The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400 Stephen Boyanton Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2015 ©2015 Stephen Boyanton All Rights Reserved ABSTRACT The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China 1000-1400 Stephen Boyanton This dissertation explores the profound changes that occurred in literate Chinese medicine during the Song (960-1279), Jin (1115-1234), and Yuan (1276-1368) dynasties— changes which established the pattern of the text-based Chinese medical tradition from that time to the present day. In particular it examines the transformation of the Han dynasty (206 BCE-220 CE) text, the Treatise on Cold Damage (Shanghan lun 傷寒論), from one member of a diverse tradition of texts giving instruction on the treatment of cold damage disorders (shanghan 伤寒, a class of potentially epidemic, febrile illnesses) into the preeminent—almost the only—canonical text about such illnesses and a touchstone for medical thinking on all types of illnesses. I argue that a two primary factors account for the Treatise’s remarkable rise in status: the rise in the frequency of epidemics caused by Chinese society’s crossing of epidemiological frontiers, both in terms of population and in terms of geographic distribution, and a crisis of trust in medicine which was part of a much broader epistemic crisis brought about by the radical changes in social structure, commerce, governance, and material culture during the Song. The increase in epidemics gave added weight to the topic of cold damage, but the decisive factors singling out the Treatise were related to its usefulness in addressing the medical crisis of trust. Medical authors were unanimous in their condemnation of the status quo in medicine. The focus of their criticisms was the figure of the common physician (shiyi 世醫). Common physicians, the dominant practitioners of text-based medicine in the Northern Song, belonged to social stratum just below that of the elite. For elite medical authors, common physicians were the primary problem with medicine: they were inadequately or incorrectly educated, failed to appreciate the complexity of illness, and lacked elite ethical values. While elite authors agreed that common physicians were the problem, they disagreed on how to resolve this problem. Three approaches developed a more elite form medicine—which I term “literati medicine.” It was among the proponents of one of these approaches—“literati-physician medicine,” which held that only members of the elite could be proper physicians—that the Treatise on Cold Damage became central to medical thought and practice. Literati physicians found the Treatise useful for a variety of reasons. In terms of their social relations, both within the clinical encounter and in broader society, it was a useful tool for arguing for their own superiority over their common physician competitors. In terms of their clinical doctrines, it provided a model by which to deal with what they saw as the central problem in medicine: the protean nature of illness. As long as that remained the central problematic of their medical tradition, the Treatise retained its central place. By the Yuan, literati physicians dominated all of literati medicine and ultimately all of textually based medicine, making the Treatise a central text for all physicians. The history of the Treatise’s transformation into one of the most fundamental texts of the Chinese medical tradition is therefore rooted in the formation of literati medicine, and its struggle for both social legitimacy and clinical efficacy. The Treatise’s continued importance from the Yuan to modern times is the result of the survival of literati medicine for nearly one thousand years. In spite of many changes, modern Chinese medicine remains committed to a vision of illness as irreducibly complex and to an approach to cure—individualization of treatments—first learned from the Treatise on Cold Damage during the Song dynasty. Table of Contents FIGURES AND TABLES ii INTRODUCTION: Problems of Continuity and Rupture 1 PART ONE: The Treatise on Cold Damage and the Song Dynasty 6 CHAPTER 1: A Narrowing of Vision, a Broadening of Discourse: Cold Damage Studies before and after 1065 10 CHAPTER 2: The Song Dynasty: Social, Epidemiological, and Medical Frontiers 55 CHAPTER 3: The Problem with Common Physicians and its Solutions in the Northern Song 76 PART TWO: The Treatise on Cold Damage and Literati-Physician Medicine 116 CHAPTER 4: Fashioning Literati Physicians: Canonization, Competition, and Community 122 CHAPTER 5: "A Thousand Changes and Ten Thousand Transofrmations": The Treatise on Cold Damage and the Problematic of Literati-Physican Medicine 171 CONCLUSION: Continuity and Rupture Revisited 221 BIBLIOGRARPHY 227 i Figures and Tables Table 1-1: Sources for Pre-Song Cold Damage Studies 15-16 Table 1-2: Ingredients Used in Common Pre-Song Formulae to Treat Early-Stage Cold Damage 24 Table 1-3: Pre-Song Texts Attributed to Zhang Ji 37 Figure 3-1: Cullen’s Chart of the Healthcare Marketplace in Late Imperial China 99 Figure 3-2: My Modification of Cullen’s Chart for the Song-Yuan 99 Table 3-1: Extant Formularies by Northern Song Authors 112 Table 4-1: Publications of the Bureau for Editing Medical Texts 127 Table 4-2: Texts Attributed to Xu Shuwei 144 Table 5-1: Texts Attributed to the Hejian Current 198 Figure C-1: A Bust of Zhang Ji 223 ii Acknowledgements Many people deserve recognition for their contributions to the completion of this dissertation, and I fear I may forget some of them. If I have done so, I ask that you forgive me and know that my gratitude to you remains. Without the guidance of my advisor, Robert Hymes, this dissertation would be far less than what it is today. His example led me to consider explanations I had never thought of before. The social historical aspect of this work is largely the result of his inspiration. His drive for precision and clarity in thought and word pushed me to improve my research, analysis, and writing. He has been the best editor any author could hope for, and his advice on how to be a scholar has been invaluable. I am truly grateful. Although I have never officially been her student, Marta Hanson has been my mentor for many years. Among many other acts of selfless assistance, she helped me refine my writing skills, understand the nature of scholarly discourse, and develop useful contacts with other historians of Chinese medicine. It is difficult to imagine how I could have reached this point in my own career without her help. I owe Matthew Jones a special debt for introducing me to the literature on the history and sociology of science. As even a casual perusal of this dissertation will reveal, that literature has become my theoretical touchstone. It has allowed me to resolve several of the perplexing issues that came up in the course of my research and also to speak to a wider audience through my work. The remaining members of my dissertation committee—T.J. Hinrichs, Dorothy Ko, and Shang Wei—have generously spent of their time reading and critiquing this work. I thank you all. iii A number of my clinical professors deserve mention for their guidance as I struggled to develop a more nuanced and accurate understanding of Chinese medicine. Tantan Huang, J. Min Fan, Yuan Wang, Ye Pinliang, Song Naiguang, and Xiao Xiangru all provided insights I could not have obtained on my own. Liang Yongxuan, professor of Chinese medical literatue at Beijing University of Chinese Medicine, provided particularly useful guidance on the quality of various editions of the texts I study. The first year of research for this dissertation was funded by a Fulbright Fellowship. I would like to thank the Institute for International Education and Beijing University of Chinese Medicine for their support of my work. In particular, I would like to thank Janet Upton and Jonathan Akeley of IIE and Fu Yanling and Gong Jiapei of BUCM for their kindness and efforts on my behalf. One year of my write-up was supported by a Sasakawa Young Leaders Fellowship from the Tokyo Foundation. Their gernerous support gave me the time to devote myself to writing completely, without which this project could not have been completed in as timely a fashion. Finally, I would like to express my appreciation to my family: my parents, Charles and Zana Boyanton, for their unfailing support and encouragement throughout my long and unusual student career; my wife, Dengting Boyanton, for accompanying me on what must have at times felt like a fool’s quest; and my daughter, Ellen Xianglan Boyanton, whose smiles, laughter, and drawings labeled “For Daddy, From Ellen” kept me going through the final push to finish this dissertation. I love you all. iv For all those who share my love of Chinese medicine, may it survive into the 22nd century and beyond! v INTRODUCTION Problems of Continuity and Rupture The research that became this dissertation grew out of a purely personal sense of puzzlement. I am both a historian and a clinician of Chinese medicine. During my clinical education, I began reading the great classics of Chinese medicine. I started with the Yellow Emperor’s Inner Classic (Huangdi neijing 黃帝內經, ca. 1st c. BCE, hereafter the Inner Classic), the oldest text in the received tradition of Chinese medicine and traditionally seen as its foundation. I found it fascinating and inspiring, but foreign. It felt very distant from the medicine I was learning to practice.