HISTORY OF HYGIENE. Proceedings of the 12th International Symposium on the Comparative History of
Medicine - East and West. August 30 - September 6, 1987, Susono-shi, Shizuoka, Japan. Edited by
Yoshio Kawakita, Shizu Sakai, Yasuo Otsuka. Ishiyaku EuroAmerica, Inc. Publishers.

Pharmacotherapy and Chinese Hygienic Concepts as Seen in
the Xiao Pin Fang*1of Medieval China
*Chinese characters in this paper by Japanese JIScode

The Oriental Medicine Research Center of the Kitasato Institute
5-9-1 Shirogane, Minato-ku, Tokyo, Japan

    Inany system of medicine, treatment and hygiene form an inseparable relationship. (In this discussion, "hygiene" is used in its classical Greek sense of a regimen for the promotion of health.) Especially if our definition of illness is expanded to include general ill health, or a lack of wellness, it becomes very difficult to clearly differentiate between these two aspects of medicine.
    A close relationship exists between treatment and hygiene not only in modern medicine, but also in the traditional medicines of East and West. Hygiene was given at least as much, if not more, value than treatment in the past, when the available treatments were not as decisive in effect as modern medicine is in treating otherwise fatal diseases. Thus a wealth of experience and knowledge was accumulated about hygiene. In our times, when fatal infectious disease has for the most part been conquered, people are beginning to show renewed interest in traditional medicine and we must not overlook the major role once played by concepts of hygiene.
    Chinese medicine in particular has a long tradition of emphasizing hygiene. Although there are many aspects of and objectives to hygiene, here I wish to concentrate on the connection between treatment and hygiene - or more specifically, on hygiene for those who are already ill. Because a great deal of material has been lost over time, there is a problem with the paucity of medical literature and references on this subject from medieval and pre-medieval China, but I believe that it is at least possible to shed some light on certain aspects of the issue if the scope of discussion is limited. Therefore, I am surveying the subject based on my study of the Xiao Pin Fang, a Chinese medical text highly regarded in medieval times. In discussing that work, I hope to elucidate the relationship between the medieval concepts of hygiene and pharmacotherapy.


    The medical text Xiao Pin Fang, consisting of twelve volumes, was written by a Chinese physician named Chen Yan Zhi.*2 In the 8th century, theXiao Pin Fang was designated as a compulsory text for Japanese medical students, concomitant with Japan's imitation of the Tang*3legal code. During that period, the Xiao Pin Fang was highly acclaimed in Japan as an important medical work.
    But by the time of the Northern Song*4dynasty (960-1127), the Xiao Pin Fang could no longer be found in China, even in the Imperial Court Library. The text was thought to have been irretrievably lost, both in China and Japan, from that time forth.
    My colleagues and I, however, have been extremely fortunate in discovering a hand-copied edition of the first half of the first volume of the Xiao Pin Fang in the Son Kei Kaku*5Library in Tokyo. Previously, the time period during which this text had been written was unknown, but with the discovery of this copy, it was established as between 454 and 473 A.D., during the Southern dynasty (Liu-Song*6) of the North and South Kingdoms.1) This discovery of a portion of the Xiao Pin Fang and the determination of its approximate date of origin have afforded for us valuable insight into the condition of medicine during that period, and has provided historical perspective on various related fields.
    The contents of the extant portion of the Xiao Pin Fang can be divided into seven sections: (l) preface and bibliography, (2) a list of contents for all twelve volumes, (3) precautions in combining crude drugs, (4) methods for processing crude drugs, (5) standard weights and volumes for crude drugs, (6) analysis of the background of diseases, and instructions for administering prescriptions, and (7) prescriptions for specific diseases.
    Here, I will focus on the seventeen articles in the sixth section, which is titled "Shu Kan Fang Ji Ni He Bei Ji Yao jue."*7 This section contains an analysis of the factors which are part of the background of a disease: factors such as climate, sex, age, and physical constitution. Logically consistent instruction is then given for administering medication according to those variables and the severity of the disease. This section of theXiao Pin Fang is, quite literally, an extended discourse on the connection between treatment and hygiene. Therefore, I will introduce each of the seventeen articles in order, and examine them from the perspective of hygiene as it pertains to the realm of pharmacotherapy.


Rules of Treatment
    In the first article, Yan Zhi sets forth the following basic rules of treatment as an introduction to the seventh section.

    At the end of this passage, Yan Zhi establishes a hierarchy of priorities in the study of medicine, starting with the treatment of acute, life-threatening diseases and progressing on to means of aiding convalescence. In short, his emphasis was on a acute diseases. Hygiene, the last thing to be studied, is expressed by the Chinese characters (bu wei*9) which mean "support" and "protect." Thus, in this context, hygiene can be understood as the promotion of recovery and the prevention of relapse through pharmacotherapy.
    Interestingly, traditional ancient Chinese concepts of medicine differ from Yan Zhi's approach in that hygiene, particularly the prevention of disease, is given primary emphasis. This view is expressed not only in classical medical texts such as the Su Wen*10 (0-200 A.D.), but also in non-medical works such as Lao Zi*11and Huai Nan Zi*12 which contain passages such as: "The best form of medicine is that which treats diseases before they appear." 2,3,4) In other words, the ideal is to regulate physiological condition before pathological signs are manifested. In contrast to this, Yan Zhi's approach to medicine tends to emphasize the condition after a disease has occurred, or the treatment of pathological conditions, which is then complemented by the regulation of physiological condition (hygienic concepts) to promote recovery.
    It can be said that Yan Zhi's approach, rather than refuting traditional concepts of medicine, was perhaps an attempt at establishing a better balance between treatment and hygiene by advocating a medical model which emphasized treatment. On the other hand, in his preface, Yan Zhi takes a critical stance on contemporary hygienic practices and medical treatments for serious cases. His comments give evidence of a strong character, and assert that, in a sense, any approach to medicine which emphasizes only one aspect of hygiene or treatment is not practical.

Rules for Diagnosis and Selection of Prescriptions
    Article 2 goes a step further than Article 1, introducing several aspects of diagnosis:

    The causes of disease Yan Zhi lists follow a specific sequence: first are factors related to internal medicine (climate, life style, and emotional changes), second are gynecological factors and factors related to surgical medicine, and last come the adverse effects of drugs taken for therapy or longevity.5)Such an ordered list of pathogenic factors is unusual in early Chinese medical texts, and this passage probably represents the oldest such list. Nevertheless, only the pathogenic factors are listed, and no further explanation is given. Judging by the way this article is written, the list of pathogenic factors is most likely presented only for the sake of introduction. The main point of this passage seems to be the suggestion in its latter half that pulse palpation is not always necessary.
    In the third section of this text, however, Yan Zhi criticizes intellectuals who do not believe in pulse palpation. Also there are repeated references to pulse palpation and pathogenic factors throughout this work. So it is also clear that Yan Zhi did not consider pulse palpation for the determination of pathogenic factors to be totally unnecessary in medical treatment. Given that fact, one might wonder why he lists the pathogenic factors only to state that questioning the patient and administering conventional prescriptions or their variations was often sufficient.
    In his preface, Yan Zhi states that the composition of and indications for the traditional prescriptions he has recorded were determined through numerous examinations for pathogenic factors and a great deal of clinical experience. He also asserts that it is not always necessary to determine pathogenic factors when traditional formulas are used, and he goes on to state that such a prescription can be used if only half of its indications correspond with the patient's symptoms. Why, then, were just half of the indications considered to be enough? If traditional prescriptions were in fact formulated through accumulated experience, ostensibly all the symptoms likely to occur due to a certain pathogenic factor would be included. However, idiosyncratic symptoms unique to each patient would not necessarily be included by this inductive process. Since there are individual physiological differences between patients, it is not likely that all the symptoms related to a certain pathogenic factor would appear. In his preface, Yan Zhi also states that traditional prescriptions need to be modified according to the physiological characteristics of patients, who are each subject to different conditions, and also in consideration of the action and characteristics of the drugs. For the reasons mentioned, only half of the indications need to be present, but the prescription must be modified to take care of the symptoms not included among its indications.

    Thus far, based on Articles 1 and 2, I have analyzed Yan Zhi's approach to medicine. My observations can be summarized by the following two points diagrammatically represented in Figure 1. The first point is that the objective of medicine is to treat disease. In Yan Zhi's approach, hygiene is secondary to treatment, and is applied in the recovery stage to regulate physiological functions in order to promote recovery and prevent relapse. The second point is that treatment during the period of disease is mainly administered by using traditional prescriptions originally formulated on the basis of determinations of pathogenic factors. In Yan Zhi's view, however, it is also necessary to modify prescriptions in consideration of individual differences in physiology among patients and the effects of the crude drugs.
    I would now like to highlight the following point: regulating individual physiology is, in fact, at the very core of the concept of hygiene in traditional Chinese medicine, which in essence says "treatment before the onset of illness." Yan Zhi, however, places emphasis on hygiene as "treatment after the onset of illness." I would like to examine Articles 3 through 17 to analyze specifically what Yan Zhi considers to be hygiene, as far as "treatment after the onset of illness" is concerned.


Types of Patients, Severity of Diseases, and Dosage
    In Articles 3 through 8, medication dosage is stipulated and the reason for using a particular dosage is explained on the basis of severity of the disease (Article 3); length of time from the onset of illness (Article 4); physical strength, age and experience in taking medication (Articles 5 and 6); young or strong patients with mild illnesses verses old or weak patients with severe chronic illnesses (Articles 7 and 8). Since the contents of each of these articles is organized according to indications for large doses vs. indications for small doses, they can be summarized as follows:

When to Use Larger Doses and Why

(a) In mild illnesses, or the early stages of an illness (in patients with normal strength), the amount of physical strength consumed by the illness is small. Therefore, the patient still has enough strength to endure the adverse effects of the medication, and the dose can be increased (Articles 3 and 4).
(b) In young or strong patients with severe illnesses, even though the physical strength consumed by the illness is great, the patient's strong constitution means that dosage can be increased (Article 5).
(c) For strong patients with mild illnesses, only a little strength is consumed by the illness, and in addition the patient has a strong constitution, so the dose can be increased (Article 7).
(d) For weak patients who have taken much medication, although they are physically weak, their body has developed the ability to counteract the effects of the medication, and the beneficial effects of the medication have been reduced. Therefore, increase the dose (Article 5).

When to Use Smaller Doses and Why

(a') For severe and chronic illnesses in patients with normal strength, the illness consumes much of their strength. Because they no longer have the strength to endure the adverse effects of the medication, the dose is reduced (Articles 3 and 4).
(b') In old or weak patients with mild illnesses, although only a small amount of physical strength is consumed by the illness, the patients have a weak constitution, so the dose must be reduced (Article 6).
(c') For chronic or severe illnesses in old or weak patients, a great amount of strength is consumed by the illness, and furthermore the patients have a weak constitution. They have almost no strength left, and the adverse effects of a large dose of medication will only further deplete their strength, aggravating their condition. Thus, reduce the dose (Article 8).
(d') For strong patients without any experience with medication: Although they are strong, their body does not have much ability to counteract the effects of the medication, and they are more susceptible to its adverse effects of the medication. Thus, reduce the dose (Article 6).

    As is clear from the summary above, each of the corresponding items under the two headings ((a) & (a'), (b) &. (b'), etc.) deal with completely opposite conditions and lead to opposite conclusions. The Logical progression is nevertheless fully consistent. Viewing the above conditions, the first thing worth noting is the information used. All this information can be readily obtained by questioning and visual examination, and the degree of subjectivity in such judgements is not so great. Moreover, three basic parameters are used. That is, general information about the individual (age and physical strength), information regarding the individual's pathological condition (symptoms and duration of illness), and information about the individual's use of medication (experience with medication). This information is all related to individual characteristics of the patient, and thus a basic formula of pathology - individual - medication, with the individual at the center, can be derived.
    Examining the logical progression which follows the initial condition given in each of the items above, we can identify specific concepts being used as logical premises, which I will outline later. These concepts or premises are used to determine the patient's strength or physiological condition during the period of illness, which in turn becomes the basis for deciding on the dose of medication used to fulfill specific aims. These aims are: first, to minimize the adverse effects of the medication on the patient's physiology; and second, to maximize its beneficial effects on their pathology. Given this perspective, a larger dose is recommended under the first heading, thus achieving a balance between the first and second aims in (a) and (b), and attaining the second aim in (c) and (d). Likewise, smaller doses are recommended under the second heading in all of the items from (a') to (d') for the sake of the second aim.
    In ancient texts on Chinese medicine, the dosage of medication is very seldom discussed from the standpoint of the first aim, minimizing adverse effects. Usually, the dose is based solely on the inter-relationship between pathology and pharmacology (i.e., the effect of the medication). For example, according to the general rules in the Su Wen,6) if the pathological condition is mild, as in (a) under the first heading, the dose is decreased, and if the pathological condition is severe, as in (a') under the second heading, the dose is increased. Yan Zhi's logic, because it takes into account the individual's physiology and the adverse effect of the medication, gives the exact opposite instructions concerning dosage. This clearly reflects his unique approach to medicine, emphasizing the physiological condition of the individual not only in the recovery stage, but also during the period of illness. The practical explanations he gives stress both aspects of using medication-its beneficial and adverse effects. This also indicates a perception of a triad of pathology, pharmacology, and physiology with pharmacology as the central component.
    Now, returning to the concepts used as the premises for Yan Zhi's logical progression, they can be summarized as follows:
(l) The effect of the medication controls the illness (pharmacological action suppresses pathology).
(2) The illness reduces physical strength (pathology suppresses physiology).
(3) The effect of the medication reduces physical strength (pharmacological action suppresses physiology).
(4) Physical strength reduces the effect of the medication (physiology suppresses pharmacological action).
(5) The continuous use of medication reduces the effect of the medication (physiology suppresses pharmacological action).

    The mutual relationships between these factors can be described in a diagram, as shown in Figure 2.
    Yan Zhi's perception of medicine, that is to say his perception of physiology (individual factors), pathology (pathogenic factors), and pharmacology (effects of medication), was elucidated in part by the previous discussion. The above diagram provides a more complete picture of the mutual relationships of basic factors in his perception. This should further clarify his logical basis for laying down rules concerning dosage as listed in items (a) through (d').
    Even so, one wonders how the concepts listed in items (l) to (5) were established, and how they came to be used as logical premises. The concept of the beneficial effects of medication is outlined in (l), and the concept of pathological changes in the body is outlined in (2). These are fundamental concepts which have remained unchanged since the beginning of medicine, so it is only natural that these concepts were used as premises. Some special consideration seems necessary, however, concerning the meaning and historical significance of items (3), (4), and (5).
    First, the concept presented in item (3). According to the Su Wen: "For those who are able to endure the adverse effects of medication, large doses should be administered."7)Also in the Ling Shu*13 (first to second century) it is written: "Those with large and strong bodies can endure the adverse effects of medication, while those with small and weak bodies cannot."8) Yan Zhi's concepts obviously follow in line with such passages, and further divides adverse effects into two levels. On the first level, the patient is able to endure any adverse effects of medication, and on the second level, the adverse effects exacerbate the pathological condition. In both cases, the extent of the adverse effect is predicted, not only by the dosage, but also in relation to the physical condition and physiological function of the patient. This differs from the explanation in the Shen Nong Ben Cao Jing*14(first to second century), which warns against poisoning by medication from the standpoint of toxicity, dosage, and length of time it is administered.9)It is difficult to imagine that all the drugs for which adjustments in dosages were recommended by Yan Zhi were actually toxic.
    In the first article, Yan Zhi asserts that the essence of medicine is the treatment of acute diseases. As mentioned in the, Su Wen, in the early stages of treatment of acute diseases accompanied with fever, sudorifics and then purgatives are to be administered.10)Nevertheless, Zhang Zhong Jing*15 (early third century), who is prominently featured in the preface and bibliography of the Xiao Pin Fang, cautions repeatedly that strong medication will only exacerbate a pathological condition if the patient is weak.11)Also, one finds the following caution in theMing Yi Bie Lu*16(third to fifth century) about the usage of ephedrae herba, one of the primary sudorific and antipyretic drugs: "It weakens the body, so it should not be used in large amounts."12) Given this background, the concept of adverse effects Yan Zhi uses as a premise can be considered to be referring primarily to the actions of sudorifics and purgatives. That is to say, the effect of expelling the pathogenic factor from the body along with perspiration or stools.
   If understood in this light, the two facets of pharmacology - the beneficial effects and the adverse effects - can be seen as existing side by side, and it becomes easy to explain the grading of adverse effects based on the recognition of a safety margin. It is debatable, however, whether these concepts can be applied in interpreting the effects of all traditional pharmaceutical substances. Be that as it may, it is worth special attention from a historical standpoint that the adverse effects of medication were organized in such a logical framework at such an early period, and that there are striking similarities between ancient and modern pharmacology.
    As for the concept in (4), that physical strength reduces the effect of medication it is easy to imagine its origins in the clinical experience of small doses having little effect on strong or young patients, but having a marked effect on children and elderly patients. As far as the adverse effects are concerned, however, there is no extant literature before Yan Zhi's time which states that physical strength weakens the effect of medication. It seems only reasonable that the dose of medication should be reduced for children and old patients, but the further development of this idea, arriving at the concept in (4), may never have been attempted before Yan Zhi's time. If we take the idea of physical strength implied in (4) and replace it with body weight (amount of blood), digestive absorption and/or liver function, it is a concept which applies to modern pharmacokinetics.
    The concept in (5), that continuous use reduces the effect of medication, corresponds to the familiar principle of drug tolerance in present day pharmacology. I have already stated that experience with the adverse effects of crude drugs such as ephedrae herba and Rhei Rhizoma may have been the basis for Yan Zhi's concept in (3) relating to adverse effects. Note also that occasionally in clinical practice, after repeated use of Rhei Rhizoma for constipation, it becomes necessary to gradually increase dosage to maintain the laxative effect. This may be thought of as a type of drug tolerance. Further, the adrenergic action of ephedrine (one of the main active components of ephedrae herba) becomes increasingly weak with each dose when it is administered repeatedly over a short period, which is well known as a textbook example of tachyphylaxis in modern pharmacology, It should be noted, however, that such an action is seen only in a limited number of natural substances such as alcohol and opium. Nothing resembling this concept can be found in any existing Chinese medical literature older than the Xiao Pin Fang. It is therefore debatable whether actual observation of the effects of crude drugs such as ephedrae herba and rhei rhizoma served as the basis for Yan Zhi's concept of drug tolerance. Even so, using consumption of alcoholic beverages as an example, it can safely be assumed that regular consumption leading to increased tolerance was something noted very early in history, probably from the time humans started drinking. So although it is difficult to identify the specific substances the concept was based on, Yan Zhi's writing about a pharmacological phenomenon corresponding to drug tolerance is a noteworthy event in medical history.

Cautions for Menstruation
    In Article 9 the following recommendations are made for treating women during menstruation:

    Zhang Zhong Jing's Jin Gui Yao Lue*17 also discusses cases of contracting a seasonal illness such as a febrile disease during menstruation, and instructions are given for treatment according to the symptoms. 13)  Article 9 above mentions first the need to determine if menstruation is a factor, and second the need to differentiate between the symptoms of menstruation and the disease itself. This is clearly an approach which discriminates between an individual's physiology and pathology. The article also states that, if treatment is given without differentiating between the symptoms, the pathological condition can be aggravated because menstruation and the illness may mutually affect each other.
    The logical basis for that assumption is derived from the interrelationship of physiology (menstruation), pathology (seasonal illness), and pharmacology (pharmacotherapy) expressed in Figure 2. Nevertheless, since this article does not specifically mention the physiological changes which take place during menstruation, the aggravation of the pathological condition cannot be fully explained by the logical construct represented in Figure 2. Be that as it may, the importance of taking the individual's physiological condition into account in treatment is shown in this article in a concrete way.

Constitution, Disease, and Dosage in Relation to Locality
    Articles 10 and 11 mention differences in physical constitution and susceptibility to disease based on geographical region, and Article 12 mentions ways of adjusting dosage based on those differences.

    Two theories were prevalent in Yan Zhi's time concerning the relationship between geographical regions and physical constitution, disease, and treatment. The first one was based on the Su Wen and the five element principle. It divided China into five regions: center, north, south, east, and west.14) The second theory divided China into two sections: the cold northern and western section, and the warm southern and eastern section. Yan Zhi adopts a similar position to the latter theory by saying that differences in the climate in the regions where people live produce differences in skin function and call for corresponding changes in medication. The Ling Shu contains a passage in which the five element principle is multiplied to categorize physical constitutions into twenty-five different types,15) but obviously this theory is completely different from Yan Zhi's approach.
    Regional differences are emphasized to such an extent because, above all, of the historical circumstances of the time. During this period, China was under the rule of two opposing governments in the north and the south. There were repeated victories and reversals between the two powers. It is recorded in the Qian Jin Fang*26, how, when the Han*27 Chinese began to immigrate southward in the beginning of the fourth century because of invaders from the north and west, they encountered diseases unique to the south which they had never known before.16) The regions mentioned in the above three articles are all in south China, and these regions are all located around the Yang Zi*28River as the northern, southern, eastern, and western regions. Also the fact that Yan Zhi never mentions the regions further to the north, around the Yellow River, such as He Bei*29 or Guan Zhong*30 clearly reveals that he was primarily concerned with the climatic conditions of regions in south China.
    What is particularly noteworthy in Articles 10 and 11 is the premise that the occurrence of beriberi is primarily due to physiological factors, and that dampness, the pathogenic factor, is secondary. The physiological factors are: first, the condition of the skin and second, the strength or weakness of shen qi (kidney energy). These physiological variables could be thought of as components of the physical constitution, in a sense. It is easy to understand how that simple idea might have come about in line with traditional concepts of pathogenesis that dampness entering the body was related to the condition of the skin. But why is shen qi mentioned in this context?
    Beriberi happens to be one of the main diseases discussed in these articles. From our modern perspective, it is easy to see that its prevalence in southern China was due to vitamin B1 deficiency resulting from the consumption of white rice among the upper class. As beriberi progresses, the symptoms of edema and oliguria begin to appear. These symptoms were known from early on, as was accurately recorded by Ge Hong*31 (283-343).17)
    According to traditional medical concepts recorded in texts like the Su Wen, shen qi is the fundamental energy of life, and the function of water metabolism and excretion are controlled by this energy. This gives us our explanation: since edema and oliguria are the result of abnormalities in this energy, not only is dampness examined as the pathogenic factor, but shen qi is also discussed as an individual factor.
    Incidentally, Yan Zhi mentions "diseases from bites by poisonous insects" apart from malaria. It is inferred that these are diseases in which insect bites are clearly the cause. These would be diseases with the initial symptoms of swelling and infection in the skin. When viewed in this way, it is easy to follow Yan Zhi's logic that the occurrence of such diseases shows different tendencies according to geographical region, based on differences in skin condition. In this manner, through Articles 10 and 11, we can see that the concept of an individual's physiology is applied not only in determining treatment, but also in explaining the mechanism involved in contracting a disease.
    Article 12 recommends modifying prescriptions according to the variable of regional difference in temperature. As far as disease-categories which call for prescription modification by region, only the general category of "disease accompanied by coldness" is mentioned. The point there is clear: Give prescriptions with more warming drugs for patients living in cold regions who complain of "coldness," and give prescriptions with less of these ingredients for those living in a warm region. It is clear that the grounds of this logic is the basic principle of treatment recorded in theSu Wen and the Shen Nong Ben Cao Jing as "prescribe warming medication for coldness, cooling medication for hotness."18)Yan Zhi adds to this basic principle the regional variable, a factor concerned with individual differences, and suggests how the prescription can be modified.
    In this manner, Articles 10 through 12 address the issue of the region where the patient lives. Through this discussion, we can understand that in Yan Zhi's thinking, the climate where one lives is a kind of individual factor, in fact the most basic factor in determining physical constitution, mechanism of contracting disease, and modifications for prescriptions. Naturally, his thinking is based on the principles in the Su Wen and Shen Nong Ben Cao Jing, but we must also not overlook the political events of his day as a historical background which influenced his perceptions.

Types of Diseases and Treatment Guidelines
    Articles 13 through 17 give basic guidelines for treatment, along with precautionary explanations. Article 13 provides an overall out-line; Article 14 deals mainly with treatment using purgatives; Article 15 is primarily about effecting recovery with tonic drugs; Article 16 deals with prevention of disease by the use of purgatives; and Article 17 covers general matters. These articles comprise a somewhat lengthy dissertation, but since they are essentially the conclusion of this section, I will render the entire text below.

    In the above articles, Yan Zhi's discussion of treatment at time implies new viewpoints. These viewpoints are essentially concerned with the following four issues: (1) effects of purgatives, tonics, and harmonizing drugs, (2) the form of medication administered, (3) the order of administering medication, and (4) the prognosis. What views does Yan Zhi express concerning these issues? I would like to answer this question by examining each issue individually.

Classification of Drugs by Their Effects
    The beneficial effects of purgatives are described in the above articles as follows; they expel the pathogenic factor (Article 14), expel matter accumulated in the chest and abdomen as well as pathological humors, and remove distension in the abdomen and stagnation of food caused by continued use of tonic medication (Article 16). In other words, the beneficial effects of purgatives are a result of their action on the pathogenic factor and pathology.
    The adverse effects of purgatives are as follows: They exhaust the vital essence of life (Article 13), and reduce physical strength (Articles 14 and 15). Both of these effects relate to the physiology of the patient. As pointed out before, this concept of recognizing both the beneficial and adverse effects of drugs is very similar to that recorded in the Shang Han Lun.*32It may be assumed that the purgative medications alluded to in the above articles are those varieties in the Shang Han Lun such as cheng qi tang*33 which contains rhei rhizoma.
    The beneficial effects of tonic medications are naturally in strengthening the body (Articles 16 and 17), and tonics were used to help the body recover its strength after being weakened by the administration of purgatives (Article 15). In both these situations, there is an effect on the physiology. The adverse effects of tonics are mentioned in some detail as follows: They cause the force of the disease to return (Article 15), and if taken in excess or for too long, distension in the abdomen becomes a problem (Article 16). In other words, the first effect is on the pathology and the latter effect is on the physiology. These passages bring to mind tonic drugs such as aconiti tuber which, when used incorrectly, can exacerbate fevers, and rehmanniae radix, which can cause distension in the abdomen. It seems very possible that when Yan Zhi discussed the adverse effects of tonic medications, he had in mind formulas which contained the above-mentioned crude drugs, such as the ba wei wan*34 recorded in the Jin Gui Yao Lue. In any case, none of the extant medical texts older than the Xiao Pin Fang, like the Nei Jing,*35Shen Nong Ben Cao Jing, andShang Han Lun, have so a clear a description of the adverse effects of tonic medications. Furthermore, the recognition that adverse effects occur not only upon the physiology, but also in strengthening the pathology, is noteworthy as a point in common with modern pharmacology.
    Harmonizing drugs are mentioned in Articles 13 and 15, and the situations which they are used are as follows: When there is a pathogenic factor which must be expelled with purgatives, but it is dangerous to administer the latter because the vital essence of life is exhausted (Article 13); when the pathogenic factor has been expelled with a purgative but its adverse effects have reduced physical strength, and tonics cannot be used at that point since the pathology could reappear (Article 15). This means that harmonizing drugs do not have the adverse effects of purgatives and tonics and that they can serve as a substitute for both. Further, it is inferred from the information in Article 13 that the effect of harmonizing drugs is to replenish the vital essence of life, and while they halt the progress of a disease, they have no effect in expelling the pathogenic factor. Similarly, from Article 15 it is clear that, while harmonizing drugs have the effect of increasing physical strength after a decline, they are inferior to tonic drugs. In other words, harmonizing drugs have a beneficial effect in terms of both the pathology and the physiology, but in these respects their effect is weaker than purgative and tonic drugs.
    Incidentally, the character used for harmonizing drugs in the orignnal text is ping,*36which means even. To understand this, note that in the Shen Nong Ben Cao Jing, the purgative drug rhei rhizoma and the tonic drug rehmanniae radix are said to have a cooling effect, represented by the character han,*37which means cold. The tonic drug aconiti tuber is stated to warm the body, and this effect is represented by the character wen,*38 which means warm.19)
    The drugs represented with the character ping can be used for either warming or cooling the body.20)So, Yan Zhi, in contrasting harmonizing drugs with purgative and tonic drugs, seems to indicate that harmonizing drugs possess properties closely resembling the meaning of the characterping ("even"). It can be hypothesized that Yan Zhi is referring to the following crude drugs mentioned in the Shen Nong Ben Cao Jing and Ming Yi Bie Lu: buplenri radix, described as having "even and non-toxic properties, serves to increase the essence of life"2l); glycyrrhizae radix, described as having "even and non-toxic properties; serves to strengthen the body.''22) Ginseng radix is described as "Non-toxic, with very slight cooling or warming properties; tonifies the function of the internal organs."23)The formula for xiao chai hu tang*39given in the Shang Han Lun can be cited as a prime example of a harmonizing medication which contains the above drugs. Such formulas are used to regulate the pathological condition when neither purgatives nor tonics can be used.
    There is no specific mention of sudorifics in the articles I've discussed. This is probably because diagnosis and treatment in the early stages of a disease, which is when sudorifics are indicated, is mainly covered in Articles 3 through 8. Further, the effects of sudorifics are identical to those for the purgatives mentioned in Articles 13 through 16.

Table 1: Classification of  Drug Effects 
Clasification of EffectCorresponding DrugsCorresponding FormulasBenefical EffectsAdverse Effects
Rhei Rizoma
(Ephedrae Herba)
Cheng Qi Tang
(Mahuang Tang)
on pathology
(on pathology)
on physiology
(on physiology)
TonicAconiti Tuber
Rehmanniae Radix
Ba Wei Wanon physiologyon physiology
and pathology
HarmonizingBuplenri Radix
Glycyrrhizae Radix
Ginseng Radix
Xiao Chaihu Tangon physiology
and pathology
(weak effect)

    The results of my preceding examination on the classification of drugs and their effects are organized in Table 1. As can been seen from the table, in Yan Zhi's three categories, drugs and prescriptions are clearly differentiated by whether they have beneficial or adverse effects in relation to pathology and physiology. It is somewhat doubtful, however, whether Yan Zhi was considering this type of classification for all traditional drugs and to just what extent this classification is practical in application. Be that as it may, this type of classification is remarkably similar to the three-tiered classification system known as top, middle, and bottom, and to the concept of beneficial and adverse effects found in the Shen Nong Ben Cao Jing.24)On the other hand, Yan Zhi's view of the effects of drugs and prescriptions is basically the same as that found in the Shang Han Lun and theJin Gui Yao Lue. Furthermore, his classification of drugs is very compatible with the classification of pathological conditions according to the san yin san yang*40 principle, which is at the core of the Shang Han Lun. These similarities all serve as indications of Yan Zhi's medical background.

The Form of Medication Administered
    The three typical forms for traditional Chinese medications are decoctions, powders, and pills. The resultant differences in effect of the medication involved was debated from earliest times. For example, the Shang Han Lun states: "To induce diarrhea, it is better to use decoctions rather than pills or powder."25)Although there may be some exceptions, the fact that decoctions produce the fastest and strongest effect is common knowledge that can be obtained through experience. This being the case, what does Yan Zhi have to say about the use of these three forms of medication?
    Article 14 gives a typical example of Yan Zhi's views on such matters. There, the somewhat different effects of decoctions, pills, and powders are used to enhance the beneficial effects and minimize the adverse effect of purgatives. Article 15 goes on to state that administering tonics as a decoction can have an adverse effect, so instead, controlled amounts of pills or powders should be prescribed. Article 16 mentions that strong tonification with the intent of preventing diseases can have an adverse effect, recommending mild tonification by using pills or powder in some cases. In either case, mild tonification using pills or powder is recommended for an ordinary loss of strength, and strong tonification using decoctions is limited to cases of extreme debility, as in Article 17.
    It is clear from the preceding observations that the direct aim of selectively using different forms of medication is to regulate drug effects. In Articles 3 through 8, as well as 12, dosage of medication is discussed in the same context. The basic difference between these earlier articles and the articles discussed above lies in their perspective. The former is concerned with the type of disease and the patient, while the latter is based on a classification of the effects of drugs. The reason that the form of medication is not discussed in the former case is that those articles are mainly concerned with the early stage of diseases, when sudorifics or purgatives are indicated, and only urgent measures, using decoctions, are meaningful. The ultimate purpose in both approaches, however, is to prevent adverse effects and maximize beneficial effects. For this purpose, a determination is made of the appropriate medication, the correct dosage, and the right form. That is to say, the means of regulating the effects of the drug seems to vary according to the stage of the disease, but the aim of regulating the effects is one and the same.

The Order of Administering Medication
    Concerning the order in which medication should be administered, Yan Zhi gives several cases of pathological conditions as examples. His explanations are based on the same medical concepts and viewpoints used to explain the effects of tonics, purgatives, and harmonizing drugs as well as the differences in effect caused by varying the form of medication. Some of my observations here will necessarily overlap with things already stated in the previous sections.
    (l) For patients with a pathogenic factor that must be expelled, but whose essence of life is exhausted: Purgatives will aggravate the pathological condition, so administer harmonizing drugs first. After that, administer purgatives, but never for small children. (Article 13)
    (2) For patients with a pathogenic factor that must be expelled with purgatives: First administer purgatives by decoction, then switch to purgatives in the pill or powder form, but also administer decoctions from time to time. (Article 14)
    (3) For patients in whom the pathogenic factor has been expelled with purgatives, but whose physical strength has been exhausted: Tonic decoctions cause the pathology to recur, so either prescribe rest or harmonizing drugs. Then administer controlled amounts of tonics in pill or powder form. (Article 15)
    (4) For prevention of disease in those who are susceptible to disease despite having ample physical strength, and for those who have pathological matter in the chest or abdomen: Expel the pathological matter with purgative decoction. Then administer tonics in pill or powder form. (Article 16)
    (5) For prevention of disease in those who are weak and have taken tonics over a long period, or in those with stagnation of food in the abdomen: Administer only purgatives. (Article 16)
    In item (l), the physiological condition is such that the adverse effects of purgatives appear. Therefore, physiological condition is improved first with harmonizing drugs, and only then are purgatives administered. Tonics are not used to improve physiological condition in this case because of their adverse effects, which could strengthen the pathogenic factor. In the case of young children, however, purgatives are not to be administered even in the second stage of treatment. It can be seen from this that Yan Zhi considered young children with a weak constitution to be prone to the adverse effects of purgatives even after their condition was improved with harmonizing drugs.
    Item (2) presents a basic methodology for cases in which purgatives are to be administered over a long period. The switch to pill or powder form prevents the adverse effects resulting from the powerful action of the decocted form. Later on, decoctions are administered from time to time to assist the beneficial effects of the purgative in the pill or powder form. The logic underlying this methodology is sound, but the same objective could be attained without using different forms of medication: by adjusting the dose of the decoction. Therefore, it seems natural to interpret this example in item (2) as being more of a description of the differences in effect of different forms of purgatives.
    Item (3) presents a method for restoring physical strength after it has been depleted by use of purgatives. Normally we would think of tonics for effecting recovery from a depleted condition, but tonics are not to be administered right away because of the possible adverse effects. In such a case, harmonizing drugs, which have no adverse effects, could be used as in item (l), but here rest is recommended as the first step. After physical strength is almost restored, pill and powder tonics are administered, with special care given to the dosage. This last step is taken in consideration of the adverse effects of tonics if the effect is too strong, even after physiological condition has almost returned to normal.
    What then is the reason for further prescribing tonics after physical strength is nearly restored? This can only be to raise physical strength to an even higher level than before to build a healthier constitution, increase resistance to disease, and ensure a long life. The aim here is nothing other than hygiene. Recall that in Article l, Yan Zhi states that hygiene should be studied last. By this we can understand Yan Zhi's perception of medicine, in which hygiene based on the use of medication actually does more harm than good, unless based on sound knowledge and correct administration in stages.
    Item (4) deals with persons who are prone to illness and who desire tonic medication to prevent illness. Yan Zhi submits that the accumulation of pathological matter in the body is the cause of susceptibility to illness, and he suggests expelling this matter first with purgative decoctions. It is permissible to induce strong diarrhea with the purgatives in this situation because the body is not yet weakened.
    Once the pathological matter causing the susceptibility to illness is expelled, it would seem that the objective of preventing illness has been achieved. It should therefore be appropriate to prohibit the use of tonics and prescribe rest or harmonizing drugs at most. Yet tonic medication is prescribed later, as desired by the patient. This is probably due to the fact that item (4) concerns cases prior to the appearance of disease, so the adverse effects of the tonics in exacerbating pathology do not appear that often. Nevertheless, tonic medication is limited to the pill and powder forms, and moreover, the selective use of such medication by prescribing according to the presence of heat or cold in the body is advised. As mentioned earlier, aconiti tuber was probably among the tonic drugs used for warming, and rehmanniae radix among those used for cooling. Thus, not only are the tonics used in their more benign forms, but care is also taken not to cause problems like aggravating a febrile condition by using warming drugs like aconiti tuber. Adverse effects were so carefully avoided probably not only for the sake of the patient's health, but also because such effects could be detrimental to the physician's own life and position.
    Item (5) is another case of administering medication to prevent illness. It is concerned with those with weak constitutions who have taken tonics over a long period, or those who eat an overly rich diet. Yan Zhi thinks that excessive consumption of tonics or rich foods overburdens the digestive system and produces adverse effects on the body. In his medical perception, tonics can of course have an adverse effect by accumulating in the abdomen, but food and drink can also become a pathogenic factor in their own right, as stated in Article 2. In cases such as this, he only recommends using purgatives to expel the accumulated pathological matter. The reason purgatives can be prescribed for those with a weak constitution is probably that, as stated in Article 5, physiological function counteracting the adverse effects of medication has been developed through habitual use of medication. The use of purgatives alone is advised because if tonics are then taken again, they will merely accumulate in the abdomen. Furthermore, it is possible that the patient's strength will recover on its own once the accumulated matter is expelled. On the whole, the example in item (5) can be taken as a countermeasure for the practice of ingesting tonic drugs for hygiene and longevity, which must have been quite common among the upper class in that period.

    In Article 13, Yan Zhi states that those who are not expert in pulse palpation cannot know how long a patient's recovery will take. Setting aside the problem of pulse palpation, I will instead examine what other approaches are suggested for judging the prognosis and will analyze their logical bases. Let us begin by examining Yan Zhi's references to prognosis one by one.
    At the beginning of Article 13, "serious febrile disease affecting physical strength, appetite, and behavior" is contrasted with "mild disease affecting appetite and sleep." Here, factors such as appetite and physical strength refer in every case to physiological function and not to pathological symptoms such as fever or pain. On the other hand, in the latter half of this same article, a case is mentioned in which recovery appears to be only three to five days away, and Yan Zhi states that the pathogenic factor is probably already expelled and only the physical strength has to return. This distinction between a pathogenic factor and physical strength is identical to the distinction noted earlier (see beginning of this paragraph) thus indicating that Yan Zhi always discriminated between a patient's physiology and pathology, as well as noting the corresponding conditions and symptoms, as pointed out before.
    This means that a prognosis of recovery in three to five days is based on the observation that the pathological symptoms are already gone. In such cases, Yan Zhi recommends rest and observation of the patient's progress: in other words, check the prognosis by putting the patient under observation to confirm the complete disappearance of pathological symptoms and the recovery of normal physiological functions. This is obviously advice for a case with a favorable prognosis.
    Article 13 also contains an example of an unfavorable prognosis. It is a case in which the essence of life has been exhausted. Yan Zhi states that when purgatives are administered to such patients, the adverse effects will further exhaust the essence of life and the patient could be confined in bed for a year. In this case, the prognosis is judged to be unfavorable because, while the pathological symptoms are mild, the physiological damage is severe. Article 17 gives two similar cases, neither of which are conditions which can be cured after three to five days of treatment. One is a case of an extremely debilitating disease, and the other is one of an illness caused by wind. The former plainly involves severe physiological damage.
    The nature of the latter illness is, for some reason, not explained in this article. It can be inferred, however, that an illness "due to wind" was regarded as a condition of severe pathology for the following reasons: First, failure to heal in three to five days; second, wind is at the top of the list of pathogenic factors in Article 2. Further, wind is the first pathogenic factor mentioned in Article 9 among the seasonal illnesses contracted during menstruation.
    Of course, this assumption (the severity of illnesses "due to wind") is not explicitly stated anywhere. It is more than likely, however, that if pathological symptoms are severe, then physiological condition is also damaged to some extent. In any event, the prognosis for the two cases given in Article 17 is not good. The text also states that, if these two conditions occur simultaneously, recovery can take from one score to over one hundred days.
    To summarize, the prognosis is judged according to the extent of physiological damage and the severity of pathological symptoms. The standards and methodology for determining the prognosis are thus quite unequivocal. Clearly, Yan Zhi consciously set aside complicated traditional medical theories and simplified all pathological conditions into "strong" or "weak" states of physiology and pathology. Leaving aside the question of the practicality of his method of arriving at a prognosis, understanding it allows us to appreciate Yan Zhi's pragmatic approach towards medicine.
    I have thus far examined Articles 13 through 17, focusing on several different topics. Following this detailed examination, what can be seen from an overall perspective of Yan Zhi's medical views is that prevention of the adverse effects of drugs is given equal if not greater emphasis than their application for beneficial effects. Yan Zhi maintains this attitude not only in his views on treatment of acute cases, but also in his views on prevention of relapses. Another key point is that factors indicating physiological condition, such as physical strength, are given equal weight as the signs of pathology in deciding on such matters as the pathological condition, treatment principle to be used, effectiveness of treatment, means of preventing relapse, and prognosis. Yan Zhi's approach to medicine is equivalent to a practical approach for "hygiene in treatment after the onset of illness."


    The foregoing has been an analysis of the connection between treatment and hygiene in the medicine of Chen Yan Zhi, author of the medieval Chinese medical text Xiao Pin Fang. In Yan Zhi's approach, the most important principle in traditional hygiene, the regulation and improvement of physiological function, is consistently applied to every aspect of medical treatment. This seems to have been based on a strongly critical attitude towards his contemporaries' attitudes on treatment and hygiene, and he sets forth an approach to medicine which systemizes the traditional medicine of his time, and does so according to his unique views.
    In Yan Zhi's time, medical treatments and hygiene practices using medication tended to have inherent biases, with the former aimed only at suppressing pathological symptoms and the latter being solely aimed at regulating and improving physiological function. Yan Zhi argues for and explains in detail the need to consider both aspects of treatment, to do so from the outbreak of the disease to recovery, and for the purpose of initial treatment as well as preventing relapse. He places special emphasis on the recognition of individual factors and resultant physiological tendencies, as well as on an analysis of the background of the disease, which are matters physicians often fail to take into account.
    As some practical examples of individual factors, Yan Zhi mentions physical strength, age, sex, history of taking medication, area of residence, and life style, and uses these factors to explain physiological tendencies. Based on these factors, he explains the ways of modifying a prescription; of determining dosage; of ascertaining the connection between physical constitution and mechanism of contracting disease; of choosing medication, form of medication, and order of administration; and of judging the patient's prognosis. The consistent aim throughout all of this is to make full use of the beneficial effects of medication against a pathology, and also to prevent the adverse effects of medication from affecting the patient's physiology. Yan Zhi's conception of pharmacological effects was extremely pragmatic, and many of his ideas still apply today in modern pharmacology.
    I would like to call special attention to one aspect of the Xiao Pin Fang. The Yin-Yang*41and Five Element principles, fundamental concepts in traditional Chinese medicine, are not mentioned at all in the articles I examined. Also, very few traditional medical terms are used, and no explanation is given of them. In their place are the concepts and principles outlined in Figure 2 and Table 1. Perhaps this simplification is due to the introductory nature of this text. Nevertheless, we can see a unique rationalism in Yan Zhi's presentation which, while being based on traditional medical concepts, stands in clear contrast to them in its pragmatic and logical approach. If a leap of logic may be permitted, his attitude and approach to medicine, in its pragmatism and rationalism, bear a closer resemblance to the kanpo*42style of Chinese medicine practiced in Japan from the latter half of the Edo*43 period (eighteenth century) than to the mainstream of Chinese medical thinking from the Jin-Yuan*44period (twelfth to fourteenth century). This issue calls for more discussion in the future among scholars in this field.
    Chinese medicine is a system with an unbroken tradition extending from ancient times to the present. In its long history, Chinese medicine developed a complexity and copiousness which owed a great deal to the vastness of the Asian subcontinent, with its tremendous variety of geographical regions and cultures. On the other hand, the repeated rise and decline of various governments and cultural groups over time has without question made it very difficult to safely preserve written documents. In many cases, only fragments or titles of documents remain to tantalize us today. In spite of the odds, a substantial number of documents have stood against the flow of one or two millennium and survived destruction, disfiguration, and obscurity to reach us intact today. The Xiao Pin Fang is one such precarious document, and its discovery by the author and his colleagues in Tokyo is something on the order of a miracle. This text contains many significant and noteworthy revelations. In this article, I have dealt with only a small portion of our findings, attempting to highlight the relationship between medical treatment and the philosophy of hygiene.


1) Hiroshi Kosoto, "A Introductory Study on the Xiao Pin Fang; with Reference to a Recently Discovered Old Manuscript", Journal of the Japan Society of Medical History, 1986, Vol.32, p.1-25.

2)Su Wen (references here-in-after are based onHuangdi Neijing Su Wen: reissued by the National Chinese Medicine & Drug Institute, Taibei, 1960), Vol.1, Chap.2.

3)Lao Zi, reissued by Zhonghua Shuju, Taibei, 1981, Chap. 71.

4)Huai Nan Zi, reissued by Xin Wenfeng Chuban Gongsi, Taibei, 1978, Vol. 16.

5) Hidemi Ishida, "Medical Thought of theXiao Pin Fang, Bunka, 1986, Vol.50, No.1-2, p.1-16.

6)Su Wen, Vol.22, Chap.74.

7) Su Wen, Vol.20, Chap.70.

8) Ling Shu (references here-in-after are based on Xin Kan Huangdi Neijing Ling Shu, reprinted in the Ming dynasty of China, currently stored at the Naikaku Bunko of the State Documents Library, Tokyo), Vol. 16, Chap.53.

9) Shennong Bencao Jing (references here-in-after are based on Jingshi Zhengrei Daguan Bencao reissued by Hirokawa Shyoten, Tokyo, 1970), explanatory notes, Art, l,3, 10.

10) Su Wen, Vol.9, Chap.31.

11) Zhang Zhong Jing, Shanghan Lun (references here-in-after are based on Song ban Shanghan Lun, reprinted in the Ming dynasty of China, currently stored at the Naikaku Bunko of the State Documents Library, Tokyo), Vol.7&9. In those volumes, detailed contra-indications of sudorifics and laxatives are described.

12)Jingshi Zhengrei Daguan Bencao, Vol.8, the front side of 18th leaves, Art. Mahuan, black printed words.

13) Zhang Zhong ling, Jin Gui Yaolue (Xinbian Jin Gui Fanglun, reprinted in the Yuan dynasty of China, currently stored at the Beijing University Library), Vol.3, Chap.22 5th-6th leaves.

14) Su Wen, Vol.4, Chap.12. Vol.20, Chap.70.

15) Ling Shu, Vol.18, Chap.64.

16) Sun Si Miao, Beiji Qian Jin Yaofang, reissued by Renmin Weisheng Chubanshe, Beijing, 1955, p.138.

17) Yasuyori Tanba, Ishinho, reissued by Japan Koigaku Shiryo Center, Tokyo, 1973, Vol.8, the front side of  7th leaves.

18) a) Jingshi Zhengrei Daguan Bencao, Vol. 1, the back side of 15th leaves, explanatory notes, Art. 11, white printed words. b) Su Wen, Vol.22, Chap.74, the back side of 15th leaves & the front side of 28th leaves.

19)Jingshi Zhengrei Daguan Bencao; Vol.10, the front side of 15th leaves, Art. Dahuan, white printed words. Vol.6, the front side of 26th leaves, Art. Gan Dihuan, white printed words. Vol. 10, the back side of 1st leaf, Art. Fuzi, white printed words.

20) Makoto Mayanagi, "An investigation of Yao-Xing theory; on Xing-Ping Fang", Japanese Journal of Oriental Medicine, Vol. 33, No.4, p. 115, 1983.

21)Jingshi Zhengrei Daguan Bencao, Vol.6, the back side of 46th leaves, Art. Chaihu.

22)Jingshi Zhengrei Daguan Bencao, Vol.6, the front side of 23rd leaves, Art. Gancao.

23)Jingshi Zhengrei Daguan Bencao, Vol.6, the front side of 15th leaves, Art. renshen.

24) Yasuo Otsuka, "On the system of drug categorization; as seen in ancient Materia Medica of East & West",Journal of Kanpo Medicine, Vol. 15, No.4, p.3-11, 1968.

25) Zhang Zhong ling,Shanghan Lun, Vol.9, the back side of 14th leaves.