The Greatest Benefit to Mankind. Roy Porter

apprenticeship as well as book-learning. Such families would gain a name for themselves by specializing in a particular disorder or by possessing some nostrum. Some had the status of regular family doctors, receiving an annual retainer from well-to-do clients. These two categories of healer hardly amounted to an organized corps of professional physicians in the modern western sense: the closest to that were those who took state medical examinations before going on to serve as imperial medical officers. Their status, however, was not high.

      The medical corpus also refers to a mass of quacks, itinerants, shamans, priests, masseurs and ‘old women’. Being neither scholars, philosophers nor gentlemen, they all lacked prestige. Female healers were dismissed in medical texts as both ignorant and rapacious; but, despite male misgiving, large numbers of midwives and wet-nurses met the health-care needs of gentlewomen. The Korean state even brought in formal medical training for women in the fourteenth century, though they were regarded as of inferior standing.

      Common people, when sick, sought aid from a variety of healers, many of them religious. Sacred healing still retains its importance throughout East Asia, and has even enjoyed a recovery in the People’s Republic of China. The first hospices and charitable medical services in China were set up by Buddhist monks in the early centuries AD. Committed as they were to strict social order, Confucians also took health responsibilities seriously; they saw the health of the body politic and the well-being of the people as equivalents, believing that being dutiful to one’s inferiors proved one’s fitness to rule.

      When Buddhist monasteries were nationalized in the ninth century under the Tang dynasty, the imperial authorities assumed responsibility for their infirmaries. State initiatives continued throughout the Song and Yuan dynasties, when the compilation of pharmacopoeias was sponsored and charitable pharmacies and clinics founded. The decline of state medical services during the late Ming Dynasty (c. 1500–1644) prompted a rise in private charities.

      MODERN DEVELOPMENTS

      Until the nineteenth century, Chinese medicine more or less matched its European counterpart in authority and efficacy. Chinese physicians showed little interest in European medicine, but the Japanese became familiar with western science through the Europeans allowed to reside in the port of Nagasaki, and what was called ‘Dutch scholarship’ (rangaku) flourished. Japanese rangaku physicians took up anatomy and surgery, introducing Jennerian vaccination in 1824. These developments helped undermine the prestige of kanpo, and schools of western medicine began to spring up. International politics, however, was a greater force of change than curative efficacy: by 1850, both Japan and China were confronted by European gunboats, and by a western medicine daily more confident of its own scientific superiority.

      In 1869, the Japanese Meiji rulers resolved to adopt the German system of medical training and, while kanpo was not banned, its practice was subject to restrictions. Japan established a state system of western medical education and services, and by 1900 three imperial and eleven other state colleges of western medicine existed, which by 1912 had trained 14,552 physicians – around two-thirds of all those in practice. Many Japanese medical students were sent to Germany for their education.

      The Chinese were exposed to western medicine through the missionaries who streamed in after the treaties following the Opium Wars. Some reformers held Chinese medicine partly responsible for the Empire’s backwardness and defeats, while others sought not to scrap but to reinforce it. In any case, the weak late Qing regime was in no position to effect Meiji-style reforms. In the end the chief force for change came not from the state but from the hated foreigners, above all the Chinese Medical Missionary Association, founded in 1886, which, together with the Rockefeller-funded Chinese Medical Commission, aimed to transform medical services and training, partly through the ‘union medical colleges’, established in Peking (Beijing) and other key cities after 1903. Yet by 1913, there were still only 500 Chinese medical students receiving training in all the mission services throughout the empire.

      Republican China (1911–49) sought to establish a modern state medical system. By 1926 about one hundred cities had western-style medical services, which the Nanjing-based Nationalist government turned into the nuclei for health institutions, organizing a chain of medical education, hospitals and health centres stretching from the capital right down to rural paramedics. Peasant health-care was given priority: village health workers received training in smallpox, typhoid and diphtheria vaccination, in hygiene, the diagnosis and treatment of minor complaints, and referral of serious illnesses to specialists. The system drew upon western medicine and, whilst Chinese medicine was not banned, it came to be seen as old-fashioned, not least by Marxist revolutionaries.

      After 1948, this nationalist health-care structure was taken over wholesale by the new People’s Republic, though under the Marxist regime Chinese medicine could also be depicted as ‘socialist’ and integrated into the Communist system. Science was exalted as the key to the future, yet patriotic sentiment, reinforced by anti-capitalist ideology, also gave Chinese medicine a renewed symbolic authority, leading to professional parity with western medicine (readily condemned as ‘bourgeois’). The emphasis on functions and holism within traditional Chinese medicine could be squared with the ‘dialectical materialism’ of Marxism-Leninism.

      At the top of the tree, Chinese-style physicians are today required to have a basic training in western-style medicine, and vice versa. Indeed, in the late 1950s, when China was desperately short of skilled medical practitioners, thousands of doctors were withdrawn from regular medical practice for a three-year study of traditional medicine, and Beijing invested heavily in clinics and medical schools for Chinese medicine. The ‘barefoot doctors’ of the Mao era included amongst their skills simple acupuncture and a knowledge of Chinese materia medica.

      The balance between western and Chinese practice has fluctuated, and the ideal of a ‘syncretic medicine’, combining the best of both, has become an attractive one. Attempts have been made to set Chinese medicine on an experimental, scientific footing. In line with this, there has been a move from functionalism to materialism in medical thinking, accompanied by tendencies to reduce traditional terms of Chinese medical art to their modern biomedical equivalents: thus xue classically ranges over a spectrum of meanings, only one of which corresponds to the biomedical concept of ‘blood’. While most practitioners continue to recognize this distinction, the trend is towards using the readings interchangeably. Materialism thus provides a way of translating Chinese medical theory and therapeutics into western scientific terms, and thence of mobilizing experimental laboratory techniques. The pharmacological effects of Chinese drugs have been tested, the siting of the acupuncture tracts investigated, and explanations advanced of the effects of acupuncture anaesthesia in terms of endorphins.

      The classics continue to shape the thinking of contemporary practitioners: no Chinese medicine practitioner can be trained without becoming familiar with the canonical works. But, linguistically, classical Chinese is no longer essential for medical education, and physicians may cull their knowledge of the medical canon from selections in modern textbooks. Utilitarian priorities mean that many practitioners today gain only a smattering of the theoretical rationales underpinning therapy. Formerly Chinese medical practitioners won their prestige through textual erudition; now they assume the trappings of western medicine, and even traditional physicians wear white coats.

      From a wider perspective, it is evident that there has been a great parting of the ways between eastern and western medicine. Initially they shared certain common assumptions, inscribed in hallowed texts, about the harmonies and balance of the healthy body. Western medicine alone radically broke with this. An entirely new practice grew up in Europe – scientific medicine – building upon the new sorts of knowledge, programmes and power which followed from dissection and the pathological anatomy it made possible.

      Tensions thus opened up between the western and the eastern traditions which remain unresolved to this day. As early as the late eighteenth century, European surgeons visiting China were already expressing open contempt for traditional Chinese medicine; it was ignorant of anatomy and hence had no ‘scientific’ basis. Westerners found it laughable that Chinese doctors thought they could diagnose illness on the basis of the pulse alone. And though acupuncture gained some devotees