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As Robert Hymes has shown, in spite of steadily increasing competition in the civil service exams, few elite men chose medicine as a career in the Northern and Southern Song. This pattern changed in the Yuan, however, as increasing numbers of gentlemen turned to medical practice to earn their living. Hymes argues that the primary force behind this change was the abolition of the examination system in the early Yuan. With the exams cancelled, not only did elite men have no possibility of gaining government office, they also had no need to hire teachers to prepare their sons for the exams. As a result, the market for teachers—traditionally the fallback career for men who failed in the exams—also collapsed. Even when the exams were reinstated, the Yuan government continued to limit the number of official positions available to people from southern China—by now its demographic, intellectual, cultural, and economic heart.
The elite needed new career options that were considered worthy of their status.435 The literatiphysician approach to medicine, with its vision of medicine as an elite practice and doctors as scholar-physicians, provided ample justification for elite men who became practicing physicians.
The triumph of the literati-physician approach was thus secured by the development of a new social order within which it played a useful role, and thenceforth, all literati medicine was literati-physician medicine.
Hymes, “Not Quite Gentlemen?” The other two approaches to literati medicine—proven formulae and authoritative sources—offered no comparable role for elite physicians. They continued to see doctors as a potentially troublesome, non-elite group whose ministrations were best avoided by judicious self-medication. Most of the works produced within these two approaches were assimilated into the victorious literati-physician model. The intellectual compatibility of the approaches, as discussed in Chapter 3, made this a relatively simple task. Particularly unpalatable examples— such as Su Shi’s use of Sagely Powder (Shengzi san 聖子散) to treat all epidemics—were remembered as object lessons illustrating the need to carefully differentiate each individual case of illness.436 The triumph of literati-physician medicine also secured the position of the Treatise on Cold Damage. From the Yuan onward the Treatise was the central text of literati medicine.
While not every medical author or physician shared Wang Lü’s enthusiastic evaluation of its importance,437 no one could ignore it. They could argue with it, supplement it, or even correct it, but no author writing on medicinal therapy could completely neglect it.438 The Treatise has remained useful to doctors from the Yuan up to modern times, and this usefulness is the most common explanation of its central place in modern Chinese medicine. In fact, however, the utility of the Treatise is a by-product of its centrality. Literati medicine, the ancestor of modern Chinese medicine, was built on the foundation of the Treatise on Cold Su Shi and Sagely Powder continue to be used as object lessons in universities of Chinese medicine to this day.
See Chapter 5.
Texts on acupuncture, of which far fewer survive, usually refer to the Inner Classic corpus instead, but acupuncture remained overwhelmingly a non-elite practice until the 20th century. It was at best on the margins of literati medicine. See Leung, “Medical Learning from the Song to the Ming.”
Damage. The Treatise was used as a model for how to deal with the problem of illness’s complexity and mutability by individualizing treatments for each particular case of illness. So long as that problem and this solution remain central to Chinese medical practice—in other words, so long as modern Chinese medicine continues to perpetuate the cultural tradition of literati medicine—the Treatise on Cold Damage will remain useful because it articulates the core principles on which that medical tradition is based.
In the physical center of the Beijing University of Chinese Medicine’s Museum of Chinese Medical History there is a bust of Zhang Ji (see the image above). All of the other exhibits encircle it like planets orbiting the sun. I do not know if the placement of this bust was intentional, but it is an apt metaphor for Zhang Ji’s place in Chinese medicine. Zhang Ji and the Treatise on Cold Damage were the heart of literati medicine as it formed from the Song through the Yuan, and they remain so in modern Chinese medicine.
As Volker Scheid observes, the modern understanding of Chinese medicine is tightly intertwined with the concepts of “tradition” and the “traditional.”439 The latter term in particular is highly problematic. Even though Chinese speakers do not use the term Traditional Chinese Medicine (TCM) by which Chinese medicine is most widely known outside of Asia, they do refer to it as “traditional medicine (chuantong yixue 傳統醫學)” in contrast to “modern medicine (xiandai yixue 現代醫學).” As this example illustrates, the “traditional” is inseparable from the “modern,” and both are the productions of a self-conscious modernity with little relevance to the traditions described. The traditional is the longing for escape from the modern, repressed and projected onto the subjugated other. Although the term is used to refer to Chinese medicine in modern China, it is merely one pole of a continuum whose opposite pole is represented by efforts to scientize and systematize Chinese medicine. The contrast between the two makes the artificiality of the distinction all the more apparent.
Tradition as I refer to it is in no way associated with the “traditional.” Rather, as discussed in the introduction to Part II, I define tradition as a “continuity within a group that shares a common commitment to … an evolving problematic and method.”440 Traditions in this sense are living things. Though they may retrospectively invent their own history and invoke a sense of community greater than appears justified by the actual connections among their members, they are not fictions imposed after the fact. The members of a living tradition Volker Scheid, “Chinese Medicine and the Problem of Tradition,” Asian Medicine 2, no. 1 (January 2006): 59–71.
Ogilvie, The Science of Describing, 10.
participate in a shared identity even as they reshape that identity and the contents of their tradition.441 The commitment to a basic problem and an approach to resolving that problem is the thread that provides continuity across time and in spite of very real and often dramatic change.
The emergence and decline of this commitment is, I would argue, one of the few reliable methods of defining the emergence and decline of a tradition, of recognizing when change rises to the level of rupture.
All three forms of literati medicine that emerged in the Northern Song shared a problematic: the protean character of illness. Literati-physician medicine, and thus—from the Yuan onward—literati medicine as a whole, drew upon the Treatise on Cold Damage to put forward a novel approach to dealing with that problematic: individualizing treatment. Although elements of this approach can be seen in pre-Song medical texts, the attention devoted to it and the detail in which it is articulated from the Song onward are clearly new. It therefore constituted a new medical tradition. This approach to managing the complexity of disease has taken on many forms and been called many names. Some authors urged physicians to search for the root (ben 本) or source (yuan 源) of illness. Others developed lists of factors to be considered during diagnosis.442 Most recently, Chinese government textbooks and schools—and therefore the majority of doctors—have portrayed “pattern differentiation [as the basis of] determining treatment (bianzheng lunzhi 辨證論治)” as the core of Chinese medical practice.443 While these methods differ in various degrees, they are all realizations of the basic literati medicine approach of individualizing treatment in response to the ever-changing and subtle nature of illness. For this In addition to Ogilve, I am influenced in my position on tradition by Scheid, “Chinese Medicine and the Problem of Tradition”; and Alasdair C. MacIntyre, After Virtue: A Study in Moral Theory (Notre Dame: University of Notre Dame Press, 1984), 221–222.
See Chapter 5.
Volker Scheid, Chinese Medicine in Contemporary China (Durham: Duke University Press, 2002), 200–237.
reason, we may say that modern Chinese medicine is not merely a descendant of Song literati medicine, it is the same cultural tradition that has survived for more than a thousand years.
It is interesting to note that modern physicians of Chinese medicine frequently assert that the Treatise on Cold Damage is the earliest example of pattern differentiation. This claim has generally been rejected by historians—and it is clear that the medicine Zhang Ji advocated differed in many important ways from that practiced in the Song or today—but this assertion does capture the indebtedness of literati medicine to the Treatise as the initial inspiration and model for the individualization of treatment incarnated in a modern form as pattern differentiation. Likewise, the Treatise’s Song editors’ claim that they were reviving the medicine of antiquity that had been forgotten certainly resonates with the fact that they were creating a new form of medicine through appropriation from of the Treatise. Finally, the dissonance I noted between Song and pre-Song medical texts was a visceral reaction to the rupture that occurred in that period, and the sense of familiarity that I found in the Treatise on Cold Damage was a tacit recognition that I was literally reading the foundations of Chinese medicine as I know it.
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