The Greatest Benefit to Mankind

NEW ARRIVALS

Islam brought new medical practices to India, having a major impact after the eleventh-century Turco-Afghan invasions of Gujarat, and becoming entrenched especially around Lahore, Agra, Lucknow and Delhi. These were known as Yunani Tibb – Yunani (or unani) being an Indian representation of the word ‘Ionian’. Yunani medicine derives in large part from Galenic medicine as interpreted in Ibn Sina’s Al-Qanun fi’l-tibb [Canon], and continues to flourish in India today. It is practised by hakims (physicians) in rural areas especially and is advocated among those who wish to embrace a distinctively Islamic medicine.

Yunani medicine and Ayurveda have interacted to some degree, especially in materia medica. Though the primary languages of Yunani medicine are Persian and Arabic, there are also certain Sanskrit texts. Yunani postulates four basic humours, as distinct from Ayurveda’s three, and it has more of an orientation towards treatments in hospitals. The major difference between them is their clientèle. Broadly, Yunani physicians treat Muslim patients, and Ayurvedic physicians treat Hindus.

In the first half of the sixteenth century Portuguese settlers came to Goa. The first medical book printed in India was the Coloquios dos Simples, e Drogas he Cousas Mediçinais da India (1563) [Colloquies on the Medical Simples and Drugs of India] by Garcia d’Orta (1490–1570). D’Orta had gathered his material from local physicians, and the signs are that there was a free exchange of medical ideas at that time between the Portuguese and the Indians. Relationships however declined, and after 1600 the Portuguese introduced restrictions which in effect banned Hindu physicians in Goa.

Dutch East India Company officials showed great interest in the natural history and medicines of the Malabar coast where they traded and settled. Heinrich van Rheede (1637–91), the Dutch governor, published between 1686 and 1703 a work containing nearly 800 plates of Indian plants. Paul Herman’s (1646–95) herbarium and Museum Zeylanicum provided major sources for Linnaeus’s Flora Zeylanica (1747).

The British arrived around 1600. Facing unfamiliar and severe health problems, East India Company traders were keen to learn from the local vaidyas and hakims, and Indian doctors were curious about British surgery, since the art had lapsed among vaidyas. It was observed by Sir William Sleeman (1788–1856) that ‘the educated class, as indeed all classes, say that they do not want our physicians, but stand much in need of our surgeons.’

British physicians were initially prompted to adopt Indian methods by the problems involved in shipping medical stores from Europe. In time, however, they grew increasingly critical of the crudeness of indigenous drugs and contemptuous of what they saw as the shortcomings of Indian medicine. With characteristic ethnocentricity, East India Company attitudes towards Indian medicine hardened. When medical colleges had been founded in Bengal and elsewhere under the British Raj, the study of Ayurveda was given a semblance of support alongside British medicine; but with changes in educational policy after 1835 and the suppression of Ayurvedic teaching in state-funded medical colleges, British support for Ayurvedic training ceased. Ayurvedic physicians continued to practise, although their training was reduced to the traditional family apprenticeship system.

In the twentieth century, with the rise of the Indian independence movement, indigenous traditions received active encouragement from nationalists. In recent decades there have been divided loyalties: since independence in 1947, the Indian government has oscillated between commitment to western medicine in the name of progress, and acceptance of the fact that Ayurvedic medicine is widely practised, especially in the countryside, and commands sturdy loyalties. Many Indian physicians have a strong incentive to devote themselves to western medicine – it is a passport to practise throughout the world.

In 1970, the Indian Parliament passed the Indian Medicine Central Council Act, setting up a central council for Ayurveda. Since then government-accredited colleges and universities have provided professional training and qualifications. This training, however, includes some basic education in western methods, family planning and public health. In 1983, there were approximately one hundred officially approved Ayurvedic training colleges, many attached to universities. But although the number of Ayurvedic and Yunani colleges and dispensaries has multiplied since independence, government funding has been minimal. Popular perception is said to be that the students in the indigenous medical schools failed to gain admission to modern western medical or professional universities.

The traditions combine and are rarely exclusive. Private Ayurvedic practitioners make use of modern western treatments, often on the wishes of their patients: western-style injections are widely regarded as a powerful, almost magical cure. In a small 1970s study of fifty-nine indigenous practitioners in Punjab and Mysore, researchers found that the vast majority of drugs being used were antibiotics and similar western medicines. The idea that Ayurvedic physicians deal purely in herbs, roots, and therapeutic massage is a nostalgic myth. Today in India, the patient may take any of many available paths towards greater health. There exist side by side physicians of cosmopolitan medicine, Ayurveda, and Yunani, as well as others such as homoeopaths, naturopaths, traditional bone-setters, yoga teachers and faith-healers.

The trend, however, is towards the greater assimilation of western medicine, especially among the wealthy and cosmopolitan. It is noteworthy that Ayurvedic medicine has not yet achieved the vogue in the West acquired by Indian philosophy and (thanks to fascination with acupuncture and the yin-yang system) by Chinese medicine.

CHAPTER VII TRADITIONAL CHINESE MEDICINE

Rather like the Ayurvedic medicine just discussed, traditional Chinese medicine has often been presented as an authentic incarnation of timeless wisdom. Chinese medicine, assert its champions (and occasionally its detractors) has been passed down essentially unchanged since the dawn of civilization. This characterization, along with claims that, unlike western biomedicine, it is holistic and draws only upon mild ‘natural’ substances, is to some extent a propaganda exercise. Even so, the impressive antiquity of Chinese medicine, and its distinctive attitudes towards knowledge of the human body, provide some justification for the contrast. Traditional values and canonical texts were, indeed, highly valued and, unlike the West, novelity has never been prized in the Chinese medical tradition, or for that matter in Chinese thought and culture at large.

While distinctive, Chinese medicine is not totally unlike other medical traditions, and that is partly because it is not wholly indigenous. Over the centuries it has absorbed many outside influences, from India, Tibet, central and south-east Asia, while for the last hundred and fifty years it has been forced to adjust to western medicine. Certain of the key drugs in the Chinese pharmacopoeia were introduced from abroad – ginseng from Korea, musk from Tibet, camphor, cardamom and cloves from south-east Asia, frankincense and myrrh from the Middle East. The needling techniques behind acupuncture may have originated in central Asian shamanic healing. Indian Buddhism brought teachings concerning the soul and salvation which prescribed care for the ill and infirm. Buddhist charms were incorporated into classical Chinese therapy, while, in medieval times at least, cataract surgery was performed which probably derived from India (such operations later lapsed). Indian medical theories are not wholly compatible with Chinese models, however; and though some have held that Ayurvedic or even Greek influences are present in the use of such categories as ‘hot’ and ‘cold’ in Chinese medicine, these are better seen not as borrowings but as transcultural.

While Chinese medicine thus assimilated beliefs and practices from elsewhere, the reverse was happening as well. As the Chinese tongue, Confucianism and Chinese Buddhism were embraced by elites through south east Asia, so too was Chinese medicine. Along with Buddhism, it had been introduced to Korea by the sixth century AD, and Buddhist priests relayed it from there to Japan. (In modern Korea, Chinese medicine is known as hanui: and in Japan as kanpo.) From the sixteenth century, Chinese medicine arrived with migrants to Taiwan, the Philippines and elsewhere – all regions where Chinese medicine flourishes today alongside the western variety.

Alongside herbs such as ginseng and Chinese rhubarb, distinctive features of Chinese medicine, notably moxibustion and acupuncture, became reasonably familiar to Westerners from the seventeenth century onwards: from Japan, the Dutchmen Wilhem Ten Rhyne (1647–1700) and Engelbert Kaempfer (1651–1716) sent home accounts of acupuncture, including maps of the acupuncture channels. Yet this had no noticeable impact upon European medicine, even though after 1800 acupuncture enjoyed a certain vogue, especially in France.

CHINESE HEALING

Peasants traditionally went to folk or religious healers, for in popular thinking the supernatural was seen as a major cause of illness – sickness was believed to be created by demons or to be punishment for violating or neglecting one’s ancestors, who might then need to be propitiated with sacrifices. Learned medicine, by contrast, was wholly an elite matter, taught and practised by educated men, who treated clients from the middle and higher strata of society and from the state bureaucracy. This learned medicine was grounded on a corpus of texts: works on medical theory; on the classification, diagnosis and treatment of diseases (including collections of case histories); and on drugs and prescriptions.

The earliest surviving texts (over ten thousand specialized medical writings have come down) date back about twenty-two centuries, and incorporate even earlier materials. Dynastic circumstances account for this timing. The Chinese Empire became politically unified in 221 BC, and the emperors of the Han dynasty (206 BC – AD 220) established a body of political, philosophical and religious teachings. This period brought about the formation of the medical canon which constitutes the theoretical basis for the ‘high classical’ medical tradition and which was to set the mould for subsequent medical doctrines and developments. An integrated empire promoted the idea of a unified body, while policy-making for a flourishing state encouraged thinking about health. Thereafter the human body was envisaged, by analogy, to the state, as a series of operations which built up, allocated and processed precious and scarce resources, through communications networks. Good medicine was like good government.

Four core works make up the ‘high classical’ tradition, all of unknown authorship. They are the Yellow Emperor’s Inner Canon of Medicine (Huangdi Neijing), so called because it includes a dialogue between the ‘yellow emperor’ Huang-ti and his chief minister, Ch’i Po; the Divine Husbandman’s Materia Medica; the Canon of Problems; and the Treatise on Cold-Damage Disorders. The former two enjoy scriptural status, being considered as preserving the wisdom of legendary sages; every learned physician would be expected to be word-perfect with those. The latter two, for their part, were also classics which physicians would also be expected to know inside out; but they were thought to originate not in divine revelation but in experience, which was open to being queried, revised and even contradicted.

The Inner Canon contains teachings on core subjects: the physiological make-up of the body, including the circulation of qi (roughly: energy); health and the onset and prognosis of diseases; and therapy through needling (bloodletting or acupuncture). It depicts the human body like a kingdom, with organs like the heart and liver regarded as functions, or functionaries, working in harmony through communications and transport systems – the vessels and channels of the body (analogous to China’s great rivers), through which qi would flow.

The Canon of Problems addresses eighty-one ‘difficult issues’ which arise from the Inner Canon, relating mostly to diagnosis and needling treatment. Its significance alongside the Inner Canon was unquestioned until the Song dynasty (960–1279), but thereafter, where discrepancies were noted between the two works, it was assumed that the writer of the Canon of Problems had failed to grasp the authoritative teachings of the Inner Canon.

The Treatise on Cold Damage Disorders, for its part, deals with the identification and treatment of diseases caused by external cold factors (shanghan bing): approximately what western medicine would designate acute infectious fevers. Diagnosis follows what is known as the Six Warps theory, and therapy is not by needling but by drugs. Formulae are given for more than a hundred prescriptions – for countering fever, diarrhoea, and so forth – and many such items from the pharmacopoeia are still in use.

In the twelfth century Chinese physicians began to refine shanghan (cold factor) theory, developing the notion of heat-factor disorders (wenre bing), and thereby distinguishing between disorders in terms of their separate aetiologies. This tendency became more pronounced during the seventeenth century, when China was buffeted by waves of serious epidemics. Criticism of cold-damage theory then led to a succession of works on heat-factor disorders, especially the Wenre lun of Ye Tianshi (c. 1740), which elaborated the ‘triple burners’ (san jiao) system of disease classification.

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.