Thoughts on Ancient Medical Texts
What follows is another excellent guest blog by Tom Ehrman, from July 14, 2021. I am so grateful that he has generously given me permission so share some of his outstanding translation work with you all here in a public forum because I think it will be of interest to many. How often do students (and teachers and translators, too!) ask for guidance in navigating the classics and making sense of the contradictions and confusions within and between them? Well, here you get some answers that are more than 200 years old! Enjoy and feel free to pass this post around. It is meant to be shared and enjoyed.
INTRODUCTION BY TOM EHRMAN
Though the Chinese medical literature contains many commentaries on historical works, particularly the classics from the Han dynasty, it is rare for authors to express their actual opinions on the historical literature in a general way. There is one book, however, which contains an entire chapter devoted to just that, the Yīxué Yuánliúlùn (On the Origins and Development of Medicine, 1764) by the Qing dynasty physician Xú Dàchūn (1693-1771), where a kind of brief critical summary of a number of famous ancient texts is given.
This work is virtually unique, providing commentary on a huge number of topics in Chinese medicine, from antiquity through to the late 18th century. It is not a specialist work, which considers one or two subjects in detail, but is rather a record of Xú’s views on almost every area of Chinese medicine. The tone, though erudite, is light and conversational throughout. In keeping with most other medical works from the Qing the emphasis is on herbal medicine, and includes chapters on channels and collaterals (jīngluò), organs (zàngfǔ), illnesses, herbs and prescriptions, therapeutic patterns and medical specialties, as well as the medical literature, and a final miscellaneous chapter on some of his favourite topics.
Each of these chapters is divided into ‘discussions’ (lùn), which are really sections consisting of no more than a few paragraphs, making for a relatively concise book overall. Each of these lùn, in turn, provides a summary of Xú’s opinion on that particular topic, providing a fascinating glimpse into how medicine was viewed during the 18th century.
Xú’s medical works are extremely distinctive in style, being, for the most part, simple and direct, and abandoning many of the features which had crept into the medical literature from the Song dynasty onwards (an example being the almost universal tendency in these later works to identify the channels entered by particular herbs, something he dismisses as ‘far-fetched’). It becomes clear very quickly that his sympathies lie almost exclusively (though never quite) with the medical classics from the Han dynasty, with many reverential remarks about ‘the ancient sages’ and the wonders and subtleties of their medicine, which, to a modern reader at least, may occasionally seem excessive. Likewise, he makes no secret of his opinions on the medicine of his time, constantly lamenting its inadequacies, and comparing it unfavorably to a distant golden age in which medicine was the province of masters such as Zhāng Zhòngjǐng, in whom ‘profundity of thought was extraordinary, such as is barely conceivable nowadays’. Indeed, for Xú Dàchūn veneration for the classics went hand-in-hand with denigration of much of the medicine he saw around him, and his caustic comments may come as a surprise to those accustomed only to the restrained language of modern textbooks or the ancient classics themselves.
Xú Dàchūn was, in fact, one of the leading exponents of Hànxué, or ‘Han learning’, a movement that swept through China during the 18th century, and which sought to dethrone much of the Neo-Confucian orthodoxy and to return Chinese culture to the pristine purity of former times (or so it was perceived). This movement made a particularly important contribution to the field of medicine, with a huge number of commentaries on the classics being written from the 18th up to the early 20th century. It is worth reflecting that without this level of sustained interest during that period, the Classical Chinese Medicine and jīngfāng (classical formula) schools of modern times might never exist, or at least might have taken a very different form.
Below is my translation of five lùn taken from the chapter on the medical literature, mostly on familiar texts such as the Nànjīng (Classic of Difficult Issues), Shānghánlùn (On Cold Damage), Jīnguì Yàolüè (Essential Prescriptions from the Golden Cabinet) and Màijīng (Pulse Classic). Also included are two works from the Tang dynasty, the Qiānjīnfāng (Prescriptions worth a Thousand Gold Pieces) by Sūn Sīmiǎo, and the Wàitái Mìyàofāng (Secret Essential Prescriptions of the Outer Censorate) by Wáng Tāo, a government minister and expert on medical prescriptions, a work which is virtually unknown today.
Most of it is relatively straightforward, but readers will notice the considerable caution expressed by Master Xú when it comes to post-classical works (even though all of the ones he mentions are still early, historically speaking). This is not to say that he is always in total agreement with classical texts, either, particularly later editions of these works, as he makes clear in his discussion of Shānghánlùn. Though the individual lùn are fairly short, he makes many insightful comments, emphasizes the role of flexibility and intuition in understanding these works, and encourages students to acquire a ‘firm basis’ in the classics first, rather than jumping straight into the later texts, which he regards mostly as guides ‘to broaden our knowledge and add precision’. Otherwise, he fears practitioners will become confused and ‘lose those ideas that they relied on before’.
Much of what Xú says is as relevant now as it was when he wrote it. Nevertheless, readers should be aware that the kind of logical consistency that we take for granted in modern publications was never a particularly conspicuous feature of the pre-modern literature, and there is inevitably a certain amount that will strike the reader as ambiguous, if not apparently contradictory at times. This is characteristic of the work as a whole, not just the passages below. Perhaps we need to take advice from Xú Dàchūn himself, when, in the section on Shānghánlùn, he says that “Whenever you read a book you should try to understand the essential meaning and the main points, in a clear and distinctive way, at the same time tolerating whatever may be disordered and confused, so that, intuitively, a thorough understanding is achieved”!
I have included notes at the end of each section where necessary.
Yīxué Yuánliúlùn (On the Origins and Development of Medicine, 1764) by Xú Dàchūn (1693-1771)
Chapter on the Medical Literature
ON THE NÀNJĪNG (CLASSIC OF DIFFICULT ISSUES)
The Nànjīng (Classic of Difficult Issues) itself is not a classic1. Its purpose was to resolve difficulties in the classical texts, by asking difficult questions and making the issues clear. One can say that it explains difficulties in the classical texts.
The aim of this book was to extend the scope of the original classics, to elaborate on the best of their doctrines, to analyze doubtful points clearly, and to give instruction to students. It is truly of help in reading the Nèijīng (Inner Classic). However, it also contains imperfections, such as when it goes too far in attempting to explain certain statements found in the classical text. These statements were already quite obvious in the original, and such attempts miss the essential points, and render the classical text obscure. The result is that either nothing is explained, or that it contradicts the two books of the Nèijīng2, or makes other mistakes. Such are its shortcomings. However, it also sets out a number of ideas, and develops some excellent approaches not yet encountered in the Nèijīng, truly explains some mysterious passages in it, and supplements things that were not yet evident. In all likelihood it combined these with other teachings, which are equally worthy to be handed down to posterity.
I’m not sure if this is really the work of Qín Yuèrén3. It is possible that Yuèrén was introduced as its author to demonstrate that this book existed in ancient times4. Ever since the Sui and Tang, this book has received much attention, and is revered by a great many people, though there have been none with the ability to criticize and correct it. So, generations of medical practitioners who had read the Nànjīng, or at least acquired a smattering, already considered themselves to be outstanding practitioners of medicine! Why should these experts deign to dig more deeply into the Nèijīng, seeking its similarities and differences, what is gained and what is lost? But all books that have been passed down over the ages contain errors and mistakes, even if later generations dared not offer any criticism. It’s always the same. Why should the Nànjīng be any different?
All of this is discussed further in my Nànjīng Jīng Shì (Nànjīng Explained in Relation to the Nèijīng)5.
Translator’s Notes:
1. Though the word jīng does mean a ‘classic’, Xú, like many others, regarded it more as a commentary on the classics (notably the Nèijīng) with extraneous material added.
2. The two books of the Nèijīng referred to are the Sùwèn (Simple Questions) and Língshū (Magic Pivot).
3. Qín Yuèrén, legendary doctor, 407-310 BCE, also known as Biǎn Què.
4. The Nànjīng is in fact thought to date from the Eastern Han, probably 1st century, and its author or authors are unknown. This fact appears to have been unknown at the time Xú was writing.
5. Nànjīng Jīng Shì, an early work of Xú Dàchūn, published in 1727.
ON THE SHĀNGHÁNLÙN (ON COLD DAMAGE)
There are no less than ten editions of the Shānghánlùn (On Cold Damage)1, all of which creates different opinions, and results in confusion. This is because nobody now understands Zhāng Zhòngjǐng’s intentions in writing this book. If you look at the preface to Shānghán, about three or four paragraphs are devoted to exposing the mistaken treatments of quack doctors, and comparing these to proper methods of treatment. The remainder of the preface outlines methods for alleviating mistaken treatment, and is quite varied. Those who read Shānghánlùn should realize that it is a book of thoughts and conjectures. In this way they will grasp its meaning!
People now change the order of the chapters, either putting them earlier or later, so that one condition becomes something else, or one channel turns into another, with each edition seriously contradicting the others. Who now appreciates that pathologies are innumerable, and that their transmission via the channels is not mechanical? The ancients composed a prescription in response to a particular illness. They did not compile prescriptions and then wait for the right illness to appear.
The sequence of chapters in the original has long since disappeared, but probably the version established by Wáng Shūhé2 can be trusted. Why is that? Well, in his preface, Shūhé says: “I have now tracked down and gone over Zhòngjǐng’s old treatise, and made notes on the conditions and symptoms mentioned therein, as well as diagnosis according to pulse, voice and complexion. I have also gone over those prescriptions that are genuine for each disease, which have proved wonderfully effective and are intended for any emergency.”
Yet despite the fact that this version was compiled by Shūhé, common people insist on refuting it and consider that the original was not like this. They have neglected to consider how this book could have survived in the first place without the work of Shūhé! Furthermore, if that had not existed, how then could later editions made by various authors hope to correspond to Zhòngjǐng’s original text?
Now, if you look at conditions associated with the six channels, some are similar and some are different from one another. When later generations saw that a condition normally associated with one of the yang channels had been listed by Shūhé under those associated with the yin channels, they saw fit to transfer it to the yang channel category, unaware of the fact that such a condition may also be associated with the yin channels! Everyone sticks to their personal opinion, which has caused the inclusive and adaptable methods of the ancients to wither away and be forgotten!
Whenever you read a book you should try to understand the essential meaning and the main points, in a clear and distinctive way, at the same time tolerating whatever may be disordered and confused, so that, intuitively, a thorough understanding is achieved. Otherwise there will be increasing confusion over the discrepancies that are found in these ancient books, in turn causing further revision, which then leads to further obfuscation!
Translator’s Notes:
1. Shānghánlùn (On Cold Damage), the full title of which is Shānghán Zábìnglùn (On Cold Damage and Miscellaneous Diseases), written by Zhāng Zhòngjǐng (152-219) between 200 and 210, Eastern Han dynasty.
2. Wáng Shūhé, physician, 210-280, Jin dynasty. He is known to have published the first extant edition of this work (which he attributed to Zhāng Zhòngjǐng rather than claiming authorship himself), so his edition is almost certainly the closest to the original, as Xú Dàchūn says.
ON THE JĪNGUÌ YÀOLÜÈ (ESSENTIAL PRESCRIPTIONS FROM THE GOLDEN CABINET)
The Jīnguì Yàolüè (Essential Prescriptions from the Golden Cabinet)1 is a book by Zhāng Zhòngjǐng for the treatment of miscellaneous diseases. There is a lot that is either missing or incomplete, and yet it is only due to the fact that this book was preserved that we know of any of the methods used by the sages of high antiquity for treating disease by means of decoctions. It is the progenitor of the formularies (fāngshū).
While discussion of disease is based on the Nèijīng, it makes some intelligent changes. Its use of herbs is based entirely on the Shénnóng Běncǎo (Divine Farmer’s Materia Medica)2, and represents a brilliant and thorough understanding of that work. Its prescriptions are all classical prescriptions (jīngfāng) handed down, over the generations, from the sages of high antiquity, but Zhòngjǐng includes methods for varying the prescription on the basis of the presenting condition. The methods for taking the pulse are also all true instructions handed down from the Nèijīng.
Its treatment of disease is appropriate and thoughtful in every way, without the slightest vagueness or imprecision. With its help, one is in a position to observe the source of the disease, and to review it in fine detail. This means that whichever prescription is used will prove effective, as surely as a drum responds to a drumstick. It is truly the classic of medical prescriptions.
Unfortunately, the various illnesses it describes are not complete, though it is not known whether the original text itself was incomplete or not. Nevertheless, the major conditions are all covered, and it is close to complete. Those scholars of later times who considered it a classic, consulting and extending it, had already covered more than half of all there is to know about medicine! Books that came along later are not the true teachings handed down by the ancient sages. They can hardly be considered a true lineage, and cannot be compared to the Jīnguì.
Translator’s Notes
1. Jīnguì Yàolüè (Essential Prescriptions from the Golden Cabinet) is another work by Zhāng Zhòngjǐng, written at much the same time as Shānghánlùn. Its 25 chapters cover 262 prescriptions for about 60 different diseases.
2. Shénnóng Běncǎo (Divine Farmer’s Materia Medica), precise date unknown but probably near the beginning of the Eastern Han (202BC-220AD), attributed to the legendary Shénnóng (Divine Farmer). It contains 365 medicinals, classified according to upper (superior), intermediate and lower (inferior) grades.
ON THE MÀIJĪNG (PULSE CLASSIC)
It was Wáng Shūhé who published the Màijīng (Pulse Classic)1, categorizing the different types of pulse, and setting them out in a clear and detailed fashion. It is also based originally on the Nèijīng, but takes into account many doctrines expounded after the Han, not omitting a single one. Its scope is therefore too broad to allow people something simple to grasp hold of. Nevertheless, by bringing together a number of teachings, it allowed later generations to observe and consider things side-by-side, making it an indispensable work.
In my humble opinion, it serves as a good guide to assessing the pulse, though not beyond checking whether blood and qi are flourishing or debilitated, whether there is cold or heat, or in which channel or organ evil qi may be circulating. The pulse can then be compared with the presenting condition, to determine the pattern involved – whether generation or restraint [in terms of the five phases], normal or counterflow - after which a good or bad prognosis can be established.
The teachings on the pulse set forth in the Nèijīng, Nànjīng and the writings of Zhòngjǐng, though rather unsystematic by comparison, often achieved good results as well. If you adhere strictly to the teachings of the Màijīng you will think that in the case of a certain disease a certain pulse should be observed, and vice versa. Although these guidelines are also found in the Nèijīng, they are less rigid and fussy. So, if you go by its instructions but have no success, you may either blame this on an abnormal pulse, or possibly say that the disease is not genuine, or that the prescription does not fit the disease, without realizing that all of this is beside the point.
Sometimes the disease agrees with the pulse, sometimes not, and on occasion it may even contradict it. The pulse may match the disease in some cases but not others, and vice versa. Several dozen pulses may be observed in any one disease, and one pulse may be accompanied by hundreds of diseases. The variations are endless.
If you stick obstinately to one viewpoint, and the disease then fails to match the pulse, or vice versa, you will be left hesitant as to what should be done. The fact is that experts on the pulse, both ancient and modern, all differ with one another, and all have their own opinions on what is right and wrong. Everyone sticks to their own doctrines, which are both right and wrong in equal measure. All of this stems from the fact that they do not appreciate that flexibility is the key. The more closely they adhere to their views the further they depart from the truth.
Those who read the Màijīng, and who know that elaborate discussions of this sort concerning the pulse have existed since time immemorial, have all the more reason to examine the similarities and differences with other authorities, to distinguish their merits from their faults, to assess what is true and what is false, and to study exhaustively their variations. In this way they will gain insight and understanding. If they try obstinately to treat disease based solely on the pulse, however, such treatment will always lack certainty.
Students should first consult the Nèijīng and the Nànjīng, as well as the writings of Zhòngjǐng, and so acquire a firm understanding from the start. The treatises written by later authors are for broadening our knowledge and to increase precision. This is the way to read the Màijīng.
Translator’s Notes:
1. Màijīng (Pulse Classic), precise date unknown, by Wáng Shūhé, physician, 210-280, Jin dynasty (see above). Many later editions, particularly during the Northern Song (edition of 1086) and later. When Xú Dàchūn talks of the ‘many doctrines expounded after the Han’ that this work supposedly includes, he may be referring partly to additions made in later editions of this work.
ON THE QIĀNJĪNFĀNG (PRESCRIPTIONS WORTH A THOUSAND GOLD PIECES) AND WÀITÁI MÌYÀOFĀNG (SECRET ESSENTIAL PRESCRIPTIONS OF THE OUTER CENSORATE)
During the Tang dynasty the teachings of Zhòngjǐng underwent a significant change. Zhòngjǐng’s methods for treating disease, his discussion of the zàngfǔ (solid and hollow organs) and jīngluò (channels and collaterals), and the transmission and development of disease, are based entirely on the Nèijīng.
The prescriptions that he used were all classical prescriptions (jīngfāng) handed down by the ancient sages. They were never created according to his own imagination, and the modifications that he made all had a solid basis. The weights and measures he employed also followed guidelines.
As for the herbs, these were based entirely on the Shénnóng Běncǎo. Not a single ingredient was selected without good reason. Every prescription was targeted at a specific disease, and every prescription was made up of carefully selected herbs. Such profundity of thought is extraordinary and barely conceivable! The number of ingredients never exceeded five or six, and yet their actions were all encompassing. These prescriptions are imbued with the secrets of heaven and earth, and the subtle wisdom of the sages, and will last as long as heaven and earth itself.
The Qiānjīnfāng (Prescriptions worth a Thousand Gold Pieces)1 is different. Though it is always consistent with the Nèijīng, it mixes in doctrines based on the conjectures of subsequent generations. While the prescriptions that Sūn Sīmiǎo used also included ancient prescriptions, they were not without a variety of the one-sided (piān) methods from later times2.
As for the herbs he used, these were not based exclusively on Shénnóng, and miscellaneous prescriptions, simple prescriptions (dānfāng)3 and cure-all medicinals were employed at the same time. There are instances of several prescriptions listed for one illness, and one prescription used to treat multiple illnesses. Some of his medicinal preparations contain several dozen ingredients, and there are certainly many targeted at a specific disease, but also quite a few that are not, so his treatment of disease was sometimes effective but sometimes not. Generally speaking, the emphasis is on the herbs themselves, and not on the methods of prescribing advocated by the ancient sages. This represents a major change in the art of medicine. Nevertheless, the extraordinary scope of this work, and its ingenious use of herbs, has established a lineage, aspects of which will never be forgotten.
The Wàitái Mìyàofāng (Secret Essential Prescriptions of the Outer Censorate) was written by Wáng Tāo during the Tang4, in which he collected together various prescriptions from the Han onwards, and published the resulting compilation as a book. It is a comprehensive collection of prescriptions through the ages.
However, this man had no medical training, and his book is really an encyclopedia of medical formulas, which provides no proper assessment or guidance. Despite that, the fact that many pre-Tang and Tang prescriptions are preserved is due to this book, which is of enduring value as a consequence. If people should read it, however, without any well-formed plan in mind, the diversity of information to be found may prove confusing, and the unsystematic mixture of formulas may disorientate them to such an extent that they lose whatever ideas they relied on before.
Those who read the Qiānjīn and the Wàitái should therefore be well versed in the Nèijīng, Zhòngjǐng, the Běncǎo ([Divine Farmer’s] Materia Medica) and other such books. If they hold firm views already, and then make use of the strengths while rejecting the shortcomings of these two books, they will benefit from such a broad selection of approaches to choose from. If not, their minds will be plunged into chaos, and they will have nothing to go by. Alas!
Furthermore if this can be said of the Qiānjīn and Wàitái, consider the one-sided, heterogeneous and unsystematic books of later generations. Would these not confuse people’s hearts and minds? Beyond this, there are further dreadful books with absurd and unfounded notions, which are not even worth talking about.
Translator’s Notes
1. Short for Qiānjīn Bèijífāng (Emergency Prescriptions worth a Thousand Gold Pieces, 652). By Sūn Sīmiǎo, 581-682, Sui and Tang, physician and 'King of Remedies' (Yàowáng).
2. ‘One-sided’ (or ‘unbalanced’) is a term frequently used to describe prescriptions usually made up of only one or two herbs which target a particular symptom or disease and are expected to have quick effects (if they work). The downside is that they may cause damage if used for too long a period.
3. Dānfāng are simple prescriptions often containing only one or two herbs, and associated in particular with the běncǎo literature. They greatly extended the uses of herbs above those found in classical prescriptions. More theoretically inclined physicians, such as Xú Dàchūn, tended to have ambivalent feelings about their use, recognizing that they could be very effective, while criticizing their strongly empirical basis.
4. Wáng Dào (c. 670-755), author of Wàitái Mìyàofāng (Secret Essential Prescriptions of the Outer Censorate) written in about 752, who held the position of 'Censorate Minister' for 20 years, an ancient post in Tang China (hence the name of the title). Also a medical scholar and amateur ‘formula master’ (fāngshì).
