§105. Medicine

It used to be thought that professional medicine began in China with its foun­dational text, the Yellow Emperor’s Inner Canon (Huang di nei jing), a collec­tion of conversations between this sage ancestor and his physician-minister.

One thing we learn is that professional medicine, practicing a medical dao transmitted in a canonical literature, was established much earlier, by the fourth century bce. The nucleus of this medical dao was indeed books, which introduced disciples to the profession and were the foundation of eve­rything else in medical practice. These books preserved the experience of an­cient sages and contained secrets for an enlightened few, not to be wrongly circulated. In the words of the Yellow Emperor, “To obtain the right person and not teach him is called losing the way; to transmit [the way] to the wrong person is to wantonly divulge Heaven's treasure.” A mordant observer of the later Han wrote of medical books: “[If a book] bears the heading ‘so-and-so's recipes' or declares ‘already proven' and ‘previously tested' people vie to en­grave and copy it, regarding it as something treasured and secret.”⁴⁶

By the time of the Yellow Emperor’s Inner Canon a physician's credentials were evaluated by the emperor or a delegate, not by professional peers. All that was expected was evidence of having learned a medical text. A Ming bureaucrat writes, “Those who are able to recite some portion of the med­ical scripture may be permitted by the medical officer to treat people.” To be a physician was to possess such a text, having received it from a lineage master under whom one was initiated in the art.

The idea of texts attributed to ancient sages is a late theme in Chinese lit­erature; according to Sivin, it seldom predates the Han. Before then, and es­pecially in the Warring States period (the era of Mencius, Zhuangzi, and the Dao de jing), intellectuals were free agents loosely associated with courts, thinking and teaching as they pleased. They did not require a myth of origin for their ideas or a license to teach them. However, by Han times the scholars have become officials expected to confirm that the arts of civilization are a legacy of the ancient sages bequeathed to the emperor, who benevolently extends them to the people. Physicians were receptive to the new language game, and the Yellow Emperor’s Inner Canon rapidly displaced older medical texts to dominate theory and practice for a thousand years.

All of the medical canons and classics are closely associated with prac­tice and unintelligible without its experience, which gradually reveals the meaning of texts diligently committed to memory. But medicine is com­pelled to a certain empiricism and cannot be just texts. Somebody is suffering and a doctor either brings relief or not. The same Sun Simiao who wrote on alchemy and was also a physician exhorted medical colleagues to practice observation and investigation. It is “indispensable to acquaint oneself fully with the particular situation so that there remains no doubt. It is important that the examination be carried out with perseverance.” Another physician cautions on the need for close, individuating observation.

It is not enough to use your eyes and ears; one must feel the pulse, whose irregularities require undivided attention. Such knowledge is crucial to accu­rate diagnosis and also therapy, as only pulse provides information to gauge possible variations in the position of acupuncture points. European doctors of the contact generation praised Chinese skill in pulses, or thought they were, though what the Chinese do is not about pulses at all. They are probing the mo, a pulsation of the qi, and not especially the heart. These pulses convey distinct information concerning all the major organs, and there is more than one mo, or mo to be felt at many sites. The wrist alone has three major sites, with others below the fingers. The mo under one finger is completely dif­ferent from one under another. A Song dynasty physician writes, “Although the three fingers are separated by mere hairbreadths, the diseases they indi­cate are a thousand leagues apart.”⁴⁹

Information from the flux and flow of the qi is incomplete without due consideration of what can be seen in the color of the face, which is a major sign of the energy of the depths. Diligence in observing the mo requires complementary attention to the color of the face and the body generally. “A doctor may well excel in diagnosis by the pulse, but if he does not know how to observe the colors of qi he has not used the wonderful principles.... The qi of an individual has periods of strength and weakness and its color shows firstly on the face.” This idea was already in the Yellow Emperor text. “The illness can first be seen in the face (se), even though it may not appear in the body. It seems to be there, but not there; it seems to exist, yet not exist; it seems to be visible, and yet invisible.

Due diligence in medical observation was codified in the Four Examinations (si zhen): looking (wang); listening and smelling (wen); touching (qie), that is, feeling the pulse; and asking (wen), that is, obtaining a medical history. A medical literature of case histories (yian) describe symptoms in detail, including information about when they began, in what order they occur, whether they follow a seasonal pattern, or are more se­rious in the day or at night. One physician created a step-by-step template for taking a medical case. First, note the form (wasted, fat, tall, short, etc.) and appearance (red, black, glossy, dry, etc.); then observe sound (obscure, clear), pulse patterns, and state the principal treatment.⁵¹

The renaissance of Confucian philosophy under the Northern Song (eleventh-twelfth century) coincided with a new direction in medical learning that transformed the whole later history of Chinese medicine. For the first time the literati, Confucian scholar-officials, started paying attention to medical texts (a gesture they repeat when they discover swords and mar­tial arts). It was Confucian scholar-officials, not practicing physicians, who took the lead in collecting, collating, revising, and printing ancient medical canons. The sea change may have something to do with all four of the first Song emperors being interested in medicine, to the point of writing on med­ical topics, and even practicing acupuncture and prescribing drugs.⁵²

It was new to the physicians to have their works examined from the per­spective of the Confucian literati. It has been fifteen hundred years since Confucius and the early generations of Confucian teachers, and Confucian thought is much richer than it was in the Warring States period.

In a preface for a medical encyclopedia, Song emperor Hui Zong exhorts the physicians to get up to speed on the philosophy of nature. He explains that a physician has to understand the interaction between cosmological changes, local changes in the environment, and the changing body, and apply that un­derstanding to medical therapy. “I am pained by the undisciplined practices of incompetent doctors whose study is not extensive and whose knowledge is unenlightened. They ignore the regularities of the Five Phases and the trans­formations of the Six Qi, and do not search for the hidden meaning or their far-reaching implications. By ignoring small details such as climate and its variations, they cause great harm to the patient.” Among other measures, he enforced an examination requirement on medical practitioners. Questions required the candidate to recite applicable passages from medical classics, and to apply yin-yang and the Five Phases to hypothetical cases presented for diagnosis and treatment.⁵³

Song literati discover common ground between the Confucian virtue of benevolence (ren) and medical practice. “The perfected person gentleman should be like a good physician.” Plato thought statesmen should approach their work like physicians, but in China the idea is new at this later time. The author continues. “From the upper aspect use this knowledge to cure the diseases of the people and relatives, from the lower aspect save the poor from calamities, and from the middle aspect protect the body and extend perfection.” Medicine becomes a suitable field for scholar-officials and their sons, lending currency to a new bon mot, “If you cannot become a good min­ister, at least be a good physician.” The quip is unthinkable a century earlier, when the apprenticeship enforced on medical education was considered in­appropriate for a gentleman. An author of the previous Tang dynasty wrote, “Healers, musicians, and other people of the hundred occupations do not disdain being each other’s masters [and disciples].

These Confucian physicians started taking over a medical hierarchy pre­viously dominated by hereditary medical families, drawing elite and medical culture closer and widening the distance between learned practitioner and village healer. For instance, the Yuan dynasty ru yi Zhu Zhenheng regarded the practice of medicine as a form of classical study and Confucian “investi­gation of things” (ge wu). “The ancients believed that medicine is one of the concerns of us ru [Confucian scholars] in extending knowledge by investi­gating things.” His experience as a physician exerted no pressure on his nat­ural philosophy, however, and philosophy did not change what he and peers did as physicians. All that changed was the tenor of their exposition of med­ical canons, which became more closely aligned with the natural philosophy that Confucianism had by then become. The Confucian injunction to “inves­tigate things” did however motivate him (and a group of like-minded peers) to innovative investigations of the environmental conditions of illness, espe­cially seasonal cycles, which are keyed to the constitutional susceptibilities and emotional predispositions that were the internal roots of illness.⁵⁵

Wang Lu, a physician who studied with Zhu Zhenheng and wrote the no­table Ming dynasty medical work Returning to the Sources of the Medical Classics (Yi jing su hui ji), was not a ru yi, never an examination candidate, not a Confucian literatus but a professional physician from a family of physicians. Perhaps his relative lack of commitment to neo-Confucian phi­losophy encouraged his interest in testing and verifying traditional medical texts. He was also fascinated by phenomena that did not match authorita­tive norms, which he studied both in medicine and in nature through the observational method of his painting. He sought out the singular, even at some trouble to himself. In 1381 he made an expedition to Mt. Hua, China's central sacred mountain, recording his travels in an album of forty paintings together with poems and essays. Mt. Hua surprised and unsettled him, the to­pography bearing little resemblance to things he already knew how to paint. He was forced to abandon what he thought he knew and discover his capacity to create forms. He says the mountains were his teachers. He stopped trying to learn from other paintings, and began to learn from the mountains them­selves, a challenge he thought painters have to accept, and not rely on what earlier painters preserve in their paintings. It is better to rely on oneself to re­spond to the mountains and experiment in depicting their forms.⁵⁶

Physicians and literati were deeply involved in the compilation of materia medica, medicine's inventories of therapeutic substances. Chinese work in this field was extensive, employing complex and efficient classification and eventually printed illustrations. These works did not merely collect folk recipes. They were comprehensive bodies of theory and practice integrated with the fundamental concepts of natural philosophy, as modified to in­corporate phenomena of health and sickness. Nevertheless doctors had to live among the people, where ghosts could bring illness and amulets were believed to prevent it. My impression is that little effort was expended to rec­oncile these differences, with demotic material simply copied and repeated along with everything else, suggesting a certain indifference to testing.⁵⁷

Another Song emperor inaugurated an eleventh-century project to re­vise the materia medica, emphasizing the desirability of correcting errors and retaining only what is verified. A decree of 1057 reads: “The government [orders] that local people who can distinguish [drugs] should meticulously determine the shape, color, and size of roots, stems, seedlings, leaves, flowers, and fruits of indigenous herbal drugs. The localities should also provide [in­formation] about any insect, fish, bird, beast, jade, or stone which can be used as medicinal drugs. For each item [the locality is required] to add an illustra­tion, specify the season and month the fruits or flowers should be collected, and stipulate their [clinical] effects.” They also had to submit a standardized sample. The result was The Illustrated Materia Medica of 1062, which for the first time in Chinese medical history relied solely on contemporary know­ledge gathered from rank-and-file physicians and common people.⁵⁸

In drug therapy, when physicians actually applied their pharmaceuticals, criteria of proof were permissive. The connections these physicians seek among their concepts, observations, and outcomes make it difficult for any single factor to be controlled or perceived as specifically efficacious, nor was any effort made to simplify drug compounds by eliminating superfluous ingredients. In a world where everything relates to everything else, nothing is really superfluous and anything could be part of the cause of anything else, which makes controlled experiments counterintuitive. While these doctors would “try” therapies, and even try them on animals, they made no orches­trated use of experimental test. They followed inherited formulas, enjoyed merited reputations for curing, and could rationalize their diagnosis and treatment in the terms of orthodox natural philosophy. They understood the value of observation, practiced it professionally, developed methods of stan­dardized observation for case histories, and organized the large-scale collec­tion of data, all of which resembles a sort of empiricism, exposing themselves to an encounter with nature and learning from it.

However, we should also notice a persistent philologism. The scholar­physicians know that their texts need revision but they cannot forget about books and return to experience, as Gilbert and Harvey proudly claimed to have done (§41). Natural studies became a field for scholars fascinated by et­ymology. Natural phenomena were approached through their names, whose derivations connoisseurs of learning fondly traced in the texts of the past. Their compendia presented information about wu (things, phenomena) by way of a history of glosses on their names.⁵⁹

Europeans were no less fixated on Hippocrates. As late as 1830 and des­pairing of medicine, Littre, a Paris doctor, could think of nothing better to do than produce an improved edition of Hippocrates. But European med­icine has no “classics” in the Chinese sense. Nothing in Hippocratic texts or Galen promotes the idea that these authors enjoy nonpareil authority, whereas Chinese works encourage such treatment. In Chinese medicine, experience corroborates, elaborates, and extends but never contradicts its texts. The Illustrated Materia Medica of 1062 may seem exceptional in relying on contemporary research, but in retrospect this autonomy is anom­alous. The materia medica were never reduced to a satisfactory system, and new compilations continued to appear, usually falling back on philological methods and editing texts rather than the conventionally more empirical method of the Illustrated Materia Medica.⁶⁰

A last consideration in this overview of Chinese medicine’s empiricism is the relation to cosmology. To understand the changing body a physician must un­derstand change, and the first thing to understand is that bodies do not change in isolation because nothing does. That is why Emperor Hui Zong said that no one can be a good physician who does not think in cosmic terms. Comparable ideas have occasionally mingled with European medicine, for instance the mac­rocosm-microcosm idea in Ficino and Paracelsus. But this was always more of a beautiful idea than a working hypothesis, and always a minority point of view, whereas in China it was orthodox. The correlative thinking that the emperor esteems is too flexible to do more than give the illusion of comprehension. What is not wood becoming metal, or yin on the cusp of yang, if usage is sufficiently pliant? The use of these terms may seem to test poetic ingenuity more than empirical discernment, though it is perhaps a prejudice to think those are two things wrongly confused.

The expressions of empiricism in Chinese medicine are chiefly in modes of observation, including case histories and the large- scale collection ofdata. While the relation to patients made careful observation and records a professional duty, there is little empiricism in their observations, which confirm texts but do not originate concepts, provoke theories, or interact with hypotheses. Professional medicine seems to have done little to liberate experience, or make it an instru­ment of discovery. The Song dynasty alliance with Confucianism associated medicine with this philosophy of nature, but concepts and practice were never discomfited by an experience unanticipated in the texts. These doctors did not need discoveries. They already had the most important knowledge, which was in their texts, a patrimony of the ancient sages held under imperial imprimatur. What could be more credible? The challenge was not to correct the text or get out of the text, but to come into the right relation with the text as an individual practitioner. Sincerity will take you further in this medicine than empiricism.⁶¹