Читать книгу The Greatest Benefit to Mankind: A Medical History of Humanity - Roy Porter - Страница 52

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.