An Investigation of Moxibustion Treatment for Abscesses in... : Chinese Medicine and Culture (2024)

1 Introduction

Abscess is one of the main diseases in Chinese external medicine, roughly corresponding to bacterial infections in modern medicine whose cardinal symptoms include local redness, swelling, pain, and suppuration. If left untreated or treated incorrectly, it may develop into sepsis, septic shock, and even be life-threatening. In ancient times, when medical technology and hygiene conditions were underdeveloped, abscess was not only common but also life-threatening. Therefore, the disease has been taken seriously by medical experts throughout history, and many external medicine treatises were even named directly after it, such as Ji Yan Bei Ju Fang (《集验背疽方》Collected Formulas for Carbuncle of Back), Yong Ju Fang Lun (《痈疽方论》 Discussion on Abscess Formulas), and Yong Ju Bian Yi Lun (《痈疽辨疑论》Discussion on Abscess Identification).

The theoretical basis for treating abscesses originated from unearthed pre-Qin documents, with relevant records found in the bamboo and silk medical book Wu Shi Er Bing Fang (《五十二病方》Formulas for Fifty-two Diseases). The earliest record of using moxibustion to treat abscesses can be found in the Ling Shu Yong Ju (《灵枢·痈疽》Miraculous Pivot: Abscesses), which says, “When an abscess develops for four or five days, apply ruò (焫) to it”.1ruò” here refers to moxibustion. The external medicine treatise Liu Juan Zi Gui Yi Fang (《刘涓子鬼遗方》Liu Juanzi’s Ghost-bequeathed Formulas), from the Wei and Jin periods, advocated that abscess should be treated with moxibustion once it had been diagnosed, and early detection and early treatment with moxibustion was advisable. It stated that, “receiving the moxibustion treatment on the first or second day, all patients will be saved; on the third or fourth day, six or seven out of ten will be saved; on the fifth or sixth day, only three or four out of ten; after the seventh day, moxibustion is no longer effective”.2 Later medical practitioners largely adhered to this theory.3–5 During the Song dynasty, several Chinese external medicine treatises emerged, making breakthroughs in the understanding of the etiology, pathogenesis, and treatment methods of abscesses. Wei Ji Bao Shu (《卫济宝书》A Treasure Book on Life Preservation and Reliefs) pioneered the “bamboo hobbyhorse-riding moxibustion therapy (骑竹马灸法)”, while Bei Ji Jiu Fa (《备急灸法》Moxibustion Therapy for Emergency) dedicated a section to the treatment of all abscesses with this method. The Song dynasty government attached great importance to the development of medicine and adopted various measures to encourage the open dissemination of medical knowledge. Through these efforts, medical ecology for various social strata, especially the general public, improved significantly. The number of resident physicians in local medicine shops and itinerant doctors increased rapidly. Among them were highly skilled practitioners and those who gained fame for treating specific diseases, becoming essential components of the medical system in the Song dynasty. The painting Jiu Ai Tu (灸艾图 The Moxa Treatment) (Note 1) by Li Tang (李唐) in the Southern Song dynasty vividly depicts the scene of itinerant doctors treating abscesses for villagers (Fig. 1).

Paintings are common visual historical materials, which are increasingly valued by medical historians. Images have the characteristic of being more visual and vivid. From the perspective of archaeology of knowledge, medical-themed artworks created by non-medical artists, especially the social life traces intentionally or unintentionally revealed in realistic images, often contain key historical information, which can compensate for the shortcomings of textual materials and even be more authentic than textual materials. As a rare pictorial form of medical history document in the history of acupuncture and moxibustion, as well as in the history of the treatment of abscesses, Jiu Ai Tu vividly represents the medical activities of acupuncture and moxibustion and medical technique for treating abscesses in folk in the Southern Song dynasty with vivid brushwork and rich details. The treatment methods depicted in the painting, such as direct moxibustion with multiple moxa cones, purulent discharge by acupuncture, and purging heat with plaster, directly reflects the development and application of acupuncture and moxibustion techniques in the Song dynasty, which is of great significance for understanding the development of the diagnosis and treatment of abscesses as well as the level of folk medical practices in Song dynasty. The diagnosis and treatment of abscesses had become relatively mature by the Song dynasty, and paintings with medical activities as the theme emerged one after another, with Jiu Ai Tu being a representative one.

Jiu Ai Tu, also known as Cun Yi Tu (村医图 Village Therapist) or Zhi Ai Tu (炙艾图), is a colored silk painting, measuring 68.8cm in height and 58.7cm in width. It dose not bear the artist’s signature or seal but only two collection seals, one stating Qian Long Yu Lan Zhi Bao (乾隆御览之宝 Imperial Collection of Qianlong) and the other Bao Yun Lou Shu Hua Lu (宝蕴楼书画录 Treasured Collection of Baoyun Building). Currently housed in the Taibei Palace Museum, it is the earliest surviving painting with the theme of medical activities of acupuncture and moxibustion. Records related to the painting can be found in the Sheng Jing Gu Gong Shu Hua Lu (《盛京故宫书画录》Catalog of Paintings and Calligraphy in Shenyang Imperial Palace): “In Song dynasty, Li Xigu’s (李晞古) Moxibustion and Acupuncture Illustration...”.6 And at present, the academic community generally attributes the artwork to the Southern Song period judging from its spatial structure, painting style and technique, and morphological details of line drawings.7

Scholars of traditional art history usually discuss Jiu Ai Tu within the framework of genre painting.8–9 Genre painting, characterized by a realistic style, aims to objectively reflect social life and cultural landscapes of the time. Genre painting itself carries a wealth of historical information, serving as a historical mirror that cannot be replaced by textual knowledge. In recent years, more and more medical history researchers have paid attention to Jiu Ai Tu and conducted detailed research on acupuncture and moxibustion treatment, both doctors and patients, diseases, acupoint selection, and the medical system of the Song dynasty.10–14 This paper will start with moxibustion treatment of abscesses, explore the level of external treatment technology and present the folk medical ecology in the Song dynasty.

2 Theory and method of external treatment for abscesses as shown in Jiu Ai Tu

The painting depicts a total of six figures, including one doctor, one assistant (apprentice), one patient and three villagers. In the painting, the healer is seen holding needling instrument and making an incision on the patient’s back, with two moxa cones burning at the affected area. The patient in sitting position, with his upper body bare, displays such a painful expression with clenched teeth and a contorted face, that the viewers of the picture may feel as if they could hear his screams in reality. The three villagers nearby are either tightly gripping the patient’s arms or stepping on the patient’s legs to help to immobilize the patient. The artist vividly presents a scene of an itinerant doctor applying moxibustion to a patient in a realistic style (Fig. 1).

In the painting, the treated area presents with localized elevation of the skin, diffuse swelling without evident protrusion, and a dark skin color. Ling Shu Yong Ju holds that pathogenic coldness invades the meridians, causing stagnation of qi (气) and blood (血), leading to the formation of abscesses.15Zhu Bing Yuan Hou Lun (《诸病源候论》Treatise on the Origins and Manifestations of Various Diseases) states: “When the five viscera (五脏) are not in harmony, it leads to abscesses. In the case of carbuncle, the skin at lesion location is swollen and as hard as the neck skin of a cow. When the six Fu organs (六腑) are not in harmony, it leads to abscesses. Abscesses are marked by swollen, thin and bright skin appearance... if it is deep, it is a carbuncle; If it is shallow, it is an abscess.”16 It is speculated that the old patient in the painting should suffer from abscesses with the affected area on the upper back.

Abscesses that occur on the back are particularly dangerous, with carbuncles being more severe than abscesses, often leading to fatal outcomes. Ling Shu Han Re Bing (《灵枢·寒热病》Miraculous Pivot: Cold-heat Diseases), mentioned that: “There are five regions in the body. First, the Fu Tu (伏兔 musculus rectus femoris); second, the calf; third, the back; fourth, the Back-Shu points (背俞穴) corresponding to the five viscera; fifth, the nape. Those who have abscesses in these five parts may die.”17 It is believed that abscesses occurring on the back are often incurable. The back is considered as the window of the five viscera and six bowels, with the Back-Shu points of the five viscera and six bowels located on both sides of the spine, 1.5 cun (寸) away from the spine. Abscesses that occur at these points are highly prone to spreading toxins along the meridians, entering the organs and causing death. According to Liu Juan Zi Gui Yi Fang: “The hornet’s nest flat-abscess erupts on the back, spreading from Xinshu (BL15) to the shoulder bone, if not treated within twenty days, causing death... Acanthoid abscess erupts at the Feishu (BL13), if not drained, leading to death within twenty days... Dragon-like abscess erupts on the back, spreading from Weishu (BL21) to Shenshu (BL23), causing death within twenty days if not drained.”18 In Bei Ji Qian Jin Yao Fang (《备急千金要方》Important Formulas Worth a Thousand Gold Pieces for Emergencies), “People initially do not take abscess seriously, but it grows gradually with each passing day and may cause death even within ten days.”19 In the Southern Song period’s Bei Ji Jiu Fa: “There are cases where abscesses occur on the back. This is a slowly progressing disease, but its eruption is also violent. People often overlook the subtle signs and are unware of its occurrence. Once it suddenly erupts and swells, it is too late to treat... In impoverished villages and remote alleys, where can one seek medical assistance?”20 The onset of abscesses is insidious, and sometimes, it starts as tiny grain-like papules, making it difficult to detect. However, its progression is rapid, and once it erupts, it is often too late to treat (Note 2). According to Shi Ji Xiang Yu Ben Ji (《史记·项羽本纪》Records of the Grand Historian: Annals of Xiang Yu), “...before reaching Pengcheng (彭城), Fan Zen (范增) died from abscess on his back”.21 If the situation is real for the noble or landlord class, it would be far worse the poor. For them, suffering from abscesses often means waiting for death with no hope for treatment. The situation was full of misery and too painful to describe. If an itinerant doctor happened to pass by at that time, it was like grabbing a life-saving straw.

After clarifying that the elderly man in the painting is suffering from an abscess on the back, let’s take a look at the itinerant doctor’s treatment method. In the center of the picture, two moxa cones are placed in line on the affected area’s skin, and ignited simultaneously for moxibustion. The doctor holds the lower edge of the abscess with his left hand and a needle in his right hand, and the lower part of the needle tip has already penetrated into the skin (Fig. 2), suggesting an ongoing incision at the affected site. Judging by the doctor’s demeanor, it is evident that he is well-versed in treating such ailments. In view of the highly mobility of the itinerant doctors, the medicines and tools they can carry with them have the characteristics of high frequency of use, quick effect, and good curative effect, suggesting that abscesses were still a common external disease in the Song dynasty. This may be attributed to the prevalent practice of ingesting medicinal substances since the Wei and Jin periods (Note 3), along with the social upheavals and migrations of people during the Song dynasties. Furthermore, external treatment methods such as moxibustion and acupuncture, especially the former, played a crucial role in abscess treatment. Many medical practitioners believed that early and large amount of moxibustion could not only accelerate the process of its suppuration and rupture, but also prevent the abscess from invagination which may exacerbate the condition.

As for the specific treatment measures, the traditional Chinese medicine (TCM) practitioner in the painting chooses moxibustion. In fact, most of external medicine monographs throughout history have advocated the application of moxibustion in the treatment of abscesses, and believed that it should be started as soon as possible. Ji Yan Bei Ju Fang of the Song dynasty argued that moxibustion was superior to medication in treating abscesses, and pointed out that moxibustion should be started within the first day of the onset of the disease. If there was any hesitation, the abscess would become as large as a finger with dispersed toxins and the prognosis will be poor.22 Chen Ziming (陈自明), a Southern Song doctor, particularly recommended moxibustion in his specialized work on abscesses, Wai Ke Jing Yao (《外科精要》Essentials of External Medicine), asserting that moxibustion could facilitate the circulation of the heart’s channel, which may give a way to discharge toxin and prevent its internal attacks, thus preventing the disease from developing into a severe case.23Shen Jiu Jing Lun (《神灸经纶》Classic of Divine Moxibustion) also noted, “Moxibustion, if applied within the first seven days, could break up the solid masses and eliminate knots, and expel toxins from deep site to surface in most cases, and its efficacy surpasses that of medication”.24 It has been repeatedly emphasized in the literature that moxibustion should be used for the treatment of abscesses as early as possible, and the earlier the moxibustion is applied, the better the outcome and the higher the survival rate. The effect of moxibustion is better than that of medicine, which has also been recognized by many doctors. In terms of the amount of moxibustion applied, most physicians advocated for intensive moxibustion. If the abscess is initially painful, moxibustion should be continued until there is no pain. If there is no pain in the beginning, moxibustion should be applied until pain is felt.25 It can be seen that the moxibustion treatment depicted in the Jiu Ai Tu is an objective reflection of the external treatment of abscesses in the Song dynasty.

In terms of techniques as shown in Jiu Ai Tu, two moxa cones are ignited at the same time to provide strong stimulation with a focus on the lesion so as to acquire a quick effect. Chen Ziming advocated for applying moxibustion by spreading and burning moxa on the abscess directly or putting a layer of garlic between moxa and skin as an intermedium. Garlic, being pungent and warm, can activate the medicinal effects of moxa and remove swelling and abscesses. Returning to Jiu Ai Tu, the method of simultaneously igniting two moxa cones (or more, depending on the size of the abscess) is not only more convenient and flexible in operation but also allows for easier observation of the local skin and muscle morphology after moxibustion. It serves as a variation for outdoor moxibustion in sitting positions. In fact, the method of igniting multiple moxa cones simultaneously was documented as early as in the Mai Shu (《脉书》Book of Channel), unearthed from the Zhangjiashan Han tomb (张家山汉墓). The earliest using of moxibustion to treat abscesses was recorded in Liu Juan Zi Gui Yi Fang, as that moxibustion should be applied to the protruding part of the abscess, then to the four sides, six sides, or eight sides of the affected area depending on the size of the abscess. Similar methods are found in the Jin and Tang dynasties’ books such as the Zhou Hou Bei Ji Fang (《肘后备急方》Emergency Formulas to Keep Up One’s Sleeve), Qian Jin Fang (《千金方》Important Formulas Worth a Thousand Gold Pieces), and Wai Tai Mi Yao Fang (《外台秘要方》Formulas of Arcane Essentials from the Imperial Library). These methods involve simultaneous moxibustion at the affected area, 1 cun above and below, or 1 cun to the left and right, covering the surrounding areas of the lesion, acupoints, and even corresponding acupoints on the front or back of the body. The scope of treatment is no longer limited to external abscesses but extends to urgent conditions such as sudden death and acute chest pain, as well as internal diseases such as cholera and vomiting. For example, in Volume 1 of Zhou Hou Bei Ji Fang, there is a method for treating a patient who fell into a coma suddenly: “Measure the width of the patient’s mouth with a rope to get individual measurement unit with which to locate the four points on each side of the patient’s navel. Then, apply moxibustion all four points in the same time period, with three moxa cones burning on each point successively.”26 During moxibustion, multiple moxa cones are ignited simultaneously, as depicted in the Bei Shi Ku Li Zhuan Li Hong Zhi (《北史·酷吏传·李洪之》Northern History: Ruthless Officials: Li Hongzhi). During moxibustion treatment, moxa cones were applied to 2 cun around the affected part, more than ten locations on the hands and feet, all at once.27 Renowned Tang dynasty poet Han Yu (韩愈) also used the phrase “as fierce as a hunting fire encircling” to describe the scene of a moxibustion practitioner applying moxa cones.

In addition to moxibustion therapy, Jiu Ai Tu also depicts an essential step in the treatment of abscesses—incising the abscess to drain pus. The needle instrument used in the picture looks like a knife, with ridge in the middle, and the handle is wound with brownish-yellow thread-like materials, forming loop at the end. From the doctor’s grip and the operational angle, it can be inferred that one side of the instrument is a cutting edge, primarily used for cutting, scratching and incising (Fig. 3).

As to the question what exactly are the tools used by the medical practitioner in Jiu Ai Tu, there are mainly two points of view based on current research: Chan needles (鑱针) or Pi needles (铍针). Both belong to ancient nine-needle instruments, but they have different shapes and usage (Fig. 4).

The Chan needle, characterized by a large head and a sharp tip, is primarily used when there is heat in the head and body or the disease is on the skin with no fixed location. During treatment, it is inserted relatively shallowly, just as deep as piercing the skin. When dealing with early-stage abscesses, the Chan needle is often used to pierce and let blood, aiming to release heat. Yan Jianmin (严健民) believes that, according to Ling Shu Jiu Zhen Lun (《灵枢·九针论》Miraculous Pivot: Nine Needles)”, the purpose of using a Chan needle with a “large head and sharp tip” to puncture an abscess is to “prevent it from sinking deeply and allowing Yang Qi (阳气) to escape”. Chan stone (鑱石), historically used by the ancient Yue (越) people to perform shallow piercings on the body surface according to certain patterns (similar to tattooing), can improve the local “obstruction” and “stagnation” state in the initial stages of swelling abscesses with yang syndrome,28 but its superficial stimulation is not the method of incising abscesses and draining pus which is described as “puncture the abscess according to its size when there is pus inside it”. On the other hand, the Pi needle (Note 4), modeled after a sword’s edge with blades on both sides, is often used to puncture and drain abscesses, releasing pus and blood. Yi Xin Fang (《医心方》Ishinpo) suggests using the Pi needle as fire needle. Depending on the size of the abscess, a sharp-edged needle, a round-sharp needle or a Pi needle is selected and heated before incising the abscess to drain pus.29 During the Song, Jin, and Yuan periods, it was commonly used for draining pus and blood. In the Ming and Qing dynasties, the application of the Pi needle expanded further, not only for puncturing and piercing but also for cutting and incising as a knife used in external medicine. It was even used as a laryngeal needle.30

According to the Ling Shu Jiu Zhen Lun, the Pi needle is 4 cuns long and 2.5 fen (分) wide. “Ten fen make 1 cun, ten cuns make 1 chi (尺).”31 The width-to-length ratio is about 1:16, which is quite different from the needle instrument depicted in the picture.

Upon closer examination, there are several needles of different shapes inserted into the doctor’s hair bun in the painting—one with a sharp tip resembling a sword, one with a slightly pointed tip, and another with a flat circular tip (Fig. 3). These needles are different from the nine needles recorded in the Huang Di Nei Jing (《黄帝内经》The Yellow Emperor’s Inner Classic), and there are no similar needle tools found in the literature, so their specific functions are not very clear. It is speculated that they might be medical instruments used mainly in folk medicine. In the Song dynasty, with the advancement of metallurgical technology, it was common for medical professionals to innovate and create external treatment tools according to clinical needs. In Wei Ji Bao Shu, there is a special article on “needle-forging” (打针法), which introduces the creation of “Yang needles” (阳针) for needling carbuncle, “Yin needles” (阴针) for needling abscess, “pus-extracting needles” (取脓针) specifically for draining pus, and “Lei Feng needles” (雷锋针) for needling peculiar-shaped abscess.32 Unfortunately, the detailed data of the needles is not indicated in the book, and no illustrations are drawn.

In Wai Ke Jing Yao, it is suggested that, when treating abscesses with thin capsule, it is advisable to use a needle to puncture and drain the pus. For carbuncles with abscesses, it is recommended to use a Yin Bi (银蓖) needle (a set of silver needles which is similar to a hairpin or a comb) to puncture and drain the pus. The dimensions and shapes of the two needle instruments are described as follows: “For abscesses with pus, it is supposed to treat with a needle which is made of horse bits (马衔铁), shaped like a leek leaf, with sharp edges on both sides, to incise about five or six fen both horizontally and vertically… For carbuncles with pus, it should be cauterized with a Yin Bi needle which is two-cun wide and six-cun long. During the treatment,the needle is heated until red-hot, and swiftly pressed and incised to drain the pus.”

Rupturing abscesses to drain pus is a crucial step in abscess treatment. Due to the lack of metallurgical technology, the needles used for incision and drainage of abscess during the Song dynasty were mostly made of horse bits, which was prone to breakage, and not sharp enough. This kind of needle is inconvenient to use and easy to cause damage to healthy tissue. Additionally, due to limited hygiene conditions, at that time, there are infection incidents from time to time. Therefore, in the Southern Song period, some medical practitioners believed that recklessly using knives and needles to rupture abscesses and drain pus led to death in eight or nine out of ten cases. As a result, they suggested using cauterization to drain the pus. Cauterization involved using a branding iron at a higher temperature, which had a sterilizing effect on the affected area. To some extent, this method avoided the drawbacks of using needles made of horse bits, making it a progress in the external treatment of abscesses.

The technique of cauterizing to drain pus also had a place in the treatment of abscesses in the Song dynasty, utilizing various tools, such as iron chopsticks or Yin Bi needle. The choice of tools appears arbitrary but it has a deeper meaning: The pinhole made by pointed needle is easy to close after cauterization, limiting the effect of pus drainage. Therefore, tools with flat and round heads are recommended. When cauterizing, the needle should be inserted horizontally with the opening located below the abscess, allowing the pus and blood to flow out easily without leaving any residue.35 The key lies in ease of operation and facilitating pus drainage (Fig. 5). The needles inserted in the hair bun of the doctor in Jiu Ai Tu resemble the cauterizing tools with flat and round heads, but whether they are the cauterizing tools commonly used by the practitioner is uncertain due to the lack of conclusive evidence. It is only listed for reference among colleagues.

In the predominantly yellowish picture of Jiu Ai Tu, the red dots on the plaster signboard carried by the small apprentice become the only bright color in the entire picture. External application of medicated plasters directly on the affected area has a direct and rapid effect, which cannot be matched by that of oral medications. The roles of plaster application in the treatment of abscesses include three aspects: (1) When the abscess has not yet formed pus, the application of plaster should focus on clearing heat, dispelling pathogenic factors, reducing swelling, and relieving pain, making it easy to dissipate. An example is the Song Zhi Tie Fang (松脂贴方 turpentine stickers) for treating swollen and painful abscesses. Chen Shigong (陈实功) of the Ming dynasty believed that abscesses are most susceptible to invasion by wind and coldness. Therefore, in the early stage or after moxibustion treatment, the abscess should be covered with Taiyi plaster (太乙膏), which can draw out toxins, promote pus drainage and also defend against wind and coldness. If there is no pus, Huafu Zixia plaster (化腐紫霞膏) can be added to enhance the therapeutic effect. (2) After the abscess has formed pus, the application of plaster can promot toxin expulsion and pus drainage. According to the Wai Tai Mi Yao Fang, “for the application of medicinal plasters, a hole should be made in the center of the sore, allowing the hot qi from the sore to be released ... For deep sores, fill it with cotton wool soaked with ointment, and pus will naturally come out. Continue the treatment until the pus is completely drained, and then healthy tissue will grow. For shallow sores which is not deep enough to fill in, just smear it with the ointment three times a day until the necrotic tissue is cleared up”.38 From an operational perspective, this appears to be a form of external drainage. (3) When the abscess has ruptured, plaster application can promote tissue regeneration and wound healing. Additionally, Wai Ke Zheng Zong (《外科正宗》Orthodox Lineage of External Medicine) mentions the use of an Iron-bucket plaster (铁桶膏), which is applied around the abscess after it has ruptured to tighten its root and base so as to reduce the wound area gradually.39

3 Exploration of the folk medical ecology in Song dynasty represented by Jiu Ai Tu

The understanding of abscesses to a certain extent reflects the level of external medical technology during the certain period, and patients’ medical awareness and behaviors when facing such serious illnesses are related to the overall societal experiences and perceptions of health and disease. In the Song dynasty, the official system tried to meet people’s medical needs from various aspects such as medical institutions, medical education, economy trade, welfare assistance, etc., promoting the development of the medical and health services. According to the Meng Liang Lu (《梦粱录》Dreams of Liang), the government of the Southern Song dynasty established a Bureau of Huimin (惠民局 Bureau of Peaple’s Welfare Pharmacy) in Lin’an Prefecture (临安县), which sold commonly used medicines at low prices, to provide convenience for the public seeking medical service.40

However, after the Song dynasty’s relocation to the south, economic decline resulted in a challenging healthcare situation for ordinary people in remote towns, suburbs, and rural areas. This was particularly true for the majority of the population, including ordinary people and the “Yi Ren (役人 laborers)” group (Note 5). The social structure of Southern Song society was complex, with rural households accounting for the majority. Based on different economic capabilities, they were divided into four categories: Guan Hu (管户 official households), Shang Hu (上户 upper households), Xia Hu (下户 lower households), and Ke Hu (客户 migrant households). Among them, the Xia Hu and Ke Hu, who had little or even no income, accounted for over 90% of total households, forming the main social groups in the Southern Song society.41 They lived in poverty, and during difficult times, they often could not afford the basic means of production (Note 6), let alone medical treatment. For the general public, it was common to rely on itinerant doctors who were available in the community. They provided simple and convenient treatments and charged lower fees, and there were also those who specialize in treating certain diseases, and the therapeutic effect was reliable. In remote and impoverished areas lacking medical resources, itinerant doctors became an indispensable presence. As seen in Jiu Ai Tu, living in thatched cottages in rural areas, the villagers in shabby clothes with a looking of having gone through many hardships, belonged to the poor class at the bottom of society. When they suffered from diseases, they either received no treatment, or could only afford the sevices of itinerant doctors, which was in line with the social context of the time.

In Wai Ke Jing Yao by Chen Zimin of the Southern Song dynasty, the “Outline of Medications for Treating Abscesses” detailed the prescriptions used by “families living in prefectures or counties and having financial strength” and those used by “people in remote villages and those without financial means”.42 As for “farmers and elderly villagers in remote areas”, medications were often chosen from what was readily available in the countryside.

Compared to the Jin and Tang dynasties, there are fewer records of moxibustion therapy in the Song dynasty, especially the significant reduction in the use of simultaneously igniting multiple moxa cones, which may be related to the popularization of formulas and the intense pain caused by moxibustion. From the Song dynasty onwards, the government prioritized the development of medical technology, engaging in the verification and editing of medical books, establishing bureaus for the correction of medical texts, unifying standards, and formulating regulations. There was a focus on acupuncture education, promoting clinical practice, and witnessing significant advancements in acupuncture studies. Additionally, the prosperous commerce of the Song dynasty facilitated the nationwide distribution of medicinal herbs. The government even established bureaus for the benefit of the people, creating favorable conditions for the application of herbal prescriptions. Meanwhile, the severe pain caused by moxibustion led to a decrease in the willingness of affluent patients to undergo moxibustion therapy. The proportion of moxibustion in medical activities declined. In order to alleviate the pain associated with moxibustion, Dou Cai (窦材) introduced Shui Sheng San (睡圣散 Sleep Saint Powder)43 which could be taken orally before moxibustion to induce immediate drowsiness and an unawareness of pain. Despite these efforts, moxibustion no longer seemed to be the preferred treatment for the general population. According to the Bei Ji Jiu Fa, it states, “People of wealth and arrogance are often afraid of pain; when they are suggested to receive moxibustion treatment, they angrily reject it”.44 After the Song dynasty moved south, moxibustion therapy was no longer popular among the upper class, and some medical practitioners openly expressed doubts about moxibustion: “Most people undergo moxibustion without proper measure, enduring pain for nothing, and rarely achieving recovery.”45

However, although moxibustion therapy is extremely painful, it is still seen as a good remedy for curing diseases and saving lives by the impoverished population. This is the mass foundation on which moxibustion therapy flourished among the people in the Song dynasty. The creation and transmission of Jiu Ai Tu also suggest that, although more and more wealthy people tended to choose less painful internal treatment when seeking medical help, moxibustion therapy is still the first choice for the poor people.

The doctor in Jiu Ai Tu, although dressed in tattered clothes, has a firm gaze, operates calmly, and uses diagnostic and therapeutic techniques that are very consistent with the content recorded in medical records at that time, indicating that he has the opportunity to have access to relevant diagnostic and therapeutic knowledge and practice it, and has a high level of diagnostic and therapeutic skills. This is related to the openness of medical knowledge in the Song dynasty. The Song dynasty government placed significant emphasis on the dissemination and promotion of medical knowledge. Multiple directives were issued to summarize medical experiences from previous dynasties and to revise, correct, publish, and distribute medical books. Due to the high price of books, ordinary medical practitioners often could not afford them, so Emperor Zhezong of Song (宋哲宗) ordered that commonly used medical books be re-proofread and sold in small print at a lower cost for medical practitioners.46 Emperor Taizong of Song (宋太宗) changed the attitude towards medical techniques adopted by his previous generation, like “keeping them secret” and “passing them on only to certain individuals”, and ordered people from different social classes in various prefectures and counties to contribute medical works and promised generous financial rewards or official positions as rewards. Emperor Huizong of the Song (宋徽宗) dynasty took out secret prescriptions from the imperial palace and extensively collected good folk remedies, compiling them into two hundred volumes of Sheng Ji Zong Lu (《圣济总录》Comprehensive Recording of Divine Assistance). All these measures played a positive role in the production and circulation of knowledge, significantly facilitating the dissemination of medical knowledge across different social strata. It is the popularization and openness of medical knowledge led by the government that enables itinerant doctors at the bottom of the medical community to have the opportunity to access the highest level of medical knowledge and apply it to their practice.

Nevertheless, the survival environment for itinerant physicians during the Song dynasty was not favorable. In contrast to the discrimination against medical practitioners (Note 7) during the Tang dynasty, the Song dynasty placed great importance on medicine from top to bottom, considering it a benevolent art and a skill of Confucian scholars. The social status of the doctors’ group was significantly elevated. However, this elevation was primarily limited to physicians specializing in Fang Mai, while surgeons, who often had to perform crude tasks such as incising abscesses, draining pus and blood, and excising necrotic tissue, were often looked down upon as uncultured and vulgar people. Chen Ziming of the Southern Song dynasty stated when discussing the treatment of abscesses: “Abscesses are more severe than other diseases. The sages considered them the foremost illnesses among miscellaneous diseases... Nowadays, in rural areas, there are many individuals from the lower classes who specialize in this field... Most of them are vulgar and ignorant people...” He did not hide his contempt for surgeons specializing in abscess treatment. This situation was not unique to the Song dynasty, as in 12th-century Western Europe, for example, surgeons were on par with barbers and were considered the lowest class of medical practitioners, facing discrimination and exclusion from internal medicine doctors.47

4 Conclusion

Jiu Ai Tu stands as the only visual representation of the history of acupuncture and moxibustion as well as the treatment history of abscesses, which has high and irreplaceable historical materials and evidence value. The illustration realistically depicts the treatment methods for abscesses in the back. The treatment of abscesses originated from ancient medical texts written on bamboo slips and silk, and matured during the Wei and Jin dynasties. The surgical treatise Liu Juan Zi Gui Yi Fang systematically proposed methods and precautions for treating abscesses, and later generations of medical practitioners often revered its teachings with little innovation. Jiu Ai Tu emphasizes three steps in abscess treatment: Early and intensive moxibustion, incision and pus drainage, and post-moxibustion application of poultices. It is simple and efficient, requiring no exceptionally high technical expertise, and can be easily mastered by the general public, thus facilitating its spread to more people. The illustration breaks the stereotype of people’s attitudes towards moxibustion in the Song dynasty, and to some extent promotes the use and promotion of moxibustion therapy. Academically, Jiu Ai Tu demonstrates the technique of applying multiple moxa cones simultaneously, providing a visual representation of this method documented in ancient medical texts, such as those found in bamboo slips, Zhou Hou Bei Ji Fang, Qian Jin Fang, and Wai Tai Mi Yao Fang.

Although it is generally believed that the folk application of moxibustion therapy began to decline from the Song dynasty (Note 8),48 analyzing the medical activities depicted in Jiu Ai Tu, it seems that this is not the case. In terms of abscess treatment, several representative external medicine works that I have read highly praise the positive role of moxibustion in treating abscesses: blocking development, preventing aggravation, promoting recovery, and even preventing the occurrence of abscesses. The folk medical activities represented by Jiu Ai Tu directly confirm the widespread application of moxibustion in abscess treatment. Thanks to the popularization and dissemination of medical knowledge, the itinerant physicians in the Song dynasty had access to medical knowledge and put it into practice, and their technical level was greatly improved, thus becoming a powerful supplement to the folk healthcare system.

The four types of needles used by the physicians in Jiu Ai Tu are not documented in literature. Their shapes are similar to that of the nine-needle but have distinct differences, indicating that they were tools modified according to clinical needs. They may also provide image reference about the evolution and development of surgical knife and needling instruments.

Notes

1. The panting named “Zhi Ai Tu (炙艾灸)” in Sheng Jing Gu Gong Shu Hua Lu (《盛京故宫书画录》Catalog of Paintings and Calligraphy in Shenyang Imperial Palace) and Taibei Palace Museum. Researchers also refer to it as “Village Doctor Painting”. The main treatment method presented in the painting is moxibustion. The practitioner is an itinerant doctor who does not have a fixed place for medical practice. The medical system in the Song dynasty was relatively complete, and the government often equipped medical personnel in local prefectures and counties, such as neighborhood doctor, county doctor, township doctor, village doctor, and others. They have a fixed consultation room. When seeking medical treatment, it is necessary to go to the doctor’s consultation room or invite the doctor to the patient’s home. The treating place in the painting is outside the thatched cottage. Besides, the small apprentice in the painting carries a plaster signboard with him, which give the facts that the doctor in the painting is not a village doctor. Therefore, the author tends to use the name “Jiu Ai Tu”.

2. From the perspective of modern medicine, abscesses are often caused by Staphylococcus aureus infections. When bacteria invade subcutaneous tissues, they form localized infectious lesions. At this stage, the manifestations are relatively mild. If left untreated, there are two possible outcomes: first, the skin may be continuously eroded, eventually rupturing and discharging pus, leading to self-recovery. Second, if inflammation spreads, and bacteria enter the bloodstream, it may cause sepsis, septicemia, systemic inflammatory response syndrome, and life-threatening ultimately multiple organ failure. Abscesses occurring on the back are particularly dangerous. The skin on the back is thicker than that in other parts of the body, which make it more resistant to erosion. When infection occurs, bacteria often cause disseminated lesion in the body. Additionally, due to the proximity of the back to the chest and abdominal cavities, bacterial colonies are prone to implantation into the cavities and organs. So, in ancient times, abscesses erupting on the back were often fatal.

3. The trend of ingesting medicines began during the Wei and Jin dynasties, flourished in the Sui and Tang dynasties, and persisted into the Song dynasty, showing signs of gradual decline. For more details, refer to: Du WY, ed. Journal of Tang History (唐史论丛). Xi’an: Shaanxi Sanqin Press; 2014. p. 297. Chinese. Zhou SZ. Health Preservation Monthly (养生月览). Beijing: China Medical Science and Technology Press; 2021. p. 7. Chinese. The gradual application of external elixirs in clinical practice in the Song dynasty, with a predominant focus on internal administration. See: Chen GF. Study of Taoist Canon Origins (道藏源流考). Taibei: Xiangsheng Press; 1975. p. 398. Chinese. Further exploration of the Han, Tang, and Jin dynasty alchemical formulas and their integration with traditional medical practices can be found in He ZZ. Prescription of external alchemy among Han and Tang dynasty in the clinical practice of TCM (汉唐金石丹方与传统医学临床). Journal of Guangxi University for Nationalities (Natural Science Edition), 2021;27(2):15–23.Chinese.

4. Also known as Fei needle (䤵针). Some records mentioned the use of Fei needles for the purpose of lancing and draining abscesses. Regarding the term Fei, according to the Zi Hui (《字汇》 Vocabulary of Chinese Words), its pronunciation derived from the character Fu (父) and Wei (尾), and sounds close to Fei (费), meaning a small nail. Additionally, it also pronounced as the combination of Pian (篇) and Yi (夷), which sounds like Pi (铍). The Su Wen (《素问》Basic Questions) commentary states: Bian Shi (砭石 stone needle), is now replaced with Fei needle. According to the Zhen Jing ZhaiYing Ji (《针经摘英集》Essence Excerpted from Acupuncture Classics), Fei needle is one of the nine needles, also known as the Pi needle.

5. Since the Spring and Autumn periods, the concept of “four occupations”—scholars, farmers, artisans, and merchants—had already emerged due to different divisions of labor in society. Among the “four occupations”, scholars held a slightly higher status, while the others involved in farming, trading, and other activities were considered equals among the common people. For more details, refer to: Huang Z. Hang’s Daily Record (黄氏日抄). Volume 78. p. 708–787. Chinese. (Song) Ye Shi categorized common people into three classes: commoners, military personnel, and laborers. Among commoners, there were further distinctions based on different occupations. For more details, refer to Ye S. Collection of Yeshi (叶适集). Beijing: Zhonghua Book Company;1961. p. 652. Chinese.

6. According to Xu Song (徐松), the economic conditions of typical rural households were generally poor. Items such as iron agricultural tools and plowing oxen required borrowing capital for acquisition. Some farmers joined together, pooling their resources to collectively purchase and raise oxen, sharing the animals for common use. For more details, refer to: Xu S. Collected Drafts of the Song Hui Yao (宋会要辑稿). Beijing: Xinhua Bookstore; 1957. p. 5914–5918. Chinese.

7. Under the influence of Confucianism’s “emphasizing virtue and slighting tools” philosophy, the status of physicians has experienced a declining trend since the Han and Jin dynasties. During the Tang dynasty, even literati and Confucian scholars regarded the practice of medicine as shameful. Figures like Han Yu expressed disdain, stating, “Shamans, doctors, and musicians, people of all trades, are not esteemed by gentlemen.” In the Tang dynasty, “scholars in both court and countryside were ashamed of the title of medical practitioners, which taught their younger disciples to recite short texts and compose minor essays to seek ways of advancement, neglecting the path of medical treatment.” This sentiment is elaborated in detail in Sun SM. Important Formulas Worth a Thousand Gold Pieces for Emergency (Photocopy) (备急千金要方·影印本). Beijing: People’s Medical Publishing House;1982. p. 401. Chinese.

8. The decline of moxibustion therapy here does not refer to the stagnation or regression of moxibustion technology and theoretical development, but rather to the narrowing of its application scope. Mr. Yu Gengzhe has provided a detailed discussion on this topic. For details, please refer to: Yu GZ. An analysis of the background of technology choice—the changing process of the moxibustion treatment in the popular medical treatment activities from Tang dynasty to Song dynasty(唐宋民间医疗活动中灸疗法的浮沉——一项技术抉择的时代背景分析). Journal of Tsinghua University (Philosophy and Social Sciences) 2006;21(1):62–73. Chinese.

Funding

This study was financed from the grant of the National Social Science Foundation General Project (No. 23BZS010).

Ethical approval

This study does not contain any studies with human or animal subjects performed by any of the authors.

Author contribution

WANG Li drafted and reviewed the article.

Conflicts of interest

The author declares no financial or other conflicts of interest.

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          Keywords:

          Jiu Ai Tu; Abscess; Moxibustion method; Traditional Chinese medicine; Chinese external medicine

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