Superior and Inferior Physicians

While working on selecting texts for Volume Two of Classical Chinese Medical Texts, I found some interesting information on what constitutes a superior physician. There is also some information on what constitutes an inferior physician. I have picked three texts to look at. These three texts do not necessarily represent all that has been written on the subject, but as they are three of the older texts in Chinese medicine, namely the Ling Shu, the Nan Jing, and the Jin Gui Yao Lue, I consider them great models for one who strives toward becoming a superior physician.

Ling Shu Chapter 55

The superior physician treats that which is not yet ill. The inferior physician treats that which is already ill.

This is a fairly famous statement, which is often interpreted to be a call to preventative medicine. Modern physicians often complain that patients come in with specific complaints and it is impossible to treat what is not yet ill. I find this stance strange, as if we are to believe if someone has a disease which has already become manifest, the practitioner is prevented from treating what is not yet ill.

At any rate, the following quote from Nanjing has a completely different interpretation of the above passage:

Treating what is not yet ill means that when one sees illness in the liver (for example), this (can be) transmitted to the spleen. First fill (shi2) the spleen qi so that there is no way for it to accept the liver’s evil qi. This is what is called treating what is not yet ill.

As you can read, the writer of the Nan Jing felt that the meaning of treating what was not yet ill did not mean some psychic rendering of signs and symptoms, but a way of treating a person who comes with a specific complaint. One might go so far as to suggest that when the superior physician sees that one zang-organ has been afflicted by evil qi, the zang-organ in the control/destruction (ke) cycle of the five phases needs to be supported.

The Jin Gui Yao Lue explains this method works because when the spleen is supplemented,

it can injure the kidney. If the kidney is injured, then water doesn’t move. If water doesn’t move, then fire becomes abundant. If fire becomes abundant then the lung is injured. If the lung is injured then metal doesn’t move. If metal doesn’t move then the liver becomes abundant and is naturally cured. This is the secret meaning of supplementing the spleen to cure the liver.

As can be seen from both the Nan Jing and the Jin Gui Yao Lue, the superior physician understands the consequences of the actions of treatment through the five phase relationships. This may or may not have been the meaning intended by the Ling Shu; however, the closer a commentator is to the classic being commented, the more likely I am to take their claim to understanding it seriously.

In modern times, the five phases are relegated to old quackery that needs to be replaced with rigid diagnostic strategies and a focus on patient complaints to determine the affected system. If the five phases are not ignored, they are often taken to be central to Chinese medicine and not well balanced with the many other aspects of the medicine discussed in the classics.

In most modern schools, students are taught to observe, ask questions, palpate, form a treatment strategy based on the affected system, and then treat the affected organ or meridian directly.

This is almost the exact definition of the inferior physician from the same chapter of the Ling Shu.

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9 responses to “Superior and Inferior Physicians

  1. Hi – You post reminds me a story we were told in acupuncture school…

    ….that back in the day (ancient China, that is) the local physicians were paid to keep the population healthy. And when the people got sick? They stopped paying the physician, because he wasn’t doing his job.

    Wouldn’t that be an interesting idea to pass to the current healthcare debate in the US?

    I trained at the Swedish Inst. with Jeffrey Yuen (the story comes from him), and our education and training were certainly steeped in the Classics, as opposed to TCM. I am sure your posts and such are intended towards those who have not the same in depth exposure to the Classics, but I imagine if you engage any grad of Swedish Institute’s acupuncture program in a discussion of the Classics you will get a lively conversation.

    Thank you for the service you are doing to our field (the English-speaking Chinese medical practitioners, that is) and good luck with your endeavors!

  2. Richard,

    If I am not mistaken, it is also said that the superior physician treats the Shen. Heiner Fruehauf says all diseases come from the Heart.
    Five Elements is a wonderful way to treat people, and I feel it is the best way to be a superior physician who reaches those deep levels ( I don’t like these words in this context- superior and inferior).

    But in modern times, in the west, we sometimes need to be “inferior” meaning, that if someone was hurt by a car and suffered a whiplash, you need to treat the pain in the neck. There’s nothing inferior about helping that person by easing his pain (I know that you’re not saying that, I’m just thinking out loud about what you took from the classics).

    I feel that the trick is in both- use the superficial treatments when needed, and use the deeper treatments- reach the Shen and it’s parts when needed, even if you can do it without needles. That’s a wholistic point of view (as opposed to holistic, why drop the ‘w’ when that letter makes all the difference?).
    That’s the beauty of the art called Chinese Medicine.
    At least for me. 🙂

    Thanks for the interesting post,
    Yael

  3. Diana: Thank you for your comment. I have often heard this story, though I have never seen anything that leads me to believe that this was ever the case in China. Money was definitely collected for herbal remedies throughout most of Chinese history. We know this because so many physicians complained in their writings of physicians who took advantage of others for monetary or other material gain. Some physicians who came from wealthy families and later studied medicine never charged a dime. They thought charging for medicine was unethical. If I remember correctly, Li Dong-yuan (the author of the Pi Wei Lun) was one such physician. Regardless, I think it’s an interesting story!

    The post wasn’t really aimed at any specific group, as each group brings their own interesting perspective. I also believe that perspectives are limited, including my own. I try to look at Chinese medicine from every possible angle. The way I’m doing this now is by intensively studying classical texts. I’m also trying to bring out some of what the classics say in the hope that no one attaches to any one view point, which is all I can offer in such short blog posts. Thanks for reading!

  4. Hi Yael,
    I am fairly sure the Ling Shu does not say the superior physician “treats the Shen.” The classics say things like the Shen can become unrooted, the Hun can leave its home in the liver, etc. This usually happens because of an inner emotional state or an introduction of a pathogen. From what I understand, the Shen are not treated directly because they cannot have disease. Once their home is cleared up of pathogens or the state of balance returns, they return home. The Shen are always fine, it’s just that sometimes they are out to lunch. 🙂

    If there are people who believe that giving people relief is inferior, this is a total misreading of the Ling Shu. This happened in ancient times, too, as there are many commentaries that try to correct this. If we believe the interpretations of the Nan Jing and Jin Gui Yao Lue, this is about how the imbalance is to be treated. It is not about whether or not we treat the person. I think it is sad that people would put ideology over treating people’s conditions, and I certainly hope this is not the case!

    What I get from this is that the inferior physician attacks the disease directly. In the Nan Jing interpretation, the superior physician looks ahead, sees where this is all going, and stops it in its tracks. In the Jin Gui Yao Lue explanation, we are told that this works because of the five phase relationships. No one says “tell the patients they should have come before they suffered.”

    Thanks for your comment!

  5. Z'ev Rosenberg

    Clearly, the Nan Jing, Ling Shu and Jin Gui Yao Lue are asking us to practice a medicine that is process oriented, rather than a ‘this for that’, ‘symptom this, point/herb that’ approach. Seeing the transformations of a condition over time, observing the bing ji/pathogenesis, tracing its development is the mark of the superior physician. One can even treat stiff necks in this fashion. .

  6. Thanks for your comment Z’ev. I couldn’t agree more.
    R. Goodman

  7. Well, in the Ling Shu, Ch. 8, paragraph 2 it says “怵思慮,則傷神,神傷則恐懼自失” which I would translate as “Fear, worry, and overthinking damage the Shen, the injured Shen then causes panic and a loss of Self.” That sounds fairly explicit in favor of it being possible to injure the Shen. That concept is actually repeated a few times in that chapter as well, along with reference to the consciousness via the term 精神 Jingshen. I really don’t think its necessarily a case of an invulnerable Shen that only suffers via the failures of its container. I would also venture to say that the Shen is directly treated via the things that can either directly create or ameliorate the above listed conditions, meaning via the gate of Awareness. “The tongue is sharper than a two-edged sword” comes into play here. How many patients do we have that are stuck in a state of devastation, lacking any real ability to see the truth of their lives because of what they were told by a loved one at a young age or a similarly vulnerable moment? Remember when you were a kid the old ploy “wait until your Father gets home!” Worry, dread, causing panic and nearly lunatic behavior….I don’t think thats because the Heart took physical damage unseen, do you? I think this is an important distinction.

  8. Hi Michael,
    In responding to the above post, I was thinking more about “evil qi” or external pathogens unable to somehow invade the Shen, or take up residence within the Shen. I was also referring to the phrase “treat the Shen” or 治神, which does not occur in the Ling Shu (as far as I can find).

    Your point is well taken, however. I would agree that it is not just a matter of an unsuitable vessel. This is why I mentioned the inner emotional state. I would still venture to say that this refers to a leaving, though I could be off. The last two characters 自失 could also be referring to the Shen naturally or of themselves being lost once this dread or panic is present. The title of Chapter 8 is 本神, after all.

    I say this because I have never read anything about the Shen being subject to 虛實, for example. I have also never read anything about how to treat them, only to root them. They will not be rooted if there is “evil qi” in their place, nor if they have been damaged by emotions.

    I’m simply exploring possibilities here, and the ones you bring up are quite valid. At any rate, I love having discussions on this level 🙂

  9. A good point. I wonder if there’s any classical literature that talks about relative presence or absence of the Shen in a measurable form, like maybe via the pulse. I know the eyes are certainly an excellent gauge, but I wonder what else was written on that subject.

    And as fr as the “first treat the Shen” bit, I could have sworn I saw it in the LS but can’t find it either. I’ll keep looking.

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