11 May

According  to Huang  Ti, the great  sages of ancient  times did not  treat those  who were already  ill. Instead,  they gave the benefit  of their  in- struction  to  those  who  were healthy,  because  seeking  remedies  after diseases had  already  developed  was as foolish  as waiting  until  a war broke  out  to  cast weapons.  In  theory,  superior  physicians  guided  the healthy  patient;  inferior  physicians  treated  the sick. While the scholar practiced  preventive  medicine and took  no fee for his work,  hordes  of healers without scholarly pretensions—surgeons, apothecaries, magicians, fortune-tellers,   peddlers,  and  assorted  quacks—were  eager  to  collect fees and  quite  willing to  serve sick and  stupid  patients.  The  typical practitioner was accused of being more interested in fees and favors than theories and philosophy.

Although  the education  and activities of physicians in the Imperial Service are hardly  typical of the general practice of medicine in China, many  interesting  innovations are associated  with the evolution  of this institution. For example, the institutions of the Chou indicate that  dur- ing the Chou  Dynasty  (ca. 1122–221 B.C.E.,)  the government  conducted yearly examinations of those who wished to practice medicine. Schools of medicine were established in almost every province, but most practi- tioners  were  trained  by  apprenticeship, and  lower-class  healers  were largely self-taught.  For  the Imperial  Service, the salaries  of successful applicants  were determined  by how well they had placed in the exami- nations.  Rank  and  salary  for physicians  serving the government  were determined  by an analysis  of their  success rate.  Physicians  who cured all of their patients  were ranked  first class; the lowest grade contained those who could not cure more than sixty percent of their patients.  This took  into  account  the belief that  half of the patients  would  probably have  recovered  without  any  treatment at  all. Veterinarians  were also ranked  according  to their rate of successful treatment.

The Chou  Imperial  Service included  Food  Physicians,  Physicians for  Simple Diseases,  Ulcer  Physicians  (surgeons),  Physicians  for  Ani- mals,  and  the  Chief-of-Physicians,  who  supervised  the  others.  Physi- cians  for  Simple  Diseases  were  assigned  the  task  of  testing  the  five kinds of breaths,  the five kinds of sounds,  and the five colors to deter- mine whether  the patient  was dead  or  alive. The  Imperial  College of Medicine  consisted  of  about  30 physicians  attached   to  the  Imperial palaces.  Physician-scholars   of  the  highest  rank  gave  lectures  on  the classics to junior colleagues. These physicians had access to the Imperial Library’s  collection   of  12,000  works  on  medicine  and  the  natural sciences. Obviously,  very few people  were served by the sages. Lowly practitioners of public  medicine and  street  medicine far outnumbered those involved in court medicine. A rather diffuse system of public assistance  may  have  existed  in  theory,  but  it  was  never  sufficiently funded   to  have  a  significant   impact   on  the  medical  needs  of  the populace.

Patients who were more worried about demons and spirits than the five phases  found  their  medical  practitioners on  street  corners,  along with  astrologers,  geomancers,  and  fortune-tellers,  or  made  their  way

to monasteries where healers dispensed medical advice and amulets with equal enthusiasm.  Protective  measures  for dealing with magical forces included  charms,  prayers,  exorcisms,  incantations, amulets,  and  talis- mans. A talisman  might resemble an official imperial document,  except that the named official was a high-ranking demon who ordered demons lower  in  the  hierarchy  to  cease  and  desist  from  causing  illness and misfortune.

Driving   out   demons   might   require   drugs   compounded  from

powerful poisons or highly odoriferous materials. To prevent the poison from  killing the patient,  the prescription  or  drug  could  be worn  as a charm or burned as a fumigant. A worm spirit, known as the ku, figured prominently among the demon diseases described in both scholarly literature  and folklore.  Elaborate beliefs developed about  the ku spirit, including  the  belief that  the  only  way  for  the  original  victim  to  rid himself of the ku was to provide  another  host.  Ku antidotes  included prayers, charms, drugs, and centipedes (because centipedes consume worms). Law codes show that belief in ku magic survived into the nineteenth   century.   The  penalties  for  ku  magic  were  quite  severe, including  bizarre  methods  of  executing  the  criminal  and  his  whole family.

Physicians with scholarly  training  or aspirations tried to separate their profession  from magic and  sorcery, and  disparaged  the remedies prescribed  by folk  practitioners and  quacks,  but  sometimes  they  too offered prescriptions that  combined medicine with magic. One example of a mixed prescription  used in the treatment of digestive complaints consisted of magic characters written on thick, yellow paper with medici- nal pigments. The prescription  was burnt  to a powdery ash, which was added  to hot water and taken  as a medicinal tea.

Written sources generally reflect scholarly interest in medical theory, but occasional glimpses of actual interactions between physicians and their patients  appear  in collections of cases histories,  biographies,  diaries, and advice literature.  According to case histories from the Ming Dynasty (1368–1644), physicians  used the ‘‘four examinations’’  in order  to make a diagnosis. That  is, they followed appropriate steps in looking, listening and smelling, asking, and touching (pulse measurement),  depending on the condition and sex of the patient. Although pulse measurement was usually considered  the  most  reliable  part  of  the  examination, physicians  also claimed the ability to diagnose  and advise patients  they had not  seen in person.  If the physician thought  that  death  was inevitable, or the disease was inappropriate for medical intervention, he could refuse to treat  that patient.  As in other  ancient  medical  systems,  it was important for  the physician  to  predict  death  and  avoid  responsibility  for  such failures  of treatment. Frequent references to  the  deficiencies of other  practitioners seem to reflect fierce competition  between physicians.  Case histories  and autobiographies suggest that  even elite physicians  were often  forced  to travel in search of patients.  Some physicians visited patients  at fairly pre- dictable intervals, only to discover that  some of their patients  sought out other healers or foolishly medicated themselves when dissatisfied with the intervals between visits or the nature  of their prescriptions.

Texts  from  late  imperial  China  suggest an  ancient  and  complex body of theories  and practices related  to gender-based  concepts  of the body  and  its functions.  Generally,  however, classical texts focused  on the distribution of energy in the male body.  Discussions  of ‘‘women’s medicine’’ usually  dealt  with  female  fertility,  the  diseases  specific to women,  and  remedies  appropriate for  women  at  different  stages  of life. Physicians apparently used similar methods of diagnosis for women and men, but during the Ming Dynasty  male physicians were generally not  allowed to examine women directly.  Little is known  about  female practitioners, other  than  midwives, but  a Ming  Dynasty  writer  noted that  women usually sought  out female healers for themselves and their children.

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