In ancient Chinese cosmology, the universe was created not by divinities but self-generated from the interplay of nature’s basic duality: the active, light, dry, warm, positive, masculine yang and the passive, dark, cold, moist, negative yin. All things, animate and inanimate, and all circumstances were a combination of these fundamentals. The ultimate principle of the universe was the tao, “the way,” and it determined the proper proportions of yin and yang in everything. Anything that altered the natural relation of yin to yang was considered bad, and right living consisted of carefully following the tao. If one observed the tao by moderation, equanimity, and morality, as taught in the Tao-te Ching, by Lao-tzu (sixth century B.C.), one would be impervious to disease and resistant to the ravages of aging; disregard of the tao led to illness, which was not so much a punishment for sin as the inevitable result of acting contrary to natural laws. However, illness also could be caused by forces beyond one’s control: “Wind is the cause of a hundred diseases,” and atmospheric conditions could upset the harmonious inner balance of the yang and yin. One had to be alert to this possibility and combat its effects as well as modify internal imbalances of the vital forces. Longevity and health were the rewards.
Chinese medicine, in league with Taoism, was focused on the prevention of illness; for, as the legendary Huang Ti, father of Chinese medicine, observed, “the superior physician helps before the early budding of disease.” Although Taoist hygiene called for temperance and simplicity in most things, sexual mores were governed by the yin-yang aspect of Chinese philosophy. Ejaculation in intercourse led to diminution of a man’s yang, which, of course, upset the inner balance of his nature. On the other hand, one was strengthened by absorption of the yin released by the orgasm of one’s female partner—unless she was over thirty, the point where female essence lost its efficacy.
The tao was important in Confucianism also, as the path of virtuous conduct, and for centuries the precepts of Confucius (K’ung Fu-tzu, 550-479 B.C.) set the most prevalent standards of behavior. In early Chinese philosophy, there was a tendency to accept and combine aspects of all religions and to make way for new ideas. Nevertheless, the ancient Chinese were profoundly conservative once an institution, custom, philosophy, mode of dress, or even a furniture style was firmly established, and it remained relatively unchanged over centuries. As Confucius said: “Gather in the same places where our fathers before us have gathered; perform the same ceremonies which they before us have performed; play the same music which they before us have played; pay respect to those whom they honored; love those who were dear to them.”
Although ancient China’s development was relatively isolated, there was early contact with India and Tibet. Buddhism came to China from India, and medical concepts and practices were an important part of its teachings. The gymnastic and breathing exercises in Chinese medical methodology also came from India and were closely related to the principles of Yoga and to aspects of Ayurvedic medicine. There were also contacts with Southeast Asia, Persia, and the Arabic world. In the second century B.C., the Chinese ambassador Chang Chien spent more than a decade in Mesopotamia, Syria, and Egypt, bringing back information on drugs, viticulture, and other subjects. Over the centuries, knowledge of humoral medicine and of numerous new medicaments filtered into China. The introduction of the wisdom of the Mediterranean world was greatly facilitated in the fifth century by the expulsion and wide dispersion from Constantinople of the heretical Nestorian Christians. The mother of Kublai Khan (1216-94), founder of the Mongol dynasty, was a Nestorian and asked the Pope to send European doctors to China.
Early Medical Writings
Classical Chinese medicine was based primarily on works ascribed to three legendary emperors. The most ancient was Fu Hsi (c. 2900 B.C.), who was said to have originated the pa kua, a symbol composed of yang lines and yin lines combined in eight (pa) separate trigrams (kua) which could represent all yin-yang conditions. This system is followed even today in the I Ching (Book of Changes), though as a game or superstition in the West.
Shen Nung, the Red Emperor (Hung Ti), compiled the first medical herbal, the Pen-tsao (c. 2800 B.C.), in which he reported the effects of 365 drugs, all of them personally tested. One legend explains that a magic drug made his abdominal skin transparent, so he could observe the action of the many plants he evaluated. Another story tells that he cut open his abdomen and stitched in a window. Shen Nung is also said to have drawn up the first charts on acupuncture, a medical procedure presumably even older than the legendary emperors.
The fame of Yu Hsiung (c. 2600 B.C.), the Yellow Emperor (Huang Ti), rests on his great medical compendium, the Nei Ching (Canon of Medicine). Transmitted orally for many centuries, this seminal work was possibly committed to writing by the third century B.C. Its present form dates from the eighth century A.D., when the last extensive revision was done by Wang Ping. The major portion of the Nei Ching, the Sun-Wen (Simple Questions), records the discourse of the Yellow Emperor with Ch’i Po, his prime minister, on virtually all phases of health and illness, including prevention and treatment. The section called Ling-Hsu (Spiritual Nucleus), deals entirely with acupuncture. Yu Hsiung also was said to be responsible for another great compendium, The Discourses of the Yellow Emperor and the Plain Girl, which thoroughly covered the subject of sex from the Taoist point of view.
Among other notable sources for ancient medical lore, one might mention the Shih Ching (Book of Odes), which perhaps predates Homer’s epics, and the Lun-yu, discourses of Confucius probably written down shortly after his death, which affected patterns of behavior for many generations.
During the long Chou dynasty (c. 1050-255 B.C.), a lengthy compilation of medical works, Institutions of Chou, was completed and became the criterion for subsequent dynasties on the duties and organization of physicians. In the Han dynasty (206 B.C.-A.D. 220), there was a noted clinical author named Tsang Kung, who pioneered in the description of many diseases, including cancer of the stomach, aneurysm, and rheumatism. Chang Chung-ching, the Chinese Hippocrates, in the third century A.D., wrote the classic treatise Typhoid and Other Fevers.
Ko Hung, a famed alchemist and a careful observer, wrote treatises describing beriberi (a vitamin B deficiency), hepatitis, and plague, and gave one of the earliest reports on smallpox: “As the New Year approached there was a seasonal affection in which pustules appeared on the face and spread rapidly all over the body. They looked like burns covered with white starch and reformed as soon as they were broken. The majority died if not treated. After recovery purplish black scars remained.”
Sun Szu-miao (A.D. 581-682) wrote Ch’ien Chin Yao Fang (A Thousand Golden Remedies), which summarized in thirty volumes much of the known medical learning, and he headed a committee which produced a fifty-volume collection on pathology. An extensive codification of forensic medicine, Hsi Yuan Lu, was done in the Sung dynasty and became the prime source for knowledge of medical jurisprudence.
Anatomy and Physiology
Ideas of anatomy in ancient China were reached by reasoning and. by assumption rather than dissection or direct observation. Since the doctrines of Confucius forbade violation of the body, it was not until the eighteenth century, long after Vesalius, that the Chinese began systematic, direct anatomical studies. Even as late as the nineteenth century, in the Viceroy’s Hospital Medical School, anatomy was taught by diagrams and artificial models rather than dissection.
Physiological functions were constructed into a humoral system much like Greek concepts of the sixth century B.C. and Galenic views of the second century A.D., except that there were five instead of four essential humors. (The number five had mystical value for the Chinese and was used for most classifications: five elements, five tastes, five qualities, five kinds of drugs, five treatments, five solid organs, five seasons, five emotions, five colors, etc.) The medical compendium Nei Ching stated that each emotion had its seat in a particular organ. Happiness dwelt in the heart, thought in the spleen, sorrow in the lungs, and the liver housed anger as well as the soul.
Ideas in the Nei Ching concerning movement of the blood (“All the blood is under control of the heart.” “The blood current flows continuously in a circle and never stops.”) have been thought to approach an understanding of its circulation antedating Harvey by thousands of years; however, some body vessels were believed to convey air, and there is little evidence that commentators perceived the blood-carrying vessels as a contained system.
The Chinese methods of diagnosis included questioning, feeling the pulse, observing the voice and body, and in some circumstances touching the affected parts. In almost all times and cultures physicians have used a similar approach, for all healers have sought to know as much as possible about a patient in order to understand his or her illness and advise treatment. However, in some respects ancient physicians saw each patient more completely as a reflection of his surroundings (indeed, the entire universe) than does the doctor of today. The Chinese doctor wanted to learn how the patient had violated the tao, and to do this he took into account the patient’s rank; changes in his or her social status, household, economic position, sense of well-being, or appetite; the weather; and the dreams of the patient and his or her family.
Perhaps the most important diagnostic technique of the ancient Chinese was examination of the pulse. The physician felt the right wrist and then the left. He compared the beats with his own, noting precise time as well as day and season since each hour affected the nature of the pulsations. Each pulse had three distinct divisions, each associated with a specific organ, and each division had a separate quality, of which there were dozens of varieties. Moreover, each division or zone of the pulse had a superficial and deep projection. Thus literally hundreds of possible characteristics were obtainable. In one treatise, Muo-Ching, ten volumes were necessary to cover all the intricacies of the pulse.
A patient had only to extend his or her arm through drawn bed curtains for the physician to determine the symptoms, diagnosis, prognosis, and proper treatment by intensive palpation of the pulse. Whenever possible the examiner also felt the skin of the ill person. However, it was considered bad form for a man to intimately examine a woman, so special ceramic, ivory, and wooden dolls were pointed to by the invalid to indicate where discomfort was felt.
According to the Nei Ching, there were five methods of treatment: cure the spirit, nourish the body, give medications, treat the whole body, and use acupuncture and moxibustion. The physician had to put the patient back on the right path, the tao. Assuming that specific mental states caused changes in specific organs, the healer linked certain objectionable behavioral and constitutional factors with illness and attempted to have the patient rectify these. For instance, dissolute and licentious ideas led to diseases of the lungs, but acting out such thoughts brought on heart trouble. A doctor had to determine the cause of disharmony in the body and act accordingly.
Exercises were developed to keep the body fit and to restore well-being. Hua T’o, the great surgeon, worked out an ingenious system of physical therapy by advising mimicry of the natural movements of animals. Massage—kneading, tapping, pinching, and chafing—was also a regular method of treatment, as were the application of plasters and evacuation of the intestinal tract by cathartics.
In nourishing a patient’s body, the physician resorted to complex combinations of foods according to their potential amounts of yang and yin. Foods also had to fit the seasons, and each of the five tastes had benefits for a particular element of the body: sour for the bones, pungent for the tendons, salty for the blood, bitter for respiration, and sweet for muscle.
The Chinese pharmacopoeia was always rich, from the time of the Pen-tsao, the first medical herbal, to the later dynasties when two thousand items and sixteen thousand prescriptions made up the armamentarium. Drugs were considered more likely to be good if they tasted bad. As one would expect, they were classified into five categories: herbs, trees, insects, stones, and grains. The therapeutic minerals and metals included compounds of mercury (calomel was employed for venereal diseases), arsenic, and magnetic stones. Animal-derived remedies, in addition to “dragon teeth” (powdered fossilized bones), included virtually anything obtainable from living creatures: whole parts, segments of organs, urine, dung.
Two plant substances especially associated with China may be singled out. One is ephedra (ma huang), the “horsetail” plant described by the Red Emperor, which was used for thousands of years as a stimulant, as a remedy for respiratory -diseases, to induce fevers and perspiration, and to depress coughs. Ephedra entered the Greek pharmacopoeia and eventually was disseminated throughout most of the world. It only became a factor in Western medicine in the late nineteenth century after Japanese investigators isolated and purified the active principle, ephedrine, and established its pharmacologic action.
A second medicinal herb, always highly popular among the Chinese, is ginseng (“man-shaped root”). To the Chinese, preparations containing ginseng were almost miraculous in delaying old age, restoring sexual powers, stimulating the debilitated, and sedating the overwrought. In addition it improved diabetes and stabilized blood pressure. In recent years this root has been under scrutiny by Western pharmacologists attempting to evaluate its true benefits. Multitudes in Asia, and even some Westerners, are so convinced of its effectiveness that high-grade wild roots have brought fabulous prices (even reaching thousands of dollars apiece).
Although many items in the Chinese materia medica have either faded into obscurity or been labeled fanciful, others subsequently have been found to possess sound pharmacologic bases: seaweed, which contains iodine, was used in treating enlargement of the thyroid; the willow plant, containing salicylic acid, was a remedy for rheumatism; the Siberian wort has antispasmodics for menstrual discomfort; and mulberry flowers contain rutin, a treatment for elevated blood pressure. Whether opium was used as a drug before quite late in Chinese history is still in dispute.
Acupuncture and Moxibustion
These modalities have been an integral part of Chinese medical therapy for thousands of years. The Yellow Emperor is said to have invented them, but they may well have existed long before his time. The aim of these treatments was to drain off excess yang or yin and thus establish a proper balance, but external energy also could be introduced into the body. In acupuncture the skin is pierced by long needles to varying prescribed depths. Needles are inserted into any of 365 points along the twelve meridians that traverse the body and transmit an active life force called ch’i. Each of these points is related to a particular organ. For instance, puncture of a certain spot on the ear lobe might be the proper way to treat an abdominal ailment. Virtually every illness, weakness, and symptom is thought to be amenable to correction by acupuncture.
Acupuncture spread to Korea and Japan by the end of the tenth century A.D., to Europe about the seventeenth century, and recent years have seen a wider interest in this Chinese medical practice in the West. Individual paramedical healers and even some medical practitioners have been swamped with requests for acupuncture, especially for problems apparently little benefited by conventional practices. The eventual acceptability of this practice in standard Western medicine remains to be seen.
Moxibustion is as old as acupuncture, and the same meridians and points govern placement of the moxa. However, in this treatment a powdered plant substance, usually mugwort, is fashioned into a small mound on the patient’s skin and burned, usually raising a blister.
The treatment of tooth disorders was confined mainly to applying or ingesting drugs—pomegranate, aconite, ginseng, garlic, rhubarb, and arsenic, as well as animal products such as dung and urine. The Nei Ching classified nine types of toothaches, which included some obviously due to infections and tooth decay. Like the Mesopotamians and Egyptians, the ancient Chinese believed that worms were often responsible for dental problems. Toothpicks and tooth whiteners were used, and loose teeth were stabilized with bamboo splints. Gold was sometimes used to cover teeth, but the purpose was decorative rather than protective.
Although surgery was not one of the five methods of treatment listed in the Nei Ching, the knife was known and used. Hua T’o, one of the few names mentioned in connection with surgery, treated an arm wound of the famous general Kuan Yu by cutting his flesh and scraping the bone. Physicians knew how to deal with wounds, and at least two classics were devoted entirely to their treatment.
The proper attitude toward pain was to bear it without a sign of emotion, and much was made of the insouciance of the general treated by Hua T’o; he played chess while the surgeon operated. Nevertheless, apparently some kind of anesthesia was often used. Wine and drugs like hyoscyamus were probably mainstays, but the use of opium and Indian hemp is still in question.
Eunuchs and Footbinding
Another surgical procedure, though hardly therapeutic, was the frequent castration of certain males seeking advancement at court. Though originally a severe punishment, the total removal of penis and testicles came to be a pledge of absolute allegiance to the monarch, since it released the eunuch from conflict with Confucian admonitions of first loyalty to family and the obligation of siring a son for posterity.
Footbinding is also of medical interest, for it caused the development of artificially clubbed feet. Over a period of one thousand years, every young girl of proper family willingly permitted herself to be crippled by her mother and aunts to achieve the tiny foot of ideal feminine beauty. Her toes were gradually folded under the sole, and by increasingly tight bandaging her heelbone and forefoot were brought closer together. Without Golden Lotuses, as the best-shaped bound feet were called, a girl was unmarriageable, nor was the life of a courtesan open to her, for tiny feet were a woman’s most desirable feature.
For a man, a bound-foot wife had profound sexual significance, but she was also a status symbol inasmuch as her helplessness indicated that he was wealthy enough to support a woman, or women, in idleness. There was also an advantage to him in her restricted mobility, for it kept her home and made illicit amorous adventures difficult. Although China’s Manchu conquerors forbade the practice in the nineteenth century, it was not until the early twentieth that footbinding was completely abandoned.
Some epidemic diseases were understood well enough to allow the development of protective measures. In the eleventh century, inoculation against smallpox was effected by putting scabs from smallpox pustules into the nostrils, a method which may have come from India. Wearing the clothing of someone who had the disease was another means of prevention. The relationship of cowpox (as a protective) to smallpox may have been perceived, since ingesting powdered fleas from infected cows was also recommended to stave off smallpox. But other devastating pestilences were neither understood nor held in check. During the Han dynasty an epidemic of what appears to have been typhoid fever killed two-thirds of the population of one region.
Precise descriptions of leprosy in the Nei Ching and later works attest to the diagnostic accuracy of the early Chinese healers, but their explanation of the disease’s causes and their treatment follow preconceived notions of the time. “The wind and chills lodge in the blood vessels and cannot be got rid of. This is called li-feng. For the treatment prick the swollen parts with a sharp needle to let the foul air out.” Fourteenth-century writings referred to chaulmoogra oil, a pressing from seeds of an East Indian tree, as a specific for leprosy, and this oil remained the principal antileprous drug even in the West until recent decades.
An illness that may have been tuberculosis was recognized as contagious: “Generally the disease gives rise to high fever, sweating, asthenia, unlocalized pains making all positions difficult and slowly bringing about consumption and death, after which the disease is transmitted to the relations until the whole family has been wiped out.”
Venereal diseases, although not well differentiated, received a variety of therapies, including the use of metallic substances for internal medication. In the Secret Therapy for the Treatment of Venereal Disease, the seventeenth-century physician Chun Szi-sung reported using arsenic, which, until the development of penicillin, was the modern medication for venereal disease, in the form of Salvarsan and derivatives synthesized by Paul Ehrlich.
There seem always to have been places in China where the sick poor could go for medical care. With the advance of Buddhism in the Han and T’ang dynasties, in-patient hospitals staffed by physician-priests became common. However, in the ninth century, when anti-Buddhists were in control, hospitals as well as 4,600 temples were destroyed or emptied. Nevertheless, by the twelfth century hospitals had again become so numerous that virtually every district had at least one tax-supported institution. The upper classes preferred to be treated and cared for in their homes, thus leaving public hospitals to the poor and lower classes.
In the Institutions of Chou, compiled hundreds of years before Christ, the hierarchy of physicians in the kingdom was delineated. The five categories were: chief physician (who collected drugs, examined other physicians, and assigned them); food physicians (who prescribed six kinds of food and drink); physicians for simple diseases (such as headaches, colds, minor wounds); ulcer physicians (who may have been the surgeons); and physicians for animals (evidently veterinarians).
Physicians were also rated according to their results, and as early as the Chou and T’ang dynasties each doctor had to report both successes and failures—to control his movement up or down in the ranks. In the seventh century A.D. examinations were required for one to qualify as a physician, some four centuries earlier than the first licensing system in the West.
Medical knowledge was thought of as a secret power that belonged to each practitioner. Whereas in other societies, both advanced and primitive, closely knit guilds might control the spread of medical lore, the Chinese physician kept his secrets to himself—passing them on only to sons or, sometimes, specially selected qualifiers. In early times, a physician gave his services out of philanthropy, for since the original healers were rulers, sages, nobles, and, perhaps, priests, economic and social incentives were absent. Later, direct fees or salaries were instituted, and the court and certain prosperous households kept physicians on retainer.
Formal schools may have existed as early as the tenth century, and in the eleventh century an organization for medical education was set up under imperial auspices. Under the Ming dynasty in the fourteenth century, the school system became fixed. It changed little over the next centuries, except for a gradual decline, and by 1800 there was only one medical school left in Peking.
Teachers were held strictly accountable for the performance of their students, and fines were imposed if the professor failed to enforce attendance or if his pupils did poorly on exams. The examination system was complex: a pyramidal structure provided a process of elimination which continued until those with the highest scores emerged. The top students could be heart doctors, the next level were assistant examiners, and lower scores could mean limited assignment in teaching.
Specialization may have occurred early. While physicians and apothecaries were separate for a long time, they were both regarded as healers. In the Chou dynasty there were nine specialties, and they grew to thirteen by the Mongol period, early in the fourteenth century. The subdivisions became even more complex, with doctors for the great blood vessels, small vessels, fevers, smallpox, eyes, skin, bones, larynx, and mouth and teeth. There were also gynecologists, pediatricians, and pulsologists for internal diseases, external medicine, the nose and throat, and for children’s illnesses. Some healers specialized in moxibustion, acupuncture, or massage. Even the experts in incantation and dietetics were considered medical specialists and were often held in higher regard than other doctors; surgeons were generally of low rank. Furthermore, each of the practitioners in each category had assistants and students—all of whom had to qualify by examination.
Obstetrics was in the hands of midwives for many centuries; it is not known when the first women doctors were in practice. One female physician is mentioned by name in documents from the Han dynasty (206 B.C.-A.D. 220), but women may have been doctors at an earlier date. By the fourteenth century women were officially recognized as physicians.
Throughout the Ming dynasty (1368-1644), the practicing medical theorists could be divided into six main philosophic schools. The Yin-yang group focused on insufficiencies of one of these forces. The Wen-pou doctors attributed illnesses to a preponderance of yang and frequently prescribed ginseng and aconite. The Radical group used drastic medication. The Conservatives relied entirely on the authorities of the past, reedited the classic works, and made no deviations from strict authoritarianism. The Eclectic physicians, as their name implies, used a variety of principles from the other sects. The sixth school based all therapy on bringing the five elements and six vapors into harmony.
Spread of Chinese Medicine to Korea, Japan, And Tibet
Ancient Chinese medicine was well-developed long before the beginning of the Christian era, and its influence appears to have spread into adjacent Korea by the sixth century A.D. At that time, after a severe epidemic had ravaged Japan, Korean doctors who were invited to counsel Japanese physicians introduced them to Chinese medical classics and commentaries. By the seventh century, Japanese scholars and doctors were going directly to China for their information and experience. In the eighth century, a Chinese Buddhist monk named Chien Chen came to Japan and achieved a prominent position in the imperial court at Nara, where, given the Japanese name Kanjin, he taught, practiced medicine, and translated Chinese materia medica. Late in that century, Chinese medicine was well-established in Japan, and a medical school based on its methodology was founded by the Japanese physician Wake Hiroya. Early in the next century (806–10), the Emperor Heijo vainly attempted to combat foreign influence and restore traditional Japanese medical practice, but the methods of Chinese healing were too firmly entrenched. In the tenth century, acupuncture reached Japan, followed by moxibusti on (the word moxa is Japanese), and the full complement of Chinese medicine was accepted in Japan.
With medical training closely based on Chinese systems, the Japanese exacted exceptionally intensive and prolonged study before permitting entrance into the profession by governmental examination. As in ancient China, high social standing was a requirement for admission to medical school, but separate instruction by assigned teachers was apparently also arranged to accommodate the more lowly.
The authority of Chinese medicine, not to mention Chinese culture and philosophy, moved east as well as west by the seventh and eighth centuries. However, Arabic and Indian missionaries of Islam and Buddhism made influence a two-way exchange as they traveled to China seeking converts. Since their missions necessitated the translation of Sanskrit and Arabic writings into Chinese and vice versa, medical knowledge inevitably was passed back and forth. Consequently, the crossroads areas of Southeast Asia and Tibet developed a medical system combining aspects of Chinese, Indian, and Arabic practice. Arabic influence, which stemmed in part from Greek teachings, was evident in the doctrine of four humors (phlegm, blood, bile, and wind), whereas Indian ideas were seen in the Yogic placement of the soul in the core of the spinal column and reliance on breathing exercises.
Traveling Buddhist priests, who were quite successful in spreading their faith, for a long time also practiced medicine. During this early period, the two wives (one Chinese) of a Tibetan king converted him to Buddhism, and thereafter scholars were invited to bring Chinese writings into Tibet, which resulted in collections in Tibetan called Kanjur and Tanjur, the latter containing medical information. In the thirteenth century, the Mongol conqueror Kublai Khan wanted this body of knowledge available again in Chinese but was unable to carry through the translation. Nevertheless, his grandson in the next century arranged for scholars from Tibet, Mongolia, and Central Asia to accomplish the task. Ironically, while the Mongols were in control they allied themselves with non-Chinese such as Uighars, Jews, Christians, and Moslems, and they preferred Arabic medicine to Chinese.