking) were combined with fantastic measures that depended on placating a vast horde of spirits and beings within the body. The ancient idea of the body as microcosm was alive and well, informing physiology in sometimes useful, sometimes misleading analogical ways.
All these medical traditions melded into an extremely elaborate and complex framework. It allowed for classification of conditions and thus for planning treatment. Such nosology required yet another whole system of diagnostic observations: pulse, countenance, tongue appearance, reported aches and pains and other symptoms, observed lumps and swellings, evidence of weakness or unnatural activity, insomnia, excessive hunger and thirst, aversion to food, vomiting, diarrhea, and all the other medical signs known to the world.
A very complex system of nosological entities was identified, with formulas for medicines to treat each one of them (see Scheid et al. 2009).
This system had almost no points of contact with modern biomedicine beyond the obvious matters of trauma, and unmistakable medical conditions like hemiplegia and insanity. On a borderline were conditions like beriberi and malaria, recognized and described but understood so differently from biomedical understandings that they emerged as rather different clinical entities. The core meanings of terms we translate as “beriberi” and so on might be similar in Chinese medicine and modern biomedicine, but the extensions of these terms would be different from those of biomedicine.
Of course in all cases the explanations and treatments were very different indeed from those of biomedicine. Jaundice, for instance, was impossible to miss, and some connection with the liver was realized, but the condition was considered to be usually due to dampness affecting the organs, and was thus treated with warming and drying herbs that had no biomedically notable effect.
The resemblances to Hippocratic-Galenic medicine were much greater. There were the obvious matters of hot/cold, blood, phlegm, many illness categories, many medicines, and the like. There were similarities in blaming stroke on wind, insanity on anxiety or overindulgence in pleasures, and others that will be noted below. In spite of the differences in these systems, there was clearly some influence from west to east throughout history, and probably some the other way as well.
Chinese herbal medicine involved a vast number of herbal remedies that did have some effect, by biomedical as well as traditional Chinese standards. Empirical observation had made hundreds of connections between herb and cure. Oral rehydration therapy, use of qinghaosu for malaria, use of stimulant and carminative drugs, use of digestives like mint, use of antibiotic salves and washes on skin infections, and many other successful treatments were known; these were explained in Chinese terms, but can now be explained in biomedical terms. It may not matter much whether the stimulant and carminative action of cinnamon is explained by human adaptation to volatile oils or by activation of the qi and the yang energy. It does matter, however, when people extrapolate according to their beliefs: looking for other stimulant volatile oils, or trying other herbs that seem somehow to be linked to qi action. A great deal of Chinese medical practice was based on logical deduction or quasi-empirical reapplication. Such deduction, in any medical system, has to be rigorously tested against experience. This was not always the case in China (or today in biomedicine, for that matter). Errors resulted.
A quite different factor that feeds into all this was the rise in status of doctors. Partly because other avenues of advancement were rather thin under Yuan (Brook 2010:152), but partly also to take care of their families and neighbors without any concern for economic rewards, many literati took to doctoring (Leung 2013). An expectation arose that a Confucian should know enough about medicine to take care of his family—at least to be an informed consumer. Medicine became an appropriate thing to study. Thus a tradition of educated writers on medicine—something already known in Tang—grew steadily in Song and Yuan. This had mixed effects. As proper Confucian gentlemen, these scholars were not about to sully their hands in autopsies and visits to public hospitals. (Amazingly, several actually did.) Usually, they focused on intuitive understandings of the most ancient classics, such as the Yellow Emperor’s Classic of Internal Medicine. They would also deal with empirical reality to the point of assessing the success of remedies they and their friends tried, but generally at an anecdotal level, not at a statistically significant one.
Yuan and Ming medicine have found an excellent historian in Angela Ki Che Leung (2003, 2013, and sources cited therein). She has discussed in detail the rise of literati doctors, the expansion of medical work, the coming of western and Central Asian ideas, and especially the rise of an extremely elaborate and specialized medical world in Ming. Much of this is beyond our focus here, but her work on Yuan is valuable for understanding the world of the HHYF.
Another question is medical technology. Distilling was well known to both Mongols and Chinese, with various sophisticated though small stills surviving (and excellently analyzed by Luo Feng, 2012). They were used mostly for liquor, but for medicine as well. Dissection, bonesetting, and surgery had their full instrument kits. Medical technology of the period, however, largely awaits further research.
With all these trends, medical science advanced significantly in Song and Yuan, but did not develop anything like the breakthrough that happened in Europe after 1600. They began to make the final step of forthrightly going with experimental results, confirmed by others. But the ancient books still dominated too much of thought and practice. They stopped just short of the outright defiance of tradition that characterized Harvey and Sydenham and Boyle in the later west.
A digression into later times is necessary at this point, because it reveals much about Chinese medicine. The Song fascination with cold disorders led to a rise in fascination with warm illnesses, wenbing, in Ming and later; recently, SARS was included in this category when it appeared in China (Hanson 2011). Warm illnesses were naturally typical of the south, especially the far south, so infamous for its miasmas, contagions, witches who created gu poisons, and generally sick conditions (Hanson 2011:69-73). Snakes, notably hot animals especially if poisonous, abound in the south, spitting venom and corrupting the environment (Hanson 2011:71). Syphilis also abounded in the south, and men were warned to avoid loose women there (Hanson 2011:76-78). In addition to gu, even today often considered a specialty of the Miao/Hmong, there were deadly herbs such as “intestine-splitting herb” and “rat grass” (Hanson 2011:82-83).
Hanson stresses the rise of geography in Chinese medical thinking. China slants from west to east, a basic bit of cosmology in early times, and of course grows warmer from north to south; thus the illnesses are different in the southeast, a zone of hot, weak, lowland conditions. Chinese doctors also discovered class. In an oft-quoted passage, Li Zhongzi of Ming noted that “The wealthy and noble feed themselves rich foods and grains; the poor and lowly fill their bellies with sprouts and beans…. Those who labor with their minds [the wealthy] have a depleted center, weak sinews, and brittle bones. Those who labor with their bodies have full centers, strong bones, and powerful sinews” (Hanson 2011:63). Galen described exactly the same contrast in almost exactly the same terms—one would suspect borrowing except that the resemblance is too close! Li would have had to have Galen before him (and a Latin dictionary). Great minds really do run in the same channels.
Chinese Medicine and Chinese Science
“Medicine” is a contested term in the world, and its application to Chinese traditions reveals many of the complexities.
Paul Unschuld, the leading expert on the history of Chinese medicine, has recently proposed restricting the term to scientific healing—healing based entirely, or fundamentally, on inferred natural laws that transcend the whims of supernatural beings, spirits, witches, and other troublemakers. By that standard, medicine has been invented twice in the history of the world: by the Greeks in the 6th-7th centuries BCE and by the Chinese in the 2nd-3rd and after (Unschuld 2009). One might question the dates slightly, and one might feel a need to add ayurvedic medicine as a third contender, but otherwise it does seem that true scientific medicine is sharply and narrowly confined to those two (or three) cases.
The word “medicine,” however, is almost universally used to include the healing practices of all the world’s peoples, and I will continue to use the word in that wider sense. Moreover, all medical traditions, everywhere, are a mix of empirical knowledge, inferred general principles, and agentive claims. Chinese medicine before the Han Dynasty had its protoscience, including ideas of yang and yin. It was by no means totally committed to explaining all by the whims of gods and ancestors—though indeed serious illnesses of royal personages seem to have been explained that way, from what records we have. And the separation of scientific medicine from supernaturalism and purely empirical pharmacology was never as thorough in later years as Unschuld sometimes implies. But Unschuld has a point, and a very important one. The highly rational, deductive, scientific medicine of Han is a quite amazing accomplishment, even though the science is wrong by modern biomedical standards.
Unschuld argues that the need arose with society. We know that Chinese political society during the Warring States Period was undergoing a rapid and forced rationalization. Unschuld points out that laws and managerial systems were coming in, serving as models for scientific laws. I would add that states that did not rationalize their militaries, bureaucracies and economies (in Max Weber’s sense) could not compete with those that did. Either way, people came to feel that laws (fa in Chinese, a broader term than English “law”) transcended, or should transcend, whims—whether the whim of a sovereign in regard to justice or the whim of a god or ancestor in regard to medicine. Unschuld assumes that something similar happened in Greece: the development of the polis and of methods for administering it was contemporary with the development of scientific medicine by Hippocrates and others. He sees key proof in the fact that Greek medicine seems to treat organs as separate, independent, self-correcting items, like citizens in a democracy, while Chinese medicine sees organs as having designated roles in a single harmonious system, like people in a Confucian family or polity. I leave to experts the task of evaluating this theory.
Unschuld is aware that Chinese medicine, by the start of Han, already had a highly developed and effective pharmacopoeia. He is interested not in such pragmatics but in the development of a self-conscious system of principles and rules—a true theoretical medical science.
The greatest expert of his time on Chinese science and its history was Joseph Needham. A biologist and biochemist, Needham explored Chinese medicine with the help of his longterm partner Lu Gwei-djen. Needham also worked with the younger scholar Nathan Sivin, beginning with collaboration on a volume covering alchemy and Daoist medicine (Needham 1976). To Sivin, thus, fell the task of editing Needham’s work (with Lu Gwei-djen) on Chinese medicine (Needham 2000; Sivin 2000). Needham died in 1991, leaving Sivin the task of completing the “Medicine” volume for the monumental project Science and Civilisation in China that had become Needham’s life work. Sivin is a leading authority on Chinese medicine, and his introduction to this book provides a superb guide to the state of the art—brief yet extremely clear, informed, and authoritative.
However, he and Needham differed on a key point. Needham saw Chinese medicine as part of a world medical science, though developing in some isolation from other emerging medical traditions: “Throughout this series of volumes it has been assumed all along that there is only one unitary science of Nature, approached more or less closely, built up more or less successfully and continuously, by various groups of mankind from time to time.” (Needham 1976:xxiii). He goes on, however, to note that “there is another one which I may associate with the name of Oswald Spengler…. According to him, the sciences produced by different civilisations were like separate and irreconcilable works of art, valid only within their own frames of reference, and not subsumable into a single history and a single ever-growing structure” (ibid.). This was a point to make in the 1976 work because in it Needham was collaborating with Nathan Sivin, at that time a young medical historian, now the senior historian of Chinese medicine in the United States. Sivin adopted the Spenglerian view. Sivin points out that almost all contemporary scholars of Chinese medicine now see it strictly in its own terms, as a unique tradition that cannot be discussed in connection with others except to show how different it was. Needham warned of “falling into the other extreme, and of denying the frundamental continuity and universality of all science…. Such a view might be used as the cloak of some historical racialist doctrine, the sciences ofd pre-modern times and the non-European cultures being thought of as wholly conditioned ethnically…. Moreover it would leave little room for those actions and reactions that we are constantly encountering, deep-seated influences which one civilisation had upon another” (Needham 1976:xxiv-xxv).
Both have reason to say what they say. Chinese medical science is based on concepts so totally different from modern biomedical ones that they do indeed seem incommensurable. Chinese speak of qi (a word hardly even translatable), which flows in conduits that do not exist in biomedical theory. Chinese (like the Maya and the ancient Greeks) see mysterious heating and cooling influences. Chinese medicine deals with nonexistent “organs” like the “triple burner” (a “virtual” triple organ corresponding loosely to metabolic function), and even of ghosts and demons as sources of sickness (pace Needham’s overstated claims for rationality). Chinese medicine is so completely incommensurable with other medical traditions that some have even suggested that it not be called “medicine” at all (Paul Unschuld, personal communication). Unschuld takes a middle position, seeing Chinese medicine as fully comparable to Greek but not part of the same tradition—though he leaves significantly open the possibility of actual contact between the two civilizations and their medical traditions.
Needham was aware of the problem, pointing out that “the concepts with which it works—the yin and the yang, and the Five Elements…are unquantifiable…” (Needham 2000:65) and that, to be usable in biomedicine, Chinese medicine must be stated in terms of “the universality of modern mathematised natural science. Everything that the Asian civilisations can contribute must and will, in due course, be translated into these absolutely international terms” (Needham 2000:66).
To Sivin, Chinese medicine is utterly different from biomedicine; Sivin is fixing his gaze on the underlying principles, the philosophy of the system. Indeed, Chinese medicine includes such statements as this: “Au[c]klandia [an herb] harmonizes the stomach qi, frees the heart qi, downbears the lung qi, dredges the liver qi, quickens the spleen qi, warms the kidney qi, disperses accumulated qi, warms cold qi, normalizes conterflow qi, reaches exterior qi, and frees interior qi” (Ni Zhu-mo, Ming Dynasty, quoted Yang 1998:31). Biomedicine can make nothing of this.
To Needham, however, the difference is real, but can be overcome; Needham is fixing his attention on practices and remedies rather than on underlying principles, so to him the difference is merely a minor roadblock rather than a total barrier. Sivin cares that the Chinese did not mathematize the system; Needham cared that they could have.
Sivin as basically interested in cosmological principles, especially the most exotic ones, like the fivefold correspondence theory. Needham was much more interested in practical matters, where Chinese medicine is much closer to western—if only because one cannot ignore the reality of sprains, broken bones, effective herbal medicines, dietary regimens, and so on. Whether you believe in fivefold correspondence or biochemistry, willow-bark tea works for fevers and oral rehydration therapy treats diarrhea. Since practice is more apt than theory to be based on actual working experience, it is more apt to be commensurable across cultures.
Sivin correctly emphasizes throughout his Introduction that Chinese medicine is itself incredibly diverse; by his own logic, we should not really be talking about Chinese medicine, but about several different medicines. Some might be incommensurable with biomedicine. Certainly the dragons-and-demons material is. So, I think, is the fivefold theoretic that is basic to Han medical writing. But the practical lore that actually mattered in daily medical behavior is perfectly translatable.
Can Needham’s view be salvaged? There are two ways to salvage it; I believe Needham would have invoked them both had he lived. First, we can point out that the Chinese of the great dynasties were under no illusions of “incommensurability” between East and West. They imported vast amounts of western medical learning. Indian medicine came with Buddhism; many Buddhist missionaries had learned the trick of attracting converts through medical care. Indian drugs, practices, and concepts saturated Chinese medicine from about 300 to 800 CE, and left a residue that is still vitally important. Hippocratic medicine reached China well before the 6th century (Anderson 1988), perhaps by the 1st or 2nd centuries. Chinese doctors had not the slightest problem combining it with traditional Chinese medicine, proving that it was not at all “incommensurable” to them. Sun Simiao’s great book Recipes Worth a Thousand Gold consciously fuses both traditions.
Under the Mongols of the Yuan Dynasty, massive transfers from west to east took place climaxed in the Huihui Yaofang. How much influence it had on China remains to be seen, but we know that veterinary medicine entering at the same time completely remade Chinese veterinary practice (Paul Buell ms.). Chinese medicine also borrowed remedies (and probably theories) from southeast Asia and elsewhere. The Chinese physicians themselves would evidently side with Needham rather than Sivin, since they borrowed continually from any source available. They knew perfectly well there was no incommensurability.
This is because medical science is not an example of philosophers spinning beautiful dreams in isolation. It is about maintaining health. It is tested against results. To be sure, most Chinese physicians, like western ones, rarely question their systems when they fail in curing—they usually blame the unique situation at hand. But, in the end, the system has to deliver. All medical systems are kept on course (and occasionally even forced to change) by being tested against results. Biomedicine has found a somewhat better way to test (though be it noted that the Chinese invented case-control experimentation—for agriculture, around 150 BCE; Anderson 1988). So much the better for biomedicine; we can now test traditional Chinese remedies, and prove that many of them work. Ginseng, artemisinin, chaulmoogra oil, ephedrine, and many others have entered world medicine. This proves the systems are commensurable. Survival rates are the common measure, and a very fine measure they are, too. Biochemistry has now also entered the picture, and it proves that many Chinese herbs work because they contain chemicals bioactive by anyone’s standards.
Yet the classical tradition of Chinese medicine was profoundly different in concept from modern biomedicine. I believe that the conceptual framework that so strikes Sivin and others was worked out because it fit with other Chinese explanatory models, and seemed to make sense of actual clinical reality, as observed by medical personnel (Anderson 1996). Medicine was interpreted in the light of wider understandings of world, person, and cosmos.
We can see Chinese medicine in its own terms, appreciating the intellectual excitement of dragons and qi channels, whether they exist or not. We can also see them as part of the vast human healing enterprise—a part that has contributed substantially to modern biomedicine and will surely contribute more in future.
Sivin’s position would relegate Chinese medicine to complete irrelevance. It appears as a now-superseded way of thought—a quaint, old-fashioned thing for specialist scholars to pursue.
The problem is rather like that faced in reading Chaucer. No one would deny that Chaucer’s English has to be understood in its own terms, as a basically different language from anything today. On the other hand, no one would deny that Chaucer’s English is ancestral to modern English; not only is Middle English the direct ancestor of the modern tongue, but Chaucer’s writings had a more than trivial influence on the development. It is perfectly possible to understand Chaucer in his own terms without denying the latter links. It is impossible to give a full account of the development of English from Middle to Modern without taking Chaucer into account, and that means doing so on our terms.
Fortunately, a new generation of scholars, many of them trained in the Needham Institute at Cambridge, has gone beyond this outdated opposition and are analyzing Chinese medicine with the same rigor and sensitivity that historians now devote to early European medicine (see major review by T J Hinrichs, 1999, and books by Elisabeth Hsu 1999; Hsu ed. 2001).
More purely scientific in the modern sense was folk nutrition (Anderson 1987, 1988, 1996). From earliest times, this was explained by assumed natural variables. These were unobserved, but were not regarded as entities with agency that could be placated with incense. They were regarded as purely natural qualities. The five tastes—sweet, sour, bitter, salty, and piquant, all recognized by modern bioscience—had to be kept in balance. So did yang and yin. Foods that were strengthening to the body were rapidly recognized (they are easily digestible, low-fat protein foods). “Cleansing” foods—usually herbal and low-calories—were important. Western views of hot and cold were soon integrated with yang-yin theories, since its emphasis on heating and cooling humors were directly “commensurable,” and drying and wetting could be easily folded in and largely forgotten. Integration with the five-flavor theory was less easy, and the two remained somewhat separate. The resulting folk and elite nutrition theories were perfectly naturalistic and allowed individuals a very high degree of perceived control over their health and lives. A great deal of empirical, factual observation could be integrated sensibly by these theories. The fact that the theories were deeply incorrect was less important than the fact that they were the best people could do before modern laboratories. Early recognition of the value of fresh foods for beriberi, of sea salt for goitre, and of oral rehydration therapy for diarrhea were among the useful findings incorporated into tradition. One need not know about iodine to know that sea foods alleviate goitre.
Thus, pragmatic, observable data were explained by inferring nonobservable but plausible intervening variables, and constructing simple and reasonable theories. This is what science does everywhere. It makes perfect sense. The only problem in China was that innovation sputtered after 1400, for reasons to be considered in due course.
Working through Scheid et al.’s great encyclopedia of Chinese formulas (2009), one soon realizes that clinical entities were recognized, explained, and treated with great systematization and thorough scientific order. The ones of obvious cause and cure—worms, traumas, and the like—were effectively treated. The vast majority of conditions were defined by symptomatology in ways that were quite meaningful and reasonable in a world where explanations were based on qi, blood, yin, yang, external and internal heat and cold, and striking winds. The suites of symptoms do not define modern biomedical entities largely because actual infectious diseases typically cause a maddening variety of symptoms. No two cases of tuberculosis are quite alike; one person can display fever, flushing, and unnatural energy while another is hypothermic, pale and weak. Ordinary influenza occurs in dozens of strains, each with different symptoms. Cholera, plague, and other once-common diseases had numerous biovars with different syndromes. Conversely, minor respiratory illnesses all look alike, no matter what the causation; all sorts of things can cause similar skin rashes; and undifferentiated fever and “general malaise” can be associated with almost any disease. Before the full development of microscopy, laboratory tests, and epidemiological record-keeping, no one could possibly have made sense of this.
The Chinese did the best they could. Blood, the internal organs, fever and chills, and other internal matters were obvious and were obviously related to illness. Among external forces, hot and cold, wind, shocks, trauma-causing items, and the like were equally obvious. Requiring more thought was the recognition of the human body as a system—a bounded entity, made up of different organ subsystems, held together by flow of energy, nutrients, and information. Even more insightful was the recognition that the world is the same: a giant system, unified by energy flows. The Chinese extrapolated from breath and vapors to postulate qi as the great unifier in all this. They extrapolated the roles of heat, cold, winds, and fluids. They plausibly and logically, but often incorrectly, inferred that the human body is a microcosm of the wider cosmos. This may have been the best way they had to make sense of resemblances. Their invocation of the idea of “resonance” was a natural corollary.
Coding foods as heating and cooling, according to their observed effect on the body, was another perfectly logical step—probably the most reasonable way to make sense of observed nutritional realities. No one before 1900 had any better idea to offer; discovering vitamins and mineral nutrients was a huge 20th-century breakthrough, and one in which Chinese scientists were involved.
Because of all this, trying to understand Chinese medicine strictly as a system of ideas, unrelated to experience or real-world pragmatics, is a hopeless exercise, doomed to failure and irrelevance. Chinese medicine was a brilliant attempt to make sense of clinical reality. It was inevitably flawed, because the equipment to go beyond energy flows, hot and cold essences, and organ systems was yet to be invented. But it made countless discoveries that are still basic to world biomedical science, and it probably had at least as good a cure record as western medicine until the late 19th century.
China failed notably in inferring dragons and tigers in the hills and skies; in sorting everything into compulsive five-fold categories; in attributing all manner of diseases and other matters to winds; and in postulating disembodied forces that do not exist, from qi and ling to fate, evil influences, ghosts, and devils.
The west’s corresponding failures, to stick purely to “science,” include: The geocentric universe, the indivisibility of atoms, phlogiston, static continents, ether, animals as mere machines, simplistic learning theories, and many more.
Most of these involved inferring black-box mechanisms or intermediates that connect cause and effect.
The Mongols and the HHYF
The Huihui Yaofang was a huge encyclopedia of Near Eastern medicine, written in Chinese for Chinese users. We have about 500 pages left of what once must have been a 3500 to 4000 page work. It has been reissued in two modern editions. One was edited by Y. C. Kong and published in Hong Kong in1996, with a number of articles in English and Chinese that identify the plants and provide correct Arabic names and other data. The other was edited by Song Xian and published by the Chinese Arts Press in Beijing in 2000, and includes a version in modern Chinese with the Arabic transliterated in Roman script and a long and thorough listing of the medicinals and diseases. (This last would be more helpful if the authors had more consistently used scientific terms rather than often falling back on the idiosyncratic and annoying pseudo-Latin affected by Traditional Chinese Medicine practitioners.) One interesting thing about this project is that it shows that the medieval Chinese and Near Easterners had no doubts that medicine was basically one thing; they did not share the belief in some modern quarters that Chinese medicine is so utterly different from Western that there can be no point of contact or mutual understanding. On the contrary, they thought only of enriching both medical traditions by mutual exchange.
There are about 416 distinct drug categories in the surviving parts of the book. Several of these are known only from being listed in the Index. Many of these latter cannot be identified. About 398 are identifiable. Leaving out probable misidentifications and other doubtful cases, we have 381 taxa: 287 plants, 68 animals, and 26 minerals. Other items are either unidentified or represent multiple products from some species.
Evidence for the source of this herbal material is the fact that 226 of the identifiable items are discussed by Avicenna in the second volume of his Canon of Medicine (Bakhtiar 2012). These include 182 plants, 32 animals, and 12 minerals. The closest runner-up is Li Shizhen, with 203 taxa, but of course Li was writing later—with the benefit of the HHYF and other guides to western lore. Sometimes, it is fairly clear that the reason Avicenna is not scored as mentioning a taxon is that it is a Chinese substitute for a western one. I have indicated this where the equivalency is clear, but many examples must go unidentified or uncertain.
Most of the major, important taxa were discussed by Dioscorides and Galen; I have indicated this where I have knowledge, but many more would be disclosed by thorough search of the Greek and Latin materials.
Contrary to Allsen’s assessment (Allsen 2001:156), the Chinese, over centuries, picked up a good deal of Near Eastern theory, including Galenic material. The revolutionary changes in Chinese medicine in Song and Yuan are only now beginning to be appreciated. Much more is to be learned about this. Suffice it to say that the Chinese did not ignore Near Eastern lessons. However, this may be truer for animals than for people; Buell and coworkers have shown that Chinese veterinary medicine is largely a Yuan import. Near Eastern and Central Asian veterinary learning was so far ahead of Chinese that the Chinese simply engaged in mass replacement (Buell et al. 2006).
Previous studies of the HHYF have emphasized its relationship with the great Qānūn fi al-tibbi of Avicenna (Ibn Sīnā), a standard medical encyclopedia in the Islamic world. The relationship is close, but the HHYF was clearly compiled from a variety of sources. Al-Bīrūnī is one source, at one or two removes (see Al-Bīrūnī 1973). Al-Samarqandī seems surprisingly unrelated (see Levey and Al-Khaledy 1967). I suspect that especially important was Sayyid Isma’il Juzjānī’s Zakhīra-i-Khwārazmshāhī, “Thesaurus of the Khwārzamshāhs,” a monumental 12-century Persian work known to have been very important in Central Asia (Elgood 1951, 1970), where it was apparently written. Unfortunately, no translation of this work exists; copies are hard to find; little scholarship has been expended on it. Proof that one of these Central Asian Persian epitomes of Near Eastern medicine was a source is found in juan 30, p. 357: “I saw a person in Balkh” who used a particular medicine, and “was cured, I believe.” Arabs were unlikely in Balkh at the time, and Chinese doctors nonexistent there.
Buell summarizes: “The majority of the sources for the HHYF appear to have been written in the Persian language rather than in Arabic, since Persian is clearly the working language of the text. Arabic script entries are, more often than not, Persian grammatically. The characters chosen for Chinese translation indicate, again, Persian readings of the words. But not all sections were from Persian sources. The listings of materia medica, appear largely Arabic, but such sound shifts as use of “j” sound for ﻕ may indicate passage through Turkic hands (the sound shift is probably a Turkic palatalization, and the same change is found in the YSZY, where there is pervasive Turkic influence). This has been noticed by the Y.C. Kong team. They strongly suggest that the HHYF was compiled primarily by Turkic speakers, probably Uighurs. This might be expected, given the known influence of Turkic-speakers at the Mongol court. Thus the HHYF may be one more expression of a Turkistani tradition of Arabic medicine that is otherwise largely unknown and unstudied but which must have been major and highly creative in Mongol times. There appears to be a substantial Syrian-Nestorian presence in the work and in association with it as well.
“Although primarily documenting the Islamic medicine of the time and reflecting contemporary Persian and probably Turkic usage, the HHYF is also an important document for the Chinese culture of the time. It is, for example, written in a type of colloquial Chinese known from other Yuan-era documents with considerable internal evidence that the Chinese language of the text is a specialized, technical language with considerable apparent historical depth. The text, in fact, is by no means a literal rendering of its Persian and Arabic sources but reveals considerable effort not only to express and translate Islamic ideas but also to assimilate them to the concepts of the Chinese medicine of the time, including the key concept of qi, the “life force” making traditional Chinese physiology work. Qi seems often to translate the western concept of “humor.” Sometimes, however, it is clearly the traditional Chinese qi. Since the Mongol period, along with late Song (Southern Song, 1125-1279) and Jin (1125-1234) times, was a high point in the development of traditional Chinese medical theory, a close study of the Chinese language of the HHYF can expand our understanding of it considerably.
“The possibility is now being entertained of major Tibetan influence on its composition (Buell, forthcoming). This has been an entirely unexpected outcome. Tibet had its own Persian medicine that was, in many respects, quite close to that of the HHYF but showing significant adaptations to other systems (Dash 1994; Garrett 2007; Glover 2005). This includes Indian medicine, whose humoral system, more than the Islamic one, may be the system in use in the HHYF….
“The window of opportunity for the original HHYF to be written and for the Mongols to get all the medicinals easily was 1290 to 1340, when the Indian Ocean was wide open. The Genoese were running the whole show. After that there was an extended period when the Indian Ocean was not so open, until the Zheng He voyages, and then it closed up again. So the present version of the HHYF, with all the crazy substitutions, must be from post-Zheng He times, ergo, late 15th century. The important thing is that the medicinal evidence completely corresponds to the actual economic history…. The Mongols gave up attempts to directly conquer the maritime world because they didn’t need to make the effort. After 1290 the Indian Ocean was completely open and the Mongols had mounted a huge diplomatic effort to set up contacts. Ergo, they did not need to spend money on conquest to get what they needed. It all fits. And the Portuguese restored the era of direct contacts. They did do something different. Ming probably had the largest economy in the world but they voluntarily cut themselves off and that, more than anything else, put the east into decline” (P. Buell, personal communication).
Many remedies of the HHYF involve enormously long lists of drugs. This may be related to the tendency of Near Eastern working physicians to use almost anything for almost any condition, obviously in the hopes that if they tried enough drugs something would work. This is shown by the Cairo Genizah material (Lev and Amar 2008), in which this pattern is clear. The HHYF also uses theriac. Endless recipes for theriac existed in Europe; one attributed to Nicholas of Salerno had 58 ingredients (Wallis 2010:177). This sort of everything-and-the-kitchen-sink approach would be familiar to Chinese, but they never (to my knowledge) achieved that level of combining, outside of the HHYF. One is reminded of the Chinese tendency to supplicate enormously long lists of gods (Johnson 2009; see esp. 39-51) in the hopes that one might actually help, or at least that the supplicator would not offend any god by leaving him or her out.
The HHYF was apparently prepared in the hopes of improving Chinese medical practice, at least for the court, as well as serving as a basis for medical education. This was not a work of pure theory or speculation, but a working manual. As such, it should be studied to understand how it appeared to its Yuan compilers. One assumes they thought it was full of important knowledge—that Near Eastern medicine worked well for what ailed the dynastic elite. Rarely has a culture attempted to graft another culture’s medical science onto its own stock in this comprehensive, systematic way. (Significantly, one of the few other cases was Europe’s transfer of Near Eastern medicine into their own realm in the medieval period.) Moreover, the Yuan writers were apparently quite selective about what they copied and how they systematized it. How they determined what would work, how they evaluated medical knowledge, and how they decided what to include, are major goals of our project.
The first section of the HHYF that survives is juan 12, dealing with stroke and wind illnesses. The section on stroke is particularly revealing, since we have a condition that was very well recognized and described in both the Near East and China, with surviving texts from both. This section mentions an impressive 265 medicinal taxa, most of them occurring in Avicenna.
The Huihui Yaofang explains stroke thus: “If a person indulges frequently in sex, or overexerts himself, or suffers a fright, or climbs to a high place, or is overwhelmed by joy, the heart main artery [jing] strongly starts and the body struggles…. heavy inebriation, overconsumption of chill liquids, and food that is not dissipated, will…give rise to turbid [corrupt] illnesses. If the root is obstructed, the strength of the qi  does not go through and cannot reach the body.” (Dr. Buell’s translation, p. 10.) If corrupt moisture “is full within, the main arteries expand or contract” and moisture goes down from the brain to the body” (p. 29). Wind conditions occur. “Much of this is a consequence of urgent heat” (29-30). There will be dryness, and/or “moisture is roasting and cooking the brain cavity and the nostril cavity” (30) and arteries become obstructed. So it appears that the Near Easterners and Chinese, at least the ones reading this literature, were aware that obstruction of the arteries is the cause of stroke. They also anticipated the modern opinion that excessive emotion, or effort, or drunkenness can precipitate this condition. All these precipitating factors are well known in the Arabic medical literature.
This may be compared with the very different traditional view, as seen in the Pulse Classic: “The disease of wind ought to develop [i.e, normally leads to] hemiplegia…. Headache with a slippery pulse is wind stroke. The pulse of wind is vacuous and weak…. When vacuity and cold are contending with one another, the evil is in the skin (and flesh)…. Since the vessel networks are empty and vacuous, the murderous evil is impossible to drain away. Therefore, it lodges either in the left or right side. The evil qi slackens (the affected part), while the righteous [normal, proper] qi makes (the opposite part) tense. The righteous qi tries to draw the evil. Thus there arises deviation (of the eyes aned mouth) and hemiplegia. When the evil lies in the vessel networks, there is insensitivity of the muscles and skin. When the evil is in the channels, there is unsurmountable heaviness (of the limbs). If the evil enters the bowels, (the sick person) will be unable to recognize people. If the evil enters the viscera, (the sick person) will suffer form difficult tonge in speaking and drooling at the mouth” (Wang 1997:274-275).
In other words, wind has caused coldness, and if there is vacuity or emptiness of the vessels, stroke results. I am not clear what causes the vacuity.
Chinese formulas for dealing with hemiplegia generally assume that it is wind stroke (zhong feng, lit. “centering wind”). Originally this was taken to be a literal strike by a wind, but over time more and more ideas of internal involvement of such interior problems as “fire, phlegm, yin deficiency, and ascendant yang” (Scheid et al. 2009:620). Various forms and degrees are now recognized. Volker Scheid and his associates give several classic formulas for treating it. These use drugs that are, in biomedical terms, stimulant or soothing; apparently the stimulant drugs are the more important ones. The idea is to stimulate qi flow, regulate blood flow, and augment qi—preventing stagnation. With the exception of one formula that includes myrrh (p. 631), none of the formulas in Scheid’s book involves western drugs or bears any resemblance to formulas in the HHYF. On the other hand, the basic idea is the same: stimulation and warming. Some of the drugs—ones that were known everywhere—are the same, notably cinnamon, ginger, liquorice, and myrrh.
A recipe specifically credited to Galen treats excess of phlegm and thus polluted body, stroke hemiplegia, and wind disease (p. 47 of current translation ms.). Several following recipes also stress excess of phlegm, as do recipes for other types of wind illness, later in the book.
As it happens, at almost the same time that the Huihui Yaofang was being compiled, one Isaac Todros was writing on the very same condition—facial paralysis due to stroke—in medieval Spain (Bos 2010). Todros was a Jewish doctor, trained in the finest Galenic tradition, a state of the art practitioner of the very tradition the Huihui Yaofang was trying to transmit to China. His explanation of facial paresis was that it was “obstruction of the pneuma in its course” (p. 192), which is so close to the Huihui Yaofang as to sound downright spooky. (I know there are philosophic differences between the concepts of pneuma and qi, but the fine points would be lost on Isaac Todros and the Huihui Yaofang authors alike.) He thought this was in turn due to “phlegm…in most cases” (p. 193), and could be treated with lavender, oxymel infused with squill, sage, sweetflag, hyssop and fennel, to concoct the humors, and then if this is successful to go deeper with ash of fig, myrobalans, turpeth, ginger, lavender, dodder-of-thyme, salt, and gum Arabic, with fennel juice and wormwood syrup. The treatment goes on, including rubbing the area with a complicated rub, putting boiled meat of a hare on the area, drinking honey water and old wine, and many more items, mostly involving the same herbs or closely related ones including pepper, galingale and rosemary. With the exception of purely soothing items in rubs and washes, these are all fairly mild warming and stimulant drugs, i.e. targeted against phlegmatic humor. Of these, only sage and fig ash are lacking from the Huihui Yaofang lists. One of the Huihui Yaofang recipes even lists using game meats as a poultice (p. 30), though hare is not among them.
A great deal of herbal and food lore about treating strokes is found in “A Case of Paralysis,” by a student observing Guillaume Boucher and Pierre d’Ausson in early 15th-century Paris (Wallis 2010:396-399). The herb and food lists somewhat overlap those in the HHYF. The main difference is that in Paris the herbs were those found in Europe or regularly imported; the Indian and Chinese herbs are, unsurprisingly, lacking, and only a few common ones from the Near East are used. Castoreum, mustard, iris, wormwood, mint, lavender, rose, euphorbia, and many other herbal drugs are shared. Recommendations for a light diet are also shared.
In short, as far as stroke goes, we really are dealing with a single medical tradition here. The description is essentially the same, the cause is the same, and the treatment is the same: recipes involving a variety of stimulant and warming drugs. In modern biomedical terms, these would not be a good idea, since all they would do is make the blood flow faster and harder, potentially making things worse. You would want to use a blood thinner. But apparently nobody in medieval Eurasia knew about blood thinning. Isaac Todros does mention bleeding, but the Chinese sources do not, bleeding being abhorrent to Chinese.
For stroke, Wallis Budge’s Syriac manuscript recommended fennel, jackal fat, bitument, mint, peppers, camel urine, amber, camphor, castoreum, myrrh, and other ingredients (Budge 1913:vol. 2, 58ff, 145ff). Most of the herbal medicines he recommended are strongly warming. The anonymous Syriac author had an incredibly good knowledge of anatomy for the time, and has an amazingly good description of which spinal nerves cause paralysis of which organs, as well as a good general understanding of stroke (cerebrovascular accident—he did not understand its cause but did realize it was the result of brain damage, and he kept it separate from paralysis caused by damage to the spinal cord or to spinal nerves; 1913:vol. 2, 120ff). Rather little of this is reflected in the HHYF.
As to insanity, the Huihui Yaofang again blames it on phlegm and strong emotionality and drinking, which is presumably why it was put next to stroke in the book. Some recipes in the HHYF mention hellebore, a strong heart stimulant. Medieval Islam used it too (Dols 1984:53). Budge’s Syriac work explains it in terms of phlegm, yellow bile, yellow-red bile (associated with rage), but especially black bile (1913:vol. 2, 20ff). Serious madness, as well as epilepsy, is due to it. The author had duly examined livers (at least of domestic livestock). He has a good description of the liver and its functions and pathologies (1913:vol. 2, 379ff). He evidently well knew the black substance that forms with liver disease, and its association with severe depression and other conditions.
Similar attribution of insanity to excessive worry and anxiety and to overindulgence in alcohol, food and sex is common in Chinese medical literature. Chinese texts and formularies tend to use either cureall drugs—the things they list for every condition, mostly mild diuretics and things of that nature—or magical remedies. None mentions psychedelic drugs, though these were well known. Most mention soothing and mild stimulant drugs; some use a variety of minerals (see e.g. Scheid et al. 2009:639), and one classic formula depends simply on wheat grains assisted by liquorice and jujube (Scheid et al. 2009:471). Insanity and stroke are closely linked in Chinese medicine, both being caused by attacks of wind affecting a body weakened by substance abuse, worry, or qi and blood problems.
A sovereign remedy in the Islamic world that is a cureall in the Huihui Yaofang was dodder-of-thyme (Cuscuta epithymum; see Dols 1984:53-54), a plant singularly lacking in any demonstrable value. Medieval Arab sources also noted wormwood, frankincense, polypody, myrobalans, agaric, lavender, colocynth, yellowish thyme, turpeth, oxymel, hyacinth bean, euphorbia, mustard, safflower, beets, and Armenian stone and salt (Dols 1984:54; most of these plants have demonstrable and obvious physiological effect). Of these, polypody, myrobalans, agaric, lavender, turpeth, wormwood, Armenian stone, salt, and colocynth are in the Huihui Yaofang recipes. Most of the other plants mentioned in the Huihui Yaofang are mere soothing items. All the other items occur in the Huihui Yaofang as drugs, though not for this condition specifically.
In later Islam, aromatherapy was used for madness (Dols 1984:173), but we have no indication of that in Chinese sources. In fact, medieval Near Eastern medicine featured all kinds of soothing, cheering, and diverting treatments for madness: Music, horse-riding, outings, good food, rest, calm, fresh air, flowers, and even lovely girls for cases of lovestricken noblemen (Dols 1984:173 and many other places). None of this is found in any Chinse sources, to my knowledge. In so far as the mentally ill were treated at all in old China, it was generally by religious or magical means; certainly in my experience in rural Hong Kong and Malaysia half a century ago, serious mental illness was considered hopeless. Miild forms were treated by spirit mediums or Daoist priests. Some minor mental problems, from blanking on exams to excessive fear, were due to loss of a component of the soul. The medium would go through a ceremony to call it back. Other, more serious, conditions were due to haunting, and the medium or—more often—Daoist would drive the gui from the patient. Yet another cause was a curse by a witch or magic-worker, in which case the curse had to be neutralized. In all cases, mediums and priests often provided charms to be ashed and then drunk in herbal tea, but this was the only physical intervention.
Juan 30 is a collection of cureall recipes, beginning with one supposedly invented by Rufus of Ephesus. Perhaps he started it; it has been added to since. It is recommended for practically everything, including hair falling out “like the moulting of a fox”—a translation via Arabic of the Greek word alopecia, balding, literally “fox condition.” (P. 282 of Dr. Buell’s current translation ms. Many other recipes treat fox condition too.) Alas, a recipe that cures everything is informative about nothing.
Juan 30 mentions only 39 medicinals. However, they are combined in amazing complexity. Many of the formulas in juan 30 are incredibly long, apparently on the idea that combining all possible active ingredients could not fail to help. Alas, the writers did not follow the excellent advice of Al-Samarqandī: “physicians in the hospital…of Baghdad…reject the more complex electuaries…. They agree…’We did not find them of value because of the coreruption of the compounding and the use of substitutes for drugs which were difficult to locate” (Levey and Al-Khaledy 1967:54). Also, “[t]he strength of most drugs does not remain after two or three” months (p. 55), so the tiny amounts of each item found in a reasonable dose of a highly compounded medicine could not possibly have much effect.
Interesting is the lack of Chinese ingredients; this really is a western book. On page 369 the directions for “sending down” a medicine (taking it so that it will be effective) include a number of Chinese medicinal soups, calling for standard Chinese remedies like ginseng, mandarin orange peel, and apricot kernels—items conspicuously absent in most of the rest of the HHYF. Here they appear to be mere adjuvants.
A revealing comment on pp. 376-377 lists “urgent” medicines as including ephedra, euphorbia, scammony, colocynth, and agaric. With the exception of agaric—which may be a misidentification—these are all medicines with clear and dramatic effects (ephedra clears up some allergies, euphorbia is a violent spasmodic, scammony and colocynth are quite dramatic purges). The passage goes on to contrast “middle category medicines” including opopanax, castoreum, gum ammoniac, and asafoetida. These indeed have mild soothing and other qualities but are not obvious strong medicines. So our writer—whoever is translated here—knew what he was about.
Juan 34 deals with treatments of wounds, obviously a major concern in the Mongol Empire. These are mostly arrow wounds and other matters expected in battle, but also include bites, including human bites as well as rabid dog bites. Ulcerated wounds, wounds with bits of weapon material within, broken bones, and other damage are all dealt with. Surgical procedures are treated in great detail, are generally sophisticated and thorough, and make harrowing reading.
The herbal cures are often extremely long recipes involving everything medicinal that could be imagined. Most, naturally, are poultices and ointments involving protective material (gums and resins), desiccants (powdered shell, minerals), emollients (oils and salves). They would seal the wounds and have a soothing effect, but would rarely provide the antiseptic action that we would today consider necessary. About 298 medicinals are mentioned, and most of are noted in Avicenna (2012) as being used for external treatment—wounds, sores, skin problems. Many, however, are magical or dreckmedizin, useless items that clustered around medicinal treatment in the middle ages. Some of these are in Avicenna, including use of human excrement on human bites, but many are obviously folk practice.
Several antibiotics and antiseptics are used, including frankincense, myrrh, saffron, and rose oil. So are astringents such as oak galls, willow leaves, and pomegranate skin paste or tea. However, they are often in quantities too small to do anything. This is more than strange, since both the Chinese and the Near Easterners knew that things like rose oil and thyme would treat skin infections. The Maya Indians I work with in southern Mexico know the local antibiotic plants that treat wounds, skin infections, and fungus; they regard the power as due to the spirits or to God, rather than to chemicals, but they know perfectly well what works. Actual pragmatic experience does matter in things of this sort, and it is surprising to see the lack of use of it here.
A section on burns is more hopeful; it is based on poultices of egg white, with litharge, copper salts, and rose oil or mint or other antibiotic herbs. These mixes would work, though it is conceivable that the copper could further damage the skin and that the lead from the litharge might get absorbed and poison the victim.
In a general account of burns and treating them—a very sensible account—we have a particularly clear example of Galenic heating and cooling concepts: “Also, the medicines that are used at first to prevent burn lesions from forming are uniformly ones with cold natures and are not heating and drying; for example, such as egg white combined with rose oil brushed onto the burn with a chicken plume” (Buell tr., p 76. of juan 34). There are many other less clear references to this Hippocratic-Galenic system scattered through the book. Of course the system had been known since at least the days of Tao Hongjing and Sun Simiao (Anderson 1988; Engelhardt 2001), but the Huihui Yaofang used it more systematically and in a less Sinicized way. Trauma was treated quite differently in China, with, for example, erythrina wash (a very effective soothing and rash-combatting medication) being used (Scheid et al. 2009:902).
And After…Final thoughts on Chinese medicine, and some new directions
The practical side of medicine continued in later times. In Ming, when a royal prince oversaw the compilation of a famine herbal. That level of involvement died out, but readers of Cao Xueqin’s The Story of the Stone will recall the gap between elite men and women who knew a great deal about medicine and the ragged healers who hung out in the streets and markets. The family happily consulted any and all of these. The family doctor, however, was a salaried professional intermediate in status, showing that by Qing a mid-level had come to importance.
A measure of how little the HHYF changed Chinese medicine is found in the great encyclopedia of Chinese herbal formulas, Chinese Herbal Medicine Formulas and Strategies (CHMFS), compiled by Volker Scheid and associates (2009). The lack of much similarity in stroke cures has been noted. More general is the observation that there are very few western drugs in the CHMFS, and those few are of very old lineage in China. Wheat and barley are often used, but no one in old China would have thought of them as foreign. Apricot kernels are very common in the formulas, but if the apricot is not native to China it certainly got there early. Of drugs, only areca nut, benzoin, catechu, fennel, fenugreek, garlic, myrrh, natron, and safflower stand out as foreign. All these were very early (and of course areca was from southeast Asia). A single reference to Sinapis (western mustard) may be a mistaken identification. Saiga antelope horn, often used, would have had to be brought from central Asian territories that China rarely held.
The hundreds of other drugs in the book are all native to China. If anything, the flow was the other way, with Chinese cinnamon (cassia), citrus, ginger, liquorice, rhubarb, and other drugs moving west. Of course, widespread plants whose medicinal action is too obvious for anyone to miss were used in both areas; this includes artemisia, mint, onions, and several other items. The only real question involves a few cases in which a Chinese plant is used but its use may have been inspired by western use of related species, as with angelica, dodder, and thistles. The species and the uses are quite different at the opposite ends of the Eurasian land mass, and it would be hard to maintain that influence was very deep in these cases.
Moreover, there is no increase of western drugs after the Yuan Dynasty. Formulas from later dynasties are just as
Since Pillsbury’s classic article (1978) there have been several studies of “doing the month”—recovering from childbirth. Women still stay warm and quiet and eat high-protein, high-iron foods; the custom, so valuable if restricting, has not changed as much as most traditions in this modern world. Pork liver is a favorite for this and for building blood—it works, being the richest in iron and vitamin B12 of any common food. Also useful are eggs and greens. Red foods such as red jujubes, peanuts (Chinese peanuts have red skins), and red wine are used for buillding blood, but with less excuse—they have some value, but their color is the main draw. By similar magical thinking, black foods—black jujubes, black chickens, black dog meat, Guinness Stout (called “black dog” in colloquial Chinese)—are used to build body. Their saturated color is thought to indicate their strength. Variants of “doing the month” occur widely in Eurasia, from Bangladesh to Spain and thence to the New World, so it may be a part of the Greek humoral medical tradition that shares that distribution.
Infant feeding methods in old times were studied by B. S. Platt and S. Y. Gin (undated separate from Archives of Disease in Childhood, 1938). In the 1930s, Chinese (largely Yangzi Delta people) breastfeeding was almost universal. Thirty-six families had used a wet nurse; otherwise, mothers nursed their infants, though six mothers used powdered milk (having been apparently unable to nurse) and one claimed, unbelievably, to have used only rice powder. Rice powder was used as supplement from very early. From five or six months, soft rice supplemented the milk, and from about eight months, soup, eggs, and the like. Chinese jujubes often came in at this point to promote blood and body; the jujubes do have iron and vitamin C. Mothers ate pork, dry beans, cuttlefish, chicken, shrimp, sea cucumber, Chinese wine, wheat cakes, and millet to produce more milk. They were aware of the nutritional value of silkworms, which are indeed very rich in vitamins and minerals. Interestingly, soymilk was not used for feeding babies.
The myths die hard. I heard in Taiwan in the 1970s that certain rich and powerful individuals abstained from rice noodles, humorally dry foods (such as peanuts), etc., eating instead a good deal of easily digested, nutritious food like chicken and vegetables and fruits. They drink honey and use little oil. This enables them to enjoy many lovers, which in turn built more vigor, since they could absorb yin energy from them. They even eat ground pearls to supplement yang force.
Of course, some plants really are nutritionally superior. In addition to the pine seeds noted above (and now threatened by overharvesting; Allen 1989), the berries and leaves of Chinese wolfthorn (Lycium chinense; go qi zi and go qi zai respectively) are so rich in vitamins and minerals that they have served as de facto vitamin pills for millennia.
The dietary combinations (shiwu xiangfan or shiwu xiangke—“food things that mutually dominate”) so feared in Chinese tradition have received some further attention since my coverage in The Food of China; see Lo (2005). Incompatibilities between medicine and food have a different name, fuyao shiji.
Tea is proving itself; green tea, in particular, turns out to be preventive of cancer, heart disease, and other degenerative conditions. This confirms the long-maligned enthusiasm of the famous Dutch “tea doctor,” Bontekoe, who was long ridiculed for insightfully making these claims in the 17th century. This is apparently because of the tannins and other bioflavinoids and polyphenols that tea contains. “White tea”—tea leaves steamed at picking and then dried, so that they retain more of their chemical compounds—is better still. It slows bacterial growth and kills fungi (Conis 2005).
Then there are other medicinal matters…. Cockroaches, boiled to treat colds and pimples, found a more subtle yet direct use in the Castle Peak Bay community where I lived for two years. When a child was “shamming sick” to get out of going to school, his or her mother would quickly brew up some cockroaches and say, “All right, here, take this.” The usual response was, “No, no, I’m fine, I’m going to school!”
Several hallucinogenic plants were known to Chinese traditional medicine, including henbane (Hyoscyamus niger), datura (Datura spp.), marijuana (Cannabis sativa), and toxic mushrooms including Amanita and a “laughing mushroom” that may have been a Panaeolus (Li 1977). These plants made people see ghosts or “devils.” Some plants that are toxic but not really hallucinogenic were classed with them; Phytolacca and Ranunculus, for instance.
Moving from historical research to China today (see e.g. Farquhar 1993, 1994, 2002; Kleinman et al. 1975): A brilliant new group of experts on Chinese medicine has arisen, many forming a network based around the Needham Institute at Cambridge. Their research has focused largely on clinical treatment practice (Hsu 1999, 2001), but food cannot be neglected in any study of Chinese medicine, and they do not neglect it (see esp. Engelhardt 2001; Engelhardt and Hempen 1997). Livia Kohn has reviewed much practice in a new book (Kohn 2005). Newman and Halporn (2004) has several articles on food and medicine, including one by myself (Anderson 2004). Chinese traditionally focused on trying to maximize longevity—not a surprising concern in a country whose traditional life expectancy was in the 25-30 range. Equally unsurprising, given China’s history of famine, was the fact that they were most concerned with nutrition.
Chinese food is indeed very healthy, or once was. Ironically, much of the health value comes not from the foods believed to be good for you, but from the humble, often-despised everyday grains and greens. Studies by Cornell University in the 1980s and 1990s showed that Chinese under traditional rural conditions had incredibly low levels of cholesterol (average 127—vs. over 200 in the contemporary USA), were lean and in good shape, and had very low rates of heart disease, many cancers, and other circulatory and degenerative ailments (Campbell and Campbell 2005; Campbell and Chen 1994; Chen et al 1990; Lang 1989). Some areas, at least, had rather high rates of cancer. Cancer incidence can increase from having too low a cholesterol level (Barbara Anderson, personal communication). But, in general, traditional Chinese food was healthful. Some “long-life villages” in south China—often Thai-speaking villages—have especially long life expectancies (as do villages in parts of southern Japan, notably Okinawa). The secret seems to be mountain air and water, mountain exercise, and a diet of whole or nearly-whole grains, vegetables, some fish, and little meat.
Chinese women traditionally breastfed for a long time, sometimes three years (but usually half of that). Frequent pregnancy and long lactation, and frequent spells of malnutrition, meant that women rather rarely menstruated, which may explain Chinese beliefs about menstruation as a rather strange and dangerous state (Harrell 1981). A large number of fascinating medical beliefs about breasts, breastfeeding, and breast health went—in general—to support breastfeeding in traditional China, but some were complex medical beliefs with obscure origins (see Wu 2011).
On the other hand, liver flukes abounded of old, thanks largely to eating raw or undercooked carp and similar fish. Opisthorchis viverrini is particularly common today. “Many still believe that the O. viverrini parasite can be killed through fermentation, preparation of raw fish with chilies or lime, or consumption with alcohol” (Ziegler et al 2011). No, and even freezing, salting and drying do not kill it. There is no solution except thorough cooking.
Meanwhile, Chinese medicinal food has spread to the western world, not only via books but also via such restaurants as the TT Chinese Imperial Cuisine of San Gabriel, CA—a restaurant serving medicinal foods to the local Chinese community. In China itself, restaurants serving yaoshan—“medical dining,” traditional medicinal dishes—have been growing in number and elaborateness since their beginning around 1980 in Sichuan. They use variously-updated recipes from the medical-nutrition classics.
And the classic four tastes—salt, sweet, sour, and bitter—have been increased to five: the human tongue has receptors for glutamate, giving us the taste known in Japanese (and now in English) as umami. This gives the spark to MSG and many Asian ferments.
Some of the research for this ms was supported by NSF grant 0527720, gratefully acknowledged.
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 In the HHYF, qi most commonly means simply “breath.” Here the meaning is unclear but the context would be perfectly comprehensible in terms of Chinese medicine, thus the translation. An alternative translation would be “vital force.” (P. Buell’s note)