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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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讀仲景之書,當求其所以立法之意。苟得其所以立法之意,則知其書足以為萬世 法,而後人莫能加莫能外矣。 —Wang Lü (王履, fl. 1332-ca. 1391), Collection on Returning to the Medical Classics (Yijing suhui ji 醫經溯洄集, late 14th c.)303 In chapter 3, I demonstrated that Northern Song literati medical authors were deeply worried by the complexity of illness and treatment. This concern did not abate during subsequent dynasties, nor has it disappeared in modern times. From the Northern Song to the end of the imperial period, the irreducible variability of illness remained a central concern of literati physicians. Since 1911, physicians of what is now known as “Chinese medicine (zhongyi 中醫) have continued to see it as a core problem in the practice of medicine. Although the understanding of this problem and the specific solutions offered have varied over time, the essential problematic has remained unchanged. Given this commitment to a hydra-headed view of illness, Wang Lü’s eulogizing of Zhang Ji’s works is all the more striking. What made Zhang Ji’s work, and particularly the Treatise on Cold Damage, so appealing to literati physicians? In this chapter, I argue that literati physicians found in the Treatise a model for how to understand Juan xia, weiyi zonglun, in Qiu Peiran, Zhongguo yixue dacheng sanbian, 4:482.

Zhang Zhonjing shanghan lifa kao in Wang Lü, Yijing suhui ji, 18–19.

and manage the overwhelming complexity of illness. The Treatise was thus not only useful in dealing with the social aspects of medical practice—as discussed in the previous chapter—but was also essential to clinical practice and medical doctrine.

While the variability of illness is, in one form or another, a difficulty faced by any clinical tradition, the perceived urgency of this problem and the amount of effort spent in dealing with it reveal that it occupied a far more important place in Chinese literati-physician medicine than it did in many other medical traditions. In the first place, if the descriptions of literati medical authors are accurate, common physicians did not share literati physicians’ worries about the complexity of illness, and the other literati solutions to the crisis of trust in medicine, while recognizing the extreme variability in illness, attempted to side-step the problem by invoking sources of authority outside of medical doctrine (experience or socially endorsed authority).

Only literati-physician medicine theorized the complexity of illness, thereby taking it not only as the central problem that medicine needed to solve, but also as the very heart of its approach to illness and healing. Likewise, elite, scholarly medical traditions in other places and times did not place equal weight on this problem. In one of his essays, the Greek writer Plutarch (45-120) imagines a debate between three well-educated men over the possibility of the emergence of new diseases. One of the debaters rejects the possibility outright, attributing all illness to diet, which produced only a limited number of possible ailments. Although the other two interlocutors accept the possibility of new diseases, they see them as worthy of note precisely because they are not everyday occurrences.304 More importantly, they all share a conception of disease as a unified entity, not the fantastically variable illnesses recognized by Chinese literati physicians. Although the later Galenic medicine and its Islamic and medieval European descendants possessed a rich descriptive theory of illness, capable of coping with a great deal of variability in illness, Vivian Nutton, Ancient Medicine, 2nd ed (New York: Routledge, 2012), 36.

surviving evidence suggests that it was seldom used.305 Moreover, the complexity of illness was of less concern than the identification of specific therapies held to be effective in all cases of a given disease—the very antithesis of literati physicians’ insistence on the mutability of illness.306 Ontological concepts of disease, common in 18th and early 19th century Europe, explicitly sought to distinguish significant variability in signs and symptoms, which identified a disease entity, from the background noise of accidental variation, which was to be ignored.307 Likewise, germ theories of disease developed in the late 19th and early 20th centuries saw the diversity of signs and symptoms within a given disease as a distraction. What counted was the pathological agent, which was unitary and unchanging.308 In spite of rising interest in the individual variability of illness, modern biomedicine remains committed to an approach which defines illness in population terms—i.e., what is seen in most patients—as seen in modern biomedical dictionaries’ definition of disease: “A morbid entity ordinarily characterized by two or more of the following criteria: recognized etiological agents(s), identifiable group of signs and symptoms, or consistent anatomic alterations.”309 All of these more recent approaches to understanding illness see the complexity and variability of signs and symptoms as a fog that must be seen through to identify the actual illness. By contrast, literati-physician medicine’s supporters saw this variation as an inherent quality of the illness: the illness itself was transforming, and to be effective, treatment needed to be adapted to the current state of the illness.

Peter E Pormann and Emilie Savage-Smith, Medieval Islamic Medicine (Edinburgh: Edinburgh University Press, 2007), 115–138; Nancy G. Siraisi, Medieval & Early Renaissance Medicine: An Introduction to Knowledge and Practice (University of Chicago Press, 1990), 115–152.

Siraisi, Medieval and Early Renaisance Medicine, 152.

Roy Porter, “The Eightenth Century,” in The Western Medical Tradition: 800 B.C.-1800 A.D., ed. Lawrence I Conrad (New York: Cambridge University Press, 1995), 401–402; Roy Porter, Blood and Guts: A Short History of Medicine (New York: W.W. Norton, 2004), 77–78.

W. F. Bynum, ed., “The Rise of Science in Medicine,” in The Western Medical Tradition: 1800 to 2000 (New York: Cambridge University Press, 2006), 123–132.

Thomas Lathrop Stedman, Stedman’s Medical Dictionary, 28th ed (Philadelphia: Lippincott Williams & Wilkins, 2006), 550.

This chapter is divided into two sections. The first examines how Northern Song medical authors understood and dealt with the complexity and variability of illness. The second discusses prominent developments of the Southern Song, Jin, and Yuan dynasties, and traces the course of the Treatise on Cold Damage from being a text about a specific illness, to being “the method for the myriad generations.” The conclusion clarifies the position of the Treatise in literati-physician medicine by drawing a comparison to similar processes in Renaissance European natural history.

SECTION ONE: Managing Complexity in the Northern Song From its inception, literati-physician medicine was deeply concerned by the complexity and variability of illness. A number of approaches were developed to grasp this diversity, but translating such a grasp into actual treatments was more difficult.

Understanding Complexity in Illness Physicians and medical authors of the Northern Song recognized a wide variety of factors that contributed to the protean nature of illness. Ranging from environmental factors to characteristics of the patient and the illness themselves, these factors both explained variation in illness and demanded adaptability in treatment.

The seasons were among the most frequently cited causes of variability in illness, particularly in discussions of cold damage. As discussed in chapter 1, both the Yellow Emperor’s Inner Classic and the Treatise on Cold Damage saw cold damage as a broad rubric including not only cold damage proper, but also warm disease and hot disease/summerheat (shu 暑). All of these diseases were attributed to damage from cold during the winter that either immediately produced illness or lurked inside the body where it transformed into heat and manifested as an illness in the spring or summer. This doctrine was generally accepted throughout the period covered by this dissertation, though it would begin to be questioned by the late Yuan and early Ming.310 This doctrine led to a general belief that the formulae contained in the Treatise on Cold Damage were intended only for cold damage proper, which appeared in winter, and not for warm disease or summerheat.311 This led several authors to develop new formulae or find older formulae to supplement this deficiency in the Treatise. Han Zhihe, author of the oldest surviving text devoted exclusively to the Treatise, went so far as to include seasonal variations for almost

all of the formulae included in his book:

If the patient’s pulse on both wrists is sunken and slow, moderate, or tight, these are all cases of cold in the stomach. From Establishing Spring312 to Pure Brightness313, it is appropriate to use Warm the Middle Decoction. From Pure Brightness to Sowing Grain314, it is appropriate to use Orange Peel Decoction. From Sowing Grain to Establishing Autumn315, it is appropriate to use Seven-Ingredient Regulate the Middle Decoction.316 病人兩手脈沈遲,或緩或緊,皆是胃中寒也… 若立春以後,至清明以前,宜溫中湯主 之。清明以後,至芒種以前,宜橘皮湯主之。芒種以後,至立秋以前,宜七物理中丸主 之。 Han’s particular system for dividing the seasons was not adopted by any other author, but Zhu Gong and Pang Anshi both provided seasonal formulae, albeit with less consistency than Han.317 The earliest extant reference to warm disease not caused by cold damage is found in Guo Yong’s (郭雍, 1101Supplementing what is Missing in Cold Damage (Shanghan buwang lun 傷寒補亡論, 1086), but the passage is brief and not completely clear; see juan 18, wenbing lun, p. 1a-2a, in Zhu Pangxian and Wang Ruoshui, eds., Lidai zhongyi zhenben jicheng, vol. 20 (Shanghai: Shanghai Sanlian Shudian, 1990).

E.g., Zhu Gong’s Nanyang Book for Saving Lives, juan 5, questions 38-45, in Zhu Gong, Huoren shu, 69–77.

Marta Hanson cites question 43 as evidence that Zhu Gong was “skeptical about the universal applicability of Cold Damage formulas.” Since Zhu’s entire book is devoted to popularizing and explaining the Treatise on Cold Damage, the word, “skeptical” seems poorly chosen. Like other Song scholars, Zhu saw no problem in upholding a book as a classic while at the same time seeing a need to supplement it. See, Hanson, Speaking of Epidemics, 38. It is worth noting that the passage in question is a paraphrase of a passage in Pang Anshi’s Treatise on All Types of Cold Damage Illness, see juan 1, xulun, in Pang Anshi, Shanghan Zongbing Lun, 3.

The day marking the beginning of the 1st solar term, February 3rd, 4th, or 5th in the Gregorian calendar.

The day marking the beginning of the 5th solar term, April 4th, 5th, or 6th in the Gregorian calendar.

The day marking the beginning of the 9th solar term, June 5th, 6th, or 7th in the Gregorian calendar.

The day marking the beginning of the 13th solar term, August 7th, 8th, or 9th in the Gregorian calendar.

Juan xia, wenzhong pian, in Zhu Pangxian and Wang Ruoshui, Lidai zhongyi zhenben jicheng, 1990, 3:24.

E.g., Zhu Gong, Book on Saving Lives (Huoren shu 活人書), juan 6, questions 41-43, in Zhu Gong, Huoren shu, 73–76; Pang Anshi, Treatise on All Types of Cold Damage (Shanghan zongbing lun 傷寒總病論), juan 4, in Pang Anshi, Shanghan Zongbing Lun, 101–120.

Another form of environmental variability, which linked seasonal variation and calendrical cycles, ultimately became the most popular way of understanding the influence of climate on health and illness: the five movements and six qi (wuyun liuqi 五運六氣), often referred to simply as movements and qi (yunqi 運氣).318 This doctrine, which had its roots in the Inner Classic, linked together the movements of the five phases (wuxing 五行), the development and decline of in yin and yang as described by the “three yin and three yang,” and the sixty-year calendrical cycle created by pairing the ten heavenly stems (tiangan 天干) and the twelve earthly branches (dizhi 地支). Starting with the particular stem and branch of a given year, a series of correspondences and calculations allowed one to determine the quality of the qi—cold, wind, heat, fire, damp, or dryness—that would dominate in a given period of the year. In spite of complaints about overly mechanistic uses of the system, it was popular during the Song for a wide variety of applications.319 In medicine, the system was used to predict the type of illness that would predominate in a given year and to assist in diagnosing and treating it.320 The system of movements and qi had three advantages over the simpler analysis of seasonal variation in illness, which may explain its ultimate success. First, its complexity as a doctrine gave it greater explanatory flexibility. Not only could it explain the variability of illness during different seasons, it could also explain why the seasons and their associated illnesses were not always the same from year to year. Second, the relationships among the five movements—which were identical to The most common translation of this term is “phase energetics,” derived from the association of the five movements with the five phases (wuxing 五行) and modern (mis)conception of qi as a form of energy. I have chosen not to use this translation since the correlations of the five phases and the five movements differ and qi in this case refers to climatic qi, e.g., damp, heat, cold, etc., making the term “phase energetics” potentially confusing.

Catherine Despeux, “The System of the Five Circulatory Phases and the Six Seasonal Influences (wuyun Liuqi), a Source of Innovation in Medicine under the Song (960-1279),” in Innovation in Chinese Medicine, ed. Elisabeth Hsu, 2001, 121–65.

Liu Wenshu (劉溫舒, fl. late 11th c.), On the Subtleties of Movements and Qi according to Questions on the fundamental (Suwen rushi yunqi lun’ao 素聞入式運氣論奧, juan xia, pian 28-30, pp. 21a-32a, in Siku Quanshu.

those among the five phases—gave the system greater dynamism. Seasonal variability alone could not explain the transformations that occurred during the course of an illness. In skillful hands, the system of movements and qi could do so. Finally, it had roots in the Inner Classic and was seen as having connections to the Treatise on Cold Damage,321 giving it the pedigree of antiquity.

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