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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.

MODERN DEVELOPMENTS

Until the nineteenth century, Chinese medicine more or less matched its European counterpart in authority and efficacy. Chinese physicians showed little interest in European medicine, but the Japanese became familiar with western science through the Europeans allowed to reside in the port of Nagasaki, and what was called ‘Dutch scholarship’ (rangaku) flourished. Japanese rangaku physicians took up anatomy and surgery, introducing Jennerian vaccination in 1824. These developments helped undermine the prestige of kanpo, and schools of western medicine began to spring up. International politics, however, was a greater force of change than curative efficacy: by 1850, both Japan and China were confronted by European gunboats, and by a western medicine daily more confident of its own scientific superiority.

In 1869, the Japanese Meiji rulers resolved to adopt the German system of medical training and, while kanpo was not banned, its practice was subject to restrictions. Japan established a state system of western medical education and services, and by 1900 three imperial and eleven other state colleges of western medicine existed, which by 1912 had trained 14,552 physicians – around two-thirds of all those in practice. Many Japanese medical students were sent to Germany for their education.

The Chinese were exposed to western medicine through the missionaries who streamed in after the treaties following the Opium Wars. Some reformers held Chinese medicine partly responsible for the Empire’s backwardness and defeats, while others sought not to scrap but to reinforce it. In any case, the weak late Qing regime was in no position to effect Meiji-style reforms. In the end the chief force for change came not from the state but from the hated foreigners, above all the Chinese Medical Missionary Association, founded in 1886, which, together with the Rockefeller-funded Chinese Medical Commission, aimed to transform medical services and training, partly through the ‘union medical colleges’, established in Peking (Beijing) and other key cities after 1903. Yet by 1913, there were still only 500 Chinese medical students receiving training in all the mission services throughout the empire.

Republican China (1911–49) sought to establish a modern state medical system. By 1926 about one hundred cities had western-style medical services, which the Nanjing-based Nationalist government turned into the nuclei for health institutions, organizing a chain of medical education, hospitals and health centres stretching from the capital right down to rural paramedics. Peasant health-care was given priority: village health workers received training in smallpox, typhoid and diphtheria vaccination, in hygiene, the diagnosis and treatment of minor complaints, and referral of serious illnesses to specialists. The system drew upon western medicine and, whilst Chinese medicine was not banned, it came to be seen as old-fashioned, not least by Marxist revolutionaries.

After 1948, this nationalist health-care structure was taken over wholesale by the new People’s Republic, though under the Marxist regime Chinese medicine could also be depicted as ‘socialist’ and integrated into the Communist system. Science was exalted as the key to the future, yet patriotic sentiment, reinforced by anti-capitalist ideology, also gave Chinese medicine a renewed symbolic authority, leading to professional parity with western medicine (readily condemned as ‘bourgeois’). The emphasis on functions and holism within traditional Chinese medicine could be squared with the ‘dialectical materialism’ of Marxism-Leninism.

At the top of the tree, Chinese-style physicians are today required to have a basic training in western-style medicine, and vice versa. Indeed, in the late 1950s, when China was desperately short of skilled medical practitioners, thousands of doctors were withdrawn from regular medical practice for a three-year study of traditional medicine, and Beijing invested heavily in clinics and medical schools for Chinese medicine. The ‘barefoot doctors’ of the Mao era included amongst their skills simple acupuncture and a knowledge of Chinese materia medica.

The balance between western and Chinese practice has fluctuated, and the ideal of a ‘syncretic medicine’, combining the best of both, has become an attractive one. Attempts have been made to set Chinese medicine on an experimental, scientific footing. In line with this, there has been a move from functionalism to materialism in medical thinking, accompanied by tendencies to reduce traditional terms of Chinese medical art to their modern biomedical equivalents: thus xue classically ranges over a spectrum of meanings, only one of which corresponds to the biomedical concept of ‘blood’. While most practitioners continue to recognize this distinction, the trend is towards using the readings interchangeably. Materialism thus provides a way of translating Chinese medical theory and therapeutics into western scientific terms, and thence of mobilizing experimental laboratory techniques. The pharmacological effects of Chinese drugs have been tested, the siting of the acupuncture tracts investigated, and explanations advanced of the effects of acupuncture anaesthesia in terms of endorphins.

The classics continue to shape the thinking of contemporary practitioners: no Chinese medicine practitioner can be trained without becoming familiar with the canonical works. But, linguistically, classical Chinese is no longer essential for medical education, and physicians may cull their knowledge of the medical canon from selections in modern textbooks. Utilitarian priorities mean that many practitioners today gain only a smattering of the theoretical rationales underpinning therapy. Formerly Chinese medical practitioners won their prestige through textual erudition; now they assume the trappings of western medicine, and even traditional physicians wear white coats.

From a wider perspective, it is evident that there has been a great parting of the ways between eastern and western medicine. Initially they shared certain common assumptions, inscribed in hallowed texts, about the harmonies and balance of the healthy body. Western medicine alone radically broke with this. An entirely new practice grew up in Europe – scientific medicine – building upon the new sorts of knowledge, programmes and power which followed from dissection and the pathological anatomy it made possible.

Tensions thus opened up between the western and the eastern traditions which remain unresolved to this day. As early as the late eighteenth century, European surgeons visiting China were already expressing open contempt for traditional Chinese medicine; it was ignorant of anatomy and hence had no ‘scientific’ basis. Westerners found it laughable that Chinese doctors thought they could diagnose illness on the basis of the pulse alone. And though acupuncture gained some devotees in nineteenth-century France and Britain, it has been only in recent years that the claims of Chinese medicine have found a broader acceptance in the West. This is due partly to a new multiculturalism, and partly to rejection in some quarters of high-tech values; but it also owes much to ‘scientific’ explanations of acupuncture anaesthesia and other aspects of Chinese practices. Whether East and West will ever meet or even converge, medically, remains unclear, and only time will tell whether the current popularity in the West of acupuncture and Chinese medical outlooks will last.

CHAPTER VIII RENAISSANCE
THE OLD WORLD AND THE NEW

THE MOST MOMENTOUS EVENT FOR HUMAN HEALTH was Columbus’s landfall in 1492 on Hispaniola (now the Dominican Republic and Haiti). The Europeans’ discovery of America forged contact between two human populations isolated from each other for thousands of years, and the biological consequences were devastating, unleashing the worst health disaster there has ever been, and precipitating the conquest of the New World by the Old World’s diseases.

The forebears of the ‘Indians’ Columbus encountered in his attempt to find a short-cut to the ‘Indies’ or China were hunter-gatherers. Before or around 10,000 BC such people had crossed the Bering Straits from Asia to Alaska via a land bridge created by the fall in sea levels during the last Ice Age. They were relatively disease-free; lacking domesticated animals, they had no walking disease-carriers except themselves, and on their travels they encountered no other humans.

The melting of the great North American glaciers isolated that continent while opening it up to the newcomers, who spread south. In time the Maya, Aztec and Inca to the south and the Mississippian peoples of North America settled into sedentary agriculture, cultivating maize and beans, cassava and potatoes, and in some cases building complex civilizations centred on vast cities – which spawned all the familiar health problems. Tuberculosis developed, as did pinta and other treponemal infections, including non-venereal syphilis, various disorders caused by intestinal parasites, and Chagas’ disease. With agriculture came the nutritional maladies typical of monocultures.

The Amerindian peoples developed their own forms of medicine, with priests, shamans and sorcerers conducting healing rituals. Supernatural powers were believed to inflict pestilence to punish misdeeds, and in Mexico and Peru disease was connected with witchcraft and the malevolent shades of dead animals, demons and deities. Native Americans acquired knowledge of the healing properties of various vegetable products: Peruvian Indians chewed coca leaves against hunger and fatigue, while cacao (cocoa) was the Aztecs’ most important tonic and medicinal beverage, powdered and boiled in water with honey, vanilla and pepper. The Incas had herbs for headaches and other pains; and they used scopolamine, a poison from the datura plant, as an anaesthetic. Broken bones were treated with fat from the ñandu, an ostrich-like bird, and llama kidney juice was dropped into aching ears.

North American Indian tribes had a less extensive materia medica. They used sassafras, holly, sunflower seeds and infusions of flaxseed, inhaled the smoke from burning twigs to treat chest conditions, and used decoctions of mushrooms and peyote as hallucinogens. A Spanish explorer, Cabeza de Vaca, travelling in the 1520s through what is now Texas, observed the healing practices of the native Indians: ‘their method of cure is to blow on the sick, the breath and the laying-on of hands supposedly casting out the infirmity.’ He had no doubt what to think of that: ‘We scoffed at their cures.’

The New World peoples were not living in a golden age, but they had been spared Eurasian afflictions. Thus they were vulnerable virgin soil, entirely without resistance to epidemics imported by the conquistadores. This was not the first time Spanish conquest had brought diseases to a virgin population. In the fifteenth century, the Iberian conquest of the Canary islands had meant total devastation of the native inhabitants, the Guanches, whose immune systems were helpless against European infections. Originally there were some 100,000 Guanches; by 1530 only a handful was left, and in the seventeenth century they became extinct, spectacular victims of what has been called ecological imperialism.

The first epidemic, which struck Hispaniola in 1493, may have been swine influenza, carried by pigs aboard Columbus’s ships. Other deadly diseases then struck in hammerblows, so that New World populations were reeling even before smallpox reached the Caribbean in 1518. That outbreak killed one third to one half of the Arawaks on Hispaniola and spread from there to Puerto Rico and Cuba. A few Spaniards fell sick but none died and, as ever, all was attributed to God’s will, in support of the Christian conquest.

Smallpox accompanied Hernan Cortés (1485–1547) to Montezuma’s Aztec Mexico, where the main town was Tenochtitlan (modern Mexico City); with some 300,000 people, it was three times the size of Seville. Contact spread the disease among the natives outside the city and then within. In 1521, Cortés attacked with 300 Spaniards. Three months later, when the city fell, the conqueror learned that half its people had died, including Montezuma and his successor: ‘a man could not put his foot down unless on the corpse of an Indian.’ The same happened when Pizarro (c. 1475–1541) took on the Incas: smallpox ran ahead of him to Peru. By 1533, when he entered Cuzco to plunder its treasure, the Incas were incapable of serious resistance.

Infections thus primed and sped conquest, rippling outwards to fell countless indigenes the Spanish troops did not have to butcher. The consequent epidemics did not merely exterminate vast numbers, they destroyed the will to resist – the psychological impact was as devastating as the physical. Between 1518 and 1531, perhaps one third of the total Indian population died of smallpox, while the Spanish hardly suffered. With allies like microbes, the Europeans did not require many soldiers or much military acumen.

These initial smallpox outbreaks were only the beginning of a long, mainly unintentional, but almost genocidal germ onslaught unleashed against the Amerindians. Waves of measles – 1519 (Santa Domingo), 1523 (Guatemala) and 1531 (Mexico) – influenza, and finally typhus followed, all bringing devastating mortalities. In 1529 measles killed two thirds of those who had just survived smallpox; two years later it had killed half the Hondurans, ravaged Mexico, raced through Central America and attacked the Incas. Repeated epidemics followed, one of the worst being that of typhus, which towards 1600 killed about two million people in the Mexican highlands. By then, 90 per cent of the local inhabitants had died in successive outbreaks, and the fabric of life had fallen to pieces.

Though the mainland populations of Mexico and the Andes gradually recovered, in the Caribbean and in parts of Brazil decline verged upon extinction; from as early as 1520, the Spanish imported slaves from Africa to meet the labour shortages in their lucrative Peruvian silver mines. African slaves, in turn, brought malaria and yellow fever, creating further disasters. Guns and germs enabled small European bands to conquer half a continent in what might be called, to echo Gibbon, another victory of barbarism over civilization.

In later centuries the North American Indian population was similarly devastated by the English and French, sometimes by the fiendish distribution of smallpox-infected blankets and clothes. In 1645, smallpox killed half the Hurons; the same happened later with the Cherokees in the Charleston area, and with the Omahas and the Mandans. Not one European fell sick of smallpox in 1680, when the Revd Increase Mather (1639–172 3) tersely recorded that ‘the Indians began to be quarrelsome … but God ended the controversy by sending the smallpox among the Indians’. The wholesale destruction of indigenous New World populations continued for over three hundred years; twenty million slaves had to be shipped to America to fill the vacuum, causing cruelty and suffering on a scale not matched until the regimes of Hitler and Stalin.