The Greatest Benefit to Mankind: A Medical History of Humanity

Lastly, the Divine Husbandman’s Materia Medica includes descriptions of the properties and uses of over three hundred vegetable, animal and mineral drugs, arranged into three classes: upper, middle and lower. Viewed as gentle and cumulative in action, drugs of the upper class were meant to promote health and longevity; the more potent lower class of drugs was to be employed once the patient had actually fallen sick. This longevity-oriented pharmacy was abandoned in later materia medica, giving way to systems based on curative qualities, with items being categorized according to a scheme of correspondences between yin yang and wu xing (the ‘five phases’ or ‘five processes’). Thousands of materia medica listings were written down over the centuries, the principal one being the late sixteenth-century Bencao gangmu.

THE TRADITION

How have these ancient texts have been able to retain such uninterrupted authority? Was it because Chinese medicine was, at bottom, hidebound or metaphysically oriented, its physicians being concerned first and foremost with dogma and only secondarily with hard evidence and the cutting-edge of experience? Some have seen it that way, and there have been critics who have dismissed Chinese medicine as nothing more than an elaborate verbal tapestry. Sinophiles, by contrast, argue that the story of Chinese medicine is one of the progressive winnowing of the grains of science from the chaff of ignorance and superstition. Along such (seemingly Whiggish) lines it has been claimed that Chinese physicians evolved theories (such as the model of the heart as a pump) which match or even surpass the evolution of western scientific medicine.

Facing these problems of interpretation, it is crucial to remember that the Chinese medical tradition presents an example of a classical model of knowledge. The role of basic concepts such as yin yang, for instance, remains definitive, even though their meanings were capable of modification. Canonical works were regarded as the sure guides to understanding the human body (microcosm) and its relations to the macrocosm. As in the other text-based learning, there has been a scholarly predisposition in the Chinese tradition towards ironing out doctrinal conflicts by means of an attempted reconciliation in higher synthesis.

Like Greek medicine, Chinese teachings were built upon the conviction that the body represents a microcosm of Nature and society. Corporeal processes follow rhythms comparable to those governing the workings of the universe. ‘A human body is the counterpart of a state’, observed in Inner Canon:

‘The spirit [the body’s governing vitalities, shen] is like the monarch; the Blood xue is like the ministers; the qi is like the people. Thus we know that one who keeps his own body in order can keep a state in order. Loving care for one’s people is what makes possible for a state to be secure; nurturing one’s qi is what makes it possible to keep the body intact.’

Health is dependent on the maintenance of internal bodily equilibrium, and also of harmony between the body, the environment, and the larger order of things. Healing is a matter of knowing how this harmony can be restored, for which the physician must be a philosopher as well as a technician.

Classical Chinese medical theory thus views the body as a physical entity subject to natural processes: sickness can be brought on either by some internal upset or by such external factors as cold, humidity or pestilence. Before the Han Dynasty came to power (c. 600–200 BC), ailments had often been blamed on evil spirits, or ‘wind’, which took possession of the soul: cures might be achieved by exorcism or drugs, and charms and sigils were also used to fend off demonic assaults. Because they were not yet properly anchored to their soul, the young were particularly vulnerable – one class of children’s afflictions is still termed ‘fright’.

Belief in supernatural disorders was to be eroded, however, and from the earliest systematic formulations of cosmological principles around 200 BC, sicknesses were regarded by physicians as determined by certain natural principles, rather as in the Hippocratic teachings. Chinese natural philosophy deals less in things than in relations, processes and cycles of transformation. The key to the natural world is qi (also rendered ch’i), variously translated as ‘air’ ‘vapours’ or ‘energy’, and somewhat resembling the pneuma or spiritus of Graeco-Roman medicine. In natural philosophy, qi, which permeates the cosmos, is something which stimulates a process of transformation, or is the medium through which such processes take place. In living beings, qi can be designated as ‘vital energies’ whose circulation sustains life itself. Life arises from a build-up of qi; its dissipation is marked by death. To preserve good health, a person must nurture the qi which sustains bodily functions. Qi can also be disruptive, however – ‘pathogenic’ qi brings illness on.

A concept fundamental for understanding the distribution of qi is the yin yang pairing, crucial from the Yellow Emperor’s Inner Canon of Medicine onwards. Yin possesses the qualities which superficially seem the diametrical opposite of yang – pairings like lower-upper, inner-outer, cold-hot, feminine-masculine, dark-light, wet-dry, etc. But these must not be read as fixed contraries; they are always relational and complementary – in any particular situation, yin and yang are symbiotic and subject to continual cyclical change.

Yin and yang are functions of space and time. Yang is more exterior, yin more interior. Once pathogenic qi penetrates the outer yang qi, which make up the body’s defences, it reaches the interior regions of yin qi which supply the body with nourishment and growth, and thereby turns more threatening. Like every other natural process, a malady will run through active yang phases and latent yin phases: once yang sickness has reached crisis point, it moves into a yin phase, which requires a distinctive treatment. Yin yang relations, in short, are complex, and must be appreciated from various viewpoints. In health and sickness alike, the body is in continual need of vigilant monitoring.

Wu xing (Five Phases) has often been translated as ‘five elements’, but that is misleading as there is no true parallel to the Greek notion of elements; the term ‘phases’ better suggests the dynamic quality involved. The Five Phases are wood, fire, earth, metal and water, paralleling the five viscera (heart, liver, spleen, lungs and kidneys), and all the other corresponding ‘fives’ (tastes, climates, odours, emotions, sounds, etc.). Each phase represents a class of action or interaction. Physiologically speaking, wood denotes a growth phase and a branching development; fire a phase of rapid upward dispersal, and so forth. Each phase is characterized by a distinctive colour, odour, sensation, bodily secretion, etc. and definite chains of relations result. The liver, for instance, is identified with the phase of wood, and the spleen with the phase of soil. Wood, perhaps in the form of a wooden spade, could move soil; hence, a relationship between liver and spleen could be explained as resulting from the tendency of the liver to govern the functions of the spleen.

The theory covering the patterning of these phases is known as ‘systematic correspondence’, embracing a vision of health as natural harmony within a holistic system. The Five Phases spontaneously beget each other in this sequence (the order of ‘mutual production’), while a sequence of ‘mutual restraint’ also applies – wood, earth, water, fire, metal. The body thus comprises a microcosm whose processes, healthy and pathological alike, are regarded as governed by the universal characteristics of qi, yin yang and the Five Phases.

Within the body, qi has two aspects – these are not material but processual. The yang element, likewise called qi, represents the capacity for action and transformation; the yin component, called xue (literally ‘blood’), represents the capacity for circulation, nourishment and development. Another vital substance (jing), translated as ‘essence’, includes both the nourishment gained from food and also (via the Taoist tradition) the reproductive substances like semen necessary for procreation. The vital forces circulate through the body in regular cycles through the circulation passages. These circulation tracts linking the visceral systems include the anatomically identifiable blood vessels but also involve invisible pathways along which qi travels in its various incarnations.

Before the systematic correspondence theory was elaborated, Chinese thinking about tracts and viscera seems to have conformed fairly closely with western anatomy. Early texts associate certain tracts with blood vessels, while others sketch in the location of the viscera. Chinese physicians were never interested in the mechanical models of the body promoted in the West after Descartes; nor, as medical theory became oriented from matter to processes, was close anatomical knowledge of the organs themselves expected.

Classical medical theory teaches there are five yin visceral systems: the cardiac, hepatic, splenetic, pulmonary and renal. These create, transform, govern, and accumulate qi, xue and jing. There are also six yang systems: gall-bladder, stomach, large intestine, small intestine, urinary bladder and the san jiao (‘triple burner’). These process food to generate qi, xue and jing, and discharge waste. Despite apparent analogues with Western anatomical thinking about organs like the heart, lungs and liver, the emphasis is always upon functions – the Chinese body is above all a functional organism. The ‘triple burner’, which arose late in Chinese medicine, does not map onto any anatomical part of all, yet possesses a well-defined complement of functions. The connections between the visceral systems, and the sequences in which malfunctioning in one affects the others, are to be grasped in terms of the theory of systematic correspondence. Because the relationships between the viscera and the associated organs, senses, emotions and secretions are seen holistically, there can be no such thing in Chinese medical thinking as ‘Cartesian’ mind/body dualism, strict ‘localism’, or the aetiological specificity of ‘one cause, one symptom’ pathology.

When qi is circulating in the proper manner through the body, external threats are held at bay, harmony prevails, and good health is enjoyed and maintained through temperate behaviour. There are many ways to produce healthy qi: through diet, exercise, preventative acupuncture, moxa cauterization, meditation or sexual self-control. Such methods not only reinforce health but aid longevity: some texts envisage a lifespan of over a hundred years, while others aspire, in the Taoist manner, to immortality.

Illness (bing) by contrast results from imbalances of yin and yang, causing disturbance of qi circulation, which then impairs the normal operation of the visceral systems and the vital fluids. Obstruction, surplus or depletion of qi or xue in one of the visceral systems upset its functioning and distribution through the organism in ways determined by phase dynamics and modified in the individual case by the sufferer’s own constitution. If caught early in its yang (external) phase, the imbalance can be treated and health restored, but once the life-threatening yin phases are reached, the harm may be irreversible.

In these theories, a disorder can be produced either by the invasion of an external threat (noxious qi) or by internally generated imbalance. ‘Excesses’ are the main danger, but deficiencies can also do harm – gynaecological disorders, for instance, are supposed common among widows deprived of sex. External pathogens include heat and cold, damp, poisons, fright (especially in the case of children), or sexual intercourse with ghosts.

The presentation of a disorder in the particular case is shaped not only by the pathogen, but also by the sufferer’s constitution, which influences its phase dynamics. The state of disorders caused by any specific type of pathogen (cold damage disorders, for example) thus conforms to a general pattern but allows infinite variations. Though diagnostic handbooks tended to classify disorders for convenience’s sake by symptoms rather than causes, maladies could not truly be cured until their fundamental causes were fathomed.

Classical Chinese medicine thus embraced a humoral and constitutional approach to illness – ‘biomedical’ concepts of disease are foreign to its basic thinking. In the seventeenth century, however, a wave of epidemics led physicians to propose the existence of certain types of pathogenic qi, which entered the body through the nose and mouth, and which, as in the case of tuberculosis or smallpox, could be communicated by contact. This was a new concept closer to the western one of infectious diseases, but one employed for a limited category of disorders only.

PRACTICE

On being called in, a physician was expected to identify the patient’s ailment and its progress before assessing treatments. On the assumption that its primary cause would be veiled by all manner of complicating symptoms, it was crucial to know the constitution and medical history of the patient, which would shape the course of the disorder and indicate likely responses to treatment. The practitioner’s task would be to break the symptoms down into a manageable set of dynamic characteristics: the fundamental cause, how the qi was affected, which visceral systems were impaired. He might relate symptoms to the Five Phases. Examining a patient with cold feet, he would attempt to determine which of the Five Phases that particular sufferer had greatest affinity for. Cold limbs would suggest Water, which might be confirmed by the presence of a foul odour, whereas a fragrant smell would point to Earth.

Another such diagnostic system was the ‘Six Warps’, first spelt out in the Treatise on Cold Damage. This sorted out manifestations according to the degree of permeation of pathogenic qi. From the seventeenth century, this procedure was elaborated by heat-factor disorder theorists into a four-level classification based on the position of symptoms among the ‘triple burners’ (san jiao). The most popular diagnostic grid, however, was the ‘Eight Rubrics’, first outlined in the Inner Canon, which involved four sets of polar opposites of diagnostic relevance: inner-outer, cold-hot, depletion-repletion, and yin-yang.

From the earliest medical texts, pulse-taking is commended alongside the observation of other physical and emotional evidence. The pulse was believed to provide key information about the circulation of qi, thus indicating bodily imbalances and how the visceral systems were affected. Pulse-lore became a sophisticated art, the wrist pulse being sounded at three different depths at three different places, and gauged according to such criteria as force, fulness, duration, resonance, rhythm and general ‘feel’. According to Wang Shu-ho in his twelve-volume Mei Ching (AD 280) [Book of the Pulse]: ‘The human body is likened to a chord instrument, of which the different pulses are the chords, The harmony or discord of the organism can be recognized by examining the pulse, which is thus fundamental for all medicine’. Up to two hundred different varieties of pulses were identified.

Consideration was also given to the patient’s complexion, breathing, emotional condition, temperature, pain, appetite and digestion. Deep-seated visceral effects could be elucidated in well-charted ways. Ailments of the hepatic system, for instance, were manifested in the state of the eyes and were linked to anger; kidney disorders affected the bones, ears and the sexual capacities, and drew fear responses. Emotional or intellectual maladies were construed not as ‘psychiatric’ disorders per se, but as symptoms of general constitutional conditions.

The physician would take a case history from the patient and his or her family, investigating the immediate causes of the disorder (exposure to rain, over-eating, etc.), but also laying bare the perennial behavioural patterns discernible in the symptoms (insomnia, pain, appetite loss, fever, childbirth complications). Diagnostic techniques were to grow more elaborate over the centuries. Tongue examination was formalized in the nineteenth century, while the twentieth-century brought the incorporation of temperature measurements, blood-sugar levels and blood-count into case histories. Nevertheless, the essentials of the ‘Four Methods of Examination’ were, and still are, interrogation, pulse-taking, ocular inspection, and examination by sounds and smells.

Therapy is thought to involve two phases: it eliminates the pathogenic qi and counters its effects, while building up the orthogenic qi that constitutes the body’s own defences. A therapeutic plan would typically be developed. Life-threatening symptoms of an acute disorder such as coma or high fever had to be treated urgently before deep-seated imbalances could be tackled, but immediate treatments would always take those basic problems into account. For instance, certain yin drugs were judged effective for reducing acute fever, but if that were symptomatic of a yang depletion, yin drugs would simply make bad worse. The physician had to adjust his therapeutic strategies stage by stage as the malady was gradually brought under control.

Almost all complaints – even skin injuries – were understood as ‘internal’. Thus bad eyes had to be cured through treatment of the hepatic system, and a visceral system disorder could be relieved only by restoring the yin and yang balance, not by surgical removal of a diseased organ. Surgery was never part of mainstream Chinese medicine – nor were dissections staged, since Confucianism forbade the mutilation of corpses.

Associated with Taoist alchemy, drugs form by far the most important therapeutic agent. There are thousands of familiar prescriptions (fang) which have been written out for centuries. Drugs were thought to operate in various ways: some eliminated pathogenic qi, others replaced depleted qi or blood, lessened heat, or served as sudorifics or as laxatives. Most prescriptions included cocktails of drugs in measured proportions: perhaps a strong shot of a powerful ‘principal’ drug to thin viscid blood, smaller quantities of a ‘leading’ drug to direct the main agent to the affected visceral system, an ‘auxiliary’ to make the principal drug more palatable, and another to prevent undesirable side-effects. Medicines were taken in the form of pills, powders, syrups, infusions or decoctions made up by the physician or a pharmacist. Some could be purchased ready-made as nostrums, others were kept secret or handed down within a family.

Of distinctive importance were acupuncture and moxibustion therapies. Acupuncture involves puncturing the skin with fine metal needles one-half to several inches long. The needles, sometimes driven in with great force, sometimes inserted gently, are set at different depths, and the site of insertion is crucial. Once inserted, the needles are twirled and vibrated. The oldest surviving atlas of insertion points is found in the Inner Canon, but they go back further. The physiology of acupuncture rests on the Taoist doctrine that the life force circulates through the entire body. The acupuncture points – there were already 365 by the second century, and the number grew still larger – are located on fourteen invisible lines or meridians running from head to toe; specific points on those meridians ‘control’ certain physical conditions. Since disease is the outcome of imbalance in the body’s qi, and suffering or sickness is the manifestation of imbalance, acupuncture needles introduce a balancing and restorative qi.

Moxibustion is a technique involving the burning of small pellets (usually of dried mugwort) on points on the skin, a practice somewhat analogous to Western cupping. The idea is that the heat produced should stimulate qi in affected bodily parts. Like acupuncture, moxibustion is believed to produce stimulus at key nodal points along the qi circulation tracts; unblocking obstructed qi, it redirects it to depleted viscera and so restore proper circulation. Physicians mainly used drug therapy, but there were also acupuncture specialists who did not prescribe drugs, and lay people often performed both processes within the family. In 1601 Yang Chi-chou published his Chen-chiu ta-ch’eng [Complete presentation of needling and cauterization] in ten volumes, offering a survey of the literature and theories of acupuncture and moxibustion.

In elite medicine, doctor/patient relations were regulated by strict protocols. Physical contact between physicians and superior patients was kept to a minimum; females might remain hidden behind a screen, communicating with the physician only through a husband or maidservant. Obstetrics was not performed by physicians; for that there were lower-class adepts, as there were also for massage.

While the masses might believe that illness was caused by malevolent ghosts, irate ancestors, insulted gods, karma and sin, classical Chinese medicine was secular, as were the kinds of healers mentioned in the texts. One was the so-called ‘Confucian physician’ (ruyi), a gentleman scholar of good background who studied and practised the medical arts in a philanthropic spirit and was expected to treat the poor gratis. The second approved practitioner was the ‘hereditary physician’ (shiyi). He typically came from a medical dynasty, so his training included apprenticeship as well as book-learning. Such families would gain a name for themselves by specializing in a particular disorder or by possessing some nostrum. Some had the status of regular family doctors, receiving an annual retainer from well-to-do clients. These two categories of healer hardly amounted to an organized corps of professional physicians in the modern western sense: the closest to that were those who took state medical examinations before going on to serve as imperial medical officers. Their status, however, was not high.

The medical corpus also refers to a mass of quacks, itinerants, shamans, priests, masseurs and ‘old women’. Being neither scholars, philosophers nor gentlemen, they all lacked prestige. Female healers were dismissed in medical texts as both ignorant and rapacious; but, despite male misgiving, large numbers of midwives and wet-nurses met the health-care needs of gentlewomen. The Korean state even brought in formal medical training for women in the fourteenth century, though they were regarded as of inferior standing.

Common people, when sick, sought aid from a variety of healers, many of them religious. Sacred healing still retains its importance throughout East Asia, and has even enjoyed a recovery in the People’s Republic of China. The first hospices and charitable medical services in China were set up by Buddhist monks in the early centuries AD. Committed as they were to strict social order, Confucians also took health responsibilities seriously; they saw the health of the body politic and the well-being of the people as equivalents, believing that being dutiful to one’s inferiors proved one’s fitness to rule.

When Buddhist monasteries were nationalized in the ninth century under the Tang dynasty, the imperial authorities assumed responsibility for their infirmaries. State initiatives continued throughout the Song and Yuan dynasties, when the compilation of pharmacopoeias was sponsored and charitable pharmacies and clinics founded. The decline of state medical services during the late Ming Dynasty (c. 1500–1644) prompted a rise in private charities.