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The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological,
and Medical Change in China, 1000-1400
Submitted in partial fulfillment of the
requirements for the degree of
Doctor of Philosophy
in the Graduate School of Arts and Sciences
All Rights Reserved
The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China 1000-1400 Stephen Boyanton This dissertation explores the profound changes that occurred in literate Chinese medicine during the Song (960-1279), Jin (1115-1234), and Yuan (1276-1368) dynasties— changes which established the pattern of the text-based Chinese medical tradition from that time to the present day. In particular it examines the transformation of the Han dynasty (206 BCE-220 CE) text, the Treatise on Cold Damage (Shanghan lun 傷寒論), from one member of a diverse tradition of texts giving instruction on the treatment of cold damage disorders (shanghan 伤寒, a class of potentially epidemic, febrile illnesses) into the preeminent—almost the only—canonical text about such illnesses and a touchstone for medical thinking on all types of illnesses. I argue that a two primary factors account for the Treatise’s remarkable rise in status: the rise in the frequency of epidemics caused by Chinese society’s crossing of epidemiological frontiers, both in terms of population and in terms of geographic distribution, and a crisis of trust in medicine which was part of a much broader epistemic crisis brought about by the radical changes in social structure, commerce, governance, and material culture during the Song.
The increase in epidemics gave added weight to the topic of cold damage, but the decisive factors singling out the Treatise were related to its usefulness in addressing the medical crisis of trust. Medical authors were unanimous in their condemnation of the status quo in medicine. The focus of their criticisms was the figure of the common physician (shiyi 世醫).
Common physicians, the dominant practitioners of text-based medicine in the Northern Song, belonged to social stratum just below that of the elite. For elite medical authors, common physicians were the primary problem with medicine: they were inadequately or incorrectly educated, failed to appreciate the complexity of illness, and lacked elite ethical values. While elite authors agreed that common physicians were the problem, they disagreed on how to resolve this problem. Three approaches developed a more elite form medicine—which I term “literati medicine.” It was among the proponents of one of these approaches—“literati-physician medicine,” which held that only members of the elite could be proper physicians—that the Treatise on Cold Damage became central to medical thought and practice.
Literati physicians found the Treatise useful for a variety of reasons. In terms of their social relations, both within the clinical encounter and in broader society, it was a useful tool for arguing for their own superiority over their common physician competitors. In terms of their clinical doctrines, it provided a model by which to deal with what they saw as the central problem in medicine: the protean nature of illness. As long as that remained the central problematic of their medical tradition, the Treatise retained its central place. By the Yuan, literati physicians dominated all of literati medicine and ultimately all of textually based medicine, making the Treatise a central text for all physicians.
The history of the Treatise’s transformation into one of the most fundamental texts of the Chinese medical tradition is therefore rooted in the formation of literati medicine, and its struggle for both social legitimacy and clinical efficacy. The Treatise’s continued importance from the Yuan to modern times is the result of the survival of literati medicine for nearly one thousand years. In spite of many changes, modern Chinese medicine remains committed to a vision of illness as irreducibly complex and to an approach to cure—individualization of
Many people deserve recognition for their contributions to the completion of this dissertation, and I fear I may forget some of them. If I have done so, I ask that you forgive me and know that my gratitude to you remains.
Without the guidance of my advisor, Robert Hymes, this dissertation would be far less than what it is today. His example led me to consider explanations I had never thought of before.
The social historical aspect of this work is largely the result of his inspiration. His drive for precision and clarity in thought and word pushed me to improve my research, analysis, and writing. He has been the best editor any author could hope for, and his advice on how to be a scholar has been invaluable. I am truly grateful.
Although I have never officially been her student, Marta Hanson has been my mentor for many years. Among many other acts of selfless assistance, she helped me refine my writing skills, understand the nature of scholarly discourse, and develop useful contacts with other historians of Chinese medicine. It is difficult to imagine how I could have reached this point in my own career without her help.
I owe Matthew Jones a special debt for introducing me to the literature on the history and sociology of science. As even a casual perusal of this dissertation will reveal, that literature has become my theoretical touchstone. It has allowed me to resolve several of the perplexing issues that came up in the course of my research and also to speak to a wider audience through my work.
The remaining members of my dissertation committee—T.J. Hinrichs, Dorothy Ko, and Shang Wei—have generously spent of their time reading and critiquing this work. I thank you all.
develop a more nuanced and accurate understanding of Chinese medicine. Tantan Huang, J. Min Fan, Yuan Wang, Ye Pinliang, Song Naiguang, and Xiao Xiangru all provided insights I could not have obtained on my own. Liang Yongxuan, professor of Chinese medical literatue at Beijing University of Chinese Medicine, provided particularly useful guidance on the quality of various editions of the texts I study.
The first year of research for this dissertation was funded by a Fulbright Fellowship. I would like to thank the Institute for International Education and Beijing University of Chinese Medicine for their support of my work. In particular, I would like to thank Janet Upton and Jonathan Akeley of IIE and Fu Yanling and Gong Jiapei of BUCM for their kindness and efforts on my behalf. One year of my write-up was supported by a Sasakawa Young Leaders Fellowship from the Tokyo Foundation. Their gernerous support gave me the time to devote myself to writing completely, without which this project could not have been completed in as timely a fashion.
Finally, I would like to express my appreciation to my family: my parents, Charles and Zana Boyanton, for their unfailing support and encouragement throughout my long and unusual student career; my wife, Dengting Boyanton, for accompanying me on what must have at times felt like a fool’s quest; and my daughter, Ellen Xianglan Boyanton, whose smiles, laughter, and drawings labeled “For Daddy, From Ellen” kept me going through the final push to finish this dissertation. I love you all.
The research that became this dissertation grew out of a purely personal sense of puzzlement. I am both a historian and a clinician of Chinese medicine. During my clinical education, I began reading the great classics of Chinese medicine. I started with the Yellow Emperor’s Inner Classic (Huangdi neijing 黃帝內經, ca. 1st c. BCE, hereafter the Inner Classic), the oldest text in the received tradition of Chinese medicine and traditionally seen as its foundation. I found it fascinating and inspiring, but foreign. It felt very distant from the medicine I was learning to practice. As I read other medical texts, I noticed a pattern. Everything written before the Song Dynasty (960-1279) struck me as unfamiliar to one degree or another, but everything written from the Song onward appeared—for the most part—natural and logical. I knew that the Song was considered a watershed in Chinese history, and I began to suspect that it might also be a major point of transition in Chinese medical history as well.
There was one text, however, that didn’t fit the pattern: the Treatise on Cold Damage (Shanghan lun 傷寒論, ca. 206 CE, hereafter the Treatise), which I studied at the urging of one of my professors. In spite of being one of the oldest texts I read, the Treatise not only seemed natural and logical but also seemed to be a key for unlocking Chinese medical theory and practice. It resolved many issues that had puzzled me for years, and opened up new possibilities I had never considered. The Treatise felt like the foundation of everything else I had learned. As I continued my studies, I found that many more knowledgeable and experienced physicians shared my feelings—such as Liu Duzhou (劉度舟, 1917-2001) who referred to the Treatise on Cold Damage as the “soul of Chinese medicine 中醫之魂.”1 Moreover, I learned that the Treatise had
Liu Duzhou, Liu Duzhou shanghan linzheng zhiyao, ed. Chen Ming, Zhang Baowei, and Liu Yanhua (Beijing:
Xueyuan Chubanshe, 1998), 1–2.
risen to new prominence during the Song following its editing and publication by the Song imperial government. Once again, everything seemed to change in the Song.
I was left with two interrelated questions. What happened in the Song that made the medical texts written thereafter different from those written before, and why did the Treatise on Cold Damage, written so long before the Song, feel so much like a post-Song text? To reframe these questions in more historical terms: why did I have a visceral sense of rupture in the medical literature pre- and post-Song but an equally strong sense of continuity with the Treatise—an extremely old text? These were the questions I set out to answer through my research.
I soon learned there was no shortage of scholarly discussion about medicine and the Treatise on Cold Damage during the Song. The rupture I sensed with pre-Song medical texts was affirmed by many scholars. Miyashita Saburō 宮下三郎 traces out a plethora of changes related to medicine in the Song, Jin (1115-1234), and Yuan (1271-1368) dynasties.2 Paul Unschuld argues for a thoroughgoing transformation of doctrinal perspectives in this period.3 Ishida Hidemi 石田秀実 describes a revival of “classical medicine” during the Song.4 Both Robert Hymes and Chen Yuanpeng elucidate important changes in the social position of Song doctors, and Asaf Goldschmidt, following up on the work of both Miyashita and Unschuld, attempts a survey of the medical changes of the Song, including the new status of the Treatise on Cold Damage.5 In spite of this impressive amount of research, however, the continuity I sensed with Miyashita Saburō, “Sō Gen no iryō,” in Sō Gen jidai no kagaku gijutsushi, ed. Yabuuchi Kiyoshi (Kyōto: Kyōto Daigaku Jinbun Kagaku Kenkyūjo, 1967), 123–70.
Paul U. Unschuld, Medicine in China: A History of Ideas, 2nd ed. (University of California Press, 2010).
Ishida Hidemi, Chūgoku Igaku Shisōshi: Mō Hitotsu No Igaku, Shohan, Tōyō Sōsho 7 (Tōkyō: Tōkyō Daigaku Shuppankai, 1992).
Robert Hymes, “Not Quite Gentlemen? Doctors in Sung and Yuan,” Chinese Science, no. 8 (1987): 9–76; Chen Yuanpeng, Liang song de “shangyi shiren” yu “ruyi” (Taibei: Wenshi Congkan, 1997); Asaf Goldschmidt, “The Transformations of Chinese Medicine During the Northern Song Dynasty (A.D. 960--1127): The Integration of Three Past Medical Approaches into a Comprehensive Medical System Following a Wave of Epidemics” (Ph.D., University of Pennsylvania, 1999); Asaf Goldschmidt, “Changing Standards: Tracing Changes in Acu-Moxa Therapy during the Transition from the Tang to the Song Dynasties,” East Asian Science, Technology, and Medicine, the Treatise remained unexplained. Even the concrete evidence of this continuity, seen in the numerous references to the Treatise and its medicinal formulae in other medical texts, appeared largely unrecognized. My curiosity remained unquenched.
This dissertation is the result of my efforts to clarify and make sense of what was initially a very personal and visceral recognition of an unresolved problem. Over the course of my research that initial perplexity was refined into ever more precise questions, but my goal has remained to understand more clearly the place of the Treatise on Cold Damage in the transformation of Chinese learned medicine between the Song and Yuan dynasties. The questions I am asking relate to the literate medical tradition and not to the myriad forms of folk healing, ritual healing, devotional healing, etc. that were always part of the Chinese healthcare marketplace. For that reason, I have not included these other domains of healthcare within the scope of this dissertation. In doing so I am in no way implying that these other forms of healing were unimportant—they were clearly widespread and influential in the period I am studying.
They simply fall beyond the purview of my work.