Who is best qualified to study the history of medicine? Physicians with technical training? Historians with a finer appreciation of how to approach the past? This issue has mostly been resolved in the West, where historians have largely replaced physicians, fulfilling the call of Henry Sigerist in the 1940s to move from the “Great Man in medicine” narrative to a more social and cultural approach. In Europe and the Americas, the history of medicine has emerged as an acknowledged field within history. Just consider the annual conference of the American Association for the History of Medicine, where historians rather than doctors now dominate the program. A quick browse through the contents of the association's official journal, the Bulletin of the History of Medicine, confirms that most of the work is being done by scholars who belong to university history departments.
In China, however, the debate continues. This is brought to the fore by the editor of the book under review, Li Jianmin, who recalls in the introduction a challenge from an audience member at a colloquium in Hong Kong: how could someone who had not trained as a physician say anything about the history of medicine? Li points out that most of the historical work by physicians does not move beyond technical aspects of medicine. While these works are critical to furthering our understanding, only those who have been trained as historians can place medicine within broader trends, illuminating society's dramatic and subtle transformations. Li also points out that while scholars in mainland China have made significant contributions to the understanding and authentication of medical texts, it is those in Hong Kong and Taiwan who have been broadening the field with a more fully historical approach.
The book under review represents a major step in that direction, and it reflects the collaborative efforts of an international cadre of scholars from the USA, Hong Kong, China, Taiwan, and Japan. There are altogether 15 chapters covering a timeframe ranging from the ancient Shang dynasty (1766?–1050 bce) to the recent colonial administrations in Taiwan and Hong Kong. The sources used include archaeological findings, pi-chi (literary jottings), medical treatises, archival materials, as well as images (as pointed out by Huang Longxiang in his chapter on historical sources, care has to be taken when utilizing medical texts, as repeated copying sometimes produced critical mistakes).
These 15 chapters cover diverse topics that reflect the connections between developments in the theory and practice of medicine, on the one hand and on the other, broader historical processes such as intellectual trends, political and social changes, state policies, and perceived differences between northern and southern China. There studies of medicine thus illuminate broader historical trends.
Li Jianmin's chapter utilizes newly excavated materials to shed light on how changing intellectual developments altered ideas about the role of ghosts and spirits in the transmission of disease from approximately 475 bce to 589 ce. A major change occurred around the fourth century bce, when developments in mathematics enable scholars to forecast the weather, traditionally considered an important cause of illness. At roughly the same time, intellectual discourse increasingly emphasized the preservation and cultivation of the inner self. This emphasis on rationality and inner cultivation merged with the growing importance of the notion of ch'i, paving the way for the rationalization of ghosts and spirits. The supernatural was incorporated into the medical theory of fire and heat (huo je), categorized as a yang illness, and prescriptions for ghosts and spirits appeared in the materia medica. Rather than causing sudden illness, it was now believed that illnesses caused by ghosts and spirits were gradual and continuous. This change was also interwoven with developing notions of the underworld: In the Han, ghosts and spirits were linked to morality and family connections. This new focus on family, closely associated with anxieties concerning lingering disasters brought on by one's ancestors, led people to dwell on the malefic traces of the departed.
Also located at the intersection between religion and medicine is Kika Urayama's chapter on “taboos” in Chinese medical classics. Urayama calls for caution in equating the Chinese term chin-chi with taboo as it leads to misunderstandings. The emphasis in Chinese medical classics on the selection of appropriate dates was heavily influenced by an already well-developed calendrical system. Later, observations of weather, patterns of time, and bodily rhythms led medical practitioners to adopt prohibitions (chin) and avoidances (chi). These were later systematized under the theory of yin yang and the five phases. Although few physicians seem to have paid attention to this approach during epidemics and wartime chaos (for example, the last years of the Eastern Han dynasty), there was a renewed interest in chin-chi under the influence of Daoism and the pursuit of immortality.
The medieval period saw China make the transition from destitution and chaos in the Period of Disunion (220–589) after the collapse of the Han (202 bce–220 ce) to order and prosperity, cultural flourishing, the expansion of national boundaries into the south, and imperial domination in Asia under the Sui (589–618) and Tang (618–907) dynasties. In medicine, Chang Chia-Feng's chapter shows how the outbreak of epidemics and the appearance of new diseases challenged physicians to expand their medical repertoire. Pediatrics emerged as an independent field in the official medical curriculum. Though physicians had earlier recognized the difference between children and adults, most of the discussions of infant illnesses had been included within works on women's health. It took a Tang physician of great vision, Sun Simiao, to bring pediatrics into its own by combining northern and southern traditions, a change acknowledged by the Imperial Medical Bureau. Based on practical observation, physicians came to understand the stages of children's development, and they took steps to ensure their proper growth.
Chen Yuan-peng's chapter on the tradition of nourishing life through food brings into focus how the literati changed their eating and drinking habits in an effort to elevate their status. Thus, the knowledge that had been systematized by Sun Simiao influenced the literati way of life, from which it gradually spread into the general population.
In medieval China, Buddhist monasteries founded charitable institutions to treat the ill. Liu Shufen's chapter explores the relationship between Buddhist monks and the government during the Tang and Sung (960–1279) dynasties. From the patronage and indulgence of the Tang to the control and restrictions of the Song, Buddhist monks went from managers to mere assistants in free village clinics. They were relegated to patient care and the preparation of medicines, while officially appointed physicians examined the ill.
The differences between northern and southern China has been a persistent theme in the writings of the literati since the Tang dynasty. Fan Ka-wai's chapter examines the perceived dangers of the south and of political exile through a study of Liu Yü-shih's Chuan-hsing fang (Formula of Trusted Transmissions). Although Liu was not a famous physician—he was in fact an autodidact—he had taken advantage of his exile in the south to draw up a list of effective prescriptions. In the medical classics, the south was presented as hot, damp, and poisonous, a place where premature death could hardly be avoided. This contrasted with the view of the north as a place of balance and clarity, without poisonous influences. Liu's enterprise reveals the anxiety among the literati sent south, as well as the widespread faith in formulae passed down through time.
In a chapter that continues this theme of the north–south divide, Marta Hanson examines the commonly accepted notion that in treating the ill one “attacks and conquers in the north, preserves and nourishes in the south.” This sharp difference was based on alleged geographic differences. However, explanations based on climate and terrain did not go unchallenged, and Ming physicians such as Li Zhongzi believed that economic differences accounted for the different therapeutic regimens of north and south; Li warned against blindly accepting generalizations about regional differences. What emerged out of this discourse was a more objective and unbiased elite physician who promoted a way for southern physicians to carve out a new position and establish themselves as the trusted and reliable authority in the field.
The medical landscape in late imperial China was diverse, with an increase in the number of elite physicians—many of whom were failed examination candidates. Ch'iu Chung-lin's chapter emphasizes the competition within these crowded fields for status and success. Government endorsement was one way to bolster status and enlarge one's practice. Since a physician's status and reputation determined whether his practice would flourish or crash, it is not surprising that official physicians and those with celebrity or a hereditary claim to competence had the most profitable practices. They were challenged by Confucians who attacked them for lacking scholarly credentials. Ch'iu also paints a portrait of patients in the late imperial period, a fickle group who did not seek medical attention until they were quite ill and then switched physicians when cures were not immediate. As Chiu points out, many patients simply did not trust physicians, and shamans were often their first choice when they fell ill.
The late nineteenth and twentieth centuries were traumatic for China as she faced imperialist pressures on her territory and intellectual anxieties about her scholarly traditions. The crisis led to efforts to eradicate those parts of Chinese culture that were deemed unscientific, thus unsuited for a modern nation-state—traditional Chinese medicine was long under siege. Sean Hsiang-lin Lei's chapter on the birth of the antimalarial drug changshan shows how a promising medicine was wrestled from the traditional network of Chinese physicians, isolated, and inserted into the social–technical network of Western-trained physicians. For changshan to be accepted as a viable drug in countering malaria, it had to be strategically “created” through decisions that affected naming, commodification, trust, and knowledge. Even in the hands of the traditional Chinese physicians, changshan was a practice-based and fabricated object. The process through which the Western-trained physicians seized it from their Chinese counterparts was complex and multilayered.
The chapters by Liu Shi-yung on medicine in Taiwan during Japanese colonial rule and by Yang Xiangyin on the formation and development of Hong Kong's medical service network deal with the issue of colonial rule and the training and provision of medical care. Liu showed how the weak position of pharmacists in Taiwan has historical roots in Japanese colonial rule, when the provision of medicine was the prerogative of physicians. Yang's chapter traced the formation and development of medical networks in Hong Kong, showing how the colonial government gradually broke out of the narrow focus on the health of the colonizers to expanding medical resources and supporting charitable efforts in setting up a comprehensive medical network. However, it was also through government activism that traditional Chinese medicine was pushed aside.
Angela Ki Che Leung's chapter on leprosy shows how the study of a single disease can inform us about the inter-relationship between cultural traditions, medical knowledge, social attitudes, and political policies. Leung weaves together several threads presented by her fellow contributors: religious beliefs, notions of contagion and the family, perceptions of regional differences, and the challenges a nation faced as it struggled to modernize. In China, leprosy was long a highly visible and much debated disease, traditionally regulated not only by law but by religious institutions as well because of its association with immorality. But changes in medicine and social attitudes led to fundamental changes in the treatment and perceptions of leprosy. The key change in attitude and treatment of leprosy came in the Southern Song dynasty, when the disease was “demoted” from a wind disease to one of skin lesions, thus a concern of wai-k'o (external medicine), a field that was marginal to traditional medicine. With this change, the disease was pushed from the center to the margins in the hierarchy of medical knowledge, where mainstream Confucian physicians disdained wai-k'o as inferior. The typical patient also changed from a socially centered male of the cultural center to that of people of lower class. Notions of contagion meant that women's bodies as sites of contagion were of particular concern. Later, after mid-Ming, leprosy came to be geographically located in the hot and humid region of Lingnan in southern China, a region that was not only marginal but also considered uncivilized. This change shifted the disease as a gauge of moral uprightness versus moral failure to one of civilized versus barbarian. The patient that had belonged to the “we” of the cultural center now was transformed into the “they” of the marginal and uncivilized. However, the notion of contagion also meant that leprosy could be transmitted through sharing utensils or exchanging bodily fluids, and southern women's bodies were therefore particularly dangerous. The perils faced by the family of the patient were still there, but may other, including strangers, were imperiled as well. The fluidity of the boundary between the civilized and the barbaric was reinforced by the frequent interactions between China and the Yue culture in the south. All this created anxiety among the Confucians of the fear of “contagion” from the less cultured and less civilized. This “we” versus “they”, “center” versus “marginal”, and “civilized” versus “barbarian” discourse concerning leprosy was thus already in place in the late Qing when colonialism and imperialism threatened China. The Chinese elite were able to adopt the rhetoric of the imperialists and view leprosy as threatening to a modern nation through the lens of race and tropical medicine, as lepers were already considered “they”.
Changes in medical knowledge and treatment of patients often reflected broader social transformations. Thus, as leprosy is disentangled from the morality condemnation of Daoism and Buddhism and tied to personal hygiene and social customs, we also witness a diminishing religious tint to the treatment of leprosy patients, while the government's hand became more visible in the attempt to preserve social health and prevent the spread of a perceived contagious disease. This was accomplished through relegating the patients to the margins of society where they were able to continue to live and function under the watchful eyes of the government, but they were not isolated as had become the standard practice in the West. Thus, the Ming and Qing governments developed a set of measures of handling leprosy that reflected current medical knowledge, the needs of society, and the worldview of the rulers. However, these measures did not last after the collapse of the Qing dynasty when leprosariums were taken over by Christian missionaries. Adopting the Western notions of complete isolation of those afflicted with leprosy, patients were thus no longer allowed to function at the margins but were now completely isolated. This adoption of the Western rhetoric and measures was seen as necessary step as a modernizing nation and critical to the survival of China. The case of leprosy therefore shows how a disease is treated and viewed not only according to medicine, but attitudes and practices are always closely intertwined with power relationships within society.
Ch'ung i-liao k'an Chung-kuo shih has made a significant step toward a better understanding of the changing relationships among medicine and various aspects of society. The authors have shown how scholars can make significant contributions to the understanding of Chinese history through the study of the history of medicine.