«Stephen Boyanton Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Graduate School of Arts and ...»
educated man with a deep knowledge of the texts of newly formed medical canon. Both Xu and Cheng are known to have practiced medicine. Cheng Wuji practiced medicine as an occupation.
It is never explicitly stated that Xu Shuwei accepted payment for his medical services, but he is praised as a literatus who practices medicine, and may well have done so, particularly before his exam success.
Xu Shuwei Xu Shuwei was the most prolific of all writers on cold damage in the Song. Nine texts are attributed to him, of which at least six are devoted to cold damage. Of the five texts that are still extant, three of them are devoted to cold damage (see Table 4-2). Taken together, these three texts are not among the most specialized and innovative medical texts from this period. More than any other Northern Song writer, Xu’s corpus shows clearly his desire to educate people actually practicing medicine.
Songs on One Hundred Patterns of Cold Damage (Shanghan baizheng ge 傷寒百證歌, mid-12th c.) is a collection of mnemonic verses describing commonly seen patterns in cold damage illness and their treatment. The verses are rhymed to aid memorization, and commentary, scattered through the verses, clarifies points of potential confusion. While the text provides an admirable overview of the Treatise on Cold Damage, it is neither structured for easy reference nor does it attempt to simplify the complexity of the Treatise. The rhymed verses are clearly intended for the study of medical practice, not bedside reference, and the commentary not only explains difficult points but also embeds larger and more complex meanings in the pithy text of the verses. These larger meanings include the original lines of the Treatise which were abridged in the verses, quotes from the Inner Classic, and references to how other physicians—most frequently Zhu Gong—treated a particular pattern.274
E.g., juan 1, zheng 4 and 5, and juan 2, zheng 27, in Xu Shuwei, Xu Shuwei Shanghan Lun Zhu Sanzhong, 19–21, 36.
If One Hundred Patterns was Xu Shuwei’s most explicitly pedagogical work, Expounding the Subtleties of Cold Damage (Shanghan fawei lun 傷寒發微論, mid-12th c.) was his most exegetical. The two sections of this short text are composed of brief explanations of particular problems in cold damage studies. Among the problems considered are which variety of herbaceous peony should be used in Cinnamon Twig Decoction, how to reconcile conflicting statements about sweating in lesser yin disease and Xu’s objection to one of the comments on the Treatise by the Bureau’s editors.275 The text makes no effort to organize these topics in a logical order or to present a comprehensive overview of cold damage. Only a reader already familiar with the Treatise on Cold Damage could follow all of the arguments or even understand why the arguments were necessary in the first place. Xu clearly felt that there was not only a need for explication of the Treatise’s more subtle points; but also an audience possessing the necessary interest and knowledge to follow it.
Xu’s most innovative text was Ninety Discourses on Cold Damage (Shanghan jiushi lun 傷寒九十論, mid-12th c.). Comprising ninety of Xu’s case records with discussion, the text is the earliest Chinese example of a book devoted exclusively to medical case records. The textual history of this book is somewhat obscure. The earliest reference to this title is found in a bibliography dating to 1820, leading some scholars to conclude that it was a lineage text passed down among Xu’s descendants and not intended for public consumption.276 However, several points argue against this interpretation. First, in 1238, Chen Zhensun (陳振孫, ca. 1183-1262) recorded the existence of a book by Xu Shuwei titled Eighty-One Essays on Treatment Methods Juan shang, lun Guizhi tang yong chishao baishaoyao butong, juan xia, lun yin bude you han & lun Lin Yi yi Baihu tang zheng you chahu, in ibid., 121–122, 130–131.
Charlotte Furth, “Producing Medical Knowledge through Cases: History, Evidence, and Action,” in Thinking With Cases: Specialist Knowledge in Chinese Cultural History, ed. Judith T. Zeitlin, Ping-chen Hsiung, and Charlotte Furth, vol. 1 (University of Hawaii Press, 2007), 130.
for Cold Damage (Shanghan zhifa bashiyi pian 傷寒治法八十一篇), but noted that he had not seen it.277 Although the titles are not identical, the similarity of the content they describe is striking. It is possible that the Eighty-One Essays and Ninety Discourses are the same text. The discrepancy in the number of sections mentioned in the title may reflect later additions to the text or an error on the part of Chen Zhensun—who lacked a copy of the text to verify his information.
Second, many of the cases included in the Ninety Discourses also appear in one of Xu’s other books, Efficacious Formulae for Universal Aid (Puji benshifang 普濟本事方). The printing and circulation of this book is well-attested, making it unlikely that its contents could be seen as a private lineage document. Finally, and most convincingly, the Ninety Discourses is a clearly polemical document. Xu is arguing for the literati-physician approach to medicine and—at times with great vitriol—against common physicians. Such a strong polemical stance suggests the text was intended to persuade a broad audience, not merely members of Xu’s own family.
Ninety Discourses on Cold Damage comprises ninety case records, each designed to illustrate a particular pattern of cold damage illness. Each is headed by a title indicating the pattern of cold damage being described and followed by a “discussion” (lun 論) explaining the therapeutic choices made, justifying them with quotes from the Treatise and other important medical texts, or using the case to further Xu’s attack on common physicians. The cases are in no particular order and are by no means a complete sample of the various patterns seen in cold damage. The polemical aspect of the text is clear and would have been easily understood by any
elite reader in Xu’s time, but the arguments recorded in the discussions are not merely polemical:
there are also clinical points that would have been both more difficult for non-specialist readers Zhizhai’s Record of Books with Explication (Zhizhai shulu jieti 直齋書錄解題, 1238), quoted in Okanishi Tameto, Sō izen iseki kō, 394–396.
to follow and less useful to them in treating family illnesses.278 Moreover, the text makes no attempt to introduce readers to its topic. It begins, so to speak, in media res and assumes its readers understand the technical language and concepts derived from the Treatise on Cold Damage. Once again, Xu is not writing a handbook for laypeople to consult when ill. He is writing a pedagogical text for people who practice medicine seriously.
Taken as a whole, while Xu’s writings on cold damage continue to reflect the reformist zeal of authors like Zhu Gong and the desire to extirpate common physicians seen among literati medical authors broadly, they also display a desire to educate people who are actively treating patients and have already taken the time to learn the basics of the Treatise on Cold Damage. If authors of the second generation wrote introductory handbooks for laypeople unfamiliar with the Treatise, Xu was writing advanced textbooks for serious students of cold damage and its treatment.
Cheng Wuji Cheng Wuji is the most famous of all the Song cold damage authors. Although his literary output was far smaller than Xu Shuwei’s, his influence was far greater. Cheng wrote two texts on the Treatise: the Annotated Treatise on Cold Damage and Elucidating the Principles of Cold Damage (Shanghan mingli lun 傷寒明理論, 1142). The final section of the latter book, the Treatise on Medicinal Formulae (Yaofang lun 藥方論), is often treated as a separate text.
The Annotated Treatise on Cold Damage was not merely the first full commentary on the Treatise; it was also the first commentary written on a medical text outside of the Inner Classic E.g., Xu’s comments on the tretment of warm malaria (wennue 溫瘧) that are couched in terms of the medical principles involved and not in temrs of specific treatments, see pattern 65, in Xu Shuwei, Xu Shuwei Shanghan Lun Zhu Sanzhong, 191–192.
corpus. In it Cheng draws on a combination of other texts and general medical doctrine to explain the Treatise on Cold Damage line by line. The most frequent texts cited belong to the Inner Classic corpus, but other texts are also invoked, particularly those published by the Bureau for Editing Medical Texts. Cheng’s commentaries are detailed and assume a strong command of medical ideas and literature. The text is not structured to provide easy reference; neither does it include any direct medical advice. Although the Annotated Treatise was no doubt useful for firsttime students of the Treatise on Cold Damage—it was the most commonly used edition of the Treatise from the late Song up to the republication of the imperial edition by Zhao Kaimei in 1599—it was clearly intended for serious students.
Elucidating the Principles of Cold Damage is a far smaller text. It is divided into two distinct sections: the Treatise on Elucidating Principles (Mingli lun 明理論) and the Treatise on Medicinal Formulae. The Treatise on Elucidating Principles examines fifty common signs and symptoms of cold damage as described in the Treatise. For each one it gives a definition, differentiation of various ways the sign may manifest, an explanation of its etiology, and advice on treatment. While this information could be used as a home medical reference, Cheng went into far more detail than authors of the previous generation, particularly in his explanations of how the various signs and symptoms arise—information of little relevance for non-specialists.
The Treatise on Medicinal Formulae follows a similar pattern, but instead of discussing signs and symptoms explains the reasoning behind the construction of twenty formulae found in the Treatise on Cold Damage. For each formula, Cheng discussed the ingredients and how the combination of their flavors, warmth or coolness, and actions contributes to the overall function of the formula. In his preface, Cheng stated that his purpose in explaining these formulae was to
make clear the method composing formulae:
From the 112 formulae [included in the Treatise on Cold Damage], I have chosen 20 formulae that are commonly used by doctors, in order to explain them in terms of the method of constructing formulae. May it manifest in a small way the intention of the ancients!
一百一十二方之內，擇其醫門常用者方二十首，因以方制之法明之，庶幾少發古人之 用心焉。 The explanation of these twenty formulae was not intended as a handbook for home remedies, but rather as an example of how to understand Zhang Ji’s formulae. Like Xu Shuwei, Cheng was not writing for laypeople, he was writing for would-be experts.
Northern Song Medical Authors and the Treatise on Cold Damage The progression seen in the three generations reveals changing factors in their priorities and social context. In part it reflects the growing awareness of the Treatise among literati who
were not particularly interested in medicine. The first generation focused on getting the word out:
“Here’s a really useful medical text.” While authors of the second generation could assume their readers were aware of the Treatise, they still felt the need to explain even the most basic aspects of the Treatise’s ideas. By the third generation, however, Xu Shuwei and Cheng Wuji no longer felt this need, and wrote for an audience that was already familiar with the Treatise, its ideas, and even its medicinal formulae. The changing nature of their audience affected not only their writing, but also their approach to patients. In the following section, I compare case histories from the second and third generations to show how widespread awareness of the medical canon in general, and of the Treatise on Cold Damage in particular, changed clinical interactions to the benefit of literati physicians.
SECTION TWO: The Treatise and Clinical Argument in the Northern Song Medical case records of various sorts are found scattered in other genres of writing from the earliest times in China. The records on oracle bones of the ritual treatments of various maladies during the Shang dynasty (ca. 1600-1046) are the earliest records in China of the treatment of illness. The case records of Chunyu Yi (淳于意 b. 216 or 206 BCE), preserved in Records of the Historian (Shiji 史記) are another, more detailed, early example. These early examples of healthcare records, however, were preserved for purposes largely unrelated to their medical content. When case records did appear in early medical texts, such as the works of Sun Simiao, they were small in number and scattered throughout the text like anecdotes used to illustrate a particular point the author made.
As a genre, texts devoted completely or largely to medical case records would begin to flourish in the Ming dynasty and would come to be known as, “medical cases (yi’an 醫案)”.279 A lesser known forerunner of the Ming medical cases—which were not, however, called yi’an—
was developed by Song medical authors, exemplified by the two whose work is presented here:
Qian Yi and Xu Shuwei Xu’s biography and writings were discussed above. The cases below are taken from the text Ninety Discourses on Cold Damage. A variant of the first case also appears in Xu’s formulary, Efficacious Formulae for Universal Aid.280 The cases in Ninety Discourses share a similar structure. Following the title, each case begins with a description of the patient, but the level of detail varies from highly specific—name and government position—to extremely vague—“a person from my neighborhood 鄉人.” This is followed by a narrative describing Xu’s involvement in the case and its outcome. The case narratives vary greatly in length and detail, Furth, “Producing Medical Knowledge through Cases: History, Evidence, and Action,” 225.
Puji benshi fang, juan 8, Da chaihu tang, in Xu Shuwei, Xu Shuwei yixue quanshu, 143.
but frequently include a high level of social detail not strictly relevant to the medical problem being described—such as the patient’s family secretly bringing Xu in for a second opinion.281 The background and status of Qian Yi’s family are more difficult to reconstruct than Xu’s.