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History 2: The Early Medical Classics

历史沿革2：早期医学经典籍 〔歷史沿革2：早期醫學經典籍 〕 lì shǐ yán gé 2: zǎo qī yī xué jīng diǎn jí

This section discusses the theoretical approach of the Huáng Dì Nèi Jīng and Nàn Jīng, the pragmatic approach of prescription literature, and the rapprochement between the two.

Contents

Theoretical Literature: Huáng Dì Nèi Jīng and Nàn Jīng

The earliest extant medical text describing the Chinese medical model is the Huáng Dì Nèi Jīng (黄帝内经 The Yellow Emperor’s Inner Classic), often referred to in abbreviated form as the Nèi Jīng. This text is considered the work of Hàn era medical scholars, although it encompasses medical knowledge that had accumulated over a considerable time. It comprises two parts, the Sù Wèn (素问 Plain Questions) and Líng Shū (灵书 Magic Pivot). Most of it takes the form of conversations between the ancient mythological figure Huang Di, the Yellow Emperor (黄帝), also known as the Yellow Thearch, and his physician Qì Bo (岐伯). Although the conversations each center on specific topics, the organization of the content generally lacks systematization.

The Nèi Jīng describes the organs, channels and network vessels, qì and blood, fluids, constitution, causes of disease, and methods of diagnosis, all within the framework of harmonizing Heaven and Earth and attuning the microcosm of the body to the macrocosm of the universe. In its statements about physiology, it describes a highly complex model of the organism’s internal workings. The fundamental concepts of this physiological model of organs, channels, qì and blood, fluids, and constitution came to be accepted without major challenges. It remains authoritative to this very day. Most descriptions of organ functions and the pathways of the channels and network vessels that appear in modern textbooks rest on Nèi Jīng statements.

The authors of the Nèi Jīng did not attend to detailed anatomical knowledge. They described the processes by which the human body created and transformed substances. They explained all bodily activity in terms of qì. Although the pathways by which substances moved around the body were often vaguely expressed, they nevertheless formed the basis for all therapeutic interventions in Chinese medicine.

According to the Nèi Jīng, the body is composed of organs and other body parts, each with specific functions. Most important are the five viscera (storehouses) and the six bowels (dispatch houses). These are considered responsible for extracting nutrients from ingested food, drink and inhaled air to produce the qì, blood, and fluids that nourish the body and power all its activities. The five viscera—liver, heart, spleen, lung, and kidney—store essential qì (e.g., qì, blood, fluids, and essence), but do not discharge. Because they deal with the internal products of the body, they are relatively internal and yīn in nature. The six bowels are the gallbladder, stomach, large intestine, small intestine, bladder, and triple burner, the last of these being an organ with no biomedical equivalent that is associated with the flow of original qì and water through the body. The bowels convey and transform matter, but do not store. Each viscus is paired with a bowel: the liver with the gallbladder, the heart with the small intestine, the spleen with the stomach, the lung with the large intestine, and the kidney with the bladder. A sixth viscus, the pericardium, is evoked to provide the triple burner with a complementary partner.

The grouping of the five viscera obviously reflects the influence of five-phase theory, while the pairing of the viscera and bowels reflects the yīn-yáng system. Clearly, the understanding of the internal organs represents a merging of these two theoretical systems. Given that the pragmatic, observation-based understanding of the body was the basis for the association with the systems of correspondence and that the empire paradigm exerted a further powerful influence, we can conclude that Chinese medical knowledge of the organs and channels is based on three approaches: direct observation; yīn-yáng; the five phases; and the empire paradigm.

Organ Features According to the Nèi Jīng

In the following paragraphs, we present the principal features of the five viscera and six bowels as described in the Nèi Jīng as an example of the book’s content. Since the Nèi Jīng authors did not tell us how they arrived at their specific conclusions, it is important to understand that our explanations of how the theories arose are essentially speculative.

Preeminence of the Viscera Over All Elements of the Organism

According to the Nèi Jīng, both the viscera and the bowels are of central importance to the functioning of the body. However, the five viscera are preeminent. One reason for this is that each of the viscera is considered to control its paired bowel. For example, the spleen is considered to move the fluid of the stomach, thereby enabling it to perform its function of rotting and ripening ingested foods. Similarly, the opening and closing of the bladder is controlled by kidney qì. In general, the Nèi Jīng has more to say about the viscera than about the bowels.

Another reason for the preeminence of the viscera is that they have a controlling influence over and resonance with various components of the organism. Thus, each viscus is said

As previously mentioned, the hierarchical nature of the physiological model is captured in analogies to government positions. The Nèi Jīng tells us that the heart is the Sovereign; the lung is Minister-Mentor, the nation’s second in command; the spleen is in charge of the Granaries; the liver is the General who leads the military; and the kidney is in charge of matters relating to Forceful Action, probably a reference to the labor force of a nation. See empire paradigm.

Lastly, the viscera are linked by the channels and network vessels. This complex system of pathways carries qì and blood to all parts of the body, providing nourishment to all tissues. The channels and network vessels therefore provide the basis of a fully formed, accessible system for healing using acupuncture and moxibustion.

The Nèi Jīng’s Attributions of the Five Viscera
Viscus Liver Heart Spleen Lung Kidney
Phase Wood 木: east, spring, birth Fire 火: south, summer, growth Earth 土: center, late summer, transformation Metal 金: west, autumn, withdrawal Water 水: north, winter storage
Function Stores blood; free coursing Store the spirit; governs blod and vessels Movement and transformation; controls the blood Breathing; governs qì and the waterways Governs water; stores essence
Bowel Gallbladder Small Intestine Stomach Large Intestine Bladder
Orifice Eyes Tongue Mouth Nose Ears
Body Constituent Sinew Vessels Flesh Skin (and body hair) Bone
Bloom Nails Face Lips (and four whites) Body Hair Hair of the head
Humor Tears Sweat Drool Snivel (nasal mucus) Spittle
Spiritual entity Ethereal soul Spirit Ideation Corporeal soul Mind
Mind Anger Joy Thought Worry Fear
Voice Shouting Laughing Singing Wailing Groaning
Government office (Military) general Sovereign Office of the Granaries Minister-Mentor Official for forceful action

Heart and Small Intestine

The Nèi Jīng’s theories about the heart include the following: The heart belongs to fire, has its fullness in the blood and vessels, stores the spirit, opens at the tongue, and has its bloom in the face. Its humor is sweat, its mind is joy, and its voice is laughing. It stands in exterior-interior relationship with the small intestine. The heart holds the Office of Sovereign.

The Nèi Jīng does not accord the heart any functions separate from the body constituent it governs (the blood and vessels) or the spiritual entity it stores.

The notion that the heart stores the spirit, i.e., is the seat of consciousness, was probably derived from the observation that emotional reactions to external stimuli are sensed primarily in the heart. Anger, joy, thought, anxiety, and fear are all experienced directly in the heart. Although modern medicine explains these phenomena as physiological consequences (changes in heart rate) of stimulation of the central nervous system, the authors of the Nèi Jīng and successive generations of Chinese physicians related them directly to the heart. Chinese medicine associates individual emotions with different viscera. Nevertheless, they are always felt in the heart. The ability to feel them is ascribed to the spirit that resides in the heart. The main signs of heart disease are heart palpitations, heart vexation (restlessness felt in the chest), insomnia, profuse dreaming, and clouded spirit (partial or complete loss of consciousness), all of which involve disturbances of the heart spirit.

The heart’s function of governing the blood and vessels is interpreted to mean that the heart moves the blood through the vessels. However, the Nèi Jīng describes the role of the heart in the movement of blood only in vague terms. Modern authors have equated the Nèi Jīng statement that the heart moves the blood with the pumping action described by biomedicine. Yet the Nèi Jīng contains no indication of any anatomically based notion of the cardiovascular system with the heart acting mechanically like a pump. Qì moves the blood directly.

The association of the heart with fire among the five phases may be assumed to rest on its association with bodily heat, blood vessels, and with the spirit. When the heart beats faster in strenuous exercise the body becomes hotter, and when the heart ceases to beat, the body grows cold. Large blood vessels spring from the heart as warmth radiates from a fire. Furthermore, the spirit is understood as a powerful immaterial force and so is considered to be yáng in nature, thus resonating with the notion of fire, the most yáng of all the five phases.

The heart’s association with sweat would follow from the association with fire, since sweating occurs when the body becomes hotter. The statement that the heart has its bloom in the face reflects the fact that the vitality of the spirit is reflected in the face.

The heart holds the Office of Sovereign; the spirit arises from it, the Nèi Jīng tells us. It is escribed as the great governor of the five visceral and six bowels. The heart as the seat of consciousness of the individual corresponds in the empire-body to the intelligent and wise ruler. The notions of sovereign and spirit resonate strongly with that of fire. Fire flames upward as the sovereign towers over the people. Fire produces light, which is a universal symbol of wisdom and enlightenment, which are qualities expected of the sovereign. Fire is universally used to produced warmth for human communities; hence it also a symbol of social conviviality. The sovereign is the intelligent and wise ruler who ensures the health and happiness of the nation, which explains why the heart is associated with joy.

The small intestine is the dispatch house partnered with the lung. Since the functions accorded to it are related to digestion, it is discussed under Spleen, Stomach, and Intestines below. A direct functional relationship with the heart seems tenuous, arguments for it offered in modern literature resting on the tendency of heat in the heart to cause disturbances of function of separating of the clear and turbid reflected in reddish urine. We may speculate that the pairing of the heart with the small intestine was made forcefully to satisfy the esthetic of a complete system of five-phase correspondences.

Lung and Large Intestine

The Nèi Jīng’s theories about the lung include the following: The lung belongs to metal. It is in charge of breathing. The lung governs the skin and body hair. Its outer orifice is the nose, and its humor is snivel (nasal mucus). It is the receptacle that hold phlegm. Its mind is worry, and its voice is wailing. It stands in exterior-interior relationship with the large intestine. The lung holds the Office of Minister.

The lung draws in air (qì), which contributes to the production of the body’s own qì. It belongs to metal, which is the working of change. Since the body’s qì responsible for all transformations within the body, it would have been logical to pair the lung with metal, the phase described as being the working of change.

Since the lung inhales clear qì (clean air) and exhales turbid qì (unclean air), it is engaged in a process of purification that resonates with autumn, the season associated with metal, when the first frosts kill plants, insects, and some animal species. Furthermore, lung qì reaches out as far as the skin and flesh, up to the nose, and down the trunk. By these actions, it keeps nose the upper airways free of mucus, clears the lung of phlegm, and moves unwanted fluids downward to the bladder via the waterways, again reflecting the purifying action associated with metal.

The lung opens at the nose, meaning that the nose is the orifice through which air enters and leave the body, which is kept moist by nasal mucus (snivel). The statement that the lung unites with the skin and body hair reflects lung qì’s ability to reach the outer body. Worry and sorry are subjectively felt in the chest and lungs and can affect breathing.

The lung holds the Office of Minister-Mentor; management and regulation arise from it. The Minister-Mentor is the sovereign’s prime minister and tutor. It is second in rank to the sovereign, working closely with the heart to control air intake and the heartbeat. It governs the qì and hence all activity in the body, just as the sovereign’s chief executive manages the economy of the nation.

Lastly, among the bowels, the lung is paired with the large intestine. Although the functions of the two organs are very different, the fact that the large intestine removes water from the stool and discharges the solid waste out of the body means that it is part of the waterways and has a cleansing action that accords with the purification of lung-metal.

Spleen, Stomach, and Intestines

The Nèi Jīng’s theories about the spleen include the following: The spleen belongs to earth, has the functions of movement and transformation. It governs the flesh, opens at the mouth, and has drool as its humor. It stores ideation, its mind is thought, and its voice is singing. It stands in exterior-interior relationship with the stomach. It holds the Office of the Granaries.

Food entering the body first collects in the stomach, where it is ripened and rotted. The spleen is said to help in this process by moving the contents of the stomach. It then extracts the essence of grain and water. That is, it assimilates the nutrients from food. The essence of grain and water combines with qì inhaled by the lung to create the body’s own qì, which powers all physiological activity. The essence of grain and water is also transformed, by processes not clearly described, into blood, which provides nourishment for the whole body. These spleen functions are called movement and transformation.

Historically, the main organ of digestion was the stomach. It was only with the increasingly perceived need to incorporate physiological theory into the systems of correspondence that the spleen came to dominate. Even the Shāng Hán Lùn, which appeared centuries after the Nèi Jīng, discusses the digestive system mainly in terms of the stomach domain, while the vitality of the digestive system as reflected in the pulse is still to this day referred to as presence of stomach, rather than presence of spleen. Earlier medical scholars neglected the spleen obviously because it provided no indication of its function to the naked senses.

Inspired by the explicatory power of the systems of correspondence, medical scholars would have easily identified the stomach as a dispatch house on account of anatomical evidence for it as a temporary collecting place of food. Since, according to yīn-yáng scheme, the stomach required a storehouse as a partner, the spleen, lying on the under (yīn) margin of the stomach would have been the obvious choice to fill the role. This would have allowed the deduction that while the stomach was responsible for digesting food, the spleen had the function assimilating the essence of grain and water (nutrients in foods) required for the production of qì and blood and ultimately for the nourishment of the whole body, even though direct evidence for this was lacking.

The spleen and stomach hold the Office of the Granaries; the five flavors arise from them. Flavor here refers to nutrients. The spleen belongs to earth, it provides the nutrients that are the source of qì and blood production. Just as earth produces food for sustenance, the spleen produces the main nutrients for the body to flourish. Thus, in administrative terms, the spleen is therefore like the department or ministry of agriculture.

The spleen’s other associated components are the flesh, mouth, the lips and four whites, ideation, thought, and singing. The flesh reflects the level of nutrition of the body, the mouth and lips form the opening where food enters the body. Four whites is usually explained as the pale flesh surrounding the lips, but some scholars explain it as sections in the eyes surrounding the pupils. Ideation (forming ideas, intentions, plans, etc.) and though represent the productive activity of the human intellect, while singing is the creative use of the voice.

The small intestine, which presumably includes the duodenum (not mentioned in Chinese medicine) is the next segment of the digestive tract into which food passes when leaving the stomach. Sù Wèn (Chapter 8) states, The small intestine holds the Office of Reception; the transformation of matter arises from it. The transformation here is considered to be the same as the movement and transformation of the spleen. In fact, in medicinal therapy, disturbances of this function are treated as spleen-stomach problems. However, the small intestine has a further function of separating the clear and turbid. The clear is explained as referring to essence of grain and water, which is absorbed by the action of the spleen. The turbid refers to solid and liquid waste. Some of the liquid is drawn off and sent to the kidney, while the remainder is passed on to the large intestine. Because the separation of the clear and turbid involves the extraction of a considerable amount of fluid, it is also said that the small intestine governs humor|. Under the influence of the yīn-yáng doctrine, the small intestine was paired with the heart.

From the small intestine, the digesta pass to the large intestine, where more fluid is removed to allow the remaining solids to form into stool. The Sù Wèn (Chapter 8) describes this as follows: The large intestine holds the Office of Conveyance; mutation arises from it. Because the large intestine removes liquid from the stool, it is said that the large intestine governs liquid. Under the influence of the yīn-yáng doctrine, the large intestine was paired with the lung.

Liver and Gallbladder

The Nèi Jīng’s theories about the liver include the following: The liver belongs to wood, stores the blood, governs extending harmony (free coursing), opens at the eyes, governs the sinews, and has its bloom in the nails. Its humor is tear fluid, its mind is anger, and its voice is shouting. It stands in exterior-interior relationship with the gallbladder. It holds the Office of General.

The liver’s association with wood probably originally derived from the observation that the liver is a large, flat, reddish-brown organ that resembles a tree trunk or a large piece of wood. Its function of storing blood was undoubtedly deduced from the bloody texture and the profuse bleeding from it that occurred when it was ruptured by a sword or dagger.

According to the Nèi Jīng, the liver has the function of storing blood. During physical exertion, blood circulates to provide nourishment. When the body is at rest, part of the blood returns to the liver. Certain morbid states of the blood are described in terms of the liver failing to store blood.

A further function of the liver is ensuring the smooth flow of qì around the body, called extending harmony (now called free coursing). This function was probably identified and attributed to the liver by an act of projection. The liver’s qì is said to be characterized by orderly reaching, like the initial growth of plants in spring, the season corresponding to wood.

The liver holds the Office of General; strategies arise from it. The Military General also encapsulates the ability for intelligent planning. In this, it is dependent upon the decision-making capacity of the gallbladder (see below). The General heads the army, which represents the sinews of the nation. By its constant work of reconnoitering the country’s territory, it is also the eyes of the nation. Anger is the emotion of human conflict and hence is naturally associated with the armed forces. Anger is also the emotion that most easily disturbs the free coursing action of the liver. Shouting is the voice of anger and the battle cry.

Gallbladder is the liver’s partner. It stores and discharges bile. According to traditional theory, bile is produced from a surplus of liver qì. Ancient physicians understood bile to be an internal product of the body rather than a waste product. They regarded it as clean and pure. Hence, they described the gallbladder as the bowel of center essence, the bowel of clear cleanness, and bowel of center clearness. In this lies a unique feature of the gallbladder. While the five other bowels deal with external products and waste products, the gallbladder stores and discharges a clear substance, and hence has an affinity with the viscera, which store essential qì. For this reason, it is classed not only as one of the six bowels but also as one of the extraordinary organs.

The Nèi Jīng states, the gallbladder holds the office of justice; decision arises from it. This phrase emphasizes that sound judgment, equanimity, and ability to make decisions are related to the gallbladder. The liver governs the making of strategies, but it is the gallbladder that is responsible for decision. When gallbladder qì is strong, a person can make decisions easily. When gallbladder qì is weak and timid, a person may become indecisive and lacking in courage.

Kidney and Bladder

The Nèi Jīng’s theories about the kidney include the following: The kidney governs water and stores essence. It governs storage (in a wider sense of retaining substances). It is the root of the yīn and yáng of the entire body. It governs the bones and engenders marrow, and it opens at the ears and two yin. Its bloom is in the hair. It stores mind/memory and its mind is fear. It stands in exterior-interior relationship with the bladder. It holds the Office of Forceful Action.

Assuming that the Nèi Jīng authors had identified the tubular connection with the bladder by the ureter, it was only natural for them to propose that the kidney was a storehouse dealing with internal fluids, which then flowed down to the bladder, the corresponding dispatch house responsible for their periodic release from the body. These processes were summed up in the phrase the kidney governs water, and the ascription of the kidney to the water phase. This urinary function would later be ascribed specifically to the action of the kidney’s yáng qì and described by analogy to water being heated so that clear fluids steam up from the kidney to be returned into circulation, while the remaining waste fluid is drained off to the bladder to await discharge.

The kidney’s association with the water phase apparently gave rise to the notion that the kidney had a further function of storing essence. The concept of essence explains on the one hand reproduction and on the other hand the process of human development and aging. Following coitus, male and female essences combine to create a fetus. After the child is born, this essence gains in strength, causing the child’s body to develop and mature. In middle age, essence begins to weaken, causing the body to lose its ability to maintain health. The essence stored by the kidney is called the essence of earlier heaven (congenital essence), and it is replenished to some degree by the essence of later heaven (acquired essence) derived from the essence of grain and water absorbed by the spleen.

Since there is no physical evidence to support the notion that the kidney stores essence, we speculate that this function was projected onto the kidney from the five-phase concept of water. Water is associated with winter, the time when plants retreat into their stems and roots and some only survive in the form of seeds. Hence, once the kidney had been associated with water, it would have been logical to suppose that it stored an essential substance from which human life is generated. It was presumably in this way that the notion of kidney essence as a substance responsible not only for reproduction but also for growth and aging arose.

The spleen has a wider storage function of preventing not only loss of urine, but also loss of stool, excessive menstrual bleeding, excessive vaginal discharge, and loss of fetuses through miscarriage.

The kidney’s other related components are similarly based on logical connections and often poetic analogies. The bones, which evolve from suppleness at birth to brittleness in old age, reflect the strengthening and waning of essence through a person’s lifetime. The hair of the head and memory or mental faculties in general are further distinct markers of age. The association of the ears with the kidney might be explained by the fact that the loss of hearing in old age resonates with the comparative silence of nature in wintertime. The connection with the two yīn (anus and genitals) is related to the storage function, which prevents the loss of urine and stool. Lastly, the kidney’s association with fear rests on the fact that fear causes qì to descend, causing loss of urine and stool. Fear is naturally associated with the wintertime, when environmental cold and lack of food present the greatest threat to survival.

The kidney holds the Office of Forceful Action; dexterity and ingenuity arise from it. It stores the essence that determines the fundamental physical dexterity and mental ingenuity of the individual, which depend on the strength of kidney essence.

Triple Burner and Pericardium

According to the generally accepted view among scholars in China today, the triple burner represents three segments of the abdominothoracic cavity, containing the bowels and viscera and including the pathways of original qì and the fluids. The upper burner is the segment above the diaphragm, containing the heart and lung; the center burner is the segment that lies between the diaphragm and the umbilicus, containing the spleen and stomach; and the lower burner is the segment that lies below the umbilicus containing the kidney, bladder, small intestine, large intestine, the uterus, and external genital organs.

The triple burner’s functions are to ensure the free flow of original qì and water throughout the body. The Nèi Jīng states, The triple burner holds the Office of the Ditches; the waterways arise from it. However, drainage channels were not the only metaphor adduced, since descriptions of the movement of qì and fluids through the triple burner suggest that it was also understood partly by analogy to the rain cycle.

The center burner… is the recipient of qì (i.e., food), strains of waste, steams the fluids, and transforms the essence [of the qì received]. [The essence] pours it upward into the lung vessel and is transformed into blood, in order to provide nourishment for the whole body. According to the Nèi Jīng, the center burner is like foam, an image that reflects stomach’s function of rotting and ripening grain and water. However, it has been contended that 沤 ōu is a mistranscription of 枢 shū, pivot, referring to the center burner’s role in moving essence and qì up and down the body.

The upper burner is described as being like a mist; when it opens and effuses, it diffuses the five grain flavors (i.e., various nutrients contained in food), steams the flesh, fills the body, moistens the body hair, like the sprinkling of mist and dew. This passage is often adduced to explain the action of lung qì.

Lastly, the lower burner is described as being ditches that allow waste to drain out of the body.

The pericardium, or pericardiac network, is not described in detail. It was evidently evoked provide a partner for the triple burner. It figures mostly in the context of acupuncture because it has its own channel. Points on the hand reverting yīn (jué yín) pericardium channel largely treat problems such as heart pain, heart palpitation, heart vexation, mania and withdrawal, and oppression in the chest. With the development of warm disease in the Qīng Dynasty, it came to label patterns in which the spirit-mind was affected.

The Nèi Jīng’s Description of Sickness

The Nèi Jīng’s description of sickness underwent considerable reworking over successive generations. Nevertheless, it contains the basic elements of modern knowledge. Human sickness can be caused by pathogenic entities called evils (邪 xié) originating from outside the body (wind, cold, summerheat, dampness, dryness, heat, fire, and warmth), or by internal causes such as excessive emotional reactions, physical and mental taxation, or the lack of—or over-indulgence in—food and drink, sexual activity, or sleep. Both internal and external causes of disease could unleash predictable disease processes.

Pathogens or Evils?
The Chinese term 邪 xié is often referred to as pathogen in English. While this term reflects the notion of xie as a cause of disease, we prefer the literal translation evil, which metaphorically reflects the ancient conception of disease-causing entities being similar to evil demons or marauding barbarians from beyond the borders of the country. The use of the term pathogen is intended to make Chinese medicine palatable to modern taste. Unfortunately, this hides the cultural elements of the medical thought of the time and conceals the historical perspective of the Chinese tradition.

All pathological conditions could be understood in terms of bodily insufficiencies (qì, blood, yīn or yáng) and/or superabundances caused by evils. An insufficiency manifests in a condition called vacuity (虚 xū), the relative emptiness of the body. When evil qì invades the body, the body’s right qì resists it. Superabundance manifests in a condition termed repletion (实 shí), or relative fullness. The Nèi Jīng’s conception of insufficiency (vacuity) and superabundance (repletion) is holistic. It can be used to analyze any morbid state of the body. It recognizes not only disease-causing entities but also bodily insufficiencies as factors of illness.

As previously stated, yīn and yáng played a major role in the description of pathological states. Yáng qì and yīn humor (fluids) were understood by analogy to fire and water. When yáng qì weakens, cold arises. When yīn humor is depleted, heat arises. The balance between yáng qì and yīn humor is similarly affected when external evils invade the body. Externally contracted cold weakens yáng qì. Externally contracted heat damages yīn humor. Although illnesses affecting the body have many different external and internal causes, they often manifest in either yīn cold or yáng heat.

Diagnosis, according to the Nèi Jīng, rested on information about the patient’s symptoms collected by visual inspection of the body and in particular the complexion, listening to the sounds of breathing, asking questions about subjective sensations, and palpating the body and the pulses felt on the head, upper limbs, and lower limbs. This was gradually developed by later physicians into a sophisticated system of the four examinations.

The authors of the Nèi Jīng acknowledged the existence of distinct diseases in the sense of pathological processes that were generally similar for everyone affected. Examples include:

Nevertheless, the Nèi Jīng authors did not necessarily take the identification of a disease entity as the basis for treatment. They introduced the notion of different treatments for the same disease (同病异治 tóng bìng yì zhì), which means that a given diseased might affect different people in similar ways, but each patient needed to be uniquely treated because the state of their qì, blood, yīn or yáng was different. This approach to treatment would vary not only according to internal balance but also by the age, gender, and life circumstances of the patient, the time of year, and the prevailing local climate. This formed the basis for an approach that emphasized a holistic and at the same time individualized understanding of sickness. The focus was on the condition of the patient afflicted by sickness as a whole, rather than on a narrowly, and yet universally applicable disease.

Through this view of sickness, the Nèi Jīng laid the cornerstone for the development of patterns (证 zhèng) as formulations of a pathological state understood in terms of evils, imbalances of yīn-yáng, qì and blood, and the location of the disorder within the body. The Chinese term literally means evidence, demonstration, or display, reflecting the idea that a constellation of symptoms evidences an internal condition. The Nèi Jīng contains only one mention of the word证 zhèng, but its understanding of pathological states provided the foundation upon which a complex system of patterns was to develop over the centuries. In the Mīng and Qīng Dynasties (1368–1919)[10] patterns became increasingly systematized. What came to be known during the Qīng Dynasty as identifying patterns as the basis for determining treatment (辨证论治 biàn zhèng lùn zhì) is now generally recognized as a key feature of Chinese medicine. In modern texts, pattern identification has been refined into highly systematic procedures: eight principle pattern identification; qì, blood, and fluid pattern identification, and bowel and visceral pattern identification. However, the concept of patterns is firmly rooted in the Nèi Jīng.

The Nèi Jīng also established the basic principles of treatment, most notably those of draining superabundance and supplementing insufficiency. These are the holistic principles of treatment that correspond to the holistic conception of illness based on the concepts of vacuity (虚 xū) and repletion (实 shí). The Nèi Jīng’s scheme of treatment is generally allopathic in nature, as is evinced by the principles of treating cold with warming and treating heat with cooling.

In analogy with the political ideals of the Qìn and Hàn empire builders, the medicine of systematic correspondences introduced in the Nèi Jīng likened the individual organism to an empire in which a well-organized political hierarchy ensured the smooth interaction of all parts. Evil forces could attack from without or arise from within. These were kept in check by the forces of right. Thus, the strength of the right forces should be maintained and promoted. A physician could assist in this process by manipulating the flow of qì through the insertion of needles at certain points in the body known to be particularly responsive. This is analogous to the way that governments adjust one or another part of the economy to maintain, restore, or improve general prosperity. Because the aim was to achieve maximum effect by minimum intervention, the notion of treating illness before it arises (治未病 zhì wèi bìng) was of great importance. The organizing principles of the yīn-yáng and five-phase systems of correspondence neatly fit this conception.

The Nàn Jīng Developments

The Nèi Jīng’s description of health, sickness, and treatment, having been compiled from numerous different writings, was neither complete nor internally consistent. By the Later Hàn, or 1st and 2nd centuries CE, the Nàn Jīng (难经 Classic of Difficult Issues)[11] fashioned a complete and consistent systematic-correspondence approach that clarified and synthesized the ideas introduced in the Nèi Jīng. Addressing 81 difficult issues, the Nàn Jīng explains in detail both the theoretical and practical aspects of this medicine. On a theoretical level, it set forth the locations, interactions, and functions of the channels, network vessels, and acupoints, as well as the internal organs. With regard to clinical application, it clarified pulse diagnosis, pathological processes, and the principles and techniques of acupuncture therapy. It thereby represented the consummation of the Nèi Jīng’s efforts to apply the theory of systematic correspondences to Chinese medicine. Together with the Shāng Hán Zá Bìng Lùn (伤寒杂病论 On Cold Damage and Miscellaneous Diseases), a prescription text discussed in the following subsection, the Nàn Jīng thus represents the apex and conclusion of the foundational period of traditional Chinese medicine.

The significance of the Nan-ching in this historical context is two-fold. First, its unknown author contributed to the formative period of the medicine of systematic correspondence by creating a conceptual system of medical theory and practice that for the first time consistently accounted for the discovery of a circulatory movement in the organism (documented earlier in the Huang-ti-nei-ching texts). Second, the Nan-ching marks the end of this formative epoch because it discarded all the irrelevant ballast of the past and concentrated—in a most coherent manner—on nothing but the most advanced concepts of systematic correspondence.[12]

Pragmatic Literature: Prescription Texts and Materia Medica

The Nèi Jīng and Nàn Jīng, which were highly theoretical in nature, focused mostly on needling therapy and made little mention of medicinal therapy. China’s medicinal therapy was an older tradition of home remedies, but it was stimulated from early imperial times onward by the development of practice-oriented prescription texts (fāng shū 方书) and materia medica literature (Běn Cǎo 本草).

Herbs or Medicinals?
The Chinese word 藥 (yào) is often referred to as herbs in English. Strictly speaking, herb refers to only plant items. Because the Chinese phamaceutical armamentarium also includes animal and mineral products, the term medicinal is more accurate. The Chinese word for herb is 草 cǎo, which appears in the term Běn Cǎo Roots and Grasses literature, the traditional name for materia medica literature.

The difference between the theoretically based medicine of systematic correspondence and the practice-oriented modalities using mainly medicinal therapy is far greater than a difference in methods of treatment. However, the division between the two traditions is not clear-cut.

The medicine of systematic correspondences and its accompanying practices of pulse diagnosis and acupuncture aimed primarily at maintaining and maximizing good health and at preventing rather than treating acute diseases. The authors advocated individual adjustments in lifestyle to accommodate the complex systems of society, the state, and the macrocosm. They assigned responsibility for physical disorders to the individual by linking health and morality, and in this sense reflected the worldview and cosmological interests of the privileged elite class of a large empire.

Medicinal therapy is far older than the medicine of systematic correspondence. It was a tradition of symptomatic medicine that provided cures for everyday ailments. It was the medicine of the common folk, for whom the vicissitudes of life were more closely associated with the forces of nature. For this segment of society, the medicine of systematic correspondence, which saw health in terms of moderation, restraint and achieving balance in the body, probably held little sway.

All the evidence we have for the development of medicinal therapy comes from historical records preserved for posterity by scholars and literate members of Chinese society. Although compiled and written by the educated elite, the prescription texts and materia medica literature contain very few references to yīn-yáng and the five phases, to vessel theory, or to pulse diagnosis and acupuncture therapy. Instead, at least until the Sòng Dynasty, the literature of medicinal therapy was dedicated to the transmission of knowledge about plants, animals, and minerals and their combinations in formulas. The expressed purpose of this literature was to cure and prevent illness, and to maintain and strengthen health with the help of medicinal substances.

While numerous texts like the Mawangdui manuscripts on vessel theory, the Huáng Dì Nèi Jīng, and the Nàn Jīng document the formative phase of the medicine of systematic correspondence, the pharmaceutical literature from early China is less abundant and has received much less attention from modern scholars. Yet, early manuscripts and later texts provide enough evidence to reconstruct the foundation and development of medicinal therapy.

The earliest example of pharmaceutical literature in China also comes from the Mǎwángduī tombs, which date from the early Hàn period (167 BCE). Employing nearly 400 substances from plant, animal, human, and mineral sources, as well as prepared substances like condiments and manufactured products, the dominant treatment modality of these Mawangdui manuscripts is medicinal formulas. These are supplemented by moxibustion and other heat treatments, minor surgery, and massage. Exorcism and other religious treatments are also prominent. As our first evidence of a Chinese pharmaceutical tradition, the manuscripts detail the preparation and dosage of drugs to be administered internally and externally in a variety of forms including powders, pills, solutions, ointments, medicinal wines, and vinegars.

The Mawangdui manuscripts provide no explicit reference to a theoretical basis for these treatments. They reflect a combination of practical experience, naturalistic reasoning, and magico-religious thinking. Magico-religious practices were based on two notions: First, magical links to a disease were attributed to animal-based medicinals and strikingly shaped plants. For example, sexual conditions were treated with preparations that included roosters or the testicles of male dogs. Horse meat was used in preparations for increasing physical strength in the extremities.

A second way of linking a disease with a treatment was based on the belief that a disorder was caused by the unwanted presence of malevolent beings that required exorcism. Thus, treatments often consist of cursing, spitting, and ritually beating or stabbing the patient, or entrapping the offending spirit. Many formulas employed substances such as feces, menstrual cloths, peach wood or peach kernel, or pungent aromatics like zanthoxylum (Sichuan peppercorns) or ginger. All of these had strong exorcistic connotations and were particularly used for conditions related to spirit possession. Other treatments, such as chewing garlic, spitting, or chanting, are clearly apotropaic (i.e., able to avert evil).

What is most significant about these Mawangdui manuscripts is that they suggest a textual origin for pharmaceutical knowledge in pragmatic collections of prescriptions (fāng 方, the same term as that used for medicinal formulas). In these texts, treatments and disorders were linked to specific diseases without an explicit theoretical foundation and, in cases of apotropaic magic (magic used to ward off evil), to preventing disease and maintaining health. It was thus an applied knowledge based on practical experience and a combination of naturalistic and magical reasoning. Nonetheless, the high degree of correlation between this material and the received pharmaceutical literature testifies to the existence of a consistent and carefully transmitted written tradition concerning the medicinal effects of substances.

The second branch of pharmaceutical literature, materia medica literature, seems to also have arisen during the centuries prior to the Hàn Dynasty. The earliest text on medicinals that has been transmitted through the centuries is the Shén Nōng Běn Cǎo Jīng (神农本草经, Divine Farmer’s Classic of Materia Medica) compiled in the Hàn Dynasty but presumably based on older, orally transmitted material.[13] As the title makes plain, materia medica knowledge was associated with Shén Nóng, the Divine Farmer. As one of the legendary founders of civilization from high antiquity, Shén Nóng is said to have invented agriculture, divination and, among other heroic actions for the benefit of humanity, to have tasted all plants for their medicinal effects. The compound běn cǎo 本草 literally translates as Roots and Grasses/Herbs. It was originally associated with practitioners of the art of longevity who specialized in pharmaceutical knowledge. The character cǎo 草 grasses/herbs is here employed in the general sense of medicinals. The content of this important text, which formed the foundation for all future pharmaceutical literature, describes the nature of these ideas.

In its original version, the Shén Nóng Běn Cǎo Jīng discussed 365 medicinal substances ranked in three hierarchical grades corresponding to the trinity of Heaven, Humanity, and Earth. According to the preface, the highest-ranking drugs are called sovereigns (君 jūn). Sovereigns, corresponding to Heaven, maintained life, had were nontoxic and were to be taken over a long time to lighten the body and prolong life. The ministers (臣 chén) of the middle grade, corresponding to Humanity, preserved human nature, were partly toxic, and were taken to prevent illness, strengthen qì, and balance insufficiencies and superabundances. In the lowest categories, the assistants (佐 zuǒ) and couriers (使 shǐ), corresponding to earth, were toxic and were used to treat illness by expelling evil qì, heat or cold, or by dispersing stagnation. They were therefore not to be taken over a long period of time. Each drug was classified by taste and by its warming or cooling properties. The content of the text as well as its organizational structure point towards an origin not among medical doctors involved in treating disease, but among specialists in the arts of longevity and immortality.

Around 500 CE, the Shén Nóng Běn Cǎo Jīng was republished in an annotated and expanded edition by the famous Daoist priest and alchemist Táo Hóng-Jǐng 陶弘景.[14] His version became the model for the standard materia medica tradition for the next thousand years. Tao synthesized the available pharmaceutical literature of his time and considerably expanded upon the information in the original Běn Cǎo text. It is important to note that he did not discard previous knowledge but merely added information by lengthening the descriptions of previously discussed medicinals and by introducing new ones. Using variously colored inks, he clearly differentiated between the original Shén Nóng Běn Cǎo Jīng, his own comments, and citations from other texts. In an innovative scheme that was adopted by all his successors for centuries, he organized the drug monographs by their natural origin—stones and minerals, herbs, trees, fruits, vegetables and grains, insects, reptiles, birds and beasts. He subdivided each group into the three grades of the Shén Nóng Běn Cǎo Jing—sovereigns, ministers, and assistants.

Early Medical Literature

Huáng Dì Nèi Jīng, (黄帝内经 The Yellow Emperor’s Inner Classic), second to first centuries BCE, authorship unknown.

Nàn Jīng (难经, Classic of Difficult Issues), late Hàn period.

Shén Nǒng Běn Cǎo Jīng (神农本草经, The Divine Farmer’s Materia Medica), compiled in second to first centuries BCE.

Shāng Hán Zá Bìng Lùn (伤寒杂病论 On Cold Damage and Miscellaneous Disease), by Zhāng Jī (张机, also known as Zhāng Zhòng-Jǐng 张仲景), circa 150–219 CE. This text was lost, but it was later recompiled from fragments as the Shāng Hán Lùn (伤寒论 On Cold Damage) and Jīn Guì Yào Lüè 金匮要略 (Essential Prescriptions of the Golden Cabinet) by Wáng Shū-Hé.

The prevalence of magical and demonological treatments as well as clear links to the pursuit of immortality have led many modern scholars, in the West as well as in China, to dismiss the early pharmaceutical tradition as superstition, and thus irrelevant to the modern practice of Chinese medicine. Evidence shows, however, that superstitious explanations of the actions of medicinals are often intertwined with rational explanations based on clinical observation.

To cite one example, peach was originally used for killing and exorcizing demons because of its association with yáng, the sun, and the east. Accordingly, peach wood bows were used to ritually shoot demons. Peachwood figurines were buried in tombs or placed over doorways to exorcize demons. In medicinal therapy, peach kernel (táo rén 桃仁) was used internally to treat phantom pregnancies resulting from intercourse with demons and ghosts. Later, when phantom pregnancies were reinterpreted as abdominal masses attributable to blood stasis, peach kernel nevertheless continued to be prescribed. Its function was reassigned to dispelling static blood. While its medicinal efficacy was thus always recognized, and it was used in formulas that addressed particular disorders, its action in the body—and coincidentally, the etiology of the disorder to which it was applied—was reinterpreted and rationalized, from expelling demons to breaking blood stasis.

Similarly, alchemically inspired remarks such as those in the Běn Cǎo, stating that a drug will lighten the body or prolong life, tend to cause modern readers to overlook the fact that many of these same drugs are still used with the intent of preserving and strengthening the health of the body. It is regrettable that the wealth of practical experience that was recorded, transmitted, and accumulated over many centuries in the early Chinese materia medica literature is too often dismissed in toto because we are unable to relate to the etiological and therapeutic concepts by which the authors explained the clinical effects they observed.

Rapprochement Between the Theoretical and Pragmatic Traditions

The influences of popular beliefs, Daoist alchemy, and exorcism on the development of medicinal therapy indicate that the composers of pharmaceutical knowledge created this literature for markedly different purposes than the theoretical texts that explained acupuncture and vessel theory. Thus, they were originally distinct traditions. Nonetheless, attempts were made to unite the two.

The first such attempt was made by the Later Hàn physician Zhāng Jī (张机), better known to many as Zhāng Zhòng-Jǐng 张仲景,[15] shortly after the appearance of the Nàn Jīng. Zhāng Jī authored Shāng Hán Zá Bìng Lùn (伤寒杂病论 On Cold Damage and Miscellaneous Diseases), a work that did not survive the turbulence following the collapse of the Hàn Dynasty fully intact. It was pieced together by Wáng Shū-Hé (王叔和 210–285 CE) from remaining fragments to form the Shāng Hán Lùn (On Cold Damage)[16] and Jīn Guì Yào Lüè (金匮要略 Essential Prescriptions of the Golden Cabinet).[17]

Zhāng’s understanding of cold damage diseases, 伤寒 shāng hán, which roughly correspond to our notion of febrile disease, incorporated Nèi Jīng ideas concerning the passage of externally contracted evils through six levels of penetration into a new empirically based theory, using medicinal formulas as the basic therapy. The six levels bore the names of the main channels of the channel and network (经络 jīng luò) system but are now generally considered to be distinct from them.

Wáng Shū-Hé
Wáng Shū-Hé (王叔和) is known not only for editing the Shāng Hán Zá Bìng Lùn but also for his contribution to the art of pulse-taking. His understanding of the pulses came ostensibly from Zhāng Jī, but his Mài Jīng (脉经 Pulse Classic) is noteworthy because it was the first text to offer detailed descriptions of numerous pulse conditions.

The Nèi Jīng statements he drew on were chiefly those of the chapter of the Sù Wèn entitled Rè Lùn 热论 , On Heat. These are terse and highly theoretical. They describe cold damage disease spreading from level to level day by day and indicate the effects on the body at each stage, but with little mention of treatment.

Zhāng Jī retained the idea of passage through the levels. However, he described in great detail the numerous possible clinical manifestations of cold damage at each stage of the progression. Furthermore, he provided a detailed set of medicinal formulas for each stage, indicating how they could be varied in subtle ways to deal with a variety of clinical manifestations.

Since Zhāng’s primary mode of therapy was the use of medicinal agents, he created a synthesis between the medicine of systematic correspondence, whose chief treatment was acupuncture, and the pharmaceutical tradition. Because of the success of this approach, his formulas and medicinal combinations have been in continuous use unto the present. He is accorded the highest status in the annals of Chinese medicine. Nevertheless, in his own era and for centuries to come, acupuncture and medicinal therapy led relatively separate existences. It was not until the Sòng Dynasty that Zhāng’s synthesis became part of mainstream medicine.

Links to Other Periods

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