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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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They claimed descent from an illustrious Tang dynasty clan and were literate; however, the fact that Qian’s uncle, who raised him, was a practicing physician suggests that Qian’s family may not have been part of the literati elite. The failure of his biographers to mention Qian or any of his relatives sitting for the civil service examination provides further evidence that Qian’s family probably belonged to the lumpenliterati. Whether they were, as they clearly wished to be perceived, an old elite family on hard times or one of the many non-elite families that were rising into the elite during the Song, is unclear. Qian Yi himself would eventually rise to the status of physician to the imperial household, a high position, but outside of the prestigious hierarchy of civil officials.

Straightforward Guidance on the Essential Patterns of Children (Xiao’er yaozheng zhijue 小兒要證直訣), from which the case below is taken, is the only one of Qian’s four known texts that is now extant. It was published posthumously in 1119 by an admirer of Qian’s medical work, Yan Xiaozhong (閻孝忠, fl. early 12th c.).282 The text is composed of a combination of materials Yan obtained from Qian himself and others which he obtained from families whose members, like Yan himself, had been Qian’s patients. Even this text was eventually lost and reconstructed by Qing dynasty scholars on the basis of quotations preserved in other sources. It is composed of three sections: the first explains Qian’s theories about diagnosis and treatment of children, the Pattern 61, in Xu Shuwei, Xu Shuwei Shanghan Lun Zhu Sanzhong, 189.

All aspects of Yan’s life are unclear. Even his name is often reported in later sources as Yan Jizhong 閻季忠.

Some scholars identify him with the author of a postface to Xu Shuwei’s Efficacious Formulae of Universal Aid who also was also named Xiaozhong, but that postface is dated 1185 and in the only edition which provides a surname, attributed to a Zhang Xiaozhong 張孝忠, rendering it unlikely that the two individuals are identical, see Okanishi Tameto, Sō izen iseki kō, 722.

second is a collection of 23 cases recording their treatment, and the final section is a list of the medicinal formulae mentioned in the first section. The section containing the case records is titled, “Records of 23 Patterns of Illnesses that were Treated (Ji chang suozhi bing ershisan zheng 記嘗所治病二十三證).” The individual case records are not titled, but each begins with an identification of the patient in a fairly standard format. As seen in the cases translated below, Qian stresses the identity and social status of the child patient’s representative, usually a father or grandfather. The cases themselves vary a great deal in structure and content.

Box 4-1: Two of Qian Yi’s Case Records

From Straightforward Guidance on the Essential Patterns in Children:

Li, the fiscal administrator of Capital-East, had an eight year-old grandson who was suffering from cough, fullness of the chest, and shortness of breath. A physician said that there was heat in the lung channel and used Bamboo Leaf Decoction and Bovine Bezoar Paste. Qian [Yi] said, “What is this treatment?” The physician said, “Abating heat and abating drool.” Qian [Yi] said, “How is it caused by heat?” [The physician] said, “The lung channel is hot and generates coughing. If prolonged coughing is not eliminated, it generates drool.” Qian [Yi] said, “[This is a case] caused by [the patient’s] preexisting vacuity and [the invasion of] wind-cold.

What heat is there? If you took it to be lung heat, why did you not treat his lungs but on the contrary regulated his heart? For Bamboo Leaf Decoction and Bovine Bezoar Paste are medicinals for treating the heart!” The physician looked abashed. Qian [Yi] treated [the patient] and he recovered.

*** The grandson of Mr. Zhang from the Eastern Capital, 9 years old, suffered from lung heat.

Other physicians had used rhinoceros horn, pearl, borneol,283 musk, and raw bovine bezoar. After one month, he had not recovered. His pattern [included] coughing and wheezing, oppression and derangement,284 constant drinking of water, and a complete inability to eat. Mr. Qian used Quisqualis Pill (Shijunzi wan 使君子湯) and Boost the Yellow Decoction (Yihuang tang 益黃 湯). Zhang said, “There is already heat. Why are you using warm medicinals? Other physicians used cool medicinals to attack [the illness]. After one month, there is still no result.” Qian [Yi] said, “[If one takes] cool medicinals for a long time, then there will be cold and an inability to eat.

When a child is vacuous and cannot eat, one should supplement the spleen. Afterwards, when eating and drinking are normal, then one drains the lung channel, and [the patient] will certainly recover from the illness.” [The grandson] took medicinals that supplement the spleen for two days and then desired to eat and drink. Qian [Yi] used Drain the White Decoction (Xiebai tang 瀉白湯) to drain his lungs, and afterwards he recovered. Zhang said, “Why did he not become vacuous [when you used cold medicinals to drain his lungs]?” Qian [Yi] said, “I first replenished his spleen and afterwards drained his lungs; therefore, he did not become vacuous.”285 The text abbreviates the name of these medicinals, in this case it says only “dragon (long 龍),” which could indicate a number medicinals whose names include this character. I have chosen the translation “borneol (longnao 龍腦),” because borneol, like all of the other medicinals in this list, was held to act primarily on the heart and is found in several formulae included in this text.





The precise meaning of this symptom is unclear, but, judging from the cooling medicinals used by previous physicians, it may have indicated a combination of a sense of tightness in the chest and deranged behavior.

Xiao’er yaozheng zhijue, juan zhong, in Qian Yi and Liu Fang, Qian Yi, Liu Fang yixue quanshu, 25.

Box 4-2: Two of Xu Shuwei’s Case RecordsFrom Ninety Discourses on Cold Damage:

14. An Urgently Purging Yang-brightness Pattern A strong boy in the village contracted cold damage. His body was hot and his eyes hurt.

His nose was dry and he could not sleep. He was constipated, and all positions of his pulse were large. He had already [been ill] for a number of days. The previous evening he began to sweat profusely. I said, “Quickly use Major Bupleurum Decoction (Da chaihu tang 大柴胡湯) to purge him.” The assembled doctors were shocked, saying, “In a Yang-brightness disease with spontaneous sweating, his body fluids are already exhausted. Why would you use Major Bupleurum Decoction?” 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.

Discussion: In discussing Yang-brightness [disease] Zhongjing [in the Treatise on Cold Damage] says, “In Yang-brightness disease, in the case of those with profuse sweating, urgently purge them.” [Yet] people frequently say that when there is already spontaneous sweating, if you further purge [the patient], won’t this make both the exterior and the interior vacuous? In discussing Lesser Yin [disease, Zhongjing] says, “In Lesser Yin illness that is one to two days old, in those with [signs and symptoms of] dryness, urgently purge them.” [Yet] people frequently say that if [an illness] develops in the yin, it has only been a few days, and you only see dryness, then if you further purge [the patient], how can their [pathological] yin qi not become even stronger? The common people seldom read. I regard [this situation] otherwise.

Zhongjing calling this urgently purging [a patient], is similar to [the situations in which he says one] should urgently rescue the exterior or should urgently rescue the interior. He terms all of these emergencies. There are three places [in the Treatise on Cold Damage] where [Zhongjing calls for] urgently purging [the patient]. From these, one can realize that when there is profuse sweating but it has not reached the point of drying out the body fluids, it is expedient to quickly purge [the patient]. This will avoid the necessity of using a honey suppository. For when one uses a honey suppository, it is already a case of waiting too late to purge. It is simply that one has no other alternative. If you understand this clearly in your heart, what danger is there?

***

23. A Greater Yin Pattern Cao Sheng initially suffered from cold damage. After six or seven days, his abdomen was full and he was vomiting. He couldn’t get food down. He had a fever, and his hands and feet were hot. His abdomen ached, and he was nauseated. The physicians called it excessive yang.

[His family] still had misgivings about his hands and feet being hot, fearing that heat had amassed in the stomach causing vomiting and nausea, or, seeing the vomiting and diarrhea, took it to be sudden turmoil [disease]. [They] asked me to diagnose [him]. His pulse was fine and sunken. I evaluated him saying, “This is a greater yin pattern. In greater yin disease, there is abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and occasional spontaneous pain of the abdomen.” I used Regulate the Center Pill (Tiaozhong wan 調中丸) to stop [the illness]. I used five or six pills the size of an egg yolk per day. Then I used Five Accumulations Powder. After several days [Cao] recovered.

Discussion: I see common physicians diagnosing cold damage and only labeling them yin patterns and yang patterns. Zhongjing has three yin and three yang [diseases]. Even in one pattern, there are also leanings toward exuberance or insufficiency. What is necessary is to clearly differentiate in which channel [the illness is present]. The formula must correspond to the signs, and there are standards for the use of medicinals. Moreover, in the case of greater yin, lesser yin, and reverting yin, they have [situations which demand] either supplementing or draining. How can [they] stop at naming [the disease] a yin pattern!286 Medical Learning and Technologies of Persuasion The most striking similarity in Qian and Xu’s case records is the attention given to acts of persuasion. In the first case, Qian Yi is presented as debating with and ultimately shaming the physician who is his opponent. In the second case, Qian must persuade a doubting grandfather that his treatment, which differs from that of previous doctors, is correct. In the third case, Xu Shuwei is positively belligerent in the dealing with the other physicians present, and states forthrightly that he “argued forcefully,” to win the argument over how the patient should be treated. In the final case, Xu is summoned because the family doubts the diagnoses of other physicians, and he proceeds to convince them to follow his advice. I refer to these debates as “clinical arguments.” As the second and fourth cases demonstrate, the families of the patients were the final arbiters of what treatment would be used, and clinical arguments among the physicians present were ultimately aimed at gaining the family’s agreement.

Xu Shuwei, Xu Shuwei Shanghan Lun Zhu Sanzhong, 158–159, 164–165.

As any modern clinician can tell us, convincing a patient and a family to cooperate with a proposed treatment remains an extraordinarily important part of clinical practice in the 21st century. In 11th to 12th century China, however, winning the support of patients and their families was both more difficult and more important. The healing marketplace of pre-modern China was not only far more diverse than that of most modern societies, it was also unregulated. No one group of healers could dominate the marketplace by legal fiat.287 High-status physicians such as Qian Yi and Xu Shuwei had to compete on a more or less level playing field with ritual healers of all kinds, popular medical customs, devotional forms of healing, and, of course, common physicians. All of these methods of healing could claim legitimacy and were widely accepted as efficacious. The arts of persuasion were therefore essential to clinical success.

Doubtless, all of these healers had methods to secure patients’ trust. When these methods were improvised on the spot to deal with specific situations, I call them tactics. When these tactics become more routinized and established, I refer to them as technologies.288 The division between tactics and technologies is not rigid, and they are best thought of as two poles of a continuum. In the case records presented here, we see Qian Yi and Xu Shuwei drawing on a variety of tactics and technologies. The differences in the tactics and technologies they use reflect the changes that had occurred in the highest echelons of text-based medicine between Qian’s and Xu’s generations.

Case Records and the Northern Song Healing Marketplace Before examining the details of the case records, a word should be said about the publication of such records, in general, and the presentation of the clinical argument, in See Cullen 1993 for an excellent discussion of this issue.

I am drawing on a distinction developed in Biagioli 1993 and 2006.

particular, as literary devices. The authoring and publication of case records is itself a technology of persuasion, but one aimed at a reader rather than a patient and his family. If the tactics and technologies which Qian and Xu are shown using serve the purpose of winning the clinical argument, what purpose does this literary technology of persuasion—the publication of case records—serve?



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