A historical overview of traditional
Chinese medicine and ancient
Chinese medical ethics
Cai Jingfeng
Traditional Chinese
medicine (TCM) has a time-honored history of several thousand years. It
is the sum of knowledge gained by all the nationalities of our country
in fighting disease and maintaining good health in the course of a
considerably long historical period. As pointed out by the first
theoretical medical classic, the Internal Classic of Yellow Emperor,
the human body is built upon two opposing aspects, the yin and the
yang, which are interdependent and interrelated. TCM aims at
maintaining the harmonious relationship between these two aspects so as
to achieve physical health and longevity. In a chapter of the
above-mentioned classic, it is stated that "when one masters the
mystery of the yin-yang principle, one can even enjoy a life as long as
nature itself" [21. The lofty goal of TCM is thus matched and in line
with what the WHO defines for "health" in 1948 as "a state of optimum
physical, mental and social well-being and not merely the absence of
disease and infirmity".
TCM, being one of the
world's oldest medical systems with remote antiquity and opulent
contents, has made brilliant achievements and contributed significantly
to the health of the Chinese people and the whole world in the course
of its historical development. It features a series of theoretical
systems and practical experience.
Under special natural
conditions, our ancestors gradually accumulated some primitive medical
experience through continuous practice. Early in the New Stone Age,
they learned how to treat disease with stone tools and this eventually
led to the invention of acupuncture therapy. Our ancestors discovered,
through the production process, that movements of the body and
extremities are capable of conquering fatigue and exhaustion, and even
curing some diseases. Furthermore, this greatly promoted the condition
of the body. Such activity, on the other hand, led to the invention of
the art of Dao Yin, or what are known today as Qigong
(breathing exercises) and Tai Ji Quan (shadow boxing).
The vast territory and
wide diversity of natural conditions bestows our motherland with rich
resources of materia medica, including herbal plants, animals and
minerals. As early as the start of the agricultural period, our
ancestors had already gathered rich experience in the application of
herbal drugs. Early developed civilization ultimately led to the making
of wine and the improvement of food-cooking techniques, including
dietotherapy which, in turn, was the foundation of the invention of
decoction treatment, a specialized compound herbal remedy characterized
by the combination of multiple herbal drugs compounded together to
produce its therapeutic effect. This is one of the important features
of TCM.
For the time being, we can only present the most important achievements and characteristics of TCM from our rich treasure
house.
1. A unique system of medical theory
Compiled in around the fifth century BC, the first monograph of medical theory of TCM now extant, the Internal Classic of the
Yellow Emperor, laid the foundations for TCM theory.
Making use of the archaic
philosophical thinking of ancient China, the nucleus of this medical
theory is made up of the yin-yang and "five phases" principles, which
explains quite uniquely physiology, pathology and etiology, guides the
diagnosis, treatment and prevention of disease, and provides the,
criteria for the application of drugs.
The theory of the
yin-yang principle holds that the internal viscera, both functional and
corporeal, are of the counter-reacted aspects of the yin and yang which
are interdependent, intersupporting and interconsuming and in a
harmonious state. Loss of this harmony would result in the occurrence
of disease. The goal of treatment aims at restoring such harmony to the
body.
The five-phases theory, somewhat similar to the humourism theory, is made up of five elements, wood, fire, earth, metal and
water. There are interpromoting, counteracting and harmonious relationships between them. The visceral phenomena, physiology
and pathology of the body can be well explained by the harmony or disharmony of the five phases.
TCM maintains that the
causes of all diseases can be grouped into three categories: the
exogenous, endogenous, and the intermediate (miscellaneous) causes. An
endogenous cause consists of over stimulation of emotion, including
joy, anger, melancholy, fear, fright, meditation and grief. Exogenous
causes consist of unseasonal changes of climatic factors, such as evil
wind, cold, summer heat, dampness, dryness and fire, while the
intermediate cause refers to burns, frostbite, bites from snakes,
insects and other animals, injuries by metals and, last but not least,
irregular and inadequate or intemperate food eating and drinking
habits, as well as sexual activities.
TCM holds that disease is
a state, under the influence of etiological factors, in which the body
loses its harmonious relationship with the environment and within the
body itself. Based on the symptoms and the underlying relationship
between the body and the disease, TCM applies the "eight key
principles" for judging the conditions, i.e. for diagnosis, namely,
surface and interior, cold and hot, sthenia and asthenia and yin and
yang. The last two comprise the general key-principle, while the first
two refer to the site of disease. Cold and hot refer to the nature of
the disease, while sthenia and asthenia refer to the severity of
disease evils and the condition of physical resistance, respectively.
There are also four kinds
of diagnostic method in TCM, namely, inspection, inquiry, auscultation
and olfaction and palpation; of these, palpation, or feeling of the
pulse and inspection of the tongue, are the most important ones, with
distinctive characteristics. Nevertheless, a final and accurate
diagnosis can only be reached by an overall analysis and a
comprehensive judgement combined. None of them alone can give a correct
diagnosis.
Combining, or holistic
treatment, is generally adopted in TCM. It is emphasized that the
patient's body should be viewed as an organic whole rather than
individual parts functioning separately during the course of treatment.
Emphasis in TCM is not laid on the disease itself, but rather the
patient is considered as an organic whole and integral part of nature
and treatment measures should be varied according to differences in the
individual patient's inhabited location and seasons, in order that the
balance and harmony of the bodily functions can be restored. This is
what we call "treatment on the basis of differential diagnosis of
symptoms and signs (known in TCM terms as Zheng)". As to the concrete
treatment measures, there is a wide variety. A few might be mentioned
here, namely dietotherapy, drug therapy, acupuncture and moxibustion,
massage, breathing exercises, and spiritual therapy, etc. The first
choice of these is dietetic therapy due to its convenience, easy
mastering, economical and practical application, inter alia, lack of
side effects. Then comes acupuncture and moxibustion. Drug therapy is
to be applied in cases where these measures fail or prove ineffective.
However, TCM holds that prevention should be put first, just as the
Internal Classic of Yellow Emperor states it: "A superb physician
'treats' before the ailment occurs", which laid down the precious and
active prophylactic conception in TCM.
2. Achievements in clinical practice
TCM, being one of the
integral parts of Chinese ancient culture as a whole, always stood at
the forefront of the world's medical domain in ancient history.
Sphygmology in TCM is the earliest in the world's medical history. Early in the Jin Dynasty (third century AD), Wang Shuhe's Classics of
Sphygmology
mentioned that the Cunkou (the site at the wrist where the radial
artery can be felt pulsating) is the place for taking the pulse. At
that time, 24 different kinds of pulse could be distinguished: fu (floating), kou (hollow), hong (full), hua (smooth), su (rapid), cu (running), xian (string tight), jin (tense), chen (deep), fu (hidden), ge (hard and hollow), shi (forceful), wei (faint), se (sluggish or hesitant), xi (minute), ruan (soft), ruo (weak), xu (feeble), san (scattered), huan (moderate), chi (slow), jie (slow with irregular intervals), dai (intermittent) and dong
(tremulous).In fact, these pulses touch subjects concerning heart
rhythm, rate, elasticity of the artery, position of the vessels, the
flowing condition of circulating blood (hemorrheology), viscosity of
blood and its rheological characteristics. By indepth exploration of
knowledge about the pulse, TCM is able to judge the condition and
resistance of the patient, the severity of the ailment and the
condition of the internal viscera. Thus, it affords rather accurate and
reliable information for correct diagnosis. Once the compilation of theClassics of Sphygmology
was completed, it spread into the ancient Tibet region between the
seventh and eight centuries AD [1]. Ultimately, passing through many
places. this classic was introduced into the Arabian countries via
ancient India. The famous Avicena's Canon of Medicin [3] mentioned more than 40 kinds
of pulse in which some 20 kinds are believed to be cited from the same classic work of Wang Shuhe.
On the recognition and
treatment of diseases, again, TCM made dramatic achievements. Early in
the eleventh century BC, the oracle of tortoise shell or animal bones
mentioned diseases of the head, the ear, the eyes and the nose. Dental
caries and intestinal parasites were also recorded, which showed
undoubtedly that our ancestors recognized such diseases at that early
stage.
One of the prominent achievements in TCM is the recognition and
treatment of infectious disease which were termed "seasonal febrile
disease" or simply "febrile disease". In the second century AD, the
distinguished physician of the Eastern Han Dynasty, Zhang Zhongjing
compiled a famous medical classic titled On Febrile Diseases and Miscellaneous Diseases,
which laid down the compact and rigorous rules and, in addition,
recipes for therapeutic compounds for the treatment of infectious
disease, of which some are still effective and applicable today with
satisfactory results. For instance, a decoction known as "White Tiger
Decoction" (composed of gypsum fibrosum, rhizoma anemarrhenae, radix
glycyrrhizae, semen oryzae nonagglutinosae) for B-encephalitis, decoction of rhei and paeonia for acute appendicitis, decoction of ephedra,
gypsum, Glycyrrhiza and almond for acute pneumonia, decoction of artemisia for acute viral hepatitis, etc.
Living around 281-341 AD,
the well-known physician and alchemist of the Eastern Jin Dynasty, Ge
Hong, made prominent contributions to the knowledge of infectious
disease. In his famous medical book entitled Handbook of Prescriptions for Emergency Treatment,
he mentioned a kind of sand flea. According to his description
concerning the symptoms and course of this disease, he was referring to
what we call tsutsugamushi today. In the same work, he also pointed out
a kind of acute infectious disease manifesting skin eruption, pustules
and pigment-free scars or pit formations. This, again, is believed to
be the earliest record of smallpox in the world's medical history.
For the treatment of
acute infectious diseases, Ge Hong proposed some valuable opinions and
concrete methods. In treating hydrophobia (rabies), he suggested the
application of the brain tissue of the same rabid dog that had bitten
the patient on the patient's wounds as treatment. This method, based on
the archaic concept of "like cures like" or "poison attacked by
poison", might be considered as the beginning or birth of the primitive
concept of immunity. Moreover, such a concept was so highly developed
that it eventually led to the invention of variolation with a humanpox
vaccine and is the predecessor of the cowpox
vaccination. According to historical records, in no later than the
sixteenth century, our ancestor began to inoculate the humanpox vaccine
for the prevention of smallpox. It should be emphasized that the virus
is attenuated by passing through several generations of inoculation in
the human body, and yet the immunity of the virus is still preserved
intact as a prophylaxis against smallpox. This measure is comparable,
and quite similar in principle, to the preparation of attenuated viral
vaccines in modern times. Medical documentation indicates that Jenner's
invention of vaccination was enlightened by the variolation technique.
In TCM, another well-known physician of world renown is Hua Tuo. Living in the later Han Dynasty, Hua Tho invented Ma Fu powder,
which was taken with wine as an anesthetic for performing surgical
operations, including abdominal operations. Some researchers maintain
that the powder might contain rhododendron molle (B 1) G. Don or Datura metel (L.). The prestige of Hua Tuo for the invention of anesthetics and the
role they played may be understood by quoting what Lawall wrote in his "Four Thousand Years of Pharmacy ",
published in the US in the 1920s: "Some of the Arabian authorities
speak of a form of anesthesia by inhalation. This was probably derived
from Chinese, for Hua Tuo, the Hippocrates of China, is said to have
taught this practice and used for the purpose a combinatin of aconite,
datura and herbal".
Another distinguished contribution of TCM is the establishment of Tai Yi Shu
(Imperial Academy of Medicine) which is believed to be the first of its
kind in history, devoted exclusively to the teaching of medicine, in
which some 300 faculties are divided into four departments: internal
medicine for adults, pediatrics, massage and incantation. The
institution embraces a system of academic professionals including
doctors, assistants, practitioners and technicians. There is a very
rigorous system of examination every month, season and year. Only those
who pass the examinations may qualify for clinical practice. Of course,
the Academy also includes a department for the training of students
qualified in the identification, cultivation, preservation and
processing of Chinese materia medica.
Turning to medical jurisprudence, a book entitled Washing Away the
Wrong Cases (xi yuan lu), compiled by Song Ci of the Song Dynasty in
1247, described the examination of the corpse, identification and
analysis of death caused by mechanical wounds, causes of poisoning and
antitoxicity, and on-the-spot examination of criminal cases. This work
is recognized by medical professionals as the first monograph on legal
medicine. This monograph was introduced abroad and has been translated
into various languages, including Korean, Japanese, Russian, English,
German, French and Dutch and spread all over the world.
In the area of clinical
medicine, the techniques for the treatment of foreign bodies in the
esophagus and artificial respiration are noteworthy. For instance, Ge
Hong advocated swallowing a bundle of bulbus allii macrostemi
fibres for small foreign bodies in the esophagus, or a sophisticated
technique of pushing rosary beads through the hock string remaining in
the mouth cavity to treat children having accidentally swallowed
fish-hooks into the esophagus, Meanwhile, Zhang Zhongjing recorded the
method of artificial respiration for the emergent treatment of a
suicide attempt by hanging. Moreover, there are records of enemas with
bees honey or animal bile. Abdominal paracentesis was also mentioned in
the fifth century BC.
3. Achievements of acupuncture, moxibustion and Chinese pharmacology
TCM features the
art of acupuncture and moxibustion, which originated in the New Stone
Age with stone needles and knives as its predecessor. In the Bronze Age
(sixteenth to eleventh century BC), our ancestors applied metal needles
for treating disease. Through the manipulation of acupuncture and
moxibustion, knowledge about vessels or channels gradually developed
and became complete. Acupuncture and moxibustion, by adjusting the
yin-yang principle of the body itself by means of a manoeuver, could
cure many kinds of disease, ranging from microbial infection to
diseases of the nervous system and functional diseases, and are
especially effective for relieving pain. Owing to its capacity to
relieve pain, ancient medical workers applied acupuncture to supress
pain prior to minor operations. And this eventually resulted in the
invention of acupuncture analgesia (acupuncture anesthesia). The art of
acupuncture and moxibustion was spread abroad in the early period. In
the East, Japan and Korea were the two countries that first came into
contact with the Chinese art of acupuncture and moxibustion. Early in
562 AD, a Chinese scholar, Zhi Cong, took Illustrated Channel and Point Chart to Japan. Thereafter, the Japanese authorities stipulated that the Classic of Acupuncture and Moxibustion, the earliest work of its
kind now extant, be a required course for medical study. In 1673, W.
Rhijne, a physician of the East Dutch India Company, introduced
acupuncture/moxibustion into France. Meanwhile, E. Kampfer, a German
physician, introduced it into Germany. The science of
acupunture/moxibustion flourished in Europe thereafter and made its
contribution to the health of the people in all European countries.
Chinese pharmacology is another important contribution made by the Chinese people to the world's medical arsenal. The Shen Nong's Classics
of Materia Medica,
the earliest pharmacological work now existant, was written in around
the second century AD. It recorded 365 kinds of materia medica.
Although its classification of drugs is rather primitive and clumsy, it
contains many highly effective remedies, among them herba ephedrae for asthmatic coughs, radix dichroae as an anti -malarial drug, rhizoma coptidis for dysentery, radix et rhizoma rhei
as a cathartic agent and sargassum as an anti-goiter drug are the
famous ones, which have been proven by modern scientific methods to be
effective. Perhaps the most prominent and influential work in this
field is the Compendium of Materia Medica,
written in 1593 by Li Shizhen, which embraces 1892 kinds ot herbal
drugs divided into 16 categories: water, fire, earth, metal and stone,
grass, cereal, vegetable, fruit, wood, utensil, worm, scale, shell,
bird, beast and man. The classification applied by this work appears to
be fairly advanced when compared with contemporary works in the same
field. This naturalist work embraces achievements in biology, chemistry
and other natural sciences, in addition to its classification. For
example, Shizhen mentioned the phenomena of genetics, correlative
variation and the adaptation of animals to their environment. He also
mentioned the extraction of mercury from herba portulacae and gallic acid from galla chinensis.
For the preparation of certain drugs, he adopted various ways in which
distillation, evaporation, sublimation, precipitation, burning and
efflorescence were applied. No wonder this work has drawn the attention
of many scientists in foreign countries with ever-increasing
enthusiasm. Domestically, this voluminous work has been republished and
reprinted in some thirty editions so far, and it has been translated,
partially or completely, into foreign languages including German,
French, English, Latin, and Russian for Europe and Japanese and Korean
in the East, the latter two appearing even earlier than the former. The
most prominent evolutionist, Charles Darwin, cited some material,
either directly or indirectly, from Li Shizhen's work. It is quite
natural that Li Shizhen became one of the most prominent and well-known
scientists in the history of ancient natural science in the world.
4. Medical ethics in ancient China
In tandem with the advent
of medical activities in remote antiquity, ethical problems appeared,
albeit in a very primitive form. Based on the economic infrastructure
of the society, medical ethics is a particular social ideology
reflecting the mutual relationship between different people and
communities and maintained by the inner belief of medical workers,
social opinion and medical professional tradition. During the middle
stage of primitive society, when the professionalization of medical
workers and the medical profession appeared, the idea of medical ethics
began to take shape, which is, in fact, a historical category. As the
main subject of medical ethics, the doctor adjusts the mutual
relationship between himself and his patients, the society and doctors
themselves constituting the main body of the domain of medical ethics.
China is a time-honored
civilization with several thousand years of history of medicine; thus
it follows that it also has a long history of medical ethics. However,
the ethical knowledge in the medical world at this early stage was by
no means complete or systematic, but rather fragmented and trivial.
During the Zhou Dynasty 3000 years ago, doctors wore divided into
different groups according to their responsibility, namely, ji yi (doctors for curing internal disease) yan yi (doctors for external disorders), shou yi (veterinary doctors), and shi yi (dietetic doctors). To determine their salary, the various doctors had to undergo
examinations at the end of each year, judged in terms of the effectiveness of their treatments. The reward system for these
examinations was: full salary for a 100% cure rate, and decreased salary based on the percentage of treatment failure. Thus,
doctors were urged to improve their medical skill in order to achieve better compensation for their profession.
As is generally known,
Confucianism, the ruling and guiding philosophical ideology of Chinese
feudal society for over 2000 years, established by the great
educationalist, thinker and philosopher, Confucius, was also the
guiding principle of medical ethics in ancient China. The core of
Confucian thinking is "benevolence" or "love and kindheartedness",
"humanity", maintaining that "those who are kindhearted or benevolent
love the people". In other words, all people should love one another,
not alone doctors their patients. As a motto for doctors, Confucianists
advocate that "medicine is a benevolent art" or, as a technical art for
saving life and curing disease, doctors should have a kind heart.
Confucius also pointed out that he who does not have perseverance is
not qualified to become a doctor. These are the minimum qualifications
for a doctor. In summary, this benevolent art, as the core of Confucian
medical ethics, embodies the spirit of humanity and reflects the social
responsibility of medicine and the characteristics of the medical
profession.
The Internal Classic of Yellow Emperor,
the earliest medical classic now extant and written about 2500 years
ago, instructs doctors to focus their attention, in addition to their
skill, primarily on the prevention of disease, instead of focussing on
treatment after the onset of disease. He who is conversant with the
prevention of disease is a "superior worker" in the medical province.
It also states as a prerequisite that a doctor should be erudite, with
extensive knowledge regarding "astronomy, geography and worldly
affairs". Only those with such inmense erudition and great originality
can serve their patients well and combat and conquer disease.
About half a century after the advent of the Christian era, Buddhism was introduced into China. This religion exerted certain
influences on medical morality in our country. The concept of samsara,
or transmigration due to causality and retribution, advises people to
do only good deeds in this world, to their credit in the next, meaning
that a doctor could have a magnificent and glorious next-life.
Naturally, the medical profession is an ideal profession to satisfy
such a demand. Ort the basis of the old ethical tradition, this new
idea helped to shape a primitive standard for medical ethics between
the third and fifth centuries AD, including three aspects: careful
examination and consideration when dealing with disease, diligent
manner when dealing with medical art and careful and appropriate
administration when prescribing a recipe or drugs.
The seventh century saw the maturity of medical ethics in ancient China, embodied in two special chapters regarding the
requirements for a doctor in the book Qianjinfang (Prescriptions worth a Thousand Gold) written by the famous physician Sun
Simiao (581-682). The titles of the two chapters are "Perfect Proficiency of a Great Doctor" and "Practising and Conducts of a
Great Doctor", respectively. These formulated the standards for ancient traditional medical ethics, including:
- Be erudite in medical
knowledge and diligent in learning: all doctors should progress
constantly and keep improving their skill of the medical art and
technical know-how.
- Be sympathetic to
patients and serve them wholeheartedly. Serve all patients equally,
regardless of their age, sex, wealth, rank, nationality and
intelligence. Treat all patients as if they were your own relatives and
their illness as if it were your own suffering. Meet the patient at any
time or any place when a doctor's help is needed, notwithstanding any
danger.
- Be painstakingly careful in diagnosing a disease. Think carefully when prescribing treatment. Be objective and avoid any
personal considerations of responsibility or being swayed by personal feelings.
- Be solemn in one's conduct without making any personal demands: no humor, demands for money, or sexual issues should be
raised.
- Be respectful to one's
tutor and profession. Avoid any arrogance and rashness. Do not
criticize other doctors' skill or conduct in the presence of a patient.
Do not be arrogant about one's own achievement. Learn from other
doctors to ensure one's own progress, only charlatans are jealous of
other doctor's superb skills.
This is the ancient Chinese manifesto on medical ethics, embracing almost all aspects of present day medical morality, and
becoming the standard motto for Chinese traditional doctors to follow. Even so, the author summarizing this glorious chapter on
medical morality had his own
limitations, personal and historical. He was a devotee of Buddhism, so
much so that he advised a "standard" or model doctor not to apply drugs
of animal origin in order to observe the Buddhist taboo regarding the
taking of life, by saying that "it is far from saving (patients') life
by killing (animals') lives, because all animals, man and domestic
animals, have pity on their own lives". He even emphasized that, when
using snake drugs, one must purchase those dead ones sold in the
market, and he was even very reluctant to use hens' eggs for medicinal
purposes, because the egg, in his opinion, was already a potent life.
Ironically enough, in Sun's text mentioned above, he applied a lot of
animal drugs in his thousands of recipes, indicating that the Confucian
idea of whole-heartedness is far more important than and superior to
Buddhist taboos, a pragmatic concept to meet the demands of patients'
practical needs.
In summary, ancient Chinese medical ethics was standardized in the seventh century and further developed to its complete form
thereafter. Though it is far later than the Hippocratic oath, Sun's chapter on medical morality may be boasted as the earliest
complete text of morality in China.
References
- Huard P (1969) In: Poynter FNL (ed) Medicine and culture. Wellcome Institute of the History of Medicine, London, p. 291
- Plain Question (1956) Yellow Emperor's Internal Classic. Reprinted by People's Health Publishing House
- Yuanyi S, Chun G (eds) (1988) History of Medicine. Hubei Press of Science and Technology, Wuhan, China
Cai Jingfeng
The China Institute for History of Medicine and Medical Literature
China Acaderny of Traditional Chinese Medicine 
tcm-2
