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SECTION TWO: Solutions to the Crisis of Trust in Medicine Drawing on Arthur Kleinman’s division of modern healthcare in Taiwan into three sectors, Christopher Cullen argues that healing during imperial times was divided into three sectors: literate, classical healers who were physicians of various sorts, folk healers who practiced a wide range of ritual therapies, and a popular sector comprised of practices passed down within and among families, friends, neighbors, etc (figure 3-1). Though he acknowledges the distinction between common physicians and literati who practiced medicine as an occupation, Cullen placed both groups within the literate, classical healers healthcare sector.210 This portrayal appears to be fairly accurate before the Song dynasty, but the Song elite’s concern over the poor quality, as they perceived it, of common physicians resulted in the creation of a new sector of healthcare practices within Chinese society which I term “literati medicine.” Literati medicine was medicine by the elite, for the elite, and was designed to remove, as completely as possible, common physicians from elite healthcare. Cullen’s principal source, the novel Plum in the Golden Vase (Jinping mei 金瓶梅, 1612), dates from the late Ming dynasty (1368-1644), by which time it is possible that common physicians had been absorbed as the lowest level of literati medical practitioners. Such was definitely not the case, however, during the Song, Jin, and Yuan dynasties.
Cullen, “Patients and Healers in Late Imperial China,” 100–103.
Figure 3-1: Cullen’s Chart of the Healthcare Marketplace in Late Imperial China211
Adapted from ibid., 103.
Three Approaches to Resolving the Crisis Literati medicine was created as a solution to the crisis of trust in medicine, but what form that solution should take was far from clear during the Northern Song. The methods Song elite authors proposed for improving medicine were diverse not only in the range of solutions offered as a whole, but even in the range found within a single text. Broadly speaking, three basic approaches can be found within the medical writing of this period: the collection of proven formulae, the appeal to authoritative sources, and the development of a literati-physician approach to medicine. Far from being mutually exclusive, they were used in varying combinations by most authors, the mixture often varying depending on the topic at hand. In spite of this eclecticism, most authors displayed a preference for one or the other of the solutions—a preference which I argue reflected deeper commitments regarding the ideal medical knower.
The Characteristics of the Proven Formulae Approach Authors who collected proven formulae held that, given the complexity of illness and its treatment, the only way to be certain of a treatment’s usefulness was to have witnessed its efficacy. They therefore collected medical formulae, and occasionally other forms of medical treatment, the effectiveness of which was personally confirmed by themselves or by someone they deemed reliable. The preface to one of the earliest surviving examples, Wang Gun’s
Formulae for Abundant Aid, explains the author’s method:
I abundantly picked out secret formulae for over twenty years. The formulae that I obtained numbered over seven thousand. All of them were passed down in old family books, and I obtained them through relatives and old friends… Since I selected from among them those which are particularly essential, their therapeutic effect can be relied upon. Formularies must be proven.212 Author’s preface, in Siku Quanshu, 6–7.
博採禁方，逾二十載矣。所得方論，凡七千餘道，皆傳之於家牒，得之於親舊… 因於 其中擇尤精要者，理療可憑，方書必驗。 Wang culled his formulae from old books passed down in the families of relatives and friends.
Other authors were more eclectic in the sources of their formulae. Shen Gua, in the preface to his
Excellent Formulae (Liangfang 良方) states his criteria for choosing formulae:
As for what I call excellent formulae, the proof [of their effectiveness] must have been personally witnessed…213 予所謂良方者，必目睹其驗… An examination of the sources he used includes formulae passed down within his family, formulae reported to him by others he deemed trustworthy, and formulae from well-respected medical texts whose efficacy he felt was well-established. Proof of a formula’s effectiveness could be accepted second-hand or even third-hand, provided the ultimate source of the formula was a reliable individual who had personally witnessed the formula’s use.
In the individual entries of his formulary, Shen Gua shows us what proving a formula meant to him in actual practice. Following the formula for Aconite and Schizonepeta Pill (wujing wan 烏荊丸), Shen states, This medicine is particularly miraculous in treating bloody stool. One person after another has obtained good results [using this formula]. Within a single year, I have already seen several people with bloody stool take this [formula] and recover.214 此藥療腸風下血尤妙，累有人得效，予所目見下血人服此而瘥者，一歲之內已數人。 Longer proof statements could include one or multiple case records of the formula’s use or quotations reporting what Shen was told about the formula’s effects.
Author’s preface, in Su Shi and Shen Gua, Su Shen neihan liangfang, 4; Shen Gua’s Liangfang now only exists as a combined text including material by Su Shi 蘇軾 (1037-1101).
Juan 2, in ibid., 72.
Generally, collections of proven formulae eschewed discussions of medical doctrine.
Each formula was preceded by a description of the conditions for which the formula was useful.
These descriptions were often quite short:
To treat nosebleed: Japanese Thistle Powder215 治鼻衄: 刺薊散 They could, however, be far more detailed. In any case they are notable for the relative absence of attempts to explain the cause of the illness in terms of yin and yang, the five phases (wuxing 五行),216 and the functions and interrelationships among organs. Precisely this sort of explanation was of great importance to proponents of the literati-physician approach, and its absence in proven formulae collections is the clearest distinction between these two approaches. A comparison between the explanations provided by a proven-formulae text and a literati-physician text will help to clarify this distinction. The first example is taken from Essential Formulae for Travelers, by Dong Ji (董汲, fl. Late 11th c.). The second example is taken from Xu Shuwei’s Efficacious Formulae for Universal Aid (Puji benshifang 普濟本事方, mid-12th c.), which, though it included proof statements for many of its formulae, remained strongly committed to a literati-physician style of learning and practice.
Pinellia Transform Phlegm Pill: Treats phlegm repletion [causing] nausea and vomiting, dizziness and a muddled feeling, heart palpitations, a cold back, soreness of the arm, coughing up of spittle, and discomfort of the epigastrium.217 半夏化痰丸 治痰實，噁心嘔吐，頭目昏暈，心悸背寒，臂病涎嗽，膈不快。 Job’s Tears Powder: Treats dampness that damages the kidney, [causing] it to fail to nourish the liver. The liver then spontaneously generates wind, thus forming windSu Shi and Shen Gua, Su Shen liang fang, juan 7 in ibid., 181.
The five phases—metal, water, wood, fire, and earth (jin, shui, mu, huo, tu 金、水、木、火、土)—represented five archetypal classes of activity arranged in two cycles—one of generation and one of conquest. All things could be categorized into one of the five and the relations among the five were then held to govern the relations of the things classified as well. The system was commonly applied to the relationships among organs in the body.
Lüshe beiyao, in Siku Quanshu, 7.
dampness, which pours into the tendons and bones of the four limbs or enters the shoulder bone,218 causing extreme pain in flesh, and gradually enters into the fingers.219 薏苡仁散 治濕傷腎，腎不養肝，肝自生風，遂成風濕，流注四肢筋骨，或入在肩 髃，肌肉疾痛，漸入在指中。 The proven formulae text provides more detail on symptoms, but doctrinal and causal explanation are limited to the initial statement that the illness is due to “phlegm repletion (tanshi 痰實).” By contrast, the literati-physician text provides slightly less detail regarding symptoms but explains causation in great doctrinal detail.
A lack of reverence for famous pre-Song medical texts often accompanied proven formulae authors’ disinterest in medical doctrine and causal explanation. Of the surviving authors Shen Gua was the most outspoken in this regard, rejecting the famous Tang dynasty medical texts by Sun Simiao and Wang Tao, though even Shen quoted with approval and occasionally at length from the Han dynasty works of Zhang Ji, which were highly revered by both common physicians and advocates of a literati-physician medicine.220 Finally, all proven formulae texts take the form of a formulary: a listing of formulae and the conditions they treat. This choice of genre reflected both the authors’ lack of interest in doctrinal discussions and their focus on what they perceived as the practical task of amassing a large number of useful formulae. Unlike the other two approaches, advocates of this approach self-consciously used the term “proven formulae (yanfang 驗方)” to label it, often including this term in the titles of their formularies.
“Shoulder Bone (jianyu 肩髃)” is also the name of an acupuncture point (LI-15) located near the prominence of the acromion. I am inclined to read it more generally in this instance since “In the fingers (zhizhong 指中) is not the name of any acupuncture point.
Puji benshifang, juan 3, in Xu Shuwei, Xu Shuwei yixue quanshu, 107.
Su Shen Liang Fang, preface and juan 3, in Su Shi and Shen Gua, Su Shen neihan liangfang, 3, 82–83.
The Characteristics of the Authoritative Source Approach Authors who relied on the authoritative source approach, as the name conveys, attempted to produce trustworthy medical texts by taking all their information from a source or sources which in their judgement possessed impeccable credentials. The precise authority chosen varied widely, but three broad categories can be distinguished: famous medical texts, respected family lineages, and imperial medicine.
Texts which relied upon famous medical works took the form of a digest, selecting those formulae which the author considered the most effective or the most practical. Guo Si’s (郭思, fl.
1082-1125), Precious Essentials of Formulae worth a Thousand Gold (Qianjin baoyao 千金寶 要, 1114), selected what he considered the most useful formulae from the Tang dynasty Essential Formulae worth a Thousand Gold. No preface for the text survives, but the selection of formulae reflects an interest in simple, easily prepared treatments.221 Appeals to the authority of family lineages of medicine were apparently common. The New Book on Children, for example, lists twelve books with titles in the form Mr. X’s Family Transmission (X shi jiachuan X 氏家傳) and three others with titles in a different form but also attributed to particular families.222 More such texts are known from other sources, but very few have survived, making it difficult to generalize about their content. The final category of authoritative source—appeals to imperial authority—is known only through titles preserved in bibliographies and other sources. Judging from the relatively small number of titles recorded, it seems to have been the least common type of authoritative source text. This may be due to the fact that the Northern Song government Guo Si and Sun Simiao, Qianjin Baoyao, Sun Zhenren Haishang Fang, ed. Su Li, Yang Chengzu, and Jiang Xiao, Zhongyi Guji Zhengli Congshu (Beijing: Renmin Weisheng Chubanshe, 1986).
Liu Fang 劉昉, juan 40, “Shidafu jiachuan,” in Qian Yi and Liu Fang, Qian Yi, Liu Fang yixue quanshu, 975.
published a large number of texts on its own initiative, making the claim to possess the “secrets” of imperial medicine ring hollow.
Due to their low rate of survival, it is difficult to generalize about texts which primarily relied on the authoritative source approach. On the basis of the small number of extant Northern Song representatives and the rather larger number of surviving Southern Song texts of this type, it is likely that their content varied widely, adhering for the most part to a format and style similar to the proven formulae texts, but sometimes invoking the doctrines and explanations found in literati-physician texts.
The Characteristics of the Literati-Physician Approach At the heart of the literati-physician approach was a conviction that medicine should be learned and practiced in ways which accorded with literati sensibilities and practices. Medicine was a noble and difficult endeavor both worthy of and demanding the skills of a qualified