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«Stephen Boyanton Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Graduate School of Arts and ...»

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If a spleen cough does not end, then the stomach will contract it. The signs of a stomach cough are coughing with vomiting. If the vomiting is severe, long worms will be spit up.338 五藏六府皆令人欬,非獨肺也 … 五藏乆欬,乃移於六府。脾欬不已,則胃受之。 胃欬之狀,欬而嘔,嘔甚則長蟲出。 Even when specific treatments were mentioned, they were nearly always acupuncture or moxabustion. Altogether, the Inner Classic lists only thirteen medicinal formulae,339 but medicinal formulae were the treatment of preference for the majority of literati physicians, who saw performing acupuncture and moxabustion as beneath their status.340 Equally problematic were certain gaps in the doctrinal structure of the Inner Classic. The concepts of vacuity (xu 虛) and repletion (shi 實) had been central to the drug therapy tradition since the end of the Han, and remained central in the Song.341 Vacuity indicates that a condition is due to some component of the body performing its function inadequately; repletion, on the other hand, attributed illnesses to pathological excesses within the body, whether contracted from the external environment or generated within the internal environment. Although both of these terms are found in the Inner Classic, they are rare and not particularly important. Only two chapters of the Inner Classic use them systematically.342 Generally, the Inner Classic merely notes that an illness is in a particular organ, without mentioning whether the illness is vacuous or Suwen, juan 10, pian 38, p. 12b, in Chen Yongguo, ed., Chongguang Buzhu Huangdi Neijing Suwen, Mingchao Jiaqingnian Gu Congde Chongdiao Ban (Taibei: Tianzi Chubanshe, 1989), 79.

Cheng Shide and Meng Jingchun, eds., Neijing jiangyi (Shanghai: Shanghai Kexue Jishu Chubanshe, 1984), 206.

Leung, “Medical Learning from the Song to the Ming,” 383.

There are a variety of synonyms or near-synonyms for these terms; e.g., insufficiency (buzu 不足) and excess (taiguo 太過), weakness (wei 微) and exuberance (sheng 盛), etc.

Namely, chapter 80 of the Suwen and chapter 8 of the Lingshu.

replete. By way of comparison, the character xu 虛 occurs 266 times in the Questions on the Fundamental division of the Inner Classic but 96 times in Zhu Zhenheng’s far shorter A Few Words on Investigating [Things] and Extending [Knowledge]. The character shi 實 occurs 146 times in Questions on the Simple, but 47 times in A Few Words. The Inner Classic could not provide detailed doctrinal or clinical guidance on these two important concepts.

For all of these reasons, the Inner Classic required major supplementation if its doctrines were to be applied clinically. The sources drawn upon to supplement it were diverse. The formularies of the past—in particular the works of Sun Simiao and the Song government formularies—were used to amend the Inner Classic’s lack of formulae, and the doctrines found in works like Sun’s Essential Formulae Worth a Thousand Gold and Chao Yuanfang’s (巢元方, fl. early 7th c.) Treatise on the Origins and Signs of Diseases filled in doctrinal gaps.

The imperial physician Qian Yi’s work contains the most influential Northern Song effort to build a systematic method for the diagnosis and treatment of miscellaneous diseases. Among the sources used by Qian Yi to supplement the Inner Classic, there is one that is somewhat unusual. According to Yan’s preface, Qian argued that the doctrines of the Inner Classic were only suitable for children older than five years old. For this reason he turned to the Fontanel Classic (Luxin jing 顱囟經), a text devoted to the treatment of children.343 The Fontanel Classic claims great antiquity and was associated with both the Yellow Emperor and a student of Zhang Ji. There is abundant evidence for the existence of a book with this or a similar title from the 6th century onward, but the relationship of those texts, the book used by Qian Yi, and the Fontanel Classic available today is unknown.344 It is evident, however, from Yan’s preface and from a Yuanxu, pp. 1a-2a, in Qian Yi, Xiao’er yaozheng zhijue.

Ma Jixing, Zhongyi wenxianxue, 230–231; Yan Shiyun and Li Qizhong, Sanguo liang Jin Nanbeichao yixue zongji, 99–100.

slightly later discussion of the text that the version used by Qian Yi contained both doctrinal discussions and formulae designed for the treatment of children, allowing Qian to remedy the two deficiencies of the Inner Classic.345 In diagnosing miscellaneous diseases, Qian Yi emphasized the five viscera and their interrelationship as articulated through the five phases. After a brief discussion of the medical differences between children and adults Straightforward Guidance presents a list of the five

viscera and the signs and symptoms that are present when a given organ is replete or vacuous:

The spleen governs fatigue. If it is replete, [the patient] will sleep heavily, the body will be feverish, and [the patient] will drink water. If it is vacuous, there will be diarrhea and vomiting, and wind will be generated.346 脾主困。實則困睡,身熱飲水。虛則吐瀉,生風。 The symptoms listed appear to be derived from a variety of earlier sources,347 but Qian Yi neither quotes any such sources nor cites them in support of his position. These five basic patterns of

illness—and their treatment—were complicated by the mutual influence of the five viscera:

… When the liver is strong and conquers the lungs and the lungs are weak and cannot conquer the liver, you should supplement the spleen and lungs and treat the liver.

Assisting the spleen is a case of the mother causing the child to be replete. To supplement the spleen, [use] Assist the Yellow Powder. Treating the liver is governed by Drain the Green Pill.348 … 肝強勝肺,肺怯不能勝肝,當補脾肺治肝。益脾者,母令子實故也。補脾,益 黃散。治肝,瀉青丸主之。 An illness of the liver, associated with the wood phase, could only transmit to the lungs, associated with the metal phase, if the lungs are weak, because in five-phase doctrine metal normally conquers wood, not the reverse. In such a situation, one supplements not only the lungs, E.g., Liu Fang, juan 12, jingxian di’er, in Liu Fang, Youyou xinshu, ed. Ma Jixing et al., Zhongyi guji zhengli congshu (Beijing: Renmin Weisheng Chubanshe, 1987), 404.

Xiao’er yaozheng zhijue, juan shang, wuzang suozhu, p. 2b, in Qian Yi, Xiao’er yaozheng zhijue.

For example, this line could be derived from either the Suwen or Zhubing yuanhou lun; see Suwen, juan 7, pian 22, pp. 6b, in Chen Yongguo, Chongguang Buzhu Huangdi Neijing Suwen, 54; and Zhubing yuanhou lun, juan 15, pian 3, in Chao Yuanfang, Zhubing yuanhou lun jiaozhu, 470–471.

Juan shang, ganbing sheng fei, p. 5a, in Qian Yi, Xiao’er yaozheng zhijue.

but also the spleen, associated with the earth phase, because earth generates metal (making spleen-earth the mother of lungs-metal), thus assisting in strengthening the lungs. Even the names of Qian’s formulae emphasize the importance of the five viscera and five phases. Yellow (huang 黃) is the color of earth and the spleen, and green (qing 青) is the color of wood and the liver. The names of the formulae thus explicitly state their function. Even when Qian used the disease-name differentiation of illnesses that had been important before the Song, he typically divided the disease into five sub-diseases, each caused by one of the five viscera. Regarding the seizure disorder known as xian 癇,349 Qian informs us, “As for the five xian, you treat them according to the respective viscera 凡五癇,皆隨藏治之.”350 Likewise, of sores and rashes (chuangzhen 瘡疹) he says, “The five viscera each have a pattern 五藏各有一證.”351 In so doing, he inverted the structure of texts like Formulae Worth a Thousand Gold and the Treatise on the Origins and Signs of Diseases. In those books, the viscera were used to name entire sections of the text within which diseases associated with that viscus were grouped. In Qian’s work, the viscera serve as subdivisions of a given disease.

What is most striking about Qian Yi’s system for diagnosing and treating miscellaneous diseases is the degree to which it was a creation ex novo. Although there was no shortage of doctrine and formulae scattered in the pre-Song sources, this material was neither systematic in its doctrine nor comprehensive in its clinical scope. In order to deal with the potentially infinite variability of illness, Qian Yi had to rework this material into a set of scripts that could explain any given illness and offer guidance on its treatment. Qian’s system was ultimately very Xian is frequently translated as “epilepsy,” but the recent work of Fabien Simonis has shown how problematic this association is. I have therefore chosen not to translate this term. See, Simonis, “Mad Acts, Mad Speech, and Mad People in Late Imperial Chinese Law and Medicine.” Juan shang, wuxian, p. 8b, in Qian Yi, Xiao’er yaozheng zhijue.

Juan shang, chuangzhen, p. 9a, in ibid.

influential: Zhang Yuansu and his students Li Gao and Wang Haogu expanded and modified it, and through them many of Qian Yi’s ideas and formulae became widely known and accepted.

The Treatise on Cold Damage as a Model for Dealing with Variability If the Inner Classic presents a great deal of doctrine but offers very little explicit clinical guidance and almost no formulae, the Treatise on Cold Damage is its precise converse. Doctrine is seldom mentioned explicitly, but clinical guidance and formulae are abundant. The importance

of this difference was recognized by Northern Song writers, as seen in Zhang Lei’s (張耒, 1054postface to Pang Anshi’s Treatise on All Diseases of Cold Damage:

Why is it that the excellent physicians of the past did not prepare formulae? … Only Zhongjing’s Treatise on Cold Damage both discusses illnesses and prescribes formulae.

The details are certainly complete. It also describes the method of increasing or reducing [the quantity of medicinals] and adding or removing [medicinals].352 古之良醫,皆不預為方何也 … 惟仲景《傷寒論》論病處方,纖悉必具,又為之增 損進退之法 … The Song imperial edition of the Treatise is composed of separate lines, each of which describes

a particular clinical situation. Many, but not all, of these lines end with a recommended formula:

In cold damage, when the pulse is slippery and there is reversal[-cold of the extremities], there is heat in the interior. White Tiger Decoction governs it.353 傷寒,脈滑而厥者,裏有熱。白虎湯主之。 In essence, the Treatise was a collection of ready-made clinical scripts, including information on diagnosis, prognosis, and treatment method. In the imperial edition, all of the lines that included a recommended formula were gathered together at the beginning of each chapter in a numbered Postface, in Pang Anshi, Shanghan Zongbing Lun, 206. This postface is no longer this dissertation of any editions of the text, but is found in the Mount Ke Collection (Keshan ji 柯山集), juan 44.

Shanghan lun, juan 6, pian 12, line 350, in Zhang Ji, Zhongjing quanshu, 458.

list of “methods (fa 法).”354 These methods were the most valued part of the Treatise on Cold Damage, and the fact that it contained methods and not merely formulae alone appears to have led to a truism among physicians, reported (disparagingly) by Wang Haogu, that in treating cold damage there were methods, but in treating miscellaneous diseases there were only formulae (fang 方).355 As seen in Zhang Lei’s comments, Northern Song authors particularly valued the extreme detail of the Treatise on Cold Damage’s clinical advice. Northern Song medical authors highlighted this detail in their texts about cold damage. Xu Shuwei, who wrote more texts on cold damage than any other author of this period, used his case records to illustrate the

importance of these details. In explaining one of his clinical decisions he notes:

The seventh pattern356 [in the fifth chapter of the Treatise] is that [after] promoting sweating, the sweat leaks out incessantly and urination is difficult. The sixteenth pattern [in that chapter] is spontaneous sweating and frequent urination. Thus, if there is a small difference in the numerous signs [presented by the patient], Zhongjing changes the method by which he treats him. Therefore, you must be precise regarding [medicinal] decoctions.357 蓋第七證則為發汗漏不止,小便難,第十六證則為自汗,小便数。故仲景於諸證候 紛紛小變異,便變法以治之,故於湯不可不謹。 As I mentioned in the previous chapter, Zhu Gong structured his book as a list of one hundred questions about cold damage and within each question presented long lists of possible variations

and how to treat them:

It is unclear whether the Song editors added these lists or found them in one of the editions they examined.

Neither their preface or postface mentions adding them, but they give few details about their editorial decisions in general.

Supreme Commander of the Bastion of Medicine (Yilei yuanrong 醫壘元戎, 1237), juan 12, p. 47a, in Siku Quanshu.

Throughout this text, Xu refers to the numbered methods as “patterns (zheng 證).” Ninety Discourses on Cold Damage (Shanghan jiushilun 傷寒九十論), zheng 2, in Xu Shuwei, Xu Shuwei Shanghan Lun Zhu Sanzhong, 149.

You should investigate whether there is or isn’t sweating in order to distinguish between hard tetany358 and soft tetany. If there is no sweating, Kudzu Root Decoction governs it. If there is sweating, Cinnamon Twig Decoction with Kudzu Root governs it.359 當察有汗無汗,以分剛 Zhu’s distinction between hard and soft tetany and his choice of formulae were derived from the Treatise.360 Much of Zhu’s text consists of similar statements—often paraphrasing the Treatise itself—emphasizing the diversity of cold damage illness, and the need for precise diagnosis and treatment.

The Treatise on Cold Damage did, however, require supplementation in two areas. The first area consisted of what might be called “omissions” in the text. A number of lines in the Treatise describe a clinical situation but either give no advice on treatment or give only general

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