How should we understand the strange disparities between the human body described in classical Greek medicine, and the body envisaged by physicians in ancient China? How is it that this basic and most intimate of human realities came to be conceived by two sophisticated civilizations in radically diverging ways?

We glimpse the legacy of this divergence in illustrations from two works of later Chinese and European medicine – the Shisi jing fahui by the Yuan dynasty physician Hua Shou (Plate 1), and Andreas Vesalius' Fabrica (Plate 2). Viewed side by side, the illustrations each betray ‘lacunae’. In Hua Shou's figure, we miss the precisely articulated muscles of the Vesalian man; and indeed, traditional Chinese medicine had no true equivalent for the notion of muscle. Fascination with musculature was a peculiarly Western phenomenon. Conversely, the points mapping out the acupuncture man eluded Vesalius' vision of the body – necessarily, since they were, even to Chinese eyes, invisible. Thus, when Europeans in the seventeenth and eighteenth centuries began to peruse Chinese medical literature, the descriptions of the body they encountered appeared to them like accounts of an imaginary land – ‘fantastical’, one English physician would deem them, ‘absurd’, would judge another.

Introduction

In his commentary on Aristotle's De sensu et sensato, written in 1269, Thomas Aquinas did not hesitate to define the physician to his students as the artifex factivus sanitatis, the maker of health. The context in which this attractive definition arose was the relationship between natural philosophy and medicine, a problem that greatly concerned medieval scholars, whether they were physicians or not, in the period between the twelfth and fourteenth centuries. For this reason, Latin European students were confronted with a question that was by no means trivial and in no sense abstract: what was the difference, in intellectual and practical terms, between two activities that had emerged from the newly founded universities of the time. I refer, on the one hand, to the new, university-trained physicians, educated according to the Galenic paradigm following an intellectual model that was increasingly clearly defined in the Latin West in the twelfth century, and, on the other, to the natural philosophers, who had become firmly established in the already influential Schools of Arts. Neither of these two groups of ‘professionals’ could remain detached from such important human phenomena as health and illness, at both the individual and collective level. In case of the physicians, this was for obvious reasons; in the case of the natural philosophers, their intellectual discipline could not remain detached from anything connected with the human being. ‘It is the task of the natural philosopher’, commented Thomas Aquinas,

It is axiomatic that virtually all the extant medical treatises of Graeco-Roman antiquity were written by men, but the extent of women's role in the compilation of these writings is debated. Paola Manuli believes the Hippocratics treated the female body as a dumb canvas on which to project their theories, while Aline Rousselle claims the Hippocratic treatises were little more than the written mouthpiece for the female oral tradition. Needless to say, most scholars believe the truth lies somewhere between the two. G.E.R. Lloyd has drawn attention to the interplay between developing scientific medicine and folk medicine, and Ann Ellis Hanson divides women into two types: the inexperienced, whose knowledge of her own body is indeed shaped by the physician, and the ‘woman of experience’, who functions as an authoritative source for male physicians. The very existence of this debate, however, indicates the recognition that for the ancient Greeks and Romans the epistemological basis of their gynaecology differs somehow from that on which the rest of their medicine is founded. Neither ancient authors nor modern scholars are so concerned to analyse the contribution of the male clientele to Hippocratic theories and treatment.

In practising clinical medicine the ancient physician recognized two sources of information: autopsia, his own observations, and historia, what he was told by other people. We might assume that it was the social impropriety of a doctor examining a woman's body in an intimate manner which caused a different emphasis in the epistemology of the gynaecology by restricting the opportunities ancient physicians had for autopsia in the case of women's diseases, but this is not acknowledged as a problem by the Hippocratics.

Someone spoke of our endeavour as building a house in which the foundation is solid. But perhaps it's more like repairing a ship while at sea, where the foundation is not all solid but somehow it floats. And indeed, the whole foundation of what we tried to do, namely, to compare cultures, to compare bodies of knowledge, is, I would say, very flimsy, very unsafe, very uncertain both from a philosophical vantage point but also from a historian's vantage point.

First, there is the perennial problem that, when we compare two bodies of knowledge – say Indian, Chinese, Western medicine or within the Western tradition, medieval, early modern, Greek, Arabic – what is it precisely that we compare? Furthermore – and this is a philosophical question – is comparison logically possible? How do we safeguard the objectivity or vantage point for such a comparison? And do we have to give up the claim for truth if we relativize radically?

Now this logical problem of comparison is that if you compare the theories of science, or the periods of science, and even more so if you compare the very disparate bodies of knowledge, there is the question of commensurability. How do you translate a term, an observation, any item of one theory to the other? How do you translate from one language into another, from one system or concept to another? Is such a translation at all possible? Can one look for similarities?

These are questions of principle and you may argue that such translations are a priori impossible.

The historiographical problem of early medieval medicine

Since the time of Karl Sudhoff and his students, medical historians have been labouring with patience and energy to edit the texts available in the pre-Salernitan period (sixth to eleventh centuries), and to present the manuscripts through which these texts were conveyed. Yet no satisfactory history of early medieval medicine has appeared, nor has any been attempted since MacKinney's slender 1937 survey. This lacuna is all the more curious in that, more than half a century ago, Henry Sigerist set out a cogent plan for how a critical and synthetic history of early medieval medicine, based in the manuscript sources, might be written. Sigerist proposed a survey in three volumes. The first would be a catalogue of manuscripts containing early medieval medical materials, the second an anthology of texts, the third the narrative history.

Sigerist's plan seemed clear and practical, yet it never materialized. To be sure, the intention of the first volume was fulfilled in 1956 with the publication of Augusto Beccaria's repertory of early medieval medical manuscripts, supplemented in 1966 by that of Ernest Wick-ersheimer. As well, the editing of texts and the provision of studies of individual manuscripts continues apace. Yet despite the wealth of primary materials now accessible, there is no sign of any plans to attempt the third stage, the general history. Was there something wrong with Sigerist's logic? Why is a plethora of sources not leading us inexorably towards a narrative account?

I would suggest that the problem lies in the process of text edition itself, or more precisely, in the often unexamined assumptions about texts that editing reinforces.

‘Epistemology’ is a term that can be used in a looser, and in a more strict, acceptance. In the looser one, which a number of contributors to this volume appear to have in mind, it may be used of any statement or position that may be thought to imply a claim to know or that allows one to investigate how such a claim might have been sustained, for example, by reference to what is represented as the correct method to adopt. All uses of expressions for cognitive states or processes, all methodological observations, have, on this view, an epistemological component. In a stricter acceptance, however, epistemology relates solely to explicit statements that directly address such questions as the criteria of knowledge or the conditions that have to be met for a knowledge claim to be justified. While clearly no hard and fast distinctions are to be drawn between the two ends of the spectrum indicated by these acceptances, I shall be concerned here with the strict, or stricter one, that is to say with explicit discussions of the nature of knowledge and of the basis of claims to have secured it.

It is well known that extant Greek medical texts from the fifth century BC onwards offer many examples where the authors reflect self-consciously on the status of medicine. Can it be said to be an art, technē, or a branch of knowledge, epistēmē, and if so, why? What distinguishes the true practitioner from the lay person or the quack?

My work as an anthropologist has been divided between two medical traditions: traditional Ethiopian (Amhara) medical beliefs and practices and psychiatric medicine in North America. Ethiopian medicine includes a textual tradition, derived from Graeco-Arabic sources, but my knowledge of texts extends only to recipe books and divinatory texts – humble stuff compared to the traditions discussed at this workshop. On the other hand, while psychiatric medicine has a rich textual tradition, it is also rather far removed from the humoral traditions represented here. So I can claim no expertise in any of the scholarly discourses represented among the workshop's participants.

Because my own research has focused on clinical settings, I am disposed to see these textual traditions in a similar context. Throughout the workshop, I have been asking myself these two questions. What is or was the relation between these various texts and the medical practices that each encodes? What is or was the relation of the texts cum practices to sickness in these societies? I recognize that in many instances, we have only the texts and there is no plausible way to reconstruct the clinical realities. In my comments, I want to suggest that the questions are worth asking anyway, as a tentative step to contextualizing these literate traditions.

What I require at this point is a textual tradition to which I can claim equal access and expertise with the workshop's other participants. Fortunately for me, Dr Kuriyama has introduced just the thing. You may have missed it, since his (chance) remark flashed by before the start of his splendid paper on visual knowledge in classical Chinese medicine.

The subject of this paper is how physicians in late imperial China (c. 1500–1850) understood women's bodies and health problems. Two questions raised in this paper relate closely to issues explored by Lesley Dean-Jones. First, did orthodox Chinese physicians, all of whom were men, feel any uncertainty about their knowledge of the female body? And second, what value did they place on women's testimony about their bodily states and experiences? In the third part of the paper I look at patterns of medical reasoning and choices of diagnosis in the case of a single, sex-specific health problem, amenorrhoea, which physicians and lay people alike thought of as life-threatening. The late imperial gynaecological texts on amenorrhoea offer interesting insights into levels of medical causality, the relationship between professional and lay reasoning, and the power of words to influence therapeutic choice.

Knowing the other sex

Orthodox physicians in late imperial China included literati and hereditary physicians. The literati doctors were also well trained as scholars and more deeply versed in general philosophy than the hereditary physicians, but both groups had studied the medical canonical texts and shared a cosmological understanding of the nature of the human body and its disorders. These physicians were exclusively male. Did they, like certain Greek physicians, have any doubts as to their understanding of the female body?

Such uncertainty clearly relates to how the physical difference between the sexes was understood. In the Greek medical tradition, the explanation of sex differences centred mainly on a contrast in reproductive form and function from which other secondary differences derived.

Preface

This paper poses the question as to whether and how far it is possible to talk of epistemology in relation to a learned tradition in medicine, when that tradition is well established and is concerned to emphasize the unchanging nature of its knowledge in the struggles against its competitors in the medical market place. Some of the discussion bears upon the question of why learned medicine came to die out in England, but this issue is not the main focus of the paper.

I have not spelled out modern-day historiographic categories (for instance, epistemic or sociological, or to use more old-fashioned terms from the history of science and medicine, internal or external). They express dichotomies which for the sixteenth and seventeenth centuries are not historically grounded. (For instance, a sixteenth-century divine or politician would not have agreed that a point of religious doctrine was a matter either of epistemology or sociology – even if the latter could have been recognized at the time – though it might be seen as a blend of both. Our modern scholarly traditions and disciplinary rivalries mean that one or the other tend to be given priority.)

Introduction

The epistemology of Western learned or scholarly medicine was not completely successful; it did not produce knowledge of such certainty as to kill off all other rivals in the medical market place. It is also doubtful if in early modern Europe learned medicine was using epistemology in any heuristic sense to create new knowledge.

The title for the workshop from which this volume evolved was ‘Epistemology and the Scholarly Medical Traditions’. The original idea was to look at the question, ‘How did Galenic, Chinese and Āyurvedic doctors use written texts as authorities for their claims to knowledge?’ Contributors were left considerable freedom, however, to interpret the original title as they pleased because enforcing any particular orientation would have risked subverting our comparative enterprise before it had begun.

That proved to be a wise decision. In our very first session together, Jim Hankinson defined ‘epistemology’ as ‘a self-conscious theory of knowledge’. A little later, Judith Farquhar observed that, for a Sinologist, every word of that definition would have to be reinterpreted, ‘quite possibly including “of”. As the reader will discover, ‘epistemology’ turns up frequently, and it is indeed a troublemaker. It has a decidedly Eurocentric ring to it. In an effort to avoid some of the pitfalls associated with the term, this essay will step back a bit and reflect, historically, anthropologically and meta-epistemologically, on the ways in which these traditions have (or have not) claimed special status for their scholarly medical knowledge at various times in history.

But first, a word or two is needed about the overall strategy of the volume. All the chapters are devoted to the past except for those by anthropologists Judith Farquhar and Lawrence Cohen who talk about present-day events in China and India, respectively. In retrospect, I regret the omission of something about modern Unani medicine so as to have touched on living examples of all three traditions.

In 1928 Dr Frederick Russell, recently appointed Director of the International Health Division, reminded Dr Michael Connor, Director of the Health Division's Brazilian Yellow Fever Commission, of the Division's real objectives. ‘What we want to do’, he elaborated, ‘is to help each country establish a health organization suitable to the needs of the country … and we hope that the yellow fever work will lead to a better health organization in the states and in the nation of Brazil.’

That indeed was the original goal of the organisation founded in 1913 as a mirror of the older Rockefeller Sanitary Commission for the Eradication of Hookworm Disease from the south. Using hookworm as their weapon, both organisations hoped to awaken public interest in (1) hygiene and sanitation by which hookworm could, it was hoped, be prevented and in (2) scientific medicine, which had revealed the cause and cure of the disease. By such means both Rockefeller organisations were then prepared to follow up their hookworm demonstration work by helping to set up local health agencies to promote health, hygiene and public sanitation. ‘The purpose of our work in any country is not to bring hookworm disease under control’, Wickliffe Rose, the organisation's first Director, noted in 1917, ‘but to make demonstrations which will lead ultimately to the enlistment of local agencies in the work.’

Introduction

The development of the application and use of scientific research — including natural science, medicine and social science — in relation to government and policy-making is a twentieth-century phenomenon.

Introduction

The theme of this chapter is the influence of the United States of America on the development of international health organisations in Western Europe. The period focused upon is the short four-year span between 1918 and 1922 during which new international organisational bases were being created for the health work of the League of Nations (LN) and major conflicts were occasioned among existing organisations. It was a time of the building of new power bases and political structures in the context of the Paris Peace Conference; it was also the period in which domestic health policies were being negotiated in separate national discourses.

I will argue that American influence in international health organisations was exercised through the powerful corporate philanthropic organisations of the American Red Cross (ARC) and the Rockefeller Foundation (RF). The influence of the RF, through the International Health Board, on public health in Europe has been documented and researched. The role of the American Red Cross, under the chairmanship of Henry Davison, and its War Council has been less studied, although Howard-Jones suggests it may have been pivotal in the formation of the Health Section of the LN.

Background

The United States played a major role in the post-war construction, financing and design of what were two of the largest international health organisations in the world, the League of Red Cross Societies (LRCS) and the League of Nations Health Organisation (LNHO), the forerunner of the World Health Organisation (WHO).