Hippocratic Medicine in China

Since the days of the Roman Empire, there has been communication between China and the West through the silk route, as documented in the standard histories of China, such as the History of the Later Han Dynasty:

The nation of Ta-ch’in [Eastern part of Roman Empire] is to the west of the great sea. [In AD 166] an envoy from King An-tun [Emperor Marcus Aurelius Antoninus, AD 121-180] came to China, bearing gifts of ivory, rhinoceros horns, and tortoise shells.”

Later, in the Old History of the T’ang Dynasty:

[In AD 667] an envoy from Fu-lin [Syrian province of the Roman Empire] offered ti-ya-cha [theriac, antidote against all poisons]

And in the New History of the T’ang Dynasty:

There are clever physicians in Ta-ch’in who open the brain to extract worms and cure blindness.”

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After the banishment of the Patriarch of Constantinople Nestorius in AD 431, his teachings spread throughout the Eastern churches. There was a strong missionary spirit among them during the 7th and 8th centuries. Nestorian Christians were famous in western Asia for their medical skills. It is reasonable to conclude that they also introduced Western medical practices into China.

The T’ang dynasty (AD 618-906) opened its doors to foreigners of every order. Missionaries were welcomed, bringing fresh streams of foreign thoughts. Interaction with India, central Asia, and the Near East was carried out via trade routes. Christianity following trade routes had been strongest in commercial centres. The capital Hsi-an-fu (modern Hsi-an in Shen-shi Province in northwestern China) was a cosmopolitan meeting place where Arabs, Persians, and Syrians met with Koreans, Japanese, and Tibetans to discuss literature and religion with Chinese scholars.

A monument erected in 781 commemorating the “diffusion of the brilliant doctrine of Ta-ch’in through the Middle Kingdom” was unearthed in 1625 at Hsi-an-fu. It documented the arrival of a missionary A-lo-pen (Olupun, or Ruben, an apostle) from the empire of Ta-ch’in in AD 635. On the monument is the following inscription indicative of the medical mission of this religious sect:

The hungry came and were fed, the naked came and were clothed, the sick were attended to and restored, the dead were buried in repose.”

The first Chinese treatise on bone and joint injuries

A manual dedicated to bone and joint injuries surfaced around AD 846, attributed to a hermit named Lin Tao-jen (literally Lin, a man of the Way, c. AD 790-850): the Secret prescriptions from immortals for the treatment of injuries and bone setting. It commences with practical instructions on management of fractures and dislocations, followed by formularies of 44 decoctions and drugs for external and internal applications.

Lin recommended short splints for limb fractures that leave the adjacent joints free to move. For compound fractures, he suggested the following 14 steps in fracture treatment: (1) washing with boiled water; (2) assessment of injured part; (3) traction; (4) manipulation; (5) reduction; (6) application of hei-lung-san (literally black dragon powder, containing raw ginger and onion juice, for pain relief and reduction of swelling) to the injured site; (7) application of feng-liu-san [literally wind-flow powder, containing armadillo flesh, cinnamon, and tang-kuei (Angelica dahurica) for antisepsis] to any wounds; (8) bandaging and splinting; (9) oral medication; (10) repeat Step 1; (11) repeat Step 6; (12) repeat Step 7; (13) repeat Step 8; (14) repeat Step 9. Oral herbal medication administered to improvement circulation and healing, active and passive movements of the injured limb were encouraged.

The Hippocratic Corpus

Orthopaedics in the West began in Greece as a branch of surgery that concerned itself with correction or realigning body deformities subsequent to injuries. It was closely associated with the techniques of treating athletics injuries in the gymnasium. Its foundation is the Hippocratic Corpus. This collection in its extant form contains 60 or so treatises from 460 BC to 350 BC, corresponding to the active lifetime of Hippocrates (the Second or the Great) of Cos (from about 460 BC to 375 BC). It is believed that Hippocrates wrote at least part of the collection to preserve the oral tradition of his family of Asclepiads. The two treatises – On Fractures and On Joints– written by the same author, are remarkable for the competence of the technical analysis and the quality of writing. Exuding the strong personality of the author throughout, these are worthy of admiration among the surgical writings of the Hippocratic school. Rational and accurate, they reflect a profound practical knowledge and wide experience in the management of these conditions, the results of a long and profound experience. Traditionally attributed to the school of Cos, many believe that these were indeed written by Hippocrates himself.

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On fractures

In reducing fractures or dislocations, Hippocrates recommends one should set it in a straight line, for this is its most natural to do. The following are comparable excerpts from the Hippocratic Corpus and Lin’s Secret prescriptions from immortals for the treatment of injuries and bone setting:

Hippocrates on reduction:

Make extension in as straight a line as possible, for this is most conformable with nature … Then apply bandage.”

Lin on reduction:

Traction should be applied as near to the fracture as possible, not beyond the adjacent joint. One, two, or three men should be employed depending on the situation.”

Hippocrates on bandaging and splinting:

The bandage should be clean, light, soft, and thin…The form of bandage should be suitable to the form and affection of the part to which it is applied … At the end of the day the pressure should seem less, and on the third day you should find the bandages loose … bandage again with a little more pressure … tighten up the splints, especially at the fracture, and the rest in proportion. Tighten the splints every third day very slightly …. When removing the dressing, douche with warm water and replace it, using a little less pressure and fewer bandages. Apply loose as possible consistently with firmness”.

Lin on bandaging:

Splints and bandages should be changed in two or three days in summer; three to five days in winter will suffice. Wash the part with warm decoction, and apply black dragon powder. For wrist, foot, or finger cover with medicated bandage, mobilize frequently. Bath swollen part with warm water apply black dragon powder. Fill in the hollow parts with soft silk cloth. For splints, use strips of bark tied tightly on three sides of the limb, leaving spaces in between.”

For fractures of the distal radius, according to Hippocrates:

Dislocation can occur volar, dorsal, radial, or ulnar, the commonest being volar dislocation with fracture of the distal radial epiphysis and displacement of the ulna. In these cases the assistants require strong extension. At the same time, the projecting bone is pressed downward on the table and ulnarly using the heel or the palm, while the counter-extension is applied to the depressed part.”

Lin:

In protrusion of the hand, if displaced to the right, pull towards the left; if displaced to the left, pull towards the right. In applying traction assess the direction of the force, either straight or oblique.”

The role of dietetics

Dietetics in Greek medicine is central to all therapeutics. Dietetics, built as it was on natural philosophy, was the speculative core of Hippocratic medicine. Rational Hippocratic therapy consists in correcting by diet and drugs, any imbalance of the four humours (blood, warm and moist; phlegm, cold and moist; black bile, cold and dry; and yellow bile, warm and dry).

To the Chinese, diet plays vital roles in maintaining health and preventing illnesses. In its earliest from dietetics was concerned with preparation and administration of foodstuffs in liquids, gruels, and solids to match the severity of the illness. Food is the source of energy, bodily activities, and foundation of life. Proper food intake is based on a well-balanced daily diet, avoiding the over- or underconsumption of a particular flavour. For these two civilizations, to term a substance a food or a drug is sometimes entirely subjective.

Hippocrates on the role of diet:

Light diet for cases where there is no open wound, it should be restricted for the first ten days, seeing that the patients are resting; and soft foods should be taken…Avoid wine and meat, afterwards gradually feed him up.”

Lin’s advice on diet:

Avoid cold dishes, fish, and beef when taking medicine. Medicines should be taken warm to promote blood flow and healing.”

On dislocations

Of all that has been written on orthopaedics, the following classic description account on shoulder dislocation is probably the best known and the least altered.

The classic Hippocratic method:

The patient must lie on the ground…Then the operator, seizing with his hand the affected arm to pull it, while with his heel in the armpit he pushes in the contrary direction … A round ball of suitable size must be placed in the hollow of the armpit…Another person must be seated on the other side of the patient to hold the sound shoulder; a supple piece of thong sufficiently broad is placed around it, and some person taking hold of its two ends is to seat himself above the patient’s head to make counter-extension, while at the same time he pushes with his foot against the bone at the top of the shoulder. Or, place the patient on your shoulder, with the shoulder in his armpit. Or with the heel, something being introduced to fill up the hollow of the armpit, using the right foot to the right shoulder. Or, by rotation made with a piece of wood stretched below the arm. Or with the step of a ladder.”

Lin on shoulder dislocation:

In protrusion of the shoulder, support the armpit with a chair bench covered with cloth, steady the shoulder by one man while two men pull down the wrist followed by rotation; immobilize with bandage.”

For hip dislocations, Hippocrates recommends the suspension (“succussion”) method:

The patient is to be suspended by the feet from a cross-beam… When the patient is suspended, a person properly instructed and not weak, having introduced his arm between his thighs, place his forearm between the perineum and the dislocated head of the os femoris; then, having joined the other hand to the one thus passed through the thighs, he is to stand by the side of the suspended patient, and suddenly suspend and swing himself in the air as perpendicularly as possible. In some, the thigh is reduced without any apparatus by the aid of slight extension, such as can be managed with the hands and a little jerking; while in many flexion of the leg at the joint and making a circumduction is found to reduce it.”

Lin’s method for hip dislocations:

For hip protrusion above the buttock, two or three men pull on the thigh, reduce with the foot.”

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From the description of Lin in the preface to his manual, his name, appearance, his diet of maize, his wine consumption, and his incomprehensible songs all suggest that he could be of foreign origin. His hermitic existence and his abhorrence of authority indicate that he could be a refugee consequent to religious persecution by the State. From the above evidence, it has been hypothesized that Lin was a foreigner, possibly a Nestorian Christian in hiding after banishment of that sect by imperial decree.

Such assertions and conclusion on the identity of Lin are caused by misinterpretation of the descriptions of him. The title of Tao-jen could be equally applied to Taoist disciples and Buddhist monks.

During the T’ang dynasty, due to influx of foreigners, coconut container and wine drinking were not unusual even among strict indigenous religious persons. It was more likely that Lin was a Chinese Taoist priest. Taoism (signifying a “way of life”), the indigenous religion of China, had for its purpose the drawing away of worldly cares to Nature worship. It taught religious, alchemical, and health methods to attain longevity. It flourished during this period and had many followers among the literary and elite. It has been closely associated with traditional medical practice. Lin’s manual is included in an encyclopaedic collection of Taoist works – the Tao Chuan.

Notwithstanding the uncertainties surrounding Lin, his manual is the earliest known Chinese treatise entirely on bone and joint injuries. It represents a continuation and development of orthopaedics in China. From the above comparisons with the Hippocratic Corpus there is internal evidence from the language and treatment techniques that Lin’s manual might have incorporated Hippocratic principles. That such medical interchange is not impossible is evident in the flourishing trade communications between China and the West at that time.

Alternatively, it is possible that such similarities in the principles and techniques of treatment could arise spontaneously and simultaneously in two widely separated but well-developed civilizations. Such similarities may be coincidental, arising by way of chance. Four general similarities stand out. Firstly, Greece and China evolved comparably elaborate cultures with concepts and languages that could be used to explore every aspect of individual and collective experience. Secondly, people of both societies saw the need for such enquiries. Thirdly, specialist groups in both societies led in many branches of studies, acquiring new knowledge and understanding. Fourthly, both societies were convinced that what they learned was necessary to understand the place of human in the universal scheme of matter, and that this understanding would be of help in human affairs. In both societies, such investigations would be of intense value. Both China and Greece had passed through analogous transitions and have left comparable records from 400 BC to AD 200.

(Source: “Hippocratic Medicine in China: Comparison with a 9th Century Chinese Manual on Bone Setting”, by Louis Fu)

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Research-Selection for NovoScriptorium: Maximus E. Niles

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