Annotations to Yangke Xinde Ji (1)
The Yangke Xinde Ji (Reflections on the Practice of External Medicine) by the Qing-dynasty surgery master Gao Bingjun is the representative work of the “Xinde” (Reflections) school, one of the three great schools of Chinese external medicine, and it has had an important influence on Chinese surgery. The author has been deeply influenced by it, and so attempts to annotate it. The author is limited in talent and learning; these annotations are not a bid to show off before experts, but are the author’s own study notes, intended mainly to deepen my understanding and memory of Yangke Xinde Ji. It is hard to finish all at once; I can only complete it gradually in my spare time.
General Treatise on Ulcers (1)
Original text: The human body is a small heaven and earth. Heaven has the sun, moon, and stars; earth has mountains, rivers, plants, and trees; man has the five zang and six fu organs. All this is nothing beyond yin-yang and qi-transformation. Qi-transformation cannot be entirely without bias, nor always smooth without reversal; thus heaven is sometimes disordered, earth sometimes desolate, and man sometimes diseased.
Annotation: Chinese medicine stresses holism, embodied in three ways. First, the body’s own zang-fu organs form an organic whole; second, human beings and nature form an organic whole; third, human beings and society form an organic whole. Moreover, Chinese medicine’s understanding of the body and disease often uses the method of “analogical resemblance,” so its understanding of causes and pathology is often drawn by analogy with natural phenomena.
Thus the author emphasizes from the outset that the human body is a small heaven and earth: just as heaven has sun, moon, and stars and earth has mountains, rivers, plants, and trees, so man has the five zang and six fu organs. Moreover, the human zang-fu, like the celestial bodies and the earth’s mountains and rivers, also operate according to the laws of yin-yang and qi-transformation. The yin-yang qi-transformation of heaven and earth sometimes becomes biased and disordered, and so does man; hence heaven has unforeseen winds and clouds, and man sometimes has disease.
Original text: The arrival of disease is varied and changeable, but on the whole it does not go beyond two categories: internal patterns and external patterns. The causes of disease likewise do not go beyond internal and external causes. What is the internal cause? Joy, anger, worry, thought, grief, fear, and fright—the seven emotions; these are yin. What is the external cause? Wind, cold, summer-heat, dampness, dryness, and fire—the six qi; these are yang. Those arising from yang are light and easy to cure; those arising from yin are grave and hard to heal. Internal medicine and external medicine are governed by the same rule.
Annotation: This passage classifies the nature and causes of disease and introduces the general prognosis of diseases caused by different causes. Although diseases are numerous, on the whole they fall into two major categories—internal and external patterns—and Chinese medicine is accordingly divided into internal medicine and external surgery. Causes of disease fall into internal and external causes. However, Chinese medicine also has the doctrine of three causes; besides internal and external causes, there is also the neither-internal-nor-external cause. Chen Yan of the Southern Song dynasty treats this in detail in Sanyin Ji Yi Bingzheng Fanglun (Systematic Treatise on the Three Causes of Disease), which may be consulted.
Internal and external causes can be summed up in eight words: “internal damage by the seven emotions, external contraction by the six excesses (or six qi).” The seven emotions—joy, anger, worry, thought, grief, fear, and fright—are the seven human feelings, belonging to yin; the diseases they cause are also yin patterns, hard to cure, with poor prognosis. The six excesses (qi)—wind, cold, summer-heat, dampness, dryness, and fire—are six external pathogenic climates, belonging to yang; the diseases they cause are also yang patterns, easy to cure, with better prognosis.
Original text: Now consider internal medicine: conditions such as mania, consumption, drum distention, and diaphragm obstruction arise from the zang; they are yin and are not easy to cure. Conditions such as cold damage, malaria, and summer-heat stroke arise from the fu; they are yang and are easy to cure. In cold damage, transmission through the yang channels is easy to cure, while transmission into the yin channels is not; everyone knows this.
Annotation: This passage discusses yin and yang patterns of internal disease. Mania (suspected to be a scribal error for wind, i.e., stroke) is a mental disorder; consumption is tuberculosis; drum distention is ascites as seen today in cancer or late-stage cirrhosis; diaphragm obstruction refers to esophageal or cardiac cancer. The ancients considered these yin patterns arising from the zang, with poor prognosis. Cold damage is an externally contracted disease; malaria is malaria; summer-heat stroke is a damp-heat disease; these are yang patterns arising from the fu, with better prognosis. Cold damage, as it develops, shows channel transmission—i.e., progression of the disease; transmission into a yang channel such as Yangming or Shaoyang is easy to treat, while transmission into a yin channel such as Shaoyin, Taiyin, or Jueyin is hard. This further illustrates the preceding passage.
Original text: Are external-surgery conditions any different? Some arise from the zang, some from the fu. Some are in the skin, muscles, or bones; all are nothing but the result of congestion and stagnation of qi and blood and the retention of the construction and the defense. Those arising from the zang are white in color, flat and sunken in shape, with thin watery pus, sometimes foul and putrid, with a weary spirit—this is yin. Those arising from the fu are red and swollen and elevated, with thick sticky pus, and a clear, alert spirit—this is yang. Such is the general outline.
Annotation: This passage says external-surgery diseases are also divided into yin and yang; those arising from the zang are yin patterns, those from the fu are yang patterns. The disease may be located in the skin, or in the muscles and bones; its cause is nothing but congestion and stagnation of qi and blood and obstruction of the construction and defense, so Chinese surgery commonly uses herbs that move qi and activate blood. External-surgery diseases arising from the zang have lesions whose color is no different from normal skin, with flat, sunken lumps, usually painless in the early stage; when ulcerated, the pus is thin and watery, sometimes foul and putrid, and the patient’s spirit is weary—this is a yin pattern. Those arising from the fu present with red, swollen, painful lesions and thick sticky pus, and the patient remains alert and spirited—this is a yang pattern.
Original text: In detail, those arising from the zang are an internal cause; regardless of deficiency or excess, cold or heat, they all arise from qi stagnation—conditions such as shirong, gan gan, and ru yan. If treated properly, one can at most live out one’s years with the disease. As for those arising from the fu, these are an external cause, with varied origins: sometimes fire-heat assisting the heart causes an ulcer, sometimes cold evil injuring the heart, sometimes dryness evil plundering the heart, sometimes damp evil congesting and stagnating; these are all due to seasonal atmospheric influences and should all be treated by what overcomes.
Annotation: This further discusses the causes of external-surgery diseases. External-surgery diseases arising from the zang, whether deficiency or excess, cold or heat, are all caused by qi stagnation. Because in antiquity it was hard to study pathology as deeply as today, they could only ascribe it to qi stagnation. Which external-surgery diseases are caused by qi stagnation? The examples given here are shirong (comparable to modern lymphoma or lymph node metastasis of advanced cancer), gan gan (tongue cancer), and ru yan (breast cancer). Such diseases, if treated properly, may prolong life with the disease but are hard to cure—at most one “lives out one’s years with the disease.”
As for those arising from the fu, these are due to external causes, with complex origins: fire-heat assisting the heart, cold evil injuring the heart, dryness evil plundering the heart, damp evil congesting. Why do so many causes relate to the heart? Because Huangdi Neijing says that all pain, ulcers, and sores belong to the heart; Chinese medicine holds that the heart belongs to fire in the five phases, so the causes all relate to heart fire. This is the conservative side of Chinese medicine: later physicians, in explaining causes and pathology, often had to seek support in Huangdi Neijing and dared not propose new views, so scholarship found it hard to make breakthroughs. These external causes all relate to climatic change, belonging to externally contracted six excesses; the treatment principle is, according to the generating and overcoming cycles of the five phases, to treat with “what overcomes.” Among the five phases, what overcomes me is my “overcomer-not,” and what I overcome is my “overcomer.” For instance, metal overcomes wood; thus for wood, metal is its overcomer-not, and for metal, wood is its overcomer.
Original text: There are also cases where cold evil lodges and congeals the blood so that it cannot flow, producing alternating chills and fever, irritability, and aching that looks like heat; where heat evil prevails, flesh putrefies and pus becomes fetid, even severing tendons and exposing bone, so that the voice becomes hoarse and the complexion pale, looking like cold; and cases where sweating from toil meets wind, the construction rebels in the flesh, and cold and heat are hard to distinguish.
Annotation: This further discusses, among external-surgery diseases, true cold with false heat and true heat with false cold, as well as mixed cold-heat patterns. Lodging cold evil causing congealed, blocked blood produces alternating chills and fever, restlessness, and muscle ache that looks like a heat pattern; long-contracted external heat evil causes the patient’s flesh to putrefy, the pus to become bloody and foul, and even the lesion to rot away so that sinew and bone are exposed, and then a hoarse voice and pale complexion appear, resembling a cold pattern. Some other patients, after sweating from toil, coveted the wind for coolness, so the construction blood is attacked and qi and blood fail to move; the cold and heat in such patients are hard to distinguish.
Original text: There is also the neither-internal-nor-external cause: accumulation of rich, fatty food, the influence of fox-spells, the disorders of sexual excess, and the potency of elixirs and minerals—all can produce major ding or large yong. Even things such as mistakenly eating poison, falls, crush, beating and rods, burns, scalds, and insect or beast bites all produce yong and pus; in short, all are caused by non-conformity of the construction qi.
Annotation: This passage says that the neither-internal-nor-external cause can also produce external-surgery swelling-ulcer diseases. “Accumulation of rich, fatty food” means excessive eating of meat; “the influence of fox-spells” refers to the ancients’ belief that mysterious ghosts and spirits could adversely affect health; “the disorders of sexual excess” mean those caused by excessively frequent sexual intercourse; “the potency of elixirs and minerals” refers to the bad habit of taking so-called elixirs of immortality, producing toxic lesions. All these can cause major ding and large yong in the body. In addition, food poisoning, traumatic injuries, burns and scalds, and even insect and animal bites may also cause yong, ju, and suppuration; in short, these diseases all belong to obstruction of the construction and defense.