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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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Under the Yuan, a temporary halt to the civil service examinations combined with systematic government discrimination against southern Chinese—by this time long-established as the largest and most intellectually prolific segment of the elite—caused substantial changes in the careers elite men deemed acceptable for themselves.

Within literati-physician medicine, a new form of social organization emerged: the current. As discussed in the introduction of this chapter, currents were self-selected groups of physicians who shared allegiance to a particular founding figure and a set of texts, ideas, and practices. Currents stretched out across time and were usually conceived of as lineages of teachers and students, but belonging to a current did not mean you had studied with any of its members. We have no means of knowing with certainty, but it is likely that most of a current’s members learned its teachings through books alone.

Under the Jin and Yuan dynasties we can recognize two major currents of medical thought and practice: the Yishui current—which traced its teachings to Zhang Yuansu (張元素, fl. late 12th-early 13th c.)—and the Hejian current 河間派—centered on the ideas of Liu Wansu (劉完素, ca. 1120-1200). No currents are identifiable during the Southern Song; however, a cluster of medical authors surrounding the famous physician Chen Yan (陳言, ca. 1131-1189) was active in the Wenzhou region and enjoyed substantial popularity.292 I refer to this group as the Yongjia cluster. Finally, during the Yuan dynasty, the Danxi current 丹溪派 formed around the teachings of Zhu Zhenheng (朱震亨, 1281-1358) and went on to dominate most of literati medicine in the early Ming Dynasty.

The soft borders and lack of organization within currents have led some scholars to dispute their historicity,293 but a number of contemporary sources from this period indicate that these groups, and even rivalries between them, were very real. Some of our best information on this is found in the writings of Wang Haogu (王好古, ca. 1200-1265), a famous physician and

member of the Yishui current:

I describe these groups and their ideas in greater detail in Chapter 5. Liu Shijue describes the Yongjia cluster as the Yongjia current, but since there is no evidence of a sense of membership and no later texts claiming to present this groups ideas, I prefer to describe them as a cluster, see Liu Shijue, Yongjia Yipai Yanjiu (Beijing: Zhongyi Guji Chubanshe, 2000).

E.g., Fabien Simonis, “Mad Acts, Mad Speech, and Mad People in Late Imperial Chinese Law and Medicine” (PhD Dissertation, Princeton University, 2010), 131–132. Simonis is correct, however, to refute the notion that these currents were “schools” of medical thought or practice. Their structure was far too loose to merit that name.

Nowadays among those who discuss medicine, there are those who advocate [the Heijian current of] Mr. Liu, from Hejian and those who advocate [the Yishui current of] Mr.

Zhang from Yizhou.294 今世之論醫,有主河間劉氏,有主易州張氏者。 Wang’s implication that the medical world of his time was divided into two camps is strengthened by the evidence that famous physicians could draw large numbers of students to themselves. As one observer noted of Chen Yan, “… more than seventy young men followed the gentleman in his travels … 鄉之從先生游者七十餘子.”295 Further evidence of the contemporary influence of these currents is found in the sheer number of books that claim to propound their teachings and—even more tellingly—the number of their contemporaries who referred to them in their medical writings. While these currents were never rigid, fixed, or institutionalized, they were powerful forces shaping the medical practice of their time.

It is not entirely clear why currents began developing at this point in time, but a key factor seems to have been the increased competition among literati physicians. As the number of literati physicians increased, they were increasingly in competition with one another rather than with common physicians. The ability to claim affiliation with a famous physician was potentially very lucrative, a fact that may explain the large gifts of cash that came to be customary for the privilege of studying with a well-known physician.296 The preface to one of Zhang Yuansu’s books tells the story of how Liu Wansu, founder of the rival Hejian current, fell ill and attempted to treat himself using his own signature approach—cooling and draining medicinals. Since his condition worsened, Zhang Yuansu was called in to diagnose him. Zhang examined a reluctant Liu and explained that it was Liu’s own methods that were at the root of his illness. After These Things are Difficult to Know (Cishi nanzhi 此事難知, 1264), juan xia, Xu xiansheng lun guanzhong liangkuan fuzheng, in Wang Haogu, Wang Haogu yixue quanshu, ed. Sheng Zengxiu (Beijing: Zhongguo Zhongyiyao Chubanshe, 2004), 159.

Lu Tan (盧檀, fl. late12th-early 13th c.), Correcting Errors in Simple and Easy Formulae (Yijian fang jiumiu 易 簡方糾謬, date unclear), juan 1, yangwei tang, in Liu Shijue, Yongjia Yipai Yanjiu, 242.

Leung, “Medical Learning from the Song to the Ming,” 387–389.

receiving the treatment Zhang was famous for—warming and supplementing medicinals—Liu recovered. While it is unlikely that Zhang ever actually treated Liu, the story—which was written in the 13th century—reveals that even shortly after their lifetimes, the currents of Zhang and Liu were perceived as competitors with differing styles of practice.297 Another factor that may have increased the appeal of currents was the appearance, within Learning of the Way Confucianism, of master-disciple relationships and lineages. Zhu Zhenheng was a fourth generation disciple of Zhu Xi (朱熹, 1030-1100), the famous systematizer of the Learning of the Way. The title of his most famous text, Insightful Views Produced by Investigating Things and Extending Knowledge (Gezhi yulun 格致餘論, 1357), reveals the influence of the Learning of the Way by its invocation of the important technical term, “investigating things and extending knowledge (gezhi 格致).” Once the Yuan court made Zhu Xi’s version of the Learning of the Way the curriculum for the civil service examinations, the prestige of their precedent must have become great indeed.298 Regardless of what led to their emergence, one characteristic shared by all these currents was the high esteem in which they held the Treatise on Cold Damage. Liu Wansu wrote at least one book on the Treatise, and several others claimed to present his teachings on it (see Table 5-1 in Chapter 5). Li Gao (李杲, 1182-1251), Zhang Yuansu’s most famous student and the true center of the Yishui current, was famous for his knowledge of cold damage and composed a text Awakening to the Origins of Medicine (Yixue qiyuan 醫學啟源, date unclear), preface, in Zhang Yuansu, Yixue qiyuan, ed. Ren Yingqiu (Beijing: Renmin Weisheng Chubanshe, 1978), 1–2.

Charlotte Furth, “The Physician as Philosopher of the Way: Zhu Zhenheng (1282-1358),” Harvard Journal of Asiatic Studies 66, no. 2 (December 2006): 423–59, doi:10.2307/25066820; Leung, “Medical Learning from the Song to the Ming,” 387–389; Simonis, “Mad Acts, Mad Speech, and Mad People in Late Imperial Chinese Law and Medicine,” 136–201; Wu, “A Medical Line of Many Masters.” on it that is no longer extant. 299 Although neither Chen Yan nor Zhu Zhenheng authored texts on the Treatise, they frequently cited its formulae and drew on its doctrines in their own work.300 Thus, while their interpretations and emphases differed, all of these currents placed great importance on the Treatise on Cold Damage.

In some ways, the Treatise retained the argumentative value it held for Northern Song physicians. Even if you could not accuse your opponents of ignorance of the Treatise, you could still accuse them of failing to understand it correctly. All of the cold damage texts attributed to Liu Wansu and the two cold damage texts written by Wang Haogu, a student of both Zhang Yuansu and Li Gao, present distinctive interpretations of the Treatise’s ideas and treatments. As we saw in the story about Zhang treating Liu, these differing interpretations could be turned to polemical advantage. Wang’s case histories illustrate this well (see Box 4-3).

Whereas Xu Shuwei sought to demonstrate his opponents’ outright ignorance of the Treatise, Wang merely accuses them of failing to understand it adequately. Both White Tiger Decoction and Bupleurum Decoction are formulae from the Treatise, and their use in this case is understandable—they both treat internal heat, the most common cause of macular rashes and spontaneous external bleeding. Wang, however, argues that the other doctors have made an overly superficial diagnosis. To Wang, the patient’s pulse and the lack of palpable heat indicate that this illness was not caused by internal heat. On asking about the origin of the illness, he confirms his suspicions: the patient contracted cold damage and then drank a large quantity of cold fluid, damaging his internal yang qi and causing an interior cold pattern.

Yuan History (Yuanshi 元史, 1370), fangji, Li Gao liezhuan, in He Shixi, ed., Zhongguo lidai yijia zhuanlu, vol.

1 (Beijing: Renmin Weisheng Chubanshe, 1991), 301; Wang Haogu, These Things are Difficult to Know (Cishi nanzhi 此事難知, 1264), preface, in Wang Haogu, Wang Haogu yixue quanshu, 115.

I discuss this issue at length in Chapter 5.

Box 4-3: One of Wang Haogu’s Case RecordsExternal Yang and Internal Yin

The general Wanyan’s grandson, also a general, had been ill with cold damage for six or seven days. He suffered from intermittent chills and fever. Above his wrist there were three to five macular spots, and a little bleeding from his nose. The physicians used medicinals like White Tiger Decoction and Bupleurum [Decoction] to treat him and he didn’t recover. At the time I diagnosed him, the pulse on both hands was deep and rough. On palpation, his chest, diaphragm, and four limbs certainly had no great heat. This was internal cold. On asking the cause [of the illness, I learned] that in the summer heat he had slept [outside] by the corner of one of the halls.

First he had cold damage, then he was extremely thirsty, and he drank a large bowl of ice-cold koumiss [fermented mare’s milk]. His external contraction [of evil environmental qi] was mild, but his internal damage was severe. The external [illness transformed] according to the internal illness and both were yin [patterns]. Therefore, at first there were macules and spontaneous external bleeding, but afterwards he manifested [signs of] internal yin. As for the intermittent chills and fever, spleen [illnesses] also have them, it is not a case of lesser yang alternating chills and fever. I gave him Regulate the Center Decoction (Tiaozhong tang 調中湯), and he recovered after several doses.301 Wang’s cases reveal a change in the role the Treatise played in justifying the social position and clinical decisions of literati physicians. We do not know who his opponents were, but their knowledge of the Treatise was taken as a given. By Wang’s time, literati-physician medicine had achieved a certain measure of dominance, and knowledge of its canonical texts was widely expected of good physicians. The Treatise, however, remained socially useful both because it underpinned physicians’ identity as literati physicians and because the various currents each claimed to possess a more accurate understanding of its methods. The Treatise was now both a tool of clinical argument and the arena within which many such arguments took place.

Brief Precedents on Yin Patterns (Yinzheng lueli, 1243), Haicang zhiyan lu, waiyang neiyin, in Wang Haogu, Wang Haogu yixue quanshu, 108.

CONCLUSION: The Social Practice of Literati-Physician Medicine Like any human activity, medical practice occurs within a social space and is constructed as a practice by social processes. A full understanding of changes in medical thought and practice therefore demands an understanding of its social context, justifications, purposes, and uses.

In addressing the social aspect of the Treatise’s usefulness, I am not claiming that literati physicians’ decision to promote the Treatise was primarily based upon social grounds as opposed to medical ones. Literati physicians genuinely believed that the new medicine they were promoting would produce better medical results than other approaches to medicine. Their medical reasons for promoting the Treatise are the subject of the final chapter of this dissertation.

I do claim, however, for the reasons discussed in this and the previous chapter, that the social element of such interventions in medical knowledge and practice was, and remains, irreducible.

In order to accomplish their medical aims, literati medical reformers—for they saw themselves as such—had to establish not only new medical doctrines and therapeutic techniques and not only a new vision of the ideal medical knower, but also a living community of such knowers and the means of convincing others to trust them. The Treatise’s usefulness in arguing for this new vision and new community was an inherent element of its overall appeal to literati physicians without which we cannot hope to understand literati physicians’ fondness for the Treatise on Cold Damage.

–  –  –

Once an illness is generated, it has a thousand changes and ten thousand transformations.

No one can exhaustively understand them. Therefore, in the world, those who are good at medicine do not worry about the difficulty of treating an illness; they worry about the difficulty of knowing an illness.

病一生,千變萬化,莫能窮究。故世之善醫者,不患治病之難,患識病之難。 —Shi Kan, Shi Zaizhi’s Formulae (Shi Zaizhi fang 史在之方, early 12th c.)302 When reading Zhongjing’s books, you should seek [to understand] his intent in establishing a method. If you obtain [an understanding of] his intent in establishing a method, then you will understand that his books are adequate to be taken as the method for the myriad generations, and later people can neither add to it nor go beyond it.

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