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Differences in geography were another way of understanding the impact of the external environment on illness. Pang Anshi associated different illnesses with the north and south and
with mountainous and flat land:
In the south there are no places [covered in] snow and frost; therefore, people are not struck by cold qi. The qi of the earth is not contained, and vermin discharge toxin. Mists and miasmas [cause illnesses] that occur episodically. These are not covered by this method. There are separate formulae for their treatment. Furthermore, within a single prefecture, there are mountain dwellings that are the abode of accumulated yin. At the height of summer, the snow freezes. The climate is cold, and [people’s] pores are sealed, so it is difficult for an evil to harm them. These people are long-lived, and the sick among them mostly [suffer from] wind strike and cold strike illnesses. There are also flatland dwellings that are the abode of accumulated yang. At the height of winter, plants still grow. The climate is warm, and [people’s] pores are lax, so it is easy for an evil to harm them. These people are short-lived, and the sick among them mostly [suffer from] damp strike and summerheat-strike illnesses.322 南方無霜雪之地，不因寒氣中人，地氣不藏，蟲類泄毒，嵐瘴間作，不在此法，治 別有方也。又一州之內，有山居者為積陰之所，盛夏冰雪，其氣寒，腠理閉，難傷 於邪，其人壽，其有病者多中風中寒之疾也。有平居者為居積陽之所，嚴冬生草， 其氣溫，腠理疏，易傷於邪，其人夭，其有病者多中濕中暑之疾也。 E.g,, Xu Shuwei, writing shortly after the loss of North China, associated the transmission of evils through the Treatise’s three yin and three yang with the reverse of the annual progression of six qi in movements and qi doctrine.
Puji benshifang, juan 9, pp. 9a-b, in Xuxiu siku quanshu bianzuan weiyuan hui, Xuxiu siku quanshu; The earliest edition of Cheng Wuji’s Annotated Treatise on Cold Damage as well as the Zhao Kaimei edition contain a series of charts and a brief discussion related to the system of movements and qi, but the content seems unrelated to the rest of the text and is neither found in other editions nor mentioned in other discussions of Cheng’s commentary. I am inclined to see it as a later addition. See, Cheng Wuji, Zhujie Shanghan lun, ed. Zhao Kaimei, Zhongjing quanshu (1599; reprint, Beijing: Renmin Weisheng Chubanshe, 1956), 13–18.
Shanghan zongbing lun, juan 1, xulun, in Pang Anshi, Shanghan Zongbing Lun, 3–4.
Seasonal and geographic influences on illness were not, therefore, mutually exclusive. As noted above, Pang made reference to seasonal variation as well.323 Combined, these environmental influences alone could therefore greatly complicate the presentation of any given illness.
Apart from the external environment, the internal environment of the patient and the character of the ailment itself were potential sources of variability and complexity in illness. One of the earliest extant descriptions of this type of variability is found in Shen Gua’s enumeration
of the “five difficulties (wunan 五難)” of treating illness:
Nowadays those who examine ill [people] only inspect the six pulses of the qi opening and nothing else. In ancient times those who inspected ill [individuals] had to investigate their voice, facial color, movements, skin texture, emotions, and likes. They inquired into what the patient did [for a living] and investigated the patient’s activities. Having already obtained the better part [of what they needed to know], they then thoroughly diagnosed the welcoming people [pulse], the qi opening [pulse], and the twelve vessels. If the illness occurs in the five viscera, then the five colors will correspond to it, the five sounds will change in accord with it, the five tastes will incline to it, and the twelve vessels will move according to it. They sought the illness with this sort of thoroughness, but they still feared lest they lose it. This is the first difficulty: differentiating illnesses.324 今之觀疾者，惟候氣口六脈而已。故之觀疾，必察其聲音、顏色、舉動、膚理、情性、 嗜好，問其所為，考其所行，已得其大半，而又砭診人迎、氣口、十二動脈。疾發於五 臟，則五色為不應，五聲為之變，五味為之篇，十二脈為之動。求之如此其詳，然而猶 懼失之。此辨疾之難，一也。 While most supporters of literati-physician medicine could have agreed with Shen’s presentation, their own explanations of this sort of complexity were usually framed in stronger doctrinal terms.
One early example is Shi Kan’s discussion, already quoted in chapter 3:
Therefore, those who are good at practicing medicine must, once an illness has appeared, first investigate its source, determine how it was transmitted and contracted, scrutinize its punishment and conquest [according the five phases],325 distinguish its coolness and heat, coldness and warmth, differentiate whether it is above or below, interior or exterior, E.g., Shanghan zongbing lun, juan 1, xulun, in ibid., 3.
Author’s preface, Excellent Formulae of Su and Shen, in Su Shi and Shen Gua, Su Shen neihan liangfang, 1. This preface dates to ca. 1090.
All editions of this text read “punishment and conquest (xingke 刑剋),” a term which I have been unable to locate.
“Generation and conquest (shengke 生剋),” would fit the context, but a scribal error of xing 刑 for sheng 生 seems unlikely.
whether the true [qi] or the evil [qi] predominates, whether it is vacuous or replete … Each of these has its standard and one cannot err in the slightest.326 故善為醫者，一病之生，必先考其根源，定其傳授，審其刑剋，分其冷熱寒溫，辨其上 下內外，有真有邪，有虛有實… 各有其常而不可差之分毫也。 Around the same time, Kou Zongshi (寇宗奭, fl. early 12th c.) included a more systematic discussion of this problem in the preface to Expanded Meaning of the Materia Medica (Bencao
yanyi 本草衍義, 1116, published 1119):
In treating illness, there are eight essentials. If the eight essentials are not carefully examined, the illness cannot depart. It is not that the illness does not depart, but that there is no path327 by which it can depart. Therefore, you must carefully differentiate the eight essentials, so as to make no mistakes. The first is vacuity: this is the five vacuities. The second is repletion: this is the five repletions. The third is cold: this is the organs contracting accumulated cold. The fourth is heat: this is the organs contracting accumulated heat. The fifth is evil [qi]: it is not an illness [generated by] the organs themselves. The sixth is correct [qi]: it is not [an illness caused by] the attack of an external evil. The seventh is internal: the illness is not on the exterior. The eighth is external: the illness is not in the interior.328 夫治病有八要，八要不審，病不能去。非病不去，無可去之術也。故須審辨八要，庶不 達誤。其一曰虛，五虛是也。二曰實，五實是也。三曰冷，臟腑受其積冷是也。四曰 熱，臟腑受其積熱是也。五曰邪，非臟腑正病也。六曰正，非外邪所中也。七曰內，病 不在外也。八曰外，病不在內也。 Similar statements can be found in the works of Zhu Gong, Xu Shuwei, and many other Northern Song literati physicians.329 Pang Anshi saw this internal variation as rooted in part in very
physical differences between individuals:
People’s five viscera can be large or small, firm or brittle, established correctly or leaning askew. The six bowels can also be large or small, long or short, thick or thin, relaxed or tense. This causes a person to frequently have a particular illness for their entire life.330 Shi Kan, Shi Zaizhi fang, juan xia, “Weiyi zonglun,” in Qiu Peiran, Zhongguo yixue dacheng sanbian, 4:482.
The character “shu 術” most commonly means “technique, method,” but one of its earlier meanings is “path, road.” In this instance, Kou seems to be playing on this dual meaning.
Juan 1, in Kou Zongshi, Bencao Yanyi, ed. Yan Zhenghua, Chang Zhangfu, and Huang Youqun, Zhongyi Guji Zhengli Congshu (Beijing: Renmin Weisheng Chubanshe, 1990), 7–8.
E.g., Zhu Gong, Nanyang Book for Saving Lives, author’s preface, in Zhu Gong, Huoren shu, 19–20; Xu Shuwei, One Hundred Songs on Cold Damage Patterns, zheng 3-6, in Xu Shuwei, Xu Shuwei Shanghan Lun Zhu Sanzhong, 18–22.
Shanghan zongbing lun, juan 1, xulun, in Pang Anshi, Shanghan Zongbing Lun, 3; A similar phrase, though referring only to the stomach and intestines, is found in Lingshu, juan 11, pian 31, p. 3, in Lingshu (zuishanben) [Xinkan Huangdi neijing Lingshu], Ming dynasty 24 juan anonymous edition (unpublished ms., n.d.), 50.
人五臟有大小、高下、堅脆、端正偏傾。六腑亦有大小、長短、厚薄、緩急，令人 終身常有一病者。 Regardless of how it was conceived, patients’ individual characteristics were seen as a major factor interacting with external influences in the formation of illnesses. These two broad sources of variability combined to give illness its protean character.
Treating Complex Illnesses If Northern Song approaches to grasping the variability and complexity of illness were notable for their abundance and diversity, literati physicians’ approaches to treating variable and complex illnesses are notable for their small number. Literati physicians drew almost exclusively on two sources in establishing doctrines to guide treatment: the Yellow Emperor’s Inner Classic and the Treatise on Cold Damage. These two texts served as sources of scripts by which literati physicians could seek to understand and treat the illnesses they saw around themselves.331 Throughout the Northern Song and during the early Southern Song and Jin, a strict division of labor separated the spheres in which each of these texts could be used. The Treatise on Cold Damage and its formulae were used for cold damage in its broad sense—encompassing potentially epidemic febrile illnesses in all seasons—and miscellaneous diseases, all other illnesses, were the domain of the Inner Classic. The doctrines of the Inner Classic were used to explicate difficult passages in the Treatise on Cold Damage, but the Treatise’s doctrines had priority when dealing with cold damage.332 The reverse, the use of the Treatise’s doctrines and I borrow this use of the term “scripts” from Simonis, “Mad Acts, Mad Speech, and Mad People in Late Imperial Chinese Law and Medicine,” 11–12.
The rejection of day-counts (as discussed in chapter 3), a prominent feature of the Inner Classic’s cold damage doctrine, is a this dissertationicularly clear example of the Treatise’s priority when dealing with cold damage.
formulae for miscellaneous diseases, did not occur.333 Even as ardent a supporter of the Treatise as Xu Shuwei adhered to this rule. In his formulary, Efficacious Formulae for Universal Relief, formulae from the Treatise are only found in the section devoted to “Cold Damage and Seasonal Epidemics (shanghan shiyi 傷寒時疫).334 The Inner Classic and Miscellaneous Diseases All of the methods of understanding the variability of illness discussed above had precedents in the Inner Classic. The system of movements and qi is the topic of the seven great treatises (qipian dalun 七篇大論) added to the Inner Classic by Wang Bing (王冰, fl. 8th c.),335 and seasonal variation is discussed extensively.336 Geography and local environment are also linked with specific illnesses.337 Variation in the internal environment particularly as understood through the five phases and five viscera, is a consistent concern throughout the Inner Classic.
There are a handful of ambiguous instances in which an author appears to be using a cold damage formula to treat a miscellaneous disease. For example, Shi Kan’s recommendation of Five-Ingredient Poria Powder (wuling san 五苓散) to treat inhibited urination or Qian Yi’s (錢乙, 1032-1113) use of White Tiger Decoction to treat persistent vomiting and diarrhea, but these were seen as cases which resembled miscellaneous diseases but were caused by the invasion of environmental evil qi. Moreover, both of these formulae are also found in the Treatise’s sister-text Essentials of the Golden Coffer, which was devoted to miscellaneous diseases. See Shi Kan, Shi Zaizhi fang, juan shang, liuqi suoshengzhi bing, xiaofu bi, in Qiu Peiran, Zhongguo yixue dacheng sanbian, 4:459; and Qian Yi, Straightforward Guidance on Medicinals and Patterns for Children (Xiao’er yaozheng zhijue 小兒藥證直訣, 1119), juan zhong, pp. 8a-b, in Qian Yi, Xiao’er yaozheng zhijue, ed. Yan Xiaozhong, vol. 39–40, Zhoushi yixue congshu (Yangzhou: Jiangsu guji keyinshe, 1984).
In Siku Quanshu; the separateness of cold damage as an illness is further seen in the insistence that it’s methods of diagnosis differed from miscellaneous diseases. Xu wrote an entire book on cold damage pulse diagnosis, now lost. A fragment of Xu’s pulse studies can be found in Wang Haogu’s (王好古 fl. early-mid 13th c.) Brief Precedents on Yin Patterns (Yinzheng lueli 陰證略例, 1232), Xu Shuwei maili, in Zhu Pangxian and Wang Ruoshui, Lidai zhongyi zhenben jicheng, 1990, 20:16–17; a more complete example of Northern Song cold damage pulse diagnosis can be found in Han Zhihe’s Shanghan weizhi lun, juan shang, shanghan pingmai pian and bianmai pian, pp. 3b-7b, in Siku Quanshu.
Yellow Emperor’s Inner Classic: Questiosn on the Simple (Huangdi neijing suewn 黃帝內經素問, 1st c. BCE), pian 66-71, 74, in Wang Bing, Wang Bing yixue quanshu, 299–392, 410–436.
E.g., Suwen 2, in ibid., 19–23.
E.g., Suwen 12, in ibid., 76–77; for further discussion of this passage see Hanson, Speaking of Epidemics, 30–35.
The majority of these discussions, however, remained at the level of etiology, explaining how particular illnesses were related to pathologies of the five viscera, qi, blood, yin, yang, etc.
They did not provide guidance on treatment. The following passage is typical:
The five viscera and six bowels all cause people to cough. It is not only the lung. If the five viscera [cause a] cough for a long time, then it will be contracted by the six bowels.