HEALING AND MEDICINE: HEALING AND MEDICINE IN CHINA

In modern Western societies people tend to demarcate disciplines of healing as they divide the self: biomedicine for the body, psychology for the mind, and religion for the spirit. If the popularity of holistic alternative healing systems suggests that these categories do not sit entirely well even with modern Westerners, they are even more inadequate to China. Historically and still today in China, the management of sickness and health is rooted in different views of self, different social and institutional configurations, and different healing traditions.

Patients: Disordered Selves

Chinese sources do make distinctions not dissimilar to those of body, mind, and spirit: they speak of the body as physical form. They speak of the person's spirit, of multiple bodily spirits, and of yin and yang souls. People are known to think and to have emotions, and medical sources speak of these states as both normal functions and, when out of balance, illness. These categories, however, are subsidiary in the organization of understandings of health and treatment of disease. Medicinal therapies are ingested for ailments related to emotional excess and to the destabilization or detachment of the body's spirits. Herbal and ritual therapies are applied to prevent attack by animals as well as demons, and to treat gross bodily pathologies. Affects are not only implicated in, they are integral to both the origins and processes of bodily disorders, and to their healing. Major Chinese categories and practices distinguish four modes for imagining the healthy self, and illness as deviation from it: the resonating self, the dissipating self, the moral self, and the ecological self.

The resonating self is the mode most characteristic of Chinese canonical medicine, but it also came to powerfully shape everyday Chinese views of the body, and to contribute to nonmedical styles of healing. The core features of this physiology developed in the fourth to first centuries bce and have remained fairly stable, albeit with elaboration and variation along the way, over the following two millennia. In this view, the person, polity, and cosmos operate as a series of nested microcosms and macrocosms according to the cyclical, dynamic, and complementary principles of yin and yang and the Five Phases. The emperor and his bureaucratic representatives stand at a critical nexus of responsibility for order in these realms. If they do not properly align their behavior to the normative cycles of the cosmos, heaven and earth resonate, producing floods, drought, and epidemics. The people resonate, straying from their socially appropriate roles, even as far as banditry and rebellion. As emperor and officials must match their policies and ritual to cosmic cycles, so must individuals harmonize their activities, whether sleep, work, diet, or sex, to the appropriate phases of the day and year. Discordant activity can produce illness.

Yin and yang and the Five Phases, then, were understood to pattern and resonate through all phenomena. From the Han period (206 bce–220 ce) the Five Phases mapped, for example, the seasons, directions, colors, virtues, and musical notes, as well as different aspects of physiology. The last included organ systems, sense organs, affects, the tracts (also translated vessels or meridians ) through which qi (pronounced "chee" and also sometimes spelled ch'i, here vapor and vitality) flows, and nodal points along them through which qi might be affected (see Tables 1 and 2). Physiological patterns could be felt through the pulse, most commonly felt through three spots at the left and right wrists. Changes in one system will manifest in multiple associated registers: in changes in emotion, perception and sensation, color, smell, and discharge of bodily fluids.

The medium of this resonance is qi, which could refer multivalently or in different contexts to air, vapor, breath, vitality, vitality in its yang aspect, and something akin to "the psychophysical stuff and energy" that constitutes all phenomena. Besides resonating, qi could also dissipate. The dissipating self was understood as being born with a full endowment of vitality, or "original qi," which dissipates through the course of life. Health and longevity could be enhanced by replenishing qi, or by slowing its dispersal. This could be affected most commonly through ingestion of tonifying medicines, a range of "cultivating vitality" practices (see below), or by avoiding particularly qi -draining activities. For men, a special focus of concern was the expenditure of the most concentrated essence of yang vitality, semen, in sexual intercourse. Women were particularly vulnerable to the draining of yin vitality, blood, through menstruation.

Despite these sex-specific sources of danger, canonical medicine did not take gender as a fundamental human or medical division. Gender tended to be constructed according to social function rather than biological essence. While femininity was yin and masculinity was yang, both male and female bodies operated according to these principles and the circulation of both yin blood and yang qi. Women and men were not absolutely yin and yang, but contingently yin and yang in relation to each other, on a continuum rather than radically distinct. While medical texts did include separate sections on disorders related to the uniquely female functions of gestation and childbirth, it was only in the learned medicine

of the Song period (960–1279 ce) that therapies for non-gender-specific disorders came to be constructed on the basis of gender-differentiated bodies. Female physiology was set apart from male here by the dominance of blood (yin vitality) over qi (yang vitality), not absence of the latter. While this therapeutic distinction fell out of practice in later centuries, the approach generated attention to menstrual regulation as a basis of health and of the essential social function of fertility, concerns that continue today.

In this modality, the integrity of physical structures was considered an essential precondition of health, but intervention was more concerned with alterations that occurred prior to gross corporeal change. Tracts mapped not visible anatomical structures, but felt flows of qi. Organs were of interest less for their size, shape, and location than as systems of function for which the physical organs might be considered substrates. Each of the Five Phases and its associated organ system is also linked to every other Phase and organ system through either a "promoting relationship," such that it is nourished by one system and nourishes another, or a "controlling" relationship, such that it is restrained by one system and restrains another. Thus, excessive or deficient activity in one system can propagate stagnation, repleteness, and imbalance in other systems (see Table 3).

While this cosmos operates according to rationalistic principles of yin, yang, and the Five Phases, it is also both inherently moral and animated. The emperor can provoke disastrous weather and social disturbances through unrighteous behavior, not only by failing to perform rituals and enact policies that are synchronized to the phases of the cosmos. Besides cosmic resonance, the moral self can become ill in retribution for misdeeds. From the Han period, as the spirit world came to be seen as dominated by a celestial pantheon modeled on the human imperial bureaucracy, illness also came to be seen as resulting from celestially administered punishment. Aggrieved spirits could make people ill by directly attacking them, or from medieval times often through litigation in the courts of the afterlife. As in the worldly legal system, punishment could extend to family members, so that for the sources of ailments one might need to address the crimes of a forebear. With the spread of Buddhist ideas, illnesses and other misfortune could also be understood as karmic consequence for the misdeeds of a previous life.

As in most of the world's societies, the self was not conceived as a thing utterly detached from the world around it; it was permeable to and an organically integral part of its environment. The ecological self not only responds to the world through cosmic resonance, it is acted upon by agents, things, and events in its internal and external social, spiritual, and physical environments. The outer world provides nurture, but again poses threats to one's well-being, for example through the stress and violence of interpersonal conflict, improper diet, poisons, and physical attack or accidental injury.

Besides dangerous animals and people, vectors of violence included spirits and ghosts. Although ancestors, when ritually cared for, looked after their descendants, if not attended to they could punish their neglectful offspring. The pores and orifices expose the self to invasion by poisonous substances, noxious fumes, and demons or ghosts. Prior to the twentieth century, small demonic creatures were understood as capable of infesting the body, sometimes entering as ethereal spirits but taking form within as gnawing insects or worms. With the acceptance of germ theory in the twentieth century, infecting parasites, viruses, and bacteria joined with or replaced this list of external hazards.

This ecosystem extended to the body's internal and numinously populated landscape. Han period texts describe a yin and a yang soul. After the Han, especially but not exclusively in Daoist texts, we find descriptions of three yang and seven yin souls, spirits associated with the various organ systems, and the "three corpse worms." Most of the souls and spirits of the body are responsible for its healthy function, and not unlike bureaucratic officials, can produce disorder if they do not attend to their posts properly. Dreams, often understood as the roaming of the yang soul, are considered an occasion of particular vulnerability. The three corpse worms are demonic agents that are, like the body spirits, born within the person, in this case located in the three cinnabar fields, centers of vitality located in the head, chest, and lower abdomen. These body spirits seek release from their host by his or her death, and expedite this by inciting qi -squandering behaviors, such as sexual indulgence, gluttony, and immoderate ambition; by conspiring with external demons to infest the person and bring about illness; and by reporting to the Celestial Jade Emperor on the person's misdeeds so that compensatory time is deducted from their allotted lifespan.

Healthy selves, then, would resonate harmoniously with a properly aligned polity and cosmos, would retain or only slowly dissipate their vitalities, would be morally upright, and would harmonize with both internal and external environments, maintaining strong relationships with good people and spirits, and avoiding dangerous people, spirits, and situations. Selves could be disordered in resonance with cosmic discord; could be weakened by draining vitalities; could face consequences for misdeeds in this or in previous lives, or even for the crimes of their forefathers; and could suffer distress or violence from within or without. These views of the self contribute to organizing approaches to health management, and inform the choices people make among healers and healers' therapeutic recommendations. These choices,

however, are also significantly shaped by social context and by available choices in healing specialists.

Personal and Social Contexts of Health Management

Social contexts of health management correspond to spheres expanding from the individual to the family, community, and polity. Structuring these arenas are hierarchical relationships, such as those based on patriarchy and class.

Self

From the mid-fourth century bce we have texts describing methods for cultivating vitality geared both toward slowing its dissipation and toward harmonizing it with the cosmic cycles. Practices included meditation, regulation of breath/qi /vitality and its circulation around the body, gymnastic movements for "guiding and pulling" qi in the body, retention and recirculation of seminal essence during intercourse in order to prevent the attendant loss of original qi, dietary restrictions, and absorption of vitalities from sexual partners or from the outside world. These practices seem to have been widespread among the Han elite, and were associated during that period with Huang-Lao, practices of the mythic figures of the Yellow Emperor and Laozi, and with the pursuit of transcendence. The descriptions of physiology developed through these practices contributed greatly to the canonical medical tradition. In later centuries, while some moderate breathing and dietary practices remained part of the elites' repertoires of healthcare, more esoteric practice came to be associated with religious Daoists.

From the Han and continuing into the seventh or eighth centuries, Daoist cultivation included the ritual concoction of elixirs, the process recapitulating a reverse cosmogony in both the elixir cauldron and in the self. In later centuries, the imagery of this "external alchemy" remained a part of "internal alchemy," cultivation of vitality primarily through breathing and visualization, without the actual production and ingestion of elixirs. This includes the cinnabar (a mercuric sulfide that also gives East Asian lacquerware its distinctive red) that also stands synecdochically for both elixir and Daoist alchemy.

While women also participated in these practices, it is only from the seventeenth century that texts describing a distinct style of cultivation geared to female physiology and for the guidance of women practitioners appear. These were written by men, and aimed in part at supporting practice by women in the home, and discouraging them from seeking guidance by leaving the home or by bringing in teachers who elite men saw as potentially corrupting. Among its distinctive characteristics, this practice aimed at "beheading the red dragon," or stopping the menses and returning the body to a prepubescent state.

Family, community, and state

As in most societies, the primary locus for managing health in China was the family. The first to care for the sick were usually the adult women of the family, although especially from around the Song period elite men often also took an interest in medical learning and sometimes practiced in an amateur capacity on their friends and families. Women left their natal families upon marriage, bringing with them and exchanging with

their new families practical everyday knowledge about healthcare, including management of diet, methods of massage, herbal remedies, and avoidance of pollution or contagion. With the spread of commercial printing from the eleventh century, some of this household lore, as well as specialist medical works, made their way into publication, increasing the circulation of knowledge about health and healing.

When illnesses seemed to warrant specialist attention, the decision of whom to consult was often made in consultation with members of the extended family and local community. In the large and complex households of wealthier families, which could contain multiple generations, several subsidiary wives, and numerous servants, decision-making could involve negotiation among the preferences of competing parties. In general, elite men of late imperial times (roughly, the fourteenth to nineteenth centuries) seem to have favored the services of elite scholar-physicians, while women tended to prefer the more eclectic and hands-on ritual, massage, moxibustion, acupuncture, and also herbal and dietary treatments of female and other lower-status specialists.

Households and communities were also a basic unit for containing or repelling contagion. When someone was thought to bear a contagious illness, they might be isolated in their room, with their care charged to a specialist healer. Outsiders would avoid visiting a family or village so stricken, and in severe cases members of the family and community might flee the area, leaving the sick behind. The windows, doorways, and circumference of a household might also be ritually sealed to prevent the entrance of plague-spreading demons. Early texts contain references to annual exorcistic festivals for cleansing the community, or in some cases the palace or capital, of demons responsible for disease. In later periods, for which more is known, other annual festivals, such as the Dragon Boat Festival, also had such apotropaic functions, and special rites could be commissioned to prevent or expel particular plagues.

Monasteries (especially from the fifth century) or local gentry (especially between the twelfth and nineteenth centuries), often with administrative help from officials, would also organize food, shelter, burial, and medical relief for the indigent during disasters. Monasteries also built hospitals with state cooperation in the eighth century. After confiscation of monastery properties in the 840s, these were shifted to state administration. In response to disasters, emperors often granted tax abatements and distributed relief on an ad hoc basis. It became more common in the Northern Song period (960–1127 ce) for officials to distribute medicines during epidemics, and later in the period state-run subsidized pharmacies and hospitals were set up in the capital and in some prefectural seats. Christian missionaries began to set up clinics and hospitals providing Western-style medical care beginning in the nineteenth century. In the twentieth century, the state again became the primary builder of both biomedical and Chinese medical hospitals.

While most healing, healthcare, and disease prevention has always taken place without the aid of specialist healers, extant writings tend to leave better records by and about these figures.

Healers

Disorders of different types might suggest particular healing specialties, but often a given ailment might be considered susceptible to multiple avenues of attack. Ecstatic and ritual specialists were concerned with expelling demons, with moral management and consequences, and with alignment with cosmic cycles. Canonical medical traditions were concerned primarily with patients' disharmonies and the dissipation of their vitalities, but also sought to buttress defenses against violation by external noxious agents. Experts in esoteric practices of cultivating vitality shared these concerns, good health being prerequisite to higher goals of transcendence, but additionally advised devotees in methods of alchemical refinement and transformation.

Ecstatic and ritual healers

Analysis of the earliest surviving written references to disease and healing, from Shang period (c. 1500–1050 bce) oracle inscriptions, suggests that at this time, in what today is northern China, Shang royalty attributed at least some disease to the dead and to demons. They responded by communicating with and propitiating their ancestors or expelling disease demons through wu, often translated as "shaman" or "spirit-medium." As Chinese-writing empires spread, the ecstatic and religious healers of diverse peoples came to be identified in literature as wu, the once-respected term taking on senses of exoticism and derogation close to "witch doctor." While in many dynasties through history wu enjoyed the court's favor and high status, they came under attack from competitor physicians, from Daoists and Buddhists beginning in the third to fourth centuries, from Confucian officials as early as the Han but especially in the eleventh century, from local gentry between the twelfth and nineteenth centuries, and from the state-building Nationalist and Communist governments in the twentieth century. Despite these periods of suppression, however, ecstatic healers are active in Taiwan and China today.

Priests of the Daoist religion could intervene for parishioners in illnesses produced by litigation from beyond the grave, submitting counter-petitions and countersuits on their behalf. They also guided parishioners in confessing and purifying themselves of their misdeeds, performing exorcisms and communal rituals, and providing talismans for the expulsion of evil spirits for pasting on doorways or for ingesting.

Whereas Daoist cultivation tended to take the health of the whole self, including the physical body, as a precondition for soteriological goals, Buddhists took the illusory nature of the phenomenal world, including bodily illness, as a central tenet. The rigors of monastic practice in fact were known to be hard on health. On the other hand, Buddhists taught compassionate concern for the suffering of others, and introduced new therapeutic and institutional approaches to the treatment of illness. The idea of karmic causality and the provision of medical and disaster relief were mentioned above. Buddhist missionaries introduced South Asian drugs and therapies, including cataract surgery, to China. Buddhists also introduced practices that were applied to prevent or treat illness, including mudrās and mantras, new types of incantations and rituals, and new approaches to meditation. Certain South Asian ideas about illness, such as the Four Elements, also occasionally appear in Chinese medical texts, notably Sun Simiao's (581–c. 682) Beiji qianjin yaofang (Essential prescriptions worth a thousand in gold for preparing for emergencies). Over the long term, however, these do not seem to have fundamentally reshaped Chinese medical approaches to etiology, nosology, diagnosis, or therapeutics.

Drug sellers

From at least the Han we also have records of specialized drug sellers. They were sometimes associated with Daoist transcendents, and drugs were stored in gourds or gourd-shaped containers, an image of primordial chaos in Daoism. With the expansion of commerce from the eleventh century, commercial pharmacies and itinerant drug sellers became more widely available as sources of both medicines and medical advice.

Hereditary doctors, scholar-physicians, and specialists

The fourth to first centuries bce saw the emergence of literate medical practitioners who distinguished themselves from other healers with the development of distinctive textual traditions and practices based on the cosmologically resonating and vitality-dissipating models of physiology developed at the same time by cultivating vitality practitioners. They did not, however, entirely eschew ritual therapies or demonic views of disease.

These physicians tended to pass their knowledge and texts to sons or to duly recommended outsiders deemed worthy. Although literate, these were not those family lines with access to the highest levels of office. In the late tenth and eleventh centuries, however, expansion of imperial involvement in producing and disseminating medical texts and in medical relief raised the status of medicine. The period also saw increased socializing between literati and physicians, and literati and official compilation and publication of prescription texts. Between the twelfth and fourteenth centuries, as office became accessible to a larger and more fluid stratum and chances of actual attainment to this coveted status became increasingly rare, pursuit of medicine as avocation and eventually occupation became a socially accepted alternative for elites. Reacting both to the more eclectic practices of hereditary physicians and to the standardized prescriptions of eleventh-century official relief efforts, these scholar-physicians developed styles of medicine based more strictly on canonical texts, such as the Inner Canon of the Yellow Emperor (second to first century bce), and followed more individualized and dynamic approaches to diagnosis and treatment. They focused on the treatment of underlying physiological conditions rather than "superficial" manifestations, and they might, for example, leave the treatment of lumps or lesions to specialists in external medicine. Scholar-physicians employed complex and individually tailored herbal prescriptions, eschewing those therapies that were considered both less subtle and less suitable to their social standing, such as acupuncture, moxibustion, and massage.

These therapies became the preserve of lower-status healers. Besides specialists in particular diseases or therapies, these included shamans, diviners, and other religious figures; itinerant healers; and in general female healers and midwives. Ironically, the stricter segregation of genders in the late imperial period increased demand for female experts. Besides those who practiced a more eclectic mix of skills, female physicians who were trained in their family's hereditary learned medicine also practiced in elite circles, including at court.

In the twentieth century, as "modernity" and "science" came to be broadly valued in China, and as a result of nation-building efforts and anxiety about Chinese culture, indigenous healing practices came under attack as "superstitious." Both in order to stave off threats to their legality and to make their practices more modern, practitioners experimented with different approaches to reforming Chinese medicine: mapping tracts and disorders onto Western-style anatomical structures and biomedical disease categories; dropping minor surgery from the repertoire of what we know as acupuncture; emphasizing aspects of the tradition that resembled biomedicine in some way; shedding the more elaborate cosmological frameworks; emphasizing the empirical foundations of Chinese medicine; integrating Chinese and Western medical practices; and asserting the scientific legitimacy of a newly emphasized "differentiation of manifestation types" in opposition to Western "distinguishing of diseases."

For a time it was anticipated that these modern transformations, confusingly referred to as traditional Chinese medicine, would leave these traditions completely subsumed under biomedical paradigms. The utility of acupuncture would be disproved or explained in relation to nerves and the endocrine system. The active components of individual herbs would be isolated and their efficacy would be identified by biomedical procedures. Complex diagnoses and herbal prescriptions would be eliminated. Instead, the styles of Chinese medicine have proliferated with the revival of respect for the virtuosity of older masters, with the increasing popularity of "complementary and alternative medicine" around the world, and with variations brought about by attempts to adapt Chinese styles of healing to diverse environments. Attempts to test the efficacy of Chinese medical systems in randomized trials have been stymied by their very diversity, by the individual tailoring of much practice, and by the failure of attempts to map Chinese onto biomedical physiology or diagnoses.

Health and illness in China must be understood in relation to Chinese understandings of self. Their management is shaped both by the social context of care, and by the available range of healing resources. While institutions of the last century have tended to support the separation of biomedicine from Chinese medicine, and the dominance of the former and standardizing of the latter, the preferences of both healthcare consumers and providers for eclecticism have kept multiple indigenous traditions alive and changing.

See Also

Chinese Religion; Qi.

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