Andrew Edmund Goble. Confluences of Medicine in Medieval Japan: Buddhist Healing, Chinese Knowledge, Islamic Formulas, and Wounds of War. Honolulu: University of Hawai'i Press, 2011. xx + 202 pp. $52.00 (cloth), ISBN 978-0-8248-3500-2.

Reviewed by Anna Andreeva (University of Heidelberg)
Published on H-Buddhism (August, 2012)
Commissioned by Mikael Bauer (University of Leeds)

Confluences of Medicine in Medieval Japan focuses on the two extant works of the Buddhist priest and physician Kajiwara Shôzen 梶原性全 (1265-1337) who practiced at the Gokurakuji Temple in Kamakura, the first capital of warrior government located in eastern Japan. In his pioneering historical study, Andrew Edmund Goble draws attention to Shôzen’s Ton’ishô 頓医抄 (Book of Simple Physician) of 1304 and Man’anpô 万安方 (Myriad Relief Prescriptions) of 1327, treating them as landmarks in Japanese medical history. Both works are seen as prime examples of appropriation of new medical knowledge, produced predominantly in Song (and Yuan) China, and incorporated some elements of Islamic medicine. While adapting such knowledge to the conditions of medieval Japan, Shôzen addressed diverse and important topics, including incised wounds, obstetrics, postpartum ailments, pediatrics, theory of medicine, viscera and anatomy, and moxibustion. In addition, the study highlights Shôzen’s role in completing an extensive identification guide to Chinese and Japanese names for materia medica, a guide to tastes and flavors of medicine, and augmenting these topics with his own comments, formulas, and instructions for their preparation. Shôzen’s extant writings, therefore, provide important insight into the state of medical knowledge in the late thirteenth- and fourteenth-century Japan and are treated as the first major improvement of such knowledge in Japan since the compilation of the tenth-century Ishinpô 医心方 (The Essentials of Medicine, 984) by the court physician Tanba Yasuyori 丹波康頼 (912-995).

Goble’s book, essentially, is an exploration of Japan’s medieval history with regard to the acquisition, circulation, and appropriation of medical knowledge between the multiple cultural contexts of East Asia and beyond. It is first to analyze Shôzen’s writings in English, and, in fact, in any language at all. More important, this study makes a very timely and useful introduction to the larger issues of medicine and society in premodern Japan by placing them within a global, transcultural context. For example, not only does the study give insight into the substance and contents of medieval priest-physicians’ work, but it also aims to do so against a much larger, constantly shifting dynamic background of the preexisting and emerging maritime and religious networks, the interaction between Buddhist notions of disease, healing practices, Asian pharmacopaeia, Islamic formulas, and contemporaneous sociocultural trends in medieval Japan. In other words, this books sets out some important and ambitious goals, aiming to refine our understanding of the history of medicine and other related issues in medieval Japan and broader East Asia while highlighting the case of Japan, as integrated into what Goble calls “East Asian macroculture.”

Based on the translation of Shôzen’s two writings and their correlation to printed Song Chinese medical works, such as the Taiping shenghui fang 太平聖恵方 (Formulas of Great Peace and Sagely Benevolence, 992), Chen Shiwen’s 陳師文 Taiping huimin Hejiju fang 太平恵民和剤局方 (Formulas of the Pharmacy Service for Great Peace and for the Benefit of the People, c. 1110), the Tang-era Beiji qianjin yaofang 備急千金要方 (Priceless and Essential Formulas for Emergencies, 196), and the Sanyin fang 三因方 (Formulas for Diseases Due to the Three Causes, first printed in 1174), Goble’s study utilizes a diversity of original sources, including official court records, personal diaries, and writings of aristocrats and religious leaders; hand-painted scrolls; literary sources; and selected Buddhist scriptures. The view of medieval Japan that emerges from his research owes much to the scholarship of Jeffrey Mass and traditions of medieval Japanese history studies at Stanford University, as well as a selection of Japanese historical scholarship on both medieval history and the history of medicine in Japan.

Chapter 1 provides a useful entry to the subject by laying out the historical context of thirteenth-century Kamakura. Juxtaposed with the sense of exclusiveness prevailing in aristocratic Kyoto, this town emerged as a hub of newly developed maritime trade networks, reaching out to the cosmopolitan port cities of Ningbo in southern China and Hakata in northern Kyushu, a development that, argues Goble, was to play a significant role in creating new routes for acquisition and circulation of new knowledge, goods, and technologies. Contacts between monastic communities, primarily those based in China and Japan, were another type of network that was involved in dissemination of medical and religious knowledge in post-1200 Japan.

Goble points out crucial differences in the view of the outside world by the aristocracy based in Kyoto, and those inhabiting the cosmopolitan and well-connected port towns in Kyushu and Kantô. The emergence of Kamakura as the end destination for ships arriving from Hakata, southern China, and beyond, argues Goble, had major implications for the field of medical knowledge and trade in materia medica. Buddhist networks, such as those between the Zen (Chan) or Vinaya (Ritsu) monasteries in China and Japan, and increased travel of Japanese Buddhists to China were additional major factors in dissemination of religious and medical knowledge. Goble demonstrates that Buddhist monks, including Myôan Eisai 明菴栄西 (1141-1215), Enni Ben’en 円爾弁円 (1202-80), Dôshô 道生 (active in 1240s-50s), and Mujû Ichien 無住一円 (1226-1312), trained mostly, although not exclusively, in the Rinzai Zen tradition, were involved in production and circulation of medical knowledge within the Buddhist framework in Japan. Another monastic group, which Goble prefers to call the Vinaya (or Ritsu) movement, of which Shôzen’s home temple Gokurakuji formed a part, based much of its activities around social relief work. The religious and social activities of the Ritsu-affiliated priests, led by the likes of Eizon 叡尊 (1201-90) and Ninshô 忍性 (1217-1303), embraced advocating the precepts, worshipping bodhisattva Mañjuśrī, and constructing medical facilities. Combined with the cosmopolitan settings and outward orientation of Kamakura, these social and religious dynamics serve as major focal points for Goble’s argument.

Chapter 2 begins by addressing the scarcity of Japanese medical works prior to the thirteenth century. Apart from the tenth-century Ishinpô and a few other texts compiled in the centuries after Tanba Yasuyori’s medical collection, Goble concludes that the textual horizons of Japanese medicine must have been quite limited: “Not many works were produced, access to them was highly restricted, and those in possession of them do not seem to have been at all motivated to share their knowledge” (p. 27). By contrast, the development of wood-block printing, subsequent availability of medical texts, and efforts to standardize existing knowledge of materia medica, prescription formulas and earlier classical works in northern and southern Song China created a strikingly different environment.

On the one hand, the availability of such new and revised medical knowledge, argues Goble, exposed Shôzen to the contemporaneous advances of Song medicine and informed his own medical writings. On the other hand, working with the new sources and adapting them to the conditions of medieval Japan highlighted the deficiencies in Japanese medical knowledge, which were further augmented by difficulties in technical translation and the necessity to find substitute ingredients suitable for producing the prescription formulas in Japan. Most valuable, in this respect, are Shôzen’s own comments, appearing in both Ton’ishô and Man’anpô, in which he painstakingly identified incorrect information about treatments and stressed the difference in attitudes between Chinese and Japanese physicians, for example, in relation to women’s medicine.

Chapter 3 concentrates on the pharmaceutical aspects of the new knowledge available through the increasing and multi-cited overseas contacts in “the East Asian macroculture.” Although Goble uses this notion of “macroculture” to a self-descriptive effect and without much further theoretical elaboration, it serves as a framework for mapping out the porous boundaries between the cultural and geographical entities within China and Japan not necessarily bound by notions of rigidly defined nation-states as opposed to the West, which is broadly defined elsewhere as “the modern Middle East, Southwest Asia, South Asia and perhaps Southeast Asia” (p. 58). Of crucial importance to the discussion is the fact that overseas materia medica arrived to Japan via the maritime trade networks that “ultimately linked the east coast of Africa, the Arabian peninsula, the Persian Gulf, coastal ports of India, ports of Southeast Asia,... the trading cities of south China..., and the Ryukyu Islands,” which in its entirety Goble describes as a “Silk Road of pharmaceuticals and formulas” (p. 46). He further points out, however, that the beneficiaries and consumers of the traded items did not necessarily know the actual origins of purchased items: for instance, it would not be out of place for officials in China and Korea to think that some items arriving from Southeast Asia were products of Japan.

This chapter elucidates the challenges encountered by the Japanese physicians who attempted to handle foreign materia medica. Different measurements and dosages, as well as changes in standards between the Tang and Song eras, confronted such medical practitioners as Shôzen with the necessity to correlate earlier norms to the new Song ones, thus requiring a major reassessment of almost twenty thousand formulas and terminology for the materia medica that were available during his time in Kamakura. Goble draws attention to Shôzen’s formidable contributions to the long-ranging processes of identification, recognition, and naming of botanicals and important components for medicinal prescriptions, and to his suggestions for effective alternative substitutes for items unavailable in Japan.

One of the most provocative observations made in this chapter relates to changes in the Chinese pharmaceutical regime from the Tang to the Song dynasties, and the influence of Islamic (Arabic) medicine on Song Chinese medicine. The presence of notions and recipes deriving from Islamic medicine in Japan is obviously a tantalizing topic, little studied in English so far. Goble’s study approaches it through the examination of a new illness category, “disorders of Qi,” which was first encountered in the Chinese medical writings of Hejiju fang, a work that was extensively studied by Shôzen, and the formulas for aromatic stomachics, which featured in Ibn-Sînâ’s classic Canon of Medicine  and also appeared in the Chinese Hejiju fang. However, to what extent Shôzen may have been aware of such influences remains a difficult issue, since Chinese medical works, which he used, did not provide any explanation to that effect. Goble’s study stops short of offering any further specifics on this topic or references to corresponding modern research on Islamic and Chinese medicine that could be of help in sufficiently expanding the scope of such a suggestion.

Chapter 4 investigates the interconnections between the rai 癩 disease, Buddhist notions of karmic causation for illnesses, and innovations in Song medicine. Goble provides an insightful translation of Shôzen’s description of rai 癩 (in most cases rendered as “leprosy”) and his approaches for its treatment in Ton’ishô and Man’anpô, linking the efficacy of medicines and treatment, along with the religious framework that was one of the major constituents of spiritual and material life in medieval Japan. The study demonstrates that even though he was aware of the Buddhist argument about karmic causation of illnesses, Shôzen approached leprosy as a clinical physician, trying to establish a platform for its pharmaceutical treatment and better understanding of its natural causes. This could serve as an important example of the emergence of popular physicians’ practice based on an empirical and pharmacological approach rather than only religious and ritual methods of healing in fourteenth-century Japan.

The discussion of karmic illness acts as a major linchpin of this chapter. Influential in both premodern China and Japan, this concept brings together Buddhist ideas on karmic causation of diseases and disorders, and the motivation of the Buddhist environment to relieve suffering and provide comfort for those in need, who may serendipitously appear in the form of a leper, beggar, or, possibly, a Buddhist saint Mañjuśrī in disguise. An interesting question to discuss here is how this particular construction of disease interacted with preexisting notions of illness as a result of invasion by malevolent spirits, or accumulation of ritual pollution, both usually calculated by means of divination. One could hazard a guess that these notions did not get phased out momentarily but rather continued to coexist with the newly developing empirical approaches, such as that championed by Shôzen, and consequently also deserve a mention.

Due to its focus on Chinese sources and the practice of Buddhist medicine from the perspective of a clinical physician, Goble’s study does not refer to the innovative medico-religious construction of soteriologies, which involved mapping out the workings of the human body, and the intense sacralization of the five viscera and other human organs. Such soteriologies were rapidly spreading within the esoteric Buddhist environment during the thirteenth and, particularly, fourteenth centuries. Buddhist priests, such as Myôan Eisai, who was familiar with the teachings of esoteric Buddhism, or monks connected to the temples specializing in the study and practice of both esoteric Buddhism and the Vinaya (later referred to as Shingon Ritsu) and Sôto Zen temple networks both in Yamato and Kamakura, would undoubtedly have been aware of such trends.

Chapter 5 is dedicated to a new category of medical knowledge dealing with curing and treatment of wounds. Warriors, subjected to prolonged and violent military campaigns, provided considerable information on injuries requiring treatment. Wound medicine is thus of crucial importance, since it emerged, in addition to obstetrics, women’s health, and pediatrics discussed earlier in chapter 2, as an area of medical knowledge based on empirical evidence and clinical experience. Goble helps to further this understanding by citing the intensifying warfare and violence in medieval Japan and, particularly, the changes in the nature of military conflicts from the 1330s as major historical factors that necessitated advancement of wound medicine. This chapter first concentrates on surveying the state and sources of knowledge for wound medicine before the 1330s. It then investigates new sources, both human and textual, related to this topic, before returning to the theme of materia medica and Song medicine.

Having investigated the above-mentioned themes, Goble concludes that Japanese Buddhist priest-physicians, such as Shôzen, were faced with the formidable task of engaging Song medicine, while being able to draw on at least two different systems of knowledge and explanation, which he defines broadly as Buddhist and Chinese. His study casts light on the processes of both intellectual inquiry and clinical engagement of a Japanese physician who single-handedly studied Song medical knowledge and pharmaceutical regime while adopting different systems of knowledge and improved understanding of illness.

For the complexity of the topics it tries to tackle, the book is impressively slim. At 120 pages without notes or bibliography, this volume may be the result of a deliberate strategy by the publisher. However, even within this short length, it demonstrates sufficiently that there is an urgent need to rethink the history of premodern Japan along the lines of transnational maritime networks, circulation, and appropriation of knowledge, and acknowledge the contribution of other cultures (whatever those may be at any one time) to the formation of the intellectual, cultural, religious, and political framework in medieval Japan.

Confluences of Medicine does not address larger topics, such as diverse notions of illness in China and Japan or previous understandings of the human body and its workings by Buddhist priests and physicians. Partially, this may be because Goble chooses to limit his consideration of the contribution made to this area of knowledge by the fourteenth-century esoteric Buddhist specialists, citing the traditions of Shingon and Tendai as either of no interest to clinical physicians, such as Shôzen, or “too secretive” (p. 26). Consequently, this limits our understanding of such texts as Gotai miwakeshû 五体身分集 (Collection on the Five Portions of the Body) and other medico-religious treatises, which feature the five viscera and six organs to the purely “medical,” clinical view. Part of the issue here, of course, is whether one can employ modern notions of clinical medicine, or to what extent one can separate categories of medicine and religious thinking when it comes to premodern pasts. In its entirety, Confluences of Medicine argues that the origins of such medicine may be sought in fourteenth-century Japan.

In prompting so many questions, Confluences of Medicine is undoubtedly a thought-provoking and much-welcome volume. It can be recommended to graduate students and scholars of premodern Japan and the history of medicine and society in East Asia, particularly for its capacity to invoke a vision of medieval Japan within a larger, more dynamic historical context and to offer many directions for future studies.

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Citation: Anna Andreeva. Review of Goble, Andrew Edmund, Confluences of Medicine in Medieval Japan: Buddhist Healing, Chinese Knowledge, Islamic Formulas, and Wounds of War. H-Buddhism, H-Net Reviews. August, 2012.
URL: http://www.h-net.org/reviews/showrev.php?id=35395

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