Formative era – the earliest texts – third century BCE to third century CE

It is difficult to determine when drug therapy began in China since we have no documents dating before the third century BCE, but we assume it has been in use from early human civilisation. The earliest surviving texts on drug therapy are not systematic compilations but rather are excavated texts dating to the Han dynasty (202 BCE–220 CE); additionally, one materia medica and one formulary have survived to the present from this era. It is probably due to doctors’ reluctance to share their proven remedies that we have such scant literature on drug therapy from this period. These texts, at least during this period, were of very little interest to the elite or to government officials who managed the imperial archives.

The earliest textual record of prescriptions dates to the Qin dynasty and was discovered in a well in Liye 里耶, Hunan in 1996. Among the thousands of boards and slips unearthed, at least twelve recorded medical prescriptions and even mentioned an official doctor (Yates 2012). The earliest complete text devoted to medical prescriptions, unearthed from a Han-dynasty tomb originally sealed in 168 BCE in Mawangdui in Hunan Province, is titled Prescriptions for Fifty-Two Ailments (Wushier bingfang 五十二病方) (Harper 1998). As the name suggests, the text is arranged according to fifty-two categories of ailment. In fact, the text ends with additional prescriptions for several more ailments deviating from the original list written at the beginning of the text, listing in total 283 prescriptions. The diseases predominantly revolve around external injuries such as flesh wounds, warts, haemorrhoids, and snake bites, but there are also other disorders such as injury of child by a demon. The prescriptions are sometimes presented in a sentence or two, and sometimes provide much longer descriptions of symptoms, drug preparation, and therapy. It is important to note that the text often lists prescriptions that include exorcistic incantations or magico-religious operations along with drug formulæ for the treatment of the same disorder. The text cites various methods of treatment, including moxibustion, cupping, and massage, but the application of herbs is the predominant method of treatment. The format of the text is straightforward: a disorder is listed and the treatment is given. No theoretical discussions are found. This leaves us to surmise that either the author assumed that the reader would understand the medical theories underlying the treatments or the treatments themselves were simply pragmatic, with no particular theoretical underpinnings.

The second surviving text recording prescriptions was unearthed from another Han-dynasty tomb originally sealed in the mid-first century CE in Wuwei 武威 in Gansu Province. It is titled Han Dynasty Medical Bamboo Strips from Wuwei (Wuwei Handai yijian 武威漢代醫簡), later named Formulary for Curing all Disorders (Zhi baibing fang 治百病方) (Yang and Brown 2017). This text represents a more developed material culture for drug preparations than the Prescriptions for Fifty-Two Ailments, listing decoctions, pills, powders, syrups, and many external applications as well. This formulary covers a wider array of disorders than its predecessor, including external injuries, female and children’s disorders, and various diseases such as cough, breathing problems, eye and ear problems, and even bleeding, resembling the diversity of later formularies. This formulary’s prescriptions are predominantly drug formulæ and the majority of the recorded drugs also appear in the Bencao jing, discussed below. The text also discusses the preparation of decoctions, pills, ointments, powders, and so on. It also provides instructions on how and when to administer the prescriptions. There are altogether thirty-six prescriptions in it.

The earliest formulary not from archaeological excavations is the Treatise on Cold Damage and Miscellaneous Disorders (Shanghan zabing lun 傷寒雜病論), written at the end of the Eastern Han dynasty by an official turned physician, Zhang Zhongjing 張仲景 (150–220 CE). ³ This formulary brought forth a new system of diagnosis based on the six warps (or stages, liujing 六經) of disease as well as a well-developed taxonomy of diseases. In addition, each of the formulæ is given a name, and the dosage and method of preparation of the herbs are specifically described. In fact, this book provides by far the greatest single source of formulæ in traditional Chinese medicine. Zhang, who described himself primarily as a collector rather than as a composer of formulæ, was the first person we know of to identify the condition of a patient (the diagnosis) with a particular formula used to treat that condition (Goldschmidt 2009, ch. 3; Brown 2015, ch. 5).

An unknown author or authors wrote the first materia medica in Chinese history during the Han dynasty, titled the Divine Husbandman’s Materia Medica ( Shennong bencao jing 神農本草經, Bencao jing for short). This book, lost not long after its completion, survived due to the fact that a fifth-century Daoist priest, Tao Hongjing 陶弘景, reconstructed it. The Bencao jing was the first of a line of encyclopaedic books that listed medicinal materials or drugs in a systematic manner. The full title of the Bencao jing includes the name of a legendary emperor, the Divine Husbandman (Shennong 神農), who, according to tradition, ruled during the third millennium BCE. He was said to have thrashed all plants and other drug materials to extract their essential qualities, tasted them, and then classified them according to their value as foodstuffs and drugs. According to the same tradition, he poisoned himself and found the antidote in each and every instance. ⁴

The Bencao jing, now believed to be a compilation dating to the second or first century CE, organised its drugs into three classes. The upper class (shangpin 上品), or monarchs, included 120 drugs, which were considered to be non-toxic (or non-curative) and aimed to prolong life. These drugs would not cause harm even if taken in large doses for long periods of time. The middle class (zhongpin 中品), or ministers, included another 120 drugs that were designed to prevent diseases and were somewhat toxic (or with curative effects). These drugs could be dangerous depending on dosage and on the other drugs with which they were used. The lower class (xiapin 下品), or assistants and envoys, included 125 drugs that were considered to be toxic with side effects, and were specifically used for therapeutic purposes to treat diseases or to produce medicinal effects. ⁵

Altogether, the Bencao jing listed a total of 365 Chinese medicines of which 252 were of plant origin, 67 from animals, and 46 from minerals. For each drug listed, the canon discussed its thermal influence or qi as well as its sapor (see above). It also discussed drug preparation methods, recommended doses, and the correct time to consume the drugs based on its traits. The major treatment strategy offered in the canon is treatment by opposites, for example, heat symptoms or heat disease should be treated by cold or cooling drugs.

In sum, by the end of the third century CE, drug therapy literature, unlike the literature of canonical classical medicine which was under official auspices, was not in wide circulation and was often transmitted within lineages of physicians. It took a major change in both the political and religious scenes to bring drug therapy to the fore.

Second stage – fourth to tenth centuries: the expansion and systematisation of knowledge

After the collapse of the Han dynasty, China splintered into a series of small kingdoms, beginning centuries of political disunity initiating an era known as the Northern and Southern Dynasties (317–589) or as the Six Dynasties period (222–589). North China was dominated by the Sixteen Kingdoms (304–438) ruled by five non-Chinese peoples later to be unified under the Northern Wei dynasty (386–535). The period of disunity and the Sui (581–618) and Tang (618–907) dynasties which followed were an era when drug therapy and its literature flourished and evolved rapidly. Without the early imperial preference for canonical medicine that favoured the cosmology of systematic correspondence and with the ever-growing penetration of Buddhism into China and the expansion of the Daoist religion, this period saw the growing production of practical books discussing drug therapy, including materia medica literature and formularies. One of the highlights of this era was the appearance of the ‘great’ religions in China, namely Buddhism and the Daoist religion. The impact of both on medicine is discussed in depth in Chapters 27 and 28 in this volume, but we have to reiterate the latter’s decisive impact on drug therapy, predominantly on materia medica literature. During this era, materia medica literature expanded significantly, some claim due to Daoists’ interest in longevity and their search for the immortality elixir though this is probably only partially, if at all, true.

Materia medica literature advanced dramatically during this era. One of the most important figures in the development of drug therapy literature in Chinese medicine was Tao Hongjing 陶弘景 (456–536). Tao not only reconstructed the original Bencao jing, but added to that his original knowledge of materia medica, expanding the number of listed drugs from 365 in the original Bencao jing to 730 in his work. Additionally, he augmented the information on the herbs’ nature, location, and time of harvesting. Tao categorised drugs into seven groups: ‘jade and stones’, ‘herbs and trees’, ‘insects and animals’, ‘grains’, ‘fruits’, ‘vegetables’, and ‘miscellaneous’, and many later medical practitioners followed his classification system. One of the additional sources he drew on was a collection referred to as Separate Records of Famous Physicians (Mingyi bielu 名醫別錄). Although both the original and Tao’s texts were later lost, they have been reconstructed based on later bencao literature. Tao’s book entitled [Divine Husbandman’s] Materia Medica, with Collected Annotations ( Bencao jing jizhu 本草經集注) dominated pharmaceutical literature until the middle of the seventh century CE, when the Tang government sponsored the compilation of an official materia medica.

In 659, a group of over twenty officials and physicians led by Su Jing 蘇敬, working under an imperial directive issued by Tang emperor Gaozong (650–683), compiled a new official materia medica that followed and relied on Tao Hongjing’s materia medica. The Tang Materia Medica (Tang bencao 唐本草, also known as the Newly Revised Materia Medica [ Xinxiu bencao 新修本草]) included a total of 850 drugs. The Tang government made this book the official standard with regard to drug usage, though we are not sure to what extent this regulation was implemented beyond the Imperial Palace and maybe the capital, since without print technology few physicians are likely to have had access to the book or to have been able to read it. This book had special significance, not only because it was the first officially compiled materia medica in China but also because it standardised the knowledge of materia medica developed since the first century CE and provided illustrations in addition to the written text. The book, however, has not survived intact to the present, and what we know about it is through scattered quotations in other later works.

Su’s text was one of many medical compendia compiled in a period when the trade in natural and medical objects between China and its neighbours flourished. Tang China saw a new market for drugs, medicines, and spices. A burgeoning economy and the fact that the Tang capital of Chang’an became a cosmopolitan urban centre, drawing merchants from all over Asia, greatly expanded the number of drugs used as ingredients in pharmaceutical recipes. Buddhist monks who travelled to China also facilitated the transmission of Indian medicine and Indian pharmaceutical knowledge to China. The adoption of knowledge from India, however, was by and large limited (Salguero 2014, 2017).

Materia medica literature was not the only drug therapy literature to flourish during this period, which also saw a growing production of practical books of therapeutic recipes, or formularies. Two of the most important formularies of Chinese medicine, and the first belonging to the ‘great formularies’ genre, date to the Tang dynasty.

The earliest formularies took the form of manuals often for urgent use rather than comprehensive cover-all books. A good representative of this early formularies is the most important formulary of the Jin dynasty – Ge Hong’s 葛洪 (?283–?343) Emergency Formulas to Keep Up One’s Sleeve (Zhouhou beiji fang 肘後備急方, published between 306 and 333). ⁶ Ge Hong, who is best known for his writings on alchemy, authored this formulary introducing a rational structured presentation of formulæ. This book details simple and inexpensive, yet effective, formulæ and their application by symptom. Ge Hong thereby provided an organised set of formulæ making the text more useful as a reference for physicians and maybe laypeople. Tao Hongjing, mentioned above, further edited and supplemented Ge Hong’s formulary, in One Hundred and One Supplementary Formulas to Keep up One’s Sleeve (Buque zhouhou baiyi fang 補闕肘後百一方). ⁷ In general during this era, collections of formulæ, targeting either specific disorders or specific groups of society (women, men, or children), became popular. This has probably to do with the new notion of ‘proven formulæ’ (yanfang 驗方) that served as the basis for the majority of these publications.

In addition to shorter formularies designed for laypeople’s practical reference, the period saw the production of works that aimed to comprehensively collect and organise therapeutic knowledge, something more useful to the learned physician, serious medical scholar, or official educator. In this category, we find Sun Simiao’s 孫思邈 (581–682) Essential Prescriptions Worth a Thousand Gold, for Urgent Need ( Beiji qianjin yaofang 備急千金要方, pub. 659), and Wang Tao’s 王燾 (670–755) Arcane Essentials from the Imperial Library ( Waitai miyao 外台秘要, pub. 752). ⁸ These were the two grand formularies of the Tang dynasty. During the Song dynasty, the government printed these two works, establishing them as part of the canonical medical literature. Together, these works assembled thousands of remedies, from which we can learn much not only of Tang medicine but also of daily life. Wang’s collection quoted extensively from Six Dynasties works that are no longer extant, preserving much that otherwise would have been lost. Sun’s work, which represents one of the greatest works by a single physician, presented to the reader the complete scope of a physician’s clinical practice, including ethical dilemmas and healing practices borrowing from religions (Unschuld 1979: 24–35; Sivin 2017).

Another notable formulary of this era, though it was compiled during the tenth century in Japan, is the Prescriptions at the Heart of Medicine (Ishimpō 醫心方). ⁹ A Japanese scholar, Tamba Yasuyori 丹波康賴, compiled this formulary between the years 982 and 984 relying on over 200 earlier Chinese medical books, the majority of which have not survived to the present. Citations of these earlier works are very well documented in this text, making it an ideal source, reflecting the state of prescriptions during the Tang dynasty. It is important to note that many manuscripts from Dunhuang include formulæ; however, none is a comprehensive formulary like those listed above (Lo and Cullen 2005; Despeux 2010).

To sum up, drug literature during this stage contained great amounts of drugs but with relative lack of discrimination probably since a certain level of knowledge was presumed of the readers. Drug therapy literature during this stage focused on the treatment of diseases (bing 病) rather than differentiating patterns (zheng 證), of which there were hundreds. Consequently, the authors of these texts listed under each disease up to twenty formulæ without any indication as to which of them is most effective in a particular situation. Furthermore, many of the formulæ from this era contained a large number of herbs.

Third stage – tenth to thirteenth centuries: standardising drug therapy and integrating with canonical doctrines

The Song dynasty (960–1276) was an era of major changes in every aspect of life. The change with the most impact on drug therapy was the large-scale implementation of print technology leading to the democratisation of medical knowledge (Goldschmidt 2005, 2009). Another change was the fact that two empires established to the west and to the north of the Song limited its land commerce via the Silk Road. Consequently, the Song expanded and intensified maritime trade with Southeast Asia enabling access to a new drug lore not readily available to previous generations (earlier drugs were predominantly from India and Central Asia) (Lo Jung-pang 2012; Schottenhammer 2015). The Song also exhibited a change in society and in social order leading to a growing interest in medicine among scholar-officials and shifting the focus of the bureaucracy to regions previously ignored by the government. These changes created a new context in which drug therapy underwent major transformations in drug therapy literature, predominantly the standardisation of materia medica literature and the incorporation of canonical medical doctrine into the discussion of the characteristics and effects of drugs and formulæ (Goldschmidt 2009).

Up to the Song, drug therapy literature flourished and expanded, however, without incorporating canonical doctrines of physiology and pathology into its discussion. Moreover, records of drugs and formulæ were not standardised and often identical drugs or formulæ were listed under different names or different drugs were designated by the same name leading to much confusion. The origin of the transformations in drug therapy can be traced to the Song government’s printing of drug therapy manuals thereafter extending doctors’ familiarity with the literature. The Song government’s wide-ranging and unprecedented book-collection projects led not only to centralised, standardised, and hybridised medical knowledge, but also to equally unprecedented dissemination of newly forged medical texts through the feverish literary activities of scholar-officials (Goldschmidt 2009). Thus, older texts collected by Song officials initially served as the foundation for authoritative government materia medica collections and grand-scale formularies. Later, this same foundation was used for new styles of drug therapy literature.

Our discussion of drug therapy literature during the Song should be divided into two stages: the first consisted of printing and disseminating earlier literature, whereas the second consisted of standardising and then integrating canonical doctrines into the contents of these books. Early during the Song dynasty, the imperial government initiated a few projects for the collection and printing of drug therapy manuals resulting in one edition of materia medica and two formularies. The founder of the Song dynasty, Taizu 太祖 (r. 960–976), instructed his officials to compile a new materia medica collection. The newly printed Kaibao Materia Medica (Kaibao bencao 開寶本草, pub. 974) was designed to make materia medica literature widely available to a broader audience. This manual expanded the number of recorded drugs, adding 134 records, but made no other modifications. During the early years of the Song, the government published two grand formularies. In the year 981, the Imperial Court issued an order to compile the first government-sponsored formulary. A group of editors headed by Jia Huangzhong (賈黃中, 941–990) worked on this project for five years. In 986, the editors completed a gigantic manuscript entitled the Divine Doctor’s Formulary for Universal Relief (Shenyi pujiu fang 神醫普救方). This enormous work consisted of 1,000 substantial chapters, the table of contents alone comprising ten chapters. This work has not survived to the present. In 982, the second emperor of the Song, Taizong 太宗 (r. 976–997), issued a decree instructing Wang Huaiyin (王懷隱, fl. 978–992), who was a medical official of the Hanlin Academy and the Chief Steward of the Palace Medical Service, to compile a new formulary. After ten long years, in 992, Wang and his associates completed work on what had become one of the largest government-sponsored medical compilation projects to survive to the present, the Imperial Grace Formulary of the Great Peace and Prosperity Reign Period ( Taiping shenghui fang 太平聖惠方, pub. 992). It consisted of 100 chapters and included 16,834 different formulæ, including some from Taizong’s personal collection of formulæ. ¹⁰ In order to stress this book’s importance, Emperor Taizong personally wrote a preface for it.

The second stage of drug literature arose from the realisation that the uncritical reprinting of ancient knowledge was insufficient. This realisation occurred when the Emperor Renzong 仁宗 (r. 1023–63) ordered the publication of yet another revised version of ancient materia medica, titled Jiayou Bencao (嘉祐本草, pub. 1061), during the 1060s. Facing inconsistencies within the text, the editors of the Bureau for Printing Medical Books decided to rejuvenate and revolutionise materia medica literature by initiating an empire-wide survey of drug knowledge. They requested all the prefectures as well as entry ports into China to send them samples of all drugs grown at or imported to that locality along with local knowledge about these drugs. The editors then compared the samples with recorded information on drugs in existing materia medica collections and compiled the most up to date materia medica manual, the Illustrated Materia Medica (Bencao tujing 本草圖經, pub. 1062). The Illustrated Materia Medica, as is evident from its name, also provided illustrations of all the drugs to aid identification. Early in the twelfth century, the Song government sponsored its last materia medica combining previously published information with many southern drugs recorded in a Tang-dynasty manual. This created the greatest materia medica collection to that date, entitled the Classified Materia Medica (Zhenglei bencao 證類本草, pub. 1108, 1116), which recorded 1,748 drugs. This book served as the gold standard for drugs until Li Shizhen 李時珍 (1518–93) compiled his Systematic Materia Medica ( Bencao gangmu 本草綱目) in 1596 (Lu Gwei-djen 1966; Sivin 1973; Métailié 2001, 1990; Nappi 2009; Bian 2020).

In 1117, an official-physician named Kou Zongshi (寇宗奭, fl. early twelfth century) privately compiled his Dilatations on Materia Medica (Bencao yanyi 本草衍義) in which he began to integrate classical doctrines into the explanation of drugs’ effects for the first time ever. This process continued for over a century until the complete integration of these doctrines into drug descriptions in Wang Haogu’s (王好古, fl. thirteenth century) Materia Medica for Decoctions (Tangye bencao 湯液本草, pub. c.1238–48). The accessibility to the ancient literature, both canonical and drug therapies, created recognition that there was incompatibility in the knowledge since the traits of drugs and formulæ did not make use of canonical physiology and pathology. This compelled doctors to build bridges and integrate the two genres into one systematic medical tradition (Unschuld 1977; Goldschmidt 2009; Chapters 4 and 5 in this volume).

Song formularies also changed during the early twelfth century. In 1122, the Song government published a second grand formulary – the Medical Encyclopaedia: A Sagely Benefection of the Zhenghe Reign Period (Zhenghe shengji zonglu 政和聖濟總錄). This formulary consisted of 200 chapters and recorded over 20,000 formulæ. The biggest innovation of this formulary was the fact that throughout the text classical doctrines are interwoven with the discussion of formulæ. This formulary included information collected from practitioners as well as from contemporary and ancient medical texts. The contents of the book are divided into sixty-six categories of general manifestation types or patterns (zheng 證), which does not differ from earlier formularies. But instead of just providing the reader with the specific formula designed to alleviate the symptom with limited elaboration on how and why, the Medical Encyclopaedia adds to the discussion of the formula a thorough theoretical explanation serving as a background to better understand the treatment. For example, phrases such as ‘Treating deficient heart qi’ or ‘Treating original deficiency in the spleen’ occur with much greater frequency than in the earlier Song formulary, the Imperial Grace Formulary. In contrast to earlier formularies, the number of infusions in this book is limited, with a sharp increase in other forms of prescriptions such as powders, ointments, pellets, and boluses. This change is probably linked to the establishment of the Imperial Pharmacy, which sold these new forms of pre-prepared prescriptions rather than providing the ingredients for formulæ that the patient had to boil at home in order to make the infusion (Goldschmidt 2008).

The standardisation in formulæ took longer and occurred due to an external trigger. In 1076 the Song government established the Imperial Pharmacy initially to regulate the drug market, and later to benefit the people by supplying a wide range of drugs at a subsidised price. In 1110, the Imperial Pharmacy published a formulary listing all the pre-prepared prescriptions on sale at its branches along with the symptoms they treated. The extant version we have lists 297 formulæ, an almost insignificant number in comparison to the Medical Encyclopaedia (Goldschmidt 2008). At the same time, physicians began looking to reconcile the discordant information recorded in the government-printed formularies with both their clinical know-how, accumulated over generations of medical practice, and the physiological and pathological doctrines delineated in the newly available Han-dynasty canons. These tensions concerning the clinical application of formulæ and textual knowledge, along with the need to demarcate themselves from the ready-to-be-applied over-the-counter prescriptions sold at the Imperial Pharmacies, pushed these physicians to create theoretical bridges to span the gap between medical theory and drug therapy practices.

In sum, by the end of the Song dynasty, Chinese drug therapy was transformed. First, it underwent systematisation and standardisation following the many editorial projects sponsored by the imperial government. Formularies became all-inclusive mammoth compilations that contained virtually all earlier practical medical information on record, given that Song officials were now able to obtain copies of the texts. Materia medica collections expanded dramatically, more than doubling the number of recorded drugs. Additionally, their contents were standardised by imperial editors and physicians, producing a unified illustrated materia medica. Second, during the twelfth and thirteenth centuries, drug therapy was integrated with classical cosmology, physiology, and pathology. This change was much more profound and took a longer time to complete. By the end of the Song dynasty, we find a standardised medicine that discusses drugs and formulæ using terminology originally belonging to classical canonical medicine (Tables 8.1 and 8.2).