Shih Ching

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Nosological data in the Shih Ching (Book of Odes, about eighth century B.C.) have been analyzed in detail by Yii Yiin-hsiu, but there is a special difficulty here because these ancient folksongs naturally took advantage of poetic license and it is sometimes difficult to determine whether the disease terms are being used in their proper medical sense; some of them may have been used to indicate malaise or depression in general. Nevertheless, shou chi (feverish headaches), shu (enlarged neck glands, perhaps goiter, tuberculosis, or Hodgkin's disease) and meng, sou (various forms of blindness) are all of interest. Nosological data derived from the Tso Chuan, the greatest of the three commentaries on the Chhun Chhiu already mentioned, are more reliable and also much more abundant. More than 55 consultations or descriptions of diseases occur in these celebrated annals. Perhaps the most important is the consultation dated 540 B.C. which the Prince of Chin had with an eminent physician, Ho, who had been sent to him by the Prince of Chhin. Physician Ho, as part of his bedside discourse, included a short lecture on the fundamental principles of medicine that enables us now to gain great insight into the earliest beginnings of the science in China. Especially important is his division of all disease into six classes derived from excess of one or other of six fundamental, almost meteorological, pneumata (chhi). Excess of Yin, he says, causes han chi; excess of Yang, je chi; excess of wind, mo chi; excess of rain, fu chi; excess of twilight influence, huo chi; and excess of the brightness of day, hsin chi. The first four of these are subsumed in the Nei Ching classification under je ping, diseases involving fever; the fifth implies psychological disease;

and the sixth, cardiac disease. The classification into six divisions is of extreme importance, because it shows how ancient Chinese medical science was independent of the theories of the Naturalists, who classified all natural phenomena into five groups associated with the Five Elements. Chinese medicine never entirely lost its 6-fold classification; but that is a long story, which cannot be told here. Physician Ho diagnosed the illness of the Prince of Chin as ku1, by which he did not mean the artificial poison nor, so far as we can see, schistosomiasis, but rather some kind of physical exhaustion and melancholia arising from excessive commerce with the women of his inner compartments.

Tso Chuan

There is something of interest in every one of the medical passages of the Tso Chuan. For example, in 638 B.C. a deformed (wang) sorceress, doubtless suffering from rickets or osteomalacia, was to be burnt as a remedy for drought, but a skeptical statesman, Tsang Wen-chung, intervened and said that other means would be much more efficient, so this method was not used. Two years later, we hear of Chhung Erh, the son of Prince Hsien of Chin State, who suffered from phien hsieh (i.e., his ribs were so distorted and deformed as almost to meet in front of the sternum). Moved by scientific curiosity perhaps, the Prince of Tshao succeeded in getting a view of him while in the bathhouse. In an episode of 584 B.C., a certain country was described as dangerous for giving people a disease named o, although in this particular case the disease endemic there seems to have been beriberi, because there is talk of edematous leg swellings and waterlogged feet (chui). We encounter the same term again (o ping) in the Lun Yii, the discourses of Confucius, dating from about a century later. One of his disciples, Po Niu, suffered from o ping, and the universal interpretation of all the commentators since that time has been that this disease was leprosy. We do not find the term lai at such an early date, but there seems no reason to reject so old and continuous a tradition that this was the first mention of leprosy in Chinese literature.

Another case relating to the date 569 B.C. was death by heart disease (hsin chi, hsin ping)-, it happened to a general, Tzu-Chung (Kung tzu Ying-chhi of Chhu), who was greatly distressed after a military failure, and we may regard it as angina pectoris brought on by anxiety. Soon afterward, the term shan came into use to denote this disease, the symptoms and psychosomatic nature of which are so characteristic. We find this word in the Nei Ching, used instead of the term just mentioned for the parallel hsin thung of the Shan Hai Ching, an ancient geographical text that belongs to the middle of the Chou period. In 565 B.C., the Tso Chuan notes another case of fei chi, some kind of chronic disability that prevented the normal life of a minister's son. Hydrophobia is also fairly clearly indicated in an entry connected with 555 B.C., where a mad dog (chi kou or hsia kou) entered into the house of Hua Chhen, a minister of Sung State. The word khuang was used indiscriminately for the mad dog itself and for the disease that it caused. Toward the end of the Tso Chuan we have a story dated 497 B.C., in the latter part of the life of Confucius, which includes the famous remark that "only he who has thrice broken his arm can make a good leech."

Shan Hai Ching

We have already mentioned the Shan Hai Ching. This is a strange book, full of legendary material, which reached its present form probably about the second century B.C., but which contains much far older material. Many legendary and mythological elements pervade its descriptions of the mountains and forests of the Chinese culture area, the spirits proper to be worshiped by travelers in any particular region, and also the peculiar plants and animals and their virtues. More than 30 herbs, beasts, and stones are recommended to ward off various diseases, and this is where the nosological interest comes in. Many terms we have already met with, such as epidemic fevers (i, li1), epidemics with rash (chieh), edematous swellings (chung), goiter (ying), rodent ulcers (chii), and eye defects, probably trachoma (mi). Ku1 disease is also mentioned. Yu1 we have not encountered previously; it means both swellings in the neck and also torticollis or palsy. If equivalent to yu2 or chan, the commentators interpret it as paralysis agitans or senile tremor, but it may also refer to an affliction called yu3 chui. This consists not only of large swollen lymph glands or the parotitis of mumps, but also small, wartlike tumors on the head, neck, and extremities which recall verruca, the multiple warts produced by a rickettsia. Another of the disease terms met with in the Shan Hai Ching is chia, which undoubtedly refers to a massive infestation with intestinal worms (ascariasis or oxyuriasis). This brings us to the great period of Han case-histories, and so to the work of Shunyu I.

Han Period: Shunyu I

During the Warring States, Chhin, and early Han periods, there were two great schools of medicine:

The earliest grew up in the western state of Chhin; the other was located in the eastern seaboard state of Chhi. From Chhin came the physician Huan, whose attendance on the Prince of Chin in 580 B.C. long remained famous; the physician Ho, already mentioned as examining another Prince of Chin 40 years later, also came from there. More celebrated than either of them was Pien Chhio, about whom there is much to be said, but as the records concerning him do not give us very much in the field of disease nomenclature, we mention him only in passing. But Shunyu I is a different persona entirely. Born in 216 B.C. in Chhi, he studied under Kungsun Kuang and Yang Chhing, practicing medicine successfully from about 180 B.C. on. In 167 B.C., he was accused of some crime and taken to court, but he was acquitted after the supplication of his youngest daughter. As he had been attending on the Prince and lords of Chhi, he was summoned to answer an inquiry from the imperial court some time between 164 and 154 B.C., then released again, and he continued in practice until his death about 145 B.C. It is owing to this perquisition by the imperial authority that we possess today the records of some 25 detailed case histories which Shunyu I reported. For every one we have the name of the patient, the circumstances in which the disease was contracted, the details of the attendance of Shunyu I, the treatment that he prescribed, the explanations that he gave of his diagnostic reasoning, in which the pulse played a very prominent part, and finally the ultimate result. We also have the answers that Shunyu I gave to eight general questions, answers that throw a flood of light upon the general conditions of medical education and practice in the second century B.C. R. F. Bridgman (1955), who had given us a pioneer study of Shunyu I and his times, has concluded that the general level of Chinese medicine thus revealed was in no way inferior to that of the contemporary Greeks, and in this judgment we concur. For the present purpose the point is that the clinical descriptions are so detailed that we can see exactly what Shunyu I meant by his own technical terminology.

Let us first look at some of the less severe cases that Shunyu I was able to cure - or at least relieve for a time. In a child, chhi ko ping was clearly difficulty in breathing, probably influenza or catarrh, perhaps acute laryngitis; some fever is implicit in the explanation. In a palace superintendent, yung shan was evidently vesical schistosomiasis, accompanied by hematuria, urinary retention, vesicular calculi, perhaps prostatorrhea. Other similar cases, however, were too far gone to recover - for example, a police chief who seems to have had bladder cancer accompanied by intestinal obstruction due to heavy ascaris infestation (chia). The Chief Eunuch of the Palace of Chhi fell into a river and got very cold and wet, so his je ping due to han was surely bronchitis or pneumonia; Shunyii I gave antipyretic drugs and pulled him through. Then the Queen Mother of Chhi had feng tan, which is clearly interpretable as acute cystitis, probably connected with nephritis. She had hematuria, but she got better under Shunyu's treatment. An old nurse of the princely family had je chiieh, with hot and swollen feet; this may have been gout accompanied by chronic alcoholism, or possibly simply a traumatic infection of the extremities. Chhiu chih was clearly dental caries, and one of the grand prefects of Chhi had it. One of the concubines of the Prince of Tzu-chhuan had a difficult childbirth; Shunyu I gave nitrate and obtained the rejection of postpartum blood clots. A young courtier had shen pi - traumatic lumbago or muscular strain caused by trying to lift a heavy stone, together with dysuria, perhaps caused by compression of the hypogastric plexus; he also got better. By means of a vermifuge prepared from the gingko tree, a girl was cured of an intense Enterobius infestation (oxyuriasis). Here the description is particularly precise because the term used was jao chia, and already by this time there were several other terms (hui, chiao, pa, etc.) for other types of intestinal parasites. Another case of pi was that of a young prince who had acute lobar pneumonia but recovered.

One of the more striking features of Shunyii I's practice was the way in which he was able to give a long-term diagnosis. For example, on one occasion he was asked to give a general health checkup of the serving maids of the Prince of Northern Chhi, and among these he found one who was certainly not ill but in his opinion was going to be. She was, he said, suffering from shang phi, and this must have been tuberculosis because it ended in a sudden and fatal hemoptysis some 6 months later. No one would believe that Shunyii I was right in saying that she was ill, but events confirmed his opinion. On another occasion he was alarmed by the appearance of a slave of the client of the Prime Minister of Chhi, who again, in his view, had a shang phi chhi, although the man himself did not feel particularly ill. Shunyii I said that he would not last through the following spring, and he did not. Here the clinical description suggests hepatic cirrhosis, almost certainly of parasitic origin, caused by liver flukes (hepatic distomia-sis); jaundice was apparent, and the case might also have been one of acute yellow atrophy of the liver.

One of the most extraordinary cases reported by Shunyii I was that of another royal physician, by name Sui. He must have been interested in Taoist arts, for he had himself prepared elixirs from the "five mineral substances," and when Shunyii I saw him he was suffering from chung je, apparently in this case a pulmonary abscess, presumably brought on by arsenical or mercury poisoning. Shunyii I warned him that it would be hard to avoid a fatal result, and in fact some months later the abscess burst through under the clavicle, and Sui died. Another man had what Shunyii I described as ping khu tho feng (i.e., some progressive paralysis), possibly disseminated sclerosis or possibly progressive muscular dystrophy.

More rapidly fatal in termination were other cases. A palace chamberlain had a peritoneal abscess, perhaps a perforating ulcer (chii, leading to chung je); perhaps the perforation was due to heavy ascarid infestation. Another man died of fei hsiao tan with delirious fever {han je). This would have been acute hepatic cirrhosis, probably caused by liver and blood flukes. In this case, the royal physician of Chhi had diagnosed and treated it quite wrongly. It is curious that up to this time we have not found the characteristic term for cholera (ho luan), but it seems that Shunyii I may well have had a case of it among his records, for a minister of the Lord of Yang-hsii died of "penetrating pneuma" (tung feng), the description of which suggests total failure of digestion, intense diarrhea, possibly due to enteric fever, perhaps to cholera. The word shan appears again in a combination mu shan, where it clearly refers to an aortic aneurism that caused the death of a general. The last case we shall mention was that of a Court Gentleman of Chhi who had a fall from his horse onto stones; the resulting traumatic abdominal contusion followed by intestinal perforation of a gut probably already weakened by parasitic infestations of one sort or another was termed fei shang, that is, injury not to the lung but to the tract (ching) of the lung. This brings us to the last subject that we can touch upon here, namely the medical system of the Nei Ching.

The Nei Ching

The Nei Ching was, we think, approximately already in its present form by the first century B.C. The full title under which it is commonly known is the Huang Ti Nei Ching (The Yellow Emperor's Manual of Esoteric Medicine), consisting of two parts, the Su Wen (Pure Questions and Answers) and the Ling Shu (Spiritual Pivot). This was the recension that came from the editorship of Wang Ping in the Thang dynasty, but it is probable that this was not the recension that the Han people had. Another one, known as the Huang Ti Nei Ching, Thai Su, which was edited 100 years or so earlier than Wang Ping, by Yang Shang-shan in the Sui period, and which has only come to light in very recent times, may be considered nearer the original text of the Han. The Nei Ching system of diagnosis classified disease symptoms into six groups in accordance with their relation to the six (n.b., not five) tracts {ching) which were pursued by the pneuma {chhi) as it coursed through and around the body. Three of these tracts were allotted to Yang (Thai-Yang, Yang-Ming, Shao-Yang) and three to Yin (Thai-Yin, Shao-Yin, and Chiieh-Yin). Each of them was considered to preside over a "day," one of six "days" - actually stages - following the first appearance of the feverish illness. In this way, differential diagnosis was achieved and appropriate treatment decided upon. These tracts were essentially similar to the tracts of the acupuncture specialists, though the acupuncture tracts were composed of two 6-fold systems, one relating to the hands and the other to the feet, and crossing each other like the cardinal {ching) and decumane {lo) streets of a city laid out in rectangular grid arrangement. Moreover, by the time of the Nei Ching the physicians had achieved full recognition of the fact that diseases could arise from purely internal as well as purely external causes; the ancient "meteorological" system explained by physician Ho had therefore been developed into a more sophisticated 6-fold series, namely feng, shu, shih, han, sao, huo. As external factors, they could be translated as wind, humid heat, damp, cold, aridity, and dry heat; but as internal causes we could name them blast (cf. van Helmont's bias), fotive chhi, humid chhi, algid chhi, exsiccant chhi, and exudative chhi. It is interesting to notice the partial parallelism with the Aristotelian-Galenic qualities, which were part of a quite different, 4-fold, system.

In the brief remaining space of this contribution, it would be impossible for us even to sketch the etiologic and diagnostic system of the Nei Ching, but it is fair to say that the system provided an elaborate classificatory framework into which the results of keen clinical observation could be fitted. A rather comprehensive theory of medicine, both diagnostic and therapeutic, was now available. Interpreting a whole millennium of clinical tradition, the physicians of the former Han dynasty were able to combine into one science the influences of external factors on health, the abnormal functioning of internal organs whether by excess or by defect, and the manifestation and interrelationship of symptoms; using the concepts of Yin Yang (the two fundamental forces in the universe), Wu Hsing (the five elements), Pa Kang (the eight diagnostic principles), and Ching Lo (the circulatory system of the chhi). The five elements had not been part of the most ancient Chinese medical speculations; they derived from another school, that of the Naturalists (Yin-Yang chia) whose greatest exponent and sys-tematizer had been Tsou Yen (c. 350-270 B.C.) Five-element theory (a lengthy discussion of which can be found in Science and Civilisation in China, Volume 2 [Needham et al. 1954]) was so influential and so widespread in all the nonmedical sciences and protosciences of ancient (and medieval) China that the physicians could not remain unaffected by it, but in incorporating it into their theoretical disciplines they added a sixth unit or entity to conform with their 6-fold categories. Thus there were five Yin viscera (liver, heart, spleen, lungs, and urino-genital organs) and five Yang viscera (gallbladder, stomach, larger and small intestines, and bladder) recognized by all schools. To these the physicians added a further entity in each category, the hsin pao lo (pericardial function) and the san chiao (three coctive regions); and the particular interest of this lies in the fact that these additions represented physiological operations rather than morphologically identifiable structures. The six "viscera" could thus correspond readily with the six chhi, the six tracts, and so on. It must not be supposed that the state of Chinese medicine at the time of the Nei Ching synthesis was destined to remain unchanged through the following nearly two millennia of autochthonous practice; on the contrary, there were great developments, many elaborations, and a proliferation of diverging schools. However, if we are to think of any presentation of Chinese medicine as classical, this is what deserves the name.

The ancient Chinese physicians were extremely conscious of the temperature-regulating and -perceiving systems of the human body, so that although they had no means of measuring temperature accurately, the observation of subjective chill or fever, together with algophobia or algophilia, was extremely important for them. By this time also the study of the pulse and its modifications had advanced to a highly developed state.

All fevers were placed in a category of shanghan diseases and termed diseases of temperature (je ping). Every sign that is still examined today (pain, perspiration, nausea, etc.), short of the results of modern physicochemical texts, was studied by them and meant something to them. For example fu man, or abdominal fullness, was an important sign. This could mean edema (.chung). The Nei Ching actually says that "fluid passing into the skin and tissues by overflow from above and below the diaphragm forms oedema." It could also mean ascites occurring in liver cirrhosis, heart failure, and especially schistosomiasis, undoubtedly so common in ancient China. Fu man was also accompanied by the excretion of watery feces with undigested food (shih i) found in gastroenteritis, cholera, and the like. Fu man was also called fu chang and tien. This latter word is a good example of a word that can be pronounced in two ways; pronounced tien, it meant abdominal distension; but pronounced chen, it meant various forms of madness and, in the binome chen hsien, epilepsy. It is clear from the clinical description that from Han times onward the terms lao feng and lao chung referred to tuberculosis. The term feng by itself always had the connotation of convulsion or paralysis; it might be regarded as a violent pneuma, in distinction from the mild pneuma (chhi), which was part of the physiology of the normal body. Other forms of chung feng, therefore, were hemiplegia (phien khu) and cerebral hemorrhage giving full apoplexy (fi). Among the fevers (wen ping) we now find fairly clear descriptions of diphtheria, as she pen lan (lesions at the root of the tongue), doubtless complicated by streptococcal infections. Diphtheria is also clearly denoted by meng chii, "fierce ulcer" (of the throat). Hepatic cirrhosis caused by liver and blood flukes was now called kan je ping; tuberculosis, phi je ping; pneumonia, fei je ping.

It does not always follow that the organs referred to in descriptions (in the three preceding cases: liver, spleen, and lungs, respectively) were those to which we might refer the diseases today. Rather these were the organs concerned with the six tracts already spoken of, each one of which was connected with an organ. Of the malarial types of fever (chiai nio) we have already spoken. The terminology now continued with little change, but one disease, tan nio, may be identified with relapsing fever caused by Borrelia spirochetes as Sung Ta-jen has suggested.

One last word on diabetes. Polyuria was recognized as the sign of a special disease in the Nei Ching, where it is called fei hsiao. Han ideas about this illustrate the principle of successive involvement or shifting (i) when some pathological influence spreads from organ to organ in the body. Thus in fei hsiao the cold chhi in the heart passes over into the lungs and the patient excretes twice as much as what he drinks. Though the characteristic name for diabetes (hsiao kho, hsiao chung) had not been developed by the end of this period, there can be little doubt that diabetes was here in question. The sweetness of the urine was discovered a good deal later, indeed in the seventh century A.D.

The fact that mummification was not practiced in ancient Chinese civilization has no doubt militated against the acquisition of a mass of concrete evidence concerning many of the diseases from which people suffered in those times, such as has been developed for ancient Egypt. As far as we know, almost nothing has been done on the pathological anatomy of the skeletons that have been excavated from ancient tombs in China, whether in the Neolithic or in the Chou, Chhin, and Han periods. Since there must be a mass of skeletal material in the Chinese museums, it may be that this task could still be accomplished with valuable results by Chinese archeological pathologists. However, the study of the written records of ancient China, from the middle of the first millennium B.C. down to the beginning of our era, shows that they have preserved a veritable mass of information concerning the diseases prevalent in those times, and although the study of human remains themselves may bring precious confirmation of what the writings reveal, it may well be that on balance the written records, when fully analyzed, will present a broader picture than the study of the skeletal remains themselves alone could ever give us.

Lu Gwei-Djen and Joseph Needham

We acknowledge with thanks an earlier version of this essay printed under the title "Records of Diseases in Ancient China" in the American Journal of Chinese Medicine (1976, 4 [1]: 3-16), published by the Institute for Advanced Research in Asian Science and Medicine, Inc., which was previously printed in Don Brothwell and A. T. Sandison's Diseases in Antiquity, 1967, published by Charles C. Thomas.

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