During the first decade of the twenty-first century, a network composed of politicians, regulators, bioscientists, clinical researchers, and Chinese medicine specialists has emerged that seeks to bridge an imagined gulf between the modern West and ancient China in order to create a new type of personalized medicine. The central building block of this bridge is the Chinese medical concept of zheng 證/証, variously translated into English as syndrome, pattern, or type. My paper places side by side two different genealogies of how zheng assumed this central role. The first genealogy examines the process by means of which zheng came to be considered as something shared by both ancient China and cutting-edge biological science and, by extension, how it manages to hold together the entire institutional, political, and economic framework into which this bridge is embedded and which it co-creates. The second genealogy shows zheng to be central to a much older series of redefinitions of Chinese medicine and Chinese medical practice that extend from the eleventh century to the present. Read together, these two genealogies—neither of which should be seen as exhaustive—raise three important issues that are further discussed in the conclusion of the paper. First, I explore how the concept of zheng has come to tie a medical tradition derided by its adversaries for being a pseudoscience to one of the most cutting-edge fields of bioscience research. I ask what is at stake in this synthesis, for whom, and why, and how it transforms Chinese medicine and/or systems biology along the way. Second, I am interested in finding out how and why the very same concept can be at the heart of two apparently agonistic visions of Chinese medicine's future as it is popularly imagined in China today. Finally, I insist that the medical humanities need to become actively involved in the construction of emergent articulations such as the ones I am exploring. Merely writing a history of the present will not be productive unless its critique can somehow be articulated into the very processes of emergence that historians or anthropologists seek to examine.
In May 2012, two eminent statesmen—Xu Jialu, former vice-chairman of the Standing Committee of the National People's Congress of the People's Republic of China (PRC), and Romani Prodi, previously president of the European Commission and prime minister of Italy and now president of the Foundation for World Wide Cooperation—invited a select group of European and Chinese scientists and politicians to Bologna for a meeting called “Dialogue on Human Health between Traditional Chinese Medicine Culture and Western Medicine” (Secretariat of the Congress 2012). Following two days of presentations and discussion lauded by Prodi as the first dialogue between these two traditions on a scientific basis (De Giuli 2012), the meeting concluded with the signing of a “Declaration of Friendship between Traditional Chinese Medicine (TCM) and Western Medicine (WM)” (Xinhua 2012: 4487).
As a historian I find it difficult to share Prodi's exuberance and hyperbole. For it demonstrates—if such demonstration were indeed still necessary—of how little interest actual history is to those who see it as their business to make it. Prodi's lack of knowledge of a century of intensely productive debate regarding the nature of science conducted by Chinese scholar-physicians may be excused as too esoteric a topic for one of Europe's top politicians. To depict China and the West as cultural monoliths that finally need to be brought into conversation for the betterment of mankind, on the other hand, effectively combines historical ignorance and arrogance for the purposes of political expediency. For only through willful disinterest in and rewriting of all that came before can people like Prodi present themselves as true heroes of our age who shoulder the burden of building bridges between hitherto disconnected cultures and who are therefore worthy of substantive financial and institutional support.
The task of history as an intellectual discipline, specifically the kind of history advocated by Walter Benjamin, appears mean by comparison. Instead of slaying dragons, the historian brushes history against the grain, revealing what is conventionally portrayed as progress as a sequence of violent battles that have vanquished possible alternatives. And yet, what appears to be mean is essential for the good. Not, as Michel Foucault argues, for the sake of a history that consists in the production of facts, but for writing “the history of the present” (Foucault 1979: 31). By that he means to reveal as contingent what is claimed by those who make history, like the signatories of the Bologna Declaration, as necessary and universal; and even more in order to open up a space for transforming the present by “grasping it in what it is” (Foucault 1984: 41).
This essay seeks to do precisely that—to write a history of the present—by placing side-by-side two different genealogies of one of the boundary objects (Star and Griesemer 1989: 393) by means of which historical actors involved in the Bologna workshop and numerous similar projects seek to bridge the gap between “Chinese” and “Western” medical cultures. This boundary object is the concept of zheng 証—variously translated into English as pattern, syndrome, manifestation, or type.
The “holism” (zhengti gainian 整體觀念) that characterizes its theories and the zheng-based diagnosis and treatment (“pattern differentiation and treatment determination” or bianzheng lunzhi 辨證論治) that constitute the fulcrum of the clinical encounter are widely portrayed today as capturing the two most essential characteristics of Chinese medicine. Predictably, one of two “master lectures” on Chinese medicine at the Bologna workshop was entitled “Pattern Classification in Traditional Chinese Medicine.” It was delivered by Lü Aiping 呂愛平, a researcher from Beijing now based in Hong Kong. Lü, who has written extensively on zheng as a bridge between Chinese and Western medicine, works in the emergent discipline of systems biology, which more and more researchers and opinion formers define to be the natural partner for Chinese medicine in the construction of that bridge. One of my genealogies will therefore examine the process by means of which zheng came to be considered something shared by ancient China and cutting-edge biological science, and, by extension, how it manages to hold together the entire institutional, political, and economic framework into which this bridge is embedded and which it cocreates.
A second genealogy, placed alongside the first, will examine zheng as central to a much older series of redefinitions of Chinese medicine and Chinese medical practice that extend from the eleventh century to the present. This genealogy will uncover the historical transformations that make the work of Lü Aiping and his colleagues possible, even as their own genealogies actively seek to vanquish the many alternative medicines that zheng has made possible over time.
Read together, my two genealogies—none of which should be seen as exhaustive—raise three important issues that are further discussed in the conclusion. First, I want to explore how the concept of zheng has come to tie a medical tradition derided by its adversaries for being a pseudoscience to one of the most cutting-edge fields of bioscience research. I will ask what is at stake in this synthesis, for whom and why, and how it transforms Chinese medicine and/or systems biology along the way. Second, I am interested in finding out how and why the very same concept can be at the heart of two apparently agonistic visions of Chinese medicine's future popular in China today. Finally, I will insist that the medical humanities need to become actively involved in the construction of emergent articulations such as the ones I am exploring. Merely writing a history of the present will not be productive unless its critique can somehow be articulated into the very processes of emergence that we as historians or anthropologists seek to examine.
Genealogy I: Constructing a Bridge between Traditional Chinese Medicine (TCM) and Systems Biology through a Focus on Zheng
The Meeting of Systems Biology and Chinese Medicine
Although by no means uneventful or proceeding along a linear track, the relationship between Chinese and Western medicine in the course of the twentieth century has always been a rather one-sided affair. If Western medicine and science have functioned as guiding lights in efforts by physicians and later the state to develop and modernize Chinese medicine, biomedical physicians and the scientific establishment generally perceived Chinese medicine as an outdated practice that at best offered some empirically useful treatments. As a result, efforts to integrate Chinese and Western medicine, even when they became official state policy, took place almost exclusively within the Chinese medical domain (Hsu 1999; Scheid 2002; Taylor 2004). During the Republican era, these efforts were driven by Chinese-medicine physicians who had acquired some knowledge of Western medicine and who assimilated Chinese medicine to modern institutions such as colleges, professional associations, and scholarly journals. In Maoist and post-Maoist China, the guiding figures of medical integration were young physicians of Western medicine commandeered to study with renowned Chinese medical experts, often against their will, in the course of the 1950s and early 1960s.
One of these young physicians was Shen Ziyin 沈子尹 (b. 1928), who went on to become one of the most emblematic figures of Chinese medical modernization of the PRC era. After graduating from Shanghai No. 1 Medical College in 1952, Shen was ordered to apprentice with the famous physician Jiang Chunhua 姜春華 (1908–92) as part of the state's program of “western medicine learning from Chinese medicine” 西醫學中醫 (Hong 1991: 218–19). “Traditional” in the sense that he practiced Chinese medicine, Jiang Chunhua was by no means a traditionalist. As a student of Lu Yuanlei 陸淵雷 (1894–1955), one of the most outspoken and radical modernizers of Chinese medicine during the 1930s and 1940s, Jiang was a proponent of the integration of Chinese medicine even before it became official government policy (Hong 1991: 342; Zhang 1994). Lu's own teachers included two other well-known advocates of medical reform in Republican China, Yun Tieqiao 恽铁樵 (1878–1935) and Zhang Taiyan 章太炎 (1869–1936), placing Shen Ziyin into one of the most impeccable modernizing lineages within Chinese medicine (Scheid 2007: 208–19).
Shen Ziyin's own claim to fame dates to the late 1950s, when his research team was able to demonstrate that a main metabolite of cortisol excreted in the urine (17–OHCS) is significantly decreased in patients diagnosed by Chinese medicine as suffering from “kidney yang deficiency” (shenyangxu 腎陽虛). This suggested to Shen that from the perspective of 1960s biomedicine, “kidney yang deficiency” involved a malfunction not of the Western medical kidneys but of the hypothalamic-pituitary-andrenocortical axis. Furthermore, if similar results could be obtained in other domains, it should then be possible to anchor the practice of Chinese medicine in the physiological realities of the biomedical body (Hudong baike 2013; Shen 1999).
Unfortunately, this turned out to be rather more difficult than Shen had imagined. Finding similar biomarkers for other Chinese medical diagnostic categories proved difficult, contributing to the gradual disillusionment among researchers, physicians, and the public with the project of integrating Chinese and Western medicine. By the late 1980s, “Integrated Chinese and Western medicine” had become a subdiscipline within the Chinese medical sector, institutionalized as a third way of practicing medicine rather than the state that all official health care was gradually moving toward.
Shen himself was not so easily defeated. In 2005, at a time when Chinese medicine was once again facing a public campaign seeking to outlaw its practice as a pseudoscience, he published a visionary paper in the journal Integrated Chinese and Western Medicine in China titled “Research into Systems Biology and Chinese Medical Zheng” (“Xitong shengwuxue he zhongyi zheng de yanjiu” 系統生物學和中醫証的研究; Shen 2005). Shen proposed that the emergent field of systems biology offered the potential to remedy earlier failures of validating Chinese medicine scientifically because its interest in complex patterns matched Chinese medicine's focus on zheng. In other words, the problematic status of Chinese medicine as a science was not rooted in Chinese medicine itself but in the slow development of biomedical science, which only now was gradually developing the tools to understand complexity.
Even more interestingly, if hitherto the question of integration had been a concern primarily for Chinese medical researchers, in the early years of the twenty-first century systems biologists, who by their own estimation represent the cutting edge of bioscience, are actively discovering Chinese medicine as a potential partner in research and drug development. Here is a somewhat simplistic account explaining why.
It is widely recognized today that the most prevalent disorders in societies with advanced economies—diabetes, cardiovascular disease, cancer, depression—have multifactorial causes that, in turn, produce complex pathological pathways. These disorders are neither satisfactorily explained nor easily treated by means of the reductionist cause-effect model that has dominated biomedicine for well over a century and that are mirrored in a pharmacological approach in which single-entity drugs interact with well-defined molecular targets. First explored in the treatment of AIDS but increasingly extended also to other disorders such as hypertension, malaria, arthritis, and cancer, the concept of multi-target drugs or multicomponent therapy has been gaining traction within the biomedical world (Zimmermann, Lehár, and Keith 2007). Simultaneously, it has been demonstrated that a single disease such as breast cancer can manifest with several different types, each responding better to targeted treatment than a disease-based approach (Gallagher 2012). Personalized medicine, defined as a practice that delivers to each patient the treatment that most effectively matches their unique presentation and constitution, has thus become the new holy grail of cutting-edge biomedical research (Hamburg and Collins 2010).
The pursuit of personalized medicine is enabled by developments in biology, in which an entirely new research paradigm called “systems biology” appeared in the late 1990s. Systems biology denotes the attempt to study biological systems as complex totalities rather than building up our understanding of their functions from the bottom up. This has been made possible by the vast amounts of data generated by the genome sequencing projects and other large-scale molecular data-gathering exercises that combine computer modeling with high-throughput “omics” techniques (Auffray et al. 2003). The suffix -omics—as used in terms such as proteonomics, genomics, and transcriptomics—designates a focus on the collective characterization and quantification of networks or systems of biological molecules that translate into the structure, function, and dynamics of an organism rather than on individual molecules linked to each other in cause-effect chains.
Since its institutional inception in 1999 in Tokyo and Seattle, systems biology has become one of the fastest growing—and some would say most hyped—fields of bioscience research, strongly supported by governments in both Asia and the West. This support is made on the promise that systems biology will provide not merely a more accurate understanding of life but better solutions to the complex medical problems that have become the greatest drain on health-care budgets precisely because they are proving resilient to the simplifications of biomedicine's still dominant “magic bullet” approach. Inasmuch as systems biologists, or at least some of them, actively seek to overthrow the “molecularization” practices that tied together biology and medicine during the twentieth century and on which the concept of the “magic bullet” is based (Chadarevian and Kamminga 1998), they take a stance vis-à-vis biomedicine not all too dissimilar to that of modernizers such as Shen Ziyin in the Chinese medical domain.
Personalized medicine by way of polypharmacy, of course, is what Chinese medicine claims to have delivered for centuries already through its use of complex prescriptions (方) (Farquhar 1994: 175–89). This claim establishes potential for cooperation as Chen et al. (2006: 1092) outline to a Western audience in the British Journal of Pharmacology: “The development of systems biology has led to a new design principle for therapeutic intervention strategy, the concept of ‘magic shrapnel’ (rather than the ‘magic bullet’), involving many drugs against multiple targets, administered in a single treatment. TCM offers an extensive source of examples of this concept in which several active ingredients in one prescription are aimed at numerous targets and work together to provide therapeutic benefit.” In his ethnography of genomic research, Sunder Rajan (2006) shows that the development of the contemporary biosciences can be understood only in relation to the economics of late capitalism in which they emerge. Specifically, funding for basic research and drug development is dependent on hype or promissory marketing. That is, in order “to generate value in the present to make a certain kind of future possible, a vision of that future has to be sold, even if it is a vision that will never be realised” (116). In fact, some of the most prominently hyped and funded paradigm shifts in the biosciences in recent years, in particular genomics, are widely seen as having failed to deliver on their promissory notes. In this environment, in which capital flows and the development of the biosciences coconstitute each other, it is not difficult to see why cooperation with Chinese medicine as an already present embodiment of personalized medicine offers advantages that, at least to some systems biologists, warrant the risk of crossing into potentially dangerous “pseudoscientific” territory.
Connections between the two fields are further enabled by structural commonalities and shared ideologies. Modern Chinese medicine prides itself on transcending narrow disciplinary boundaries and combining in its practice influences from the humanities and the natural and social sciences. Systems biology, too, is an intrinsically multidisciplinary endeavor that relies on inputs from biology, chemistry, physics, information technology, and engineering. Beginning in the 1950s, in an effort to delineate their practice more clearly from Western medicine, Chinese physicians turned to the Western philosophical concept of holism. During the 1980s, they mobilized cybernetics and systems theory to demonstrate the scientific nature of their practices (Zhu and Sun 1990). Within Chinese medical circles, these ideas are today widely accepted as self-evident descriptors of what Chinese medicine is and has always been. Many systems biologists, likewise, employ the concept of holism to differentiate themselves from the reductionist molecular biologist they seek to replace, while the very name they chose as a label for their discipline points to its roots in systems theory and cybernetics (Calvert 2011; Calvert and Fujimura 2011). They thereby converge on Chinese medicine not merely by way of shared goals and orientations but also by way of a common genealogy.
Shared interests and practical cooperation do not imply, however, that both sides in this encounter necessarily also share a common agenda. First, neither side should be imagined as a homogeneous group. Systems biology, like Chinese medicine, is a field fractured along multiple dividing lines without, as yet, a commonly shared paradigm (Calvert 2011). In fact, it might be argued that the modern institutionalized form of Chinese medicine, which was purposefully constructed to overcome precisely this heterogeneity (Karchmer 2010), is actually more paradigm oriented—and thus scientific in the Kuhnian sense—than systems biology itself.
On the Chinese medicine side, some proponents of cooperation argue that systems biology will finally validate their tradition scientifically but otherwise leave it untouched or be a partner in the common pursuit of personalized medicine (Li 2007; Sun, Zhang, and Wang 2012; Y. Wang et al. 2012; Zhang et al. 2012). Others, instead, see it as a tool for driving forward a much more radical agenda of modernization and transformation (Pelkonen et al. 2012). Likewise, the interest of some systems biologists in Chinese medicine is clearly predatory. They view it as a resource to be mined in the cause of drug development with no intrinsic value of its own (Wang, Zhang, and Sun 2012; Zhao et al. 2012; Zhou et al. 2007).
Others, instead, describe systems biology as a partner in the development of a shared vision of personalized medicine (Chen et al. 2006; Ma et al. 2010). The writings of some of the leading researchers in the field not only express a deep respect for Asia and Asian medicines (Noble 2006; Wang et al. 2005; van der Greef et al. 2010: 2038) but also actively seek to create a level playing field. Van der Greef et al. (2010: 2038), for instance, advance their argument for convergence by means of a representation (Fig. 1) that “illustrates the Western systems biology view of the body and the Chinese view of the body as a landscape.” Functioning as a neutral reference point, the body-as-landscape analogy here explicitly accords equal epistemic status to both Chinese medicine and systems biology. This is underscored in the text appended to Figure 1, in which Daoist landscapes of qi circulation and metabolomic networks are explicitly equated with each other in both content and form.
On the basis of such shared interests and common goals, systems biologists and Chinese-medicine practitioners and researchers needed to establish a way of working with each other across different paradigms, even if these paradigms have not yet themselves stabilized. One way such cooperation may be organized across different fields of practice is through what Susan Star and James Griesemar (1989: 393) call “boundary objects.” Such objects are “plastic enough to adapt to local needs and constraints of the…parties employing them, yet robust enough to maintain a common identity across sites.” For Chinese-medicine researchers and systems biologists, such boundary objects are constituted, for instance, by herbal medicines and formulas, which can mean different things to different people while their very physical presence provides sufficient stability across disciplinary boundaries to allow for cooperation.
Once researchers working in different fields become interested in the syntax that ties together the meaning of terms or objects within specific practices, they begin to establish “trading zones.” Such trading zones are places where researchers “can hammer out a local coordination, despite [their otherwise] vast global differences” through the creation of local interlanguages (Galison 1997: 793). We must await more detailed ethnographies of the emergent interface between systems biology and Chinese medicine to determine whether it constitutes such a trading zone and, if so, how precisely the hammering out that takes place in it is carried out. What we can say already, however, is that the Chinese medical concept of zheng and its common English-language translations—and by implications biomedical concepts—as “patterns” or “syndromes” will occupy an important focus of any such investigation. For it is around this apparent equivalence that much current interaction is being constructed with all the misunderstandings and reconfiguration of practices this implies.
Creating a Bridge(head)
As we saw above, the potential for zheng to act as a bridge connecting Chinese medicine and systems biology was recognized early on by Shen Ziyin (2005), whose paper outlined a cooperative research agenda that has not fundamentally been altered since. Lü Aiping, whom we met earlier as a presenter at the Bologna conference, notes in a recent overview that carries the title “Bridging the Traditional Chinese Medicine Pattern Classification and Biomedical Disease Diagnosis with Systems Biology,” “Being the unique core of traditional Chinese medicine (TCM), pattern classification exerts a direct effect on the efficacy and safety of herbal interventions.…Integration of pattern classification with biomedical diagnosis by systems biology is not only a new direction of personalised medicine development, but also provides a new drug development model” (Lu, Bian, and Chen 2012: 883). Employing terms more readily understood by bioscientists, a group of researchers led by Jan van der Greef in the Netherlands makes the same argument in a review paper with the very similar title, “Systems Biology-Based Diagnostic Principles as Pillars of the Bridge between Chinese and Western Medicine”: “The systems approach to medicine that is now developing in the West has the potential to integrate with Chinese medicine. In particular, the systems biology approach of patient profiling using modern genomics, proteomics, and metabolomics technologies is a perfect match for the systems diagnosis in Chinese medicine” (van der Greef et al. 2010: 2038).
The claim made in both papers and repeated in similar terms again and again throughout the literature can be summed up as follows. Chinese medicine administers treatment based on zheng rather than biomedical diseases. Zheng are well-defined groups of symptoms and signs—hence the English translation of the term as pattern or syndrome—that are more or less systematically matched in the literature as well as in clinical practice with corresponding treatments, such as herbal medicine formulas or acupuncture point prescriptions. The same biomedical disease can manifest with a number of different Chinese medical zheng, while the same zheng may be present in a number of different biomedical disorders. In the language of systems science, it is possible to imagine zheng as constituting discrete system or network states. Chinese medicine reads these system states off their phenotypical presentation by grouping symptoms and signs into distinctive patterns.
Systems biology is similarly interested in determining and rectifying abnormal system states. It thus shares with Chinese medicine the same object of intervention. However, unlike Chinese medicine, its ability to define these states is grounded not merely in “two thousand years of experience” and difficult-to-comprehend classical writings but in the apparently objective realities of biology. Specifically, it seeks to match abnormal system states to emergent networks (or patterns) within the totality of a person's metabolic fingerprint, gene expression, or set of proteins analyzed via various types of “omics” technologies.
A study carried out collaboratively by Lu's and van der Greef's research groups in China and the Netherlands elucidates where their shared focus on zheng and patterns may lead (van Wietmarschen et al. 2009; van Wietmarschen et al. 2012). In this study, patients suffering from rheumatoid arthritis (RA) were divided into “RA Heat” and “RA Cold” groups on the basis of Chinese-medicine pattern typing. Blood samples taken from these patients showed statistically relevant different gene expression and metabolite profiles between healthy controls and RA patients as well as between the RA Heat and RA Cold groups. This allows the researchers to suggest that “subgrouping of patients according to Chinese medicine diagnosis has the potential to provide opportunities for better treatment outcomes by targeting western or Chinese medicine treatment to specific groups of patients” (van Wietmarschen et al. 2009: 330).
The advantage to Chinese medicine arising from such research is obvious and clearly stated as such by all participants. Employing various types of omics technologies, systems biology “has allowed for an additional bridge between the ‘seen and the unseen’” capable of objectifying zheng in a manner that still eluded Shen Ziyin in the 1950s and 1960s (van der Greef et al. 2010: 2041). To understand why this is so important to Chinese-medicine researchers and practitioners such as Shen and Lu, it is important to understand that zheng are widely accepted in China as constituting the distinguishing characteristic of Chinese medicine. As a popular saying goes, “Chinese medicine differentiates zheng, Western medicine diagnoses diseases” (zhongyi bianzheng, xiyi bianbing 中醫辨證，西醫辨病). Hence in contemporary China, teaching, clinical practice, and research, at least within the state sector, are all built around zheng. Anchoring zheng not only in canonical texts and two thousand years of clinical experience but also in actual biological facts would in one fell swoop legitimize Chinese medicine “scientifically” and silence its modernist critics.
For systems biology, the focus on zheng appears equally advantageous. Systems biologists are sometimes criticized by their own peers within the biosciences for carrying out large-scale data-mining operations rather than undertaking proper scientific, hypothesis-driven research. (Dis)confirming the reality of zheng, viewed as hypothetical propositions awaiting biological confirmation, circumvents this criticism. Even more importantly, it holds out the promise of reverse-engineered, patentable biomedical drugs from the nonproprietary Chinese-medicine herbal formulas currently used to treat specific zheng. Constituting zheng biologically through omics-type research is a logical first step in this process.
However, no clinicians I have ever observed or studied, no Chinese medical textbooks, and not even the simplifications of state-driven standardization practices presently attempt to reduce the complex manifestations of rheumatoid arthritis to merely two hot- and cold-type zheng. Even less would clinicians treat them with just two formulas. Thus a recent overview of the treatment of RA by Chinese medicine lists thirty-one experts who use sometimes vastly different approaches, even if all of them are intelligible through the paradigm of zheng differentiation (Tao 2002: 3–69). In other words, rather than constituting the “unique core of traditional Chinese medicine,” the zheng that currently center Chinese-medicine-meets-systems-biology research appear to emerge in the process of that research itself. Inasmuch as they are only revealed to biologists if biology itself is filtered through the mask of Chinese medicine, they cannot be said to be simply present to us in nature. Nor are zheng present within Chinese medicine as they were before they encountered systems biology. Rather, they read back the body of systems biology into a newly constituted practice of Chinese medicine—if we accept that Chinese medicine is defined by its treatment of zheng. In this new systems biology, Chinese-medicine zheng are interpreted via notions such as the “neuro-endocrine-immune network” (Li 2007) even as they also retain their hot/cold and yin/yang characteristics (Ma et al. 2010).
These newly articulated zheng-as-biological-patterns are therefore not boundary objects exchanged between different groups of researchers. Rather, they are phenomena—in Karen Barad's (2006) sense of the term—created within an entirely new type of disciplinary practice. And again, while the performativity of this articulation awaits more detailed examination, these new zheng are already revealed as emergent objects that possess a degree of plasticity not generally acknowledged by those engaged in their contemporary remolding. Even more importantly, this emergence is indebted to a previous series of conceptual, practical, and institutional transformations that turned zheng from a clinically useful concept into the single most important cornerstone of contemporary Chinese medicine.
Paradigms and Simplifications
Historians and anthropologists in China and the West have documented the history of these transformations in great detail (Andrews 1996; Hsu 1999; Karchmer 2010; Scheid 2002; Taylor 2004). They show that the status of zheng as “the unique core of traditional Chinese medicine” is not a self-evident truth as claimed by Shen Ziyin, Lü Anping, and many others who seek to define traditional medicine and culture in essentialist terms. Rather, it emerged gradually over the course of the twentieth century as the consequence of the struggle by Chinese physicians to demarcate themselves from Western biomedicine within contexts of practice that were increasingly hegemonized by scientism and modernity.
During the first phase of this struggle, lasting roughly from 1895 to 1929, Chinese physicians pursued a strategy that sought to define Chinese and Western medicine as categorically different though sometimes complementary to each other. If Western medicine provided more accurate and detailed descriptions of the body's anatomy, Chinese medicine was superior at understanding the processes of change and transformation that kept it alive and linked it to the universe. Yun Tieqiao, one of the main protagonists in these debates, arrived at the most extreme formulation of this position when he claimed that the organs of Chinese medicine did not refer to “the body of flesh and blood” but were merely—or above all—concepts aimed at capturing the transformative processes that animate the cosmos (Yun 1922: 21).
Yun's proposition succeeded, at least for a time, in liberating the Chinese medical body from pressures that demanded it squeeze itself into the corset of biomedical anatomy. It endures to the present day in the often-repeated opposition between a holistic Chinese medical body of process and a reductionist Western anatomical body, an opposition that became even more acceptable once it was wedded to Thomas Kuhn's notion of incommensurability in the 1960s. It also paved the way for the first wave of systems science that swept through Chinese medicine in the 1980s by allowing researchers to “black-box” any problematic (in biomedical terms) element of Chinese medicine and focus, instead, on these elements as descriptions of systems (Zhu and Sun 1990).
After 1929, when Chinese physicians decided to move their medicine into the domain of the state in order to gain for it equality before the law, a new strategy was needed (Lei 1998). Instead of insisting on radical difference, they now required a method for protecting the autonomy of Chinese medicine even as it had accommodated itself to a health-care system organized by the state on biomedical terms. During the early 1930s, this struggle for autonomy centered on the question of whether Chinese medicine should keep its own disease names or, as suggested by the newly established Institute of National Medicine (Guoyiguan 國醫官), replace them entirely with biomedical disease names.
The background to this debate was the widely held assumption among modernizers of all kinds at the time that a key aspect of science's power lay in its ability to order the world by establishing coherent, universally valid systems of classification. While Western medical practice seemed to be based on such a system, Chinese medicine was fractured into different currents of thought that employed different and often mutually exclusive nosologies. The famous cultural critic Liang Shuming 梁漱溟 (1893–1988) famously mocked the lack of “objective standards” in Chinese medicine by stating, “Treating illness [under such conditions], how could ten different people not arrive at ten different treatments” (Liang  1989: 1354–55). China's one-time minister of education Fan Jingsheng 范靜生 (1874–1927) made a similar point to the physician Ye Guhong 葉古紅 (1876– ca. 1940s): “If I were so unfortunate to be infected with a disease and die in the care of western medicine, at least I would know the name of the disease that had caused my death. If I died in the care of your colleagues of Chinese medicine, ten doctors would have ten different opinions. I would not be able to know for sure the name of the disease [that had caused my death]. This amounts to being killed by stupidity” (Ye 1930: 1).
Advocates of medical reform such as Yun Tieqiao's student Lu Yuanlei, who was a leading figure in the Institute of National Medicine, argued that abandoning Chinese medical disease names would greatly promote its development as a science. The proposal met with stiff resistance from the majority of Chinese-medicine practitioners, however, who feared it threatened their very identity and would severely reduce the effectiveness of clinical practice. As a result, it was quickly abandoned, and Lu was forced to resign his position at the institute. Yet, it was in the course of these debates that the nowadays stereotypical association between Chinese medicine's focus on zheng and Western medicine's treatment of disease was formed (Karchmer 2010).
Yang Zemin 楊澤民, one of the first Chinese physicians influenced by Marxist dialectics, proposed that Western medicine focus on the classification of disease even if it also recognized zheng, while Chinese medicine primarily concentrated on treating zheng even if it also knew of the existence of disease (Dong and Chen 1981). This definition of zheng and disease as something common to both Chinese and Western medicine, by a scholar who had a foot in both yin/yang thinking and European dialectics, established the possibility of a shared lexicon between the two domains and in doing so marked out the outlines of a possible trading zone. Accepting the power differentials between the two traditions, in which Chinese medicine was willing to yield to biomedical concepts and practices but not vice versa, Yang's definition of zheng as something shared between the two traditions suggests a reading of the term as either syndrome (zonghezheng 綜合症/證) or symptoms (zheng or zhengzhuang 症/證壯). Although in contemporary Chinese these terms are distinguished from each other by the use of different ideograms (證/証 vs. 症), this separation was not as stringently established in the 1930s and is itself a consequence of the struggles described here (Li 1995). Furthermore, this reading of zheng was not shared by all Chinese physicians at the time. Lu, for instance, agreed with Yang that Chinese medical practice could be rooted in zheng, but he defined zheng to be radically different from biomedical symptoms.
Following the establishment of the PRC in 1949 and the gradual establishment of a plural health-care system, the practical (rather than legal) problematics of integration took on a new dimension. As Chinese-medicine physicians were recruited into the delivering of public health campaigns and began working in hospitals and cooperative clinics rather than private practices while their patients became increasingly fluent in understanding their bodies and disease through the lenses of Western medicine, biomedical disease nosologies increasingly worked their way into daily practice, demanding some form of integration. In these new contexts of practice, Yang's dialectical scheme quickly became axiomatic. After all, it did not demand of Chinese medicine to abandon its “own” diseases altogether. It merely stopped making them essential (Karchmer 2010). For as long as a physician knew how to diagnose and treat a zheng such as “Kidney yang deficiency,” it mattered little whether he was treating the kidney yang deficiency of a patient suffering from renal failure or from a lesser yin disorder (shaoyinbing 少陰病).
From the early 1960s onward, regulators thus began to institutionalize Yang's disease/zheng dialectic as a fundamental principle of Chinese medical practice (Scheid 2002). The primary instrument through which this was achieved was a series of national textbooks for the teaching of Chinese medicine in state-run institutions. These textbooks now located in the diagnosis and treatment of zheng the true core of Chinese medicine, when fewer than thirty years earlier, such an idea had seemed anathema to a majority of the profession (Karchmer 2010; Taylor 2004). Yet, in a manner that was not imagined by Yang Zemin, in doing so they fundamentally redefined the nature of zheng themselves.
First, by compiling the first comprehensive list of zheng and their associated symptoms and signs, textbook authors narrowed the possibility of their existence even as they affirmed their very right to exist. Previously, it had been possible for any physician to create a zheng simply by diagnosing it. Diagnosing particular zheng and the diagnostic technologies required for doing so could express affiliation with distinctive medical lineages. Now, only those zheng included in the textbooks could be said to officially exist. Over time, this process was pushed ever further, culminating in the mid-1990s in the compilation of national standards for the diagnosis and treatment of zheng. It is a current goal of the State Administration of Chinese Medicine to create international standards comparable to that of diseases by the International Classification of Diseases (ICD), thereby limiting even further previously existing possibilities for defining Chinese medicine in practice (Scheid 2002).
National standards and Chinese medical textbooks thus considerably simplified the complexity of a previously heterogeneous and divided field of practice. This led to zheng's increasingly coming to resemble lists of symptoms and signs that had an existence independent of the diagnostic practice through which they were revealed. That is, they became something akin to biomedical syndromes. One of the consequences was that techniques such as pulse diagnosis previously considered essential in order to diagnose a given zheng could be considered optional. Hence, in clinical research zheng are sometimes diagnosed today by questionnaires alone.
Second, as previously existing connections between Chinese medical diseases and zheng were loosened, zheng increasingly became the primary objects of treatment itself. That is, rather than pointing to a deeper pathodynamic (bingji 病機) that needed to be understood in relation to the manifestations it produced, signifier and signified fused into the same object. Although this reading of zheng continues to embody an alternative understanding of disease that stands in tension with the standard disease nosology of biomedicine, it nevertheless deprives Chinese medicine of explanatory power. For as some critics correctly point out, it was precisely this disconnection of an entirely zheng-based practice from theory that contributed to the vanquishing of traditional medicine in Japan, where it was outlawed in the course of the country's Western-style modernization of the late nineteenth century (Sugiyama 2004).
Third, by organizing clinical textbooks around diseases subdivided into a number of zheng, the authors of the second edition of national textbooks produced in the early 1960s created a model that has since come to dominate official and semiofficial Chinese medical discourse at home and abroad. Once biomedical diseases are substituted for Chinese medical ones, zheng begin to take on the nature of mere “disease types” (bingxing 病型). Or they are defined as simply constituting different stages of a given disease (Li 1995). No longer referring to the Chinese body in any meaningful way, such types or stages simply represent a mode of organizing biomedical disorders into variants. Critics argue that such typing no longer reflects any of the temporal characteristics of zheng as manifesting the coming-into-being of an illness at a particular moment in space/time that is the foundation of any truly personalized medicine. Nevertheless, today all Chinese-medicine practitioners learn to associate specific biomedical diseases with a small number of Chinese medical zheng. At least during the early stages of their careers, they often begin diagnosis from this starting point and many never lose the habit.
Genealogy II: Six Nodes in the Transformation of Medical Practice in China and Japan Enacted through Zheng
The First Node
In 1076, in the course of a series of sweeping reforms aimed at promoting the efficacy of state bureaucracy and its ability to serve the needs of the people, the Song court established the Imperial Pharmacy Service. The service bought medicines, processed them into pills, powders, and pastes, and sold them at below-market price to the public. During times of epidemic it even distributed them for free through its own pharmacies. These pharmacies were initially established in the capital, but at the height of its influence in 1151, the pharmacy service operated seventy outlets in all major prefectures. Between 1078 and 1252, the pharmacy service also compiled and distributed a series of official formularies. These formularies listed around three hundred prescriptions that had been collected from skilled physicians and after evaluation by members of the pharmacy service judged to be effective. The formularies served as the basis for the preparation of the prescriptions manufactured and sold by the pharmacy service, but they were also distributed more widely in order to “benefit the people [with their] illnesses” as the “Treatise on Bureaucracy” of the official Song History (Songshi: Zhi gong zhi 宋史·职官志) would state later (Toqto'a et al. 1346).
To this end, the formularies were organized initially into five and, later, in the revised edition, ten chapters. Chapters might be devoted to one or more specific medical disorders, such as “cold damage” or “phlegm drool,” but they could also list formulas according to medical specialities such as eye disorders or women's and children's disorders. Each formula entry stated the indications before listing the ingredients, followed by the method of preparation. For instance, the entry on the formula Separate the Heart Qi Drink (Fen xinqi yin 分心氣飲) in chapter 3 of the Formulary of the Pharmacy Service for Benefitting the People in an Era of Great Peace (Taiping huimin heji jufang 太平惠民和劑局方) reads,
Treats any disharmony of qi in both men and women. These often arise from grief, sorrow, worry, or anger qi damaging the spirits; or from worrying while eating; or from affairs not proceeding as planned. These lead the constrained qi to accumulate without dispersing so that it tarries in between the diaphragm so that its [movement] is not smooth. This leads to focal distension and oppression in the Heart and chest, deficiency distension in the flanks, choking with obstructed passage, belching and sour reflux, vomiting and nausea, dizziness and blurred vision, fatigue in the four extremities, a wan yellow complexion, bitter taste and dry tongue, reduced intake of food and drink and gradual emaciation; or deficiency constipation in the Large Intestine; or deficiency focal distension of the diaphragm in the aftermath of an illness with no desire for food and drink. It treats any combination of these. (Chen et al.  2001: 110)
Under another formula of the same name listed a few pages farther down we learn, “It treats the same zheng as the previously listed Separate the Heart Qi Drink” (Chen et al.  2001: 123). It follows that the indication for a prescription at the time was not what we would nowadays think of as a disease but a distinctive combination of symptoms and signs referred to as zheng. This term is commonly translated into English as syndrome, pattern, or type, and many modern Chinese physicians do, indeed, think of it as such. However, inasmuch as zheng only acquired these meanings in the course of the twentieth century, we need to be careful of ascribing them to Song Dynasty medical practice.
Thus in the first ever Encyclopaedic Dictionary of Chinese Medicine (Zhongguo yixue dacidian 中國醫學⼤大辭典) published in 1921, the Shanghai-based scholar-physician Xie Guan 謝觀 (1880–1950) defined zheng as “the external expression of an internal illness.…It testifies to the illness of the internal organs and guides therapy” (Xie 1988 : 4487). In its reference to organ malfunctions, a reference that is entirely absent in many of the zheng described in the pharmacy's Formulary, Xie's definition reflects Republican-era politics. For organs, present in both Chinese and Western medicine, provided a space for marking out commonality and difference that a definition of zheng as the external manifestation of a disordered “qi dynamic,” which would have been more in line with the Formulary but unintelligible to biomedicine, lacked. Yet, in its emphasis on explicating a relationship between exterior and interior, Xie's definition does maintain a link not only to the usage of the term in the history of Chinese medicine but also to the etymological origins of the term zheng as the verification of phenomena by means of words.
The literary critic Stephen Owen argues that the entire history of Chinese literary thought begins with the problem of recognizing what something truly is in particular instances rather than, as say in Plato, with a search for abstract ideals to which instances might be compared. That “inner” nature manifests in “outer” phenomena was therefore invariably accepted as given. What distinguishes those who know from those who do not is their ability to correctly identify within the shifting complexity of external manifestations “that from which it comes” by means of a particular attention. Yet, even those who know still face the problem of capturing such relationships in spoken language (言) and even more so within the scope of a literature (文) that aims to endure over time and to reach across different contexts of practice.
The Song literati culture in which the pharmacy service's Formularies were produced was characterized by a belief that it was both possible and necessary to produce such literature; or, to put it another way, that a transparent relationship between words and things was attainable. There existed, furthermore, a widening of intellectual interests that went beyond the “classics” in order to place such knowledge on a sound intellectual footing. Wang Anshi 王安石 (1021–86), one of the leading reformers of the time, for instance, wrote, “If one were only to read the Classics, it would not be enough to know the Classics. I thus read everything, from the hundred schools and various masters to [such medical texts] as the Classic of Difficulties and the Basic Questions, the pharmacopeia and various minor theories, and I inquire of everyone down to the farmer and the craftswoman” (cited in Bol 1992: 228). Wang Anshi and Song thinkers like him sought such knowledge not merely for its own sake but to order affairs of the state for the purpose of “benefitting the people.” The work of the Pharmacy Service demonstrates that these aspirations did not exhaust themselves in empty words. However, the Song state equally and purposefully employed the medicine it created as a tool of governance. Thus it set out to standardize and supervise medical practice and to displace local customs in areas into which it was expanding through the strategic imposition of imperially sanctioned forms of health care.
The Formularies' articulation between illness and therapy mediated by zheng was an exemplary product of these efforts that succeeded in aligning all of these various inputs and demands into a workable practice. It is predicated, first of all, on the elite's belief that words are able to capture and communicate the coherence of phenomena across different contexts of practice. It assumes that external manifestations, if read in the correct way, match internal disease states on the one hand and effective prescriptions on the other. It constitutes a manual for organizing and, if necessary, changing local practice. To this end it downgrades in the description of zheng aspects of medical practice such as pulse taking that are more closely embodied, more difficult to put into words, and more resistant to being moved across different contexts of practice in favor of straightforward symptom lists. Yet, inasmuch as these lists continue to include specialist terms such as deficiency distension or Lung deficiency, they remain tied to a distinctive cultural discourse and heritage. This discourse transcended that of a narrow professional elite, but it was distinctive, nevertheless, in its framing of medical problems as bodily zheng rather than as spirit possession or ghost affliction.
The Second Node
Not surprisingly, resistance to this articulation of medical practice arose both from the so-called shamanic healers (巫) that imperial medicine sought to displace and from elite physicians. These physicians shared the Formularies' focus on zheng but were cut out of the medical market by the pharmacy services' attempt to detach health-care delivery from specialist expertise. If the former simply continued to do what they had always done, the latter challenged the imperial vision of health care on the terrain of elite discourse by redefining the very terms that structured medical practice. Thus when in 1347 the Yuan Dynasty physician Zhu Danxi 朱丹溪 (1281–1358) composed a critique of the imperial pharmacy titled Elaborations on the Pharmacy's Formulary (Jufang fahui 局方發揮), he focused on its deployment of zheng in the very first sentence of his argument:
The Formulary of the Pharmacy is a book by means of which one can look up prescriptions on the basis of zheng [ju zheng jian fang 據證檢方]. Even though one takes medicines in the form of prescriptions, there is no need to consult a physician who would adjust [the prescription] or [modify the ingredients] through [different modes] of preparation. All one has to do is pay for the selected pill or powder and all disease and pain can be alleviated and cured. The intention of benefiting the people can thereby said to have been realized. From the Song dynasty to the present day, court and local officials abided by [the Formulary] as a method [of governance]. Physicians transmitted it as [the foundation] of their trade. The sick depended on it as the foundation of their life. Everyone studied it and thereby turned its [form of medicine] into a social custom. Only my humble self has suspicions [as to its usefulness]. Why should that be? (Zhu 1993b : 31)
Zhu was not the first to advance such a critique. However, more than anyone else, he was able to synthesize the disparate styles of practice of the newly emergent scholar-physicians (ruyi 儒醫) into a single-person-centered medicine. He furthermore succeeded in aligning this practice with core tenets of Neo-Confucianism and thereby with the culture of the southern elite to which he addressed himself. With the fall of the Northern Song in 1127 and the move of the capital to Hangzhou, the cultural center of China had shifted south. The Yangzi River delta in particular, a region commonly referred to as Jiangnan 江南, became the commercial and intellectual hub of the country, whose physicians likewise came to dominate the production of medical knowledge until well into the twentieth century. This southward shift of economic and cultural power was accompanied by important social transformations. Under the Northern Song, elite career strategies were oriented entirely toward the central government and office holding. This gradually changed over the course of the Southern Song as an ever-increasing pool of candidates competed for the same number of positions. Following the Mongolian conquest and the fall of the Southern Song in 1279, official office became even more difficult to obtain for Han Chinese. With vertical strategies for social advancement closed off, the elite increasingly oriented toward their locale to become what modern scholars refer to as the “local gentry.” Occupations such as medicine emerged as possible alternatives to an official career for members of this gentry elite, allowing scholars to engage in intellectual activities even as they earned a living and benefitted the common good. Intellectually, this elite was attracted to and, in turn, transformed by broad renaissance-like intellectual currents, whose proponents emphasized the possibility of direct personal access to the coherences underpinning the operations of the world and thereby to the principles that should guide ethical behavior and living.
A member of this southern elite, a disciple in the direct line of the leading Neo-Confucian intellectual Zhu Xi 朱熹 (1130–1200), and a scholar who had turned physician only in his mid-thirties, Zhu Danxi embodied all these trends in his own person. As a southerner, he looked for a style of medicine that matched the needs of his elite gentry clientele, for whom he found the acrid warming prescriptions of the Formulary too harsh. As a Neo-Confucian scholar, he required a model of medical practice that honored its literary heritage without being weighed down by it. As a working physician, he needed to convince others that his skills rather than medicines alone guaranteed clinical results. As a Confucian gentleman, his medical practice had to be driven by benevolence rather than profit. Zhu laid out a solution that met all these demands by answering the rhetorical question with which he had concluded the introductory paragraph of his Elaborations:
The ancients [divided physicians into] spirits, sages, workers, and technicians when discussing medicine. They also said that [the practice] of medicine [depends on] conception [yi 意]. For even if they possess [skills] imparted through transmission as well as profound scholarly attainment, they still need to adapt these strategically to changing circumstance. This is comparable to the skills of a general who faces the enemy, or those of a captain at sea. Certainly, unless one strives to the utmost [to embody] a gentleman's subtle [skill] to at times go against the norm, does one not fail to live up to being a physician? He thus cannot simply take formulas used by previous generations because they were effective and apply them to the treatment of the diverse illnesses of today's people. That would be [as stupid as the man from Chu] who tried to remember the place in the river where he had lost his sword by cutting a mark into the side of his boat, or the son of Bo Le, who when searching for a horse relied solely on drawings and thereby mixed up a toad with a horse. That someone should attain their goal in this way surely will be accidental. (Zhu 1993b : 31)
Stripped to its essence, what Zhu proposed was to substitute the government's policy of benefitting the people through centrally organized health-care policies with a style of medical practice that roots the same ethical objectives in the agency of individual scholar-physicians. Precisely for this reason, Zhu argues, it produces superior clinical outcomes. Hyping potential gains, Zhu's vision convinced others to invest the effort it took to become a scholar-physician and thus came to dominate elite medical practice in China for the next five hundred years.
The Second Node Developed
In post-Song scholarly medicine as conceived by Zhu Danxi, zheng no longer speak or even exist by themselves. Of course, disease still manifested externally in various symptoms and signs. In fact, from the late sixteenth century onward, a new character, 症, pronounced in the same way as zheng, came into usage to denote specifically these external manifestations of illness (Li 1995). In literati medical discourse, the older zheng continued to be used but with a meaning that reflected the changed orientations of scholarly medical practice. Instead of standardized symptom lists as in the Formulary, the term now denoted constellations of meaningful but heterogeneous bits of information filtered out of the noise of surface signs by the practicing physician. Besides bodily symptoms reported by the patient and signs revealed through pulse diagnosis or visual inspection, this might include information about a person's age or constitution, their place of residence, dietary habits, or anything else that pointed to the pathodynamic or internal root (ben 本) of any given disorder (Volkmar 2007). A zheng as noted down in a scholar-physician's case record might thus consist solely of a pulse reading, or it might involve a longer narrative that traced the development of an illness in more detail.
These zheng as constellations were meant to capture the specificity of a unique illness episode. As such they became meaningful only within the signifying practices of individual heart/minds (心). This practice was built on the premise, initially developed from Neo-Confucian philosophies but subsequently intermingled with Chan Buddhist and Daoist ideas, that the properly cultivated heart/mind has the capacity of penetrating to the “coherence” (li 理) beyond the sensory world of phenomena. A broad-based familiarity with things, principles, and methods formed the foundation, but the goal was always the realization of knowledge in the context of concrete practice. Successful clinical practice was thus built on a succession of insights (yu 悟) rather than the knowledge of facts or the possession of techniques. As a recurring trope in scholarly medical discourse put it, only the capacity of flexibly adapting lifeless methods to the exigencies of continually emergent situations turned them into productive medicine that was truly alive and therefore effective.
Remembering his own apprenticeship, Zhu Danxi recounts how in over eighteen months of training his teacher Luo Zhiyi 羅志義 never wrote out the same prescription more than once. Instead, he modified the formulas and strategies he had memorized to match more precisely with what his patients presented (Zhu 1993a : 28–29). Five hundred years later, Fei Boxiong 費伯雄 (1800–1879), the most famous Jiangnan physician of his time, reiterated the continued validity of this approach, including the metaphors that underpinned it:
Skillful action relies on customary rules [of practice]. Reality, however, is never constrained by such rules. [The famous general] Yue Zhongwu did not bother too much with mapping out the deployment of troops in great detail. He reasoned that the deployment of troops [in given formations] prior to going into battle is standard practice. The ingenuous use [of these forces in battle], instead, is grounded entirely in our heart/mind. Above all, [he was convinced] that the most important [element of success is the ability] to react flexibly to events as they unfold [on the battle field]. How excellent these words are! In using ancient formulas I, too, favor this [strategy]. (Fei 1985 ): 10)
Both Zhu Danxi and Fei Boxiong referred to the specific faculty of the heart/mind that made it possible to turn dead models into living effective practice as yi 意. Yì, like zheng, is a concept with multiple meanings that preclude translation by means of a single English term. In Chinese literary thought, yi frequently denotes the conceptions of things through which the heart/mind grasps the external world. These conceptions, in turn, become the source of literary or poetic expression. Yì, therefore, is an awareness located both before and beyond words. The poet Mei Yaochen, for instance, defined yi as something vague and indeterminate that through its very haziness guaranteed authenticity. For “when a writer has attained it in his own heart/mind, the reader will comprehend it through yi,” precisely because the meanings in the images conveyed through poetry and language “appear beyond the words” (Owen 1992, 376–78). Similarly, for the Song statesman and philosopher Wang Anshi, yi denoted the conceptions one makes out in the work of the sages on which one models the formulation of concrete policies.
That “medicine is yi” (yi zhe yi ye 醫者意也) because effective practice resides in the embodied subjectivity of the practicing physician had first been asserted by the imperial physician Guo Yu 郭玉 (fl. 89–105). Reemphasized by Zhu Danxi, it became the slogan and guiding principle for scholar-physicians in late imperial China. The Ming Dynasty physician Wan Quan 完全 (1500–1585), for instance, employed yi as a method for understanding and responding to not only the nature but also the meaning of an illness (Volkmar 2007). A little later, the influential scholar-physician Yu Jiayan 喻嘉言 (1585–1664) recounted how he had dedicated his life as a physician to understand illness by way of yi. Yu emphasized that this pursuit might necessitate moving toward a state in which he would actively seek to embody his patients' illness (Yu 1999 : 371). Nor was he averse to administering unorthodox treatment if he believed this was required in order to produce a cure (Dai 2001). The mediating capacities of yi as necessary link between focused perception and effective action thus not merely rested on cognition but extended to bodily practices, ethical orientations, and an aesthetics that perceived a lack of detail, the indeterminate, and that which can be experienced but not put into words not as a hindrance but as essential to the production of effective medical practice.
The Third Node
Cultivated by scholar-physicians from Zhu Danxi to Fei Boxiong, yi thus provided the embodied foundation of a truly personalized medicine: “If [a physician] is brilliant in his considerations and perfect in his skills, he will adapt his [treatment] to the [individual] circumstances [of each illness]. And, since the circumstance of an illness may vary one thousandfold, he will establish ten thousand different [therapeutic] patterns” (Xu 1999 : 171–72).
The problem, as Xu Dachun 徐大椿 (1693–1771) never failed to remind his readers, was that most physicians lacked the necessary ability and skills to realize these lofty ideals. In Xu's opinion, this was made worse by the virtual absence of rules and regulations in the medical market, which from the fourteenth century onward had become a virtual free-for-all. This economic context amplified a danger, ever present in a medicine grounded in personal insight, for displays of virtuosity and individual difference to be driven by the search for fame and reputation rather than the authenticity of practice described by Zhu Danxi, Wan Quan, and Yu Chang. From the late sixteenth century onward, an increasing number of physicians thus became ever more suspicious of the emphasis on subjectivity that characterized post-Song medicine. They argued that a return to the classical sources of tradition provided the appropriate antidote.
This movement became particularly powerful in Japan among a group of physicians known today as the “ancient-formula current” (古方派). The most influential of these ancient-formula physicians was Yoshimasu Tōdō 吉益東洞 (1702–73) from Kyoto, who squarely put the blame for the degeneration of post-Song medical practice on its emphasis on yi:
Once the notion that medicine is about yi had emerged, it became over time a deceptive strategy and finally an excuse [for bad practice]. In my opinion, if progress on the path of medicine depends only on yi, then why does one first need to study books in order to learn one's trade but later rely on [yi]? How truly absurd and ridiculous. How could this be called a path [of learning]? [Is it not rather the other way around], namely that proceeding from established strategies on the path of medicine prevents one from going astray? Clearly that is how it is. (Yoshimasu 2009 : 11)
To avoid yi getting in the way, Yoshimasu proposed a purely empirical style of medical practice that “viewed the identification of zheng as treating the root [of the disorder 見證為治本] without seeking to establish its cause” (Yoshimasu 2009 : 16–17). That is, instead of seeking to identify hidden pathodynamic processes or speculating as to why a specific illness occurred in this person, the goal of medicine should once more be to select effective medicines on the basis of corresponding clinical presentations. This required a redefinition not only of core precepts of post-Song medical practice but also of its physician/patient relationships.
To this end, Yoshimasu reduced all disease to a single process, namely, the presence of toxin within the body. The physician's task was to determine the location of this toxin and to expel it from the body. This would cure the disease and preclude the need for any further contact between patients and physician. Clearly, this is a very different conception of illness and the physician's role in it than that of scholar-physicians such as Yu Chang, who aimed to become one with their patients, or Fei Boxiong, who was famous for mild treatment of patients with deficiency disorders that could stretch over many months. Yoshimasu explicitly denounced the frequent patient visits and repeated modifications of formulas this style of treatment usually involved and argued for changing the social relationships between physicians and patients that underpinned it.
In post-Song China, these relationships had fundamentally changed with the widespread movement of literati into medical practice. As members of the gentry elite, these new scholar-physicians moved in the same social circles as their patients and naturally shared with them the frequent preoccupations with physical fragility and weakness that developed specifically among the Jiangnan gentry. Such social proximity coupled to the nature of the medical market in late imperial China is one of the reasons why the critiques of post-Song medicine in Jiangnan itself never reached the traction they did in Japan. There, the changing social and intellectual conditions during the Edo period, in which physicians were not generally members of the elite, coupled to an earlier influence of new ideas about the body imported from the West, allowed for the far more radical challenges to medical orthodoxy advocated by the ancient-formula current.
Intellectually, however, Yoshimasu was very much indebted to Chinese critics of post-Song medicine such as Xu Dachun and Ke Qin 柯琴 (1662–1735). These authors had argued that the works of the Han Dynasty physician Zhang Zhongjing 張仲景, widely regarded as the ancestor of prescription-based medicine, provided the clearest and most reliable foundations for effective medical practice. Ke Qin, specifically, had argued that the key to understanding these texts was to study the manner in which they related specific zheng to specific prescriptions. Yoshimasu, following Ke Qin's lead, developed sophisticated philological techniques to tease out these correspondences, which he then sought to confirm empirically within his own practice (Yu 2001a, 2001b).
On one level, this matching of prescriptions with zheng simply returned post-Song scholarly medicine to its status quo ante, as realized in the imperial pharmacy's Formulary. We may recall that this text, too, listed prescriptions under their matching zheng and that the effectiveness of the formulas used was vouched for by the pharmacy's physicians who had examined them. There are, however, equally important differences. If the Formulary's zheng were essentially lists of symptoms and signs intelligible to the educated layperson, Zhang's zheng are altogether different things, as explained at length by the Shanghai physician Lu Yuanlei one of the leading reformers of Chinese medicine in China during the republican era:
What are [these things] called zheng? Zheng are manifestations [zhenghou 證候]. They also constitute criteria for using medicinals. The various items in the Treatise on Cold Damage and the Essentials from the Golden Casket [i.e., the texts of Zhang] such as heat effusion, aversion to cold, stretched stiff nape and back, stiffness of the neck and nape, fullness in the chest and rib-side, vexation and agitation, vexation and thirst, distress below the heart, distress below the umbilicus, hard glomus below the heart, glomus below the heart that is soft when pressed, sweating, lack of sweating, hard stools, shifting fecal qi, clear food diarrhea, and so on, these all are manifestations. All of these manifestations cannot be entirely comprehended by studying the text. They require explanation by a teacher, or precise and clear annotations. This is what I previously referred to as the correct method for reading the Treatise on Cold Damage and the Essentials from the Golden Casket. (Lu 2010: 1439)
Lu's thinking owed much to the ancient-formula current and in particular the works of Yoshimasu. These ideas had crossed into Jiangnan when, in the wake of the first Sino-Japanese War of 1895, Japan became the guiding light for Chinese modernizers across a wide variety of domains. Lu was attracted to Yoshimasu's empiricism as a strategy for claiming for Chinese medicine the same scientific status accorded to Western medicine, a powerful new entrant into the medical marketplace with which it was now competing in a struggle for its very survival. In Lu's eyes, this struggle required of Chinese medicine to align itself with the epistemological orientations and institutional arrangements of China's modernizing society, while holding fast to the radically different ontology of illness that marked out its difference and guaranteed its clinical effectiveness. In a paper titled “Chinese Medicine Formulas and Medicinals Are Specific for Zheng but Not Specific for Diseases,” Lu Yuanlei laid out this ontological difference:
Manifestations [zhenghou 證候] are not the same as the symptoms [zhengzhuang 症狀] listed in Western medical texts. Symptoms are nothing else than descriptions of the abnormal sensations reported by patients. They do not have much influence on either diagnosis or treatment. The manifestations in Zhongjing's texts, on the other hand, constitute the very criteria for using medicinals and [determining] treatment. Western medical texts refer to symptoms in great detail. Hence, even for a disease one has never encountered, once one has read its symptoms in a book, one can clearly imagine an average patient [with that disease]. Zhongjing's manifestations, however, are not like that. There are several very obvious [disease] states about which Zhongjing does not lose a word, while he is not afraid to elaborate two or three times on some very subtle ones. All gentlemen can thus understand that all those conditions on which Zhongjing does not elaborate are not conditions that can serve as criteria for employing medicinals. They are only good to be handed to Western-medicine physicians as symptoms. Those conditions that Zhongjing explains in detail, on the other hand, constitute criteria for using medicinals. When we read Zhongjing's texts we must absolutely not neglect this. (Lu 2010: 1439)
By reserving the intelligibility of zheng to “gentlemen” (zhu jun 諸君), that is, scholars who are capable of correctly reading Zhang's texts, Lu furthermore linked this ontology to the epistemic orientations of a specific social group. Like Yoshimasu before him, he thereby differentiated his vision of Chinese medicine from both that of the imperial pharmacy, whose standardizations reduced the importance of professional expertise, and that of post-Song scholar-physicians and their Neo-Confucian concerns for the cultivation of yi and insights beyond language and texts.
Not surprisingly, Yoshimasu and Lu shared a common interest in reorganizing medical education to instill in budding physicians the right epistemic virtues. For Lu, this included, besides familiarity with Western medical science and the Chinese medical classics, the study also of Japanese. In the context of such learning, Zhang's texts functioned not as sacred objects but as models that explicated the relationship between zheng and treatment in the clearest possible way.
Around the same time that Yang Zemin and Lu were developing their distinctions between disease and zheng, their contemporary Zhu Weiju 祝味鞠 (1884–1951), who had spent some time studying medicine in Japan, coined the phrase “eight-parameter zheng differentiation” (八綱辨證). It expressed the idea that Chinese medical practice as developed from the works of Zhang Zhongjing captured illness by means of an eight-parameter grid constructed out of four oppositional pairs: hot/cold (han/re 寒熱), exterior/interior (biao/li 表裡), deficiency/excess (xu/shi 虛實), and yin/yang 陰陽 (Zhu 2005 ). When conjoined to the disease/zheng dichotomy, this grid furnished an intellectual toolkit that suggested the possibility of bringing all Chinese medicine into the orbit of one single paradigm. This made Chinese medicine systematic and thereby scientific (in the sense that the term science was then understood by the majority of those involved in the modernization of Chinese medicine), even as it provided it with its own unique identity.
Known today as “zheng differentiation and treatment determination” (bianzheng lunzhi 辨證論治), this paradigm was created in the late 1950s and early 1960s by physicians primarily from Shanghai, among them Lu's disciple Jiang Chunhua, the teacher of Shen Ziyin. While these physicians held fast to the distinction between zheng and disease as the respective foci of Chinese and Western medicines, the political necessities of constructing a truly nationalist medicine required widening the definition of zheng and to rearticulate it with (biomedical) disease. Given that many Chinese physicians continued to work broadly within the orientations of post-Song medicine and that in the wake of the second Sino-Japanese war the Japanese influence on Chinese medicine evaporated almost overnight, the definition of zheng within the paradigm of “zheng differentiation and treatment determination” became more ecumenical again. In fact, resonating with the new Maoist emphasis on “practice,” both Jiang Chunhua and Qin Bowei explicitly emphasized the practical dialectic between the objective reality of zheng and medicines on the one hand and the contextual and strategic nature of diagnosis and treatment formulation on the other. By the late 1990s, when Maoist practice philosophies were no longer in vogue, the historian of science Liao Yuqun 廖育群 (2006) even resurrected yi, shorn of its wider ambitions, to comprehend the true why of illness as the modus operandi of zheng differentiation and the distinguishing feature of Chinese medicine.
This vision of zheng as pivot of “knowing practice” has been lucidly analyzed by Judith Farquhar (1994) based on fieldwork carried out in the 1980s. This was the time, as Farquhar herself has documented, when the senior physicians or laozhongyi 老中醫 who defined this style of Chinese medicine were at the height of their power and influence. Their life stories, collected in the three-volume Paths of Renowned Senior Chinese Physicians (Laozhongyi zhi lu 老中醫之路; Zhou, Zhang, and Cong 2005), evince a collective struggle that against all the odds sought to hold onto what Farquhar (1994: 202) describes as “a certain cultural logic…that mediates…between individual (ailing) human beings and the myriad things of the world…, bringing the myriad things to bear on the human in a rigorously articulated and situationally sensitive form.”
These laozhongyi were educated during the Republican period in schools and colleges that emphasized discipleship and the careful study of classical texts even as they modeled themselves on modern educational institutions. For them biomedical knowledge was something acquired after and on top of a solid foundation in Chinese medicine. Subsequent generations of students, particularly those educated from the late 1970s onward, learned their Chinese medicine together with or even after biomedicine by studying textbooks that seek to make the many diverse currents of their tradition speak with a single voice. It is hardly surprising that for the vast majority of these physicians zheng constitute the very essence of Chinese medicine, even if what they understand by the term is often nothing but a collection of symptoms akin to what biomedicine calls a syndrome. As likely, a zheng is simply a subtype of a biomedically defined disease, especially in the context of clinical research. Treating such zheng no longer requires long clinical training and experience. Instead, it demands to match zheng with treatments whose effectiveness can be proven through clinical research.
By the time systems biology encountered Chinese medicine in the early twenty-first century, most Chinese-medicine physicians had long forgotten the processes that had turned zheng differentiation and treatment determination into the fulcrum of their practice. That zheng constitute “the unique core of traditional Chinese medicine” is accepted to be self-evident and in no need of further explanation.
Yet, the tensions that this process of articulation created by stitching together remnants of the medicine of yi with formula/pattern combinations whose associations with Japanese ancient-formula current medicine had to be repressed, even as it solved the practical problems of integration between Chinese and Western medicine in Maoist and post-Maoist China, are readily apparent everywhere. Thus even as the Chinese state forcefully promotes the globalization of standardized zheng that look just like the symptom lists of the imperial pharmacy, physicians in clinical practice continue to rely on personal experience and insight to develop and practice what works best for them. Given the enormous difficulties and risks this involves, it is not surprising that a sizable number of doctors are turning, once more, to the relative safety of classical formula-style practice with its limited number of zheng and clearly articulated relationships between zheng and formulas.
One of the most prominent spokespersons of this movement in both China and abroad is Liu Lihong 劉力紅, a media savvy practitioner and educator from Guangxi. In Reflections on Chinese Medicine (思考中醫), one of the most popular Chinese medical texts of the last decade, Liu (2006) argues for a return to traditional forms of practice unpolluted by the modernization and institutionalization policies of the twentieth century but vastly superior in terms of clinical effectiveness to institutionalized TCM. Liu specifically holds up the Han Dynasty Treatise on Cold Damage as the foundation of a more authentic and effective Chinese medicine. It is difficult to ascertain whether Liu is riding the crest of a wave that had been building for some time or whether he fanned the winds that drive it. However, one only needs to visit the Chinese-medicine section of any large bookshop, peruse relevant Internet chat rooms, or examine journal publications to get an idea of the extent to which so-called “classical formula” (jingfang 經方) styles of practice associated with the Treatise on Cold Damage have come to dominate the field in recent years. Just to give readers not familiar with Chinese medicine an idea, it is as if the classical music section of record shops would suddenly expand to such an extent that pop, rock, and jazz occupied only small sections at the back.
At the other end of the spectrum, advocates of scientization and further modernization were thrown an unexpected lifeline by the transition of biomedicine into the post-genomic era. Attaching themselves to systems biology and the emerging field of personalized medicine allows Shen Ziyin and his successors to continue their quest for objectifying zheng scientifically. This, they hope, will finally silence those critics that view any zheng-based traditional practice—pre- or post-Song, Chinese or Japanese, ancient or modern—as pseudoscience while simultaneously advancing Chinese medicine's effectiveness in practice.
The question therefore arises what my own intervention into this already fractured field is intended to accomplish. Some may feel that the status of a traditional medicine in twenty-first-century health-care systems is so weak that it can do without being brushed against the grain. Clinical researchers, even those who seek to overcome the reductionism of positivist science, will argue that one has to start somewhere. If zheng conceived of as patterns, syndromes, or attractors are capable of building a bridge between systems biology and Chinese medicine, then that is surely good enough.
I am sympathetic to both positions. Yet, I would hold that humanities-based interventions into clinical/research practice can be constructive even as they raise difficult questions for those involved in such practices. More recently, for instance, members of the so-called “third wave” of science studies have highlighted the positive contributions humanities scholars and social scientists can make to the construction and maintenance of interdisciplinary trading zones precisely because of their ability to communicate across disciplinary boundaries and the detached position they occupy (Gorman 2010). Again, while I am broadly supportive of these suggestions, humanities researchers should be careful before surrendering their capacity for critique in an attempt to achieve the measurable impacts nowadays demanded by those funding their research. Instead, I believe that critique is essential for enabling and insisting on the responsible risk taking that I view to be the hallmark of both good science and medicine.
With that in mind, we can begin by drawing up a preliminary typology of zheng-based practices as elaborated in Chinese medicine from the Song to the present. The limited nature of my historical overview implies that this typology must be open to future revisions. In what we have observed, however, we can distinguish six quite different modes of practicing Chinese medicine on the basis of zheng. Each of these requires a different English translation of zheng as outlined in Table 1.
Next, let us recall that with the exception of modern institutionalized traditional Chinese medicine or TCM, the physicians and institutions who created these different modes or styles of zheng-based practice explicitly rejected other styles of which they were aware. Put another way, whereas previous styles viewed each other agonistically, TCM claims that its own novel syntheses have overcome the tensions between previously competing styles of Chinese medicine. From a historian's perspective, however, in vanquishing difference through state-imposed simplifications, it has merely created its own style. Hiding the repressive aspects of this production simply marks this style as truly modern.
The modernity and difference of the TCM style reveals itself in yet another domain, that of the separation of the natural from the social. The reformers who created the imperial pharmacy, Zhu Danxi and his fellow post-Song revisionists, Yoshimasu Todo and Lu Yuanlei, Jiang Chunhua, Qin Bowei, and their fellow laozhongyi, were all open about one simple fact: namely, that effective practice implies a relating to nature/body–persons/disease that is fundamentally ethical and social. That is, they did not view zheng as phenomena existing in nature waiting to be revealed. For all of them, without exception, zheng were social facts created within particular social arrangements. For all of them, therefore, changing what zheng signified implied changing relationships between physicians and their patients as well as the “epistemic virtues” (Daston and Galison 2007) toward which ideal medical practice is orientated. Although TCM is no different in scope or intention, its claim to embody all of Chinese medicine demands to separate any social reorganization of practice from the attributes of that practice itself. For only if zheng embody the timeless virtues of Chinese medical culture are they not affected by the organization of social space in historical time. Yet, the burden placed on zheng by this articulation—to be facts of nature that are strangely revealed only to Chinese-medicine physicians—marks them out as distinctly modern Latourian hybrids whose existence in the long term can be sustained only at considerable cost (Latour 1993).
To share this cost is precisely, of course, why Chinese-medicine researchers such as Shen Zimin are turning to systems biology. Selling their own definition of zheng as the only game in town makes that task considerably easier. However, in doing so they redefine Chinese medicine. For in depicting zheng as timeless aspects of reality toward which China and the West are moving from different directions, they seek to ground it in the very same “tenacious assumptions” (Gordon 1998) regarding the ultimate separation of the natural and the social that have provided biomedicine with a sense of coherence throughout its own numerous transformations. Needless to say, these are assumptions not shared by the majority of Chinese physicians throughout the history of their tradition.
Systems biologists, who thus carry their own historical burden, may therefore only gradually become aware that they are entering into a centuries-old struggle for the very soul of what Chinese medicine is and who should practice it. In seeking to match patterns of gene expression or protein networks to zheng, the researchers engaged in articulating systems biology and Chinese medicine are busy creating new possibilities of what zheng are and how they might be inserted into particular arrangements of clinical practice. For instance, the single feature shared by all previous realizations of zheng is their origin in clinical practice. The intervention of systems biology into this field raises the possibility that in the future zheng as omics-derived patterns will be stabilized independent of therapy, and that the particular gaze of the practicing physician will be excluded not only from treatment delivery (as in the Song) but also from treatment construction. Will such zheng, even if they are later matched with herbs from the Chinese materia medica or acupuncture point prescriptions, still be part of Chinese medicine? What does this possibility imply for what Chinese medicine is and, as importantly, what in the future we come to think of what it has been in the past? Vice versa, what are the epistemic virtues within life-sciences research driven by formula patterns that constitute sedimentations of historically specific individual or collective heart/minds? Will these processes be acknowledged or hidden from sight, leaving it to later generations of physicians, patients, and administrators to remedy their unintended consequences?
Raising these important questions and insisting that they be answered is what the medical humanities can contribute to the emergent interface between Chinese medicine and systems biology. In former times, scholar-physicians such as Zhu Danxi, Yu Chang, or Lu Yuanlei embodied within their own persons the different perspectives of what we, today, have separated into different disciplines and fields of practice. In that sense, the kind of interdisciplinary collaboration I am advocating here merely returns us to a status quo ante that defined the domain of Chinese medicine before it sought to remodel itself after the modern West. It may make the building of bridges a rather more difficult process but also a more honest one. For it will need to recognize, once again, what these scholars and physicians had grasped quite clearly already: that transformations of medical knowledge are transformations also of sociality. Whether or not the personalized medicine to be built at the interface of systems biology and Chinese medicine will be more “holistic,” as some of its proponents claim, or if, indeed, it should be; whether it will function as a Trojan horse that finally assimilates all that is still different in Chinese medicine to biomedical naturalism; and to what extent a return to ancient traditions is a feasible proposition—all these questions are then revealed not merely as matters of will and intent but as entangled with the struggle for creating different cultures and societies.
Research and writing of this paper was supported by the Wellcome Trust (097918–Z-11–Z). I would like to acknowledge my gratitude to Prof. Denis Noble and Prof. Jan van der Greef for their openness in engaging with my ideas and thoughts and for reading and commenting on an earlier draft of this paper. I am grateful to Dan Bensky and Steve Clavey for their feedback on my initial draft, as well as the two anonymous reviewers whose thoughtful and challenging comments helped me to clarify my argument. All remaining shortcomings are solely attributable to me.