In the above book, Kuriyama has taken up a very difficult task of comparing Greek and Chinese medicine systems, as medicine systems are conditioned not only by scientific criteria but also by cultural differences. Kuriyama's emphasis is more on diagnosis than on medication.
It goes to the credit of Kuriyama that he has dealt with this difficult and technical subject in a very lucid language, almost in a lyrical prose. He divides the book in six chapters:
(1) Grasping the language of life
(2) The expressiveness of words
(3) Muscularity and identity
(4) The Expressiveness of colours
(5) Blood and Life
(6) Wind and Self
Chapter 1 essentially deals with the art and science of pulse reading. There were sceptics who rejected Chinese pulse science. Kuriyama quotes, "Against sceptics who rejected Chinese pulse teachings because of their "mistakes in anatomy," John Floyer argued in 1707, "that the want of anatomy does make their art very obscure, and gives occasion to use phantastical notions: but their absurd notions are adjusted to the real phenomena, and their art is grounded upon curious experience, examined and approved for four thousand years.
A basic difference between the Chinese and the Greek system was that the Greeks read only the wrist pulse. But the Chinese specialised in reading pulse at different parts of body. Kuriyama explains, "Comparatively viewed, this is perhaps the most salient characteristic of palpation in China: the belief in the significance of place. From Herophilus through Galen, Greek diagnosticians evinced little interest in, or even awareness of, the differing feel of the pulse in distant parts. Galen merely remarks that one inspects the wrist because the pulse there can be felt clearly and without offending the patient's modesty. The idea of systematically comparing alternative sites never arises. Why should it? Since the arteries all spring from the heart, doctors expected traits like speed, frequency, and rhythm to be the same in them all." (Pp. 40-41).
Reading of pulse vividly brings out the differences in the basic concepts.
"We could also say: they felt it differently because they knew it differently. My argument is not about precedence, but about interdependence. Theoretical perceptions at once shaped by the contours of haptic sensation. This is the primary lesson that I want to stress: when we study conceptions of the body, we are examining constructions not just in the mind, but also in the senses. Greek and Chinese doctors grasped the body differently- literally as well as figuratively. The puzzling otherness of medical traditions involves not least alternative styles of perceiving….What goes into a perceptual style? This chapter has highlighted the influence of the presumed object of perception. We've learned that interpretations of the pulse and the mo entailed radically diverging expectations about what could and should be felt." (P.60)
Explaining the Chinese medicine, Kuriyama cautions, "Palpation was just one, and the lowliest, of four ways to know the body – theoretically. Diagnosis encompassed the "divine" art of gazing, the "sagely" art of listening and smelling, the "crafty" art of questioning, and the "skilful" art of touching. Someone who learned the last thus qualified only as skilful, while those who mastered hearing and seeing achieved sageliness and divinity. In practice, however, doctors made a regular fetish of palpation and, worse, brazenly paraded their bias as a special virtue." (P. 71)
Kuriyama brings out the contrast in the intellectual style of the West and the traditional values of the Chinese: "Distinguished scholars have pointed out, of course, that Western intellectual life was marked by more vigorous and radical debate than can be found in China, whereas Chinese thinkers tended to place greater weight on canonical texts and authorities. Viewed against this backdrop, the stable transmission of the classical language of palpation seems almost predictable – another instance of a familiar pattern, further proof of the irenic traditionalism running through all of Chinese medicine." (P. 74).
In the second Chapter, Expressiveness of Words, the author explains that some aspects of the pulse defied ready visualization. Qualities such as strong and week, full and empty, hard and soft, for example. The fingers had somehow to grasp these directly.
Kuriyama's thesis is that the history of conceptions of the body must be understood in conjunction with a history of conceptions of communication. When Greek and Chinese doctors palpated the body, they were guided not only by specific beliefs about the arteries and the mo and the organization of the body, but also by broader assumptions about the nature of human expressiveness. In seeking to understand people doctors in each tradition often felt with their fingers in much the same way that they listened with their ears...The arts of pulse diagnosis and qiemo arose from the conviction that people express themselves not just in words, in a language accessible to the ears, but also in a language accessible only to the touch. Sometimes, as in the rhythmical articulations of the pulse, doctors drew explicit parallels between these two forms of expression. More often, though, they simply took it for granted that the style in which the body communicated messages by palpable movements would resemble how people conveyed meaning by the voice. (P. 107-108).
In Chapter 3 Kuriyama discusses Muscularity and Identity. The muscularity of the Greek body and the flabby body of the Chinese manifestly contrasts the two systems of medicine. Interest in individual muscles and indeed the very notion of muscles – as distinct from flesh, tendons, and sinews – developed uniquely in medical traditions rooted in ancient Greece. Elsewhere, as in China, "ignorance" of musculature was the rule. (P.111)
But why did the Chinese miss the muscles? Kuriyama explains that dissection must have something to do with the matter. Leonardo, Alberti, and Jombert all tell us explicitly: to perceive muscles on the living person, one must first study the anatomy of the dead. And this presumably is a significant reason why Chinese doctors didn’t notice them – because in their perspective on the body dissection played only a minor role. To solve the enigma of the western preoccupation with muscles, therefore, we must factor in the contributions of anatomical seeing. (P.118)
Kuriyama, however, informs that major medical traditions, such as the Egyptian, Ayurvedic, and Chinese, all flourished for thousands of years without privileging the inspection of corpses. For that matter even the treatises of Hippocrates, the reputed source of Western medical wisdom, manifest scarce interest in anatomical inquiry.
The author asks, 'And why should we expect otherwise'? There are innumerable ways to know the body. The body can be investigated, for instance, by observing how it is affected by particular foods in particular circumstances. It can be apprehended, too, as something shaped by the environment, varying under the influence of airs, and waters, and places. There is also the detailed practical understanding that comes from studying how the body changes when it is burned, or bled, or needled in diverse ways, at disparate sites. Nor can we ignore the self-awareness gained through exercises that transform the self – through yogic meditation and breathing, say, or bodybuilding. All these methods yield abundant real insights. No natural bias requires seeking the truth of the body in the dismembered corpse. Pp. 118
Summarising the Chapter 2, the authors says that while the rise of anatomy undoubtedly contributed to nurturing muscle-consciousness, we would be wrong to regard the latter as an incidental by-product of the former. Rather than subsume the history of the muscular body under the history of dissection, I shall try to show, on the contrary, how a study of the muscular body alters our perspective on the anatomical imagination – how it beckons us to broaden our view of anatomical form, and invites us to see afresh, too, the bonds binding body and self. (P. 133).
In Chapter 3, The Expressiveness of Colours, Kuriyama admits that doctors in China missed much of the detail observed by Greek dissectors and incorporated invisible features that dissection could never justify. This especially is what makes the acupuncture man seems a mystery – the blind indifference to the claims of anatomy. (P.153).
For the Chinese gazing was more important. The Shanghanlun was blunt: the physician who knew by gazing belonged to the top class (shanggong); the physician who questioned and knew was average (zhonggong); the physician who touched and knew was inferior (xiagong). Mastery of medicine was defined first by an exceptional eye. (P. 154)
The author says that when the Neijing drew parallels between the body and the body politic, it did speak of the heart as the ruling lord (junzhu zhi guan), and it even endowed the heart with intelligence (shenming). But the heart hardly monopolized a person's mental resources. Decisiveness, for example, belonged to the gall bladder, the capacity for calculated planning resided in the liver, craftiness belonged to the kidneys, and the sense of taste to the spleen. Accounts of the heart in China offer little hint of the commanding dominance invested in the Greek hegemonikon. In the dynamics of the five phases, the heart conquered the lungs, but the heart in turn tended to be overpowered by the kidneys, the kidneys by the spleen, the spleen by the liver, and the liver by the lungs. Power circulated. No one zang lorded over all the others. (P.161). Also, the opposition of floating versus sunken ranked as perhaps the most fundamental distinction in qiemo, and this because in Chinese medicine all changes in the body, physiological as well as pathological, were governed by the logic of depth. (P.166).
The Chinese doctors preferred was to gaze upon the surface. For them skin shone as the site of privileged revelations. For there, at the surface, doctors contemplated a person's se – as in wuse, the five colors. If Hellenistic dissectors scrutinized the functional meaning of organic shape, healers in Han-dynasty China peered into the profound significance of hue. …But mainly seeing in Chinese medicine entailed gazing upon color (wangse). The contemplation of colors defined, theoretically, the use and rationale of sight; and in practice, too, it was colors that commended the most intense and searching scrutiny. Those skilled in diagnosis scrutinize se and palpate the mo. For all the importance of palpation, one couldn’t truly know the body without knowing se. (P. 171).
The puzzle of Chinese seeing is only partly about color. It is also about reading faces.
Kuriyama brings out the contrast between the Western and Chinese concepts. Western commentaries on Chinese medicine and philosophy frequently stress the holistic unity of the Chinese body/self. For a predictable reason: viewed against the dualisms that have so forcefully framed Western readings of the human condition – the radical oppositions of divine spirit and corrupt flesh, of immaterial mind and material body – the absence of such polarities leaps out as the critical difference. But the surprise at not finding these dichotomies in Chinese thought has often induced the neglect of distinctions that the Chinese did make. One such distinction is that between form and face – or, to be exact, between xing and se. Xing and se (xingse), Mencius tells us, are our natural endowment….Doctors treasured se because it signalled the faintest changes. Physique and physiognomy metamorphose over months and years; by the time an illness reshapes these, it has usually been long at work. Yet well before an illness emaciates and disfigures, it appears in fugitive and ineffable changes in look. The physician who gazes and knows, who truly sees se, perceives realities that remain invisible to others until much later. (P.180).
The Greek medicine also studied the colours. "The second-century treatise on physiognomy by Polemo included several chapters on the interpretation of complexions. Still, se in Chinese medicine engaged an intensity of interest and had a range of significance unmatched by colors in Greek medicine." (P. 185). The Shanghanlun explains, "When the protective qi declines, then the face becomes yellow; when the nourishing qi declines, the face becomes green. The nourishing qi forms the root; the protective qi, the leaves. When both are feeble, then the roots and leaves become withered and desiccated. (P. 187).
Despite many divergences, about the substance of vitality, Greek and Chinese doctors agreed. Both traced life's power to blood and breath. Which leads us to wonder: How did this shared sense of life's rootedness in blood and breath mesh with the diverging views of vitality manifest in muscles and in se? Our inquiries into the pulse and the mo have whispered to us from the start that knowing the body was inseparable from a feel for blood and breath. (P.192).
The Indian Ayurvedic system also gives due importance to observation. The Charak Samhita, an Indian medical treatise of Second Century BC, emphasises that of all types of evidences the most dependable ones are those that are directly observed by the eyes. In Ayurveda successful medical treatment crucially depends on four factors: the physician, substances (drugs or diets), nurse and patient. The qualifications of physician are: clear grasp of the theoretical content of the science, a wide range of experience, practical skill and cleanliness; qualities of drugs or substances are: abundance, applicability, multiple use and richness in efficacy; qualifications of the nursing attendant are: knowledge of nursing techniques, practical skill, attachment for the patient and cleanliness; and the essential qualifications of the patients are: good memory, obedience to the instructions of the doctors, courage and ability to describe the symptoms.
But it seems that Kuriyama is more concerned about the "expressiveness of the body" which means mainly diagnosis through physical examination. He does not deal with medication in detail.
In Chapter 5, Blood and Life, the author discusses the importance of blood letting in both the medicine systems. Kuriyama informs that from antiquity through the mid-nineteenth century, the letting of blood flourished as one of the most common and trusted means of caring for the body in the west. But not in China. (P. 196). Bleeding became a prime pillar of Western medicine only later, after Hippocrates. Galen devoted no less than three lengthy works to venesection (On Venesection, On Venesection Against Erasistratus, and On Venesection Against the Erasistrateans), elaborating in these and other writings a theory of the body and its afflictions which made bleeding both the preferred treatment for a wide range of disorders, and the chief tool of prophylaxis. Attitudes had changed.
Bloodletting wasn’t unknown in ancient China either. References to it still abound in the Neijing (ancient Chinese medical text), and one modern scholar has even described bleeding as the main therapy promoted in the work. Long before the development of acupuncture needles – a development which Yamada Keiji dates to the Western Han – Chinese healers punctured abscesses and let blood with bladed-stone or bronze scalpels called bianshi. (P. 197-198). Though the identification of blood with vitality militated against bloodletting, the association of qualities of blood and qualities of life made blood a competing target of cures. (P. 201)
But the problem was how to decide how bloodletting from one organ would cure the afflicted one. Let blood from the leg or arm to relieve pain in the head, say, or the liver. We find the same principle also in Hippocrates. Sometimes, Chinese and Greek treatments even coincide: doctors in both traditions thus bled the back of the knee for back pain. A number of Hippocratic cures, moreover, such as bleeding the inner ankle for testicular pain, have close analogues in acupuncture. Though the match between the paths of the phlebes and the mo is nowhere exact, the two arguably share more with each other than with the arteries and veins defined by dissection. Early on, Greek and Chinese physicians articulated the bonds between blood and pain through conduits that are tantalizingly alike.
Kuriyama suggests that acupuncture may have evolved out of bloodletting. Or there may be a genetic kinship between developments in ancient Greece and China. The movement of peoples and goods between the eastern and western reaches of Eurasia is prehistoric, and it isn’t hard to conceive of a cure such as drawing blood from the knee for back pain migrating across the continent.
Kuriyama complains that by a curious irony, many in the West today readily concede the possibility of an empirical basis for the exotic technique of acupuncture, while they dismiss offhand the phlebotomy (blood-letting) practiced assiduously in Europe for over two millennia. Yet as we've just seen, acupuncture and topological bleeding were actually kindred techniques, positing similar, sometimes identical connections between sites of treatment and distant ailing parts. To the extent that we willingly entertain the possibility of some physiological rationale for acupuncture, we may also need to rethink bloodletting. (P.206)
Kuriyama suggests that underlying the devotion to phlebotomy was the dread of excess blood. While acknowledging the general usefulness of fasting, Galen objected that in many cases bleeding was the more efficient, even the only effective cure. (Pp.208-211).
But later on, ancient Chinese therapeutics evolved in almost the exact opposite direction from the Greek. Once a major cure, bleeding lost its popularity after the Neijing. The split between bloodletting and acupuncture, Kuriyama explains, was the difference between fears of corruption and fears of dissipation, between fears of retention and fears of loss. Whereas Greek medicine emphasized the benefits of menstruation, nosebleeds, and hemorrhoids as ways to forestall or relieve excess, Chinese physicians saw little good in nosebleeds and hemorrhoids; they simply tried to stop them. And though they recognized the need for regular menses, they treated lack of menstrual bleeding not so much as dangerous suppression, as a potential cause of sickness, but rather as a sign of exhausted blood, a consequence of prior depletion. (P.227).
Greek and Chinese medicine thus both stressed the primacy of the body's inner state. Seeds of disease, gashes and bruises, violent winds, and cold all might harm and kill; but they were still secondary concerns. They really endangered only those predisposed towards sickness, just harmed the already sick. For the phlebotomist, pestilence and wounds festered only in bodies burdened by overeating and indolence, bodies full of corrupting residues; for the acupuncturist, it was the emptiness of squandered vitality which invited the invasions of wind and cold. Bloodletting and acupuncture, in other words, both underlined the tendency of human beings to make themselves sick, but they diverged in their conceptions of dissolution.
Proponents of yangsheng, or the cultivation of life, brooded above all over the loss of precious essences in sexual abandon. But they also sensed vitality escaping from all the orifices. It flowed out of the eyes as one lingered on beautiful sights, and from the ears as one lost oneself to rapturous harmonies. The orifices were "the windows of the vital spirit," and sights and sounds drew this spirit outward, empting the body, inviting affliction. (Pp. 222-223). The Chinese sages complained that people of our times are not like that. Wine is their drink, caprice their norm. Drunken they enter the chamber of love, through lust using up their seminal essence, through desire dispersing their inborn vitality. They do not know how to maintain fullness (buzhi chiman)….Lacking self-control in their activities, they are worn out at half a hundred. (P.219)…It is interesting to note that there are similarities with the Indian concept of Brahmacharya (celibacy) too. Seeds were the purest concentration of life, and every drop lost meant a narrowing of vital possibilities. This is why adepts of the sexual discipline of Fangshu so scrupulously studied techniques for retaining and "returning" the semen in intercourse. (P. 228).
There are legends in China which seem to emphasise on fasting as the Indian Jains and Buddhists did. Legends in ancient China told of sages who "avoided grains" (bigu), that is, shunned the coarse foods of ordinary mortals. Dwelling in misty mountains, they nourished themselves only on the fine pure breaths of high altitudes and enjoyed as a result extraordinary longevity and lightness of being. Reputedly, they floated around on clouds.
Diet and fasting is also an important part of Indian medical system, Ayurveda, which is basically a humoural medical system that maintains that there are three essential humours which cause disease if they become imbalanced. These three humours are usually translated in English as Wind, Bile and Phlegm. Occasionally in the surgical tradition a fourth humour - blood - was added. Surgery and physical Ayurveda became two separate traditions, surgery being more important amongst the Buddhists, who for one reason or another are less hung up about ritual purity and contact with taboo bodily products such as blood.
According to Ayurvedic medicine most people are born in a state of equipoise but quickly lose it, either through bad diet, bad treatment or moving away from the physical location most conducive to their natural constitution and temperament. Everyone is recommended to discover for themselves what the optimum conditions for them might be and to try to keep themselves on an even keel. The primary method for returning and maintaining the humours to a state of equipoise is diet.
In Chapter 6, Kuriyama discusses Wind and Self. Wind in China, though a vital factor in health and disease, seems to be quite different from the Ayurvedic concept of Vata, In China winds foreshadowed change, exemplified change, caused change, were change. They presaged the waxing and waning of imperial charisma, warned of imminent wars and famines. But in Greek medicine winds transformed not as some special, independent force, but by virtue of their dryness or moistness, warmth or cold. It was because all things were governed by the dialectics of dry and wet, hot and cold, that northerly and southerly breezes induced irresistible, throughgoing changes-in people, in the surrounding land and sea, in not just the human body, but even in "large and powerful bodies" like the sun, the moon, and the stars. (P.250). By the Spring and Autumn era, we start to glimpse other emphases. Why do people fall ill? The physician Yi He (sixth century B.C.E.) ignored demonic attacks, but instead blamed six causes: the yin, the yang, wind, rain, darkness, and brightness.
In China, in spring, the liver gained ascendance, in summer the heart, in autumn the lungs, in winter the kidneys. If Greek anatomists advanced a science of articulated forms, here was a body articulated by time. Easterly winds arose in spring and brought disease to the neck and the back of the head; southerly winds arose in summer and caused disease in chest; westerly winds arose in autumn and hurt the shoulders and upper back; northerly winds arose in winter and attacked the lower back and legs.
Kuriyama admits that there was a tension at the heart of Chinese medicine. At the same time that it celebrated the resonance of microcosm and macrocosm, it asserted the body’s latent independence from wind. Despite the rootedness of human being in the world, despite the confluence of cosmic winds and personal spirit, the body remained separate from the world around it. (P. 257).
Greek wind consciousness also evolved. But rather than gain in menace, as they did in China, winds in Greek medicine drifted instead toward the periphery of concerns. The Galenic body differed from the Hippocratic not just in its richer structural details, that is, not just because of the new science of dissection, but also in an altered awareness of pneuma.
Chinese conceptions of the body's interior centered around the five zang and six fu. The five zang were the liver, heart, spleen, lungs, and kidneys; the six fu included the gall bladder, small intestines, stomach, large intestine, and bladder. Reading casually, we might say: here is a list of organs.
A modern Chinese textbook cautions, though, that we "cannot simply impose Western medicine's conception of the internal organs" to the concepts of zang and fu; and Nathan Sivin adds, "[W]hat we learn about the Chinese conception is not anatomical but physiological and pathological…not what the viscera are but what they do in health and sickness. The observation is accurate. (P.265). The zang and the fu weren't tools of some controlling source, weren't implements of the soul. Literally, zang and fu both referred to repositories, and therein lay their principal role in the body. They both stored qi, vital breath.Real security, however, lay in inner fullness. To the extent that the zang storehouses kept vital breaths secure within the body, a person could deflect the perils of chaotic change. Empty winds could inflict no harm, for the fullness within left them no room to enter.
Where Airs, Waters, Places surveyed the sculpting of physiques by local airs, the anatomical forms admired by the dissector reflected the proposeful articulation of matter by innate breath. Parts ceased to be mere shapes, schema, and became organs, implements of the soul; and muscles, in particular, were born as the organs of voluntary motion, actions determined by the self. Where once pneuma served luck, in the flexing of muscles it expressed decisive will. (P.269).
Hidden by their physical transparency and by centuries of oblivion, winds are invisible in the pictures that introduced this book. Yet to overbook their latent presence in figure 1 and figure 2 would be to miss a crucial part of what these illustrations mean. For the capaciousness of one body and the muscularity of the other portrayed, among other things, differing answers to a problem once posed most forcefully by wind, namely, how to imagine human being in a world of ceaseless change.
In his beautifully expressed Epilogue, Kuriyama explains the intricacies of diagnosis. "….In taking the pulse or feeling the mo, in dissecting muscles or scrutinising colour, doctors doctors strove above all to comprehend what the body expressed (hence the title of the book, The Expressiveness of the Body D. P. Agrawal). They sought to know the invisible, inaudible, intangible truth of living beings through bodily expressions that could be seen, and heard, and touched – to work back from manifest signs to their secret vital source." (P.271).
He also shows the cultural differences in both diagnosis and medication in different medical systems.
Kuriyama admits that the truth, however, is that there is no unique road back and there are no fixed and unmistakeable signs. A vast chasm gapes between the inescapably limited scope of human awareness in any given era at any given place and the unknowable boundless plenitude of life's manifestations. Changes and features that speak eloquently to experts in one culture can thus seem mute and insignificant, and pass unnoticed, in another. Greek pulse takers ignored the local variations that their counterparts in China found so richly telling; Chinese doctors saw nothing of muscular anatomy. This is how conceptions of the body diverge – not just in the meanings that each ascribes to bodily signs, but more fundamentally in the changes and features that each recognizes as signs. Differences in the history of medical knowledge turn as much around what and how people perceive and feel (at once apprehending the body as an object, and experiencing it as embodied beings) as around what they think.
Emphasising the challenges and the excitement of such comparative studies, Kuriyama sums up, "I have presented concrete illustrations of such differences in ancient Greek and Chinese medicine, and identified some of the factors that shaped them. I have proposed parallels between ways of touching and seeing on the one hand, and on the other, ways of speaking and listening; I have stressed the inseparability of perceptions of the body and conceptions of personhood; and I have highlighted the interplay between the sense of embodied self and the experience of space and time. Throughout it all, however, I have also sought to convey a more general, and yet more intimate lesson. I have tried to suggest how comparative inquiry into the history of the body invites us, and indeed compels us, ceaselessly to reassess our own habits of perceiving and feeling, and to imagine alternative possibilities of being – to experience the world afresh. Such is the great challenge of charting the geography of medical understanding. And also its alluring promise." (P.272).
For a lay reader, it would have been easier to give absolute dates of the Chinese Dynasties instead of saying only Han or Shang. Or he could have given a chronological table. But it’s a minor lacuna. The book is not only a stimulating read, alluring in its lyrical prose, but also full of medical and cultural information about the world’s two oldest civilisations. The long contacts of India with China through Buddhist monks transmitted technological and medical knowledge too, but a discussion of Indian and Chinese medical systems would require another treatise, which we hope the author would take up some day. The book is a must for the students of culture and history if medicine.
Chattopadhyaya, D. 1982. Case for a critical analysis of the Charak Samhita. In Studies in the History of Science in India (Ed. D. Chattopadhyaya). Vol. 1. New Delhi: Editorial Enterprises. Pp. 209-236.
Morgan, Kris. 2000. Medicine of the Gods: Basic Principles of Ayurvedic Medicine. Oxford: Mandrake.