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 instruction 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 during 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 practitioners 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 examinations. 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 Animals, and the Chief-of-Physicians, who supervised the others. Physicians for Simple Diseases were assigned the task of testing the five kinds of breaths, the five kinds of sounds, and the five colors to determine 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 talismans. 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 medicinal 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 predictable 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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