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«Stephen Boyanton Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Graduate School of Arts and ...»

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Of old, people had a saying, “For the first two days, [the illness] is in the skin. By the fourth or fifth days, it has transmitted to the organs.” Therefore, when it is in the skin one can promote sweating; when it has transmitted to the organs, one can purge. Among those who today study [medicine], there are none who do not revere this as a fixed doctrine.

Thus they do not realize that just as there are people who are vacuous or replete, so there are illnesses which are mild or severe; just as there are illnesses that are mild or severe, so there are transmissions which are slow or fast… Those who are good at practicing medicine should thoroughly examine the pulse in order to precisely locate the illness.

That is all.197 古人有言 “一日二日在於皮膚,四日五日傳之藏府” 故皮膚之間可汗,傳藏府之間 可下。世之學者未嘗不宗之為定論。然不知人之有虛實則病之有輕重,病之有輕重則 傳之有遲速… 善為醫者當審察其脈,審其病之所在而已。 Shi Kan (史堪 late 11th-early 12th c.), Shi Zaizhi fang 史在之方 (early 12th c.), juan shang, in Qiu Peiran, ed., Zhongguo yixue dacheng sanbian, vol. 4 (Changsha Shi: Yuelu Shushe, 1994), 468.

The famous doctor and official, Zhu Gong, also complained of this practice:

One cannot inflexibly use day-counts [in prescribing]. Sweating, vomiting, and purging should be used according to the pattern [presented by the ill patient].198 不可拘以日數,發汗吐下,隨證施行。 For literati medical authors, the complexity of illness demanded a more subtle approach.

According to elite authors, proper diagnosis required distinguishing many aspects of an illness, but common physicians seldom went beyond the most basic differentiations. Xu Shuwei, one of the most ardent critics of common physicians, provides a taste of the complexity of illness

as seen by literati medical authors and the failure of common physicians to meet their standards:

I see common physicians treating cold damage and only naming it a yin pattern or a yang pattern. But Zhongjing had three yin and three yang [patterns]. Even within a single pattern there are also those that lean to surfeit and those dominated by dearth. It is necessary to clearly differentiate the character [of the illness] and in which channel is it located… Moreover, as in greater yin and lesser yin [patterns], even within a yin pattern there are [differences of] supplementing and draining. How can one stop at saying [an illness] is a yin pattern!199 予見世醫論傷寒,但稱陰證陽証,蓋仲景有三陰三陽,就一證中又有偏勝多寡,須是 分明辨質,在何經絡… 且如太陰、少陰,就陰証中自有補瀉, 豈可止謂陰証也哉。 At stake in the subtlety of diagnosis was the determination of correct treatment. Misdiagnosis or failure to understand the doctrines that should guide diagnosis and treatment not only made

treatment ineffective, it could also directly harm the patient:

Commonly, when doctors treat cold damage illness, if they encounter [a case where] the evil qi is in the exterior, they do not distinguish whether the evil qi is shallow or deep or whether the pattern of the pulse is vacuous or abundant. They just rely on the [presence of a] floating pulse, seize on an exterior-effusing medicine, and prescribe it. Should the strength of the medicine exceed the measure, then it causes nosebleeds, spitting-up of blood, a macular rash, or contraction of the four limbs…200 凡醫者治傷寒病,遇其邪氣在表,並不分邪氣之輕重,脈理之虛盛,只憑脈浮,便將 發表藥一例投之,務期汗多為快,藥力過劑,遂致衄血、吐血、發斑、四肢居攣… Nanyang Book for Saving Lives (Nanyang huroren shu 南陽活人書, 1118), juan 6, question 46, in Zhu Gong and Pang Anshi, Zhu Gong, Pang Anshi yixue quanshu, 54.

Shanghan jiushilun 傷寒九十論, zheng 23, in Xu Shuwei, Xu Shuwei yixue quanshu, 62.

Han Zhihe 韓祇和 (fl. 11th c.), Shanghan weizhi lun 傷寒微旨論, juan xia, “Bian hanxia yaoli qingzhong pian,” in Zhu Pangxian and Wang Ruoshui, Lidai zhongyi zhenben jicheng, 1990, 3:21.

In the eyes of their opponents, the simplistic diagnoses and treatments of common physicians could never adequately manage the immense complexity and subtlety of illness and healing.

A similar problem noted by elite authors was the tendency of common physicians to use formulae without an adequate grasp of when those formulae should or should not be used. Shen Gua recorded that the formula, Minor Bupleurum Decoction (xiao chaihu tang 小柴胡湯), was

used to treat cold damage indiscriminately:

Common people merely know that Minor Bupleurum Decoction treats cold damage.

Without asking what pattern [the patient presents] they just take it. Not only does it have no positive effect, there are also those whom it harms…201 世人但知小柴胡湯治傷寒,不問何證便服之,不徒無效,兼有所害… At the other end of the spectrum, one of Xu Shuwei’s case records complains of common

physicians’ resistance to using a formula when it was appropriate:

A strong boy in the village contracted cold damage. His body was hot and his eyes ached.

His nose was dry and he could not sleep. He was constipated, and all positions of his pulse were large. He had already [been sick] for a number of days. The previous evening he began to sweat profusely. I said, “Quickly use Major bupleurum Decoction to purge him. The assembled doctors were shocked, saying, “In a yang-brightness illness with spontaneous sweating, his body fluids are already exhausted. A honey enema should be used. Why would you use Major bupleurum Decoction?” 202 鄉里豪子得傷寒,鼻乾不眠,大便不通,尺寸俱大,已數日矣。自昨夕,汗大出。予 曰:“速用大柴胡湯下之。”众醫駭然曰:“陽明自汗,津液已竭,當用蜜兑,何故用大柴 胡藥?” Major bupleurum Decoction is a powerful purgative formula. The other doctors’ concern is that forceful purging will harm the boy, whose body fluids they believe have already been desiccated by the combination of severe fever and profuse sweating. Xu Shuwei, however, does not back

down from his position:

Shen Gua, Su Shen liangfang, juan 3, in Su Shi and Shen Gua, Su Shen neihan liangfang, 86.

Shangha jiushi lun, zheng 14, in Xu Shuwei, Xu Shuwei yixue quanshu, 61.

I said, “This is one of Zhongjing’s miraculous points which has not been transmitted.

How would you gentlemen know about it?” I argued forcefully. Finally, they used Major bupleurum Decoction. After taking two doses, [the boy] recovered.203 予曰“此仲景不傳妙處,諸公安知之。”予力爭竟用大柴胡,兩服而愈。 Xu accuses his common physician opponents of being overly hesitant due to their ignorance of the correct use of this formula as discussed in its source text.

Xu’s rather brusque rebuttal of his interlocutors reveals one of his primary reasons for opposing common physicians: the nature of their medical learning. Common physicians learned medicine by apprenticeship to a master. Initially, learning would take the form of observing the master, receiving oral instructions, and being guided in the memorization of texts. When the master decided the student was ready, he would transmit the actual medical texts to the student, meaning that the student would copy the texts and the master would orally impart explanations of the text’s meaning. Texts were not necessarily transmitted in their entirety or in any given order; as a result, the medical texts possessed by common physicians resembled compilations more than treatises, and the full content of a medical text (in this case the Treatise on Cold Damage) was seldom available.204 Xu’s comment that, “This is one of Zhongjing’s miraculous points which has not been transmitted,” accuses his common physician adversaries of faulty and incomplete learning. Xu, on the other hand, based his medical knowledge on study of the original

texts themselves. His commentary on this case record makes this point explicit:

Discussion: In discussing yang-brightness [illness] Zhongjing says that in yangbrightness illness, in the case of those with profuse sweating, urgently purge them. [And yet] people frequently say that when there is already spontaneous sweating, if you further purge [the patient], will this not this make both their exterior and their interior vacuous?… The common people seldom read…205 論曰:仲景論陽明云:陽明病,多汗者,急下之。人多謂,已自汗,若更下之,豈不表裡 俱虛也… 世人罕讀… Ibid.

Sivin, “Text and Experience in Classical Chinese Medicine,” 77–86; Keegan, “The ‘Huang-Ti Nei-Ching,’” 219– 247.

Shanghan jiushi lun, zheng 14, in Xu Shuwei, Xu Shuwei yixue quanshu, 61.

Xu’s preferred method of learning is that of the literati: the meticulous study of texts, possibly assisted by a teacher, but ideally resulting in a direct relationship between the student and the texts studied. He holds that the common physicians’ approach to learning, in which texts are secondary to a master-disciple relationship, is defective.

A final front in the war on common physicians was their purported ethical standards. The Confucian tradition had long objected to the quest for personal profit, and though Song dynasty merchants could amass great fortunes in the burgeoning economy of the times, their cultural status remained low. Although many literati families were engaged in commercial activity, they were careful to maintain their perceived status through education, marriage, and culturally appropriate displays of wealth. Similarly, elite physicians and their eulogists repeatedly emphasized the altruistic nature of proper medical practice and denounced the practice of medicine as a means of amassing profit. Common physicians practiced medicine as an occupation and, of course, expected to be paid, leaving themselves vulnerable to elite criticism.

Hong Mai, writing in the Southern Song, recounts the story of a doctor who, having already been paid 300,000 copper coins for his services—a very substantial sum—insists on further payment before he will complete the treatment.206 While this story should not be taken at face value as an accurate record of the fees paid to doctors, it does reflect elite anxiety over the possibility of extortion on the part of unscrupulous physicians. Xu Shuwei linked the desire for profit with the

decline he perceived in the effectiveness of medicine over the centuries:

Why were the ancients so ingenious, while contemporary people are unable to reach [their level]? I have pondered this [problem]. The ancients used this [medicine] to save people, so heaven bestowed [medicine’s] Way. Later people used this [medicine] to produce profit; therefore heaven was miserly with [medicine’s] techniques and did not lightly confer them…207 Yijian zhi, dingzhi, juan 10, in Tao, Biji zazhu yishi bielu, 741.

Puji benshifang, authors preface, in Xu Shuwei, Xu Shuwei yixue quanshu, 83.

何古人精巧如是,而今人之不逮也?予嘗思之。古人以此救人,故天畀其道… 後人 以此射利,故天嗇其術,不輕畀予… A further example of the ways in which practicing medicine for profit corrupted common

physicians was found in the practices of secrecy surrounding their medical formulae:

The common people, when they obtain an efficacious formula or acquire an unusual technique, seal it away and keep it secret, cautiously fearing only that other people might learn of it. This is wishing to benefit oneself only, and is not the broadly loving heart of a humane person.208 今之人,有得一效方,獲一奇術,乃緘而秘之。惕惕然惟恐人之知也。是欲獨善其 身,而非仁人泛愛之心也。 Humaneness (ren 仁) was considered the cardinal Confucian virtue and the epitome of a true gentleman’s character. To accuse a man of lacking humaneness was therefore simultaneously to state that he had no place among gentlemanly society. As Shapin noted, the boundaries of trust are identical with the boundaries of the community.209 The perceived ethical shortcomings of common physicians placed them outside of the moral community that elite society was defining for itself.

The attacks on common physicians’ style of learning and ethical standards reveal that beneath the varied criticisms of elite medical authors, there lay a more fundamental problem with common physicians: they were not members of the literati elite. Their knowledge of medicine was learned in non-literati ways; they held themselves to ethical standards that differed from those which the elite attributed to themselves; and the criteria by which they justified their diagnoses and treatments appeared inadequate to someone with a literati education. How could they be anything but untrustworthy?

Wang Gun, Boji fang 博濟方, author's preface, in Zhu Pangxian and Wang Ruoshui, eds., Lidai zhongyi zhenben jicheng, vol. 9 (Shanghai: Shanghai Sanlian Shudian, 1990), 1.

Shapin, A Social History of Truth, 36.

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