«Stephen Boyanton Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Graduate School of Arts and ...»
This dissertation is divided into two parts and five chapters. The first part places the Treatise on Cold Damage in its historical context. The introduction to Part One introduces the Treatise and its basic history as well as the illness it is devoted to describing: “cold damage (shanghan 傷寒).” Chapter 1 reexamines the changing status of the Treatise in the Song by tracing the development of cold damage studies from the Han (206 BCE-220 CE) through the no. 18 (2001): 75–111; Asaf Goldschmidt, “The Song Discontinuity: Rapid Innovation in Northern Song Dynasty Medicine,” Asian Medicine: Tradition and Modernity 1, no. 1 (2005): 53–90; Asaf Goldschmidt, “Huizong’s Impact on Medicine and on Public Health,” in Emperor Huizong and Late Northern Song China: The Politics of Culture and the Culture of Politics, ed. Patricia Ebrey and Maggie Bickford (Harvard University Asia Center, 2006), 275– 323; Asaf Goldschmidt, “Epidemics and Medicine during the Northern Song Dynasty: The Revival of Cold Damage Disorders (Shanghan),” T’oung Pao 93, no. 1 (March 2007): 53–109; Asaf Goldschmidt, “Commercializing Medicine or Benefiting the People – The First Public Pharmacy in China,” Science in Context 21, no. 3 (2008): 311– 50; Asaf Goldschmidt, The Evolution of Chinese Medicine: Song Dynasty, 960-1200 (New York: Routledge, 2008).
Song. I argue that an inadequate understanding of the Treatise’s situation before the Song has led to an incorrect understanding of what occurred during the Song. The Treatise did not experience a “renaissance” or “revival,” because it was always a highly valued text. Rather it changed from being one of many texts on cold damage to being the only authoritative text on cold damage, but this narrowing of vision counter-intuitively led to a flowering of writing about cold damage unlike any previously seen. Chapter 2 introduces the Song Dynasty and its history. The Song is one of the most important periods of change in Chinese history, and this chapter outlines the transformations most relevant to the topic of this dissertation—those in the social, epidemiological, and medical realms. Chapter 3 introduces a new perspective on the medical changes that occurred in the Song. I demonstrate that the Song elite’s well-known “interest” in medicine was in fact a fear of poor medical treatment. “Common physicians (shiyi 世醫),” the literate but sub-elite practitioners who dominated textually based medicine in the Song, came to be seen as incompetent and unethical by an elite that had lost faith in the foundations of contemporary medical knowledge and practice. The search for solutions to this problem was one of the driving forces behind the changing landscape of text-based medicine up through the Yuan.
Supporters of one of the proposed solutions advocated for the development of a form of medicine practiced by elite men. I call that medicine “literati-physician medicine.” Supporters of literati-physician medicine were responsible for elevating the Treatise on Cold Damage to the new position it attained in this period. Part Two of the book is devoted to explaining why literati physicians found the Treatise useful. It begins by presenting two useful theoretical perspectives by which I analyze literati-physician medicine. Chapter 4 then discusses how literati physicians made use of the Treatise in their many social interactions. I contend that the Treatise was useful in arguing for literati-physician medicine both within society broadly and within the particular context of clinical encounters, where physicians had to win the trust of patients and their family.
Chapter 5 turns to the more explicitly medical benefits the Treatise provided to its supporters. I show that the overarching problematic that concerned both literati physicians and elite nonphysicians was the complexity and changeability of illness. The Treatise on Cold Damage provided a model for how to cope with the protean character of illness. It offered both a means of learning how to treat illness and a base from which to develop literati-physician medicine further.
It therefore came to be seen as the most fundamental text for all of medical practice—not merely for treating cold damage. In the conclusion I return to the issue of continuity and rupture.
Literati-physician medicine ultimately succeeded in dominating the field of learned medicine, and the Treatise on Cold Damage, by this time its most essential text, thus became central to textually based medicine in China generally. I argue that since the Song, Chinese physicians have continued to see complexity and mutability as the central problematic of medicine, and therefore the Treatise has remained central to their education, practice, and innovation.
To a great degree, the history I am presenting hinges on the nosological entity, cold damage. Although this is not a history of cold damage, a good deal of that history is included here, often for the first time. Like most terms, cold damage was not completely stable over time.
Its meaning shifted in important ways. The reader will discover many of these shifts in later chapters; for the moment it is adequate to understand the basic meaning that cold damage carried throughout most of this period.
At its simplest, cold damage was a generic term for any acute, potentially epidemic, febrile illness. Cold damage was understood as an illness caused by invasion of external, climatic cold during the winter. This cold initially lodged on the surface of the body, trapping the body’s native heat in the interior and thereby causing fever. Not all cold invasions led to an immediate illness, however. In some cases, the cold entered the interior of the body and hid. During spring or summer, the warmth of the weather would cause the cold to transform into heat and manifest itself as an illness characterized by a more severe fever. Regardless of whether the illness manifested immediately or only after some time, all of these illnesses were categorized as cold damage. After its initial manifestation, cold damage usually moved deeper into the body, causing a variety of different symptoms. The Treatise on Cold Damage presented a method of understanding, anticipating, and treating the various transformations of cold damage disease.
The Treatise began its life as part of the larger text, the Treatise on Cold Damage and Miscellaneous Diseases (Shanghan zabing lun 傷寒雜病論) that included information on all types of illness and was divided into two large sections, one covering cold damage and another covering all other types of illness, collectively known as miscellaneous diseases (zabing 雜病). It was composed by the late Han dynasty (206 BCE-220 CE) physician Zhang Ji (張機, styled Zhongjing 仲景, ca. 150-219). Little is known about Zhang Ji’s life. The preface of the text, now part of the Treatise, reveals only that he saw himself as part of the elite stratum of society (shi 士) and that he belonged to a large clan.6 The earliest reference to Zhang Ji is provided by Huangfu Mi (皇甫謐, ca. 215-287), who recounts an anecdote regarding Zhang Ji’s medical skill in the preface to his Systematic Classic of Acumoxa (Zhenjiu Jiayi Jing 針灸甲乙經, completed between 256-282). Huangfu Mi concludes by stating, “Zhongjing expanded on Yi Yin’s [Classic of] Decoctions and composed several tens of fascicles using his extensive experience.”7 Neither the Records of the Three Kingdoms (Sanguozhi 三國志, 297) nor the History of the Latter Han (Hou Hanshu 後漢書, 445) mentions Zhang Ji. The earliest discussion of Zhang Ji’s life is found in the Tang dynasty (618-907) Records of Famous Physicians (Mingyi zhuan 名醫傳, date unclear) by Gan Bozong (甘伯宗, dates unclear). This text is now lost, save for a handful of fragments preserved in other works. Among these fossilized fragments is a biography of Zhang Zhongjing quoted in the preface to the Song dynasty edition of the Treatise: “[Zhang Zhongjing was] a person from Nanyang 南陽 [in modern Henan province]. His given name was Ji.
Zhongjing was only his style-name. He was selected for office on the basis of merit and served as an official in Changsha as the Grand Protector. He first received his [medical] skills from Zhang Bozu, who was from the same prefecture [as Zhongjing]. People at the time said the subtlety of his knowledge and skill surpassed his teacher. In the treatise he authored, his words The authorship of the preface of the Shanghan lun is complicated. Few scholars now accept the entire preface as the work of Zhang Ji. The portion I cite here, however, genreally accepted as authentic; see, Fu Yanling, Zhang Zhongjing yixue yuanliu (Beijing: Zhongguo Yiyao Keji Chubanshe, 2006), 158–159.
In Huangfu Mi, Zhenjiu jiayi jing jiaozhu, ed. Xu Guoqian and Zhang Canjia, Zhongyi guji zhengli congshu (Beijing: Renmin Weisheng Chubanshe, 1996), 16–17. All translations my own unless otherwise noted.
are concise yet profound, his methods simple yet thorough.”8 Later biographies of Zhang Ji based themselves on this discussion and add nothing significant to our knowledge of his life.
The Treatise on Cold Damage was eventually separated from the remainder of the Treatise on Cold Damage and Miscellaneous Diseases and circulated independently. The section of the text devoted to miscellaneous diseases survives only in an abbreviated form as Essentials of the Golden Coffer (Jingui yaolue 金匱要略, ca. 206). Zhang Ji’s authorship of the Essentials of the Golden Coffer, as it currently exists, is generally accepted, with the limitation that the text has undergone serious editing by unknown hands—as indicated in the title—and was further edited by the Song dynasty editorial committee.9 The authorship of the received Treatise is more complicated. The Song dynasty edition, from which almost all extant editions descend, is divided into ten fascicles and twenty-two chapters. Zhang Ji’s authorship of the fifth to the fourteenth chapters is almost universally accepted. The authorship of the first four chapters is disputed, and the last eight chapters are generally considered to be additions to the text made after the time of Zhang Ji.10 The chapters to follow in Part One set the stage for the larger argument I am making.
Chapter 1 presents a new interpretation of the history of cold damage studies and the place of the Treatise in it. A lack of information on the period between the Han and the Song has produced a number of erroneous viewpoints on the Treatise’s history. If we are to understand the transformation of its status during the Song and the role it played in the medical history of the In Zhang Ji, Zhongjing quanshu zhi Shanghan lun, Jingui yaolue fanglun, ed. Zhang Xinyong (Beijing: Zhongyi Guji Chubanshe, 2010), 307.
In this dissertationicular, the final three chapters of the Jingui yaolue are suspect. The Song editors extracted this text from a larger text called the Essentials of the Formulary of the Golden Coffer and Jade Case (Jingui yuhan yaolue fanglun 金匱玉函要略方論). The term “golden coffer (jingui 金匱)” was frequently used to refer to the works of Zhang Ji and the phrase “jade case (yuhan 玉函)” often indicated the works of Ge Hong (葛洪, 283-343), and these chapters contain material similar to that found in Ge Hong’s known works. This has led many scholars to suspect the final three chapters derive from a Ge Hong-inspired tradition, and not from Zhang Ji or his students.
Gu Wujun, Shanghan lun qiushi gouxuan (Beijing: Xueyuan Chubanshe, 2006), 351–352.
period, we must first understand clearly what actually happened. Chapter 2 contextualizes the present study by summarizing previous research on the social, epidemiological, and medical changes that occurred during the Song Dynasty. Finally, Chapter 3 examines the state of medicine in the Northern Song (960-1127), paying particular attention to the motivations that led both the Song government and many private gentlemen to take an interest in or even take up the practice of medicine.
The Song dynasty has long been recognized as a watershed in Chinese medical history.
The upsurge in writing on cold damage—a category of potentially epidemic febrile illnesses11— is one of the more significant changes scholars have recognized in the medical literature of the Song.12 At the center of this upsurge was the Han dynasty (206 BCE-220 CE) Treatise on Cold Damage composed by Zhang Ji around the year 206. Following the Song government’s editing, printing, and distribution of this text in 1065, the production of medical texts devoted to cold damage studies (shanghanxue 傷寒學)13 increased dramatically. In the 214 years between 1065 and the end of the Song dynasty, 75 texts are known to have been composed on the Discourse, compared to a mere eleven in the 105 years from the beginning of the dynasty to 1065.14 Studies of Song medicine have described this phenomenon as a “revival of cold damage disorders” after an extended period of neglect or a “renaissance” of the Treatise on Cold Damage.15 This chapter draws on pre-Song medical texts and on Song medical texts produced earlier than 1065 to challenge this characterization of cold damage studies in the Song dynasty and before. I argue that the study of cold damage illnesses and their treatment was a flourishing part of learned medicine in China prior to the Song, and the Treatise on Cold Damage was always a valued part This characterization of cold damage illnesses is open to debate, this dissertationicularly from the point of view of many Ming dynasty (1368-1644) and later authors, but this characterization accurately portrays what authors from the Song to the Yuan saw as the most basic and important features of cold damage.
E.g., Miyashita Saburō, “Sō Gen no iryō”; Ishida Hidemi, Chūgoku Igaku Shisōshi; Unschuld, Medicine in China;
I take this term from Li Maoru and Ren Yingqiu both of whom argued for the existence of a broad pre-Song cold damage studies tradition on the basis of material in the works of Sun Simiao 孫思邈 (d. 682) and Wang Tao 王燾 (692-756), see, Yiji Xulu Ji (Beijing: Zhongyi Guji Chubanshe, 2009), 82; Ren Yingqiu, “Shilun gudai zhi ‘shanghanxue’ de gaikuang ji qi liupai de xingcheng,” in Dangdai mingyi lun Zhongjing shanghan, ed. Liu Shi’en and Mao Shaofang (Beijing: Xueyuan Chubanshe, 2008), 127–131.