Political Thinkers' Access to Medical Knowledge

Italy and southern France (Montpellier in particular) at the turn of the twelfth and thirteenth centuries witnessed a revival of medical science, especially in the field of surgery. Medical works before the eleventh century had very little to say about surgery; from the twelfth century on, however, surgery was recognized intellectually, socially, and professionally.Footnote ²¹ The Arabic surgical treatises by Albucasis as well as Galen's On the Technique of Healing had a significant impact on the reawakening of surgical interest in Western Europe. One of the first surgical treatises by Western European surgeons was Roger Frugard's (Ruggero di Parma) Cyrurgia, which was widely used in the late twelfth and early thirteenth centuries.Footnote ²² By the end of the thirteenth century, northern Italy emerged as a center for surgical studies.

In the middle of the thirteenth century, however, surgery was not regarded as a part of medicine: Bruno de Longoburgo and Teodorico Borognoni had considered surgery to be instrumental to medicine. This ancillary status was declared null and void by Guglielmo da Saliceto (c. 1210–1276/1277), who taught and practiced surgery at Bologna and wrote a work on therapeutics, Summa conservationis et curationis in 1276. Guglielmo asserted that surgery was “one of the sciences contained within medicine, and it is possible to acquire this science [through reason], without ever having practiced, confirming it by testing it on particular cases.”Footnote ²³ Lanfranco of Milan completed his surgical treatise in 1296, which disseminated the new surgical techniques in northern France.

The development of surgery was concomitant with the rise of anatomical studies. The first recorded public dissection in the Middle Ages was performed around 1315 by Mondino de' Luzzi (c. 1275–1326) in Bologna. Anatomical knowledge did not remain a theoretical exercise but was incorporated into surgery. Henri de Mondeville (c. 1260–c. 1325), a leading anatomist, established the technical art of surgery; and Guy de Chauliac (c. 1298–1368), Mondeville's successor as doctor and surgeon to the Popes at Avignon, composed a treatise on surgery, which remained a standard textbook until the eighteenth century.Footnote ²⁴ With Mondeville and Chauliac, Paris and Montpellier witnessed the rise of surgical studies in France. Thus, the later Middle Ages may rightly be described as a time during which surgery once again received recognition as both an art and a science.

The revival of medical learning was not irrelevant to medieval intellectuals who wrote on government and politics. One of the earliest scholastic thinkers responsible for wider dissemination of medical learning is Albertus Magnus (c. 1200–1280). In his De animalibus the Dominican theologian examined a number of contradictions between Aristotle, Galen, and others. Albertus was not a medical scientist by training; however, he expressed serious interest in medicine and identified it as an autonomous discipline: “Augustine is to be preferred rather than the philosophers in case of disagreement in matters of faith. But if the discussion concerns medicine, I would rather believe Galen or Hippocrates, and if it concerns things of nature, Aristotle or anyone else experienced in natural things.”Footnote ²⁵ Thus Albertus situated medicine in the map of scholastic learning. The Austin theologian and a staunch “papalist” Giles of Rome is also known for his medical treatise on conception: De formatione corporis in utero (On the formation of the body in the uterus). In it, Giles expounded his physiological views, which were largely Aristotelian and anti-Galenic.Footnote ²⁶ Engelbert of Admont, abbot of the Benedictine monastery at Admont, whose treatise on the empire is widely known, also wrote extensively on theology, philosophy, and medicine.Footnote ²⁷

Perhaps the most illustrious case is Marsilius of Padua. His Defensor pacis (The Defender of the Peace), which aimed at identifying the one and only cause of war and strife in early-fourteenth-century Christendom, frequently compared the civil community with the animal body, thereby alluding to medical knowledge. Such allusions can be attributed to Marsilius's early academic training in medicine. Although he was born into the Mainardini, a prominent family in the civic administration of Padua, which was one of the centers of legal studies, he opted for medical studies before moving to the University of Paris, where he became a master of arts but failed to complete his studies at the Faculty of Medicine. As a result, Marsilius seems to have returned to Padua and resumed medical studies with Peter of Abano, a leading medical scientist of the fourteenth century.Footnote ²⁸

Medieval political thinkers did not need to have specialist training at the Faculty of Medicine in order to gain some medical knowledge. Aristotelian medical views were taught and studied in the Faculty of Arts at medieval universities, where all students were required to enroll before proceeding on to their specialist training in theology, law, or medicine. In the thirteenth-century University of Paris, students in the arts faculty were expected to study all Aristotle's works on natural philosophy including De animalibus.Footnote ²⁹ Hence, while the medical educational curriculum mainly featured non-Aristotelian works like Galen's Tegni and Ars Parva, Avicenna's Canon and Hippocrates's Aphorisms, students were already familiar with Aristotle's medical views prior to admission to the faculty of medicine. And through the study of Aristotelian views, medieval Arts students knew the differences between Aristotle and other medical authorities, such as Galen.Footnote ³⁰

However, the diffusion of anatomical and surgical knowledge in particular is probably not so much attributable to universities as to the papal court. The rebirth of anatomy has often been associated with Innocent III.Footnote ³¹ Indeed, the thirteenth century witnessed the warm reception of medical scientists by the papacy. The pontificate of Innocent III was the first to have a “papal doctor.”Footnote ³² Before the thirteenth century, no medical doctors entered the papal record. After the pontificate of Innocent III, medical scientists found their niche in the papal court and increased their presence. By the pontificate of Boniface VIII who is widely known for his uncompromising assertion of papal sovereignty, the papal court was inhabited by leading medical scientists of the time including Taddeo Alderotti and Arnold of Villanova. Throughout the thirteenth century, medical doctors were increasingly in charge of the “care of the [pope's] body (cura corporis)”;Footnote ³³ just as the curial theologians contributed to empower papal authority theologically and ideologically, so “court physicians” offered cutting-edge medical treatment for the prolongation of the pope's life. The papal court recruited not only leading theologians and legal experts but also talented medical scientists, thus forming a forum for intellectual exchanges.

Tokugawa Japanese political thinkers' access to medical knowledge is perhaps more evident. Tokugawa medicine was shaped by the assimilation of classical Chinese medicine. At the core of the medical curriculum was the Treatise on Cold-Damage Disorders. It was a canonical text on the diagnosis and remedy of diseases. Because Chu-Hsi Confucianism was employed by the Tokugawa Shogun regime as the official orthodox learning, physicians assimilated Confucianism, thus producing a number of “Confucian physicians (jui);” by the end of the seventeenth century, it had become common that physicians lectured on Confucianism and Confucian scholars were versed in medicine.Footnote ³⁴

The relationship between Confucian and medical learning was problematic, however. Some Confucian scholars criticized the fusion of the two disciplines; others denounced those who identified themselves as Confucian physicians since they were often neither Confucian scholars nor physicians; yet others vindicated the combined learning of Confucianism and medicine.Footnote ³⁵ The role of Confucian scholars was to explore government philosophically, while that of physicians was to heal illnesses. Confucian learning was regarded as the great art of ruling the body politic, while medicine the lesser art of ruling the body natural. Yet Confucian physicians emerged between Confucian scholars and physicians in terms of social hierarchy: Confucian scholars dealt with the state; Confucian physicians dealt with medical learning, and physicians healed illnesses. Accordingly, the canons that they studied were stratified: the Confucians' canons were Six Canons, and physicians' was the Treatise on Cold-Damage Disorders (c. 200 AD). Confucian physicians identified the Huang-ti nei-ching or the Yellow Emperor's Canon of Internal Medicine (probably before 200 AD) as their canon.Footnote ³⁶The Yellow Emperor's Canon of Internal Medicine was not simply a medical treatise of anatomy, physiology, pathology, diagnosis and therapeutics but also discussed cosmology and geography. Its scope covers both philosophical arts of ruling and healing. Physicians who were versed in Confucianism and Confucian scholars who studied and/or practiced medicine were expected to familiarize themselves with the work. When we examine medical metaphors in Tokugawa Japanese political writings, we shall therefore find medical references to sections of the Yellow Emperor's Canon of Internal Medicine.

Perhaps the best example of a Tokugawa political thinker who was well versed in medicine was Ogyu Sorai (1666–1728). Sorai is widely known as Japan's first modern political philosopher; among his voluminous literary output, less known is a treatise on the Yellow Emperor's Canon of Internal Medicine Su wen.Footnote ³⁷ In Responsals, too, he exhibited his pharmaceutical knowledge.Footnote ³⁸ Sorai's father and grandfather were physicians. Sorai did not practice medicine but was well versed in it. Dazai Shundai, Sorai's leading disciple, was a critic of Confucian physicians; however, he, too, practiced medicine before he established himself as a Confucian scholar and maintained some interest in it throughout his academic career.Footnote ³⁹ Miura Baien (1723–1789), arguably one of the most profound and erudite Confucian philosophers of Tokugawa Japan, was also well versed in medicine. His philosophical works, especially Zeigo (Superfluous Words),Footnote ⁴⁰ include substantial accounts of natural philosophy on medical issues. Baien also wrote a practical guidebook for healthcare, Yojo kun (On Healthcare). In both writings, Baien drew on the medical views of the Yellow Emperor's Canon of Internal Medicine Su wen. Nakai Chikuzan (1730–1804), a leading Confucian philosopher of the Kaitokudo school in Osaka, was from the medical family of Banshu-Tatsuno principality.Footnote ⁴¹

At the twilight of the Tokugawa era, Sakuma Shozan, a Confucian political thinker and a Western-style military scientist, was also a skilful physician and surgeon. He is one of the pioneers in surgical operation and vaccination.Footnote ⁴² Fukuzawa Yukichi (1834–1901) is one of the greatest leaders of “Japanese Enlightenment” in the post-Tokugawa period; however, before the fall of the shogun regime, Fukuzawa was trained in medicine by Ogata Koan (1810–1863), an expert in Dutch medicine.

Thus, the relationship between medicine and political thought is not as distant as one might assume. Medieval European political thinkers did not necessarily engage in the specialized study of medicine, but they had access to medical knowledge through the study of Aristotelian natural philosophy in the faculty of arts in the universities as well as by their involvement in papal circles, which included leading medical experts as well as popes and high ecclesiastics who were seriously interested in medicine. Tokugawa Japanese political thinkers were well informed about medicine as a result of the fusion of Confucianism and medicine; they were not only aware of the analogous relationship between Confucianism and medicine but also were required to be proficient in both disciplines.

Medical Metaphor in Late Medieval Political Writings

So wrote Dante. He thought that medical treatment was comparable to political rule. “The knife and fire” refer to surgery and cauterization, respectively, alluding to the use of physical force in resolving a political dispute. But they were “a last resort.” Medical treatment can take a variety of forms, just as there are various types of constitutional arrangements. Medieval medical practitioners treated mental and physical illness with three main types of therapy: diet, medication, and surgery.Footnote ⁴⁴ Arnold of Villanova argued that medical treatment must follow three stages from diet to use of drugs and to surgery.Footnote ⁴⁵ Gentler treatment ought to precede harsher ones. The “treatment” of the body politic, however, is, according to political thinkers in medieval Europe, largely twofold: surgery and medication. I am unaware of any case in late medieval political writings where diet—the gentlest treatment—is featured as a metaphor for government. Diet as a medical treatment depended on the theory of humoral physiology, in the light of which some pathological accounts of the body politic were produced. Nicole Oresme described tyranny as the excessive inflow of humors into the head.Footnote ⁴⁶ Philippe de Mezières explained that the corruption of four humors resulted in seven types of illnesses and argued that the good government requires four virtues: norm, chivalrous discipline, obedience, and justice. The corruption of any of these would cause corruption in government.Footnote ⁴⁷ Similarly, Nicholas of Cusa described pathological states of the body politic by comparing “melancholy” with the crimes of avarice—like fraud, deceit, and theft—and “fever” with wars, dissensions, and divisions.Footnote ⁴⁸ Late medieval European medicine was aware of the importance of daily healthcare. Indeed, the regimens of healthcare, including diet and hygiene, had been discussed by medical thinkers in antiquity as well as in the Middle Ages. For example, Avicenna's Canon of Medicine, which circulated widely in the fourteenth century, followed Galen's notion of health by arguing that the art of preserving health lies in establishing equilibrium among various aspects of life including the selection of food and drink, care for the body's composition, moderate exercise, and so forth.Footnote ⁴⁹ In turn, this notion of equilibrium was incorporated metaphorically into the political discourse on peace and order. Nicholas of Cusa, for instance, compared the emperor with “an expert doctor” and wrote: “[T]he emperor's concern should be to keep the body well so that the life-giving spirit can dwell in it properly because it is well-proportioned.”Footnote ⁵⁰ Here the role of medicus rei publicae is not to treat diseases by medication or surgery but to maintain wellbeing.

However, none of these examples relates the humoral physiological accounts to any discussion of treatment; as far as I can determine, there was no account of how to maintain good proportion of humoral balance. Cusa only suggested to “seek a remedy and listen to the books and advice of the most learned doctors of the commonwealth in earlier times.”Footnote ⁵¹ The reference to surgical and pharmaceutical treatment, by contrast, is markedly prevalent. I shall, therefore, focus on the metaphors of surgery and medication. Understanding the significance of the emphasis on harsher treatment, however, requires an examination of medical metaphor in late medieval European political writings.

The removal of criminals from society is typically compared with amputation of diseased members. In response to the question of whether it is legitimate to kill sinners, Thomas Aquinas maintained that killing is legitimate as long as such action serves the wellbeing of the whole community. And the right to kill malefactors should be reserved to those who are in charge of the care of the entire community. To illustrate the point, Aquinas employed a metaphor of amputation: “[I]f … the wellbeing of the whole body demands the amputation of a limb, say in the case where one limb is gangrenous and threatens to infect the others, the treatment to be commended is amputation.” Since every individual constitutes a part of the whole, Aquinas concluded that “if any man is dangerous to be community and is subverting it by some sin, the treatment to be commended is his execution in order to preserve the common good.”Footnote ⁵² Aquinas addressed the same question as regards sinners; he was unequivocal in maintaining that should any man pose danger to the community on account of some sin, the commended course of action would be his execution in order to preserve the common good. In this context, Aquinas explicitly compared the surgeon to the ruler. The surgeon who has been entrusted with the health of the whole body may amputate a gangrenous limb. Similarly, the ruler who has been entrusted with the care of the whole community exercises public authority and, therefore, may execute wrongdoers.Footnote ⁵³

Ptolemy of Lucca (c. 1236–c. 1327) appealed to the metaphor of amputation when he discussed the cases in which rulers could justly use the private property of their subjects “by reason of transgression.” He suggested that private property could be seized for reasons of justice. In this context, Ptolemy writes: “We cast off a more vile part in order to preserve a part that is nobler. We amputate a hand so that the heart and brain, in which a human being principally consists, might be preserved.”Footnote ⁵⁴ Amputation of a hand was comparable to the seizure of private property from individuals who transgressed the law. Like Thomas, Ptolemy associated amputation with punishment.

In an ecclesiastical context, the metaphor of amputation could refer to excommunication. Giles of Rome argued that those who dissent from spiritual authority can be slain by the spiritual sword in order to separate them from the community of believers. In this context, he wrote: “[J]ust as a limb amputated from the body is necessarily a dead limb, because the heart can no longer infuse the force of life into a member thus cut off, so the soul which does not obey the spiritual powers is spiritually dead by reason of ecclesiastical censure, since that which is thus separated and cut off from the communion of the faithful will not be able to share in the influence of spiritual grace.”Footnote ⁵⁵ John Wyclif, however, referred to amputation in relation to what he believed to be the “invisible” true Church. He maintained in the light of his doctrine of predestination that the Church as the congregation of the predestinate should amputate the reprobate.Footnote ⁵⁶ In both cases, amputation alluded to the spiritual sanction for those outside the community of the faithful.

Another type of medical treatment that is sometimes employed less often than amputation is medication. When Ptolemy of Lucca discussed regal and despotic rulership, he compared “the penalties that persons institute through laws” with medicine.Footnote ⁵⁷ Similarly Marsilius of Padua discussed the efficient cause of governance and wrote: “[I]f any part should do or suffer injury, he who inflicts the injury must be cured through the action of the ruler, by sustaining punishment.” “For punishment is like medicine for a delict.”Footnote ⁵⁸ Both Ptolemy and Marsilius referred to medicine as a punitive measure. John Wyclif argued that the “medicine” that is required to purge the Church of its blasphemy and to restore its first perfection was “to expropriate the entire clergy and renew the former order of Christ.”Footnote ⁵⁹ Wyclif clearly compared his radical program of ecclesiastical reform with medication, implying punitive sanctions on corrupt priests.

The use of medicine might appear a gentler approach than surgical measures such as amputation; however, the essential characteristic of these treatments was effectively the same: the punishment of wrongdoers. We have seen earlier that medieval medical practice was not confined to harsh treatments: the common practice was to begin with a mild treatment such as a diet, which was followed sequentially by harsher treatments such as drugs and surgery. The dearth of any discussion of “diet” in the political use of medical metaphors is illuminating. While both amputation and medication are curative in the sense that they both aim to restore health to the body, they are grasped as means for eradicating the causes of physical abnormalities. These medical metaphors suggest that an important function of government was to uproot the sources of political upheaval and social strife by coercive measures.

These metaphorical expressions may be rooted in the traditions of classical rhetoric. For instance, the metaphor of amputation has a millennium-old literary tradition: Cicero, for instance, compared tyrannicide with amputation:

Amputation was compared to the punishment of a wrongdoer, a tyrannical ruler in this case. Clearly, the rhetorical reference to amputation was not unprecedented in the Western tradition of political discourse.

Likewise, the characterization of medical treatment as punishment may be traced back to Aristotle. When Aristotle discussed how to build up an excellent personality in his Nicomachean Ethics, he maintained that punishments were given because of pleasures that were brought about by performing wrongdoing. Yet pleasures and pains follow from every action, and wrongdoings must be followed by pain: “punishment is a kind of cure.”Footnote ⁶¹ The Aristotelian metaphor between punishment and medical treatment, however, was used in an educational rather than a political context. Cicero, by contrast, employed the metaphorical reference to the use of drugs specifically in a political context. Cicero inquired: what if an excellent political leader is faced by crisis? His response was that “[W]hen confronting danger, … we should copy the doctor, whose custom it is to treat mild illness mildly, though he is forced to apply riskier, double-edged, remedies to more serious illnesses. … That is particularly so when a successful outcome may bring more good than the period of uncertainty evil.”Footnote ⁶² This Ciceronian idea of “the physician of the commonwealth” (medicus rei publicae) survived into the Middle Ages, being echoed in John of Salisbury. John argued in his Policraticus that the prince should confine the amount of affection that he shows to his subjects “to the limits of moderation” and continued:

Clearly John of Salisbury modeled his argument on Cicero. Clearly, the metaphor of medical treatment largely invoked an understanding of political rule as a punitive function: physicians and surgeons of the commonwealth are largely expected to eradicate the sources of political, religious, and social disorder by punitive measures.

While it is possible to surmise that rhetorical knowledge was the experiential basis of medical metaphors, we cannot dismiss the medical experience of the later Middle Ages as the “source domain” of such metaphors. Modern scholarship notes that it was in the field of surgery that medieval medicine made notable advances.Footnote ⁶⁴ I have already illustrated the rapid development of medieval surgery. The progress in surgery was widely acknowledged since the results of operations were perceptible and, therefore, more evident than those of other therapeutics.Footnote ⁶⁵ The use of medical metaphors in political writings is prevalent from the thirteenth century onward. Indeed, the examples of medical metaphors aforementioned are all drawn from the political writings of the thirteenth and fourteenth centuries. It is no coincidence that medical language penetrated political writings in the thirteenth century. As already noted, Innocent III is attributed with the reawakening of medical science in the papal curia. Innocent III also introduced medical language in his writings. He often cited the opinions of physicians, and his sermons were full of medical references.Footnote ⁶⁶ The papacy contributed to the spread of not only medical knowledge per se but also medical metaphors in political and religious texts. The remarkable development of anatomy and surgery formed an experiential basis for the metaphorical association between political rule and medical treatment.Footnote ⁶⁷

Recently, Cary J. Nederman has shown rightly that the so-called organic metaphor of the body politic was not as monolithic as had been conventionally considered;Footnote ⁶⁸ however, the historical diversity of medical metaphors may be attributed to the developing knowledge of the human body. As anatomical and surgical knowledge developed in the later Middle Ages, anatomical metaphors in political discourse underwent significant changes. This can be illustrated by a comparison of medical metaphors employed by the twelfth-century humanist John of Salisbury and the fifteenth-century theologian Nicholas of Cusa. John of Salisbury devoted books 5 and 6 of his encyclopedic treatise Policraticus to a comparative analysis of the structure and function of the natural and political bodies. John claims that his bodily metaphors are modeled on Plutarch's work, The Instruction of Trajan, which was, in fact, John's own invention. John first distinguishes the soul from the body. The soul corresponds to those who administer the practice of religion. “Indeed, those who direct the practice of religion ought to be esteemed and venerated like the soul in the body. … … [J]ust as the soul has rulership of the whole body so those who are called prefects of religion direct the whole body.”Footnote ⁶⁹ The soul's relationship to the body is that the soul stimulates and rules the head. The position of the head is occupied by a prince, who is “subject only to God and to those who act in His place on earth.”Footnote ⁷⁰ At the heart of the commonwealth is the senate, “the office of counsel and rulership.”Footnote ⁷¹ The eyes, ears, and tongue of the prince are the governors of provinces, who would rule provinces in the name of the prince. Financial officers and keepers are compared to the stomach and intestines. The armed hand is soldiers and the unarmed one is tax collectors. Finally, the feet are compared with peasants “perpetually bound to the soil.”Footnote ⁷² Clearly, John's bodily metaphors mainly cover the external organs, and his reference to internal organs is scant.

Nicholas of Cusa's deployment of bodily metaphors, by contrast, is far more detailed and elaborate in anatomical terms. Cusa concluded his Catholic Concordance, a complex treatise on the principles of government in the Roman Church and the Holy Roman Empire, with an extensive comparison between the Church and the Empire, on the one hand, and the soul and the body, on the other. Cusa argued that the body consisted of bones, nerves, and flesh. He compared the nerves with the imperial laws. The head represents the emperor, the country the bones, and the flesh “the transitory men.”

The harmony of the ecclesiastical order depends upon “the divine and canonical sanctions,” which stem from the Holy Spirit and the natural law. The Holy Spirit needs to reach every corner of the body, and Cusa compares the blood with the vehicle of the soul. Thus he wrote:

Similarly, Cusa compared “the veins that start from liver and spread through the whole body” with canon law. Indeed, the liver corresponds to a council, the legislative organ in the Church. It is fair to say that John of Salisbury's organic metaphor largely focused on externally observable bodily parts, and his references to internal organs were scant: he mentioned only heart, stomach, and intestines. By contrast, Cusa demonstrated sophisticated anatomical and physiological knowledge when he underlined the functions of the nerve and blood systems, of which John was clearly unaware.

Cutting-edge medical research might possibly contribute to Cusa's medical discourse on the Church. His notion of a “blood system” in the Church was arguably modeled on Galen's theory. Indeed, Galen's theory remained authoritative until 1628, when William Harvey published his discovery on the circulation of blood. Galen believed that blood was used up at the end of the body, never to return to the heart. The Galenic model of the blood system explains that two types of blood—the venous and the arterial—are conveyed through various pathways connected to two chief organs—the liver and the heart—that provide nutrition and vitality, respectively. The venous blood originates in the liver, which provides nutrition for the blood, while the arterial blood originates in the heart, which provides pneuma (spirituous air) to the blood.Footnote ⁷⁴ Just as the blood created by the liver is provided with pneuma by the heart and conveyed to all the members of the body, so, Cusa argued, canon law created by councils inspired by the Holy Spirit is conveyed to every corner of the Church. Clearly, Cusa's metaphor of the blood system is parallel to Galen's theory. In the twelfth century, the Galenic medical writings were not readily available outside southern Italy. By the fifteenth century, however, Latin translations of Galen's medical writings circulated widely in Latin Europe. Cusa's surviving library at Kues contains a good range of medical books.Footnote ⁷⁵ He had studied in Padua, one of the leading centers of medical studies,Footnote ⁷⁶ and he was arguably well versed in contemporary medical theories. The precision of Galenic physiological and anatomical knowledge that underpins his metaphor of the body politic cannot be comprehended without knowledge of contemporary medical science.

Cusa's metaphorical emphasis on the circulatory system in his political discourse was not an isolated case. In his On the Laws and Governance of England, Sir John Fortescue discussed the origin of political rule by using an embryological metaphor and compared blood with political provision that nourishes the whole body.Footnote ⁷⁷ The emphasis on the circulatory system was entirely absent from the medical metaphors in medieval political discourse before the revival of medical studies. Clearly, Fortescue was not unaware of contemporary medical views.

Medical Metaphor in Tokugawa Political Writings

Anatomical metaphors were markedly absent from Tokugawa Japanese political writings, and this absence may not be irrelevant to the contemporary state of Japanese medicine. Anatomical and surgical interest in the human body was almost entirely unknown in Japan until the middle of the eighteenth century.Footnote ⁷⁸ Vesalius's De humani corporis fabrica arrived at Nagasaki, Japan, in 1645; however, Vesalius's influence on Japanese medicine is entirely unknown.Footnote ⁷⁹ More than a century later, Yamawaki Toyo (1705–1762) dissected the body of an executed criminal and wrote Zoshi, the first Japanese treatise on anatomy (1759). Sugita Genpaku (1733–1817) cultivated serious interest in anatomy through his encounter with Dutch medicine; in 1771, he observed the dissection of an executed criminal and was astonished by the accuracy of anatomical descriptions in Tafel Anatomia, a Dutch translation of a treatise on anatomy by a German doctor. This experience led Genpaku and his colleagues Maeno Ryotaku (1723–1803) and Nakagawa Junan (1739–1786) to translate Tafel Anatomia, a most ambitious undertaking completed in 1774. Before the dawn of anatomical studies, the approach of doctors in Tokugawa Japan to the human body followed the lead of ancient Chinese medicine.Footnote ⁸⁰

Why did Japanese medical scientists not express interest in the interior of the human body until the middle of the eighteenth century? Since the eighth century (possibly earlier) in Japanese criminal law, dismembering a corpse was considered one of the worst of crimes. No statutes issued by Tokugawa government (bakufu or kogi) prohibited dissection of bodies, which, however, was widely deemed as a de facto crime.Footnote ⁸¹ In addition, skepticism about the utility of anatomical knowledge remained influential until the eighteenth century. Yoshimasu Todo, for instance, argued that human organs are as such when they are inhabited by the soul. The “soulless” organs are not the same as those when they were alive. Hence, the observation of dead organs will not add any significant medical knowledge. The critics of emerging anatomists were largely not interested in the ultimate cause(s) of morbid states. Their attention was focused on symptoms. Indeed, no one would dissect a patient's body to determine the pathological cause(s).Footnote ⁸²

Correspondingly, the anatomical and surgical metaphor was unknown in Tokugawa Japanese political writings before the mid-eighteenth century. Tokugawa Japanese political writings before the mid-eighteenth century adopted organic metaphors, and yet the political use of bodily metaphors drew on the nonanatomical dichotomy of mind and body. Tokugawa Japanese intellectuals were familiar with the Chinese medical classics and one such work, The Yellow Emperor's Classic of Internal Medicine, used an anatomical metaphor when discussing the body politic. It compared a human body with a state and identified the heart, where spirit and enlightenment originate, with the ruler, the lungs with the ministers, the liver with the general, the stomach with officials in charge of storing provisions, the kidneys with other officials and so forth.Footnote ⁸³ And yet, early Tokugawa Japanese intellectuals did not assimilate anatomical metaphors into their political discourse. The Confucian philosopher and medical doctor Kaibara Ekiken (1630–1713) identified the mind with the ruler; the five sensorial organs—ears, eyes, mouth, nose, and the rest of body—were identified with the ruler's subjects.Footnote ⁸⁴ When the seventeenth-century Japanese military scientist Yamaga Soko (1622–1685) discussed the functional parts of a political community, he compared the mind and body with the ruler and the ruled, respectively. However, his reference to bodily parts lacked anatomical detail. Soko classified the ruled subjects into three groups—farmers, craftsmen, and merchants—and described farmers as the most important of the three. To reinforce this, Soko deployed a bodily metaphor: “[T]he absolute necessity for a person is food and agriculture is comparable to the flesh of a human body. This explains why agriculture is most salient.”Footnote ⁸⁵ No reference to the internal organs of the body can be found in any discussion on the functional parts of the political community by Tokugawa intellectuals before the mid-eighteenth century.

It was Miura Baien who introduced anatomical imageries into the discourse on governing institutions. Baien was well versed in Japanese anatomical findings as well as the Dutch discoveries through Genpaku's translation of Tafel Anatomia; indeed, he himself practiced the dissection of animals. He considered that the human's flesh consisted of two elements: organs (zo) and bowels (fu) (muscles are categorized as part of bones). The central part of “organs (zo)” is the heart, while the central part of “bowels (fu)” is the stomach. Baien's anatomical metaphors are focused on ruling offices. He compared the heart with the princely palace and the stomach with government offices.Footnote ⁸⁶ The anatomical metaphor of the body politic did not gain significant currency, however, in Japanese political discourse. Arguably, Japanese medicine's interest in the internal structure of the body was too recent to establish a metaphorical language of anatomy or surgery.

The widely circulated medical metaphor in Tokugawa Japanese political discourse was the use of medicine. Pharmaceutical treatment, however, was compared not so much to coercive measures used by political authority as to admonition to political rulers. Such use of pharmaceutical metaphors can be found, for example, in the work of Yamamoto Tsunetomo (1659–1719). Tsunetomo was one of the close retainers of Nabeshima Mitsushige, a lord (daimyo) of the Principality of Saga. Upon his death, Tsunetomo retired from service, became a Buddhist priest, and produced his celebrated work Hagakure, in the period between 1710 and 1716. His intellectual background was shaped by Confucianism and Zen Buddhism along with Bushido (The Way of Samurai). In his discussion on giving advice to the prince, Tsunetomo advocated tolerance of “diseased” rulership. Hagakure discussed extensively the way of life of a samurai. One of the salient features of the work is that Tsunetomo accentuated the importance of giving admonitions (kangen) to the lord as the duty of a samurai. He argued that the admonition should be given to the lord before he practices unjust policies. In this context, he used a medical metaphor: “[W]e would not need to use medicine after getting diseases; daily maintenance of the wellbeing would suffice.”Footnote ⁸⁷ Tsunetomo did not believe that medicine would effectively heal diseases; it would only help to maintain health. Likewise, offering admonitions—the use of medicine—would not help remedy unjust rule. Tsunetomo's view of the handling of the unjust ruler corresponds to the Japanese medical idea that the maintenance of health, rather than the uprooting of disease, is considered of primary importance. Tsunetomo dissuaded readers from using “medicine” for the lord's wrongdoings because he feared that such use of “medicine”—giving admonitions after the lord had actually soiled his hands—might damage the reputation of the lord by rumor.Footnote ⁸⁸ A significant implication of this idea is that the maintenance of wellbeing—frequent admonitions before the lord's wrongdoings are actually performed or become public knowledge—virtually amounts to the concealment of the tyrannical nature of the lord.

The comparison between admonition and daily healthcare was not unique to Tsunetomo; Kaibara Ekiken, a physician and Confucian thinker, also employed a similar metaphor repeatedly. “[A] lord's refusal to listen to his subject's admonition is comparable to a patient's adamant refusal to take any pills which would lead to death.”Footnote ⁸⁹ Ekiken's notion of admonition clearly differed from Tsunetomo's in that the former viewed admonition as a corrective means for a lord's wrong-doings, while the latter regarded it as a preventative means. They disagree on how to use drugs but agree on the notion that the use of drugs was comparable to the admonition to rulers.

However, the most striking feature of the political use of medical metaphors in the Japanese political writings is the emphasis on the importance of preventative medicine. Medical treatments, such as the use of drugs, are of secondary importance. What government should achieve is comparable to preventing “illnesses,” thereby comparing political rule with daily healthcare. The conceptual metaphor—“government is daily healthcare”—formed a deep undercurrent in Tokugawa Japanese political discourse. Miura Baien, for example, underlined the importance of the maintenance of wellbeing. According to him, “medicine can be attributed to hygiene and healing.”Footnote ⁹⁰ Healing concerns the use of drugs, while hygiene relates to the training of the body and the maintenance of wellbeing. The importance of daily healthcare pervades his comments on rulership. Referring to Su-wen (Pure Question) section of the Yellow Emperor's Canon of Internal Medicine, Baien wrote:

Baien practiced clinical medicine while he produced a number of treatises on natural philosophy. He was unique in his wide-ranging knowledge of both Eastern and Western medicine and the natural sciences. And yet, his notion of medical treatment was firmly anchored in the Su wen—the canon for Japanese Confucian physicians; he believed that medicine should primarily serve daily healthcare.

The passage that Baien quoted from Su wen was commented on and praised by Ogyu Sorai (1666–1728), arguably the greatest political philosopher of Tokugawa Japan.Footnote ⁹² He wrote: “This is the statement of utmost importance in Su wen.”Footnote ⁹³ Sorai's understanding of medicine informs his emphasis on the limits of political rule. Ogyu Sorai often wrote that human affairs were a living thing (ikimono). An important implication of this fact, according to Sorai, is that the affairs of the state and society are unpredictable. The workings of a living being are so complex that one could never fully comprehend them; one could only try to control them. Sorai's notion of the state as a biological being enabled him to make a metaphorical reference to medical treatment in his discourse on political rule. In his Responsals, for example, Sorai wrote about how to read history books. He argued against a “theoretical” interpretation of ancient Chinese history; he advises an understanding of historical facts as brute facts. Sorai, then, noted that “ruling a country is like a physician controlling an illness.”Footnote ⁹⁴ However, he did not believe that a doctor could take full control of a combination of symptoms. One cannot tackle all the symptoms at once. In so arguing, Sorai suggested that some diseases would heal naturally: “Although some treatments first eliminate phlegm and fever and then restore the vital force, simply restoring the vital force obviates the need to pay attention to anything else, and the various other ills will disappear naturally. If lumbago is diagnosed as the original ailment and controlled, the rest will heal naturally.”Footnote ⁹⁵ In the political context, therefore, it is not always necessary to tackle every single symptom of political malaise. Some political upheavals may settle naturally.

Some other political diseases, on the other hand, can never heal, especially prolonged ones. In such cases Sorai argues against appeal to any drastic measure.

Sorai makes it clear here that there is no “cure” for long-standing diseases of government. He was certainly not a proponent of radical solutions to political stagnation, and this conservatism stems from his vision of the “body” politic: “The people of the world are interdependent, complementary, and one body. And this is why the affairs to which they have become accustomed over the years have taken root and spread in all directions. Many have profited by relying on them” (emphasis added).Footnote ⁹⁷ Sorai's preference for controlling the status quo is manifest when he stated that “[T]he people are comfortable with what they are used to. Things that have been done over and over for some time began to leave their imprint several generations ago, … and thus even something that is bad is regarded as good.”Footnote ⁹⁸ Political and social deeds that should be regarded as bad can turn to good if they are practiced by a multitude of people for a long period of time. Sorai's vision of the country as a “body” politic allows for injustice for the sake of the prolongation of the body's life; any drastic treatment of a long-standing disease cannot be recommended since it might risk the patient's life. In his vision, political rule as medical treatment is far from the art of curing; Sorai was emphatic on the limits of politics as means for resolving conflicts. This was the reverse side of his Chinese notion of medicine as daily healthcare.

Japanese medical scientists who were instrumental in the reception of Western medicine were not immune to the idea of ideal medical treatment in Su wen. When Sugita Genpaku commented on diplomatic affairs, he observed that Russia would be the source of a serious “disease” for Japan, and wrote: “A great doctor would cure a disease before its symptoms appear. An error in handling Russia would lead Japan into an almost incurable disease” (emphasis added).Footnote ⁹⁹ While Genpaku is known as the pioneer in the introduction of Western medicine, his notion of medical treatment was anchored in the ancient Chinese view.

Healing wounds or illnesses was the concern of “mere” physicians who relied on the Treatise on Cold-Damage Disorders. For Confucian physicians who considered themselves to be superior to physicians, however, medicine was primarily the art of maintaining wellbeing (yojo). Yojo is more than dietary control or preventative medicine; it concerns how to choose good doctors, use medicine, and control one's desires, and also covers hygiene and health and the moral education of children. It encompasses a wide range of issues in human life and is the “art” of living to achieve a healthy, moral life.Footnote ¹⁰⁰ Kaibara Ekiken elaborated on his theory of yojo in his Lessons on the Maintenance of Well-being (Yojo-Kun).Footnote ¹⁰¹ In it, Ekiken underlined that yojo would prevent diseases and quoted Su wen: “The sages did not treat those who were already ill; they instructed those who were not yet ill.” The Japanese notion of pharmaceutical treatment was deeply anchored in this classical Chinese view of healthcare.

The arrival of Western learning (yogaku) in the mid-eighteenth century, however, transformed medical metaphors in nineteenth-century Japanese political writings. Takano Choei (1804–1850), one of the first Western-style physicians, is well known for his criticism of the Tokugawa government's foreign policy, which resulted in his imprisonment and subsequent death. Choei expressed serious concern about the dearth of effective defense against colonial forces in Okinawa and wrote, “[I]f Western troops conquer Okinawa, there will emerge a major disaster for Japan. … Once the poison of a contagious disease arrives, it will be widespread very quickly and reach neighboring countries. In order to combat the contagious disease, one must treat it at its source.”Footnote ¹⁰² Medical treatment is seen by Choei as the eradication of the roots of a disease, not daily healthcare. Sakuma Shozan (1811–1864), a military scientist and a Western-style physician, served the Tokugawa government as a political advisor. In one of his recommendations for policymaking, Shozan compared a series of attempted coups d'état with “sudden pain,” which requires “temporary treatment to ease the pain,” but suggested the need to identify the ultimate cause of the disease in order to uproot it.Footnote ¹⁰³ As Western medicine penetrated Japanese academic activities, the traditional imageries of daily healthcare increasingly gave way to the Western counterpart of the eradication of pathological causes.