A Chinese Physician: Wang Ji and the Stone Mountain Medical Case Histories (Needham Research Institute Series)

A CHINESE PHYSICIAN A Chinese Physician is the portrait of Wang Ji, a sixteenth-century medical writer and clinical pr...

Author: Joanna Grant

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A CHINESE PHYSICIAN

A Chinese Physician is the portrait of Wang Ji, a sixteenth-century medical writer and clinical practitioner. Three methodologies – loosely termed socioeconomic/biographic, textual analysis, and gender analysis – and a variety of sources, from hagiographical biographies to medical case histories, are used to tell three very different but complementary stories about what it was to practise medicine in sixteenth-century China. Woven together, these stories combine to create a multidimensional portrayal that brings to life the very human experiences, frustrations and aspirations of a well-respected and inﬂuential physician who yet struggled to win respect from fellow practitioners and loyalty from patients. In so doing, the author creates a vibrant and colourful picture of contemporary medical practice that at the same time deepens our understanding of the interrelationship between gender, culture and medicine. After graduating from Oxford University in 1993 with a degree in Oriental Studies (Chinese), Joanna Grant carried out research into various aspects of Chinese medical history at the School of Oriental and African Studies in London, for which she was awarded a Ph.D. in 1997.

NEEDHAM RESEARCH INSTITUTE SERIES Series Editor: Christopher Cullen

Joseph Needham’s ‘Science and Civilisation’ series began publication in the 1950s. At ﬁrst, it was seen as a piece of brilliant but isolated pioneering. However, at the beginning of the twenty-ﬁrst century, it is clear that Needham’s work has succeeded in creating a vibrant new intellectual ﬁeld in the West. The books in this series cover topics relating broadly to the practice of science, technology and medicine in East Asia, including China, Japan, Korea and Vietnam. The emphasis is on traditional forms of knowledge and practice, but without excluding modern studies which connect the topics with their historical and cultural context. CELESTIAL LANCETS A history and rationale of acupuncture and moxa Lu Gwei-Djen and Joseph Needham With a new introduction by Vivienne Lo A CHINESE PHYSICIAN Wang Ji and the ‘Stone Mountain medical case histories’ Joanna Grant CHINESE MATHEMATICAL ASTROLOGY Reaching out to the stars Ho Peng Yoke

A CHINESE PHYSICIAN Wang Ji and the ‘Stone Mountain medical case histories’

Joanna Grant

First published 2003 by RoutledgeCurzon 11 New Fetter Lane, London EC4P 4EE Simultaneously published in the USA and Canada by RoutledgeCurzon 29 West 35th Street, New York, NY 10001 This edition published in the Taylor & Francis e-Library, 2003. RoutledgeCurzon is an imprint of the Taylor & Francis Group © 2003 Joanna Grant All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Grant, Joanna, 1970– A Chinese physician : Wang Ji and the ‘Stone Mountain medical case histories’ / Joanna Grant. p. cm. — (Needham Research Institute series) Includes bibliographical references and index. 1. Wang, Ji, 1463–1539. 2. Medicine, Chinese. I. Title. II. Series. R604.W357 G735 2003 610′92—dc21 2002036711 [B] ISBN 0-203-42304-6 Master e-book ISBN

ISBN 0-203-42481-6 (Adobe eReader Format) ISBN 0-415-29758-3 (Print Edition)

CONTENTS

List of illustrations Acknowledgements

vii viii

Introduction

1

The ‘traditional socioeconomic and biographic’ method 2 The ‘textual analysis’ method 4 The ‘gender analysis’ method 9 1

Wang Ji, medical culture and contemporary society

21

Contemporary society 22 Medical culture 29 Wang Ji 39 2

The ‘Stone Mountain medical case histories’

51

The structure of the text 51 The case history genre 52 The purpose of writing case histories 54 Use as source material 60 3

Wang Ji’s medical practice: a textual analysis of the ‘Stone Mountain medical case histories’ Theory and practice 68 The clinical encounter 73 The patient/physician dynamic 86 Interaction with other physicians and healers 91 v

67

CONTENTS

4

Gender, culture and medicine: a gender analysis of the ‘Stone Mountain medical case histories’ 103 General facts and ﬁgures 105 Diagnosis 109 Aetiology 116 Illness syndrome 140 Treatment 147 Outcome 148 Conclusion

155

Notes Bibliography Character glossary Index

161 189 200 204

vi

ILLUSTRATIONS

Plates 1 Portrait of Wang Ji; taken from the 1531 edition of the Shishan yi’an 2 Portrait of Wang Ji; taken from the Ming edition of the Wang Shishan yishu bazhong

x xi

Figure 4.1 Comparative aetiologies

119

Tables 4.1 4.2 4.3

Disorder classiﬁcations Distribution of male and female patients in the text Number and percentage of women in each group

106 107 108

Boxes 1.1 1.2

Wang Ji’s interactions with contemporary medical culture Wang Ji’s oeuvre

vii

45 47

ACKNOWLEDGEMENTS

The thesis on which this book is based was funded by a generous scholarship from the Wellcome Trust, who, along with SOAS and the Sino-British Fellowship, also provided additional funding for a period of research in Beijing and Shanghai in 1995. A further grant from the Wellcome Trust supported me during the summer of 1997 as I took my ﬁrst tentative steps towards carrying out the transition from thesis to book. That transition could not have taken place without the invaluable assistance I received from the numerous scholars who gave so generously of their time, intellect, wisdom, and experience, and in so doing, guided me through the long and difﬁcult process. I am indebted to my Ph.D. superviser Christopher Cullen for his continued support and encouragement. I count my lucky stars that I had the good fortune to be guided through my research by someone with his unique combination of brilliance, enthusiasm, and humour. The conﬁdence he showed in my abilities and the unfailing interest he showed in my work as it progressed kept me motivated, focused, and most importantly, sane. I owe a huge amount to Charlotte Furth, whose pioneering work in the ﬁeld of gender and Chinese medicine sparked my own interest in the subject and provided much intellectual food for thought. She has been incredibly generous with her time, offering guidance and encouragement, and sharing her ideas and materials. In addition, she reviewed the ﬁnished manuscript and provided many valuable and insightful comments for which I am very grateful. I am also fortunate to have received substantive input from Nathan Sivin. He very kindly reviewed my thesis, and offered welcome words of support and guidance, along with constructive viii

ACKNOWLEDGEMENTS

criticism and incisive comment. My work has beneﬁted enormously from his rigorous attention to detail and famously extensive knowledge, and I very much enjoyed our transatlantic correspondence. Lawrence Conrad and Paul Unschuld, my thesis examiners, gave me the conﬁdence to embark on the journey from thesis to book, and through their kind and instructive comments gently pointed me in the right direction. Help along the way has also come from many others including Bridie Andrews, Francesca Bray, Cythia Brokaw, Chang Chiafeng, Frank Dikötter, Benjamin Elman, Vivienne Lo, Laura Newby, and David Wright. I was honoured that the Needham Research Institute elected to publish the ﬁnished manuscript as part of their monograph series, and I owe them an immense debt of gratitude for their continued support over the years. I ﬁrst visited the NRI in 1993, before beginning my Ph.D., and have spent many happy days since ensconced in their excellent library and calming environs. My heartfelt thanks go to everyone there, especially John Moffett and Sue Bennett. I would like to thank my current employers, Allen & Overy, who have wholeheartedly supported my alternative literary career and graciously allowed me periods of study leave to work on the manuscript. In particular I am grateful to Guy Henderson, Ian Elder and Suki Allday. Many thanks also to the team at RoutledgeCurzon – Jonathan Price, Lucy Swainson, Nicola Cooper, and Digby Halsby – and my copy editor Rosamund Howe for all their assistance in bringing the ﬁnal stages of this project to a successful conclusion. None of this would have been possible without the love and support I have received from my family and friends who have been there for me every step of the way. Above all, I would like to thank Martin Kuper, my constant companion, who has read draft after draft, talked over ideas late into the night, hotly debated the positioning of commas, and who now knows more about a sixteenth-century Chinese physician than he can every have imagined possible. It is to him that this book is dedicated.

ix

Plate 1 Portrait of Wang Ji; taken from the 1531 edition of the Shishan yi’an

x

Plate 2 Portrait of Wang Ji; taken from the Ming edition of the Wang Shishan yishu bazhong

xi

H

INTRODUCTION

INTRODUCTION

This is the story of a Chinese physician and the environment in which he lived and worked. The physician is Wang Ji , a sixteenth-century medical writer and practitioner from Anhui province in China who was born in 1463 and died in 1539. He was relatively well known and respected in his lifetime, leaving around a dozen extant texts in his name. All his life he lived and worked in the Huizhou prefecture of what is now Anhui province, building up a thriving medical practice which is described in one of his texts, the Shishan yi’an ! [Stone Mountain medical case histories], compiled by his disciples, and completed in 1531. This is his story, the story of what it was to be a physician at that time and in that place, as can be reconstructed from his text the Shishan yi’an and other contemporary sources. I use three methods to tell his story, so perhaps it would be more accurate to say that there are three different interlinking and overlapping stories. Each method, and the story it reveals, is the subject of a separate chapter of my book. I begin in Chapter 1 by setting the scene, using what can very loosely be termed a traditional socioeconomic and biographic method to describe the predominant cultural features of sixteenth-century Anhui, contemporary medical culture, and the life of Wang Ji as told through various biographies. I then take just one of his texts, the Shishan yi’an, and after a short second chapter on the nature of this text, use it as the basis of both a textual analysis and a gender analysis in Chapters 3 and 4 respectively. What follows here is a brief introduction to each of the three methodologies in turn, describing their applications and limitations, assessing the relative contribution to the ﬁeld of previous studies which adopted similar or related methodologies, and summarizing 1

INTRODUCTION

some of the insights thereby derived into the life of this sixteenthcentury physician.

The ‘traditional socioeconomic and biographic’ method The traditional socioeconomic method used in Chapter 1 consists of a pretty straightforward examination of Wang Ji’s life and times carried out using historical and biographical sources from the period, as well as relevant modern studies on related topics. I begin with Huizhou, the Anhui prefecture where Wang Ji lived and worked, and I explore the changing social and economic features of the early sixteenth century, before narrowing my focus, ﬁrst to the medical culture of the region, and then to Wang Ji himself and what biographical evidence can tell us of his life as a medical practitioner. The results of my study revealed the sixteenth century to be a time of profound social change in Huizhou, characterized by increasing commercialization and the emergence of a wealthy merchant class that, on the one hand, was responsible for the increasing levels of literacy, promotion of publishing, and patronage of the arts found in the region at that time, and, on the other, provoked anxiety among the literati on account of the merchants’ collective desire to improve their social status and, also, on account of their lifestyles which were perceived as being extravagant and decadent. Focusing more closely on contemporary medical culture, I was interested to examine the impact of those developments on medicine at that time, and in particular on issues such as the composition of the medical elite, the level of interaction between physicians, and the transmission of medical knowledge through mechanisms such as the master–disciple relationship and the increased publication of medical texts. As might be expected, the developments taking place on a regional level were reﬂected in the medical culture of the time: travelling merchants and improved transportation links resulted in a wider dissemination of medical knowledge; the boom in publishing, combined with increased literacy, stimulated the creation of new genres of medical texts aimed at a diverse and growing readership; and social mobility brought new blood and fresh talent into medical circles, from the ranks of both failed scholars and aspiring merchants. 2

INTRODUCTION

In the last part of the chapter, I draw on a variety of historical and biographical sources to reconstruct Wang Ji’s private and professional life, from aspects of his family history, character and personal beliefs, to his professional motivations, literary achievements and level of involvement with local medical culture. The inﬂuence of contemporary culture can be clearly detected in many aspects of Wang Ji’s life as a practising physician and proliﬁc medical writer. From his concerns about declining morals in society to his reasons for becoming a physician, and from his interaction with medical culture to the type of books he wrote and his reasons for doing so, Wang Ji emerges in every respect as a product of his times. As a single study, this method uncovers a vibrant and exciting period of Chinese medical history of which Wang Ji was an important part. The decision to focus on just one physician was deliberate. The ﬁeld of Chinese medical history is relatively new, and much of the research carried out to date has often been of a very general nature, drawing conclusions from a wide range of texts, the authors of which have come from different temporal and spatial locations. While this has resulted in the production of a solid framework for further research, it fails to emphasize sufﬁciently the fact that traditional Chinese medicine was not based on a single, uniﬁed, coherent or internally consistent body of knowledge. Nor does it take into account the effect that both individual perceptions and cultural factors can have on the interpretation of medical knowledge and its implementation in clinical practice. I wanted to produce a more in-depth and focused work that conveyed a sense of the continuity, change and diversity to be found within the tradition. Small-scale historical studies such as this, which focus on one speciﬁc aspect of Chinese medical history in a well-deﬁned cultural and socioeconomic context, are gradually increasing in number. Useful examples of such studies include those by Angela Ki Che Leung and Carol Benedict on the subject of the relationship of the state to medicine, with regard to disease control, medical institutions and public health;1 Robert Hymes’s article on the changing social status of elite physicians in the Song and Yuan dynasties;2 Ellen Widmer and Marta Hanson’s explorations of the Huanduzhai publishing house and the world of medical patronage in seventeenth-century China;3 and Chao Yüan-ling’s study of the professionalization of Suzhou physicians in late imperial China.4 3

INTRODUCTION

For my purposes this method also serves to set the scene, introducing the predominant cultural factors and prevailing trends that characterized society at that time, placing Wang Ji squarely in his appropriate historical context, and providing a backdrop against which his writings can be examined. Without this contextualization, the dialogue between the text and contemporary culture would be lost and many of my ﬁndings from the following analyses of Wang Ji’s book, the Shishan yi’an, would lose their resonance. Having begun with the rather expansive topic of the socioeconomic and cultural aspects of Huizhou in the sixteenth century, I then narrow my ﬁeld of enquiry ﬁrst to medical culture, then to a speciﬁc physician, and ﬁnally to a single text, the Shishan yi’an. Whereas in this chapter I attempt to draw together my ﬁndings from a range of sources to create a composite picture of Huizhou society, by contrast the next two methods take almost the opposite approach and analyse just a single text to see what it can reveal about Huizhou society and medical culture at that time. Before embarking on either analysis I take a closer look at the nature of the text itself in Chapter 2, including its authorship and structure, the genre of writing to which it belongs, the reasons for its compilation, and its suitability as the source material for the two analyses.

The ‘textual analysis’ method Chapter 3 is a textual analysis focusing on the Shishan yi’an, a set of physician’s case histories made up of over one hundred cases that describe the medical encounter between the physician, Wang Ji, and his patient from the initial examination through to recovery. I chose this particular text because I wanted to gain some insight into the world of clinical medical practice, and the case history format of this text offers a unique opportunity to do just that. Through the cases, the experiences of a practising physician in sixteenth-century Huizhou are brought to life, not least because of their long and anecdotal nature. This is no doubt because, as one of the earliest examples of the case history genre, the Shishan yi’an does not adopt the more concise and standardized structure later imposed on it. Often the cases contain fascinating information about the way in which medicine was practised at the time, the personal lives of the patients, their 4

INTRODUCTION

interaction with other healers, and the course of their illnesses over many months or years. In addition, Wang Ji has very strong and distinctive theoretical beliefs which are manifested through his case histories, and I wanted to investigate the inﬂuence of his theoretical framework on his clinical practice and vice versa. At this point I should make clear that throughout this book by theory I mean the doctrines underlying practice. This can be contrasted with its meaning in Western medical history, where as a result of a historical split between theory and practice, theory is commonly understood to be something studied apart from therapeutic work.5 One of the great attractions of textual analysis as a method is that in focusing on just one text to reconstruct Wang Ji’s medical practice I am using only his own words, which even if not necessarily written by him were at the very least written by his disciples in his lifetime and approved by him. Despite this multiple authorship, the text speaks with one voice, that of Wang Ji, and this then is his story. In contrast to the no doubt somewhat hagiographical versions of his life as a famous physician and medical writer described in his biographies, I believe this to be as close as we can get to what he would tell us if he were alive today. In my analysis I have endeavoured as far as possible, at this distance from the events in question, to listen to what Wang Ji was saying about his experiences and reﬂect that in my writing. Throughout the text the same themes are repeated over and over again, leaving little doubt as to Wang Ji’s opinions and concerns or the message he wanted to convey. A vivid picture of Wang Ji’s medical practice emerges from my examination of the case histories of the Shishan yi’an. Wang Ji describes in some detail his management of each patient’s illness from the initial encounter to the ﬁnal outcome of the case, including the processes involved in reaching a diagnosis, deducing the cause of the illness, reaching an understanding of the illness mechanism, and deciding on an appropriate therapy. The theoretical framework he employs is clearly articulated, and emphasizes the use of sweet and warming drugs, such as ginseng and astragalus root, to treat disorders of qi depletion. It appears that Wang Ji faced much resistance to his theories: the Shishan yi’an relates countless examples of conﬂict in this regard, not only between Wang Ji and other elite physicians, but also between Wang Ji and his patients. Although the case histories selected for inclusion in 5

INTRODUCTION

this text demonstrate that Wang Ji was correct in his diagnosis and treatment of patients, the picture of medical practice that emerges is one of frustration, insecurity and rivalry: Wang Ji faced strong competition from his elite rivals and could not count on loyalty from his patients, many of whom canvassed the opinions of a range of elite physicians and other healers both before and after being seen by him. This depiction adds another dimension to the portrait of the successful author and physician derived from the traditional socioeconomic and biographic method. However, it is also important to be aware of certain limitations that are inherent in the picture derived from a textual analysis using this type of source material, and these are discussed in more detail in Chapter 2. For example, the number of case histories presented in a published text represents only a fraction of the cases a physician will have seen in his lifetime. Therefore, there is no way of knowing the extent to which these published cases are representative of his practice as a whole, and as a result these selected cases may well give a distorted or idealized picture of his medical practice. In addition, case histories such as these can only reﬂect the perceptions of the physician himself, and cannot reﬂect those of other healthcare practitioners or patients. I am very conscious that the picture of clinical medical practice that emerges from the text is very much as seen through the eyes of Wang Ji. This is how he perceived his world as a result of his time, location, cultural background and social class. The accuracy and representativeness of his perceptions remain unsubstantiated, but at the same time are not necessarily relevant if it is acknowledged that these are the experiences of an individual physician at that time as opposed to an objective depiction of Ming dynasty medical practice. Medical case histories have been used before to good effect as the subjects of textual analyses to examine various aspects of medical practice. One of the most famous and inﬂuential examples of this is Barbara Duden’s explorations of perceptions of women’s bodies, using the case books of the German doctor, Storch.6 Storch left seven casebooks containing a total of 1,816 cases relating to about 1,650 different women. Duden found that the body experienced by women in eighteenth-century Germany was remarkably different from the body we have today, owing to the power of social and cultural perceptions to create their own sense of reality. She uses the case histories to explore 6

INTRODUCTION

not how doctors visualized women’s bodies, but how women experienced their own bodies, and she does this, for example, by looking at the vocabulary they used to describe sensations such as pain. From the case histories, Duden reconstructs various aspects of Storch’s medical practice, such as the range of healers available to his patients, including, to a large extent, self-help and the recommendations of family and friends. In Storch’s case, for example, there appeared to be a ﬂuid boundary between healers which did not seem to be dictated by social class, geographical location or the nature of the complaint itself. Duden also examines the encounters between Storch and his patients which were mainly carried out through intermediate channels such as letters, messages, requests and often through the woman’s mother, husband or servants who would explain the nature of the illness to the doctor. These encounters highlighted important aspects of Storch’s medical practice, for example that touching was not an important diagnostic aid and was rarely used, that there was no embarrassment about graphically describing bodily emanations, that in many cases women only used Storch to conﬁrm their own opinions about the illness and its treatment, and that there were differences between Storch and his patients in their perception of the human body. Case histories have also been a feature of research into traditional Chinese medicine, and as early as 1967 Nathan Sivin examined a number of the case histories relating to the personal illnesses of the Tang physician Sun Simiao found interspersed among his medical writings.7 Sivin also revisited the genre recently for his investigation into emotional counter-therapy whereby one type of emotion is used to treat a different type of emotion according to ﬁve-phase theory.8 As I discuss at greater length shortly, case histories also lend themselves very well to the study of gender in traditional Chinese medicine, and Charlotte Furth has undertaken a study of the case histories of the late Ming physician Cheng Maoxian , and has also examined an unusual set of of thirty-one case histories authored by an elite female healer.9 Francesca Bray10 and Lisa Raphals11 have also utilized case histories in their gender-based studies. In addition, the origins of the case history genre and its emergence as a distinct style of medical writing form the subject of a recent study by Christopher Cullen.12 7

INTRODUCTION

Nor is the use of case histories limited to historical research. The anthropologist Judith Farquahar has written a book, Knowing Practice,13 which combines the ethnographic study of practising physicians in China with analysis of contemporary medical literature, and examines how clinical practice both creates and draws on knowledge. Focusing on just three case histories, she examines the many different elements of the clinical encounter which combine to make up the complete process that ﬁnally results in a syndrome being diagnosed and a treatment being prescribed. This question of how theory is translated into practice, and vice versa, has not yet received in-depth attention from historians of Chinese medicine. Again this is in part a result of difﬁculties in uncovering exactly how the clinical side of medicine was practised in the past. However, physicians’ case histories do provide a means, although imperfect, of examining this transformation and this is an issue I examine as part of both the textual and gender analyses. Case histories are not the only means of examining historical medical practice, however, and certainly in the case of non-elite, non-literate or popular healers often no written record is left. One innovative way in which historians have tried to gain access to the clinical practice of such healers is through literature. For example, Laurence Thompson and Christopher Cullen have both based research on the Ming dynasty novel, Jin ping mei [‘Golden lotus’], which gives a detailed portrayal of society at that time that also includes encounters between the characters and various types of healer.14 From it they attempt to reconstruct the range of practitioners available, and so far as possible determine which practitioners were resorted to by which patients, for which illnesses, and why. This exercise serves as a reminder that historically the Chinese healthcare system did comprise a large range of healers, and that the implications of such a multiplicity of healers being active in Ming dynasty China is an important consideration when drawing any conclusions from my data, which relate to only one small sector of the health system. I found the method of textual analysis, particularly when combined with a text belonging to the case history genre of medical writing, a very fruitful and revealing approach to understanding the medical practice of a sixteenth-century physician. Through the text he spoke to me of his world, his fears, his frustrations and his experiences, and I tried to listen. In the next method that I use to analyse this same text, however, instead of listening to 8

INTRODUCTION

what Wang Ji is telling me I try to look beyond the written word and to read between the lines to uncover a story that is quite different from the one Wang Ji thinks he is telling.

The ‘gender analysis’ method Revealing as the last method was, this is in no small part due to the author and his own tales of the trials and tribulations of practising medicine. Although it is impossible to be certain, I am as conﬁdent as I can be that the portrait I have drawn, if not identical in every aspect, would at least be instantly recognizable to Wang Ji and his contemporaries. Whereas last time, successful or not, I endeavoured to leave my cultural baggage behind, in Chapter 4 I am consciously and deliberately bringing to the text the twentieth-century method of gender analysis to see what further dimension it can bring to our understanding of Wang Ji and his medical practice. My analysis of gender issues in Chapter 4 is divided into ﬁve parts: diagnosis, aetiology, illness syndrome, treatment and outcome. In each part I employ a combination of qualitative and quantitative techniques to compare Wang Ji’s treatment of the various ailments suffered by his male and by his female patients. In the analysis I was looking not only for areas of similarity and difference between the sexes, but also for differences in Wang Ji’s treatment of members of the same sex, in particular with regard to the reproductive status of his female patients, to see what effect this has on his understanding of the disorders they suffer. I then refer back to the social, economic and cultural context of sixteenthcentury Anhui, as described in Chapter 1, in an attempt to account for the differences I ﬁnd by recourse to the speciﬁc cultural forces acting on society at that time. Before any discussion of the results of this gender analysis and their implications, a brief examination of gender as a method of analysis and an introduction to some of the more inﬂuential texts for historians of gender and medicine in both China and the West over the past few decades might help to contextualize my own research. In this context, the term ‘gender’ is used to denote differences between the sexes which have no physiological basis, but which have been socially and culturally constructed.15 This can be contrasted with the term ‘sex’ which denotes the biological sex to which a person belongs. Therefore, whereas biological sex is largely 9

INTRODUCTION

ﬁxed, the dynamics of gender relations in any society are shaped by the operation of speciﬁc social, cultural and historical forces. An exploration of the relationship between the sexes in any particular context is often able to uncover the processes by which gender differences are constructed, legitimized and normalized, and thus can lead to a greater understanding of society and the forces that shape it. A study of gender differences can prove more revealing than an examination of just one sex alone. The gender identities of both men and women are cultural constructions which are often formed in relation to one another, and societal change will affect the perceived attributes of both genders. As a result, by concentrating solely on the cultural understandings of one gender in a given context without an awareness of either the other gender or the changing dynamic between them, a distorted and unbalanced picture can result. By way of example, early studies of women in the history of medicine revealed that particularly harsh treatments were meted out for menstrual and uterine disorders in Victorian times, and their authors concluded that this was indicative of hostile contemporary cultural attitudes towards women.16 When later studies revealed that treatments for male sexual problems were equally severe, the conclusions of the earlier studies were clearly undermined.17 Therefore, studies informed by an appreciation of the changing dynamics of the relationship between the sexes can often achieve more constructive and illuminating results. Like gender, medicine too is a cultural construction, and the foci of its concerns are inextricably linked with the beliefs, interests and anxieties of the society responsible for its creation and development. Recently, many scholars have begun to examine gender within the context of the history of Western medicine. One reason why this has been particularly fruitful is that Western medical science has often been credited with the ability to uncover the ‘truth’ about the body. Therefore, any pronouncements made about the nature of men and women have the potential to be widely accepted within the society and culture as statements of fact. For example, Victorian medical science often served to bolster cultural beliefs in white male supremacy, in one instance by trying to demonstrate the inferiority of both women and other races through their supposed smaller brain size. As the historian of medicine Ludmilla Jordanova wrote: 10

INTRODUCTION

[Gender] is about the dynamics between the sexes, as these are experienced, explained, and represented. It manifests itself in innumerable ways, at material, ideological and symbolic levels. It is not a biological given, but a cultural product, and hence is not inherent in objects but assigned to them through social and cultural practices. As embodiments of such practices, the natural and biomedical sciences fully participate in the forging of gender, and are themselves informed by it. As ﬁelds with a privileged relationship to nature, they play a major role in explaining and disseminating gender as a naturalized category.18 In this way, medicine, at least in the West, has been extremely inﬂuential in the creation and dissemination of gendered stereotypes within society. For me, Ludmilla Jordanova’s Sexual visions19 was one of the most innovative works on women in medicine, and one of the few to make full use of gender as an analytical tool. Adopting an iconographical approach which focused on medical images of gender in the last three centuries, Jordanova made use of hitherto neglected sources such as anatomical models, painting, medical illustrations, literature, ﬁlm and advertisements to examine concepts such as nature, gender, body image and the dichotomies male/female, public/private and nature/culture. For example, she shows quite revealingly how wax anatomical models representing women were recumbent, replete with long hair, naturalistic colouring, eyebrows and eyelashes, and placed in poses which in many cases were suggestive of those of women in well-known works of art, whereas the models of men were either truncated torsos or upright bodies in athletic poses without ﬂesh in order to display the muscles. These models were clearly representative of a culture which saw men as active, muscular and powerful, and women as passive, soft and gentle. Jordanova concludes that medicine helped construct and maintain cultural images of the differences between men and women, and that the issue is not one of women or oppression, but of gender and the cultural processes by which bodies are viewed and understood. Her work also gives new insights into the way in which a society unconsciously manifests its cultural values through a variety of media other than the written word, and shows how these values can later be 11

INTRODUCTION

reconstructed and deciphered. However, as Charlotte Furth has pointed out, the power of Chinese physicians to construct and maintain these cultural images of gender in the same way cannot be assumed, but will need to be established.20 Jordanova is also very critical of the overemphasis on pregnancy, childbirth, menstruation and gynaecology in most works on women in the history of medicine, as this implies that such topics were and are deﬁnitive of women’s lives. This is a point with which I am very much in agreement. Her work demonstrates that gendered assumptions are prevalent in medicine and medical imagery regardless of whether reproduction is involved. This is a fact which also comes out very strongly in the case histories of the Shishan yi’an. Another inﬂuential work for me is Lesley Ann Dean-Jones’s Women’s bodies in classical Greek science.21 In this text DeanJones examines medical understandings of the female body as reﬂected in the medical texts of the Classical period (500–323bc). Her work displays an acute awareness of contemporary gender theory, particularly in terms of the role of culture in constructing gender difference and of the role of medicine in legitimizing and naturalizing these sexual divisions. This awareness is apparent in her methodological approach which is to compare and contrast the physiology, pathology and reproductive processes of women in Hippocratic theory with those of the slightly later Aristotelian theory, and to examine the extent to which social and cultural change might have inﬂuenced the different medical perceptions of women’s bodies that she ﬁnds in the two traditions. She concludes that the Aristotelian belief in women’s basic similarity, but fundamental inferiority, to men reﬂects the contemporary cultural situation where women were gradually gaining more social, economic and legal rights, thus making them seem more like men, but where they were still regarded as being of subordinate status. From the perspective of my own work, interestingly, it seems that more often than not physicians in Classical Greece did see issues of menstruation and reproduction as central to female health, and evidence from the case histories Dean-Jones studied would seem to indicate that almost all female disorders were regarded as having a reproductive root. As I shall demonstrate, this is not at all the case in the Shishan yi’an. Work on gender in traditional Chinese medicine is only just beginning. General ahistorical introductions to the subject, such as works by Kaptchuk22 or Porkert,23 present a picture which 12

INTRODUCTION

suggests that Chinese medicine was largely the same for men and women. In fact, the question of difference is not even raised. This no doubt reﬂects the situation in the primary theoretical medical sources they consulted, where the body, as a physical reality, is not the central issue. More commonly, theoretical discussions were, and are, based around abstract concepts, such as yin () and yang (), the movement of qi (), the correlations of the ﬁve phases (wood, earth, metal, ﬁre, water), and invasion by external pathological inﬂuences such as wind, damp or summer heat. In discussions such as these where the sex of the subject of the text is often not explicitly stated, the traditional Chinese medical view of the body is not obviously gendered. The only obvious area where difference between the sexes becomes an issue for discussion is with regard to reproduction. Commonly, medical texts would discuss general medical theories and disorders in the main body of the work, and have sections on ‘women’s disorders’ (fuke ) and ‘children’s disorders’ (erke ) at the end. Generally, the section on women’s disorders would deal only with complaints relating to conception, pregnancy and childbirth, giving the impression that, reproductive differences apart, there was little difference between men and women in a medical sense. This impression is also borne out by quotations such as this one from the section on women’s disorders in the Qing dynasty medical encyclopaedia Yizong jinjian ! [‘The golden mirror of medical orthodoxy’], ‘The two branches [of medicine] relating to men and women have the same treatments. What differs is that [with regard to] menstrual regularity, uterine bleeding, vaginal discharge, bowel obstruction, conception, pregnancy, postpartum, the external genitalia, and breasts, the diseases are not the same.’24 This quotation, while highlighting reproduction as an area of difference between men and women, also draws attention to the presumed similarity of medicine for men and women in all other areas. This distinction between general and reproductive medicine is maintained in the early secondary literature concerning women in Chinese medicine which was almost exclusively centred on explorations of fuke literature, that is on texts dealing with the reproductive disorders suffered by women. Charlotte Furth, for example, the pioneering author in this ﬁeld, examined medical connotations of blood in fuke texts, looking at the association of women with blood, and blood with pollution, vitality and loss.25 13

INTRODUCTION

She also looked at concepts of pregnancy, childbirth and infancy in the Qing dynasty using medical texts,26 and at conception, gestation and infancy from a cosmological and philosophical viewpoint.27 However, despite the interesting insights provided by these and other similar articles, in the absence of other research at the time dealing with women’s non-reproductive experiences of illness the result was an overemphasis on the disorders of menstruation, conception and pregnancy. In addition, often many of the early articles did not take temporal, regional or authorial differences into account, giving the impression of a homogeneous corpus of medical texts which when added together would result in a uniﬁed picture of Chinese medical theory and practice. Similarly, women were often presented as a single undifferentiated group and factors such as class status, region and age were not taken into account. It was Charlotte Furth again who led the way in the 1990s with articles on gender, as she had in the 1980s with articles on women. In her article entitled ‘Ming-Qing medicine and the construction of gender’, she focused on the changes in medical theory over time, the gendering of the Chinese body, and the extent of medical inﬂuence on society.28 In another article she revised Van Gulik’s Sexual life in ancient China, the classic reference work on the subject, arguing that it was imbued with Eurocentric and androcentric constructions of sex and the Orient.29 Francesca Bray, another proliﬁc author in the ﬁeld, devoted a section of her book Technology and gender to an exploration of medical and gender history, covering topics such as generation, abortion, menstrual regulation and reproductive hierarchies.30 Furth has also now published her deﬁnitive guide to gender in Chinese medical history over the seven hundred-year period from the Song dynasty in the tenth century through to the late Ming dynasty in the seventeenth century.31 She combines a chronological historical approach with gender methodology and techniques for exploring the cultural construction of the body to examine her subject. Beginning with the androgynous body of the medical classic, the ‘Inner canon of the Yellow Lord’, she guides us through the changing understandings of male and female bodies over the centuries, as well as covering Ming obstetrics and ‘nourishing-life’ texts, the male– female dynamic in the clinical encounter as evidenced in a set of medical case histories, and the wide variety of female healers practising in the Ming. 14

INTRODUCTION

The work of Furth and Bray and other gender historians has shown that studies which focus on gender, that is the dynamics of the relationship between the sexes, and not just on one sex alone, can provide a more balanced and illuminating approach to medical history. However, overall the focus of scholarship on gender in Chinese medicine is still too centred on women’s reproductive disorders, and does not adequately represent the complete experience of illness suffered by women, or the physician’s response to similar illnesses in both men and women. Case histories seemed to me to be an ideal way to begin such an examination: whereas standard theoretical texts often lack an expressly gendered subject and gloss over differences between the sexes, and fuke texts have a certain bias towards the reproductive sphere, case histories present an opportunity to compare a physician’s treatment of men and women side by side. Case histories cover the broad spectrum of ailments suffered by a physician’s patients, which, although it includes reproductive disorders, also encompasses more general ailments which could conceivably be suffered by members of both sexes, and describes the manner in which the physician diagnosed and treated both men and women suffering from these disorders. I hoped that through an examination of a set of case histories it might be possible to uncover certain underlying assumptions about gender which existed in a certain area and among certain social classes in Ming dynasty China. In addition, I thought that when combined with my previous study of the cultural, social and economic context it might be possible to examine potential cultural origins of these perceptions, and the reasons underlying their perpetuation, and that this might help to create a better understanding of the interaction between gender, culture and medicine. I had three main reasons for choosing the case histories of the Shishan yi’an for my study of gender in traditional Chinese medicine. The ﬁrst of these is the juxtaposition of men and women in the text. Under the heading of each particular disease category, such as fever or dysentery, Wang Ji describes a number of cases, typically between one and ﬁfteen. For each case, Wang Ji outlines his management of the illness, from the initial encounter, through pulse taking, diagnosis, aetiology and recommended treatment, to the eventual outcome. Wang Ji saw both male and female patients, and as the accounts of the illnesses of the men and women are juxtaposed within each category, his treatment of each sex can be 15

INTRODUCTION

directly compared. Given that most other variables have been removed, the extent to which gender is a determining factor in any of the differences uncovered can be more easily ascertained. Case histories also have the advantage that each one begins with the words ‘a man’ or ‘a woman’, so it is Wang Ji himself who makes the primary distinction between the sexes; it is not a distinction I am imposing on the text. The depiction of clinical medical practice found in case histories is also advantageous for a gender analysis, and is another reason for selecting the Shishan yi’an, not least because the anecdotal nature of the case descriptions means that information is given above and beyond the simple diagnosis and can add to a deeper understanding of the gender dynamics of the patient/physician encounter. An example of this would be to compare the extent to which modesty was a factor in the examination of male and female patients. As I explained in relation to the textual analysis of Chapter 3, this access to the world of clinical medical practice can also be used to examine the transformation of theory into practice and vice versa. The same applies here in relation to the gender analysis: because many theoretical texts state that the only medical difference between men and women comes from their different reproductive capacities, if an analysis of non-reproductive disorders in the case histories highlights certain areas of gender difference which are not present in theoretical medical texts, or in a given physician’s theoretical framework, this would indicate that other factors, such as cultural preconceptions or religious teachings, may come into play when the theories are translated into practice. Finally, the depiction of individual patients as opposed to abstract notions of men or women, thus allowing differences between members of each sex to be explored, is another characteristic of the case history genre that lends it to a gender analysis. As many scholars have pointed out, women (and men) are not all the same, and cannot be treated as if they were some kind of homogeneous and self-deﬁning category. Factors such as social class, age, race, wealth and marital or reproductive status all may affect not only their health, but their self-perception and the physician’s perception of them. The case histories of the Shishan yi’an often contain information about the patient which facilitates an examination of differences between the women themselves. For example, it is possible to compare the treatment of women who are, are not or recently have been pregnant, or of women who are 16

INTRODUCTION

married or widowed, and so on. This is an important advantage of using case histories instead of theoretical texts which often do not differentiate between the sexes, let alone discuss age or class differences arising within each sex. Using just a single text for such an analysis, instead of drawing examples from across the case history genre, was also a deliberate choice. The contained nature of the text facilitates a direct comparison of the physician’s treatment of male and female patients whom he perceived to be suffering from a similar or related disorder. Most other variables not related to gender are eliminated, as all the cases examined would have originated in the same cultural, social, economic and geographical context, and the treatment and diagnosis would be carried out within a consistent theoretical framework. In an analysis of this kind, which attempts to assess the impact of various social and cultural factors on medical perceptions of gender, it was essential that as many of these external variables as possible are kept constant, as otherwise difﬁculties in the interpretation of any results obtained would have arisen. In looking at the text in this way, I am both bringing to it and taking from it something very alien to Wang Ji. Gender was not a concern of his, and he was not trying to convey anything about the differences between the sexes when he wrote the book. Because of this I am conscious that whereas with the textual analysis I can be conﬁdent that what was revealed was quite close to what Wang Ji was trying to convey, and bore some relation to his life and work, with this analysis the results are much more speculative and involve a high level of abstraction from the text. What I feel that I can know, as opposed to what I can simply hypothesize, is much less. However, so long as this is borne in mind, it should not detract from the very interesting insights derived using this method of analysis. For differences do indeed emerge from the text, and they were not at all the differences I was anticipating, yet nonetheless when considered in the context of contemporary culture an intriguing and exciting explanation began to take shape. One of the ﬁrst ﬁndings to emerge from my analysis was that in many respects differences found between women suffering from reproductive disorders and women whose disorders were not linked with reproduction were often more signiﬁcant than those found between men and women with non-reproductive disorders. Or put another way, reproduction apart, medical understandings of the male and female body were indeed often remarkably similar; 17

INTRODUCTION

neither Wang Ji’s diagnostic procedure, fundamental theoretical principles, understanding of the mechanism of illness, nor the type or quantity of treatments he prescribed seemed to be affected by the sex of the patient. This is consistent with the genderneutral content of theoretical medical texts, and would suggest that the conclusions drawn to date by researchers who focused on medical understandings of the female body as represented in texts dealing with the disorders of menstruation, pregnancy and childbirth cannot necessarily be extended to encompass women whose disorders did not fall into those categories. The results of this analysis also strongly support my hypothesis that cultural factors do exert a strong inﬂuence on a physician’s perceptions of gender and, by extension, on his treatment of men and women suffering from similar disorders. I found that although Wang Ji’s theoretical framework did not make any distinction on the basis of sex, in practice he was more liable to diagnose his male patients as suffering from disorders of depletion, as a result of their perceived overindulgence in sexual activity, drinking and rich foods, and that he was more likely to treat them with replenishing drugs and to give them more treatments before they recovered. Men, not women, were the focus of medical concern. I argue that when these gender differences are examined within the speciﬁc cultural context of sixteenth-century Anhui, this treatment of his male patients can be interpreted as a reaction to the anxiety he felt at what he perceived to be the declining morals of contemporary society, as exempliﬁed by the emerging merchant class with their new-found wealth, decadent behaviour and social aspirations. These three perspectives reveal different but complementary dimensions to Wang Ji’s life, work and experience which, when taken together, provide a more balanced picture than would result from any one method taken in isolation. They are not the only methods that could have been used, and they in no way amount to the whole story, nor are they the stories that Wang Ji or his disciples would tell. This raises the perennial issue for historians: what can we know of the past? And how do we know it? What credence should we give to the writings of those long gone? Does our existence in the present preclude us from seeing what they saw, or allow us to see more clearly with the beneﬁt of hindsight? Does their existence in the past give them access to truths we can never understand, or prevent them from understanding their own experience with the same clarity as a dispassionate and distant observer? 18

INTRODUCTION

These questions form the basis of any historical enquiry and this is no exception. My own perspective is that there is not one true history, or one correct historical methodology, but that multiple histories can be told and that only the vantage point of the viewer can determine their relative worth. Here we have three very different stories about the same Chinese physician, uncovered using three different methods and conjuring up three very different life experiences. One of the methods, for example, tries to get close to and convey the experiences of the physician as articulated by him, whereas another very consciously depicts a world he might not recognize. I would argue that it is not possible to say that any one of the methods is more ‘valid’ or that any of the stories is ‘wrong’: these three stories are not mutually exclusive but constitute different dimensions of one big picture varying with the approach taken to the subject matter. What is essential, however, is methodological awareness – awareness of the method used, what it can reveal about the past, what its limitations are, the extent to which conclusions drawn are fact, ﬁction or supposition, and an appreciation of the subjectivity of both the historian and the historical subject. This is analogous to the different images of a landscape obtained from aerial photography, a watercolour painting and a geologist’s report. Each of these methods of capturing the landscape is equally valid and yet results in a very different picture. At the same time, none of these methods can or ever will ‘be’ the landscape. This is also true of history. The past can never be wholly reconstructed, but aspects of it can be recaptured. The same can be said about the present, and observers, historical subjects or historians can only offer an interpretation of the world they are experiencing or studying. As for which method to take, utility has to be one of the driving forces, and the methods I have chosen serve my purposes with respect to what it was I wanted to ﬁnd out. I hope through their cautious and informed use to provide some illuminating insights into Wang Ji and his sixteenth-century medical practice.

19

INTRODUCTION

20

MEDICAL CULTURE AND CONTEMPORARY SOCIETY

CHAPTER 1 WANG JI, MEDICAL CULTURE AND CONTEMPORARY SOCIETY

Wang Ji (1463–1539), like his father before him, was a renowned physician, and practised medicine in and around Qimen , in present-day Anhui province, during the early sixteenth century. Along with She , Yi , Xiuning , Jiqi , and Wuyuan which is in present-day Jiangxi province, Qimen is one of the six counties (hsien ) in Southern Anhui situated south of the Yangzi river which constitute Huizhou prefecture. Many sixteenth-century scholars, Wang Ji included, would commonly refer to this area as Xin’an , in reference to the Xin’an Mountain in Qimen. Xin’an is also the term used by modern-day researchers writing on the subject of Huizhou medical culture. The Zhengde (1506–21) and Jiajing reigns (1522–66) of the Ming dynasty (1368–1644), during which Wang Ji was actively practising medicine, marked a period of historical change that was to have far-reaching implications both within Qimen and throughout China, and that heralded a new era characterized by increased social mobility, and in particular the emergence of a wealthy merchant class. It is clear that the factors which on a national and regional level affected change in social, economic and cultural terms also greatly inﬂuenced many aspects of Wang Ji’s life and work. Therefore any analysis of his text, the Shishan yi’an ! [‘Stone Mountain medical case histories’], needs to be accompanied by a thorough contextualization that incorporates an awareness of the changing dynamics of contemporary society and their effect on the medical culture of the region. 21

MEDICAL CULTURE AND CONTEMPORARY SOCIETY

Contemporary society The reign of the Jiajing emperor is usually seen as the beginning of the decay of the Ming dynasty, with imperial neglect, government corruption, increasing power held by the eunuchs, the decline of the military, increasing taxes and other signs of dynastic decline being clearly visible.32 However, the early sixteenth century is also considered to be the dawning of a new age – late imperial China, a distinct historical period spanning four centuries and possessing a number of key characteristics, in particular with regard to the continuity of its social and economic structure, that give it internal cohesion and mark it out from what had gone before.33 In general terms, factors crucial to this transition include the commercialization of the economy, increasing urbanization, reforms to the government-controlled salt monopoly, and population increases combined with a reduction in the number of civil service posts. The effect of these forces was further intensiﬁed in Huizhou by their interaction with speciﬁc regional factors such as the availability of natural resources and steep increases in land tax. During the Zhengde and Jiajing periods there was an increase in the use of silver as a medium of exchange, partly due to imports from Japan, the Philippines and Europe, as well as government attempts to make taxes payable in silver. As a result, silver became the main unit of currency in the lower Yangzi valley, and this in turn promoted commercialization of the economy, which was accompanied by an expansion in interregional trading, and extensive growth in both industrial and agricultural commerce. Widespread urbanization combined with improvements in transportation networks, which served to connect these new urban developments, to create local and regional market systems and to promote commercial activity on a wider scale than had previously been possible.34 At the same time, alterations were made to the regulations governing the trade in salt which greatly enhanced the proﬁtability of salt trading as a commercial enterprise, and therefore naturally increased the number of merchants engaging in it. Previously salt merchants had had to transport grain to northern frontier posts in order to gain certiﬁcates which entitled them to purchase salt, but in 1492 the regulations were changed and these certiﬁcates could be bought with silver, removing the need for costly and time-consuming grain shipments, and moving the focus of the salt trade away from the northern provinces of Shaanxi

22

MEDICAL CULTURE AND CONTEMPORARY SOCIETY

and Shanxi to the salt-producing areas of Jiangsu and Zhejiang .35 One of the most noticeable effects of these new developments on contemporary social structure was the emergence of a wealthy merchant class, and nowhere was this effect more pronounced than in Huizhou.36 There are a number of reasons which are generally held to account for this. Firstly, in geographical terms, Huizhou is a particularly mountainous and barren region with little arable land. This combination of low agricultural productivity with an usually high population meant that ever since the Song dynasty the inhabitants of Huizhou had had to turn to trade for survival, often leaving Huizhou to look for a livelihood elsewhere.37 It also led to the early commercialization of Huizhou agriculture and a shift to the production of local export commodities, such as tea.38 Therefore Huizhou merchants were well placed to take advantage of the new commercial opportunities brought by the economic developments of the sixteenth century. Secondly, despite the scarcity of agricultural land, the area was extremely rich in natural resources such as timber, paper, tea, ink, cotton, clay and silk which could be traded for grain or silver in other provinces. Qimen, for example, was particularly renowned for its ﬁne teas, and for its white clay which was used for making porcelain in nearby Jingdezhen .39 Thirdly, Huizhou was ideally located, with the mountains providing a barrier against invasion, and near two rivers, the Dagong and the Xin’an, connecting it to Jingdezhen and Jiangxi province on the one hand, and the tea market at Tunxi and Zhejiang province on the other, thus facilitating the transportation of local produce to market towns and cities and, just as importantly, giving access to Huai’an and Yangzhou which were the centres of the lucrative government-run salt monopoly that the Huizhou merchants famously dominated.40 Finally, the early sixteenth century saw land taxes in Huizhou increase dramatically. A connection between these steep taxes which discouraged land owning and the increased interest in mercantile activity in the area was made by the writer and ofﬁcial Xie Zhaozhe (1567–1624) who contrasted the situation in Anhui with that in Fujian where the taxes were light and people competed for land.41 As a result of these factors Huizhou witnessed an explosion in trade and commerce, and such a sudden increase in the number of merchants that in some areas they were thought to outnumber farmers.42 Huizhou merchants were renowned throughout China, 23

MEDICAL CULTURE AND CONTEMPORARY SOCIETY

and as well as trading in local produce such as timber, paper, ink, books, tea, silk and porcelain, they were extensively involved in salt, grain and ﬁsh. Their interests also extended to pawnbroking, usury and the building of storehouses and inns to store their merchandise.43 Such was their reputation that there was even a common saying to the effect that ‘a city would not be a city without the presence of a Huizhou merchant’,44 and indeed their domain stretched from the northern capital of Beijing45 to the southern coastal markets of Fujian and Guangzhou.46 Nor were their activities conﬁned to China; they were even engaged in maritime trading, selling silks to Japan, Siam and Korea.47 And, needless to say, Huizhou merchants were not merely proliﬁc, they were also fantastically wealthy, as this quotation from Xie Zhaozhe suggests: Those renowned for their wealth to the south of the Yangtze are from Hsin’an, and to the north of it from Shansi. The great merchants of Hsin’an deal in ﬁsh and salt and have acquired fortunes of up to a million taels of silver; those with only two or three hundred thousand only count as middling merchants. The Shansi merchants deal in salt or silk or go in for reselling or the grain trade. They are even wealthier than the Hsin’an merchants.48 One of the most signiﬁcant factors resulting in changes to the fabric of society, that is the phenomenon of increased social mobility, was greatly inﬂuenced by the emergence of this merchant class with their new-found wealth.49 Naturally the mere accumulation of funds did not satisfy the merchants’ desires – they wanted the power and the status that money can buy. They also needed the protection that strong ties with local ofﬁcials could afford. This necessitated their ﬁnding ways of gaining acceptance to the gentry world. Their attempts to buy their way into the elite manifested themselves in a variety of ways, and had a substantial impact on Huizhou’s cultural life.50 One way in which they aped elite culture was through patronage of the arts, collecting rare books, paintings and antiques such as jewellery, amber, ivory and so on.51 They learned to compose poetry and play musical instruments such as the zither, accomplishments which showed an understanding of and a long-term commitment to the cultural practices of those they sought to emulate.52 They also became generous 24

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philanthropists, building ancestral temples; funding schools, colleges and the publishing of rare books; arranging for medicines to be distributed to the poor; helping less well-off lineage members to better themselves; and partaking in other charitable works.53 Marriage was another mechanism by which merchants could effect an entry into elite circles: by marrying a son or daughter into a scholar-ofﬁcial family, they could achieve closer personal, political and social alliances with them.54 However, as one might expect, the most popular and sought-after symbol of status was to hold government ofﬁce or to pass the civil service examinations, and it was in the pursuit of this goal that the merchants perhaps had most effect on local culture. There were two routes to gaining an ofﬁcial title: the ﬁrst, which became easier after 1451,55 was by purchase and in this way being accorded the privileges of higher rank, and the second of course was to take the examinations. It was this latter method which was to have far-reaching repercussions on levels of literacy and education within the region. In using their wealth to achieve academic status, merchants stimulated intellectual development in a variety of ways. They ﬁnanced both charity elementary schools and higherlevel academies and colleges,56 collected and reproduced rare books, often amassing large private collections,57 and funded the publication and circulation of both ancient classics and new genres of texts.58 One such new genre was the encyclopaedia. These appeared on a range of subjects, from management of household affairs to letter writing and exemplary examination answers, intended to help people of lower status attain the necessary knowledge to improve themselves and their opportunities. In the same vein, there was also increased demand for morality books, which promoted the idea that by doing good deeds and accumulating virtue it was possible to be rewarded in this world, not the next; such books were therefore popular with all those wishing to achieve success in a wide range of ﬁelds.59 Apart from merchant patronage, other factors affecting this boom in publishing and literacy included: a wider market for books brought about by the improvement in transportation networks which gave access to urban centres throughout the country; the natural resources and technology available in the region for the production of the ‘four treasures of stationary’, inkcakes, inkstones, paper and brushes;60 the high level of quality craftsmen and engravers required for the manufacture of woodblocks for printing; and innovations made 25

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in publishing technology such as the invention of copper moveable type and colour illustrations.61 Over time the Huizhou merchants had considerable success in assimilating themselves into elite culture. However, the social mobility characteristic of the period was not a one-way process; scholars and ofﬁcials were also turning to trade, often because of the increasing difﬁculties in attaining ofﬁcial posts as a result of increased competition from the aspiring lower classes and reduced civil service intake quotas. Having become successful merchants, they would then often encourage their sons to study for the civil service examinations. This quotation from the Ming dynasty scholar Wang Daokun (1525–93), an examination graduate (jinshi ) of 1547, illustrates this phenomenon: Hui-chou, with approximately one scholar out of every three merchants, is a highly cultured area. For just as merchants seek after handsome proﬁt, scholars strive for high honours. It is not until a man is repeatedly frustrated in his scholarly pursuit that he gives up his studies and takes up trade. After he has accumulated substantial savings he encourages his descendants, in planning for their future, to give up trade and take up studies. Trade and studies thus alternate with each other, with the likely result that the family succeeds either in acquiring an annual income of ten thousand bushels of grain or in achieving the honour of having a retinue of a thousand horse carriages. This can be likened to the revolution of the wheel, with all its spokes touching the ground in turn. How can there be a preference for any one profession?62 The effect of this process was to increase the blurring of distinctions between scholars, ofﬁcials and merchants to the extent that some have suggested that by the seventeenth century the social positions of ‘merchant’ and ‘literatus’ were almost interchangeable.63 One contemporary writer is quoted as praising a Huizhou merchant family for being ‘gentry yet merchants’, and one Huizhou merchant is said to have instructed his son that ‘gentry and merchants pursue different methods but share the same commitment’.64 Even if these sentiments were not universally shared, they do show the extent to which the Confucian maxim placing the merchant as the lowest of the four social categories – gentry 26

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peasant, artisan, merchant – had been superseded in Huizhou society in the mid-Ming.65 However, this blurring of status did not occur without anxiety and tension, particularly on the part of the elite who saw their lofty status disappearing and their old way of life being eroded. Their ofﬁcial careers were no longer secure, and they were facing stiff competition for fewer places from the newly cultivated merchant class. Their traditional reliance on land owning was in jeopardy, particularly in Huizhou with its exorbitant land taxes. This understandably provoked feelings of insecurity and anxiety, and as Timothy Brook has noted, merchants were made to bear the moral disapprobation accompanying the changes to the social hierarchy and settled village life wrought by the expansion of domestic and maritime trade.66 Elite concerns were manifested through a preoccupation with a perceived moral decline that pervaded society as a whole and a nostalgia for a past golden age where the traditional order still applied.67 According to the gentry, this decline could be seen in the changing socioeconomic structure, growing disorder in rural relations, declining standards in the management of foreign trade, and not least in the extravagance of the merchants who used their wealth not only for social advancement but also for personal pleasure.68 Merchants were described as ﬂaunting their wealth, building sumptuous palaces, wearing expensive clothes, riding in carriages, and surrounding themselves with beautiful women.69 There is also plentiful evidence in literati sources to the effect that the Huizhou merchants adopted decadent and debauched lifestyles, gambling, banqueting and frequenting brothels throughout the Jiangnan area.70 Nor were scholars seen to be exempt from taking advantage of the region’s new-found prosperity by indulging in drinking, feasting and the company of ‘sing-song’ girls;71 Xie Zhaozhe comments that even monks were drinking wine, eating meat and marrying wives.72 One clear example of literati disapproval of this new decadent merchant culture is the anonymous late sixteenth-century novel Jin ping mei [‘Golden lotus’] which is both a reaction to, and an undisguised criticism of, the perceived low morals of the age, not only at the level of the individual household depicted, but also at the level of government and society as a whole.73 The novel narrates the rise and fall of a wealthy merchant who bribes his way into an ofﬁcial post and lives a debauched, decadent and corrupt lifestyle before ﬁnally dying of sexual exhaustion. It is no 27

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coincidence that a merchant was chosen to represent the declining morals of contemporary society. As well as being popular with merchants aiming to improve their social status, the morality books, so prevalent in the Ming, have also been associated with literati anxiety. According to Evelyn Rawski, status anxiety on the part of the older elite may have motivated them to write morality books which they hoped would help to halt the moral decline brought about by the rise of new groups to social and economic prominence.74 In stark contrast to these images of extravagance and excess, Huizhou also enjoyed a reputation for frugality and thrift. Gazetteers in the Jiajing period described merchant families as being practical and frugal. Huizhou women in particular were said to be very restrained, not eating meat or ﬁsh, and working industriously to contribute to the family economy.75 These women were also regarded as being very chaste, remaining loyal to their husbands who were away on business for much of the year.76 Indeed, Anhui had more chaste widows than any other province in the Ming, with an increasing number of lifelong widows and suicides from 1460.77 Zurndorfer suggests two explanations for this contradiction. Firstly, the merchants lived simply when at home with their families, but when away on business in the city they lived up to their extravagant reputation. If this is taken one step further, perhaps a distinction can be made between the sojourning man who was exposed to the temptations of the city, and the stay-athome wife who managed the family’s ﬁnancial affairs, drawing up and keeping to a sensible budget, investing any savings in property or proﬁtable ventures, and preventing her husband from squandering the family’s wealth, in the process giving the region its reputation for thrift and diligence.78 Alternatively, Zurndorfer proposes that the gazetteers may have exaggerated the Spartan lifestyle led by the inhabitants of the area so as to draw attention away from the extravagant reputation of the merchants and thus avoid even higher government taxes.79 Another reason for such exaggeration might be that the writers, critical of what they perceived as the increasingly proﬂigate and lavish behaviour of many members of their society, emphasized the virtues of chastity and frugality when writing a biography, preface or eulogy, painting their subject as having led an exemplary simple and restrained life in order to encourage similarly exemplary behaviour in others. 28

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In sum, the Zhengde and Jiajing eras in which Wang Ji lived and worked were periods of intense change marking the transition to late imperial China. The economic boom engendered by the monetarization of the economy, and characterized by widespread urbanization, better transportation networks and greater trading opportunities, had far-reaching social, economic and cultural implications for Huizhou. The emergence of a new merchant class hungry for wealth, power and status triggered a ﬂourishing of cultural life with merchant patronage of the arts, education and publishing. However, while the elite also beneﬁted from these developments, increased social mobility fostered an atmosphere of profound anxiety and gave rise to a perception of declining morals and decadent behaviour. It may be that the merchants did indeed lead the extravagant lifestyles ascribed to them, but it could equally be argued that such assertions of moral superiority formed a discourse that was used by the literati to maintain some sense of the difference between themselves and the merchants, a difference which was being continually eroded as the boundaries between the two social classes became increasingly blurred. Brook interprets the nostalgic contrived memories of a previous golden age, and language of decline, as a rhetoric designed to suppress the powerful changes sweeping China in the mid-Ming, where even though, ironically, the gentry stood to gain in many ways from the wealth generated by commerce and the shifting balance of power and status, they lacked an ideological framework by which they could rationalize, let alone condone, the changes taking place around them.80 I shall argue later that this rhetoric and its underlying tensions are clearly visible in Wang Ji’s understanding of illness as it is reﬂected in his Shishan yi’an.

Medical culture 81

Xin’an medical culture ﬂourished during the sixteenth century, attaining an unprecedented level of activity, inﬂuence and accomplishment which continued throughout the late imperial period. In fact, one modern scholar has reckoned that, between the Song dynasty and the end of the Qing, Xin’an produced a total of 523 famous physicians, and generated 449 medical books.82 This productivity is in no small part attributable to the changes, already documented, which were affecting the whole of cultural life in the region. Increasing commercialization, the emerging merchant class, 29

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improved transportation networks, and the publishing boom all had a profound effect on medical culture. Some idea of the impact of socioeconomic development on contemporary medical practice can be gleaned from an examination of issues such as the size and composition of the medical elite, the extent to which physicians were aware of their contemporaries and the works they produced, and the various mechanisms by which medical knowledge was transmitted, including the increasing use of printed materials as a means of instruction. The rich profusion of historical sources that date from this period also makes it possible to identify some of the most inﬂuential physicians and medical writers who rose to prominence at this time and to trace some of the links between them. In Qimen during the sixteenth century, apart from Wang Ji and his father Wang Wei (1433–1515), the physician of most renown was Xu Chunfu (1520–96), author of the Gujin yitong daquan !"# [‘Complete synthesis of medical knowledge past and present’] and ofﬁcial of the Great Medical Ofﬁce (taiyiyuan ) in Beijing. It was while he was in the capital that Xu Chunfu created one of China’s ﬁrst medical societies which called a meeting of forty-six physicians from around the country in 1568.83 This inaugural meeting was also attended by another Qimen physician, Wang Chen . Also of note is Chen Jiamou (1486–1570), who specialized in materia medica and wrote an introductory work on the subject which was praised by Li Shizhen (1518–93), also a contemporary of Wang Ji but from Hubei province, and famous as the author of China’s best-known materia medica, the Bencao gangmu [‘Systematic materia medica’].84 She county produced more physicians of note than any other in Anhui. The best known of these were Jiang Guan (1503–65) and his son Jiang Yingsu who compiled the ﬁrst collection of medical case histories, the Mingyi lei’an ! [‘Cases of famous physicians arranged by category’]. As well as containing case histories from famous physicians throughout the ages, this work also included the cases of many contemporary physicians, several of whom came from Xin’an, including Wang Ji, his father Wang Wei, and Wu Qiao , also from She.85 Wu Qiao’s father Wu Yang had travelled, receiving medical teaching from a number of physicians, including Wang Ji, and his skills were passed on to his son and his grandsons Wu Pingzhong and Wu Hezhong .86 Medical knowledge was commonly passed 30

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down through families in this way, and She county had a number of families of hereditary physicians. One of the most prominent families of this kind was the Wu family which began with Wu Zhenglun (1529–68) and continued for ﬁve generations.87 Wu Zhenglun’s brother’s grandson Wu Kun (1551– 1621), author of the Yifang kao [‘Studies of medical prescriptions’], was apprenticed to another local physician, Yu Wuting , who was himself the founder of a family of hereditary physicians in She that endured for eight generations. Finally, Fang Youzhi (1523–93) produced a revised version of the Shanghan lun [‘Treatise on cold damage disorders’], entitled Shanghan lun tiaobian !" [‘Treatise on cold damage disorders: systematic critical examination’], which was published in 1591 and proved to be very inﬂuential.88 The physician of greatest renown from Xiuning is perhaps Sun Yikui (1522–1619) who received the teachings of Wang Ji indirectly through Wang Ji’s disciple Huang Gutan . Sun Yikui travelled extensively throughout the Jiangnan region, receiving teaching from various physicians, and practised for over thirty years. He passed his medical knowledge on to his sons, who compiled a volume of his case histories, entitled Sun Wenyuan yi’an !" [‘The medical case histories of Sun Wenyuan’].89 Also from Xiuning, but slightly later, was Wang Ang (b. 1615). Wang Ang was from a merchant family connected with the Huanduzhai bookstore in Hangzhou, and turned to medicine late in life. He believed in the accessibility of medical knowledge, and his main accomplishment to this end was to simplify and abridge the ﬁve-volume Bencao gangmu into a more practical one-volume text entitled Bencao beiyao ! [‘The comprehensive essentials of materia medica’]. His sons and grandsons all followed in his footsteps, and his medical inﬂuence can be traced through ten generations to the present day.90 These then were the physicians of greatest renown in Huizhou in the sixteenth century. But who were they, and what made them choose a career in medicine? Angela Ki Che Leung writes that doctors retained an ambiguous status in Ming and Qing times, and that ‘even the most learned medical man was likely to have abandoned Confucian studies or failed the civil service examinations’.91 This picture is borne out to some extent by the Xin’an physicians, in that Wang Ji92 and Wu Kun,93 for example, both turned to medicine after failing to pass the civil service 31

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examinations. Although Wu Kun came from a family of hereditary physicians, and therefore might have been expected to follow that path initially, he only turned to medicine when he had achieved no academic success after ten years of study. However, there are other reasons cited for a medical career, and contrary to what Leung suggests, it was not always a downward step. For example, for merchants trying to climb the social ladder, although a bureaucratic career was preferable, being a physician was a good second best in terms of respectability and status. The Wang family of hereditary physicians alternated between trading in salt and following medical careers,94 and Wang Ang, the founder, said that he speciﬁcally chose to turn to medicine in order to serve the community. His wealth, gained as a merchant, enabled him to distribute medical texts freely, and this charity enhanced his prestige and respectability.95 Such a desire to serve one’s kin or community in a Confucian sense is often cited as a reason for becoming a physician, particularly following the illness of a family member: Wang Ji is said to have decided to study medicine to help his ailing mother;96 Sun Yikui gave up trading to follow a medical career after his father’s repeated illnesses;97 Xu Chunfu was prompted to give up his studies after his own illnesses;98 and Fang Youzhi turned to medicine after the death of two wives and ﬁve children.99 However, it must be remembered that in some cases these benevolent motives may have been ascribed to them by their biographers and may not accurately reﬂect their own sentiments. Finally, some physicians saw medicine as a way of earning money, for example Huang Gutan, who is said to have given up his vocation as a poet because of family impecuniosity.100 Huang Gutan’s situation leads to the question of the extent to which becoming a physician was a way of making a living. This is something which is rarely, if ever, mentioned in medical texts. It is thought that this reticence is in part related to elite physicians’ desire to convey an image of themselves as respectable gentlemen, not commercially minded artisans or tradesmen.101 The Shishan yi’an contains no references to remuneration of any kind received by Wang Ji for services rendered. While remuneration may not have been an issue for those from elite or wealthy merchant families, others such as Huang Gutan or families of hereditary physicians must have been looking to make some kind of a living from their profession. Patronage by emperors and high ofﬁcials had been 32

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one form of support for physicians in earlier dynasties, but by the Ming, medical patronage appeared in the more indirect forms of support for the publishing of medical texts and funding for temples to medical deities.102 Apart from gifts received from grateful patients, one likely source of income may have been the prescriptions that Wang Ji and other physicians provided to their patients to treat whatever disorder was diagnosed through the clinical encounter. Research among modern practitioners of traditional Chinese medicine has shown that often they do not charge for advice but expect to be paid for the medicines they procure,103 and this may also have been the case in the Ming dynasty. In addition, increasing numbers of physicians in Xin’an during the Ming dynasty, Wang Ji included, are known to have set up their own pharmacies dispensing medicines,104 and it has been suggested that as the market for materia medica became increasingly sophisticated such pharmacies were a means by which a physician might become a wealthy man.105 Thus the increased competition for an ever dwindling number of ofﬁcial posts does not solely account for the choice of Xin’an physicians to follow a career in medicine. Although medicine may have been a second-choice career for those from elite or scholarly families, for some merchant families it represented a step up in terms of social status, not only because of the level of literacy and depth of knowledge required, but also because of the opportunity it provided to serve one’s community and by doing so to gain both spiritual merit and earthly respectability. Thus Xin’an physicians did not necessarily share a common background. Their ranks included failed scholars looking for an alternative career; those following medicine as their forefathers had done before them; those who desired to serve their kin or community, either for reasons of Confucian ﬁlial piety or to attain spiritual merit by doing good deeds; and those for whom a medical career was a way of improving their family’s prestige and social status. And whatever their background, a career in medicine may also have provided some with a much needed means of making a living. The decision to become a physician was therefore based on a number of factors and, in Xin’an in particular, was very much inﬂuenced by the changing social, economic and cultural situation. To what extent were these physicians aware of each other? Did they practise and write as individuals, or did they perceive themselves as part of a wider tradition? The evidence would suggest 33

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that a number of cultural factors combined to create a body of physicians who were much more aware of each other, and of their shared heritage, than had previously been the case. In terms of direct contact between physicians, as before, there was a strong master–disciple relationship, but in contrast to the situation in previous times, the improved transport networks and increased regional contacts through trading links meant that the reputation of a physician spread further, and that disciples had greater access to their teaching. For example, we know that Sun Yikui, from Xiuning, was a disciple of Huang Gutan from neighbouring Yi county, but he also travelled extensively throughout Jiangnan, receiving teaching from many other physicians.106 Similarly, Wu Kun, from She, was apprenticed to Yu Wuting who was also from She, and again travelled throughout the region, reputedly being taught by a total of seventy-two physicians.107 The presence of Huizhou merchants throughout China brought them into contact with physicians from other areas, thus allowing the possibility that they might acquire knowledge from these physicians, which would then be carried back to Huizhou when they returned. For example, Wang Ji is said to have received information about the acupuncture and moxibustion skills of Lin Hanzhang and Li Qianhu , who came from neighbouring provinces, through travelling merchants. Conversely, merchants who moved away from the region with their family, and who either had a physician as a member of the family or were physicians themselves, would increase the inﬂuence of Xin’an medicine in other parts of the country, particularly if they took on disciples and opened bookshops or pharmacies.108 There was also a trend towards physicians networking with each other, exempliﬁed by the society created by Xu Chunfu which met with forty-six physicians from seven provinces in Beijing in 1568.109 The rapid expansion of the printing industry at this time also meant that direct contact between physicians became less essential as knowledge could be transmitted in written form.110 Books became more accessible, and as a result physicians became more aware both of their heritage, through reprints of ancient classics, and of the work of their contemporaries, through the circulation of newly published texts. Thanks to the increased circulation of books by travelling merchants, texts were not just conﬁned to the region in which they were published, so physicians from different regions had access to each other’s work. For example, as mentioned 34

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above, Li Shizhen (1518–93) from Hubei commented on a materia medica compiled by Chen Jiamou (1486–1570). Given that the two men were contemporaries, Chen Jiamou’s work was obviously circulating during his lifetime. Similarly, Fang Youzhi produced a revised edition of the Shanghan lun which was transmitted to Jiangxi where it inﬂuenced three authors to write books expanding on his ideas.111 We also know that Wang Ji was aware of the written work of at least four of his contemporaries from other provinces, Xue Ji (1486–1558) and Wang Lun (1453– 1510) both from Zhejiang, Han Mao (ﬂ. 1522) from Sichuan, and Wei Guiyan (ﬂ. 1525) from Jiangsu, as their works were very inﬂuential on his own writings and theories. This awareness of other physicians is also demonstrated in writings such as Xu Chunfu’s Gujin yitong daquan which is not only a comprehensive theoretical work but has a section devoted to biographies of famous physicians, including Wang Ji. This would indicate that the actual lives of the doctors, as well as their theories, were being recorded and regarded as of interest. The vast collection of 2,405 case histories by 141 different physicians, dating from the Han through to the Ming, amassed by Jiang Guan for inclusion in his Mingyi lei’an is added conﬁrmation that medical knowledge, both ancient and contemporary, was available to Xin’an physicians.112 In addition, the increasing level of overseas contact meant that the inﬂuence of Xin’an medicine was not just conﬁned to China; a number of books are known to have been sent to Japan and Korea, including Wang Ji’s Shishan yi’an, Jiang Guan’s Mingyi lei’an, Wang Ang’s Bencao beiyao, and Wu Kun’s Yifang kao.113 The large number of families of hereditary physicians in the area also ensured that medical knowledge was not just transmitted horizontally, but was passed down vertically through successive generations. Later generations would then publish the writings of their ancestors. Often this occurred only one or two generations later, such as the collection and publication of Sun Yikui’s case histories by his sons,114 but on occasion many generations later, as in the case of the writings of Yu Wuting which were published in 1746 by a member of the eighth generation, Yu Zhaoling .115 These examples represent only a fraction of the many links Xin’an physicians had both with other physicians from the region, and with physicians on a more national level. The social and economic changes in Huizhou in the sixteenth century served to increase the opportunities for physicians in terms not only of 35

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direct contact with other physicians, but also of indirect contact through the increased publication and wider circulation of medical texts. As a result, there was a heightened awareness among Xin’an physicians not only of their heritage but also of new developments being made in contemporary medicine. The effect of merchant culture on medical education and publishing was not limited simply to the increased publication and circulation of texts; merchant patronage, and the desire to use knowledge as a means of increasing social status, resulted in much more profound changes in these areas. For example, merchants would donate money to schools and colleges,116 fund the medical education of less wealthy lineage members,117 and collect ancient medical texts, thus ensuring their continued survival. However, their area of greatest inﬂuence in relation to the publishing industry was perhaps on the type of books being produced, and who published them. The increasing commercialization of the period meant that many people, and merchants especially, had the funds to publish books privately. Of particular renown as private publishers were Wu Mianxue and Wang Ang. Wu Mianxue published a great many medical works, but his aim was not proﬁt but rather the accumulation of spiritual merit through correcting the errors found in medical works and thus creating a new medical orthodoxy. As Wu Mianxue was a merchant, his respect for orthodox tradition can be seen as an attempt to achieve elite status through embracing traditional values. Wang Ang has already been mentioned several times as the author of the Bencao beiyao, but he was also involved in publishing and connected with the Huanduzhai bookstore. Again, he was concerned with spiritual merit, but his focus was the popularization of medical knowledge, and to this end he simpliﬁed and published medical classics in order to make them more accessible to the general population.118 Alternatives to publishing by merchants included the publication of medical works by physicians. For example, Jiang Yingsu published his father’s Mingyi lei’an, Fang Youzhi published his annotated Shanghan lun, and Wang Ji’s disciple Chen Jue published his master’s Wangshi yixue qishu !"# [‘The seven medical books of Mr Wang’].119 In addition, bookstores, private book collectors, colleges and the imperial government were also involved in the publication of medical texts.120 A number of factors, including the general prosperity of the region, rising levels of literacy, and concerns about the accessibility of medical 36

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knowledge therefore combined to create a vibrant and diverse range of medical publishing initiatives. The type of book being written and published also reﬂects the changing culture, the concerns of the publisher, and the different needs of the reader.121 As noted above, merchant publishers such as Wang Ang saw the opportunity for spiritual gain by acting as charitable benefactors, producing and distributing general readers and simpliﬁed versions of standard medical works. These must also have been popular with their intended audience, the newly literate sector of the population, as a great number were produced, often in rhyme to aid memorization, like Wang Ang’s Yifang tangtou gejue !"# [‘Medical prescriptions in verse’]. This tendency towards simpliﬁcation is also reﬂected in the increasing number of annotated classics being produced, such as Wu Kun’s Huangdi neijing su wen Wu zhu !"#$% [Wu’s annotated version of the ‘Inner canon of the Yellow Lord – basic questions’] for example, perhaps reﬂecting their use as self-help guides for those wishing to pursue a medical career but unable to afford an apprenticeship with a physician. In the same vein, medical case histories, like Wang Ji’s Shishan yi’an and Jiang Guan’s Mingyi lei’an, which demonstrated the practical application of medical theory, also emerged as a genre of writing. At the opposite end of the spectrum, the other main trend was towards comprehensiveness, with a range of encyclopaedias, printed collections (congshu ) and reference works arranged by category (leishu ) being published. Both of these trends represent the changing mechanism by which medical knowledge was transmitted, with the emergence of a new audience who gained their learning from books, be they aspiring scholars or simply enthusiastic amateurs. Book collectors were also inﬂuential regarding the types of book published, and were often responsible for ensuring the republication and circulation of earlier texts, such as the reprinting of the Tang dynasty classic Waitai miyao ! [‘Arcane essentials from the imperial library’] by Cheng Yandao from She, thus ensuring the survival of these classics and increasing contemporary familiarity with the work of their medical predecessors. In addition, in-depth analyses relating to each individual speciality, including materia medica (bencao ), prescriptions (fangji ), internal medicine (neike ), surgery (waike ), paediatrics (erke ), gynaecology (fuke ), and acupuncture and moxibustion (zhenjiu ), were aimed at a readership of more 37

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advanced physicians and scholars. This wide variety of medical works is both a reﬂection of an increased level of activity within the region on the part of physicians and publishers, and also a response to the wide-ranging demands of a newly captive audience of readers. Wang Ji was therefore an important part of Xin’an medical culture during what many would consider its most inﬂuential and productive period. Medicine was not immune to the social and economic changes affecting the entire region, and their impact was noticeable on many aspects of medical culture. The social mobility characteristic of the period meant that physicians came from a variety of backgrounds, and often had very different reasons for deciding to pursue a career in medicine. The increasing amount of contact between physicians, both in terms of direct contact resulting from improved transport networks and greater mobility, and in terms of indirect contact resulting from the boom in publishing and increased access to books, created an environment in which they were more aware of each other. Therefore, despite their diversity of background, physicians appeared as more of a cohesive group than they had previously. The effect of general prosperity and merchant patronage was to increase both the type and quantity of medical books being produced, and many new genres, such as general readers and medical case histories, emerged to satisfy the needs of a new and diverse readership. Many of these features characteristic of Xin’an medical culture were also noted by Chao Yüanling in her study of Suzhou physicians in late imperial China.122 She interprets these developments as part of a move towards professionalization on the part of the elite physicians, and much of her analysis could equally apply to the elite physicians of Xin’an. In her view, the increasing number of physicians in Suzhou fostered the need for a demarcation of boundaries to exclude those who did not share a common social and intellectual heritage. Those physicians who had turned to medicine only after failing the civil service examinations shared classical knowledge and moral virtues, and by emphasizing the Confucian ideal of benevolence they were able to elevate their status by claiming that through the practice of benevolent medicine they could continue to perfect their virtues and become Confucian gentlemen. At the same time, the development of a group consciousness and a sense of community and identity was facilitated by social and literary networks, with the writing and publication 38

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of texts acting as both a forum for discussion and a way for physicians to validate their reputations and thus compete in an ever more crowded marketplace. As we shall see, many of the elements characteristic of the elite physician in this model of professionalization are applicable to Wang Ji: he was a failed scholar striving to emulate his sage forebears; Confucian benevolence is often cited as a motivating factor in the prefaces to his many works; and he was successful at establishing a reputation through his written works and at participating in Xin’an’s nascent social networks.

Wang Ji Aspects of Wang Ji’s life and work are chronicled in a number of contemporary Ming sources which I have used to build up a comprehensive picture of his personal and professional life. The most authoritative source, on which many of the others draw, is the biography ‘Shishan jushi zhuan’ !" [‘The biography of the retired scholar Stone Mountain’], written by Li Xun .123 This work can be regarded as particularly credible because it was written during Wang Ji’s lifetime and appeared in the appendix of the very ﬁrst edition of the Shishan yi’an, the preface of which is dated 1531. The author also contributes an appraisal of Wang Ji at the beginning of the work, and his biography is mentioned both in the original preface by Cheng Zeng , which was commissioned by Wang Ji himself, and in the later preface of 1541 written by Wang Ji’s main disciple Chen Jue. These facts would lend weight to the belief that Wang Ji was personally known to Li Xun and may well have contributed to the biography. Wang Ji’s biography of his father, written in 1522, also provides useful, and obviously reliable, information about his family history.124 More concise biographies can be found in the Qimen xianzhi ! [‘Qimen gazetteer’] which dates from the Wanli period (1573–1620),125 and also in Xu Chunfu’s Gujin yitong daquan which was ﬁrst published in 1556.126 Much information, particularly regarding Wang Ji’s professional motivations, can also be gleaned from the prefaces to his many books. Wang Ji, whose style (zi ) was Shengzhi , was born in the ninth month of the kuiwei () year of the reign of the Tianshun emperor (1463), and died in the twelfth month of the jihai () year of the Jiaqing emperor (1539), aged 76.127 39

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Detailed accounts of his family history over several generations are provided in his biography and in that of his father. In the Yuan (1260–1368) his ancestors were living in Shishan in Qimen, then at the end of the dynasty a certain Wang Xinyi moved south to Pushu where the family remained until the time of Wang Ji. Wang Ji’s nickname (hao ) Shishan [Stone Mountain] is said to be an acknowledgement of the fact that his ancestors had come from Shishan.128 Wang Ji’s greatgreat-grandfather was called Wang Qian and was renowned for his charitable works in the region, but found himself in trouble with the authorities in the early Ming, and had to be helped out by his son, Wang Ji’s great-grandfather, Wang Daoyu . Then came Wang Lun , Wang Ji’s grandfather, followed by his father Wang Wei.129 Wang Wei was married to Yuezhen (1429 –1520) of the Fang clan from Dakeng in neighbouring Xiuning, who was reputed to be neat and tidy, and good at embroidery.130 Wang Wei was well known in the area as a physician, treating patients from as far aﬁeld as She, Xiuning and Wuyuan, and his case histories are recorded both in his biography and also in Jiang Guan’s Mingyi lei’an. Wang Ji particularly praises his father’s frugal and simple nature, his lack of desires and his abstinence from drink and sex, saying that these are virtues everyone can follow. As suggested earlier, the emphasis placed on the qualities of frugality and absence of desire at that time may have been a reaction to the extravagant behaviour of the emerging merchant class and, as I shall discuss later, may well have had a signiﬁcant impact on Wang Ji’s medical practice. Wang Wei had three sons, Wang Hui , Wang Ji and Wang Gui , and two daughters Lanxiu and Miaoxiu . His sons were all married, to women from the Cheng , Xie and Wu clans respectively, and produced a total of eight sons and four daughters, and eight grandsons and four granddaughters.131 Various aspects of Wang Ji’s character are described both in his biography132 and in a self-appraisal he penned as an introduction to his Shishan yi’an.133 Wang Ji portrays himself very much as the archetypal Confucian gentleman, with a benevolent heart, the qualities of sincerity, modesty and frugality, and a desire to follow the Way of the ancient sages. His biographer, Li Xun, describes him in a similar fashion, emphasizing his tranquil and sincere nature, his simplicity in dress and diet, and restraint in all areas, with the exception of his extraordinary generosity in matters of 40

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moral duty. Two examples are given to illustrate this generosity. Firstly, we are told that his younger brother, Wang Gui, died at sea and his son was sent to collect the cofﬁn and return with the body. This task proved both arduous and costly, and as a result the son would have lost everything had Wang Ji not helped him ﬁnancially or encouraged others to contribute as well. The other example concerns a temple for ancestor worship that the family wanted to build, but were having difﬁculty raising the large amount of money required. Wang Ji personally donated one-ﬁfth of the cost and his example inspired others to do likewise so that in only four days the full amount had been collected. The Confucian virtue of ﬁlial piety and a desire to beneﬁt society are also demonstrated in Wang Ji’s decision to follow his father into the medical profession. According to his biography, in his youth Wang Ji had studied the classics and made repeated attempts at the civil service examinations, but was unsuccessful. Li Xun records that his father then said to him: Fan Wenzheng once said, ‘If you cannot become a good minister, you should hope to become a good doctor.’ The meaning of this is that if an ofﬁcial cannot reach the position of minister then his inﬂuence will not be as widespread as that of a physician.134 At this, Wang Ji is reported to have given up his studies and put all his efforts into reading the medical classics. With his father’s help, Wang Ji quickly became an accomplished physician and was able to cure his mother who had suffered with a headache and vomiting for over ten years, and his father who fell ill three times during his later years. As he followed his father into medicine it is tempting to see Wang Ji as a hereditary physician, but alternatively he is described by Cheng Zeng in the preface to the Shishan yi’an as a Confucian physician (ruyi ) and this portrayal is further validated by Wang Ji’s espousal of traditional Confucian values, by his scholarly studies and by his attempts to succeed in the civil service examinations. Chen Jue commented that Wang Ji was a ﬁlial son who had chosen a career as a physician because he believed that in order to serve one’s parents (shiqin ) one should know medicine,135 again demonstrating the central role played by the Confucian ethic of benevolence in Wang Ji’s beliefs, 41

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as in those of many elite physicians of the time. Wang Ji therefore shared a common intellectual and social heritage with his elite contemporaries, and from his writings there is no doubt that he saw himself as belonging to their ranks, and was so perceived by others. That his father was also a physician and that he could therefore also be labelled a hereditary physician indicates how the changing socioeconomic climate of sixteenth-century Anhui rendered strict classiﬁcations of social status more problematic.136 Wang Ji’s biography then records that his reputation as a physician spread far and wide, with people coming from all around to receive treatment, and that within a short time he had successfully cured several thousand patients.137 There is much evidence to substantiate this assertion, as Wang Ji seems to have been well respected in his own lifetime. Firstly, the biography contains many of Wang Ji’s case histories, recorded by his disciples Zhou Chen and Xu Zhong , and they comment that their reason for printing these cases and the biography was the sheer volume of people asking to borrow and read it. This biography is dated 1523, so Wang Ji must have already gained a reputation in his area by this time.138 Secondly, and perhaps most tellingly, Wang Ji has more case histories in Jiang Guan’s Mingyi lei’an than almost anyone else. With his tally of 153 case histories, he comes third out of a total of 141 physicians, being rivalled only by his contemporary Xue Ji with 484 cases and the Yuan dynasty physician Zhu Zhenheng (1281–1358) with 355 cases.139 There are also two roughly contemporaneous references to Wang Ji in connection with Li Shizhen. The ﬁrst is a not entirely favourable mention of Wang Ji’s Bencao huibian ! [‘The collected and arranged materia medica’] in Li Shizhen’s review of previous materia medica at the start of his Bencao gangmu.140 The second reference occurs in Li Shizhen’s biography which is recorded in the Mingshi [‘Ming history’] where he is included in a list of physicians who are said to be particularly good at medicine and to have treated many people successfully.141 In addition, there are the references to Wang Ji already mentioned in his local gazetteer Qimen xianzhi and in the comprehensive medical text Gujin yitong daquan. When taken together, these facts suggest that Wang Ji was a well-known and well-respected participant in Xin’an medical culture in the sixteenth century. The above examples of Wang Ji’s inﬂuence and renown are largely based on his reputation as it was transmitted indirectly, 42

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either through word of mouth or through his medical writings. However, Wang Ji also had a more direct means of inﬂuencing local medical culture and transmitting his medical knowledge, that is through his disciples. At least seven of Wang Ji’s disciples can be identiﬁed from either his writings or theirs, but it is probable that there were others. Wang Ji’s chief disciple was Chen Jue, also from Qimen, who was not only responsible for compiling the Shishan yi’an from the records taken by other disciples but, as mentioned above, also arranged the publication of Wang Ji’s collected works, Wangshi yixue qishu. In addition, he helped produce Wang Ji’s book on shanghan ( cold damage disorders) entitled Shanghan xuanlu ! [‘Selected notes on cold damage disorders’], along with another disciple Cheng Tingyi .142 Cheng Tingyi also wrote an essay on the use of ginseng and astragalus root, ‘Bing yong shenqi lun’ A [‘Treatise on the use of ginseng and astragalus root in treating illness’], which is included in the appendix to the Shishan yi’an.143 Zhou Chen and Xu Zhong, who have already been mentioned as the compilers of the collection of case histories by Wang Ji to be found in Li Xun’s biography, were also disciples. In addition, we know of disciples who came from other counties in Xin’an, such as Huang Gutan from Yi who later passed on Wang Ji’s teachings to Sun Yikui from Xiuning,144 Wu Yang who travelled from She to receive Wang Ji’s teachings,145 and Wang Fuhu from Xiuning. Therefore, despite the increasing transmission of medical knowledge through the medium of published works, the master/disciple relation was still an important mechanism by which knowledge could be transmitted and disseminated, and one which, certainly in Wang Ji’s case, played a key role in ensuring the spread of his medical theories throughout the region. The transmission of medical knowledge is a two-way process, and in addition to inﬂuencing other people, Wang Ji himself was greatly inﬂuenced by a number of other physicians. However, unlike his disciples, he usually found out about their theories through their books which appeared in wide circulation only a very short time after their publication. The main contemporary inﬂuences on Wang Ji’s writings were Xue Ji, Wang Lun, Han Mao and Wei Guiyan. Wang Ji drew heavily on Xue Ji’s Waike xinfa ! [‘The inner essence of external medicine’] and Waike fahui ! [‘An elaboration of external medicine’] when he compiled his own Waike lili ! [‘Surgical principles and 43

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examples’].146 Both of Xue Ji’s books were published in Zhejiang in 1528, and yet were available for Wang Ji to use for his work which has a preface date of 1531. Wang Lun, also from Zhejiang, is the author of Mingyi zazhu ! [‘Miscellaneous writings of illustrious physicians’] which was heavily criticized by Wang Ji for its taboo on the use of ginseng and astragalus root for treating disorders of yin depletion.147 This work was not published until 1549 but was written in 1502 and must have been circulating in manuscript form for it to be accessible to Wang Ji, as his comments can be found in the Shishan yi’an with its preface date of 1531. Wang Ji was sufﬁciently impressed by Han Mao’s Hanshi yitong ! [‘Mr Han’s comprehensive survey of medicine’] to include excerpts in his Shishan yi’an. Han Mao was from Sichuan and his Hanshi yitong was published in 1522, so again the transmission time is comparatively short. Finally, in Wang Ji’s work on poxes, the Douzhi libian ! [‘Differentiating theories regarding the treatment of poxes’], he devotes the latter half of his text to a discussion of Wei Guiyan’s Bo’ai xinjian ! [‘Reﬂection of the universal love in my heart’] because he found his theories and treatments to be superior to all others he had come across. This explanation is given in the preface to Douzhi libian dated 1531, only seven years after the publication of Bo’ai xinjian in Jiangsu in 1525.148 No doubt the presence of Huizhou merchants throughout China at this period accounts for these texts, from places as far aﬁeld as Sichuan, reaching Wang Ji so quickly after publication. Their part in the transmission of medical knowledge can also be seen in the instance where Wang Ji obtained information on the acupuncture and moxibustion skills of Lin Hanzhang and Li Qianhu through travelling merchants. Such transportation networks played an important role in the distribution of medical texts and stimulation of intellectual debate during this period, and clearly enabled Wang Ji to keep track of contemporary developments in the ﬁeld of medicine on a national, rather than a regional, basis. These examples indicate that Wang Ji was very much an active participant in Xin’an medical culture, both inﬂuencing the work of others, either indirectly through his books or directly through his taking on disciples, and being inﬂuenced by the writings of other physicians. Wang Ji’s interactions with his contemporaries as described in the preceding paragraphs are summarized in Box 1.1. 44

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Box 1.1 Wang Ji’s interactions with contemporary medical culture Wang Ji exerted inﬂuence on: Disciples (direct contact) • • • • • • •

Chen Jue, Wang Ji’s chief disciple, and compiler of the Shishan yi’an and Shanghan xuanlu Zhou Chen, co-compiler of cases to be found in Li Xun’s biography of Wang Ji Xu Zhong, co-compiler of cases to be found in Li Xun’s biography of Wang Ji Cheng Tingyi, author of the theoretical essay ‘Bing yong shenqi lun’ and co-compiler of Shanghan xuanlu Huang Gutan, disciple from Yi, passed Wang Ji’s teachings on to Sun Yikui, from Xiuning Wu Yang, disciple from She, passed Wang Ji’s teachings down through his family Wang Fuhu, disciple from Xiuning

Other (indirect inﬂuence) • • • • • •

Jiang Guan: 153 of Wang Ji’s case histories included in his Mingyi lei’an Xu Chunfu: Wang Ji’s biography included in his Gujin yitong daquan Li Shizhen: Wang Ji’s materia medica reviewed in the Bencao gangmu Japan: Wang Ji’s Shishan yi’an was exported to Japan, and a Japanese edition appeared in 1696 Ming history: Wang Ji is mentioned in the Mingshi as being a particularly ﬁne physician Wu Mianxue: revised Wang Ji’s Yixue yuanli, a general reader intended to beneﬁt the people

Wang Ji inﬂuenced by: Physicians (indirect inﬂuence) • •

Xue Ji: Wang Ji drew heavily on his Waike xinfa and Waike fahui for his own Waike lili Han Mao: Wang Ji included some of Han Mao’s cases and theoretical comments taken from the Hanshi yitong in his Shishan yi’an

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• • • •

Wang Lun: Wang Ji wrote an essay criticizing Wang Lun’s Mingyi zazhu for its taboo on the use of ginseng and astragalus root Wei Guiyan: in Wang Ji’s Douzhi libian he discusses the theories put forward by Wei Guiyan in his Bo’ai xinjian Lin Hanzhang: information about Lin Hanzhang’s acupuncture and moxibustion skills was transmitted to Wang Ji by merchants Li Qianhu: information about Li Qianhu’s acupuncture and moxibustion skills was transmitted to Wang Ji by merchants

A total of eleven books, covering practically every medical subject area, are commonly attributed to Wang Ji, and these can be divided into four types: revised editions of earlier medical works; compilations of other people’s theories with a commentary; works compiled by his disciples; and entirely new medical tracts.149 This is evidence of Wang Ji’s very broad-ranging medical interests, with a text on almost every medical subject area, including acupuncture and moxibustion, poxes, shanghan theory, materia medica, surgery and so on. What is more, all of the genres of medical writing that were so characteristic of the early sixteenth century, such as revised editions of previous texts, annotated classics, case histories and general readers, are represented in his oeuvre. Box 1.2 sets out each of Wang Ji’s texts according to type. Also very typical of the period are the motivations he claims for writing these books, which are often revealed in his prefaces. There are several themes which occur repeatedly and which can be divided into three broad categories: Confucian benevolence and ﬁlial piety; a desire to correct errors and establish an orthodoxy; and a belief in the need for public awareness of basic medical principles.150 These categories are not mutually exclusive, and often the reasons given can ﬁt into more than one category. Confucian benevolence is the most frequently cited reason for writing and publishing a medical text. In the preface to Tuiqiu shiyi ! [‘An examination of the ideas of my master’] Wang Ji writes that medicine is the art of benevolence, and he believes that by writing, publishing and circulating this book he will be able to beneﬁt the sick of the world, and increase other physicians’ ability to do likewise.151 This theme is echoed in the preface to his Douzhi libian where he describes how an epidemic the previous winter had resulted in many deaths, and how the grief he felt at this prompted him to research all the theories on the 46

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Box 1.2 Wang Ji’s oeuvre Revised editions 1

2

3

Du Suwen chao ! [‘Notes on reading the Basic questions’] Preface dated 1519. Three fascicles. This work was originally written by the Yuan dynasty physician Hua Shou . Wang Ji restructured and edited it, and incorporated the commentary on the Huangdi neijing su wen !"# [‘Inner canon of the Yellow Lord – Basic questions’] by the Tang physician Wang Bing , along with some of his own opinions. Maijue kanwu ! [‘Correcting the errors of The pulse in verse’] Preface dated 1523. Two fascicles. This is a reworking of the eponymous text on the pulse by the Yuan dynasty physician Dai Qizong . Wang Ji revised it and supplemented it with an appendix which is composed of other physicians’ theories on the pulse. Tuiqiu shiyi ! [‘An examination of the ideas of my master’] Preface dated 1534. Two fascicles. This is an interpretation of the theories of the Yuan dynasty physician Zhu Zhenheng written by his chief disciple Dai Yuanli . Wang Ji took Dai Yuanli’s work and revised and further developed it.

Compilations 1

2

3

4

Yunqi yilan ! [‘The (ﬁve) revolutions and the (six) climatic factors at a glance’] Preface dated 1528. Three fascicles. Based on the theories of wuyun liuqi found in the ‘Basic questions’. Zhenjiu wendui ! [‘Questions and answers on acupuncture and moxibustion’] Preface dated 1530. Three fascicles. Wang Ji takes the theories on acupuncture and moxibustion to be found in the ‘Basic questions’, the Nanjing [‘Canon of problems’] and other texts, and reorders them into a question and answer format to help clarify some of the more complex concepts involved. Waike lili ! [‘Surgical principles and examples’] Preface dated 1531. Seven fascicles. This book revises, summarizes and combines theoretical excerpts and practical case histories taken mainly from Xue Ji, but also from other sources including Zhu Zhenheng and Li Gao to create one uniﬁed text. Douzhi libian ! [‘Differentiating theories regarding the treatment of poxes’]

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5

Preface dated 1531. One fascicle. After a local epidemic one winter Wang Ji took all the theories on poxes he could ﬁnd from a variety of books and edited them into one text so they could quickly and easily be reviewed in an emergency. This forms the ﬁrst part of the book; the second half, as mentioned above, is a discussion of the theories of his favoured pox physician, Wei Guiyan. Bencao huibian ! [‘The collected and arranged materia medica’] This book is no longer extant, but is referred to by Li Shizhen in his Bencao gangmu where he states that it has twenty fascicles and is based on Wang Lun’s Bencao jiyao ! [‘Collected essentials of materia medica’] but Wang Ji was unhappy with the division of medical products into three categories so rearranged it into two.*

Books compiled by disciples 1

2

Shishan yi’an ! [‘Stone Mountain medical case histories’] Preface dated 1531. Three fascicles. A collection of over one hundred case histories of the physician Wang Ji recorded by his disciples and compiled by the disciple Chen Jue. There is also an appendix which contains two theoretical essays on the use of ginseng and astragalus root, with the biographies of Wang Ji and his father. Shanghan xuanlu ! [‘Selected notes on cold damage disorders’] Preface dated 1536. Eight fascicles. Wang Ji writes that over the years he had taken notes down on the various shanghan theories, and had structured them with comments, but that at the age of over seventy he was no longer able to work on them, so he asked his disciples Chen Jue and Cheng Tingyi to complete it for him.

Entirely new medical books 1

Yixue yuanli ! [‘Medicine from ﬁrst principles’] Revised by Wu Mianxue and published in 1601. Thirteen fascicles. As the title suggests, this is a general medical reader. It was the last book written by Wang Ji, and must have been later than 1536, as the Shanghan xuanlu is mentioned in the preface. This work covers basic medical theory, including the twelve channels (jingluo ), the six pernicious inﬂuences (liuyin ), the disorders of Blood (xue ) and qi, the syndromes of internal damage (neishang zhuzheng !), and the specialities of gynaecology and paediatrics.

* Bencao gangmu. 1993. Volume 1, fascicle 1, p. 8.

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treatment of poxes and compile them into a single text for quick and easy reference.152 Correcting the errors of both past and contemporary physicians in order to aid future generations is another common theme. For example, in the preface to Waike lili Wang Ji explains that he compiled this book because he was concerned that his contemporaries only saw the external manifestation of the illness and failed to examine whether the channels were replete or depleted, so their medicine could not be without error.153 A similar reason is given in the preface to Maijue kanwu ! [‘correcting the errors of the pulse in verse’] where he states that by correcting the errors in previous texts he will be able to help future scholars follow the correct path and avoid being deluded by erroneous scholarship.154 Wang Ji obtained this text from a man in She who regarded it as secret and was reluctant to let others see it. By transcribing it, correcting its errors and circulating it, Wang Ji hoped that scholars would be able to have access to its secrets. Scholars were not the only ones he wanted to beneﬁt; the preface to Yixue yuanli ! [‘medicine from ﬁrst principles’] indicates his desire to increase the medical knowledge of the general public when he writes that the achievements of his long career were pointless if he was not able to communicate his knowledge to his sons and grandsons. He adds that by reading this book future generations would be able to understand the mechanism of illness, correctly read the pulse, and make up a prescription, and in doing so would be able to serve their parents, nourish their bodies, and save many lives.155 The fulﬁlment of these goals would certainly result in spiritual merit, and it is perhaps for this reason that this latter text was later revised and published by Wu Mianxue. In Wang Ji we see reﬂected many of the main characteristics of Xin’an medical culture in the early sixteenth century. Through his personal choices and motivations, and his professional inﬂuence and accomplishments, he truly encapsulates the spirit of the age. For example, his reasons for becoming a doctor – repeated failure in the civil service examinations coupled with a desire to realize the Confucian virtues of benevolence and ﬁlial piety – could not be more typical. The three most common modes of transmission of medical knowledge, that is hereditary transmission, the master/ disciple relationship, and transmission through published materials, are all represented during his working life: he learnt from his father, he passed his skills on to his disciples, and he both acquired 49

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knowledge from books and wrote books for others to read. His medical writing, in terms of both the types of books he wrote – case histories, annotated classics, revised editions and general readers – and his motivations for doing so – Confucian benevolence, correcting errors, and increasing the accessibility of medical texts to the public – are also very characteristic of the period. Finally, the extent of his inﬂuence, both within China and abroad, and the extent to which he was able to keep track of contemporary developments in medicine, are clearly a reﬂection of the increased level of contact possible between physicians which had come about as a result of improved transportation networks and the presence of Huizhou merchants throughout the country.

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CHAPTER 2 THE ‘STONE MOUNTAIN MEDICAL CASE HISTORIES’

The Shishan yi’an, or ‘Stone Mountain medical case histories’, is a collection of over one hundred individual case histories (yi’an ) taken from Wang Ji’s clinical practice over a period of ﬁfteen years. This work represents a selection of Wang Ji’s clinical encounters, collected by his disciples, compiled by his chief disciple Chen Jue, and published in 1531. This text forms the basis of my textual and gender analyses and the purpose of this chapter is to introduce some of the essential elements of the text relevant to both of these, such as its structure, history and purpose, and to assess the suitability of its use as source material.

The structure of the text In keeping with Wang Ji’s high proﬁle and contemporary advances in print technology, several editions of the Shishan yi’an are known to have been in circulation during the Ming dynasty, and many of them survive today. However, there are no signiﬁcant variations between the editions. The text is divided into three fascicles (juan ), and followed by an appendix (fulu ). The ﬁrst fascicle begins with a short theoretical discussion outlining Wang Ji’s beliefs regarding yin and yang depletion in relation to those of the renowned Yuan dynasty physician Zhu

An earlier version of this chapter appeared as ‘Medical Practice in the Ming Dynasty – A Practitioner’s View: Evidence from Wang Ji’s Shishan yi’an’. Chinese Science. 1998. 15: 37–80. The revised version is reprinted here by permission from the journal East Asian Science, Technology and Medicine (formerly Chinese Science).

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Zhenheng (1281–1358).156 This is followed by replies to letters sent to him by two patients. The main body of the chapter consists of forty-nine cases,157 divided into categories, such as periodic fever (nüe ) and coughing (kesou ). The rationale behind the division into the particular categories used is unclear; the organizational strategy appears simply to be the loose grouping together of cases with similar symptoms or chief complaints. The second fascicle contains a total of ﬁfty-one cases which again are divided into categories. In this section there are also two short theoretical discussions, following the cases to which they relate. The third fascicle begins with a case in the format of a reply to a letter, and is followed by a total of twenty-two cases, again with some theoretical discussions interspersed. However, in contrast to the ﬁrst two fascicles, the cases are not divided into categories of any sort, and only thirteen of the cases relate to Wang Ji. Of the rest, seven are by famous physicians of the past, which Wang Ji expressly states have been included as examples of how one should treat illnesses induced by emotion. There are also four short theoretical excerpts and two cases taken from the Hanshi yitong by Han Mao. Therefore, over a third of the cases in this ﬁnal chapter are not by Wang Ji, although he felt it appropriate to include them among his own. The appendix contains two theoretical essays on the use of ginseng and astragalus root, one by Wang Ji and one by his disciple Cheng Tingyi, as well as biographies of both Wang Ji and his father, Wang Wei. The biography of Wang Ji was written by Li Xun, and incorporates forty-seven case histories compiled by Zhou Chen and Xu Zhong.158 Wang Wei’s biography was written by Wang Ji himself and contains seven examples of his father’s clinical expertise.

The case history genre This recording of one’s clinical expertise in a case history format is common to many medical traditions. In the case of China, the writing of case histories by physicians has been traced back through medical history primarily to those of Chunyu Yi which were recorded around 100bc by Sima Qian in Chapter 105 of the Shi ji [‘Records of the historian’].159 Prior to this, there are also certain examples of encounters between physicians 52

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and patients to be found in the Zhou li [‘Rites of Zhou’], the Zuo zhuan [‘Zuo commentary of the spring and autumn annals’], and the Lüshi chunqiu ! [‘Spring and autumn annals of Mr Lü’], as well as in the form of oracle bone inscriptions. Pre-Ming medical works commonly contained case histories, either inserted where relevant, or appended at the end as a separate section.160 However, it was not until the Ming dynasty that specialist texts consisting exclusively of a collection of the case histories of one or more physicians began to appear. In addition to Wang Ji’s Shishan yi’an which, being published in 1531, is probably the earliest extant example of a specialist case history medical text, Jiang Guan’s Mingyi lei’an, which was mentioned in the previous chapter, and the case histories of Anhui’s Sun Yikui and Zhou Zhigan were all published in the sixteenth century. Interest was also taken in the style of case history writing, with Han Mao, in his Hanshi yitong of 1522, proposing a standard format for their transcription under the six rubrics of looking (wang ), listening/smelling (wen ), asking (wen ), touching (qie ), aetiology (bingyuan ) and treatment (zhifangshu ).161 As Christopher Cullen has argued, this increased interest in medical case histories was not the culmination of a long and gradual process of growth, but rather the emergence of a distinct genre of medical writing where case histories ceased to serve as an adjunct to other forms of writing and took on a new and different role.162 Even the term used to describe these case history collections – yi’an – was new and had not been in use prior to the sixteenth century.163 This term itself provides a clue as to the likely origins of the genre. The character an is also seen in the judicial phrase gong’an , meaning ‘legal case history’ and referring to a formal statement of a legal case,164 and the analogy between legal and medical case histories is expressly drawn in early examples of the case history genre. Cheng Zeng in his preface to the Shishan yi’an, for example, commented that the use readers would make of Wang Ji’s case histories was akin to that made by legal experts of settled cases (duan’ an ).165 But what prompted these sixteenth-century physicians to borrow the concept of legal case histories from their judicial colleagues and create a new style of medical writing? One plausible theory advanced by Cullen is that it was the result of market demand from the increasing number of would-be physicians, from the 53

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ranks of merchants and failed literati who were perhaps unable to obtain an apprenticeship but wanted access to practical information about clinical medicine to supplement knowledge gained from a reading of theoretical texts.166 It is notable that, in addition to a rise in the number of medical case history collections, there is also evidence of an increase in the publication of legal case histories at this time.167 This links in with a general increase in the number of ‘how to’ books being published in the Ming dynasty. These were primarily designed to enable students to pass the civil service examinations, but failing that, the similarly structured texts on topics such as law and medicine that also began to appear would have assisted them in breaking into an alternative career. For the physician as author, as opposed to student, in a time of increasing competition as the number of physicians grew, the publication of one’s own set of case histories would also have helped establish one’s reputation. Finally, Cullen also suggests that that the case history would have been given to the patient and would have acted as an encouragement to follow the recommended treatment and a reminder of the identity of the physician. The implications of this, that a patient may not otherwise follow the physician’s advice or call on his services in the future, are certainly borne out from a reading of the Shishan yi’an, as we shall see.

The purpose of writing case histories Like many of his contemporaries, Wang Ji expresses his decision to become a physician in terms of having failed the civil service examinations, wanting to show Confucian ﬁlial piety by helping an ill relative, and wanting to be of service to society. Similar motivations for writing case histories are also cited in the prefaces to many of Wang Ji’s works; in particular, the themes of Confucian benevolence, correcting errors in previous texts with a view to creating a medical orthodoxy, and increasing the spread of medical knowledge to all levels of society occur again and again. These factors no doubt played a part in the writing of the Shishan yi’an, but, other than the analogy with legal case histories mentioned above, the prefaces to the text give no clue as to why he speciﬁcally wanted to set his clinical experience down on paper. Fortunately, various comments made in the text give us some indication as to why he felt compelled to record and publish his case histories. The many reasons Wang Ji gives throughout the Shishan yi’an for 54

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having recorded his case histories can be divided into three main categories, although they are also interlinked to some extent. The ﬁrst of these I have labelled ‘didactic’, that is for educational purposes, the second ‘self-promotion’, that is to promote his own theoretical and clinical ideas while deriding those of others, and the third ‘recording the strange’, that is noting down things which are somewhat out of the ordinary. Wang Ji’s intention that his cases should be used as examples from which others can learn is made clear by his practice of appending sentences at the end of certain histories explaining the general principles raised by it which should be noted. For example, with regard to recognizing incurable symptoms he writes at the end of one case: Therefore, generally in one who has disorders of depletion and exhaustion, if they have diarrhoea for a long time, or are unable to sleep on the right or left side, no therapy can cure it.168 This principle is reiterated after this case, but its relevance to other physicians is spelt out: Generally one who suffers from depletion and exhaustion . . . and either has a cough, a sore throat and hoarseness which cannot be treated, or has a cough and anal sores, these [people] all cannot be saved. Doctors must know this.169 The need for early treatment of disorders is another piece of advice he gives. After treating one woman who was not able to be saved because her illness was at a late stage, he then also treats another woman with a similar disorder, and writes: I treated her with ginseng, astragalus root and other sweet and warming preparations, she had not even taken two or three doses when she recovered. This is owing to the earliness of the treatment.170 He also advises physicians to be careful in their use of medicines,171 and states that one sometimes has to be ﬂexible and use medicines out of their advised season if the symptoms warrant 55

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it.172 Recommendations such as these are not so much dictated by any particular theoretical outlook but seem more like the handing down of knowledge which has been acquired over years of clinical experience and may be of use to those starting out in medical practice. Conﬁrmation of this intention to educate future generations of physicians can be found in the last chapter of the Shishan yi’an where Wang Ji inserts a number of cases by other physicians regarding the treatment of emotional disorders using other emotions, according to ﬁve-phase theory. In a short theoretical introduction to this section he writes: The Book says, ‘The ﬁve emotions in excess become disorders. They cannot be treated with medicines. You should vanquish them using emotions’. In the past, and today, the prescription books mainly give an outline, but do not discuss [what to do] if you come across [someone] who has this disease, and lack examples which you can enlarge upon. Owing to this I have sought out examples of treatment by previous sages and written them down below in order to instruct those in the future about it.173 This is further validated by the fact that in none of the cases that follow is the name of the physician mentioned; what is important is not who the physician was, but the way in which a cure was brought about. I have managed to discover the authors of two of the cases. One of these cases is attributed to Han Shiliang by the late Ming physician Zhang Jiebin who quotes the case in a slightly different form in his Zhangshi leijing ! [‘Mr Zhang’s classics arranged by subject’].174 Another of these cases concerns a woman who is depressed because she is newly married but her husband has been away on business for two years. She is cured by being made angry, following the principle that the Liver/anger vanquishes the Spleen/pensiveness.175 The physician responsible for this treatment is Zhu Zhenheng. Versions of this case can be found in a number of compilations, perhaps indicating that it is a well-known one which writers would often quote when discussing the treatment of emotions.176 Wang Ji’s version is different again, but it contains sections found verbatim in other versions, suggesting the possibility that perhaps Wang Ji had learned this case off by heart because he agreed 56

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with its principles, and was quoting it from memory, which would account for its slightly abbreviated nature, and some facts being slightly altered. This didactic element found in the Shishan yi’an is consistent with the hypothesis that the rise of medical case histories as a genre in the Ming dynasty was linked to the increased publication of ‘how to’ books aimed at those seeking an alternative career, having failed the civil service examinations. The evidence from the Shishan yi’an suggests that, despite being a proliﬁc and well-respected physician, Wang Ji practised in a somewhat unstable and competitive environment in which he faced a good deal of criticism of his replenishing theories, and resistance to his warming treatments, from both patients and other practitioners. In this context, the recording of case histories can be seen as an exercise in self-promotion, a means of explaining his theoretical viewpoint and providing clinical examples which demonstrate how these views were proved to be justiﬁed in actual practice, and exposing the theories of others to be fundamentally misguided and ineffective, if not harmful, when put into practice. In many ways the Shishan yi’an reads as just such an exercise, with a theoretical introduction and additional theoretical paragraphs and essays setting out his ideas; case histories which show just how effective his favoured treatments of ginseng and astragalus root were in practice; and incessant references to the incompetence of his contemporaries. At the end of one case he actually states that he has only recorded it because he fears that otherwise incorrect assumptions will be passed down, and that he will be powerless to prevent it.177 Wang Ji is therefore recording for posterity his view of the ideal medical practice, based on his own theoretical framework, and born out of frustration with the contemporary situation, in the hope that it will act as a guide and inspiration for later generations. Also consistent with the idea that Wang Ji is promoting his vision of medical practice as an inspiration for future scholars of similar views is his quoting of like-minded contemporaries, whose opinions not only serve to complement and reinforce his own, but, to some extent, also bolster his own reputation through association. In the last fascicle, Wang Ji inserts four theoretical discussions, and two case histories taken, largely verbatim, from Han Mao’s Hanshi yitong.178 He thus explains his decision to quote from this book: 57

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The previous few sections come from the Yitong. I have become fully acquainted with it because its insights accord with my own. Therefore I have recorded them so they are not forgotten.179 The ﬁrst case history he quotes concerns a man who makes himself ill after having taken yin supplements for a decade because he read in the Zazhu180 that everyone suffers from yin depletion. This implicit criticism of the Zazhu is a sentiment with which Wang Ji heartily agrees, having criticized the harmful effect of its theories on contemporary medical practice himself.181 Thus the principles embodied in this case are so similar to those of the Shishan yi’an that it could almost have been written by Wang Ji. The second case, which appears in a heavily edited form, relates the variety of treatments given to a woman suffering from yang depletion. Wang Ji adds at the end of the case: This section also comes from the Yitong. His treatment of illness embodies the principle of using medicines appropriate to the circumstances. This is what is called knowing how to act according to the situation. Therefore I am recording it as a principle.182 So, again, Wang Ji endorses the principles found in the case history, and although he is not the author of the case, the overall effect, when taken with the rest of the Shishan yi’an, is of a consistent body of literature which is making a coherent statement of Wang Ji’s theoretical stance and its application in clinical medical practice. In this context, the writing of case histories can be understood as the desire to pass on a deﬁnitive and comprehensive account of how medicine should be practised, in the hope that posterity will deem it worthy of emulation. The input of the disciples who recorded the cases also needs consideration. In compiling and helping publish his master’s case histories, a disciple not only shows proper respect but also increases his own prestige by association if the publication is successful. Therefore, the motivation of the disciples is also a form of self-promotion, as well as promotion of their master. The publishing of physician’s manuscripts by disciples is also commented on by Wu Yiyi in his article on the Jin dynasty physician Liu Wansu . He writes: 58

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The most promising or favorite student would be likely to receive some manuscripts, so that he could carry on the master’s theory; at the same time, books served as a token of authentic transmission. In order to enhance and to carry forward the master’s scholarship, and to demonstrate their position as successors, the students would have the materials published.183 This may well have been the situation in the case of Wang Ji, as we know that not only did Chen Jue collect and compile his master’s Shishan yi’an and publish his collected works, the Wangshi yixue qishu, but two other disciples, Zhou Chen and Xu Zhong, also recorded some of his case histories which are reproduced in the appendix to the Shishan yi’an.184 Linked with this concept of self-promotion, both by Wang Ji and by his disciples, is the idea of lineage afﬁliation.185 Through the recording and publishing of case histories advocating a certain therapeutic approach or following a certain tradition it is possible to assert one’s afﬁliation to a medical lineage. In Wang Ji’s case the use of case histories as the chosen medium for this purpose in preference to any other genre of medical writing can itself be interpreted as a gesture of lineage afﬁliation. Wang Ji was very much a follower of Zhu Zhenheng, even if he did not always agree with his theories, or their interpretation by later physicians. Zhu Zhenheng has more case histories attributed to him than any other pre-Ming physician: Jiang Guan’s Mingyi lei’an, for example, includes a total of 355 of his case histories – several hundred more than any other pre-Ming physician and overall second in ranking, after Wang Ji’s contemporary Xue Ji.186 Therefore by recording and publishing case histories, Wang Ji and his disciples are following Zhu Zhenheng in form as well as content and thereby asserting allegiance to his lineage. The Chinese have a long and full literary tradition, and part of this has always been the practice of ‘recording the strange’. Examples of this can be found in the dynastic histories, and it was to some extent the inspiration behind some of China’s earliest examples of ﬁctional writing, the Han dynasty zhi guai (), which describe unusual people and strange happenings. In a medical context, we also ﬁnd collections of strange or unusual case histories being published today. It is therefore no surprise to ﬁnd that an intention to ‘record the strange’ was partly responsible for 59

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motivating Wang Ji to write the Shishan yi’an. Also, given that many of these case histories were probably transcribed some time after the event, it may well be that somewhat strange or unusual cases more easily sprang to mind. For example, one woman has no pulses, but as it is her natural disposition, she is therefore not ill. Wang Ji ends the case by writing: No pulse on both wrists in a person [whose body processes are] unaffected: this is [an abnormality] that makes no sense, and [can be the result only of ] some great transformation in things. I therefore set it down in writing.187 Other examples include one man who had worms coming out of his penis,188 and another whose navel protruded an extraordinary distance.189 After both of these cases Wang Ji comments that he has recorded them because of their strangeness. The evidence from the case histories themselves suggests that the writing of the Shishan yi’an served a number of purposes, encompassing various notions of educating future generations of physicians; enhancing one’s own reputation; producing an account of theory in practice in reaction to a contemporary context which failed to recognize the value of both his theory and his practice; and recording strange events which had occurred during his years as a practising physician. On a wider socioeconomic level both the writing and publishing of this text are consistent with contemporary developments in the ﬁelds of medical literature and medical publishing with regard to the emergence of the case history genre, the type of medical texts being published, and the different needs of a new, broader, readership.

Use as source material Before we analyse a source like this it is important to be aware of the nature of the text. Clearly we are dealing with a representation of Wang Ji’s medical practice as seen through his eyes, modiﬁed to conform to the conﬁnes of the literary genre of which it is a part, and biased to put across the message he wanted to convey to his readers. Inevitably the cases selected, only one hundred or so out of many years of clinical experience, will have been chosen to reﬂect the author’s purposes, whether to demonstrate the efﬁcacy of warming and replenishing as a treatment or to illustrate certain 60

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points of theory. No doubt only relatively successful case histories, showing Wang Ji in a good light were included, and any cases which resulted in spectacular failure, or where another physician succeeded where he could not, were omitted. We cannot be sure that the cases included in the Shishan yi’an are representative of Wang Ji’s medical practice, let alone that of other Ming dynasty practitioners. Nor do they reﬂect the views of the patient or of practitioners belonging to other medical traditions. What we can say is that the cases are accounts of actual clinical encounters as perceived by those who recorded them, describing their understanding of the way in which the clinical encounter was conducted, the type of treatments utilized, and the interaction of the physician with both his patients and other healers. The fact that the cases have been speciﬁcally selected for inclusion, while not allowing us to make any great claims as to their representativeness, provides an opportunity to scrutinize the biases of the compilers to see what this might reveal about their particular concerns, interests and beliefs. Also, although the cases are written in the ﬁrst person, and their authorship is generally credited to Wang Ji, according to the original preface they were in fact recorded by the disciples accompanying Wang Ji and given to Chen Jue, who was responsible for compiling the work. Does this mean we cannot be sure that they even necessarily reﬂect the views of their supposed author? On the one hand, the Shishan yi’an was published in Wang Ji’s lifetime, only one year after some of the cases are said to have taken place, and Wang Ji himself wrote a self-appraisal and a theoretical essay for inclusion in the text, so we know that in all probability he had a substantial authorial role and approved the compilation before publication. On the other hand, the multiple authorship of the text if anything adds weight to the likelihood of its being a recognizable account of clinical medical practice. This is because the collective view of Wang Ji and his disciples has produced a text which, despite its being a collaborative effort, presents an internally consistent depiction of his medical practice, so all those involved must to a certain extent be in agreement as to the manner of representation of the clinical encounter. Then there is the matter of the temporal distance between the events taking place and their transformation into a written format. Some of the cases narrate the course of an illness over a duration of several months or even years, and it is unclear at what stage of 61

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this ongoing process notes were taken, or how long after the event they were written up into a recognizable case history format. Cases relating to events as they were remembered after a period of some time would be more liable to the distortion inherent in the act of recollection than those taken contemporaneously. However, there are other factors testifying to the text’s close relationship to its subject matter. Firstly, there is its didactic purpose: if the text bears no relation to at least an elite physician’s understanding of actual medical practice how can it fulﬁl its intended purpose of educating future generations of physicians? Then there is its popularity – the Shishan yi’an was sufﬁciently popular to run to several editions190 and be included in the medical section of the Qing dynasty imperial collectanea (Siku quanshu ! [‘Complete books of the four treasuries’]). From this it must be possible to conclude that the text found a readership and that this readership could draw on the text to inform their own understandings of medicine and medical practice. Additionally, many of the themes that emerge from a reading of the text are common to other case histories from the Ming dynasty, making Wang Ji’s account that bit more plausible.191 It is also necessary to differentiate between the information that is contained in the text and the interpretation of that information by a historian using contemporary Western methods of analysis. I have found the concept of layers or levels of knowledge about the text a fruitful way of disentangling the complex issues raised by the Shishan yi’an. At the most basic level there is the literal text itself. Beginning with an individual case history and reading the express words used by Wang Ji, we have a picture of a single clinical encounter from the physician’s viewpoint which describes the person he saw and various aspects of the clinical encounter such as diagnosis, aetiology, the illness syndrome, the treatment and the outcome of the case. Take this case, for example: A man. Thirty years old. Pale in appearance. Owing to exhaustion he caught a fever. In the ninth month he was extremely ill with fever, headaches, thirst, vomiting, a feeling of heaviness in the chest, anorexia, spontaneous sweating, and lassitude. He was often hot, and rarely cold. A doctor used medicines to stop [the fever], but the illness worsened, and he would vomit violently if he drank 62

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water. I examined him. His pulses were all ﬂoating (fu ), big (da ), soggy (ru ), and quite strung (xian ). I said, ‘This is the type of fever where exhaustion harms the Spleen, and heat harms the qi.’ I told him to use three qian192 () of ginseng (renshen ), one and a half qian of astragalus root (huangqi A ), one qian of white atractylodes rhizome (baizhu ), one qian of ophipogon root (maimendong ), ﬁve fen193 () of immature bitter orange (zhishi ), seven fen of hawthorn fruit (shancha ), seven fen of Chinese angelica root (guishen ), seven fen of phellodendron bark (huangbai ), seven fen of anemarrhena rhizome (zhimu ), three fen of dried ginger (ganjiang ), and three fen of liquorice (gancao ). It was decocted, and he took three doses. The illness receded. He was again harmed by exhaustion and the illness returned. The ginseng in the previous remedy was increased to four qian, he took it and recovered.194 Here we have a thirty-year-old man with a fever seen by Wang Ji. He has seen another doctor who causes his illness to worsen. Wang Ji examines him, and from the symptoms and the results of the pulse diagnosis he is able to build up a picture of the illness syndrome. The man is said to be suffering from the type of fever where ‘exhaustion harms the Spleen, and heat harms the qi ’. Wang Ji prescribes a decoction of herbs, with ginseng and astragalus root as the main components, which is taken three times and brings about an improvement, but after a relapse the treatment is modiﬁed and brings about a complete recovery. This pattern can be repeated for every single case, and the result is one hundred or so different accounts of individual cases, each describing a different, but similar, clinical encounter. At this basic level each encounter stands alone as an example of Wang Ji’s clinical practice, selected and described by him, demonstrating perhaps a typical example of an illness one might frequently encounter in practice accompanied by an account of how such an illness should ideally be tackled in terms of diagnosis and treatment to bring about a cure. To be able to say more about Wang Ji’s clinical practice it is necessary to proceed to another level of analysis which includes a component of personal interpretation. Even with the basic level of analysis, the extent to which what is written is an accurate 63

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reﬂection of Wang Ji’s medical practice is unclear because of the distortions, already discussed, inherent in the transcribing of the clinical encounter. This next level remains close to the literal text, but introduces a shift from the realms of what can be known to what can be suggested. By taking all of the case histories and reading across the text, looking for patterns and trends, common themes and isolated incidences, it is possible to build up a composite, but interpretative, portrait of Wang Ji’s medical practice. The result is a more vibrant and ﬂuid account which brings out many more facets of the clinical encounter than are revealed from an examination of a single case in isolation. In addition to the wider perspective that such an approach brings to the various elements of the clinical encounter from the initial examination to diagnosis, treatment and outcome, and our understanding of the interrelationship between theory and practice, illuminating insights are also gained into the multiplicity of interactions that the physician had with the world around him, particularly with regard to the dynamics of his relations with patients, elite physicians and other healers. The third level of abstraction from the text is achieved by bringing a Western model of gender analysis to the Shishan yi’an to determine the extent to which gender appears to have been a factor affecting medical practice, and relating this to the cultural context to explain why differences between the sexes may have arisen. Again this involves taking all the case histories and reading across the text, but making additional computations based on the sex of the patient. In contrast to the second level, which was almost exclusively based on an interpretation of what was explicitly written by Wang Ji in the text and which primarily reﬂects his expressed opinions and concerns, this third level concentrates more on my interpretation of what is not explicitly stated in the text. Wang Ji does distinguish between his male and female patients, but an understanding of sexual difference in a medical context is not expressed as a motivating factor in the recording, compiling and publishing of these case histories. In reading between the lines and comparing Wang Ji’s treatment of his male and female patients I am constructing another interpretation of Wang Ji’s medical practice, involving a high degree of speculation that is still further removed from the text itself and from what the author intended to convey, but which increases our understanding of the interplay between gender, medicine and society. 64

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The most interesting of these three levels of analysis, and those which I pursue in the rest of this book, are the more interpretative approaches provided by the second and third levels of analysis. In Chapter 3, using the second level which I have termed ‘textual analysis’, in which I construct an account of medicine and society which, while very individual in its orientation, still corresponds to and complements the picture of Xin’an medical culture already gained from the earlier reading of more traditional historical sources. The gendered focus of the third level used in Chapter 4 tells a very different story, but one which resonates with what we know about the changing socioeconomic context of sixteenthcentury Anhui. The results of these analyses of the Shishan yi’an, when read in the context of contemporary culture, combine to create a detailed and vivid portrayal not only of a Chinese physician and his medical practice but also of the operation of cultural forces in society.

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CHAPTER 3 WANG JI’S MEDICAL PRACTICE A textual analysis of the ‘Stone Mountain medical case histories’

Case histories represent one of very few remaining opportunities to enter into the world of historical clinical medical practice. Whereas theoretical medical texts largely describe the premises upon which Chinese medicine was based, case histories give us some access to the actual practice of this art. Wang Ji tells us not only about the basic elements of a case, such as how he diagnosed the illness, what caused it, how he treated it, and whether or not the patient recovered, but also about how the illness corresponds to the theoretical framework of traditional Chinese medicine, and about his interactions with the patients, their families and the other healers he comes across. This colourful portrayal of his medical practice allows us to glimpse a very different side to life as a practising physician in the Ming dynasty, one more grounded in the concrete realities of sick individuals, worried families and ﬁerce rivalries between practitioners than we might have imagined, given our earlier picture of a well-respected and successful elite physician, steeped in classical learning, embodying Confucian benevolence, publishing medical texts to local and national acclaim,

An earlier version of this chapter appeared as ‘Medical Practice in the Ming Dynasty – A Practitioner’s View: Evidence from Wang Ji’s Shishan yi’an’. Chinese Science. 1998. 15: 37–80. The revised version is reprinted here by permission from the journal East Asian Science, Technology and Medicine (formerly Chinese Science).

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and participating fully in the vibrant and ﬂourishing cultural environment of sixteenth-century Anhui.

Theory and practice Although case histories, by deﬁnition, emphasize the practical aspects of medicine, theory is a very obviously fundamental and ever-present component. The Shishan yi’an begins with a long theoretical discussion, nearly every case history contains a detailed theoretical explanation of the illness syndrome, and some cases are even followed by an additional theoretical commentary. There is no question of practice belonging to a separate domain; theory and practice are inextricably linked. In fact, arguably, if anything the Shishan yi’an is more of a theoretical text than a practical one: Wang Ji sets out his theoretical position at the very beginning of the text and through the cases demonstrates the correct application of this theory in practice. It has been argued that the concept of a theory–practice dichotomy is of limited application to traditional Chinese medical history as it originated in the theory–practice split in the West that began around the sixth century, leaving medical texts in the hands of non-practising scholars and medical practice in the hands of illiterate practitioners, an occurrence that has no analogy in the Chinese tradition.195 However, despite the close relationship between theory and practice throughout Chinese medical history, where medical writers and theorists were usually also practitioners, there is still something to be gained from examining the two concepts separately. One reason for this is that theory, in the sense of the doctrines underlying practice, must surely be adapted and modiﬁed through and as a result of years of practical experience, and this practical experience must equally result in the development of new theories. Any attempt to understand this process necessarily entails making a distinction between the two. Also, what I mean by practice goes beyond theory. The Shishan yi’an describes a world of practice unrelated to theory: the elements of the clinical encounter; the social context of the patient/physician dynamic; the physician’s interaction with and attitude towards other healers – these are all aspects of a physician’s practice regardless of his theoretical stance. Finally, as the gender analysis of the next chapter demonstrates quite clearly, Wang Ji’s practice does not always exactly correspond to its theoretical counterpart. 68

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Wang Ji’s introductory essay196 to the Shishan yi’an provides a good starting point for an examination of his theoretical standpoint. Beginning with Zhu Zhenheng’s statement that in the human body yang is in excess and yin is insufﬁcient, Wang Ji argues that the meaning behind this has been misunderstood by successive generations. While agreeing that yin often needs to be replenished, unlike many of his contemporaries he also believed yang too could need replenishment. As yin and yang are relative terms, they can each be divided into elements which are more or less yin or yang in character. In terms of bodily ﬂuids, qi is considered yang, and Blood,197 yin. Wang Ji emphasizes the division of yang qi into two types, protective qi (weiqi ) and structive qi (yingqi ).198 Protective qi is the more yang of the two and circulates around the exterior of the body protecting it from invasion by external pernicious inﬂuences. It is endowed by heaven, and considered incapable of being replenished. Structive qi is also yang, but is yin in relation to protective qi, and is formed from the water and grain that constitute the human diet. Its role is to facilitate the function of protective qi and it is capable of being replenished. As a type of qi, structive qi is by deﬁnition yang; but in relation to protective qi, it is yin. Therefore it can be considered as being both yang and yin. This gives rise to Wang Ji’s argument: Those who are replenishing yang are replenishing the yang of structive qi, those who are replenishing yin are replenishing the yin of structive qi.199 This theory not only underlies the basis of all of Wang Ji’s clinical practice but is also used to unite the theoretical outlooks of the two Yuan dynasty physicians who were most inﬂuential on him, Zhu Zhenheng and Li Gao ,200 creating a coherent rationale for his beliefs: Danxi [i.e. Zhu Zhenheng] regarded replenishing yin as important, and therefore replenished structive qi. Dongyuan [i.e. Li Gao] regarded replenishing qi as important and also replenished structive qi. Regard structive qi as both Blood and qi.201 This dual nature of structive qi is the basis of Wang Ji’s medical beliefs, and in practice governs his preferred choice of treatment 69

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for depletion. This relationship between theory and treatment is expressly stated when he writes that ginseng and astragalus root replenish qi and therefore replenish structive qi, which is in effect also replenishing yin.202 Thus in cases of yin depletion, Wang Ji argues that ginseng and astragalus root should be used, because although they replenish qi they also replenish yin and can give rise to Blood. A simpliﬁed version of Wang Ji’s theoretical beliefs is that qi can be depleted, that Blood and qi disorders are particularly common, and that suitable therapies involve replenishing treatments such as ginseng and astragalus root. In practice, true to his theoretical beliefs, Wang Ji regards depletion, in its various manifestations, as being at the root of the majority of disorders suffered, and ginseng is the most popular medicine prescribed, being given in over three-quarters of all cases. Astragalus root is the ﬁfth most popular medicine, given in over half of all cases. Although this warming and replenishing approach was also favoured by other eminent physicians, including Wang Ji’s contemporary Xue Ji, both the theoretical premise and its application in practice were reformist and controversial at the time, especially with regard to the use of ginseng for disorders of yin depletion. Therefore, despite his reputation, many disciples and proliﬁc writings, Wang Ji met much resistance on a local level from physicians and patients alike. In this context, the Shishan yi’an can be read as an exposition of his theory of depletion, using actual cases to demonstrate its use and efﬁcacy in clinical practice with the intention of silencing critics and converting future physicians to his way of thinking. Wang Ji’s theoretical framework, although individual, draws heavily on the theories of his medical forebears, in particular on the work of Zhu Zhenheng and Li Gao, and to a lesser extent on the theories and prescriptions found in the Han dynasty classic, the Shanghan lun [‘Treatise on cold damage disorders’], written by Zhang Zhongjing . Although Wang Ji quotes heavily from the medical classics to back up his argument, the quotations are almost always introduced simply by the phrase, ‘The Classic says’ ( jing yue ), thus leaving the speciﬁc source of the quotation ambiguous. However, on the occasions when he does identify the source, it is nearly always from Zhu Zhenheng, Li Gao or Zhang Zhongjing. For example, on at least two occasions he quotes Zhu Zhenheng saying: ‘Blood is hard to form and easy to deplete.’203 70

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Li Gao and Zhang Zhongjing are also quoted several times by Wang Ji, mainly to justify his belief in the appropriateness of ginseng in treating disorders of depletion. He writes: Now if yin depletion ends up as yang depletion . . . you should follow Dongyuan’s [i.e. Li Gao] ‘Yang engenders and yin grows’, and use remedies that are both sweet and warming . . . Zhongjing says, ‘For Blood depletion and qi weakness you should use ginseng’ . . . Dongyuan was a Northerner. He often used ginseng. I have veriﬁed this from his writings.204 In another case, Wang Ji recognizes the disorder as being one also discussed by Zhang Zhongjing and closely follows his theories and recommended prescriptions in treating the case.205 Wang Ji therefore saw himself as belonging to a clearly deﬁned medical tradition, which stretched back through time to the Han dynasty.206 However, he also makes it clear that he does not just blindly follow the theories of those who went before him. He is mainly critical of Zhu Zhenheng, and also of what he saw as the misapplication of the beliefs of Zhu Zhenheng by followers such as Wang Lun, author of the Mingyi zazhu, who were instrumental in popularizing the view that disorders of Blood depletion should be treated by drugs which speciﬁcally target the Blood alone, and not by drugs for replenishing qi, such as ginseng and astragalus root, which are favoured by Wang Ji. However, Wang Ji does not see himself as the only proponent of such views, and quotes Li Gao and Zhang Zhongjing among others to justify his own opinions. His criticisms are mostly to be found in the theoretical discussions which are interspersed between cases, as this example demonstrates: Danxi [i.e. Zhu Zhenheng] said, ‘With qi disorders, if you replenish Blood, although it does not hit the spot, it also does no harm. With Blood disorders, if you replenish qi, then the Blood is increasingly depleted and dispersed. This is what is known as punishing one who has not committed a crime.’ Now, this disorder was a disorder of the Blood, and I treated it using ginseng and astragalus root. Would I have been better not to go against the warnings of Danxi? I say, ‘One studies to bring about 71

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understanding, you cannot be inﬂexible.’207 . . . Dongyuan also said, ‘If Blood has collapsed, increase qi. This is the method of the ancient sages.’ . . . I have examined the treatment of Blood disorders in the classics of previous sages, and they never exclusively concentrate on treating the Blood and not nourishing qi. When faced with a disorder, you have to recognize what is suitable.208 From quotes such as these we see that Wang Ji has strong and independent opinions that sometimes conﬂict with those of certain predecessors, but at the same time his criticisms do not take him beyond the conceptual framework of traditional Chinese medical theory as they are validated through recourse to the writings of other respected medical luminaries throughout the centuries. Thus the concepts of traditional Chinese medical theory form the foundation of Wang Ji’s medical beliefs, and by drawing on the theories of his illustrious forebears he is demonstrating that he is a part of that tradition and claiming legitimacy not only for his own position as an elite physician but also for his personal interpretation of that shared theoretical background. It is obvious from a reading of the Shishan yi’an that these theories of depletion, warming and replenishing in practice permeate every level of the clinical encounter from diagnosis through to treatment and recovery. To this extent theory and practice in the Shishan yi’an are not separate but constitute a single uniﬁed approach to the management of illness. What unfortunately is less clear from the text is the process by which this uniﬁed approach was achieved. Did Wang Ji’s development and reﬁnement of the theories of his predecessors come about as a result of practical experience, or were his theories in place before he ever came to practise? Nathan Sivin has put forward the idea of a reciprocal process whereby clinical work gradually reveals to the physician the meaning of canons memorized before his career begins, and as understanding of the canons deepens, meaning is given to diagnostic and therapeutic acts.209 It is not hard to see how, by a logical extension of this process, once a certain level of competency in relation to both elements has been reached subtle reﬁnements and new ideas may begin to develop. In addition, the unique circumstances in which each individual practises will no doubt inﬂuence this process. In the context of sixteenth-century Anhui, for example, as I shall 72

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argue later, cultural perceptions of physical, moral and spiritual exhaustion were at least in part responsible for the development of Wang Ji’s individual theoretical outlook and practical interventions.

The clinical encounter Beyond the theory/practice debate, an analysis of the detail given in the 114 case histories of the Shishan yi’an that relate to Wang Ji’s practice results in an unequivocal picture of the various elements of the clinical encounter from the initial meeting through to recovery. Beginning with an examination of the structure of the individual case histories, it is clear that most follow the same pattern. They are narrated in the ﬁrst person and begin with either the words ‘a man’ or ‘a woman’, or occasionally with one of the various words for ‘a child’. This is sometimes varied by giving the name of the person in question, or their ofﬁcial title or occupation. Their age is generally then given, followed by a brief description of their appearance, mainly their build and/or colouring. Next some sort of aetiology or explanatory factor is often given, such as exhaustion. The symptoms suffered are then listed, often with some mention of what time of day or year they occur, and whether they are more severe in the day or at night. Often these symptoms are described in great detail and can include information about all types of bodily function, such as frequency of seminal emission, regularity and consistency of bowel movements, and so on. The patient is then generally said to have seen a physician210 whose remedies were either ineffectual or caused the illness to worsen. This prompts the patient to invite Wang Ji to examine him. Wang Ji takes the pulse, and usually on the basis of this reading makes his diagnosis. An exposition of the illness syndrome is often then given, followed by his proposed treatment. Finally he relates the outcome of the treatment, and whether there were any later recurrences of the illness. As discussed previously, in no case is there any mention of remuneration of any kind for services rendered, advice given, or medicines prescribed, or even of a gift or reward for successfully treating a patient. Not all case histories rigidly follow the structure described above. In some cases not all of this information is present, in others the basic structure is followed but it is interspersed with additional information about, for example, when, where and how often the 73

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patient was seen, the various illnesses suffered, or Wang Ji’s opinions regarding the patient or the treatments offered by other healers. Some patients are seen several times over a number of months or years, and suffer from a number of different complaints. In these cases the chronology of events is more likely to determine the structure of the case, and the overall effect is more anecdotal than structured. For example, the case of one man suffering from recurrent swellings is narrated in a chronological fashion, and covers a duration of several months. The events are described in the order in which they happened, and include accounts of two separate visits by Wang Ji, two letters sent to him by the patient, and a number of encounters between the patient and other physicians who are trying to persuade him to abandon the treatment recommended by Wang Ji.211 The incidental information contained in these longer accounts can be used to create a better understanding of the context in which medicine was practised in the Ming dynasty. Another way in which the narration of some cases departs from the structure described above is by incorporating dialogue between the physician and the patient. This is used in a number of different ways. The ﬁrst is to elicit information from the patient about his or her symptoms, as this example shows: I asked him, ‘Are you hot?’ He said, ‘I do not feel it.’ I said, ‘Do you cough?’ ‘Only a few times in the night.’ I said, ‘What are your bowel movements like?’ ‘Recently I have had watery stool, and an abscess has developed by my anus. The pus has come out but the wound has not yet closed up.’ I said, ‘What is the worst thing?’ ‘At night I don’t sleep well and my limbs lack strength.’212 In other cases it is the patient who is described as engaging Wang Ji in dialogue. This enables Wang Ji to elaborate on various aspects of the illness. For example, in one case a man is suffering with syphilitic sores (yangmei chuang ), and asks Wang Ji a series of questions about his condition. These include enquiries as to why the medicine he had been taking was inappropriate, what caused his sores, how they were transmitted, and what medicines would be suitable for his disorder.213 Finally, in a number of cases, the phrase ‘Someone asked’ (huo yue ) is used.214 Usually the person is questioning either Wang Ji’s diagnosis or his 74

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proposed treatment. This then acts as a cue for Wang Ji to justify his actions in some detail, often quoting from the medical classics to back up his assertions. The use of dialogue in the case histories is clearly not an attempt to reproduce verbatim an actual conversation, but a literary device which is understandable on a number of interconnected levels. On one level, it reﬂects the real conﬂict between the physician and the patient with regard to the more controversial aspects of his diagnosis and treatment. Linked to this is the idea that the reader will have similar reservations, and therefore on another level the author is reacting to his expected audience by explaining and clarifying his position to the sceptical reader. Further, given the didactic tone of the text, the author is also demonstrating to the reader how he, as a skilled physician, overcomes popular objections to his methods, so that those using his text as a practical guide and following his theoretical stance can similarly meet the criticisms they encounter in practice. Finally, there are those cases which Wang Ji does not actually see. In two cases Wang Ji is merely reporting what he has heard,215 and in others the case is conducted entirely through correspondence or an intermediary.216 Obviously the structure of such cases necessarily differs from the more common form described above. The extent to which this narrative structure accurately reﬂects the clinical encounter is unknowable, but the main components of any encounter with a physician are present, from the initial examination through to treatment, and in addition many other features of medical practice are also revealed. For example, practical issues which are not the main object of focus in the narrative, such as where a physician would carry out his practice, and when and why a physician would decide not to treat a patient, are often mentioned in the text and facilitate the construction of a bigger picture of the mechanics of Wang Ji’s clinical practice. Following through the basic structure of the case history, and incorporating the elements that occur with regularity in many of the cases, our interpretative portrait of a physician’s daily practice gradually emerges. One interesting facet of medical practice highlighted in the Shishan yi’an is its itinerant nature. The evidence from the cases suggests that Wang Ji travelled around a great deal, and that his patients would both visit him and be visited by him. This is most 75

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clearly shown in some of the longer cases where there is a certain amount of coming and going over the months and years. Often this is simply expressed, and not elaborated on, in phrases such as: ‘I was invited to go to examine her.’217 Or ‘I went to see her.’218 On other occasions there is the deﬁnite impression that Wang Ji just happened to be at that particular place. For example, one man who is seen by Wang Ji later sends letters on two separate occasions asking for further advice about his case. Wang Ji writes: ‘I happened to go there, and told him to stick to the previous remedy.’219 In another case, Wang Ji has a patient whom he has been seeing over the last ﬁfteen years. He is staying at a certain place, and the patient is brought to him in a sedan chair by her mother and maidservant. After being examined she returns home, and Wang Ji tells us that when he next happened to go to that town, he saw her and the illness was completely cured.220 This type of comment suggests that Wang Ji is travelling about, and only infrequently passes through certain places.221 Perhaps as a result, some patients went quite out of their way to get to see him, such as one woman who on her return journey by sedan chair had to scale some steep hills, exacerbating her condition.222 However, Wang Ji also put himself out for his patients; for example, he is twice said to have braved terrible weather conditions, including snow and cold, and travelled on foot from Wuhu in Anhui to Yangzhou – a distance of approximately 120 kilometres – in order to visit his ailing sonin-law.223 As the Shishan yi’an was compiled from the writings of disciples, we also know that Wang Ji would be accompanied by them on his visits to patients. However, this is not directly commented on in the text itself. With regard to examination and diagnosis, all the elements of the four examinations (sizhen ) are used by Wang Ji in his assessment of the patient’s condition. The components of the four examinations are ‘looking’ (wang ), ‘listening and smelling’ (wen ), ‘asking’ (wen ), and ‘touching’ (qie ). ‘Looking’, the ﬁrst of these examinations, is evident in most of the case histories. After stating the sex of the patient, Wang Ji nearly always gives a description of his or her physique and colouring, such as whether he or she is fat or thin, pale or dark. ‘Listening and smelling’ comes across as a somewhat less important technique, as in only two cases is there any mention of the patient’s odour.224 Although in only one is there evidence of the use of dialogue expressly to elicit information about the patient’s condition,225 Wang Ji always 76

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describes in some detail the symptoms suffered, and includes information about when they began, in what order they occurred, whether they followed a seasonal pattern, whether they were more serious in the day or at night and so on. Such information, particularly about the history of the illness, could only be gleaned from conversation with the patient or the patient’s family, and therefore ‘asking’ is clearly a vital component of the diagnostic procedure. ‘Touching’, in the form of pulse taking, is probably the most important aspect of the examination, and his diagnosis invariably took the pulse reading into account. It was vital that this reading was accurate, and Wang Ji would often re-examine the pulse after a period of days, or after his proposed treatment had had time to take effect. On one occasion, a patient had come a long way by sedan chair, which, Wang Ji suspected, had caused his pulses to be unsettled, so he had to come back early the next morning to have them checked.226 There are also those patients whom Wang Ji does not see in person, where the case is dealt with either by correspondence or through an intermediary.227 Obviously this presents problems with regard to conducting the four examinations. In one such case, Wang Ji writes in a reply to a letter: Physicians take the four [examinations] of looking, listening and smelling, asking, and touching as their duty. With regard to your illness I am only able to deal with the one matter of asking, and the remaining three matters I am not able to deal with, or know clearly. I trust to fate in offering a prescription, which may or may not be successful.228 His diagnosis and recommended treatment in such cases is therefore based solely on the information regarding symptoms which he has been given in the letter, although sometimes information about the pulse can be forthcoming even in such cases. For example, the son of a woman who has been ill for some months and has seen several doctors without success goes to see Wang Ji. As well as relating his mother’s symptoms to him, when prompted he also explains that the other physicians had told him that her pulses were ﬂooding and rapid.229 That Wang Ji enquires as to the state of her pulses is indicative of their importance as a diagnostic tool. The illness is often attributed to one or more causal factors, usually related to the patient’s lifestyle. Some form of exhaustion 77

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is the most common aetiology, followed by external factors such as the weather or the effects of an arduous trip to foreign climes. Emotions also play their part in triggering illnesses: anger, sadness, pensiveness and anxiety are all blamed for either causing or contributing to the patient’s ill health. The effects of excessive sexual activity, alcohol consumption or eating also ﬁgure highly, particularly if the patient is male. Some form of moral culpability is attached to the sufferers of illnesses caused by such vices, and these patients are normally cautioned to moderate their behaviour if a recovery is to be brought about. In addition, the debilitating effects of childbirth are often implicated in postnatal disorders. Throughout Chinese medical history illnesses have been attributed to these factors, and they can all be found in the Han dynasty medical classic, the Huangdi neijing ! [‘Inner canon of the Yellow Lord’]. What emerges from an examination of aetiology in a practical context is the input of the patient: the ability to attribute an illness to many of these factors depends on a dialogue in which the patient offers up information to the physician about his or her recent history that can be interpreted as relating to the present condition. The extent to which the physician elicits this information from patients, for example by asking if they have been drinking too much lately, or to which it is offered by patients who voice concern about certain activities they perceive as contributing to their illness, is unclear. However the balance is tipped, what is clear is the possibility of a cultural component to this dialogue, with the physician following certain lines of enquiry or patients offering certain details about their lifestyle because of popular cultural understandings of illness and its causes. The results of all of the four examinations can then be combined to produce a diagnosis and a reasoned statement of the illness syndrome. Although neither the modern term for this process, ‘pattern diagnosis’ (bianzheng ), nor the term ‘illness syndrome’ (zhenghou ) denoting the resulting medical diagnosis, is explicitly used in the text, this is essentially what Wang Ji, in common with other elite physicians in the Ming,230 was doing. He utilized the information obtained from the clinical encounter to translate the patients’ symptoms into a complex and individual root pattern expressed in terms of the binary pairs that make up the eight rubrics (bagang ) – yin/yang, cold/hot, inner/ outer and depletion/repletion. This process gave Wang Ji a diagnosis that was strengthened by an understanding of the underlying 78

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pattern or root (ben ) of the illness. This in turn enabled him to predict how the illness would develop and helped him identify the appropriate therapeutic strategy for the individual patient. Wang Ji’s diagnoses are very individual and speciﬁc in nature. Except where depletions of qi or of blood and qi are diagnosed, only very rarely is the same diagnosis made of two different individuals. Certain patterns do, however, emerge, and in keeping with Wang Ji’s theoretical outlook, depletion forms a part of the majority of his diagnoses. In particular Blood and qi, yin and yang, and the Spleen and Stomach are often said to be depleted. These depletions commonly lead to stagnation and heat. Very rarely is a disorder of excess diagnosed. One case in particular demonstrates how the patient’s appearance, her pulses and symptoms all contribute to the ﬁnal diagnosis and treatment plan. Firstly, the patient has put on weight over the years, so being plump she is perceived as more prone to disorders of qi depletion. Secondly, her pulses were all ﬂooding (hong ), slippery (hua ) and lacking in strength (wuli ), which Wang Ji considers to be symptomatic of yin ﬂourishing and attacking yang. Finally, with regard to her symptoms, the pain is extreme during the day, but quite mild at night. This is interpreted in terms of yang being depleted and therefore unable to transport, so it congeals, stagnates and causes pain. Thus, the patient’s appearance, symptoms and pulse all combine to create a coherent picture of yang depletion, and Wang Ji concludes that taking both the symptoms and pulse into account, a suitable treatment would be to assist yang.231 Sometimes the four examinations would yield conﬂicting information which could not be combined into a coherent pattern. In such cases, it was necessary to prioritize the results of certain examinations over others. For example, one man, who was dark in appearance, was diagnosed as having qi depletion, although this was generally regarded as being more common in people who had a plump and pale appearance. Wang Ji explains how, despite his appearance, his pulse and symptoms both point towards qi depletion, and writes: When the ancients treated illness, there were those who relied on the symptoms, those who relied on the pulses, and those who relied on the appearance. Now, it is right to rely on the symptoms and the pulse, and make [a diagnosis of ] qi depletion.232 79

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In most cases, this one included, it is the pulse reading which is considered the most revealing of a patient’s condition, and therefore the examination which is most relied upon. For example, in one case, the pulse reading alone clearly reveals to Wang Ji that the patient has become pregnant, despite her not having menstruated in the previous year.233 When it comes to treatment, drug therapy is Wang Ji’s treatment of choice, with over 90 per cent of his patients being prescribed a combination of drugs, usually medicinal herbs in decoction, to treat their illness. In a typical case, having conducted his examination, stated the diagnosis and aetiology, and described the illness syndrome, Wang Ji will then list the medicinal herbs to be taken and the quantity required of each, and explain the method of preparation and the frequency with which the resulting medicine is to be taken. For example: I used ginseng (renshen ) and astragalus root (huangqi A), two qian of each; Chinese angelica root (guishen ), poria (fuling ), and ophiopogon root (maimendong ), one qian of each; scutellaria root (huangqin ) and tangerine peel (chenpi ), seven fen of each; and ﬁve fen of liquorice (gancao ). It was decocted, she took it and recovered.234 In some cases the function of each ingredient is stated, as in this example: You should use ginseng (renshen ), white atractylodes rhizome (baizhu ), and poria (fuling ) to replenish the Spleen, as the ruling drugs; Chinese angelica root (guishen ), ophiopogon root (maimendong ), and scutellaria root (huangqin ) to clear the Lungs and nourish the Heart, as the minister drugs; chuanxiong (chuanxiong ), tangerine peel (chenpi ), and hawthorn fruit (shancha ) to disperse the stagnation and eliminate the dampness, as the assistant drugs.235 A total of over 120 different drugs are used by Wang Ji in the Shishan yi’an, a fairly staggering number when one considers the effect of geography, climate, the seasons and local conditions on the range of herbs available to a physician at any particular time. 80

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The increasing number of pharmacies in Xin’an at this time with the concomitant development of techniques for the processing and storage of drugs may account for this, especially since it is thought that Wang Ji himself had a pharmacy in Qimen,236 and presumably medicinal herbs were yet another commodity that merchants traded in, which would enable him to procure supplies of herbs that could not be grown locally. However, of these 120 drugs less than forty are used three times or more, and only about twenty are employed on more than twelve occasions, that is in more than about 10 per cent of cases. If one examines the drugs which are used in over half of all cases, we ﬁnd a select core of about ﬁve herbs which constitute the basis of Wang Ji’s therapeutic policy. These are, in order of most use, ginseng, white atractylodes rhizome, Chinese angelica root, liquorice and astragalus root. Ginseng and astragalus root are sweet and warming, and replenish qi. White atractylodes rhizome is also sweet and warming, replenishes qi, and strengthens the Spleen. Chinese angelica root, also sweet and warming, is perhaps the best-known herb for replenishing the Blood. Liquorice also acts on the Spleen and replenishes qi, but is often used in its guiding and co-ordinating function.237 Given Wang Ji’s strong theoretical conviction of the need to replenish qi, his continual diagnosis of depletion, and his advocacy of the use of ginseng and astragalus root, and other sweet and warming drugs, it is no surprise to ﬁnd these herbs used most often. Wang Ji favours an individual and ﬂexible approach to treatment over set prescriptions, and the combination and quantity of drugs he selects in one case is rarely, if ever, an exact match for any other. This said, a total of forty-four prescriptions are mentioned in the text, although of these thirty are used only once, another seven only twice, and often certain modiﬁcations are advised to tailor the medication to the speciﬁc requirements of the patient.238 The two most commonly used prescriptions, Decoction of Four Ingredients (si wu tang ) and Decoction of Four Gentlemen (si junzi tang !), are only used on seven occasions in total, but their ingredients are all among the dozen or so drugs most frequently used by Wang Ji. Apart from treatment using medicines, Wang Ji employs very few other therapeutic interventions. There are two cases where he uses heat treatments on patients. In the ﬁrst case of a woman who has stagnant heat inside which he is not able to draw out using 81

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herbal decoctions, he makes her sit on hot bricks which have been bound in cloths.239 This treatment may derive from a passage in the Shanghan lun which describes a treatment called ‘scorching the back’ in which hot tiles, wrapped in cloth, are put on the back of a patient to obtain perspiration.240 In the other case, a jug of hot water was used to steam the feet of a female patient.241 There is also a case of a man suffering from ulcerous swellings who, in addition to being given herbal medicines, has some of his swellings lanced by Wang Ji. This latter approach is in line with Wang Ji’s views on surgery or external medicine (waike ) as expressed in his text on the subject, the Waike lili. In general, surgical practitioners would deal with disorders that manifested on the exterior of the body, such as wounds, animal bites and skin complaints such as the ulcerous swellings described in the above case. It is not thought that they performed much in the way of invasive surgery. In the preface to the Waike lili, Wang Ji thus deﬁnes this branch of medicine, ‘External medicine [i.e. surgery] deals with ulcers, abscesses, sores and boils which can all be seen on the exterior. Therefore it is called external medicine.’ He believed that although the manifestation of the illness was on the exterior of the body, the root of the illness was on the interior, so effective treatment would combine both internal remedies, such as herbal decoctions, and external remedies, such as ointments or acupuncture and moxibustion. The Shishan yi’an contains other examples of cases which would naturally fall into the waike camp, such as an itchy body, foot sores and breast lumps, and in each case it is noticeable that Wang Ji’s therapeutic strategy is to use internal remedies alone. Interestingly, at no point does he digress to discuss his rationale for this, perhaps because to do so would be to detract from the main theme of this text and because his views on the subject were already clearly set out in the Waike lili. Linked to Wang Ji’s views on waike are his views on acupuncture and moxibustion, two of the main therapies employed by waike practitioners. Moxibustion is mentioned on ﬁve occasions in the Shishan yi’an, and in two of these cases some kind of needling or acupuncture is also employed.242 However, Wang Ji never utilizes either of these techniques himself, and on each occasion the procedure is carried out by another physician and is blamed for exacerbating the patient’s condition. Wang Ji’s disapproval of moxibustion and acupuncture as therapeutic techniques is expressly stated in one case, where the patient is told that his recourse to 82

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moxibustion and needling has scorched the bones, harmed the muscles, and contributed to the depletion of the Blood: Now the Stomach does not [perform its] receiving [function], and the Spleen does not [perform its] transporting function. The muscles and channels increasingly lose that which nourishes them. Again, you have increased this with moxibustion and needles scorching the bones and harming the muscles, which has again depleted the Blood. Danxi [i.e. Zhu Zhenheng] says, ‘Blood belongs to yin. It is hard to create, but easy to deplete.’ Given this, if you then rashly undergo acupuncture and moxibustion, then the Blood is depleted and wasted.243 Again, Wang Ji recommends replenishing as a suitable method of treatment. These criticisms of acupuncture and moxibustion initially appear somewhat incongruous, coming as they do from the author of a book on acupuncture and moxibustion, the Zhenjiu wendui ! [‘Questions and answers on acupuncture and moxibustion’]. But reference to this volume quickly clariﬁes this apparent contradiction: the Zhenjiu wendui is essentially a reassessment of acupuncture and moxibustion as they appear in the early classics such as the Huangdi neijing, and itself contains many criticisms of the application of acupuncture and moxibustion in contemporary medical practice. In particular, the use of acupuncture for treating depletion disorders is heavily criticized by Wang Ji, who believed acupuncture to be depleting by nature and therefore not appropriate for treating disorders of depletion. Wang Ji was not alone in reassessing the merits of acupuncture and moxibustion as therapies at this time, or in advocating the use of internal remedies for external disorders. Acupuncture and moxibustion were declining in prestige in the Ming dynasty and waike practitioners were being marginalized. For example, Furth’s analysis of the case histories of the late Ming physician Cheng Maoxian show that he recommended moxibustion only in extreme situations when herbal tonics could not reach a patient too sick to swallow.244 Cheng Maoxian and Wang Ji share a style of male learned medical practice which focused on internal medicine, especially for epidemic disease and acute fevers, and which favoured herbal remedies. By contrast, Furth notes that the case histories of a female physician and contemporary of Wang Ji, Tan Yunxian 83

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(1461–1554), show her to be a strong advocate of moxibustion.245 Tan Yunxian was something of a rarity – a woman whose high social rank meant that she achieved the status of a literati doctor and, unusually, even authored a set of case histories which remain extant. To the extent that the account she gives of her medical practice differs from the more typical male pattern, Furth believes that it may be showing traces of popular medicine as practised by healers of both sexes and used by both women and poorer sufferers. In this context, her emphasis on external medicine, chronic afﬂictions and moxibustion is evidence of a division between elite physicians who were distancing themselves from acupuncture and moxibustion and other more marginal healers and practitioners who were not.246 So far as it is possible to tell from the Shishan yi’an, Wang Ji’s patients did not share his views as to their harmfulness and readily submitted to the ministrations of practitioners of the arts. In some cases, Wang Ji does examine a patient but declines to treat him. This occurs for two main reasons. Firstly, if it seems obvious to Wang Ji that the patient is close to death or that his illness is incurable, he will not offer any treatment. Invariably, this diagnosis is shown to be correct.247 Apart from the fact that Wang Ji may be unshakeable in his conviction that death is inevitable, another reason for declining to treat those who are dying may be the question of having to take responsibility for their death. Secondly, some illnesses are regarded as unsuitable for treatment with medicines. In these cases, Wang Ji recommends that a more appropriate approach to treatment would be for the patients to moderate their behaviour and remain calm in order to effect a cure. For example, he sees two women suffering with a similar complaint and tells them: The skin of your abdomen is distended and hangs down. Already it is not something which medicines can reduce. You should simply calm your Heart, and lessen your desires in order to preserve your life.248 If his instructions are followed, it is not inconceivable that a recovery will ensue, or at least that death will be averted. In the above case, Wang Ji goes on to say that the women became pregnant and died in childbirth. The implication is that in telling the women to ‘lessen their desires’, Wang Ji was counselling them 84

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against becoming pregnant again. This supposition is strengthened by the fact that Wang Ji comments that one of the women had previously endured this condition for over a decade without falling ill as a result of it because she lived alone as a widow and there was therefore nothing to harm her Blood. In becoming pregnant the women were not following Wang Ji’s advice and, as he predicted, the Blood/yin depletion of childbirth when combined with the existing qi/yang depletion meant that death was inevitable. This reluctance to treat certain patients also raises the issue of the limits to a physician’s medical knowledge. Wang Ji admits on several occasions that the situation is either beyond his control, or is not something that he, or mankind for that matter, knows anything about. In one case, a woman is pregnant and also has some kind of Lung disorder which keeps recurring despite having been treated. Wang Ji tells her: If the illness is eliminated after giving birth, then this is a good omen. If the illness comes back, this is not something I know about.249 In another case, the patient in question has no pulse on either hand. Wang Ji concludes that this is her natural disposition, and writes: One can see that the transformations of things in the world in truth emerge so inexhaustibly that it is simply impossible to fully understand every one according to normal principles . . . No pulse on both wrists in a person [whose body processes are] unaffected: this is [an abnormality] that makes no sense, and [can be the result only of ] some great transformation in things. I therefore set it down in writing.250 Thus it is clear that as a physician Wang Ji did not regard himself as omniscient, but was aware that he would occasionally encounter certain conditions that he felt he was not only unable to treat but was also unable to explain in terms of any recognizable theoretical framework. As might be expected from a text such as this, designed to bolster the author’s reputation as well as to educate future physicians, most of Wang Ji’s patients recover, and usually at the ﬁrst or second 85

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attempt at treatment. However, a small number of patients do die. In addition to those patients whom Wang Ji was too late to save, or whose illnesses did not conform to a recognizable or treatable pattern, there are also those whose illnesses are treatable but who disregard his advice on the necessary modiﬁcation of their behaviour required for a recovery, and consequently cannot be saved. None of these deaths are therefore attributable to any negligence on the part of the physician; in each case he has done all that is humanly possible to effect a recovery.

The patient/physician dynamic Although written from the physician’s viewpoint, Wang Ji’s case histories are also able to reveal something about his patients, and the complex relationship he had with them. One important factor in looking at the patient/physician dynamic is the level of society to which Wang Ji’s patients belonged, as choice of physician or healer and the quality and duration of treatment are all issues which can be affected by the class of the patient.251 Most of Wang Ji’s case histories begin either with the words ‘a man’ () or ‘a woman’ (), which is unfortunately not a good indicator of social and economic status. However, there are exceptions to this which can give us some clues. These come mainly from the patient’s occupation. Wang Ji tells us he treats two district magistrates,252 an attendant censor,253 the vice-magistrate of his own district,254 the vice-magistrate of Yi () district (in Southern Anhui),255 a provincial graduate256 and two assistant instructors from Confucian schools.257 Obviously, women are less likely to have ofﬁcial titles, but in one case he refers to one of his female patients as a Child Nurturess, which is a title of honour awarded to the mothers and wives of both civil ofﬁcials and military ofﬁcers of the seventh grade.258 That he mentions the ofﬁcial capacity of these people may be because they are of a rank higher than him, and he wants to be seen to have associated with them. Therefore, we cannot deduce that all of his patients belonged to equivalent ranks; it is more likely that if their occupation is not mentioned, it is because Wang Ji could gain no prestige by mentioning it because their social status was lower than his. There is, however, one occasion on which the patient is accredited as belonging to a fairly low social class, being referred to simply as a woman from the village,259 so not all of his patients came from the elite classes. 86

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There is also other information contained in the case histories which can provide some clues as to the patients’ social class. For example, we know that he treats various members of his family, such as his son-in-law,260 his grandson261 and his nephew’s wife,262 who may be of a similar status to his own. Also he makes certain comments in his discussions of the case which act as markers of status. For example, one woman is brought to see Wang Ji in a sedan chair by her mother and maidservant,263 and a man also comes to Wang Ji by sedan chair.264 Obviously, only those of a certain social standing would have had servants and travelled by sedan chair. In another case, he warns the patient against engaging in drinking and sex after concluding business deals, thus revealing him to be some kind of merchant or business man.265 Another indicator of class may well be that the majority of patients see more than one physician, and many see several. As already discussed, even if the advice was free the prescriptions almost certainly were not, so the patients or their families must have been sufﬁciently well off to afford the various medicines suggested by the physician. One other factor to be taken into consideration is the knowledge of medicine possessed by the patient. Many patients are depicted as being relatively well versed in the classics, and discuss their treatments with Wang Ji. Unless this is simply a narrative device, these patients must have belonged to the literate classes and have had some kind of classical education. To a large extent the patients make the choices with regard to their medical needs, and the physician operates in a somewhat unstable environment in which he faces stiff competition from other healing spheres as well as rival elite practitioners.266 Where we see clear evidence of the patient/physician dynamic, often the only visible interaction between patient and physician concerns conﬂict over diagnosis and appropriate treatment. Unfortunately for Wang Ji, in most cases the patients also seem to have a fairly good grasp of elementary medicine, which enables them to argue with the physician. As perhaps might be expected from Wang Ji’s controversial medical theories, almost all of these arguments concern his diagnoses of qi depletion and/or his decision to treat with ginseng and astragalus root.267 For example: I examined him, the left pulse was ﬂoating, depleted and languid, the right pulse was ﬂoating, strung and languid. This is yang depletion. The patient said, ‘I am easily 87

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hungry and like eating, my nocturnal seminal emission is extremely frequent, it seems like yin depletion. If you diagnose yang depletion and use ginseng and astragalus root, I fear it will increase the illness.’268 And again: I said, ‘This is qi depletion.’ He asked, ‘Sputum containing Blood, and sometimes coughing up black phlegm, are all disorders of the Blood. The ancients said, “In dark people qi is replete.” Now, I am quite dark in appearance. Why do you say it is qi depletion?’269 And again: I said, ‘This is Spleen depletion and insufﬁciency’. He said, ‘I have already taken an ointment of ginseng and white atractylodes rhizome. My chest also feels full and oppressed. I fear for this illness it is not suitable to use ginseng and astragalus root.’270 However, despite their fears, in most cases Wang Ji is depicted as managing to convert them to his way of thinking, persuade them to take ginseng and astragalus root, and effect a recovery. So despite their initial scepticism, Wang Ji’s counter-arguments are sufﬁciently persuasive to make them change their minds, suggesting that a physician was not entirely without authority. Again we see that the use of ginseng and astragalus root as a treatment was somewhat controversial at that time, and that even patients were aware of this and therefore unwilling to take them. It may be that cases such as these were only included because Wang Ji wanted to show that his choice of diagnosis and treatment were ultimately proved justiﬁed, and that this level of knowledge was not common among patients. However, this still indicates that some patients did not meekly comply with the physician’s recommendations, but were prepared to argue back if his diagnosis did not correspond to their own understanding of why they were ill. One could also suppose that this dialogue was simply put in the mouths of the patients, again to enable Wang Ji to expand on the theoretical basis of his treatments, but as the cases are 88

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intended to be believable, a scenario in which the patient questions his diagnosis cannot have been entirely implausible. Another facet of this dynamic is the physician’s imparting of moral advice to the patient regarding the kind of behaviour required if a recovery is to be achieved, accompanied by dire warnings of the dangers to the patient’s health if this advice is not followed. Such moral recommendations usually require patients to restrain their desires, moderate their diet and abstain from sexual intercourse.271 It is made clear that such behaviour is more fundamental than any medicines they are given, as this selfcultivation treats the ‘root’ of the problem, whereas medicines only treat the ‘branch’.272 Although the patient obviously has the choice to ignore such warnings, Wang Ji is invariably proved right, as those who comply live,273 and those who rebel cannot be saved.274 Thus the physician can be seen as having some authority in advising patients about appropriate behaviour, given that they ignore this advice at their peril. There are also several occasions in the text where patients initially treat themselves, or are treated by their family. Sometimes their treatments are successful; for example, Wang Ji tells the story of one man who suffers from worms coming out of his penis, and pulls out a total of seven over successive days using metal tweezers. He is then cured, and does not consult a doctor again about this problem.275 On other occasions their treatments are partially successful, such as the man who was twice cured of a urinary problem by having sex, but later contracted a cold damage disorder (shanghan ) and saw Wang Ji, who told him that sex acted as a curative in his case because it resolved the stagnation and dispersed the heat.276 Another man with itchy genitals applied a powdered and honey-roasted medicine to his testicles, and was much better, but he then consulted Wang Ji when he felt cold and had a bad cough.277 Wang Ji makes no comment on the efﬁcacy of this treatment. Some people worsen, however, after their attempts at treating themselves. One woman treats herself with a certain prescription (qing shu yi qi tang !") and worsens.278 Wang Ji tells her that although her treatment was suitable, it was not strong enough to combat her illness. Qingfen 279 is taken by one man with what appears to be syphilis, and Wang Ji explains to him that as its nature is ﬁerce it can only exacerbate his condition.280 Patients then have a means of accessing treatments without going through a doctor, and will attempt 89

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a treatment themselves, only seeking medical assistance if it is ineffective. It is perhaps no coincidence that several of the above cases of initial recourse to self-treatment occur with illnesses which involve the genital region, as patients suffering from genital complaints may well have been reluctant to seek medical attention for reasons of personal modesty. Wang Ji makes no comment on this practice of self-treatment other than with regard to whether or not the treatment was suitable in that particular case. Families are also involved in the illness management of relatives, and apart from acting as intermediaries in negotiations with the physician, they also examine the patient, offer diagnoses and make treatment plans. For example, in this case of a man with fever: A family member examined him and surprised said, ‘The pulses are exhausted!’ He was of the opinion that these were yin symptoms and wanted to give him fuzi tang . He had not yet decided, and invited me to come and treat him.281 Wang Ji explains that the pulses are not exhausted but hidden, and then continues to say why he does not feel the proposed treatment would be suitable in this case. However, he does not criticize the relatives’ involvement. Another man has been treated several times by Wang Ji, but as yet without success. Wang Ji then writes: His whole family were alarmed, and suspected that these were yin symptoms occurring post-coitally, and intended to give him fuzi lizhong tang !".282 Again, Wang Ji disagrees with their diagnosis and proposed treatment, and explains why, but does not criticize them for wanting to interfere in his series of treatments. The man in question is a forty-six-year old adult, so it is interesting that his family are described as having little reticence in discussing his sexual activities with the doctor, and blaming them for his illness. In both these cases the families consult the physician before implementing their treatments. As previously mentioned, some patients never interacted directly with the physician but conducted their treatment either by correspondence or through an intermediary; thus the patient/physician 90

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dynamic existed only on paper or in the form of verbal information passed between the two parties, and so was considerably more distant. Nevertheless, it was not unusual to go through such channels; the Shishan yi’an contains nine examples of replies to letters,283 mentions four occasions when the patient wrote to Wang Ji explaining their symptoms,284 and includes two cases which were conducted entirely through an intermediary, namely the husband or son of a female patient.285 There are also other cases where, because of the young age of the patient, the dynamic existed between the parents and the physician, not the patient and physician.286 This form of the dynamic obviously contained much less opportunity for interaction, discussion or disagreement, and, as Wang Ji himself noted, was much less reliable as there was no opportunity to carry out the four examinations.287 Regardless, he was still prepared to offer diagnoses and treatments on the basis of the information regarding symptoms and, occasionally, the pulse reading conveyed to him through such intermediate channels. In many ways the patient/physician dynamic is portrayed as an area of intense conﬂict, and good debating skills were essential if the physician was to convince literate patients, conversant with medical theory, of the accuracy of his diagnosis, suitability of the treatments proposed, and the need for moderation of their desires. The patient was free to choose to follow the advice given, or to seek one or more second opinions, which they frequently did.288 This must have increased the pressure on a physician who was in a position of having to continually justify his actions both to rival physicians and to sceptical patients. However, that Wang Ji was often successful in this task means that to some extent he can be seen as an authoritative ﬁgure, although on other occasions this authority was clearly undermined either by other physicians and their competing theories or by the essentially ﬁckle nature of his patients, which meant that neither their loyalty nor their compliance could be relied upon.

Interaction with other physicians and healers Over two-thirds of all Wang Ji’s patients are described as having seen at least one other healing practitioner, and many as having availed themselves of the services of several practitioners. Even Wang Ji’s own grandson289 and his nephew’s wife290 were initially seen by other physicians before Wang Ji was called in. Under such 91

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competitive circumstances it cannot be expected that a physician would be very favourably disposed towards his rivals, and indeed this comes out clearly in comments made in the case histories. In the majority of cases the other healers are also elite physicians, and Wang Ji therefore is being forced to compete against them for his patients’ loyalty, and perhaps also for his reputation and livelihood. As a result, the picture Wang Ji paints of his direct rivals in the Shishan yi’an is one of incompetence bordering on malpractice. However, underlying this rhetoric is the distinct sense of fear and insecurity, because although Wang Ji knows himself to be correct in his beliefs, he is nevertheless being constantly undermined by his rivals who are vying for the hearts and minds of his patients, and not infrequently succeeding in their attempts. Wang Ji constantly makes critical comments about the treatments other physicians offer to patients. He often recounts that he was called in after the treatments of three or four previous physicians had proved unsuccessful. He then proceeds to explain why their various approaches were fundamentally misguided, and to prescribe a more suitable treatment which is generally a success. In some cases, these other treatments are not only unsuccessful but positively harmful, and cause the patient’s condition to worsen.291 In at least one case Wang Ji regards a patient of his who is about to die as having been fatally harmed by the inappropriate treatment of another physician.292 The treatments prescribed by other physicians, as recounted by Wang Ji, generally can be divided into two categories: treatments using herbal preparations and treatment by acupuncture or moxibustion. Wang Ji’s own treatment strategies which favoured the use of herbal medicines and disapproved of acupuncture and moxibustion have already been discussed, as has his preference for the use of sweet and warming medicines which assist the Spleen and Stomach, such as ginseng and astragalus root. This opinion is most clearly expressed in the theoretical essay written by Wang Ji in the appendix to the Shishan yi’an where he attacks the taboo on these medicines found in Wang Lun’s Mingyi zazhu,293 and also in his theoretical introduction to the Shishan yi’an where he writes: All of those in the world today who say that ginseng and astragalus root replenish yang and do not replenish yin have never tested their use in practice.294 92

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He is therefore very critical of physicians who employ bitter, cold or cooling remedies, which he believes will increase the harm to the Stomach.295 In one particular case of a woman who is suffering from menorrhagia, Wang Ji rails against the attitudes of contemporary physicians, writing: Now qi is unable to transport or raise which has resulted in menorrhagia. The therapy should treat yang. Contemporary physicians are blind to this, and only know that if Blood is hot then it circulates, if it is cool then it congeals, and if it is cold then it stops. Therefore they used bitter, cold, and black ash remedies. They certainly do not know that bitter [remedies] cause purging. If the Stomach is cold then there is a downward collapse ( jiangxia ). Therefore the classic says, ‘Bitter harms qi, cold harms Blood.’ How are they able to treat this menorrhagia? The Spleen and Stomach belong to earth, they have an aversion to dampness, a liking for warmth, and a fear of cold. In principle you should use sweet and warming [remedies] to nourish the Spleen, then heat will naturally be eliminated, the qi will naturally transport, and the Blood will follow qi, and each will return to their channels.296 Having criticized contemporary medical practice in this fashion, Wang Ji goes on to praise ‘the ancients’, and Li Gao in particular, for knowing to treat Blood with remedies which nourish qi, such as those he recommends. This marked contrast between the wisdom of the ancients and the folly of his contemporaries is also a common feature in Wang Ji’s criticisms. However, his writings also indicate that he came under ﬁre from other physicians, as well as from patients, for his belief in the need to treat Blood disorders with medicines for replenishing qi. Therefore on several occasions we see Wang Ji either justifying himself, or simply despairing at the state of contemporary medicine. For example, in one case he decides to use ginseng and astragalus root in the treatment of coughing and bringing up Blood due to Spleen depletion. Someone then says: [If there is] coughing [then] the Lungs have hidden ﬁre. The Zazhu 297 says, ‘With [disorders of ] coughing 93

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Blood and vomiting Blood, the Lungs receive the pernicious inﬂuence of ﬁre. The two things that one is prohibited to use are ginseng and astragalus root.’ Now, why are you using prohibited medicines when the illness opposes it?298 While the use of ‘someone said’ may be merely a literary device to enable Wang Ji to justify his use of ginseng and astragalus root, the fact that he feels the need to include this justiﬁcation in his case history indicates that to some extent his treatments went against the common conventions of that time. This can also be seen in another case of a women who has been being treated by Wang Ji for ﬁfteen years. As she has put on weight over the years, Wang Ji changes his diagnosis of stagnation and heat to one of depletion and cold, and changes her treatment to one which includes ginseng and astragalus root. Although she recovers completely, the case history ends on a somewhat sour note. Wang Ji writes: Later I heard that she had several painful lumps on her breasts, which she had neglected to tell me about at that time. She visited a surgical practitioner (waike ), and returned blaming it on having taken too much ginseng and astragalus root. They really do not know that in plump people qi is depleted and there is much stagnation. If she had been able to take the previous medicine for a long time, not only would the breasts lack painful lumps, but even if there were any, they would also disappear. It would mainly be because the illness was receding and she stopped the medicine when the Blood and qi were not yet sufﬁcient, therefore the qi stagnated and the Blood congealed and formed these lumps.299 Clearly Wang Ji’s theoretical outlook, which emphasized the use of medicines such as ginseng and astragalus root in the treatment of depletion disorders, was at odds with that of his contemporaries. Wang Ji makes other criticisms of Ming dynasty medical practice, which do not simply consist of disagreements over appropriate therapeutic techniques resulting from different theoretical approaches, but concern more fundamental issues of contemporary attitudes to practising medicine. Firstly, in the case of the man 94

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who has been suffering from syphilitic sores and has taken a variety of treatments without success, Wang Ji complains about other physicians for whom a temporary resolution of the symptoms is more important than actually curing the disorder. He writes: People today seek quick successes, and all use qingfen.300 The dampness and phlegm are forced out, and over three to ﬁve days the sores are temporarily better, but the raging heat is still there, and after no more than ten to twenty days the sores again return. Again the previous medicine is taken, again the illness is eliminated, and again the patient is cured, but again the sores erupt, and round it goes, with no appreciation of the fact that using eliminating medicines increases the raging heat. Owing to this the limbs and the body either have oozing abscesses or spasms, and subsequently it becomes a chronic disease. The Analects says, ‘If you desire it in a hurry, you will not succeed.’301 In another case, Wang Ji is able to make a diagnosis of depletion because on examination the patient’s pulses vary from day to day, a recognized sign of a depletion disorder. However, he bemoans the fact that most physicians do not take the time to make an accurate pulse diagnosis or to prescribe medicines based on the individual nature of the patient’s disorder: Today, physicians conduct their examination in an instant, and promptly state what the illness is. They then open their bag and make up the prescription. The trouble with this is that it is unreliable, and cannot get to the bottom of the patient’s condition.302 This criticism can be contrasted with his praise for his contemporary Han Mao, some of whose case histories are also included by Wang Ji in the Shishan yi’an, primarily because the theoretical outlooks of the two physicians coincide. After one of Han Mao’s case histories, Wang Ji comments that in treating illnesses Han Mao really knows how to adapt his medicines to the speciﬁc circumstances of the case, implicitly suggesting that this ability was something of a rarity at that time.303 95

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These continual criticisms can in many ways be seen as the product of the social context of medical practice, where there was not a single coherent body of knowledge but a wide diversity of opinion on almost every aspect of medicine, and where it is the patient who has control and is in a position to dictate what medicines he will take, and which physicians he will see. It would seem that, in common with many other Ming dynasty medical practitioners, Wang Ji commanded little authority over his patients.304 In some cases, Wang Ji may treat a patient over an extended period of several months or even years,305 but there is always the possibility that at any point the patient will either see other physicians, or even change physicians altogether. An example is the above-mentioned case of the woman who had been treated by Wang Ji over a ﬁfteen-year period but failed to tell him about her breast lumps and went to see a surgical practitioner who blamed them on the treatment she had been prescribed by Wang Ji.306 In another case a man with a swollen and painful leg changes doctors a total of four times, and even after Wang Ji has told him that moxibustion will exacerbate his condition, when Wang Ji goes away he changes doctors again, and again has moxibustion performed.307 Another man, being treated by Wang Ji for scrotal swellings, sees another physician when Wang Ji is away. The new physician wants to alter Wang Ji’s prescription, but in that instance the patient defends it and refuses to change it. However, later on he gets another swelling which he allows other physicians to treat before seeing Wang Ji.308 Wang Ji is also fearful of other doctors changing his recommended treatments, and on one occasion practically has to threaten a patient to induce him to take the medicine until the spring, saying: If you are deluded by the words of men and stop the medicine, not only will the fever not be able to be stopped, but [will become] either consumption or swellings, and it will be hard to avoid later sorrow.309 However, Wang Ji himself is not averse to meddling with treatments of other physicians, as this example shows: I said, ‘They were mistaken in their medicines. The previous medicines are mainly active preparations, how can the Stomach tolerate these things?’ I told him to 96

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throw them away and change to using ginseng, astragalus root.310 Patient/practitioner loyalty was clearly not a feature of Ming dynasty medical practice, and Wang Ji’s patients would often get a number of opinions as to the nature of their illness. The sense of insecurity and impotence in the face of relentless competition this provoked is no doubt partly responsible for the tension seen in the Shishan yi’an between elite physicians. As both anthropological311 and historical312 studies have already shown in the Chinese context, the healthcare system in any society embraces both folk and popular culture, as well as the professional medical sector. This is reﬂected in the Shishan yi’an, which conﬁrms that elite medical practitioners were not Wang Ji’s only rivals; on several occasions we see that his medical practice intersects with other systems of healing. The most striking description of the practices of a non-elite healing sector comes in the case of a man with syphilis313 who takes advice from a fangshi :314 A fangshi told him to take the bones of a child. This method requires a new born child which is placed on bricked ground and surrounded with a charcoal ﬁre. Drying by ﬁre causes the dead child to become ashes. Wrap them in paper and place on the ground to remove the ﬁre poison, and make into a powder. On an empty stomach, mixed with either alcohol or decoction, take two or three qian. It is supposed to be able to replenish.315 The ﬁrst thing to note is that the patient’s ﬁrst recourse is to a fangshi and not a physician. Secondly, Wang Ji’s reaction to this rather strange-sounding practice is merely to comment that, having been roasted in a ﬁre, the treatment will be somewhat ﬁerce and violent, and therefore unsuitable for his case. He does not make any comment on the moral aspect of using the bones of a dead baby,316 or on the fact that the patient had consulted a fangshi. Also in relation to syphilis, in another case we are told of a man with syphilis who chanced upon a Daoist follower (daoliu ), who told him of an effective cure.317 Although Wang Ji does not see this patient personally, he makes no comment about either the practice of seeing Daoist followers or the prescribed treatment. 97

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Other references in the Shishan yi’an include one mention of charm water (fushui ),318 which we are told was unsuccessful in curing fever,319 and one mention of fortune telling. Interestingly, it is not the patient but her husband who has his fortune told from his facial characteristics. Wang Ji writes: A physiognomy book (fengjian ) told her husband that if his eyelids (ganmen ) were green/white then his wife would be harmed. A fortune teller foretold that her fate would worsen and she would die.320 Again, Wang Ji makes no comment on whether he believes this or on the role of fortune telling in predicting the outcome of illness. In this case, however, the prognostication proves incorrect and Wang Ji is able to save the patient. The Shishan yi’an also includes some cases by other physicians. One such case, included by Wang Ji, concerns the treatment of a girl who is depressed because her mother has died. The physician in question believes that as emotion is at the root of her illness, it can only be cured by emotion. He therefore tells her husband to bribe a female spirit medium (nüwu ) to tell the girl that her mother, in the underworld, is angry with her, blames her for her death, and is making her ill by way of retribution. The girl then becomes angry, and is cured.321 Thus anger is being used to conquer pensiveness according to the ﬁve phases, where the Liver/ anger controls the Spleen/pensiveness. This is interesting in that the spirit medium is being utilized by the physician, who is using his own theoretical understanding of disease management, whereas the patient is cured through her conceptual framework of spirits in the underworld, and the power of the spirit medium to tap into this world. Therefore, although a cure is effected, the patient and the physician have different beliefs about the nature of the treatment and why it was effective. In this situation, the spirit medium too is capitalizing on the faith of the girl in her powers, while being fully aware that she is acting fraudulently. The physician, while not necessarily believing in the power of the spirit medium or condoning her practices, is aware that, because of the nature of his patient’s problem, and owing to her belief in spirit mediums, the illness is more likely to be cured by manipulating that conceptual framework, although he uses his own medical framework to rationalize the treatment process. So here we ﬁnd an elite physician 98

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in league with a practitioner from a non-elite sphere of healing in the interests of the patient’s welfare. This is the only example in the Shishan yi’an of a female healer of any sort, and as mentioned above, this case is not even by Wang Ji. The absence of female healers from the text is initially perplexing given that there is plenty of evidence to indicate not only that there were female healers in the Ming, but that women were more likely to go to a female healer as their ﬁrst recourse for their own health problems and those of their children.322 This viewpoint is also borne out by the fact that Wang Ji sees nearly two men to every woman, so unless women had a signiﬁcantly lower rate of illness, or the ratio of male to female patients in the Shishan yi’an is not an accurate reﬂection of his medical practice, then women were looking elsewhere for their medical care. In detailing the medical histories of those women whom Wang Ji sees, although he makes general references to earlier failed treatments by other healers (who could conceivably have been female), he makes no express references to female healers or midwives. One can only conclude that either their paths did not cross or that in this exposition of his elite medical practice Wang Ji’s concerns primarily related to exactly that, elite (male) medical practice, and to demonstrating the superiority of his theories and practices over those of his elite (male) contemporaries. From the above, it is clear that individuals do not have just one explanation for their illnesses. They are capable of interpreting their illness in terms of elite medicine, which includes concepts of yin and yang, ﬁve-phase theory, etc.323 But at the same time they also have beliefs and understandings which come from a number of other sectors which relate to beliefs that are personal and religious as well as medical, and which include concepts they absorb from their families, religious groups, spirit mediums, thaumaturges, fortune tellers and so on. One does not get the impression that any of these beliefs are mutually exclusive, rather that they are coexistent, and can be employed in the relevant clinical context. The patient, or in some cases his family, chooses which of the explanatory models is most useful to him at any given time, and determines the course of action to be taken with regard to which healer he consults, and whether he elects to follow the advice they give.324 As we have seen, Wang Ji’s elite medical practice interacts at various levels with these other healing spheres as well as with 99

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other practitioners of elite medicine. He is much less critical of medical interventions by either patients and their families or other healers, than he is of the actions of rival practitioners belonging to his own sphere of healing. With regard to patients and their families, this may be because he values their custom, and is therefore wary of being openly critical, but one might have thought that a physician would want to defend his own set of beliefs and values against those of competing systems of thought. Indeed other elite physicans are on record complaining about ‘quacks, itinerants, priests of the popular religion, spirit mediums and Taoist masters’ and it has been suggested that in doing so physicians were allying themselves with conventional upper-class medicine and the tradition of the Yellow Emperor.325 One explanation for Wang Ji’s approach is that he sees other elite physicians as direct competitors with whom he is engaged in a battle for both intellectual and clinical supremacy, whereas other healers are seen as to some extent offering services which are not in competition with his own. In other words, the reverse strategy is having a similar effect: by criticizing elite healers Wang Ji is engaging on a professional level only with the group to which he feels he belongs, and by largely ignoring the non-elite healers he is distancing himself from groups to which he does not belong. Through Wang Ji’s experiences it is possible to make some general observations about the practice of medicine in the Ming dynasty.326 It is clear that a wide diversity of healing practices and practitioners was available to the patient, ranging from elite practitioners of traditional Chinese medicine to thaumaturges, religious healers and spirit mediums, and including self-treatment and intervention by the family. There does not appear to have been a prevailing medical orthodoxy, and even within the ranks of the elite practitioners conﬂicted and controversy raged over appropriate theoretical approaches, diagnostic conclusions and suitable therapeutic interventions. Certainly, traditional Chinese medicine could not be described as a single, systematized and consistent body of knowledge, even though the basic theoretical principles and historical tradition of the discipline, stretching back to the classics such as the Huangdi neijing, were recognized by the practitioners of the art. The palpable lack of patient loyalty to a single physician, evinced by their readiness to change doctors many times within the course of an illness and to experiment with a variety of healing alternatives, suggests a distinct unwillingness to trust in 100

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any one healing system, and possibly attests to a fairly low social standing for physicians, if one takes their failure to command any kind of authority over their patients as an indicator of social status. The Shishan yi’an also allows us a rare glimpse of various aspects of Ming dynasty medical practice as seen from the point of view of an individual practitioner. It has been possible to explore the interrelationship between theory and practice, with Wang Ji’s often vehement theoretical beliefs both underlying a working strategy of clinical practice and at the same time being reinforced and modiﬁed by that clinical experience. Additionally it has provided an unparalleled opportunity to examine the various dynamics of his clinical practice itself. This has included the actual logistics of practising medicine, from its itinerant nature to the practicalities of examination, to diagnosis and treatment, as well as the chance to gain a better understanding of the environment in which he practised, encompassing his interactions on a number of levels with elite physicians, other healers and, of course, the patients themselves. The world Wang Ji describes differs radically from our own understanding of medical practice, which is shaped by our experiences in the twentieth and twenty-ﬁrst centuries. Through this textual analysis I have exposed a picture of Ming dynasty medical practice which, although possibly not representative, reﬂects the experiences, frustrations and opinions of a single physician working in Anhui province in the early sixteenth century. The image he presents to us through his case histories is one of a valiant struggle to emulate his sage forebears and practise medicine to the best of his ability, despite being faced with relentless competition from his elite rivals, lack of loyalty from his patients, and continual criticism from both.

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CHAPTER 4 GENDER, CULTURE AND MEDICINE A gender analysis of the ‘Stone Mountain medical case histories’

Chapter 3, although interpretative, followed closely what was said in the Shishan yi’an by Wang Ji himself. Because of this, I am conﬁdent that the opinions expressed and conclusions reached about his clinical practice and his interactions with patients and other practitioners are a good reﬂection of his experiences as a physician and of how the changing social and economic environment, for example in terms of increased competition between physicians, affected his medical practice at that time. The gender analysis that follows is somewhat more speculative: by taking gender as the basis of my enquiry, I am examining the text in a way not envisaged by its author. Wang Ji makes no explicit statements about differences between the sexes or their impact on medical practice. Nevertheless, by using gender as an analytical tool and examining how Wang Ji treated his male and female patients it is possible to gain certain insights into the dynamics of gender relations within the text. For example, I am interested in questions of where gender is located in the body, of how the sex of the patient affects the physician’s approach to the illness, and perhaps most importantly, what factors might account for any differences between the sexes that are revealed by the analysis. The resulting interpretation of the Shishan yi’an, while remaining entirely dependent on what is written in the text for its conclusions, is the furthest removed from what its author intended to convey. However, what it is able to reveal about gender difference within a speciﬁc medical context can contribute towards a greater appreciation both of the operation of gender relations within society 103

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and of the interaction between medicine and the cultural context in which it is practised. The use of just one text, the Shishan yi’an, as a starting point for an exploration of the dynamics of gender relations within traditional Chinese medicine has certain methodological implications. My intention is to present all the data from the text in a form as close to the original as possible, as I believe this to be a more balanced approach to the use of a single text than simply bringing ideas to the text and ﬁnding examples to substantiate them. I am trying to convey a more complete picture which deals with gender in relation to every element of the medical encounter that is presented in the text. In my analysis, therefore, I follow the structure of the case histories closely, beginning with the initial encounter, and progressing through to the ﬁnal outcome of the case. In practical terms, this has meant dividing my research into ﬁve main sections. These are diagnosis, aetiology, illness syndrome, treatment and outcome. Within each of the ﬁve sections I compare the treatment of male and female patients to locate where there are differences between them, and to try to uncover why. One important consequence of adopting such an approach to the analysis is that areas of similarity, as well as those of difference, between the sexes can also be analysed for their signiﬁcance, as it may well be that similarity requires as much explanation as difference. As well as looking at difference and similarity between the sexes, I also explore differences between women, particularly with regard to their reproductive status, to see what effect, if any, reproduction has on their experience of illness. My analysis employs both qualitative and quantitative techniques. Clearly, qualitative data have to take priority in a study like this, as the nature of the source material means that a statistical analysis is simply not possible. Sets of case histories, such as the Shishan yi’an, in no way constitute a random, or even representative, sample of patients. As discussed in the previous chapter, each case will have been carefully selected for inclusion in the compilation, the main purpose of which seems to be to illustrate certain points of theory and practice. This fact may effectively reduce the reliability and validity of any results obtained using quantitative methodologies. However, because of the difference in numbers of men and women in the study, I have found the use of simple ratios and percentages helpful in highlighting areas of difference, 104

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and in making comparisons between the sexes. It should be noted that I am only using these ﬁgures as a general guide, and am not suggesting that they constitute a statistically accurate, or representative, reﬂection of gender differences in Ming dynasty medical practice.

General facts and ﬁgures Before beginning my analysis, it is necessary to examine some general facts and ﬁgures about the text. Case histories make up the main body of each of the three fascicles of the Shishan yi’an, and there are also some case histories included in the biography of Wang Ji. The earliest edition of the Shishan yi’an, dating from 1531, contains a total of 123 cases in the main body of the text.327 The cases in the ﬁrst two fascicles have been classiﬁed under a total of thirty rubrics which refer to the type of disorder suffered, such as those of pregnancy, or the major symptom of the illness, such as bringing up Blood. The criteria for classiﬁcation under a particular rubric do not seem particularly stringent, and cases within a category do not necessarily have similar aetiologies, illness mechanisms or treatments. Also, cases in the third fascicle are not arranged according to any deﬁnable pattern. When looking at these categories from a gender perspective, what is striking is how infrequently men and women are classiﬁed under the same rubric (Table 4.1), being present together in only eight out of the thirty categories. This may not be signiﬁcant, however, as most categories contain only one or two cases, and all of the four largest categories,328 fever, swellings, coughing, and bringing up Blood, do contain patients of both sexes. Unfortunately the information given here is insufﬁcient to determine the extent to which certain classiﬁcations of illness were thought to be speciﬁc to either one sex or the other. The cases in the three main fascicles form the basis of my analysis. To facilitate comparison of the sexes, I have eliminated from the quantitative side of my analysis those cases which relate either to young children or to patients Wang Ji has simply heard about, and does not treat himself, either in person or through correspondence, and I have taken account of situations where the case discusses more than one patient. This results in a tally of 109 adult patients of Wang Ji. Their distribution throughout the three fascicles of the text is summarized in Table 4.2. 105

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Table 4.1 Disorder classiﬁcations Disorder

Translation

Number of men

! !

Pestilence Periodic fever Nosebleed Dysentery Rib pains Swelling Worms coming out of the penis Itchy body Difﬁculty swallowing Urine retention Eyes Gonorrhoea Cough Qi pain Numbness Constipation Bringing up Blood Diabetes Miscellaneous Syphilitic sores Lung abscess Foot sores Ulcerous swellings Hernia swellings Menstrual regularity Pulse which has left the sections Disorders of pregnancy Postnatal Infant convulsions Diarrhoea 30 categories

1 19 1 2 2 3

0 4 0 1 0 1 (+2)

1 23 1 3 2 4

1 1 1 1 0 1 2 (1) 1 0 0 11 0 9 2 (+3) 0 0 2 2 (2) 0

0 0 0 0 1 0 3 1 1 1 1 1 3 0 1 1 0 0 9

1 1 1 1 1 1 5 2 1 1 12 1 12 2 1 1 2 2 9

! Total

0 0 0 1 () 1 () 64 (+3)

Number of women

2 2 2 1 () 0 36 (+2)

Total

2 2 2 2 1 100

Key 1. The character ‘’ signiﬁes that the patient in that particular case is a child. 2. Numbers in brackets indicate that the case in question is discussed with reference to more than one patient. The additional number of patients is signiﬁed by the number in brackets.

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Table 4.2 Distribution of male and female patients in the text

Men Women Total

Fascicle 1

%

Fascicle 2

%

Fascicle 3

%

Total

%

34 15 49

70 30 100

24 22 46

52 48 100

10 4 14

71 29 100

68 41 109

62 38 100

As Table 4.2 shows, the ﬁrst and third fascicles both have very similar ratios of men to women, approximately 2.3 men for every woman. The second fascicle has a much higher proportion of women. This is because this fascicle includes a lengthy section on women suffering from disorders of menstruation and pregnancy. Overall, the Shishan yi’an reﬂects a medical practice comprised of nearly twice as many male patients as female patients, the exact ratio being 1.7:1. Obviously this could reﬂect the biases of the compilation more than the composition of his medical practice. However, other sources also indicate that fewer women than men were seen by elite healers. For example, of the forty-seven case histories included in Wang Ji’s biography, only ten relate to female patients. Another book authored by Wang Ji, the Waike lili, contains a total of over six hundred case histories drawn from the writings of a variety of physicians, and of these cases only a quarter of the patients are female, which gives a ratio of approximately three men to every woman. Even the earliest recorded case histories, those of Chunyu Yi which date back to the Han dynasty (206 bc – ad 220), contain a much higher proportion of men to women; of the twenty-ﬁve recorded cases, eighteen are male and seven female. If true, the most plausible explanation for this difference is that women preferred to see female healers, and only went to elite male healers as a last resort, when other treatments had failed. There is evidence from contemporaneous sources, both historical329 and literary,330 to substantiate this explanation, although there is no mention of female healers in the Shishan yi’an itself. Interestingly, parallels can be found in the Greek medical tradition. Of the case histories in the seven books of Epidemics in the Hippocratic Corpus, there are twice as many male as female patients, and here too the preference of women for other forms of healing is thought 107

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Table 4.3 Number and percentage of women in each group

Number of women Percentage of women

Group A

Group B

Group C

Total

17 41

9 22

15 37

41 100

to be the determining factor.331 There are also other explanations which could account for, or contribute to, the lower proportion of female patients. For example, it is possible that women became ill less often than men, or that, living in the inner quarters, they might have had less access to a physician. For the purposes of my analysis, I have divided the women who are seen by Wang Ji into three separate groups which can be compared and contrasted. The ﬁrst group (A) are those women whose disorders have nothing whatsoever to do with reproduction; the second group (B) of women have disorders which by themselves do not have a reproductive component, such as fever, but whose illness is complicated by a reproductive link, such as being pregnant, or having recently given birth; and the third group (C) are women who are suffering from reproductive disorders such as irregular menstruation, menorrhagia or an inability to conceive. That Wang Ji also regards the latter group as separate is evinced by the fact that all those women with reproductive disorders are grouped together at the end of the second fascicle under rubrics such as ‘menstruation’ and ‘disorders of pregnancy’, while women belonging to the other groups are scattered throughout the text. Table 4.3 shows the number and percentage of women in each group. As the table indicates, just over a third of women have disorders directly linked to reproduction, which means that nearly twothirds of women, a sizeable majority, are suffering from nonreproductive disorders. This might sound unsurprising, but one might have expected that a much higher proportion of women would have been perceived as suffering from disorders of menstruation, pregnancy or childbirth, particularly given the emphasis placed on menstrual regularity in all books on women’s disorders (fuke ). Drawing a parallel with the Greek tradition, which similarly gave prominence to Blood and menstruation in medical understandings of the female body,332 a study of case histories in the Epidemics found that those relating to women were almost exclusively gynaecological in nature.333 The ﬁgures from the 108

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Shishan yi’an, then, do at least indicate that, unlike the situation in classical Greece, the medical perception of women in Ming China was not necessarily constrained by the conviction that reproduction was central to female health. As women with gynaecological complaints constitute only a third of women seen by Wang Ji, an analysis which focuses on the full range of disorders suffered by women and not just on reproductive complaints, and which compares and contrasts differences resulting from reproductive status, is integral to the construction of a more complete understanding of the complex interactions between women, society and medicine.

Diagnosis The multi-faceted and complex process of diagnosis within traditional Chinese medicine provides many opportunities for the examination of gender difference, with regard to the practical application of the four examinations which form the basis of diagnostic technique. By comparing and contrasting the ways in which the physician approaches an illness, it is possible to examine whether, and to what extent, this is affected by the sex of the patient. This includes looking at questions such as whether women were diagnosed differently, whether the physician had the same degree of access to his patients’ bodies, and whether his treatment of women was constrained by issues of modesty. Probably the ﬁrst thing to notice about each case history is that it begins with either the words, ‘a man’ (yi ren ) or ‘a woman’ (yi fu ). The sex of the patient is therefore the ﬁrst observation made by the physician, and this very primary distinction indicates that the sex of the patient may well be an important factor to be borne in mind when making a diagnosis. However, in many cases, the description of the four examinations that follows could easily apply to either sex, and the effect of biological sex on the process described is almost impossible to discern. From the text, there is a stronger feeling of similarity than of difference between the groups analysed, at least with regard to diagnostic technique, but there are some points of contrast which are revealed by an exploration of the diagnostic procedure. Wang Ji employs each of the four examinations, ‘looking’, ‘listening and smelling’, ‘asking’ and ‘touching’, in making his diagnosis. In the context of the Shishan yi’an, ‘looking’ generally refers 109

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to the patient’s immediate appearance, such as colouring and build. ‘Listening and smelling’ is the least used of the four, since in very few cases is there any mention of the patient’s voice, breathing sounds or odour. ‘Asking’ relates to the process of obtaining the patient’s medical history in terms of the duration of the illness, contributing factors and symptoms suffered, such as location of pain, sensations of hot or cold, and changes in appetite. ‘Touching’ is probably the most important of the four examinations, and is mainly concerned with the feeling of the pulse. The information obtained from each of the four examinations is used to build up a picture of the pattern of the illness, its required treatment and probable prognosis. The following example, which is fairly typical for both sexes, quite clearly shows elements of each of the four examinations: A man, quite plump and frail, thirty years old; he had a favourite concubine. During the third month because of exhaustion he caught a fever, his nose bled and dripped mucus without stopping, he smelt so rank it was hard to come near. Gradually his vision became blurred, his ears heavy, his appetite reduced, and his body tired. . . . I examined his pulses. They were all ﬂoating, soggy, and slippery, and when I pressed it, it lacked strength. I said, ‘You will not recover from this illness.’334 A direct comparison of the use of ‘looking’ as a diagnostic tool does not reveal many differences between any of the categories in my analysis. There are numerous occasions where Wang Ji describes the appearance of women in a similar way to that of men. The following female example is very like the male one quoted above: ‘A woman, pale, neither fat nor thin, aged over ﬁfty, was suffering from a sore tongue.’335 This holds true for women suffering from disorders with a reproductive link (B) and for women with reproductive disorders (C). In the following example of a woman with a menstrual disorder, whom he has been seeing over a period of years, Wang Ji comments at one point: ‘Moreover, when she was ﬁrst ill, her build was slight and small, and now her build is plump and large.’336 It is possible that Wang Ji never actually saw these women, and merely ascertained the information he required from the husbands or maidservants, but as the description is generally presented in 110

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the same manner and in the same place in the text for both sexes, and as no mention is made of any difﬁculty obtaining that information, I think it is not unreasonable to conclude that he may well have seen them. There are some cases where information about the woman’s build and colouring is not given,337 and perhaps in these cases he did not get to see them, but it is also true that there are some occasions, although admittedly fewer, where a man’s appearance is not described, so the text does not provide evidence of signiﬁcant differences between the sexes in this regard.338 Medical histories, in terms of accounts of the history of the illness, lists of symptoms, location of pain, encounters with other physicians, and attempts at self-treatment, are described equally in male and female cases. At no point in the text does Wang Ji complain that there were problems in taking case histories from women, that he had any difﬁculty having his questions answered, or that the information given by his female patients was unreliable in any way. The type of information solicited is remarkably similar, and in the female cases, unless the illness is gynaecological in nature, there is very rarely any mention of menstruation whatsoever. For example, of the seventeen women whose illnesses have no reproductive element (A), a change in menstruation is only mentioned twice in the list of symptoms,339 and of the nine women whose illnesses are linked with reproduction (B), menstruation is only mentioned once,340 although in the latter group because most of the illnesses are complicated by pregnancy or postpartum, menstruation was not an issue. This lack of reference to menstruation may suggest that women were not routinely questioned about their monthly cycle. Or put another way, there is no evidence to suggest that acquiring knowledge about the patient’s menstrual cycle was an important part of the diagnostic procedure.341 Given that regular menstruation was seen as one of the most basic requirements for female health, that a multitude of illnesses were thought to result from irregular menstruation, and that its importance is such that the ﬁrst chapter in texts on women’s disorders is invariably about menstrual regularity (tiaojing ), it might have been expected that menstruation would play a more central role in diagnosis even when the disorder was not necessarily reproductive in origin. That it appears not to indicates that the centrality of menstrual regulation to female health is not immutable, but may vary so that, for example, it would be more relevant when a woman was trying to conceive, and when reproduction 111

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was not an issue the importance placed on ensuring the patient has a regular cycle would diminish. It certainly appears from the Shishan yi’an that concerns about regular menstruation are not central to female health when a woman is suffering from an illness not related to reproduction, and that the medical view of women was not solely conﬁned to their role as potential child-bearers. One striking difference between the sexes with regard to the employment of ‘asking’ as a diagnostic tool is the disparity in the level of interaction the patient has with the physician. There are many cases where a man is described as discussing his case with the physician, for example enquiring as to how he caught the illness, and what the best course of treatment would be, or even arguing about the diagnosis, as in this case: I said, ‘This is qi depletion.’ He said, ‘Exhaustion from sexual activity, coughing Blood, and nocturnal seminal emission are all disorders of the Blood. A sinking and minute pulse in the guan () section of the left hand also signiﬁes a disorder ruled by Blood. Moreover, I have heard that plump and pale people’s disorders are mainly qi depletion. Now my appearance is dark, why do you say it is qi depletion?’342 In contrast, there are no cases where a female patient is quoted as replying to the physician or querying a diagnosis he has made. In fact, on two occasions, when the patient is female, questions are directed to, and answered by, her husband, as can be seen in this example of a woman who does not have a discernible pulse: I used my ﬁngers to search pressing the channels at the lieque () acupuncture point343 and there was also no response. I was greatly surprised at this and asked her husband about it. He said that when she had been pregnant a physician examined her and also said that she lacked a pulse.344 It is possible that the quoting of dialogue in cases such as these is merely a literary device which served the function of allowing Wang Ji to justify his theory of the illness, but even if that is wholly true, it is still signiﬁcant that speech is always attributed to men and not to women. 112

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There is no reference in the text to any kind of direct contact with the patient’s body other than pulse taking, which is considered to be the cornerstone of diagnosis for both men and women. No mention is made in the text of any difﬁculty faced by the physician in taking the pulse of a female patient, and in nearly every case the patient’s pulses are taken into consideration when reaching a diagnosis. As the above and the following examples both demonstrate, even on female patients, Wang Ji would examine the pulse on each wrist, using his ﬁngers to search it out: A women was ill and I was asked to examine her. Her left pulse was languid, soggy, and weak. The right hand lacked a pulse. Again and again I searched for it, and there was movement on the outside edge in the section between the Yangqi and Pianli acupuncture points.345 Then I said, ‘The left pulse has left its position, so it is hard to know the illness from the pulse. If one reasons from the right pulse, then it seems to belong to Spleen and Stomach insufﬁciency.’346 There does not appear to be any difference between the sexes with regard to the signiﬁcance of a certain type of pulse, and, in the category of fever for example, both men and women are most likely to have pulses which are ﬂoating, weak and soggy, suggesting that an illness will result in a similar pattern of pulses in each sex. Indeed, overall, these three types of pulse are the most common in the text, and are common in both sexes. There are a few differences, however, in the frequency of certain pulses: men are much more likely to have a strung (xian ) or depleted (xu ) pulse, and women have proportionately more ﬁne (xi ), minute (wei ), and slippery (hua ) pulses. The greater preponderance of slippery pulses in women can be accounted for by the fact that it is renowned as a very typical pulse of pregnancy, and it is indeed the pregnant women in the text that are more likely to have a slippery pulse. An issue that has strong links with diagnosis and gender is that of modesty. How could the male physician in imperial China fully conduct the four examinations on a woman, given that men and women were routinely segregated, and that strict rules of propriety were in place which further restricted male and female physical contact? There is some evidence from the Song dynasty 113

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onwards which suggests that there were indeed problems with regard to diagnosing women’s ailments. The ﬁrst recorded complaint is by Kou Zongshi , a twelfth-century pharmacologist, who writes of difﬁculties both in examining the appearance and taking the pulse of well-to-do women who would remain hidden behind a curtain for the duration of the examination, and who had a cloth draped over their protruding hand and arm, leaving the physician only the information gained from ‘asking’ and ‘listening and smelling’ to use as the basis for his diagnosis.347 This passage became a narrative trope in later writings,348 and an obstetric text from the late Ming dynasty for example similarly laments: When a doctor attends a patient, he is limited to the four methods of diagnosis, of which taking the pulse is considered the least important. As for the other three methods – observation, listening and smelling, and questioning, they can be used in the cases of men and children, but are forbidden for women. . . . Women are far too aloof to be observed or listened to for symptoms when they are ill.349 Even the Shishan yi’an itself contains a quotation taken from the Hanshi yitong, written by Wang Ji’s contemporary Han Mao, which wonders how mistakes in diagnosis can be avoided when one is not able to employ the methods of ‘looking’ or ‘listening and smelling’ when examining women of noble and elite families.350 In the case histories themselves, on no occasion does Wang Ji comment that he had any problem carrying out any one of the four examinations on the grounds of modesty. As my analysis of the four examinations above has demonstrated, Wang Ji appears to have been able to observe his female patients’ appearance, to obtain their medical history, and to feel their pulse. One of the cases included in Wang Ji’s biography relates to a pregnant women who gives birth to a boy, although the pulses had indicated that the child would be a girl. Wang Ji comments that pulse books cannot cover all the possible variations of nature, and that because of this doctors value ‘looking’, ‘listening and smelling’, ‘asking’ and ‘touching’.351 He does not mention that he had encountered any difﬁculties in conducting these four examinations because the patient was a pregnant female. However, the reason for mentioning it may have been that he anticipated that this was a situation 114

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in which a physician might have difﬁculties in carrying out the four examinations. On the other hand, he does complain in a letter to a male patient that diagnosis was difﬁcult, as of the four examinations he had only ‘asking’ upon which to base his diagnosis.352 The text provides other avenues for an exploration of issues of modesty. We know, for example, that many fewer women than men were seen by Wang Ji, and this could in part be attributed to modesty constraints. Women were no more likely than men to correspond with Wang Ji by letter, but they were more likely to go through an intermediary. In one case, a woman’s son goes to see Wang Ji and describes to him his mother’s condition. He does, however, tell Wang Ji that other physicians had been treating her, but having had no success, they had made their excuses and left.353 In another case of a woman who was suffering every month from worms coming out of her vagina just before her period was due, her husband went to see Wang Ji about the problem, and he did not see her in person.354 It should be noted, however, that men were also less likely to seek a physician if their illness involved the genital region. One man who suffered from worms coming out of his penis pulled them out himself and did not consult a physician about his problem;355 in another case of itchy genitals, the patient initially resorted to self-treatment and only consulted a doctor when this had failed.356 However, there are occasions where male genitals are described in detail, which is not the case with female genitals, and the descriptions given do suggest that the physician may be relating something he had seen. For example, there are three cases of males with a swollen scrotum where the texture or size is described, although in two of them the patients are boys under the age of ten.357 Overall, the large majority of cases involving female patients in the Shishan yi’an give no indication that there were modesty constraints on seeing or examining women, and the scanty evidence that exists is limited to reduced interaction with the physician and increased use of intermediaries. These are themes that also emerge, but with much greater prominence, from Charlotte Furth’s study of the case histories of the seventeenth-century physician Cheng Maoxian.358 Cheng’s narratives show more clearly how the treatment of sick women was expected to take place under the guidance of male authority. An adult male was usually named at the outset, he was presumed to have called the doctor and legitimized his visit, he was also present at the examination, and it was 115

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with this man that Cheng would discuss the ﬁner points of diagnosis and treatment. In addition, women were often unwilling to speak about their ailments, which presented difﬁculties for the physician in ascertaining details of their symptons. Furth notes that such issues were more evident when the illness related to the sexual or gestational body, and as the majority of Cheng’s female patients consulted him for problems of reproductive function, this may explain why modesty seems to have been more of an issue for him than for Wang Ji whose clinical practice was less centred on women with reproductive problems. In sum, the extent to which Wang Ji encountered difﬁculties in examining women is inconclusive. The evidence from the Shishan yi’an indicates that medical practice was not overly constrained by concerns over propriety when dealing with female patients, and that the physician was able to base his diagnosis on the information gained from each of the four examinations. On the other hand, it may be that Wang Ji did in fact encounter problems but that in writing the Shishan yi’an his authorial intentions lay elsewhere – on demonstrating the efﬁcacy of his treatment strategies. One thing that seems certain is that he did not face the level of difﬁculty in examining and diagnosing female patients suggested by Kou Zongshi, and it is likely that his complaints had become part of a medical rhetoric that was taken from earlier texts and requoted over and over again down the centuries with little consideration of the extent to which it represented an accurate portrayal of clinical medical practice. Nor do Wang Ji’s case histories evidence the same level of reliance on male intermediaries or difﬁculty in conversing with female patients about their symptoms as those of Cheng Maoxian, perhaps because his female patients’ illnesses were less likely to be related to reproductive function.

Aetiology Having conducted the four examinations, Wang Ji often attributes the patient’s illness to one or more causal factors. What interests me is not only what is said to have caused the patient’s illness, but also to what extent that cause is dependent on the sex of the patient, and why certain aetiologies might be more common in one sex than in the other. The gender-centred approach I use in my analysis of aetiology in the Shishan yi’an casts light on other issues, in particular on what factors might be inﬂuential in the 116

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transformation of medical theory into clinical practice. The conclusions drawn from this analysis indicate that there is a great adaptability of theory to suit individual circumstances, in terms of geographical, temporal and cultural speciﬁcity. To begin with, it is helpful to look brieﬂy at some typical understandings of disease-causing factors that are often to be found in theoretical texts throughout the centuries. This serves the dual function of providing a general context into which the ﬁndings from the Shishan yi’an can be set, and, given that Wang Ji was also familiar with many of these theoretical works which to a greater or lesser extent must have formed the basis of his medical knowledge, it also allows us to view the extent to which he adapts these theoretical understandings for his own use. Generally speaking, aetiology in theoretical works can be divided into three categories: external causes; internal causes; and causes which are considered neither external or internal. External causes are considered to be the six pernicious inﬂuences (liu yin ) – wind (feng ), cold (han ), summer heat (shu ), dampness (shi ), dryness (zao ) and ﬁre (huo ) – which can invade the body and cause illness. Internal causes are the seven emotions (qi qing ) – joy (xi ), anger (nu ), sadness (you ), pensiveness (si ), grief (bei ), fear (kong ) and fright (jing ) – any of which in excess can cause illness. Causes which are neither internal nor external include factors such as diet, excess sexual activity, exhaustion/overwork. Although the priority given to each may vary from text to text, the same elements can commonly be found. For example, the Huangdi neijing, the medical classic dating from the Han dynasty, in discussing the relationship between man and his environment, cites the climate, the seasons, external pernicious inﬂuences, emotions, diet, exhaustion and sexual activity as factors which may disrupt the balance of yin and yang and give rise to illness.359 Perhaps closer to Wang Ji’s own theoretical standpoint is the Pi wei lun [‘Treatise on the Spleen and Stomach’], written by Li Gao in the Yuan dynasty. This work places the emphasis on an incorrect diet, indulgence in emotions, and excessive exhaustion as the main agents of injury to the Spleen and Stomach.360 What is immediately striking from a gender perspective is that when aetiology is discussed in the majority of theoretical texts, there is no mention of difference with regard to the sex of the patient. For example, even a quotation in the Song dynasty text 117

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on women’s disorders, Furen daquan liangfang !"# [‘Good prescriptions from the compendia of gynaecology’], states: There are thirty-six disorders of pregnancy that are lacking in men. Of the rest: external harm by wind, summer heat, cold and dampness; internal accumulations of joy, anger, sadness, and pensiveness; eating and drinking, exhaustion from sexual activity, depletion and repletion, and cold and heat; in all these they [women] are the same as men.361 In some texts on women’s disorders, however, women are said to be particularly prone to illness resulting from their lack of emotional control or stability. Indeed, the very next quotation from Furen daquan liangfang relates how disorders of conception, pregnancy and childbirth result in women being ten times harder to treat than men, and how this is further compounded by women’s inability to control their emotions.362 However, it is unclear whether this weakness was thought to be responsible merely for the illnesses encompassed by these sections on women’s disorders, that is largely gynaecological and obstetric disorders, or whether the emotional nature of the female sex was a determining factor behind a wider range of illnesses. Using the case histories from the Shishan yi’an, I have compared and contrasted the given aetiologies for women belonging to all categories, both reproductive and non-reproductive, to discover the extent to which emotion was a feature of general, as well as reproductive, illness. I have examined the aetiologies given by Wang Ji in the 109 case histories which form the core of this analysis. For ease of comparison, I selected the seven most common types of aetiologies, and counted the number of patients whose illness is said to be linked to each of them. In many cases, the patient is said to be suffering as a result of a combination of aetiologies, such as emotion combined with exhaustion, and therefore when added together, there are more aetiologies than patients. Figure 4.1 summarizes the results and gives a general impression of the proportion of men and women whose illnesses are linked with each particular aetiology. It is immediately obvious that, unlike in the theoretical texts already discussed, there are some clear differences between the sexes with regard to aetiology. 118

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exhaustion

external

Aetiology

sex

drink

female male

diet

emotion

childbirth

none speciﬁed 0

10

20

30

40

50

60

%

Figure 4.1 Comparative aetiologies

Figure 4.1 shows that exhaustion (lao ) is the leading factor in male illness, followed by external factors such as external pernicious inﬂuences, the weather, the effects of taking a long and arduous trip, and so on. These two factors are also relatively important in female aetiology. However, the next three most important inﬂuences on male health, sexual activity, drink and diet, are regarded as having little or no impact on women. For example, sexual activity is said to be a factor in one in ﬁve male illnesses, compared with no female cases. Again, drink is mentioned in over 15 per cent of male cases, but was not considered a factor in female illness. Diet, too, was implicated in nearly one in ten male illnesses, but in only one woman’s. When it comes to emotion, however, the situation is reversed and a much higher proportion of women than men were seen as suffering because of their emotional state. Childbirth is also an important factor in women’s illnesses, but 119

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obviously not in men’s. Finally, nearly twice as many women as men had no explanation given as to why they were ill. There are two important things to note about these aetiologies in the Shishan yi’an. Firstly, the sample size is very small, and therefore any conclusions drawn have to be tentative. In their favour, however, a very similar pattern of aetiology also emerges from the forty or so cases found in Wang Ji’s biography which were collected and compiled by different disciples from the cases in the main body of the text, with a disproportionate number of men suffering as a result of exhaustion, sexual desire and alcohol consumption.363 In addition, the aetiologies are not taken alone, but read within the context of both contemporary culture and the other results from the Shishan yi’an and therefore can be seen as one small part of an emerging pattern. Secondly, the relative absence of aetiologies given for women has the potential to skew the results, particularly if one were to account for this absence by suggesting that in those cases Wang Ji feared their illnesses were caused by sexual activity or alcohol but decorum prevented him from raising this possibility in front of their husbands and families. However, as we shall see later, other medical writers did not shy away from attributing female disorders to such causes in their theoretical medical texts. This absence is intriguing and has no obvious rationale, suggesting that some degree of caution is required in interpreting the results. A simple analysis, which took the results in Figure 4.1 at face value, might conclude that as men worked more in the public sphere, they would be more likely to undertake arduous activity, and to spend time outdoors in all weathers, so they would thus be more susceptible to harm from exhaustion and external factors than were women, who spent a large proportion of their time indoors and undertook little physical activity. As regards sexual activity, diet and drinking, one could suppose that the men were more sexually active than the women seen by Wang Ji, so they contracted various sexually transmitted diseases, and that they drank more alcohol and ate richer foods, and this caused them to fall ill. Given the increasing prosperity in Ming dynasty Huizhou, and the attendant increase in recourse to prostitutes and in consumption of alcohol and meat that has been reported in contemporary historical reports, one could conclude that the different aetiologies reported for men and women are merely an accurate reﬂection of reality. 120

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While this explanation has some value at a superﬁcial level, it fails to take account of the greater complexities of the situation. For example, it may well be true that men drank and ate more, and had more sex, but would this necessarily result in the disorders to which the aetiologies are ascribed? Are women indeed more emotional than men, and if so, would this cause the illnesses from which they suffer? My point is that the above explanation credits Wang Ji with an amazing ability to interpret correctly the cause of illness, one which would be the envy of modern physicians. While allowing for the possibility that his patients’ disorders were in every case caused by the factors he gives, it must also be accepted that we are dealing with the aetiology as perceived by the physician, and that this perception is capable of being affected by a number of elements, including Wang Ji’s theoretical stance, the medical history related to him by the patient and, not least, contemporary society and culture. The fundamental ﬂaw in accepting these aetiologies at face value is that no allowance is made for the effects of the interaction between culture and medicine, or the extent to which medical practice is not based on infallible techniques or scientiﬁc fact, but is moulded by personal experience and an individual understanding of the disease process. Wang Ji was affected by the society in which he grew up and the culture in which he lived and practised, and this, as I shall demonstrate, had profound implications for his understanding of aetiology. Bearing this in mind, in the sections that follow I examine some of the cases in the Shishan yi’an, putting more detail behind these rough statistics to see what light they can shed on gender differences in the aetiology of disease. Sexual activity is the second most common aetiology among men in the Shishan yi’an, but not a single case is ascribed to such a cause among the women. Often it appears combined with exhaustion, alcohol or diet, but it can appear in isolation, as in this example: A man, aged over thirty, one summer afternoon after intercourse he sweated a lot. In the evening he bathed and again approached a woman for sex. Because of this he suffered from gonorrhoea (baizhuo ).364 This is the only case where sexual activity leads to what he considered to be a sexually transmitted disease; more often, sex is 121

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perceived as a factor in a disorder only related to sexual activity in the sense that it exhausts the patient, thus depleting him and predisposing him to attack by external pernicious inﬂuences, as in this case of pestilence: A man, young in years, was exhausted from sexual activity. Afterwards he suddenly shivered and had an aversion to cold. He suffered from spontaneous sweating and fevers, and his head, chest and abdomen all ached.365 That sexual activity is not especially thought to result in disorders of the genital region, or what we would recognize as sexually transmitted diseases, but is generally held responsible for common disorders of both sexes such as pestilence, fever and bringing up Blood, adds weight to the possibility that any understanding of sexual activity as an aetiology is open to inﬂuence by cultural factors. The ﬂexibility of understandings of aetiology means that, in theory, a case of fever, for example, could be attributed to sexual activity regardless of whether the patient was a man or a woman. That in practice it was only the men who were ascribed aetiologies of sexual activity does not necessarily have to be taken to mean that men’s indulgence in sexual intercourse was in reality causing them to suffer from disorders such as fever. An alternative interpretation, which ties in with the ﬁnding in the following section that men were diagnosed as suffering from depletion more often than women, is that there was a cultural perception of moral decline and a fear that men were leading increasingly debauched lives, causing Wang Ji to perceive sexual activity as being at the root of a multitude of disorders. An initial response to the ﬁnding that only men’s illnesses were attributed to sexual activity is to simply suppose that men were indulging in sexual activity and that women were not, so men fell ill and women did not. However, one has to ask whom these men were having excessive sexual relations with, and why their partners were not also diagnosed as suffering from a disorder caused by excessive sexual activity. In this previously mentioned example, the implication is that the man in question is ill as a result of exhaustion brought on by sexual relations with his favourite concubine: A man, quite plump but frail, thirty years old; he had a favourite concubine. During the third month because of 122

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exhaustion he caught a fever, his nose bled and dripped mucus without stopping, he smelt so rank that it was hard to come near.366 There is no mention of whether this favourite concubine was also at risk of falling ill from a surfeit of sexual intercourse, particularly given that the patient was not necessarily her only customer, even though his illness was sufﬁciently grave to be ultimately fatal. One might postulate that it is the loss of semen which might be considered the debilitating factor, and so sexual activity would thus be less harmful for women, but the emphasis, both in the theoretical texts I have seen and in the Shishan yi’an itself, is on the harmful nature of the exhaustion brought about by sexual activity, not particularly on the loss of qi from seminal emission. There is little mention of seminal loss in relation to sexual activity in the text, and it is unclear whether ejaculation was an important factor in determining the extent to which sexual activity was injurious or excessive. Nor is it clear exactly what Wang Ji considered to be excessive sexual behaviour; in some cases it appears that the desire for sex, as opposed to actual activity leading to ejaculation, was sufﬁcient to cause harm, with the extent to which these desires were acted on remaining ambiguous, as in this example: A man, pale in appearance, over thirty years old, he had a cough and would bring up Blood. He was hoarse. At night he was feverish and had spontaneous sweating. He invited me to examine him. His pulses were all delicate, soggy and quite speedy. I said, ‘You have got this [disorder] from sexual desire.’367 It is also possible that even if harm by sexual activity did not depend on loss of semen, women were simply not considered as susceptible to harm from engaging in sexual relations. However, theoretical works do not exclude women from this type of aetiology, and Wang Ji himself, in a theoretical description of the illness mechanism of syphilis, explicitly credits women, as well as men, with the capacity for debauched behaviour and notes the equally detrimental effect on their health, commenting that, ‘Dissolute men and licentious women disturb the ﬁre in the attenuated yin (jueyin ) channel.’368 123

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Therefore we have three pieces of evidence which link women with sexual activity in the Shishan yi’an: ﬁrstly, the above example of the man with the favourite concubine indicates that it was possible that women might engage in sexual behaviour that for the man at least could be considered excessive; secondly, even if men were engaging in more sexual activity through their liaisons with more than one partner, women could theoretically have succumbed to illnesses as a result of sexual desire; and ﬁnally, Wang Ji himself granted women the theoretical ability to be harmed by sexual activity; yet despite all this women’s illnesses are never attributed to such causes. While it is conceivable that the physician did not count concubines among his patients, and in general was unable to question women about their bedroom activities, resulting in a reluctance to attribute their disorders to sexual causes, I believe that sexual activity was an aetiology which Wang Ji associated almost exclusively with men because of the changing environment of sixteenth-century Huizhou in which he practised, and that this, more than the actual sexual activities of his patients, male or female, accounts for the gender difference found between men and women. Overindulgence in alcohol is commonly diagnosed as a factor in male illness, featuring in one-sixth of cases and, as with sexual activity, in no female aetiologies. According to medical theory, alcohol was thought to have a ﬁerce character, giving rise to heat, and having a detrimental effect on the bodily ﬂuids, as is clearly shown in this example: A man, over sixty, purplish in appearance, often overworked and was fond of drinking. He fell ill with a disorder of the diaphragm. . . . I said, ‘This is a disorder of great depletion. . . . Moreover, this disorder, you got it from alcohol and exhaustion. The nature of alcohol is extremely ﬁerce and devastates the Blood and qi.’369 As with the aetiology of sexual activity, alcohol is often considered as one of a number of factors contributing to illness, being combined either with each other, or with other factors, such as exhaustion or sexual activity, although each does occur alone, as in this example of a man suffering from worms coming out of his urinary aperture: 124

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Zhang Zhongjing said, ‘The strength of ﬁre conceals itself inside, its attack has strength’. The worms are forced out by the strength of ﬁre and cannot be contained, therefore they come out of the urinary aperture. This man was fond of drinking.370 In the above example, drinking is thought to give rise to dampness and heat which in turn are transformed into the worms. From a modern perspective it is hard to see how excessive drinking could result in such worms. However, in other cases, drinking results in symptoms such as bringing up Blood, and fever, which to our way of thinking might be considered more consistent with alcohol abuse: The censor, Duke Cheng, was pale and frail, over forty, and usually liked to drink. He fell ill with headaches, aversion to food, diarrhoea, short and infrequent micturition, and in the afternoons, aversion to cold and fevers. . . . I said, ‘Diminished Blood has harmed his Stomach, alcohol has made it worse, and also seasonal heat has harmed his qi.’371 However, as with sexual activity, it is hard to gauge exactly what was meant by excessive drinking in this context, and whether it would in fact result in such disorders. That men were culturally more likely than women to drink, and to drink to excess, is fairly probable, so the difference between the sexes with regard to drinking as an aetiology may well simply reﬂect the different cultural behaviour of the two groups.372 However, when one examines the combined aetiology of sex, alcohol and diet, and relates this to Wang Ji’s personal beliefs and the cultural associations of sex and alcohol, then a different picture begins to emerge which would indicate that the lack of moral virtue implicit in such overindulgence is an important factor in its prevalence as an aetiology at this time. Diet is rarely found as an aetiology in its own right, and more often forms part of a composite aetiology with alcohol or sexual activity. An incorrect or overindulgent diet is seen as at least partly to blame for the illnesses of nearly one in ten men. Meat is the main culprit, being explicitly mentioned in half of the cases, as in this example: 125

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A man, nineteen years old, thin with a sallow complexion. In the third month he felt feverish, and in the ﬁfth month owing to exhaustion and harm from alcohol and meat he had a great fever, his chest felt stuffy and he had seminal emission at night and night sweats, the fever was worse in the afternoon. . . . I gave him ﬁve to six liang of gu jing wan [Essence-strengthening pills] and told him that if he was careful with his diet and stuck to bland foods then the illness should go.373 In contrast, only one woman suffers from a disorder that is connected with her diet, and her case is somewhat different from that of the men in that she appears to be suffering from diabetes. It is not hard to see how diet could be responsible for causing illness in a number of ways, either through over-consumption or through, say, poisoning from badly preserved meat, but why would men be more likely to succumb to such illnesses? If the quality of the food was the problem, women should be similarly affected. That they were not suggests that male and female diets were different, with men having a richer diet, perhaps from attending feasts and banquets.374 However, as with the aetiologies of sexual activity and alcohol, it is likely that there is also some interplay between medical practice and cultural symbolism. Meat is a luxury food and a symbol of prosperity which was culturally linked with concepts of banqueting and feasting, and by extension, proﬂigacy and extravagance. Overindulgence in expensive foods such as meat could theoretically then be a marker of ostentation and excess, and thus subject to literati disapproval which is manifested as medical concern. I expand on this idea in the following examination of all three aetiologies, sex, alcohol and diet in combination. There are a handful of cases which combine the aetiologies of sex and alcohol, or sex, alcohol and diet, as in this example: A man with a greyish complexion, aged forty-six. He enjoyed drinking, sex, and dog meat. In the third month because of drinking continuously for two nights and having sexual intercourse, he subsequently suffered with his left abdomen being extremely painful, then it spread to the left side of his abdomen, and then the lower abdomen until his entire abdominal area was painful.375 126

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Though few in number, this group share some common features, apart from the fact that all the patients are male. The ﬁrst thing to note is the seriousness of these cases; two out of the ﬁve cases which combine sex and alcohol as an aetiology result in death, as in this case: The vice magistrate of Yi , over ﬁfty years old, returned from the capital. His ribs ached. . . . I said, ‘This is a case of the Heart and Lungs being harmed by alcohol and the Spleen and Kidneys being injured by sex, the two sides are swollen and ache.’ . . . and indeed he died.376 When this tally is added to the two men who die as a result of their sexual activity alone,377 we ﬁnd that four out of the six men who die in the Shishan yi’an, that is two-thirds, die as a direct result of their indulgence in sexual activity either alone or combined with alcohol. This demonstrates the seriousness of these factors as an aetiology. That sex, alcohol and diet were also regarded by Wang Ji as serious factors is evinced by his continual warning to patients to practise abstinence, and stay away from such inﬂuences: A man, more than thirty years old, thin. His spirit was distressed and his nature anxious. He was suffering from exhaustion and harm from alcohol and sex. In the second month of winter he brought up two basins of Blood. . . . I said, ‘. . . in the future, if you are about to settle some business and again indulge in alcohol and sexual activity then you will vomit large quantities of Blood and die.’378 This tendency to caution patients against sex and alcohol, and also to advise them to follow a moderate diet is the second common feature of this group of cases. It would seem that these warnings were ignored at one’s peril, as this case demonstrates: A man, over thirty, was not cautious with regard to drinking and sex. His abdomen swelled up like a drum. . . . I said, ‘This is dampness and heat in the extreme. Stay away from alcohol and sex and you will probably live.’ . . . After more than three months he was careless, and his abdomen swelled up again. I examined him and 127

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said, ‘It cannot be cured.’ . . . After more than a month he died.379 The third feature of interest in these cases, and those of sexual activity or alcohol in isolation, is the overrepresentation of title holders among the patients. Although the name and status of few patients are given in the Shishan yi’an, eight male patients are accredited with titles, such as vice-magistrate, censor or district magistrate. Of these, four, or half, suffer from aetiologies related to sexual activity or alcohol. This suggests that such indulgences were associated with the privileges of rank, wealth or status. It is my contention that the gendered nature of the aetiologies of sexual activity, alcohol and diet, either alone or in combination, does not simply reﬂect the cultural difference in the lifestyles of men and women, with men being more likely than women to be affected by such excesses. In looking individually at each of the aetiologies of sexual activity, alcohol and diet, I raised some points which indicated that the situation was somewhat more complex than this, and suggested that a perception of society in moral decline could also result in a physician blaming illness on the very societal trends which were giving concern to the literati. This view is further endorsed by the appearance of these three aetiologies linked together, and by the moral tone implicit in Wang Ji’s continual exhortations to avoid them, signifying a strong interrelationship between virtuous conduct and physical wellbeing. To determine the validity of such a hypothesis it is necessary to examine more closely certain cultural and historical factors which may have inﬂuenced Wang Ji’s perceptions. From a medical perspective, these factors include the extent to which the aetiologies of sexual activity, alcohol and diet are to be found in the classical medical tradition, and the extent to which they were regarded as being applicable only to males. From a more cultural perspective, it is important to examine the extent to which overindulgence in sex, drink and diet was seen as symbolic of moral decline, both in society as a whole and in the writings of Wang Ji, and to relate this to the contemporary cultural, social and economic situation of sixteenth-century Huizhou province. The perils of overindulgence in sex and alcohol appear to be a perennial theme throughout the traditional medical corpus, and date back at least as far as the case histories of the Han dynasty physician Chunyu Yi. The twenty-ﬁve cases of his recorded in the 128

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Shiji bear a striking similarity to those of Wang Ji with regard to aetiology: nearly half of male aetiologies, and three-quarters of the male deaths, are attributed to sex and/or alcohol.380 One man is also cautioned to refrain from sexual activity or risk becoming fatally ill. Unlike the Shishan yi’an, which has no female aetiologies linked to drink, there is one woman seen by Chunyu Yi whose sore foot is attributed to alcohol consumption. In terms of the development of medical theory, however, these case histories represent a very formative and somewhat immature stage, so it cannot be presumed that the views expressed agree with those in later works which draw on a more mature and standardized body of literature. The early classic, the Huangdi neijing, had considerably more impact on later theory and practice, and the very ﬁrst fascicle of one of the texts it comprises, the Su wen [‘Basic questions’], contrasts the wisdom of those in the past who, by showing temperance with food and drink, rising and retiring at regular hours, and avoiding becoming exhausted, were able to live out their full life span of one hundred years, with those men of today who treat wine as soup, keep to irregular hours, intoxicate themselves with sexual intercourse, exhaust their essence (jing ) with desires, and as a result live for only half their allotted life span of one hundred years.381 Here too, then, sex, alcohol and diet are linked as factors having a detrimental effect on health. In this contrast between present laxity and past virtues there is a deﬁnite allusion to contemporary moral decline combined with nostalgia for a previous, and lost, golden age. The key issue here is that of moderation. The point is not that one should totally avoid these things, but that a balance is required, with everything in moderation and at the appropriate time, in order to maintain harmony between the body and nature. It is noticeable that in the Huangdi neijing, these passages being no exception, the term used for ‘man’ is ren (). As in English, ren can be used either to refer to ‘the male sex’ or to encompass all ‘mankind’. Given the ambiguity of this term, which in a medical context is usually interpreted to mean ‘mankind’, are there any examples in the medical literature of women being expressly warned against indulgence in sex, alcohol and diet? Or is there an implicit understanding that these aetiologies apply more to men than women? The content of many of the fuke texts on women’s disorders provides a resounding ‘no’ in answer to this 129

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latter question. Articles by Charlotte Furth and Angela Ki Che Leung discuss in some detail the behavioural restrictions placed on women to ensure successful conception, pregnancy, delivery and breast-feeding, which include avoidance of rich foods, alcohol and sex, as well as the curbing of emotions such as anger, jealousy, lust and desire.382 One seventeenth-century author, Fu Qingzhu (1607–84), explicitly attributes a great many of the women’s disorders which he discusses to indulgence in sexual intercourse, wanton drinking, overeating and failure to control emotions such as anger and lust, and he cautions women to refrain from such indulgences. For example, excesses of sexual activity and alcohol are given among the causes of abnormal vaginal discharge, and therefore, he states, the condition is more prevalent among nuns, widows and married women, than among maidens.383 The aetiologies of sexual activity, alcohol and diet are indeed part of the traditional medical understanding of disease with which Wang Ji would have been familiar, thus legitimating his diagnoses from a historical and theoretical standpoint. However, the evidence suggests that in theory women were also liable to illness as a result of such indulgences. This makes the question of why no women in the Shishan yi’an have illnesses related to these causes all the more pertinent. There are three explanations one could put forward to account for this. The ﬁrst is that although such aetiologies were theoretically applicable to both sexes, in practice, given the constraints of Chinese society, it was not acceptable to attribute a female patient’s illness to such a morally questionable cause. While this might conceivably hold true for sexual activity, although there is no direct evidence to support it, there is less reason to suppose that it would be a factor in illnesses caused by diet or drink. The evidence from other theoretical texts also demonstrates that medical writers did attribute female illness to such causes, suggesting that even if Wang Ji felt a certain reticence about making such bold claims in front of the patient’s family he could nonetheless have alluded to what he believed to have been the cause of the illness in his writings. Since one of the purposes of the Shishan yi’an was to educate future generations of physicians in the art of medicine, to have disguised the underlying reasons for a patient’s illness would surely have been contrary to the spirit of the work. The second is that such aetiologies were thought only to apply to the reproductive disorders suffered by women and therefore 130

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discussed in fuke texts. Perhaps women were considered more vulnerable to harm when pregnant and postpartum and needed to take extra care to protect their foetus or newly born child. This is a reasonable supposition, but does not account for the fact that none of the ﬁfteen women in the text with reproductive disorders, or any of the nine women whose disorders have a reproductive link, have aetiologies in any way connected with sex or alcohol, and the one diabetic woman has no reproductive link whatsoever. Finally, the third, and my preferred, explanation centres on the chaste and frugal reputation held by Huizhou women at this time. Despite the increasing prosperity in sixteenth-century Huizhou, and the attendant rise in living standards which led to extravagant habits and debauched behaviour, the women of the region still maintained a reputation for chastity as widows, ﬁdelity as wives, and observance of frugal customs: She county in Huizhou was exceptional for the number of chaste widows in the Ming;384 there are historical references to the faithfulness of Huizhou wives whose merchant husbands were away on business for much of the year;385 and the local gazetteer of Yi county comments on the thrift of the females of the region, noting how they rarely ate meat or ﬁsh.386 This chaste and frugal reputation of the women, warranted or not, could mean that Wang Ji was less likely to associate women’s illnesses with the morally corrupt aetiologies of sex, alcohol and diet. It is my hypothesis that the focus of medical concern at that time was not women, whose morals were not in question, but men, whose behaviour was perceived as being increasingly debauched and degenerate, and whose morals were increasingly suspect. For this interpretation of the gender difference in aetiology to be viable, it has to be established that Wang Ji connected these aetiologies with moral decay, and that there was a climate of both moral decline and literati disapproval of it at that time. One avenue for exploring Wang Ji’s understanding of sex, alcohol and diet as aetiologies in the Shishan yi’an is provided by the theoretical discussions on the use of ginseng and astragalus root located in the appendix, one written by Wang Ji himself and one by a disciple.387 The point of Wang Ji’s discussion is to demonstrate the correctness of using ginseng and astragalus root for depletion, and to prove wrong a rival physician who had written that using ginseng and astragalus root for yin depletion caused by sexual activity and alcohol would result in the death of the patient. Wang Ji and his disciples use quotations and case histories 131

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from Zhu Zhenheng and Li Gao, the Yuan dynasty authors on whose theories many of Wang Ji’s own are based. These quotations almost exclusively centre on the treatment, using ginseng and astragalus root, of illnesses arising from overindulgence in sex, alcohol and rich foods. This demonstrates the centrality of sex and alcohol as aetiologies to Wang Ji’s theories and treatment. Although the quotations cited come from the works of Li Gao and Zhu Zhenheng, when one examines the overall tone of the texts from which the quotations are taken, it is very noticeable that the emphasis on sex and alcohol is much more prominent in Wang Ji’s writings than in those of either of the other two. This is suggestive of the possibility that Wang Ji’s entire theoretical outlook, based on diagnosis of depletion and use of sweet and warming drugs to replenish it, may have been inﬂuenced by a contemporary culture in which perceptions of increasing extravagance and declining morals became linked with the concept of physical and moral exhaustion, and the need for replenishment. But did Wang Ji perceive sexual activity, alcohol and diet as symbols of moral decline, and not simply as disease-causing factors? There are two types of evidence which suggest that he did. Firstly, there are the moral values espoused in the biographies of Wang Ji and his father Wang Wei, and secondly there are the opinions voiced in the cases themselves which show these values to be linked to issues of health. Biographies such as those of Wang Ji and his father, the former penned by disciples, and the latter by Wang Ji himself, undoubtedly have a strong hagiographic element. This can be helpful when examining an issue such as contemporary values, as it seems likely that the very values which are perceived as lacking in society, and therefore viewed as desirable in a man of reﬁnement and sagacity, should be attributed to the subject of a hagiographical study. Wang Ji’s own biography tells us that he was by nature both restrained and frugal, wearing simple clothing, eating only plain food, and acting with ﬁnancial restraint.388 The singling out of these facets of his character highlights the fact that at that time such qualities were to be admired, and perhaps also suggests that they were not adhered to by all. The biography of Wang Wei, being written by Wang Ji himself, is perhaps even more important as it gives an insight into the author’s own perception of values worth emulating. Firstly we learn that his father was ambivalent towards wealth, refrained from drinking and also led a frugal life: 132

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When he saw people who [were] wealthy he never envied them. When he came across those who were poor he did not insult them. He was not usually fond of drinking, but quite liked chess. . . . By nature he was frugal and simple, and he was not extravagant.389 Wang Ji goes on to explain how his father’s lifestyle did not lead to excess in sexual matters: Whenever my father would go to bed, he would fall asleep with no maidservants around him, in this manner he steered clear of sexual activity. It was said that his longevity and lack of illness were attributable to this.390 He concludes by suggesting that his father’s virtues of frugality, lack of envy, generosity, absence of desire, love of simplicity, and abstinence from alcohol and sexual activity could be taken as examples for others to follow. This clearly demonstrates that for Wang Ji sexual activity, alcohol and diet were not simply neutral factors which happened to have a detrimental effect on health, but were potent symbols of moral laxity. This dual understanding, which combines both cultural symbolism and medical theory, can be seen in certain cases which address the issue of self-cultivation.391 On seven occasions in the Shishan yi’an Wang Ji counsels his male patients to stay away from sex, alcohol and rich foods, or to restrain their desires.392 On two of these occasions,393 and also in a letter sent in reply to a query from a patient,394 this abstemious behaviour is expressly linked with the practice of self-cultivation, and their indulgence is associated with both ill health and questionable morals. This example shows Wang Ji placing greater value on moral behaviour than on medicines in the treatment of his patient’s illness: You need to stay away from sexual activity and restrain your desires in order to strengthen the root, then regulate it using medicines to treat the branch, so that both the interior and the exterior are cultivated. When the root [internal origin of illness] and branch [external symptoms of illness] are eliminated, then the illness will recover in a few days. If you rely on medicines and lack respectful achievements, this is what is called neglecting what is 133

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serious and engaging in what is easy, and it would be hard to hope for a recovery from the illness.395 In the second case, a man has been ill continuously with a variety of disorders, and no medicines seem to be of help in alleviating his condition. Wang Ji ﬁnally tells him that his disorder can only be treated using techniques of self-cultivation, which involves restraining one’s desires with regard to sexual activity and diet: Mencius said, ‘To die young or live long is not changeable. Cultivating oneself as you wait for it [fate] is the means by which to establish life.’ Now to live long or die young deﬁnitely has a decided destiny, but people cannot yield to fate and not cultivate [themselves]. . . . Men can stay away from sex, show temperance with food, nurture their nature, and set their minds on making sweat not pour out in an uncontrolled manner, and semen not be wildly dissipated.396 Wang Ji thus connects self-cultivation with health, and lack of moral virtues with illness.397 Overindulgence in sexual activity, alcohol and diet is linked with his deﬁnition of moral laxity, and thus with ill health. Such associations are not at all uncommon in the Chinese tradition and, for example, can be found in the morality books of the late Ming period which similarly viewed such physical excesses as moral transgressions.398 Wang Ji’s opinions on this matter were not therefore incongruent with those expressed by the philosophers of his era. Like the aetiologies of sexual activity, alcohol and diet, this issue of self-cultivation is of a gendered nature, and is not expressed by Wang Ji as being applicable to women. Despite the seemingly integral nature of self-cultivation to the healing process suggested by the above quotations, there is only one case in which two female patients are warned to calm their hearts and lessen their desires if they are to recover.399 Even in this case, selfcultivation is not expressly mentioned, and it is likely that he was simply warning them against becoming pregnant again because of the dangers this would present, given their medical conditions. On the whole, the Shishan yi’an depicts women as being neither prone to these excesses nor capable of bettering themselves through moral cultivation. Again, the evidence from roughly contemporaneous 134

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morality books largely harmonizes with this view, and although a woman might be cautioned to practise sexual and emotional restraint, the ultimate goal was moral perfection, not on a personal but on a social level, to the extent that she might affect those around her, ensuring good family relations or examination success for her husband and sons.400 This division between male self-cultivation for personal gain and restrictions placed on female behaviour for the sake of society and the family can also be seen in the medical sphere. For example, the restrictions placed on female behaviour during pregnancy found in fuke texts401 can perhaps be interpreted as more for the welfare of the unborn child, the possible male descendant, and by extension for the good of society, than for the woman herself. Wang Ji, however, gives his female patients no restrictive advice regarding their behaviour, perhaps because the overall emphasis of the text is not related to issues of reproduction, and thus no social message is required. However, Wang Ji’s perception of indulgence in sexual activity, alcohol and food as manifestations of moral decline, coupled with his belief in the male capacity for self-cultivation, meant that his male patients were continually having restrictions placed on their behaviour. The overall result is that whereas no behavioural requirements were placed on the women in the Shishan yi’an, the men were incessantly being told to keep their desires under control and to moderate their behaviour, or run the risk of putting their health in grave danger. So the gendered nature of aetiology and self-cultivation techniques in this context somewhat unusually leads to a situation where men might be considered more oppressed by societal demands than women. The momentous changes brought about by commercialization in Huizhou prefecture at this time are not in doubt, with an increase in recourse to brothels, lavish expenditure, drinking and banqueting being noted by many, and Wang Ji was certainly not alone in his perceptions of moral decline, or in his connection of sexual activity, alcohol and diet with a corrupt and morally bankrupt society. The late Ming novel Jin ping mei, mentioned in Chapter 1, was probably written only ﬁfty years after the Shishan yi’an and is generally regarded as a thinly disguised attack on the morals of the day. The merchant household at the centre of the novel is viewed as a metaphor for society as a whole, and the debauched antics of the protagonist are taken to be representative of a society in decline. It is no coincidence that the protagonist is 135

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a merchant who, as well as being a party to ofﬁcial corruption, leads a life of excess, indulging in sexual activity, drinking and banqueting, and ﬁnally dies from sexual exhaustion, having depleted his ﬁnancial, spiritual and physical reserves. This notion of an economy which extends beyond the ﬁnancial, and of the irreversible spending of valuable resources, has already been commented on by researchers: The resources lost in the ‘overspending’ are not simply physical money and semen. Rather the book’s constant juxtaposition of illicit sexuality and corrupt ofﬁcial dealings suggests that the loss or diversion of these entities connotes a moral exhaustion from which neither the person nor the state can recover.402 The parallels between the Jin ping mei and the Shishan yi’an with regard to the themes drawn on in their portrayal of a society concerned only with the pursuit of pleasure are striking, and it is this concept of moral exhaustion, current in contemporary thinking, which I believe to be also at the root of Wang Ji’s understanding of aetiology. The cumulative evidence, then, suggests to me that the gendered nature of aetiology in the Shishan yi’an has its origins as much in the moral values of the day as in medical theory or practice. Wang Ji lived at a time of seismic change, and witnessed many of the traditional values he espoused, such as frugality and abstinence, being neglected in a climate of new-found wealth and extravagance, typiﬁed by the newly emerging merchant class, with their fondness for wine, women and song. Wang Ji’s medical opinions can thus be seen as a reaction against this new culture, with his belief that sexual activity, alcohol and food were at the heart of his patients’ illnesses. His repeated advocacy of self-restraint and moral cultivation may be understood as a reﬂection of his concern for the physical and spiritual welfare of a society he perceived as being in a state of ‘overspending’ and moral exhaustion. That women’s illnesses were not linked with these aetiologies, and that they were not given any advice regarding their behaviour, suggests that the reputation for chastity and frugality retained by Huizhou women during this period rendered them less likely to be perceived as suffering as a result of such causes. Unusually then, the speciﬁc cultural context of sixteenth-century Huizhou caused the 136

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focus of medical concern to be moved away from the women, and it was the men whose behaviour was seen as a threat to social stability. Apart from childbirth, emotion is the only contributing factor to illness which is suffered by disproportionately more women than men in the Shishan yi’an.403 Typical discussions of the seven emotions (qi qing ) – joy (xi ), anger (nu ), sadness (you ), pensiveness (si ), grief (bei ), fear (kong ) and fright ( jing ) – in theoretical texts do not generally state that women were any more emotional than men.404 The Shishan yi’an itself also touches upon the subject of emotions in a theoretical essay, putting them in the context of ﬁve-phase theory, and similarly does not differentiate between the sexes on the harm arising from emotions.405 The theoretical tradition which differentiates between the sexes on the subject of emotions can be found in the fuke texts. These texts often state that women are harder to treat as a direct result of their failure to control emotions such as anger, jealousy, melancholy and grief. This opinion was probably ﬁrst voiced by Sun Simiao in the Tang dynasty,406 and the issue was still being raised in later dynasties.407 Reproduction does not appear to be a factor in the diagnosis of disorders resulting from emotions in the Shishan yi’an, however, as Wang Ji is no more likely to diagnose a disorder as having been brought on by a woman’s emotional state if her illness has a reproductive link. Of all the emotions, women are particularly prone to suffering from mournful or apprehensive thoughts.408 The woman in this example has been mourning her son who died ﬁfteen years ago: A woman, pale, neither fat nor thin, aged over ﬁfty. Her tongue was sore, and in her throat was heat and pain . . . Fifteen years previously she had mourned her son an excessive amount and subsequently melancholy and pensiveness harmed the Spleen and weeping harmed her qi.409 For the woman in the following example, living as a widow triggered her mournful thoughts: A woman, thin and frail, over forty, suffering from migratory qi (zouqi ). Throughout her body she had aches 137

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and pains, sometimes her back felt constricted and painful, sometimes the ribs ached . . . I said, ‘This I fear, is living as a widow, melancholy and pensiveness have harmed the Spleen and the qi has stagnated.’410 Widowhood and apprehension about consummating a second marriage are at the heart of this woman’s illness: A woman, widowed, and marrying a second husband, took a ride in a sedan chair, and was exhausted and tired. Moreover she was apprehensive about the occasion of consummating her marriage (chenghun ). Subsequently she became ill . . . I said, ‘This is exhaustion and apprehension harming the Spleen.’411 What is interesting here is the contrast between men who are warned against sexual activity and this woman who is apprehensive about it. It also appears that whereas for men, marriage can be dangerous because of the risk of injury from excessive sexual activity, for women, it is widowhood, not marriage, that presents the danger of illness.412 Wang Ji devotes part of the Shishan yi’an to a discussion of emotions, in which he describes how illnesses resulting from emotional causes can be treated using other emotions according to ﬁve-phase theory. By this mechanism, which originates in the Huangdi neijing, a disorder caused by pensiveness can be treated by angering the patient, as anger is associated with the liver and can therefore overcome pensiveness which is associated with Spleen, following the cycle of mutual control.413 Despite this, all the women were treated with drug therapy, and all recovered on the ﬁrst or second attempt at treatment. Unlike the men, who were told to stop drinking or having sex, with the women there is no discussion of how to improve their mental state or recommendations to stop thinking melancholy thoughts.414 Although there are men whose aetiologies are connected with emotion, there are a number of points of contrast between men and women in this respect. The ﬁrst difference is with regard to the type of emotion suffered. Men suffer much less with disorders related to the emotion of pensiveness, and much more from anger or an anxious nature, as in this example: 138

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A man, ﬁfty years old, pale in appearance. His nature was anxious (xing ji ), and if he stammered, then a big noise would come out and he would vomit. One day below his right breast was suddenly painful. Afterwards he again suffered with overwork and anger . . . I said, ‘This is a disorder of a depleted Spleen and ﬂourishing liver. His nature is anxious with much anger. Liver ﬁre is sometimes aroused.’415 Secondly, the men’s emotional states are depicted as being more incidental to the overall mechanism of their illness. A woman’s disorder may well be viewed almost entirely in terms of pensiveness, to the extent that this is the reason she is deemed to have fallen ill, the concept around which discussion of the illness mechanism is based, and the premise upon which a treatment is recommended. However, in the case of the men, their emotional state is often only part of the picture; in some cases it is not even mentioned in the illness mechanism,416 and in others it is combined with a number of other elements, for example the man who was caught in the rain and later was robbed, causing him to experience some alarm.417 Emotion in general, and pensiveness in particular, seem more central to female illness than male illness. Women either were more emotional than men or, being inﬂuenced by a cultural perception of their own emotionality, would volunteer information about their emotional state more readily than men would. Or perhaps, if Wang Ji perceived women as being more emotional, he would tailor his questioning accordingly, asking if they had been recently widowed, lost a child, or were upset by anything at that time. Given that discussions of emotion in theoretical texts do not expressly state that women’s illnesses are more likely to result from an inability to control their emotions, or that women are prone to pensiveness and men to anger, there appears to be some disparity between theory and practice. One explanation for this disparity might perhaps be that, because of the general tendency in many cultures to regard women as ‘other’, the ‘standard’ body discussed in these Chinese theoretical texts implicitly refers to the male body. When theory is then translated into practice, common cultural perceptions of the attributes of the genders then affect the perceived aetiology. An analysis of aetiology in the Shishan yi’an produces a picture which is indicative of a division between the sexes, with men 139

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being proportionately more likely to be diagnosed as suffering as a result of excessive sexual activity, alcohol and rich food, and women more likely to have illness attributed to their emotions. This ﬁnding was somewhat at odds with the understanding of aetiology gleaned from theoretical medical texts. My interpretation of this division centres on the effect that social and cultural conditions can have on the translation of medical theory into clinical practice. I believe that the social and economic changes in sixteenth-century Huizhou were responsible for a situation where some men, and predominantly those belonging to the newly emerging merchant class, were perceived as leading an unusually extravagant lifestyle which, while no doubt in certain circumstances would have a detrimental effect on their health, was also regarded as presenting a very real threat to social stability. Literati reaction to this perceived threat was manifested in a variety of ways, but in a medical context I believe these social concerns were played out in the domain of aetiology, with sexual activity, alcohol and diet, the very issues at the heart of the controversy, being blamed for serious illness in men.

Illness syndrome As described in the previous chapter, Wang Ji processed the information gleaned from the four examinations, using the principles of pattern diagnosis to translate it into a recognizable illness syndrome centred on the binary pairs of yin/yang (/), cold/hot (han/re /), inner/outer (biao/li /), and depletion/repletion (xu/shi /), and usually associated with one or more of the six yang organs (liufu ). He would also reﬁne his diagnosis using other concepts from Chinese medical theory such as ﬁve-phase theory (wuxing ), Blood (xue ), qi (), dampness (shi ), stagnation (zhi ) and the ﬁve yin organs (wuzang ).418 Typical diagnoses that crop up time and time again tend to centre on depletion disorders such as yin depletion (yin xu ), Spleen and Stomach depletion (pi wei xu ), or Blood and qi depletion (qi xue liang xu !). The diagnosis can also be more involved and tailored to a speciﬁc individual as follows: ‘the exterior is depleted and is not resisting wind and cold, which has given rise to stagnation and heat on the interior’ (biao xu bu yu feng han ji nei zhi yu re !"#$%&'(). Having stated what he believes to be the diagnosis, Wang Ji often goes on to explain 140

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in some detail the mechanism of illness that underlies his conclusion, that is exactly how the usual bodily processes have been disrupted by the illness, how this has brought about the symptoms experienced, and how the proposed treatment will remedy the situation. Although the basic disorder diagnosed, such as Spleen and Stomach depletion, may be common to many patients, Wang Ji’s understanding of the total mechanism underlying that disorder tends to result in a complex and speciﬁc pattern of illness almost invariably unique to a particular individual. The individuality of each diagnosis renders classiﬁcation and direct comparison of illness syndromes between the sexes almost impossible, although within some of the larger illness groupings common themes can be detected; for example, the categories of fever and bringing up Blood both have a high proportion of patients whose disorders are based around Spleen depletion. For the purposes of analysis, therefore, it is simpler and more helpful to look at broad trends, such as whether the diagnoses tend to belong to yin or yang, depletion or excess, cold or heat, and so on, and to observe the extent of variation between the groups. It is important to realize at the outset that the most inﬂuential factor with regard to diagnosis is not gender but medical theory. As discussed in the previous chapter, Wang Ji drew heavily on the theories of his forebears, in particular Li Gao who emphasized Spleen and Stomach depletion, and Zhu Zhenheng who stressed the importance of Blood depletion, and combined them with his own ideas to formulate his own individual understanding of illness. The deﬁning feature of Wang Ji’s medicine, which is expressed very clearly in the theoretical sections of the Shishan yi’an, is his belief in the centrality of qi depletion, and his resulting promotion of sweet and warming treatments, such as ginseng and astragalus root which replenish qi. It is therefore unsurprising to ﬁnd that depletion disorders feature most strongly, and that there is almost no mention of disorders of excess. Many of the disorders are speciﬁed as either Spleen or qi depletion, and often these later lead to complications of heat and stagnation, and Blood and/or qi depletion. An analysis of disorders diagnosed does yield some surprising ﬁndings from a gender perspective. A reading of fuke texts on women’s disorders, and the secondary literature based on them, gives the impression that women’s yin nature leaves them particularly prone to Blood depletion and yin disorders.419 I was initially 141

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interested in investigating the extent to which this susceptibility to disorders of yin and Blood could also be seen in women whose disorders were not related to reproduction. Given Wang Ji’s particular conception of medicine, it seemed plausible that many of the women in the text would be suffering from depletion, and indeed they were. What I was not expecting to ﬁnd was that of the cases in the Shishan yi’an men were more likely than women to be diagnosed as suffering from depletion. Within the category of women, although the ﬁgures were broadly comparable, those whose illness had no link with reproduction were most likely to be diagnosed as depleted, followed by those with a reproductive link such as having recently given birth. Women whose disorders were considered wholly gynaecological or obstetrical in nature had the lowest incidence of depletion of all the groups, and were nearly a quarter less likely than the men to be diagnosed as suffering from depletion. The breakdown of types of depletion is also interesting. Again I would perhaps have expected that women’s depletion would most likely belong to Blood and/or yin, whereas in fact yin depletion was diagnosed in barely any women in any of the three categories.420 Arguably, this could follow from Wang Ji’s emphasis on qi depletion, but this would not explain the fact that yin depletion had a much higher incidence in men than in women. Blood depletion does follow the expected pattern, and is more frequent in women whose disorders are reproductive or have a reproductive link than among those who do not. Overall, however, women were as likely to be diagnosed with yang and/or qi depletion as they were to be diagnosed with Blood depletion. The perception that men were diagnosed as suffering more depletion, and that their depletion was more severe, is strengthened by the fact that two men, compared with no women, are even diagnosed with, and subsequently die from, disorders of ‘depletion and wasting’ (xulao ), which are perhaps the most serious type of depletion disorder, and are often fatal.421 There are a number of reasons which might explain these unexpected results. Firstly, as Wang Ji’s justiﬁcation of medical theories of qi depletion, and his use of replenishing treatments such as ginseng and astragalus root, constitute the main thrust of the work, they might also be one of the major driving forces behind the selection of case histories for inclusion in the study. If this theoretical outlook inﬂuenced the choice of cases more than, say, 142

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other issues such as gender or modesty, which held less contemporary relevance for the compilers, a sample which was skewed towards depletion disorders would result. The existence of a biased sample of cases, however, would not satisfactorily explain why proportionately more men than women are diagnosed as suffering from depletion disorders. Perhaps a more compelling explanation is that the development and deployment of Wang Ji’s medical theories were affected by his disapproval of the emerging cultural trends towards extravagance and expenditure that he perceived within society. If, as I propose, Wang Ji did perceive a culture of ‘overspending’, meaning the depletion not just of ﬁnancial reserves in pursuit of pleasure but also of both bodily ones, including semen and other vital ﬂuids such as qi and Blood, and moral ones, exempliﬁed by the loss of key virtues, then his fundamental belief in, and continual diagnosis of, depletion would not seem so remarkable. Moreover, this hypothesis explains why men were more likely than women to be diagnosed as suffering from depletion: during this period the women of Huizhou retained their chaste reputation and it was the men who were the driving force behind this new merchant class, and whose perceived immoral behaviour was causing concern in literati circles. The small number of cases in this analysis means that the distribution of depletion disorders between the sexes in the Shishan yi’an is not necessarily signiﬁcant, and even if it is, given the potential for skewed reporting on this issue, it cannot necessarily be taken to be representative of the rest of Wang Ji’s practice. On the other hand, this latter explanation for his diagnosis of depletion disorders in men does ﬁt my ﬁndings on aetiology of disease. Wang Ji’s diagnoses were a reaction to the speciﬁc social and cultural circumstances found in sixteenth-century Huizhou province. Wang Ji saw these depleted men as the victims of a culture of excess, who had used up their ﬁnancial, physical and spiritual reserves in the pursuit of pleasure, and who were now paying for their transgressions with their health, if not their lives. Unlike the disorder diagnosed, the illness mechanism underlying any disorder is one area of the text where it is almost impossible to detect any noticeable difference attributable to gender. The basic understanding of how the body functions is the same regardless of whether that body is male or female. This is particularly true if the disorder is unrelated to reproduction. Compare these two excerpts: 143

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This is a disorder of the Spleen. The Spleen belongs to earth and is the producer of the Lungs. If it is depleted then the Lungs lose their nourishment, and therefore coughing is generated.422 If the Spleen is depleted then the Lungs/metal lose their nourishment, qi is inadequate and its circulation is delayed, so the channels become blocked, and therefore there is coughing.423 In the ﬁrst example the patient is male, and in the second, female. This is a typical example, one of literally dozens of comparisons of this nature that can be found in the text. The only point on which there is a discernible difference is regarding the age at which Blood and qi are said to be failing, which is over ﬁfty for women, and sixty for men: She is aged over ﬁfty, Blood and qi are already failing.424 He is aged over sixty, Blood and qi are already failing.425 This is undoubtedly related to the stages of human development described in the Huangdi neijing which ascribes seven developmental stages of seven years each to women, with decline setting in at forty-nine, and eight stages of eight years to men, with their decline not occurring until the age of sixty-four.426 This apart, with regard to non-reproductive disorders there is no evidence in the text to suggest that Wang Ji conceived of dissimilarities in the form, function or processes of male and female bodies, and no pronouncements are made, in any of the theoretical discussions or in the case histories themselves, about any differences in the nature of male or female bodies, or in the way male or female bodies react to illness. Where women are suffering from reproductive disorders, and in particular disorders of menstruation, their illness mechanisms are more concerned with Blood and yin than in other cases. Some women are said to be suffering from Blood which is hot, stagnant or depleted, and in some cases there is mention of the sea of Blood (xue hai ),427 which does not seem to feature in the mechanism of non-reproductive disorders. However, there are also cases where yin is said to be ﬂourishing, and the patient is suffering 144

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from a disorder of qi or of yang.428 There is no suggestion, however, that menstruation, Blood or yin are deﬁning characteristics of women’s bodies. Nor is there any suggestion that anatomical difference is involved in the mechanism of illness; there is no mention whatsoever of the womb, and the vagina and breasts are only ever mentioned as the location of symptoms, not as sites of fundamental difference between men and women.429 Even here, then, although the conceptualization of the illness may be expressed more often in terms of Blood, the basic framework, terminology and actual processes involved remain the same, and overall the physician’s understanding of male and female bodies is remarkably similar. This may not seem surprising, but it provides a stark contrast to, say, the early Greek tradition which perceived fairly substantial differences in the nature of male and female bodies.430 Reproduction was the key to understanding of the female body in Greek science, regardless of whether procreation was at issue.431 Whatever a woman fell ill with, her illness was often perceived as either affecting her reproductive system,432 or being caused by a problem with her womb or menstrual cycle.433 In fact, most of the female case histories in Epidemics, one of the books in the Hippocratic Corpus, are gynaecological in nature.434 Dean-Jones thus succinctly summarizes the Greek understanding of female bodies: Menstrual Blood is the linchpin of both the Hippocratic and the Aristotelian theories on how women differed from men. Whether a woman was healthy, diseased, pregnant, or nursing, in Classical Greece her body was deﬁned scientiﬁcally in terms of Blood hydraulics. . . . For the Hippocratics, menstruation had no natural analogue in a man’s body, and the process they adduced to account for it differentiated women from men in every aspect of health, disease, therapy, and reproduction.435 This is indeed very different from the image presented by the Shishan yi’an which does not raise the issue of menstruation when discussing the illness mechanisms of women suffering from nonreproductive disorders, and certainly does not appear to conceive of menstruation as being central to an understanding of the female body. 145

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How does the view presented in the Shishan yi’an accord with the relative image of male and female bodies in other Chinese medical literature? Early research into fuke texts, that is texts dealing almost exclusively with the disorders of menstruation, pregnancy and childbirth, concluded that there was a very strong bias towards concepts of Blood and yin, and that menstrual regularity was the key to understandings of female health and female subordination.436 More recent articles have focused on the relative, not absolute, nature of gender difference in traditional Chinese medicine, acknowledging the basic similarities in the theoretical principles which lie behind understandings of the mechanism of illness, but proposing a continuum of difference with conceptualizations of the female tending more towards Blood and yin, and of the male towards qi and yang.437 In all these articles there is the consensus, however, that essential differences are not anatomical, and that nowhere is the idea expressed that gender lies in, or even stems from, the external genitalia, the breasts or the womb. Away from the realm of reproduction, the equation of women with Blood and men with qi cannot be substantiated. I can ﬁnd nothing in the cases which are unconnected with reproduction to suggest that the mechanism of illness in women was affected by an association with menstruation, Blood or yin, or even that there was an association with Blood and yin. I am not suggesting that the physician saw no difference between men and women, and indeed differences arising in terms of diagnosis and aetiology have already been discussed. What I am suggesting is that Wang Ji does not appear to have conceived of differences in the mechanism of illness, that is in the way in which male or female bodies functioned under normal circumstances and how they reacted to illness, when that illness was not connected with issues of menstruation, pregnancy or childbirth.438 In this respect at least, women were not perceived as being a different species from men, and the similarities between the sexes were more striking than the differences. How far Wang Ji’s apparent perception of the essential sameness of all bodies is a representative view is unclear, but the disjunction between the very Blood- and yin-centred fuke texts and the much more neutral picture gleaned from the Shishan yi’an indicates that this issue is more complex than either view would suggest.

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Treatment My aim in comparing the different treatments given to men and women in the Shishan yi’an was to determine the extent to which gender affects the choice of therapy, as well as the quality and quantity of the chosen therapy. Treatment in the Shishan yi’an usually means drug therapy, and most of Wang Ji’s patients, male and female, were prescribed medicinal herbs in decoction to treat their illness. Drug therapy, then, was the physician’s treatment of choice, regardless of the gender of the patient. There was also an equal division between men and women who were not treated, because their disorder either did not require medical intervention or was such that death was certain and nothing could be done to help them. Ginseng, white atractylodes rhizome, Chinese angelica root, liquorice and astragalus root were the ﬁve drugs which formed the core of Wang Ji’s therapeutic policies. These ﬁve drugs, in that order, are the most used medicines for both men and women. However, whereas ginseng is given to over 80 per cent of males, and the remaining four are given to about two-thirds of male patients, the ﬁgures for female patients range from about 70 per cent for ginseng to only just around the half mark for the other four. This suggests that men were more in need of these replenishing drugs, a ﬁnding which is consistent with other observations in my analysis, such as the higher proportion of men than women being diagnosed as depleted and suffering from exhaustion as a result of their excesses. Although problems arise from the small sample sizes in any discussion of the less frequently used herbs, at least two herbs apparently stand out as being much more commonly used for women than for men. These are cyperus tuber (xiangfu ) and donkey-hide gelatin (ajiao ). On closer examination, it appears that this high frequency is entirely due to their being used in cases with a reproductive link. The properties of these herbs include regulation of menstruation, tonifying the Blood and arresting bleeding, which explains their link with reproductive cases, and their frequency of use is exceedingly low in cases which have no link with menstruation, pregnancy and childbirth.439 This is indicative of a divide not between men and women, but between women whose illnesses had no connection with reproduction and those that did. As this ﬁnding is also in keeping with the results of

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my analysis of the illness mechanism, I believe that results drawn only from analyses of fuke texts may not be applicable to all women, and that away from the realm of reproduction there may be more similarities between men and women than had previously been thought. On the whole there are no easily discernible differences between the sexes with regard to the most commonly used drugs, their method of preparation, or the quantity to be taken. Two points of interest do stand out. Firstly, the ﬁgures suggest that men are more likely than women to be given each of the ﬁve most commonly used drugs, which have strong associations with replenishing qi. This reinforces the observation made in the sections on diagnosis and aetiology that men in particular were seen as being depleted. Secondly, the ﬁnding that the discrepancies between men and women as to the frequency with which certain herbs were prescribed were attributable to their being given in particular to women whose disorders were connected with menstruation, pregnancy and childbirth is suggestive of the possibility that the main site of difference is not necessarily between the sexes but between women themselves.

Outcome In this ﬁnal section examining the comparative outcome of the cases, the relative recovery rates of men and women are assessed. By combining these rates with other linked factors, such as the number of treatments required before the recovery is effected and the number of physicians visited, it is possible to build up a picture of the relative state of male and female health. This is not an issue which can be approached without certain expectations. Even very superﬁcial forays into the primary and secondary literature quickly leave one with the impression of female inﬁrmity. Perhaps the most famous and inﬂuential quotation comes from the Tang physician Sun Simiao who wrote that women fell ill more than men, that their disorders were ten times harder to treat than those of men, and that this difﬁculty was compounded by their emotional nature.440 This assertion was still being repeated in fuke texts of the late imperial period, and a recent study of Qing dynasty case histories also found that women were more likely to suffer from grave illnesses which were labelled as disorders of yin deﬁciency, and were usually sicker before the physician was called, and that 148

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the difﬁculty in curing women was seen as a natural aspect of their yin natures.441 I was therefore interested in the extent to which the stereotypical image of the frail and sickly Chinese woman would be conﬁrmed by the textual evidence in the Shishan yi’an. Firstly, I examined the outcome of the cases, comparing the recovery rates of men and women. Of the 109 cases used in my analysis, sixty-eight of the patients were male and forty-one female. Of the men, six died and sixty-two recovered, giving a recovery rate of just over 90 per cent. Of the women, again six died and thirty-ﬁve recovered, which corresponds to a recovery rate of just over 85 per cent. The deaths occurred in women suffering from both reproductive and non-reproductive disorders. Although men have a proportionately higher recovery rate, the actual proportion of female deaths is still very low, with over four-ﬁfths of women recovering. In light of the suggestion that women preferred to see female healers and only saw elite physicians such as Wang Ji as a last resort, this recovery rate seems all the more remarkable, and certainly not indicative of women being ten times harder to treat. Of the patients who recovered I compared the number of treatments required before this recovery was effected, as one might expect that a greater number of attempts at treatment would be required for a patient who was seriously ill or suffering from a disorder which was difﬁcult to treat. Interestingly, the results from an analysis of the Shishan yi’an run contrary to expectations. Of the thirty-ﬁve women who recover, thirty-three are treated, and of these over 70 per cent recover after their ﬁrst treatment, and another 20 per cent after the second treatment, making a total of 90 per cent of women who are said to be cured after two treatments or less. The ﬁgures remain fairly constant whatever the reproductive status of the patient. When the same calculations are done on the men, I discovered that only 50 per cent recover on the ﬁrst attempt, and 30 per cent on the second, so after two treatments only 80 per cent of men have been cured, compared with 90 per cent of women at the same stage. It is only after four attempts that as many men as women have recovered. Again these ﬁgures do not indicate that the women were either sicker or harder to treat than the men. Another possible indicator of relative health or sickness is the number of physicians that each patient is recorded as having seen, 149

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as someone ill with a serious and difﬁcult-to-treat disorder might be more likely to canvass the opinions of several different physicians. Nearly three-quarters of male patients see more than one physician, compared with only three-ﬁfths of women, suggesting that the men’s disorders were comparatively more difﬁcult to treat. However, there are also other factors which may inﬂuence the decision to consult more than one physician. For example, men may have had more access to physicians, and it may be that a woman could only go to an elite physician like Wang Ji through her husband, so would be less likely to demand several opinions. Perhaps women visited more marginal healers, but did not offer this information to Wang Ji. Therefore the fact that men saw more physicians than women does not necessarily demonstrate that the women’s disorders were less severe than the men’s, but such an interpretation is not inconsistent with the other evidence. The data from the Shishan yi’an show that not only did most women survive, but they recovered more quickly than the men, and saw fewer physicians in the process. When these three ﬁndings relating to recovery can be compared with the analysis of disorder diagnosed, which found that contrary to expectations it was men, not women, who suffered from more serious yin depletion disorders, the overall picture that emerges does not correspond to the portrayal of the weak and depleted Chinese woman whose illnesses were both serious and difﬁcult to treat. Whether this picture of women being no less healthy than men is an accurate portrayal of the reality of women’s health at that time is arguable. There are two alternative, but not necessarily mutually exclusive, interpretations of this ﬁnding. Firstly, one could argue that the data are skewed, and that the Shishan yi’an contains a disproportionate number of more seriously ill men than was the case in reality because Wang Ji’s perception of moral exhaustion among the male members of society, and his strong belief in the need for replenishing to correct this, led him to include a higher proportion of such cases. The other interpretation, which does not necessarily contradict the ﬁrst, is that women were in fact healthier than the men. This explanation is borne out by a demographic study from the period which uses genealogical records to extrapolate information on the mortality rates of a certain lineage from the neighbouring county of Xiuning. Harriet Zurndorfer examined the records of the Fan lineage between 1500 150

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and 1600. She thus describes her ﬁndings on the relative mortality rates of men and women: It is also noteworthy that female mortality rates, except for the second birth cohort [1500–24], tend to be lower than male mortality, while one would expect that female mortality rates between twenty and thirty would be higher than in males because of childbirth difﬁculties, but lower at older ages. One wonders if women were better able to withstand the numerous disasters of the sixteenth century than their male counterparts. It may be that as difﬁculties ensued, women were less affected.442 Perhaps the women, enclosed in their inner quarters with merchant husbands away on business for much of the year, were less exposed to infectious diseases than the men, or perhaps Wang Ji was correct in his observation of the detrimental effect of extravagant and debauched living on the health of the male members of the local community. Whichever interpretation is correct, it is important to note that an analysis of the Shishan yi’an does not conﬁrm the usual stereotype, held by both Chinese physicians and Western scholars to date, of women as frail and sickly creatures. Even if the circumstances prove to be such that the picture of women’s health gleaned from this text is the exception rather than the rule, my ﬁndings at least demonstrate that generalizations are just that, and when a speciﬁc context is examined, the need for modiﬁcation becomes apparent. The starting point for my analysis was the question of how the dynamics of gender are played out in the text. In an attempt to answer this question I have made a detailed examination of each of the ﬁve main components of the case histories: diagnosis, aetiology, illness mechanism, treatment and outcome. The results that emerged have proved more surprising, diverse and complex than I had ever envisaged, but the tangled threads can be woven together to produce a relatively coherent picture of the interplay between medicine, gender and culture. There are two main conclusions which stand out from the analysis. The ﬁrst relates to the need to consider areas of difference and similarity between members of the same sex as well as between members of opposite sexes, and 151

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the second concerns the important inﬂuence cultural factors have on medical practice. Firstly, this gender analysis has highlighted the revealing nature of similarities, as well as differences, not only between the sexes but within them. Gender does not have a single location in the body, separating men from women, but there is a multiplicity of points of difference and sameness that shift depending on the focus of the enquiry. However, there are certain points which can be made regarding the relationship between the sexes. Of primary importance in an examination of difference is the fundamental nature of many of the similarities to be found between the sexes. The diagnostic procedure, four examinations, basic theoretical principles, mechanism of illness and the treatments, including type, quantity and preparation of medicinal compounds, did not appear to be affected by the sex of the patient. This demonstrates the essential sameness of understandings of male and female bodies. Difference, when it occurred, was often located in the reproductive sphere, with a greater degree of separation between women whose disorders were linked with reproduction and women whose disorders were not, than between men and women. This ﬁnding has repercussions for the representativeness of the conclusions drawn about the nature of women in much of the secondary literature to date which has focused almost entirely on primary source material dealing with disorders of menstruation, pregnancy and childbirth. This demonstrates that caution needs to exercised when extending those conclusions to women in general. The second point I want to make regards the remarkable inﬂuence of culture on the text, and its impact on the dynamics of gender. The changes occurring in sixteenth-century Huizhou seem to have made a signiﬁcant impression on Wang Ji’s medical practice. My analysis indicates that his male patients were more likely than his female ones to be diagnosed as suffering from depletion, have this depletion attributed to their indulgence in sex, alcohol and rich food, to be treated with replenishing drugs, and to require more treatments before a recovery is effected. I have interpreted these ﬁndings as a reaction by the physician to the changing environment in which he lived. As men were the instigators of this change, male behaviour became the focus of his concern, and the theoretical foundations of his medical practice were moulded to ﬁt his understanding of contemporary society. As a result, many of the observable gender differences in the text stem directly from 152

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the speciﬁc cultural context in which Wang Ji was practising medicine. This demonstrates two things: one, the extremely ﬂexible nature of gender relations in their adaptability to speciﬁc cultural circumstances; and two, the need for studies of individual texts which take cultural inﬂuences into account, as without an understanding of the speciﬁc historical context the ﬁndings from the Shishan yi’an would be more confusing than enlightening.

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CONCLUSION

Three methodologies, three very different stories. From the traditional socioeconomic and biographic method, a picture emerges of a well-respected and inﬂuential physician and medical writer living through, and indeed being a part of, an exciting and vibrant period of change in contemporary medical culture. From the textual analysis of the Shishan yi’an, a more human and more vulnerable physican emerges, conﬁdent of his abilities and healing strategies but struggling to win respect from fellow practitioners and loyalty from his patients. Finally, the results of the gender analysis suggest that contemporary culture shaped Wang Ji’s perceptions and inﬂuenced his medical practice. Different but complementary dimensions to the life of a sixteenth-century Chinese physician. For the ﬁrst story I used historical sources from the period such as gazetteers and literati writings, as well as modern secondary literature from China and the West, to examine the social and economic developments of the period and the contemporary medical culture. Narrowing the focus to just one physician, Wang Ji, I used his medical writings, and in particular the prefaces to his works, and the various biographies written about him both during his lifetime and after his death, to try and reconstruct something of his life and times. I discovered that Wang Ji lived through a time of social change, and that during the sixteenth century the Huizhou region where he lived and worked was characterized by an unprecedented level of social and economic activity that heralded the dawn of a new era, late imperial China. The rapid commercialization of the economy that marked the period had profound and far-reaching social implications, perhaps the most signiﬁcant of which were the increased opportunities for social 155

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mobility and the consequent emergence of a new and prosperous merchant class. Huizhou merchants exerted a strong inﬂuence on many aspects of cultural life, but the literati reaction to their extravagant lifestyles, debauched behaviour and social aspirations was understandably one of extreme anxiety which was often expressed as concern for the declining morals of society. On a medical level physicians now came from the ranks of failed scholars and aspiring merchants, and were more aware of each other and constituted more of a cohesive social group than ever before. Factors such as improved transportation, travelling merchants, medical patronage, medical publishing and an increasingly literate population meant that the sphere of inﬂuence of each individual physician was much wider. It was not unusual for a physician to travel and be a disciple of a variety of physicians, and then take on disciples of his own; any medical texts he wrote would be more likely to be published and could quickly enter into circulation and achieve a wide readership; and at the same time he would have access to the recent writings of other physicians as well as updated versions of the classical medical canons. In many respects, Wang Ji’s biographies reveal him to be the archetypal sixteenth-century physician. His father was a physician, and his decision to follow in his father’s footsteps after failing the civil service examinations was expressed as an espousal of the traditional Confucian values of ﬁlial piety and benevolence and the fulﬁlment of a desire to follow the Way of the ancient sages. He studied the classics, aligned himself to a medical lineage, took on disciples, and built up a thriving medical practice. He became a proliﬁc medical writer, writing on a range of subjects, revising previous texts and annotating classics, publishing his case histories and producing new works. His texts were circulated across China and even abroad thanks to the improved transportation of the time, and similarly he was aware of the practice of other physicians, often receiving copies of their writings within only a short time of their production and sometimes prior to their publication. However, the biographies also reveal something of Wang Ji as an individual: he was one of ﬁve siblings, three brothers and two sisters, he married a woman from the Xie clan and had children. He was a Confucian gentleman, living a frugal and tranquil life, and demonstrating his benevolent qualities through his medicine, through ﬁnancing the building of a temple for ancestor worship, and through the assistance he gave his brother’s son in 156

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collecting his father’s body after he had died at sea. He also shared the concerns of many of the literati at that time, and perceived the new merchant class as leading lavish and decadent lifestyles that were symptomatic of a culture of ‘overspending’ in terms of ﬁnancial, moral and physical reserves. The second story went deeper still and through a textual analysis of Wang Ji’s case histories, the Shishan yi’an, I reconstructed his daily medical practice, drawing on common themes repeated throughout the cases, focusing on the words Wang Ji used and concentrating on many of the issues important to him. He was, for example, convinced of the need to treat disorders of depletion using ginseng and astragalus root, he believed in his interpretation of the theoretical approaches of Zhu Zhenheng and Li Gao, he was frustrated by what he perceived to be the misdiagnoses of other physicians, and he frowned upon the misuse of acupuncture and moxibustion. These things he reiterated time and time again in his cases. Through this text he wanted to pass on the wisdom accumulated from a lifetime of practice and to teach future generations about the appropriateness of his approach to diagnosis and treatment. Story tellers cannot fail to put their own spin on a story, not least at a distance of several hundred years, yet I tried to let Wang Ji’s own voice come through, and to portray his world as he saw it. As a result, I believe the picture I have painted of his theoretical beliefs, his clinical practice, and his interactions with patients and healers would be instantly recognizable by him. From the analysis it was possible to speculate on how medicine was actually practised in the sixteenth century. Wang Ji would travel around the area visiting patients. He would use the four examinations to elicit information on the patient’s condition, in particular emphasizing the need for an accurate pulse diagnosis. This information would then be used as the basis of his diagnosis and treatment strategy. Wang Ji would then prescribe an individual combination of medicinal herbs for the patient, usually to be taken in decoction. He might also advise the patient of certain behavioural recommendations that were central to a complete recovery. The patient would then follow the prescribed treatment and recover. However, this process did not always run smoothly. Often Wang Ji had to work through intermediaries or by correspondence without actually seeing the patient. Even when he did, patients often argued about the diagnosis and treatment, treated themselves and saw a variety of other healers. Families too were 157

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often involved in the illness management of relatives, and Wang Ji would have to persuade them as well as the patient of the correctness of his approach and the need for the patient to take the medicines he prescribed. Despite his best efforts, other healers were regularly consulted and Wang Ji despaired of their mistaken diagnoses, inappropriate and harmful treatments, and shoddy practising techniques. The third story again uses the Shishan yi’an as the basis of a gender analysis. But this is not Wang Ji’s story, it is mine. Gender did not exist for Wang Ji, since it is a construct of the twentieth century. Yet this does not invalidate its use as a tool to uncover and tell a different story from the one the author intended to tell or was even conscious of telling. I imposed the analysis on the text, read between the lines, added a layer of interpretation based on a reading of contemporary culture, and brought together diverse elements to create a coherent whole. It is a fragile story. The number of case histories is far too small for any meaningful quantitative analysis in statistical terms. No sixteenth-century author analysed his medical approach in the light of the changing socioeconomic environment in which he practised. In spite of this, the story I tell in this last chapter is no less valid than those of the previous chapters, and although built on shakier foundations, it is perhaps capable of giving greater insights into how cultural values can impact on medical systems. The picture that emerged from my analysis was both consistent and coherent with each component of the medical encounter, revealing the same stories of male depletion and exhaustion, and complementing the themes of overindulgence and overspending that permeated the literature of the period. I analysed a total of 109 case histories from the Shishan yi’an and focused on gender differences to be found within the ﬁve principal elements of the clinical encounter: diagnosis, aetiology, illness mechanism, treatment and outcome. I discovered that Wang Ji’s vehement theoretical belief in the need for treating disorders of depletion with drugs for replenishing qi pervaded his clinical practice, being outwardly visible in his continual diagnosis of depletion disorders and his insistence on treatment using qi replenishing drugs such as ginseng and astragalus root. While this was the case for patients of both sexes, it was noticeable that more men than women were diagnosed as suffering from depletion, that men were particularly liable to be perceived as having 158

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fallen ill as a result of overindulgence with regard to sexual activity, alcohol and diet, and that they were more likely to be treated with replenishing drugs. My interpretation of these ﬁndings was that Wang Ji’s controversial belief in the centrality to illness of depletion disorders stemmed from his cultural perceptions of ﬁnancial, moral and physical ‘overspending’, and that the disparity between the sexes in his clinical practice with regard to diagnosis, aetiology and treatment could be explained by the supposition that men, as the instigators of social change and the all-toovisible protagonists of hedonism, had, to a greater extent than women, become the focus of medical concern. These ﬁndings had important implications for the issue of theory and practice. The results of the textual analysis suggested a convergence of theory and practice in the Shishan yi’an, with Wang Ji both advocating a certain theoretical stance in his writings and at the same time applying the same approach in his practice, and I speculated on the reciprocal process by which Wang Ji might have further developed the theories of his predecessors into his own unique outlook. The gender analysis then revealed the possible role of culture in this process, showing that although the theoretical beliefs in the Shishan yi’an were drawn from the classical literature, they appeared to be inﬂuenced by contemporary cultural perceptions of ‘overspending’ and ‘depleted reserves’, resulting in a focus on qi depletion, perceived overindulgence in sexual activity and alcohol, and a treatment strategy centred on replenishing with sweet and warming drugs such as ginseng and astragalus root. Further, despite the gender-neutral expression of this theory using abstract medical terminology, the gender analysis revealed that when Wang Ji translated this theory into medical practice a division along gender lines emerged, with men being more likely to be diagnosed as suffering from qi depletion, to be regarded as having become ill through overindulgence in sex, alcohol and rich foods, and to be treated with replenishing drugs. This suggested that although in theory Wang Ji’s beliefs could apply to members of both sexes, in practice cultural perceptions of male decadence affected the clinical application of his theoretical beliefs. The three different stories that have resulted from my analyses highlight the importance of studies inﬂuenced by a strong methodological awareness. In each case I have tried to articulate clearly my methodological approach, to assess the limitations of the source 159

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material used, and to calculate the extent to which the results obtained might be safely relied upon. The diverse nature of my ﬁndings also attests to the value of small focused studies. This applies both in terms of the subject matter and the source material. This book concentrates on just one physician, and for much of the time on just one of his texts, yet the conclusions I have drawn have much wider implications for our understanding of the interrelationship of gender, culture and medicine. Finally, when taken together, these three stories give us more insight into the life of a Chinese physician and into sixteenth-century medical practice than any one on its own. Through the cultural context of the ﬁrst method we see Wang Ji as a protagonist, a well-respected and important physician inﬂuencing those around him, as well as future generations, through his medicine, through his teachings, and through his widely circulated texts. At the same time we see him as a product of his culture in everything he did, from his choice to become a physician, to the sort of books he wrote, to his Confucian beliefs and his perceptions of contemporary society. To this portrayal, the text-based studies are in turn able to add meaning and depth and in doing so turn Wang Ji from a faceless historical ﬁgure into something more human, a living and practising physician whose frustrations we can empathize with and whose approach to medicine we can understand more easily from seeing it in practice and in the context of the times in which he lived.

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1 Leung, Angela Ki Che. 1987. ‘Organized medicine in Ming-Qing China: state and private medical institutions in the lower Yangzi region.’ Late Imperial China 8(1): 134–165; Benedict, Carol. 1993. ‘Policing the sick: plague and the origins of state medicine in late imperial China.’ Late Imperial China 14(2): 60–77. 2 Hymes, Robert. 1987. ‘Not quite gentlemen? Doctors in Sung and Yuan.’ Chinese Science 8: 9–76. 3 Widmer, Ellen. 1996. ‘The Huanduzhai of Hangzhou and Suzhou: a study in seventeenth-century publishing.’ Harvard Journal of Asiatic Studies 56(1): 77–122; Hanson, Marta. 1995. ‘Merchants of medicine: Huizhou mercantile consciousness, morality, and medical patronage in seventeenth-century China.’ In Keizo Hashimoto, Catherine Jami and Lowell Skar eds. East Asian science: tradition and beyond. Papers from the seventh international conference on the history of science in East Asia, Kyoto, 2–7 August 1993. Osaka: Kansai University Press, pp. 207–214. 4 Chao Yüan-ling. 1995. Medicine and society in late imperial China: a study of physicians in Suzhou. Ph.D. dissertation, UCLA. 5 This issue is discussed at greater length in Chapter 2. See also Sivin, Nathan. 1995a. ‘Text and experience in classical Chinese medicine.’ In Don Bates ed. Knowledge and the scholarly medical traditions. Cambridge: Cambridge University Press, pp. 177–204. 6 Duden, Barbara. 1991. The woman beneath the skin: a doctor’s patients in eighteenth century Germany. Thomas Dunlap trans. Cambridge, Mass.: Harvard University Press. 7 Sivin, Nathan. 1967. ‘A seventh-century Chinese medical case history.’ Bulletin of the History of Medicine 41: 267–273. 8 Sivin, Nathan. 1995b. ‘Emotional counter-therapy.’ In Nathan Sivin, Medicine, philosophy and religion in Ancient China: researches and reﬂections. Aldershot, Hants Variorum. II: 1–19. 9 Furth, Charlotte. 1999. A ﬂourishing yin: gender in China’s medical history, 960–1665. Berkeley: University of California Press, Chapters 7 and 8. 10 Bray, Francesca. 1995. ‘A deathly disorder: understanding women’s health in late imperial China.’ In Don Bates ed. Knowledge and the

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11 12

13

14

15

16 17 18 19 20 21 22 23 24

scholarly medical traditions. Cambridge: Cambridge University Press, pp. 235–250. Raphals, Lisa. 1998. ‘Women in a second-century medical casebook.’ Chinese Science 15: 7–28. Cullen, Christopher. 2001. ‘Yi’an: the origins of a genre of Chinese medical literature.’ Draft article based on a paper presented at the Lu Gwei-djen memorial workshop on ‘Innovation in Chinese medicine’ held at the Needham Research Institute, Cambridge. 8–11 March 1995. Farquahar, Judith. 1994. Knowing practice: the clinical encounter of Chinese medicine. Oxford: Westview Press. See also her earlier discussion of a published case history: Farquahar, Judith. 1992. ‘Time and text: approaching Chinese medical practice through analysis of a published case.’ In Charles Leslie and Allan Young eds. Paths to Asian medical knowledge. Berkeley: University of California Press, pp. 62–73. Thompson, Laurence. 1990. ‘Medicine and religion in late Ming China.’ Journal of Chinese religions 18: 45–59; and Cullen, Christopher. 1993. ‘Patients and healers in late imperial China: evidence from the Jin ping mei.’ History of Science 31(2): 99–150. For more on gender as a cultural construct, see Scott, Joan Wallach. 1991. ‘Women’s history.’ In Peter Burke ed. New perspectives on historical writing. Cambridge: Polity Press, pp. 42–66; and Scott, Joan Wallach. 1988. Gender and the politics of history. New York: Columbia University Press. Morantz, Regina. 1971. ‘The lady and her physician.’ In Mary S. Hartman and Lois Banner eds. Clio’s consciousness raised. New York: Harper and Row, pp. 38–53. Parsons, Gail Pat. 1977. ‘Equal treatment for all: American medical remedies for male sexual problems: 1850–1900.’ Journal of the History of Medicine 32: 55–71. Jordanova, Ludmilla. 1983. ‘Gender and the historiography of science.’ British Journal for the History of Science 26: 482. Jordanova, Ludmilla. 1989. Sexual visions: images of gender in science and medicine between the eighteenth and nineteenth centuries. Hemel Hempstead: Harvester Wheatsheaf. Furth, Charlotte. 1994a. ‘Ming-Qing medicine and the construction of gender.’ Jindai Zhongguo funüshi yanjiu !"#$%& [‘Research into women’s history in modern China’] 2: 247–248. Dean-Jones, Lesley Ann. 1994. Women’s bodies in classical Greek science. Oxford: Clarendon Press. Kaptchuk, Ted J. 1992. The web that has no weaver: understanding Chinese medicine. London: Rider. Porkert, Manfred. 1974. The theoretical foundations of Chinese medicine: systems of correspondence. Cambridge, Mass.: MIT Press. Yizong jinjian ! [‘The golden mirror of medical orthodoxy’]. Wu Qian . First printed in 1742. This edition: Beijing: Renmin weisheng chubanshe. 1956. Volume 4, Chapter 44, p. 4.

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25 Furth, Charlotte. 1986. ‘Blood, body, and gender: medical images of the female condition in China.’ Chinese Science 7: 43–66. 26 Furth, Charlotte. 1987. ‘Concepts of pregnancy, childbirth, and infancy in Ch’ing dynasty China.’ Journal of Asian Studies 46: 7–35. 27 Furth, Charlotte. 1995. ‘From birth to birth: the growing body in Chinese medicine.’ In Anne Behnke Kinney ed. Chinese views of childhood. Honolulu: University of Hawaii Press, pp. 157–191. 28 Furth, Charlotte. 1994a. 29 Furth, Charlotte. 1994b. ‘Rethinking Van Gulik: sexuality and reproduction in traditional Chinese medicine.’ In Christina K. Gilmartin, Gail Hershatter, Lisa Rofel and Tyrene White eds. Engendering China: women, culture and the state. Cambridge, Mass.: Harvard University Press, pp. 125–146. 30 Bray, Francesca. 1997. Technology and gender: fabrics of power in late imperial China. Berkeley: University of California Press. 31 Furth, Charlotte. 1999. 32 See Chan, Albert. 1982. The glory and fall of the Ming dynasty. Norman: University of Oklahoma Press, pp. 183, 220, 334–335. 33 Rawski, Evelyn S. 1985. ‘Economic and social foundations of late imperial culture.’ In David Johnson, Andrew J. Nathan and Evelyn S. Rawski eds. Popular culture in late imperial China. Berkeley: University of California Press, p. 3. This article succinctly summarizes many of the major social trends characteristic of the period, particularly as they relate to developments in publishing, education and the spread of literacy. 34 For more detailed discussions of the development of a commercial economy and its effect on social and economic structures see: Zurndorfer, Harriet T. 1989. Change and continuity in Chinese local history: the development of Hui-chou prefecture 800–1800. Leiden: E.J. Brill, pp. 105–109; Brook, Timothy. 1998. The confusions of pleasure: commerce and culture in Ming China. Berkeley: University of California Press; Elman, Benjamin A. 1990. From philosophy to philology; intellectual and social aspects of change in late imperial China. Cambridge, Mass., and London: Council on East Asian Studies, Harvard University, p. 9; Brokaw, Cynthia J. 1991. The ledgers of merit and demerit: social change and moral order in late imperial China. Princeton, NJ: Princeton University Press, p. 5; Carlitz, Katherine. 1986. The rhetoric of Chin p’ing mei. Bloomington: Indiana University Press, p. 7; and Chow, Kai-wing. 1994. The rise of Confucian ritualism in late imperial China: ethics, classics, and lineage discourse. Stanford: Stanford University Press, p. 16. 35 For changes in the regulation of the salt trade see: Zurndorfer, Harriet T. 1989, pp. 47–49; Chan, Albert. 1982, pp. 41–42; and Ho Ping-ti. 1962. The ladder of success in imperial China: aspects of social mobility, 1368–1911. New York: Columbia University Press, p. 70. 36 All aspects of the development of Huizhou prefecture from 800 to 1800, including commerce, culture, social structure and demography,

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37

38 39 40 41 42 43 44

45 46 47 48

49 50 51

are dealt with in Harriet Zurndorfer’s seminal work, which provides a systematic and comprehensive treatment of the changing history of a single Chinese prefecture. This point is raised in a number of secondary sources on Ming history including, Fu Yiling . 1956. Mingqing shidai shangren ji shangye ziben !"#$"%&' [‘Merchants and commercial capital in the Ming and Qing epochs’]. Beijing: Renmin chubanshe, pp. 49–50; Beattie, Hilary J. 1979. Land and lineage in China: a study of T’ung-ch’eng county, Anhwei, in the Ming and Ch’ing dynasties. Cambridge: Cambridge University Press, p. 129; and Chan, Albert. 1982, p. 84. The evidence for this comes from contemporary observers, such as the ofﬁcial and scholar Xie Zhaozhe (1567–1624) who described this situation in relation to the Xin’an region in his encyclopaedic work Wu zazu [‘Five miscellanies’]. Xie Zhaozhe. Sixteenth century. Reprint: Shanghai: Guoxue zhenben wenku. 1935, pp. 164–165. On the impact of a shift in taste from powdered to leaf tea at the beginning of the Ming on Huizhou tea production, see Brook, Timothy. 1998, p. 126. Fu Yiling. 1956, p. 52. Brook, Timothy. 1998, pp. 126–127. See also Elman, Benjamin A. 1990, p. 9. Zurndorfer, Harriet T. 1989, pp. 49–50. She also draws on Xie Zhaozhe: see Wu zazu. 1935, p. 165. Fu Yiling cites a ratio of seven merchants for every three farmers in Qimen. Fu Yiling. 1956, p. 53. An extensive and detailed description of the trading activities of the Huizhou merchants can be found in Fu Yiling. 1956, pp. 54–64. Chin, Sandi and Cheng-chi (Ginger) Hsu. 1981. ‘Anhui merchant culture and patronage.’ In James Cahill ed. Shadows of Mt. Huang: Chinese painting and printing of the Anhui school. Berkeley Calif.: University Art Museum, p. 19. Fu Yiling. 1956, p. 57. Fu Yiling. 1956, p. 49. Fu Yiling. 1956, pp. 58–59. Wu zazu. 1935, p. 154. I have used the translation in Beattie, Hilary J. 1979, p. 182. The quotation can also be found in Fu Yiling. 1956, p. 54; and Chin, Sandi and Cheng-chi (Ginger) Hsu. 1981, p. 19. The standard text on this subject, from which much of my argument is drawn, is Ho Ping-ti. 1962. See also Brook, Timothy. 1998, pp. 128–134 and Rawski, Evelyn S. 1985, pp. 3–33. Chin, Sandi and Cheng-chi (Ginger) Hsu. 1981, p. 23. For general merchant patronage of the arts, see Zurndorder, Harriet T. 1989, pp. 52, 226; and James Cahill ed. 1981. Shadows of Mt. Huang: Chinese painting and printing of the Anhui school. Berkeley: University Art Museum, pp. 7–11. Cahill examines this issue from the perspective of its effect on the Anhui school of painting in the Ming dynasty. See also the other article on merchant culture and

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52 53 54 55 56 57 58 59

60 61 62

63 64 65

66 67

68 69

patronage in his collection by Chin, Sandi and Cheng-chi (Ginger) Hsu. 1981, pp. 19–24. Brook, Timothy. 1998, p. 128. Fu Yiling. 1956, p. 83. On marriages of elite and merchant families, see Brokaw, Cynthia J. 1991, p. 5; and Elman, Benjamin A. 1990, pp. 94–95. Ho Ping-ti. 1962, p. 256. Ho Ping-ti. 1962, p. 44; Rawski, Evelyn S. 1985, p. 11. Brook, Timothy. 1998, p. 132. For innovations in the publishing industry, and the new types of books being produced, see Rawski, Evelyn S. 1985, pp. 17–28. Morality books are the subject of Cynthia Brokaw’s text, The ledgers of merit and demerit: social change and moral order in late imperial China. See Brokaw, Cynthia J. 1991. The topic is also covered in Rawski, Evelyn S. 1985, pp. 15–16, and Sakai, Tadao. 1970. ‘Confucianism and popular educational works.’ In William Theodore de Bary ed. Self and society in Ming thought. New York: Columbia University Press, pp. 331–365. Kobayashi, Hiromitsu and Samantha Sabin. 1981. ‘The great age of Anhui printing.’ In James Cahill ed. 1981, p. 25. See also Brook, Timothy. 1998, pp. 130–131. Rawski, Evelyn S. 1985, p. 17; Elman, Benjamin A. 1990, p. 142. Ho Ping-ti. 1962, p. 273 (I have used his translation). The original is taken from Taihan ji [‘The collected works of Taihan’ (i.e. Wang Daokun)]. Wang Daokun . 1591 edition. 52: 10b– 15a. Zurndorfer also uses Ho Ping-ti’s translation of this passage: Zurndorfer, Harriet T. 1989, p. 55. Chin, Sandi and Cheng-chi (Ginger) Hsu. 1981, p. 23; Elman, Benjamin A. 1990, pp. 94–95. Brook, Timothy. 1998, pp. 142–143. Brook has noted how the universal assumption that merchants were bad gradually changed. Some scholars even sought precedents justifying commerce in the classical canon, although more conventional writers still regarded the strict division of occupational categories as the true and ancient way. See Brook, Timothy. 1998, pp. 71–74, 134–135, 142–143. Brook, Timothy. 1998, pp. 124–126. See also Rawski, Evelyn S. 1985, pp. 8–9. Brook dates mid-Ming perceptions of decline to writers early on in the Jiajing reign who agreed that moral coventions governing social life had begun to erode in the Zhengde era. Brook, Timothy. 1998, p. 144. Brook, Timothy. 1998, pp. 144–152. Zurndorfer, Harriet T. 1989, pp. 51, 112–113. At the beginning of the dynasty sumptuary regulations had been passed which governed the degree of opulence people were permitted to display with regard to housing, clothing, jewellery, carriages and so on, but by the Jiajing and Wanli periods these regulations were being blatantly ﬂouted.

165

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70 For example see Wu zazu. 1935, p. 154. Xie Zhaozhe’s comments are also included in a discussion on the extravagance and proﬂigacy of Xin’an merchants by Fu Yiling. He also tells how this decadent lifestyle shortened many people’s lives, giving one example of a man from Xin’an who fell ill as a result of having sex with many beautiful women; Fu Yiling, 1956, pp. 81–82. On brothels, courtesans and prostitutes, see Van Gulik, R.H. 1961. Sexual life in ancient China. Leiden: E.J. Brill, pp. 307–312. 71 Chan, Albert. 1982, pp. 314, 320. 72 Wu zazu. 1935, p. 340. 73 Katherine Carlitz discusses at length the issues raised in the Jin ping mei in her book on the subject, The rhetoric of the Chin p’ing mei. See Carlitz, Katherine. 1986. 74 Rawski, Evelyn S. 1985, p. 15. 75 Zurndorfer, Harriet T. 1989, pp. 50 –51. The frugality of the Huizhou people is also commented on in Beattie, Hilary J. 1979, p. 144; Fu Yiling. 1956, p. 67; and T’ien Ju-kang. 1988. Male anxiety and female chastity: a comparative study of Chinese ethical values in Ming-Ch’ing times. Leiden: E.J. Brill, p. 73. 76 Zurndorfer, Harriet T. 1989, pp. 50–51. 77 T’ien Ju-kang. 1988, p. 44. 78 I am grateful to Charlotte Furth for this suggestion. On the role of wealthy or gentry wives as domestic managers in charge of the family’s ﬁnancial resources, see McDermott, Joseph P. 1990. ‘The Chinese Domestic Bursar.’ Asian Cultural Studies 2: 284– 267. 79 Zurndorfer, Harriet T. 1989, p. 51. 80 Brook, Timothy. 1998, p. 152. 81 ‘Xin’an’, not ‘Huizhou’, would appear to be the preferred term in the secondary literature for use in reference to the medical culture of the region, and I have followed this convention. 82 Xiang Changsheng . 1985. ‘Xin’an yijia dui Zhongyixue de gongxian jiqi zai Zhongguo yixueshi shang de diwei.’ !"# !"#$%&'() *+ [‘The contribution made by Xin’an physicians to Chinese medicine, and their position in the history of Chinese medicine’]. Zhonghua yishi zazhi !"# [‘Chinese journal of medical history’] 15(2): 65. 83 Li Jiren and Hu Jianbei eds. 1990. Xin’an mingyi kao !" [‘Study of famous physicians from Xin’an’]. Hefei: Anhui kexue jishu chubanshe, pp. 100–101. 84 Wu Manheng . 1993. ‘Xin’an yijia dui yixue puji jiaoyu de gongxian.’ !" #$%&'()* [‘The contribution to the dissemination of medical knowledge made by Xin’an physicians’]. Anhui Zhongyi xueyuan xuebao !"#"$ [‘Journal of Anhui traditional Chinese medical college’] 12(3): 12. The actual reference to Chen Jiamou can be found in Bencao gangmu ! [‘Systematic materia medica’]. Li Shizhen . Original edition 1590. This edition: 1993. Beijing: Zhongguo shudian chuban. Volume 1, fascicle 1, pp. 8–9.

166

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85 For information on Jiang Guan and his son, see Liu Huiling . 1993. ‘Mingyi lei’an yi’anlei jiqi laiyuan fenxi.’ !"# "! !"# [‘An analysis of the categories and origins of the medical case histories of the Cases of famous physicians arranged by category’]. Anhui Zhongyi xueyuan xuebao !"#"$ [‘Journal of Anhui traditional Chinese medical college’] 12(1): 11– 13. 86 For an account of the lives of Wu Yang and Wu Qiao, see Tong Guangdong and Wu Huaqiang . 1995. ‘Wu Yang, Wu Qiao shengping jiqi xueshu tedian.’ , !"#$% [‘The biographies of Wu Yang and Wu Qiao, and the special characteristics of their medicine’]. Anhui Zhongyi xueyuan xuebao !"#"$ [‘Journal of Anhui traditional Chinese medical college’] 14(1): 15–16. 87 All ﬁve generations of the Wu family of hereditary physicians are discussed in Xiang Changsheng . 1983. ‘Xin’an Wushi yixue shijia – jian tan Wu Chu Yi yan lu.’ !"#$% – ! !" [‘The medical lineage of the Xin’an Wu family – and a discussion of Wu Chu’s Record of medical experience’]. Zhonghua yishi zazhi !"# [‘Chinese journal of medical history’] 13(3): 177–180. 88 On Fang Youzhi, see Zhen Zhiya and Fu Weikang eds. 1991. Zhongguo yixue shi !" [‘History of Chinese medicine’]. Beijing: Renmin weisheng chubanshe, pp. 370–371. 89 Sun Wenyuan yi’an !" [‘The medical case histories of Sun Wenyuan’]. Sun Yikui . Original edition 1573. This edition: Changsha: Zhongguo yixue dacheng. 1990. 90 Details of Wang Ang’s life and his Bencao beiyao can be found in Hanson, Marta. 1995, pp. 212–213; and Widmer, Ellen. 1996, pp. 77–122. For the Wangs as a hereditary family, see Yin Dazhang . 1993. ‘Xiuning Wangshi zai Huai’an yeyi gaikuang.’ !"#$%& [‘A survey of the hereditary medicine of the Xiuning Wang family in Huai’an’]. Anhui Zhongyi xueyuan xuebao !"#"$ [‘Journal of Anhui traditional Chinese medical college’] 12(1): 10–11. 91 Leung, Angela Ki Che. 1987, p. 152. For an analysis of the historical reasons given by physicians for entering the medical profession, see also Zeng Xiongsheng . 1999. ‘Hiding in doctoring: the story of 1364 medical practitioners.’ In Yung Sik Kim and Francesca Bray eds. Current perspectives in the history of science in East Asia. Seoul: Seoul National University Press, pp. 438–448. 92 See Li Xun . ‘Shishan jushi zhuan.’ !" [‘Biography of the retired scholar Stone-Mountain’]. Shishan yi’an ! [‘Stone Mountain medical case histories’], fulu [Appendix]: 22. The Shishan yi’an was compiled by Wang Ji’s disciple Chen Jue , and the ﬁrst preface is dated 1531. I have used the Siku quanshu ! edition. Originally published in 1782. This edition: 1987. Photographic reprint. Volume 765, pp. 325–409. 93 Xiang Changsheng. 1983, pp. 177–178.

167

NOTES

94 95 96 97 98 99 100 101

102 103 104

105 106 107 108

109 110

111

Yin Dazhang. 1993, pp. 10–11. Hanson, Marta. 1995, pp. 212–213. Li Xun. ‘Shishan jushi zhuan.’ Shishan yi’an fulu [Appendix]: 23. Zhen Zhiya and Fu Weikang eds. 1991, p. 369. Li Jiren and Hu Jianbei eds. 1990, p. 100. Zhen Zhiya and Fu Weikang eds. 1991, p. 370. Li Jiren and Hu Jianbei eds. 1990, p. 103. See Needham, Joseph with the collaboration of Lu Gwei-Djen, edited and with an introduction by Nathan Sivin. 2000. Science and civilisation in China. Volume 6: biology and biological technology. Part IV: Medicine. Cambridge: Cambridge University Press, p. 31. See Needham, Joseph and Lu Gwei-Djen. 2000, p. 31. Personal communication from Charlotte Furth. Tong Guangdong and Liu Huiling . 1995. ‘Mingqing shiqi Xin’an yaodian ji qi yiyaoxue zuoyong.’ !"#$%& !"# [‘Xin’an pharmacies in the Ming and Qing dynasties and their role in medical learning’]. Zhonghua yishi zazhi ! [‘Chinese journal of medical history’] 25(1): 30–34. See Furth, Charlotte. 1999, pp. 156–157. See also Needham, Joseph and Lu Gwei-Djen. 2000, p. 32. Zhen Zhiya and Fu Weikang eds. 1991, pp. 369–370. Xiang Changsheng. 1983, p. 178. Much of the information in this paragraph relating to merchants is taken from Tong Guangdong’s article on the cultural exchange of medical knowledge promoted by the activities of Xin’an merchants. See Tong Guangdong 1993. ‘Huishang liuyu yu Xin’an yixue jiaoliu.’ !"#$%&' [‘Anhui merchants abroad and the dissemination of medical knowledge to and from Xin’an’]. Anhui Zhongyi xueyuan xuebao !"#"$ [‘Journal of Anhui traditional Chinese medical college’] 12(4): 8–9. The information regarding Wang Ji’s links with Lin Hanzhang and Li Qianhu originates from the Wang Ji’s preface to his Zhenjiu wendui ! [‘Questions and answers on acupuncture and moxibustion’]. This text is included in the collected works of Wang Ji, Wang Shishan yishu bazhong !"#$ [‘Eight medical books of Stone Mountain Wang’], and can also be found in the Siku quanshu, Volume 765, pp. 41–110. I have used the Siku quanshu edition, Volume 765, p. 42. Xiang Changsheng. 1985, p. 68. Kai-wing Chow has similarly noted that the expansion in commercial printing meant that beyond elementary level the authority of the teacher was now supplemented, if not replaced, by the commentaries written by professional writers for examinees at every level that were available from bookshops. See Chow, Kai-wing. 1996. ‘Writing for success: printing, examinations, and intellectual change in late Ming China.’ Late Imperial China 17(1): 120–157. Xiang Changsheng. 1985, p. 66; Tong Guangdong . 1989. ‘Mingqing shiqi Hui banyiji jiqi yishi zuoyong.’ !"#$% !"# [‘Medical books printed in Anhui during the Ming

168

NOTES

112 113 114 115 116

117

118 119

120

121

122 123 124

and Qing dynasties and their medical historical value’]. Zhonghua yishi zazhi !"# [‘Chinese journal of medical history’] 19(4): 245. These statistics are taken from Liu Huiling. 1993, pp. 11–12. Tong Guangdong. 1989, pp. 245–246. Tong Guangdong. 1993, p. 8. Xiang Changsheng. 1985, p. 67. Liu Shijue . 1987. ‘Mingqing shiqi Huizhou shangye de fanrong he Xin’an yixue de jueqi’ !"#$%&'()*+ !" [‘The ﬂourishing of commerce in Huizhou during the Ming and Qing and the rise of medicine in Xin’an’]. Zhonghua yishi zazhi !"# [‘Chinese journal of medical history’] 17(1): 11–12; and Li Jiren and Hu Jianbei eds. 1990, p. 1. For example, Wu Kun was apprenticed to Yu Wuting through the encouragement and ﬁnancial support of wealthier lineage members. See: Xiang Changsheng. 1983, p. 178; and Liu Shijue. 1987, p. 12. A more detailed account of the achievements and motivations of Wu Mianxue and Wang Ang can be found in Marta Hanson. 1995, pp. 207–214. See also Widmer, Ellen. 1996, pp. 77–122. Tong Guangdong. 1989, p. 242. The only other reference to this seven-volumed edition of Wang Ji’s collected works I have seen is in a manuscript copy of the Yizang shumu ! [‘Book catalogue of the medical treasury’], compiled by Yin Zhongchun in 1644, p. 20b. It is not mentioned in the Union catalogue (Zhongguo Zhongyi yanjiuyuan tushuguan !"#$%&' ed. 1991. Quanguo Zhongyi tushu lianhe mulu !"#$%&' [‘Union catalogue of Chinese medical works in Chinese libraries’]. Beijing: Zhongyi guji chubanshe), so one can only presume it is no longer extant. Tong Guangdong discusses the history of medical publishing in Anhui at depth in his article, ‘Medical books printed in Anhui during the Ming and Qing dynasties and their medical historical value.’ See Tong Guangdong. 1989, pp. 242–246. For the wide variety of works being published in Xin’an at this time, and analyses of the social and cultural factors inﬂuencing the type of books being produced see the following articles from which much of the information in this paragraph and the next is taken: Marta Hanson. 1995, pp. 207–214; Tong Guangdong. 1989, pp. 242–246; and Li Jiren and Hu Jianbei eds. 1990, pp. 1– 6. Chao Yüan-ling. 1995. Shishan yi’an fulu [Appendix]: 21–47. Wang Ji . ‘Xiankao fujun gupu xiansheng xingzhuang’ !"#$ [‘An account of the actions of my late father Mr Gupu’]. Shishan yi’an fulu [Appendix]: 12–21. Although written in 1522, this essay does not appear in any of the Ming dynasty editions of the Shishan yi’an that I have examined, but can ﬁrst be seen in the Japanese edition of 1696, and then again in the Siku quanshu edition.

169

NOTES

125 Qimen xianzhi ! [‘Qimen gazetteer’]. Compiled by Xie Cunren and Yu Shiqi . Wanli edition. ‘Yishu’ [‘Arts’]. Fascicle 3, p. 130. 126 Gujin yitong daquan !"# [‘Complete synthesis of medical knowledge past and present’]. Xu Chunfu . Original preface dated 1556. This edition 1570. ‘Lishi shengxian mingyi xingshi’ !"#$% [‘The surnames of famous and sagacious physicians of history’]. Fascicle 1, p. 68. 127 These dates are given in the later preface to the Shishan yi’an written by Wang Ji’s disciple Chen Jue in 1541, and can be found in the 1633 edition of the text arranged by Wang Wei . 128 Shishan yi’an fulu [Appendix]: 21–22. 129 This family tree is taken from Shishan yi’an fulu [Appendix]: 12. 130 Shishan yi’an fulu [Appendix]: 19. 131 Shishan yi’an fulu [Appendix]: 20–21. 132 Shishan yi’an fulu [Appendix]: 22. 133 This self-appraisal is included among the prefaces to all the Ming editions of the Shishan yi’an. It can be found, for example, on the ﬁrst page of the ﬁrst block-printed edition compiled by Chen Jue, preface dated 1531. 134 Shishan yi’an fulu [Appendix]: 22. Fan Wenzheng , more commonly known as Fan Zhongyan , is reputed to have made this comment in the Southern Song on learning that he would never become a high ofﬁcial. Robert Hymes states that medicine was seen as a digniﬁed alternative to a bureaucratic career because of the opportunity it provided for a gentleman to beneﬁt society. There is no evidence to suggest that Fan Wenzheng did consider a medical career, but the saying is very common in medical writings of the Ming and Qing. See Hymes, Robert P. 1987, pp. 43–44. 135 This remark is included in the later preface to the Shishan yi’an, dated 1541, which was written by Chen Jue after Wang Ji’s death. 136 On the blurring of the lines between the different categories of physicians in late imperial China, see also Chao Yüan-ling. 1995, pp. 174–177. 137 Shishan yi’an fulu [Appendix]: 23. 138 Shishan yi’an fulu [Appendix]: 46. That Zhou Chen and Xu Zhong, in addition to Chen Jue, recorded their master’s case histories would perhaps suggest that this was a common practice among disciples. Interestingly, their forty-seven cases which form the latter part of this biography are also entitled Shishan yi’an, and predate the actual Shishan yi’an by eight years. I have seen no other reference to their prototype Shishan yi’an, so one can only conclude that their cases do not exist independently from the biography. There is no overlap between Chen Jue’s case histories and those of Zhou Chen and Xu Zhong. 139 These statistics are again taken from Liu Huiling. 1993, pp. 11–12. 140 Bencao gangmu. 1993. Volume 1, fascicle 1, p. 8. 141 Mingshi [‘Ming history’]. Volume 25, fascicle 299, p. 7652. The main compiler of the Mingshi was Zhang Tingyu , and it

170

NOTES

142

143 144 145 146

147

148

149

150 151

152 153 154

was ﬁrst printed in 1739. I have used the collated and punctuated edition from 1974, published in Beijing by the Zhonghua shuju. Wang Ji himself thanks these two disciples for their help in the preface to his Shanghan xuanlu. I have not been able to examine this preface in the original edition myself, but have used the text copied into the Yiji kao. See Yiji kao [‘Studies of medical books’]. Tamba no Mototane !. Completed in 1819. I have used the 1936 edition, published by Shanghai zhongxi yiyao yanjiushe, fascicle 2, p. 247a. Shishan yi’an fulu [Appendix]: 7–12. Li Jiren and Hu Jianbei eds. 1990, p. 103. Tong Guangdong and Wu Huaqiang. 1995, p. 15. Wang Ji notes this in the preface to his Waike lili. The preface, dated 1531, can be consulted in the Yiji kao. See Yiji kao. 1936. Fascicle 4, p. 705a. The text of the Waike lili is in Wang Ji’s collected works, the Wang Shishan yishu bazhong, and also in the Siku quanshu. Volume 765, pp. 111–323. Wang Ji. ‘Bian Mingyi zazhu jiyong shen zhulun’ !"#$% [‘Discursive essay on the taboo against the use of ginseng in the Miscellaneous writings of illustrious physicians’]. Shishan yi’an fulu [Appendix]: 1–7. Douzhi libian ! [‘Differentiating theories regarding the treatment of poxes’]. Wang Ji. Preface dated 1531. This text is found in Wang Ji’s collected works, Wang Shishan yishu bazhong. I have used the earliest edition compiled between 1522 and 1633 by the Qimen pushu Wangshi citanghui keben. This fourfold division of Wang Ji’s works was ﬁrst devised by Li Lei. See Li Lei . 1986. ‘Shixi Wangji de zhenjiu xueshu sixiang’ !"#$%&'( [‘An analysis of Wang Ji’s scientiﬁc thought with regard to acupuncture and moxibustion’]. Zhongguo zhenjiu ! [‘Chinese acupuncture and moxibustion’] 1: 44. Li Lei also attributes a further two books to Wang Ji, the Yidu [‘Medical reader’] and the Neijing buzhu ! [‘A supplementary commentary to the Inner canon’] but I have not been able to ﬁnd any other references to these works, and so have not included them here. Marta Hanson found a very similar set of motivations with regard to the publishing of books in sixteenth-century Huizhou. See, Hanson, Marta. 1995, pp. 207–214. Tuiqiu shiyi ! [‘An examination of the ideas of my master’]. Dai Yuanli . Revised by Wang Ji and preface dated 1534. This text makes up part of Wang Ji’s Wang Shishan yishu bazhong, but can also be found in the Siku quanshu, Volume 765, pp. 1– 40. Douzhi libian. 1531. Author’s preface. Wang Ji. Waike lili ! [‘Surgical principles and examples’]. Preface dated 1531. In Yiji kao. 1936. Fascicle 4, p. 705a. Maijue kanwu ! [‘Correcting the errors of The pulse in verse’]. Dai Qizong . Revised by Wang Ji and preface dated 1523. Again this text can be found in the Wang Shishan yishu

171

NOTES

155

156

157

158

159

160 161

162 163 164 165

bazhong, but the preface can also be consulted in the Yiji kao. See Yiji kao. 1936. Fascicle 1, p. 153b. Yixue yuanli ! [‘Medicine from ﬁrst principles’]. Wang Ji. This book was revised by the renowned Ming publisher Wu Mianxue and published in 1601. I have not been able to consult a copy of this text. The details of its contents are taken from its preface which can be found in the Yiji kao. 1936. Fascicle 3, p. 557b. Zhu Zhenheng , or Danxi as he was often known, is one of the so-called ‘four masters of the Jin and Yuan dynasties’. He was responsible for developing the theories of ‘minister ﬁre’ (xiang huo ) and of yang being in excess, yin being depleted. He wrote the Gezhi yu lun ! [‘Supplementary discussions for the perfection of understanding through investigation of phenomena’], which was very inﬂuential on the thinking of later physicians, Wang Ji included. This text was originally published in 1347 and can be found in the Siku quanshu. Volume 746. The Siku quanshu edition I use has only forty-six cases in this fascicle. Three cases which appear in every other edition I have examined, including the original block-printed edition from 1531, have been omitted. Although compiled a decade earlier and by different disciples, the form and content of these supplementary cases are remarkably consistent with those found in the main body of the text. The clinical encounter is described in a very similar way, and the same views are expressed in terms of medical theory and type of treatment. Chunyu Yi’s case histories have been used as the basis for an exploration of early medical practice in China. In his ‘Text and experience in classical Chinese medicine’, Nathan Sivin uses Chunyu Yi’s writings to examine the process of becoming a physician: apprenticeship to a master as a disciple; the receiving of texts; the studying and memorizing of the texts; their application in practice; and their transmission to a medical heir. See Sivin, Nathan. 1995a, pp. 177–204. Taking a different approach, Lisa Raphals examines early yin–yang vessel theory as it appears in Chunyu’s cases and the clinical treatment of women within that structure. See Raphals, Lisa. 1998. For example, Nathan Sivin has found a number of examples of Sun Simiao’s accounts of his own illnesses interspersed throughout his medical writings. See Sivin, Nathan. 1967. For a concise and systematic account of the evolution of medical case histories from their beginnings to their emergence as a genre and beyond, see Shi Qi and Xiao Mincai eds. 1994. Zhongyi bing’an xue !" [‘Case histories in traditional Chinese medicine’]. Shanghai: Zhongguo dabaike quanshu chubanshe. Cullen, Christopher. 2001. Cullen, Christopher. 2001, p. 18. Cullen, Christopher. 2001, p. 23. See the preface by Cheng Zeng to the Shishan yi’an dated 1531, and included in all Ming editions of the text. This preface can also be found in the Yiji kao. See Yiji kao. 1936. Fascicle 3, p. 557a.

172

NOTES

166 167 168 169 170 171 172 173

174 175 176

177 178

179 180

181

182 183

Cullen, Christopher. 2001, pp. 28–32. Cullen, Christopher. 2001, p. 28. Shishan yi’an 2: 9–10. Shishan yi’an 2: 1–2. Shishan yi’an 3: 24–25. Shishan yi’an 2: 17–18. Shishan yi’an 3: 22–24. Shishan yi’an 3: 14–15. Wang Ji then sets out a total of seven cases of the treatment of disorders brought on by excessive emotion with counter-emotions. Six of these are among eleven examples of this type of case translated and discussed by Nathan Sivin in his ‘Emotional Counter-therapy’. See Sivin, Nathan. 1995b. A translation can be found in Unschuld, Paul. 1985. Medicine in China: a history of ideas. Berkeley: University of California Press, p. 331. See Shishan yi’an 3: 17. For example, I have come across versions in Yao Ruoqin and Xu Hengzhi comps. 1971, facsimile of the 1933 edition. Song Yuan Ming Qing mingyi lei’an !"#$% [‘Medical cases, arranged by topic, by famous physicians of the Song, Yuan, Ming and Qing dynasties’]. Volume One: Zhu Danxi yi’an . Xuanfeng chubanshe, p. 28; and Shanghai Zhongyi xueyuan Zhongyi wenxian yanjiusuo !"# !$%&'(. 1994. Lidai mingyi qi’anji !"#$ [‘Collection of strange cases from famous physicians in past dynasties’]. Shanghai: Shanglian sanlian shudian, p. 103. Shishan yi’an 2: 25–27. Shishan yi’an 3: 18–20. I have been able to locate all of these quotations in the edition of the Hanshi yitong ! [‘Medical insights of Mr Han’] found in Liulizhai yishu !". Qing Xiu Santang kanben. 1794. Volume 5. 1: 10, 12, 13, 19; 2: 3. Shishan yi’an 3: 19. Shishan yi’an 3: 19. The Zazhu refers to the Mingyi zazhu ! [‘Miscellaneous writings of illustrious physicians’] which was written in the Ming dynasty by Wang Lun , annotated by Xue Ji , and published in 1549. However, it was written in 1502, and copies were in circulation well before the publication date. Shishan yi’an 3: 27–29. In this case Wang Ji attacks the Mingyi zazhu for making contemporary physicians think that all coughs that bring up red Blood require remedies which replenish yin. Wang Ji also criticizes the views expressed in this text in a theoretical essay included in the appendix to the Shishan yi’an. See Wang Ji. ‘Bian Mingyi zazhu jiyong shen zhulun’ !"#$%"& [‘Discursive essay on the taboo against the use of ginseng in the Miscellaneous writings of illustrious physicians’]. Shishan yi’an fulu [Appendix]: 1–7. Shishan yi’an 3: 19–20. Wu Yiyi. 1993–94. ‘A medical line of many masters: a prosopographical study of Liu Wansu and his disciples from the Jin to the early Ming.’ Chinese Science 11: 63.

173

NOTES

184 185 186 187 188 189 190

191

192

193 194 195 196 197

198

199

Shishan yi’an fulu [Appendix]: 23–46. I am grateful to Nathan Sivin for suggesting this possibility to me. Liu Huiling. 1993, pp. 11–12. Shishan yi’an 2: 38–39. I am indebted to Nathan Sivin for this translation. Shishan yi’an 1: 33. Shishan yi’an 1: 32. According to the Quanguo Zhongyi tushu lianhe mulu !" !" [‘Union catalogue of Chinese medical works in Chinese libraries’] there are over nine separate editions of the Shishan yi’an. This does not include the edition found in the Siku quanshu, or in Wang Ji’s collected works, entitled Wang Shishan yishu bazhong !"#$ [‘Eight medical books of Stone Mountain Wang’]. See Zhongguo Zhongyi yanjiuyuan tushuguan ed. 1991, p. 627. A comparison of the results of Charlotte Furth’s analysis of the ninety-three case histories of the late Ming physician Cheng Maoxian with those from the Shishan yi’an shows that many elements of the clinical encounter and of the social context in which medicine was practised are common to both sets of case histories. See Furth, Charlotte. 1999. Chapter 7. One qian is a tenth of a Chinese ounce or tael, liang , which in the Ming dynasty was approximately equal to 1.3 imperial ounces. See Mote, Frederick W. and Denis Twitchett eds. 1988. The Cambridge history of China. Volume 7: the Ming dynasty, 1368–1644, part 1. Cambridge: Cambridge University Press, p. xxi. One fen is a hundredth of a Chinese ounce, liang . Shishan yi’an 1: 17–18. For more on the theory–practice split and the differences between the Western and the Chinese traditions, see Sivin, Nathan. 1995a, pp. 195–198. Shishan yi’an 1: 1–6. ‘Blood’ does not have the same meaning in traditional Chinese medicine as it does in biomedicine. This also holds true for the organs, such as the Spleen, Kidneys and Lungs. Therefore, following convention, capitals are used to highlight this difference. For further information on the basic principles of traditional Chinese medicine see Sivin, Nathan. 1987. Traditional medicine in contemporary China. Ann Arbor: University of Michigan, Center for Chinese Studies. This division of qi into protective qi and structive qi dates back to the Huangdi neijing, one of the earliest extant theoretical medical works, from the Han dynasty. Wang Ji was responsible for developing this theory further. See Huangdi neijing ling shu !"# [‘Inner canon of the Yellow Lord – Miraculous pivot]. Fascicle 4, section 18. ‘Yingwei shenghui pian.’ !" [‘Treatise on the production and convergence of structive and protective qi’]. I have used the Siku quanshu edition of the Ling shu, Volume 733, pp. 12– 14. Shishan yi’an 1: 4.

174

NOTES

200 Li Gao (1180 –1251), or Li Dongyuan as he is also known, was another one of the so-called ‘four masters of the Jin and Yuan’ along with Zhu Zhenheng. He emphasized the need to regulate the spleen and stomach using warming and replenishing methods. He is most famous for his work Pi wei lun [‘Treatise on the Spleen and Stomach’]. 201 Shishan yi’an 1: 6. 202 Shishan yi’an 1: 4–5. 203 Shishan yi’an 2: 20–23; 3: 20–22. 204 Shishan yi’an 3: 1–3. The quotation by Zhang Zhongjing regarding the use of ginseng for Blood depletion and qi weakness is reiterated in another case, although the wording is slightly different. See Shishan yi’an 3: 11–12. 205 Shishan yi’an 3: 3–5. 206 The authors of medical texts would commonly cite the work of their predecessors and align themselves with the medical tradition of one or more particular physicians. For a detailed study of medical lineages and the transmission of medical knowledge over several centuries, with particular reference to the lineage of the Jin dynasty physician Liu Wansu , see Wu, Yiyi. 1993–94. 207 The concept of the need for ﬂexibility in scholars is an ancient one, and can be found in book one, paragraph eight, of the Lun yu [Analects], which are attributed to Confucius, Kong Zi . I have used the Siku quanshu edition of the Lun yu, Volume 195, p. 538. 208 Shishan yi’an 2: 33–34. See also 3: 27 for another example. 209 Sivin, Nathan. 1995a, p. 197. 210 The most commonly used phrase at this point in the case history is ‘X’ as in ‘A physician used X medication’. Taken alone an alternative translation, using ‘’ as a verb, might be ‘[The patient] was treated using X medication’, allowing for the possibility that it was not a physician doing the treating, but another kind of healer, the patient’s family, or the patient him or herself. However, I think this unlikely because of the number of occasions on which only the ﬁrst translation seems plausible. For example, another phrase commonly used here is ‘XY’, which translates as ‘A physician diagnosed X disorder and used Y treatment’. This very similar phrase does not easily bear the alternative translation suggested above. Also, sometimes the construction ‘X . . . Y’ is used which translates as ‘One physician used X medication . . . another physician used Y medication’. In some cases, later references to the physician in question also make the translation clear such as where, having used the formula ‘X’, Wang Ji goes on to rationalize the physician’s actions by saying ‘ !"#$%&'()’ or ‘The physician saw this pulse and thought it was a heat disorder and so used cooling medicines’. Finally, where Wang Ji wants to indicate that another type of healer saw the patient, or the patient treated himself he indicates this, for example by using ‘X’, or ‘He himself used X medication’. By contrast, there are no occasions where only the second translation seems ﬁtting. For these reasons, and for the sake

175

NOTES

211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227

228 229 230

231 232 233

of consistency, throughout this book I take ‘X’ to mean that the patient in question was seen by one or more physicians who prescribed certain medication. Shishan yi’an 2: 27–28. Shishan yi’an 2: 9–10. Shishan yi’an 2: 20–23. E.g. Shishan yi’an 1: 31–32; 2: 29, 40–41; 3: 22–24, 25–27. Shishan yi’an 1: 33; 2: 24. Shishan yi’an 2: 18–19, 29–30; 3: 1–3. Shishan yi’an 2: 26. Shishan yi’an 2: 31–33. Shishan yi’an 2: 27–28. Shishan yi’an 2: 35–37. For further examples of this type of comment, see Shishan yi’an 1: 19–20; 2: 19. Shishan yi’an 2: 31–33. Shishan yi’an 1: 30. Shishan yi’an 1: 29; 3: 24–25. Shishan yi’an 2: 9–10. Shishan yi’an 3: 10–11. The practice of prescribing by correspondence without ever seeing the patient was also not uncommon in eighteenth-century England. See Porter, Dorothy and Roy, Porter. 1989. Patient’s progress: doctors and doctoring in eighteenth-century England. Oxford, Polity in association with Blackwell, pp. 76–78. More recently, the murderer Dr Crippen also practised postal prescribing. See Cullen, Christopher. 1993, p. 136. Shishan yi’an 3: 1–3. See also 2: 29–30, 37–38 for cases where Wang Ji makes a diagnosis based solely on symptoms related to him either in a letter or by an intermediary. Shishan yi’an 2: 18–19. There is also another example of a man who wrote a letter to Wang Ji in which he explained what his pulses were like: see Shishan yi’an 2: 15–16. ‘Pattern diagnosis’ was a Song innovation which spread gradually in the twelfth and thirteenth centuries. Charlotte Furth notes that, ‘At the outset this was less a method of diagnosis than a strategy for grouping the multiplicity of individual symptoms into a smaller number of broad categories that in turn could be related to each other dynamically.’ By the Ming, the patterns had become standardized as the eight rubrics. See Furth, Charlotte. 1999, pp. 65–66. Shishan yi’an 2: 35–37. For other examples of a combination of either appearance and pulse, or symptoms and pulse, contributing to the ﬁnal diagnosis, see Shishan yi’an 1: 39–40; 3: 9–10. Shishan yi’an 2: 5–7. For a similar example, see Shishan yi’an 2: 8–9. Shishan yi’an 2: 38. Some surprise is shown that this woman was able to conceive without having menstruated for a considerable length of time. This is indicative of the extent to which menstrual regularity

176

NOTES

234 235 236 237

238

239 240

241 242 243 244 245 246

247 248 249 250

251

(tiaojing ) was perceived as essential before conception could take place. Shishan yi’an 1: 40. Shishan yi’an 2: 5. Tong Guangdong and Liu Huiling . 1995, pp. 30–34. For more detailed information on the properties of these herbs see, Zhongyi dacidian bianji weiyuanhui !"#$%&'. 1994. Jianming Zhongyi cidian !"# [‘Simpliﬁed dictionary of Chinese medicine’]. Beijing: Renmin weisheng chubanshe, pp. 20, 777, 254, 314, 221 respectively. This approach can be contrasted with that of pharmacists who since the Song dynasty had been selling standardized prescriptions, not tailored to the individual patient, in apothecary shops across China. See Unschuld, Paul. 1999. ‘The relationship between physicians and pharmacists in China.’ In Yung Sik Kim and Francesca Bray eds. Current perspectives in the history of science in East Asia. Seoul: Seoul National University Press, pp. 429–437. Shishan yi’an 1: 37–38. Shanghan lun [‘Treatise on cold damage disorders’]. Clause 110. This text is attributed to Zhang Zhongjing and dates back to approximately the third century. I have used the following edition: 1993. Beijing: Zhongguo shudian, p. 43. Shishan yi’an 3: 29–32. Shishan yi’an 1: 19, 33; 2: 1, 37–38; 3: 20–22. Shishan yi’an 3: 20–22. See also 2: 1b, 27–28. See Furth, Charlotte. 1999. Chapter 7. For more on Tan Yunxian, see Furth, Charlotte. 1999. Chapter 8. Furth goes further and makes the interesting suggestion that as female healing seems more likely to have offered technologies that involved a hands-on medicine of bodily contact, perhaps ‘a Ming feminization of moxibustion went hand in hand with its decline in prestige, just as the rising prestige of the literati-physician model of elite practice was linked to its ritualized code of limited physical contact between healers and the sick’. Furth, Charlotte. 1999, pp. 296–297. Shishan yi’an 1: 29, 31; 2: 1–2, 9–10. Shishan yi’an 1: 31–32. See also 2: 2– 4 for a discussion of the role of self-cultivation in treating illnesses for which medicines are unsuitable. Shishan yi’an 2: 25–26. Shishan yi’an 2: 38–39. I am indebted to Nathan Sivin for this translation. For another similar example of Wang Ji being unable to explain why a woman has become pregnant when she has not menstruated in over a year since giving birth, see 2: 38. Charlotte Furth writes of her analysis of four hundred case histories from the Qing dynasty: ‘These doctors were more likely to label an illness a yin disorder when the illness was grave, the sick person low in status, and/or when the patient was female. It appears as a social pattern in these cases that women were reported as prone to negative

177

NOTES

252 253 254 255 256 257 258 259 260 261 262 263 264 265 266

267 268 269 270 271 272 273 274 275 276 277 278 279

emotion more often than men were, and that women and poor people were usually sicker before the doctors were called to the bedside.’ See Furth, Charlotte. 1994a, pp. 246–247. Shishan yi’an 1: 14; 2: 5–7. For this title, and those that follow, I have used Hucker, Charles, O. 1985. A dictionary of ofﬁcial titles in imperial China. Stanford, Calif.: Stanford University Press. Shishan yi’an 1: 24–25. Shishan yi’an 1: 24. Shishan yi’an 1: 31. Shishan yi’an 1: 33. Shishan yi’an 1: 39–40; 2: 26–27. Shishan yi’an 3: 11–12. Shishan yi’an 2: 8. Shishan yi’an 1: 30. Shishan yi’an 2: 42. Shishan yi’an 3: 24–25. Shishan yi’an 2: 35–37. Shishan yi’an 3: 10–11. Shishan yi’an 2: 1. In this context, and throughout this work, I use the term ‘competition’ not in the sense of maximizing income, indeed there is no indication that the elite physicians charged for their services, but in the overlapping senses of striving for reputation and renown among contemporaries; of battling for new patients and for the continuing loyalty of existing ones; and of striving to take one’s rightful place within a medical lineage as the true successor, interpreter of previous works, and transmitter of knowledge to the next generation of physicians. See also Shishan yi’an 2: 20–23; 3: 25–27 for examples not related to arguments over the nature of depletion and treatment using ginseng and astragalus root. Shishan yi’an 3: 9–10. Shishan yi’an 2: 8–9. Shishan yi’an 2: 17–18. See also 1: 39; 2: 5–7, 13–14, for similar examples. Shishan yi’an 1: 31–32, 32, 32–33; 2: 1, 11–12, 20–23; 3: 1–3. Shishan yi’an 3: 1–3. Shishan yi’an 1: 32. Shishan yi’an 1: 31–32, 32–33. Shishan yi’an 1: 33. Shishan yi’an 3: 12–14. Shishan yi’an 3: 27–29. Shishan yi’an 1: 19. Qingfen () is a powder of mercury (1) chloride crystals. According to the Bencao gangmu, it is formed by taking mercury (which is produced by roasting cinnabar), adding white alum and table salt, and roasting until the qingfen sublimates to the top. It was said to be pungent, cold and inactive, but Li Shizhen notes that its nature is actually warm, ﬁerce and active. See Bencao gangmu. 1993. Volume 2, fascicle 9, pp. 59–60. It was used in the treatment

178

NOTES

280 281 282 283 284 285 286 287 288

289 290 291

292 293

294 295 296 297

of syphilis and other sores. I am grateful to David Wright for helping me follow both the technical Chinese and the chemical processes involved in this passage from the Bencao gangmu. Wang Ji discusses the symptoms of the disorder suffered by this patient, and they would indeed seem to correspond to both primary and secondary syphilis. He ﬁrst describes how ‘licentious men and licentious women’ (yinfu yinfu ) disturb the ﬁre in their attenuated yin (jueyin ) channels, and how this causes the kidneys to lose control over ﬁre, which becomes phlegm, and ﬂows to the glans where it gives rise to a ‘fornicator’s sore’ (jianchuang ). If this is not treated then after some time sores appear on the legs which resemble the myrica rubra (yangmei ), so they are termed myrica rubra sores. These then spread over the whole body. The ﬁrst part of this description seems to refer to the chancre of primary syphilis, and the term ‘fornicator’s sore’ would suggest an acknowledged connection with sexual activity. See Shishan yi’an 2: 22. Shishan yi’an 2: 20–23. Shishan yi’an 1: 23–24. Shishan yi’an 3: 3–5. Shishan yi’an 1: 6–13 (eight examples); 3: 1–3. Shishan yi’an 1: 13–14; 2: 15–16, 27–28, 29–30. Shishan yi’an 2: 18–19, 37–38. E.g. Shishan yi’an 3: 22–24. Shishan yi’an 3: 1–3. Nor does it seem that dealing with negotiation in the medical encounter was unique to Wang Ji or to the Ming dynasty. Nathan Sivin has written that, ‘as early as we have detailed information on cases, from the Thang onward, we ﬁnd doctors complaining about patients who ignore their instructions and people in the sickroom who argue with the physician. When patients and their families found that their wishes were not taken seriously, or when they lost conﬁdence in their doctor, they did not hesitate to consult someone else.’ See Needham, Joseph and Lu Gwei-Djen. 2000, p. 30. Shishan yi’an 2: 42. Shishan yi’an 3: 24–25. There are numerous examples of patients’ conditions being worsened by the medical treatment they receive from physicians other than Wang Ji. See Shishan yi’an 1: 33–34, 34–35, 35, 40, 40–41; 2: 1–2, 7, 11–12, 24–25, 25–26, 27–28, 30–31, 40, 41, 41–42; 3: 20–22, 22–24, 24–25. Shishan yi’an 1: 31. See Wang Ji. ‘Bian Mingyi zazhu jiyong shen zhulun’ !"# ! [‘Discursive essay on the taboo against the use of ginseng in the Miscellaneous writings of illustrious physicians’]. Shishan yi’an fulu [Appendix]: 1–7. Shishan yi’an 1: 5. Shishan yi’an 2: 24–25; 3: 22–23. Shishan yi’an 2: 31–33. See Notes 180 and 181.

179

NOTES

298 Shishan yi’an 2: 7. 299 Shishan yi’an 2: 35–37. As previously discussed, this case is also a good example of Wang Ji’s theories on waike as set out in his Waike lili, in that he believed that this case which displayed external symptoms, that is breast lumps, should have been treated using internal remedies. 300 See Note 279. 301 Shishan yi’an 2: 20–23. The ﬁnal quotation is indeed taken verbatim from the Analects, book thirteen, paragraph seventeen. See the Siku quanshu edition of the Lun yu, Volume 195, p. 648. 302 Shishan yi’an 2: 19. 303 Shishan yi’an 3: 19–20. 304 Charlotte Furth also raises the question of whether physicians in a Chinese context commanded the same authority as their European counterparts. See Furth, Charlotte. 1994a, pp. 247–248. 305 Shishan yi’an 1: 30; 2: 19. 306 Shishan yi’an 2: 35–37. 307 Shishan yi’an 3: 20–22. 308 Shishan yi’an 2: 27–28. 309 Shishan yi’an 3: 25–27. 310 Shishan yi’an 2: 24–25. 311 Kleinman, Arthur. 1980. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley: University of California Press. 312 Cullen, Christopher. 1993. 313 On syphilis, see Note 279. 314 There is no easy translation for fangshi . The alternatives that have been suggested in the past, such as thaumaturge, wonderworker, gentleman possessing special recipes, technical specialist and quack, give a ﬂavour of what is meant. It is a term generally used of others, and is not something people would use to describe themselves. In this context, thaumaturge is perhaps the most appropriate. 315 Shishan yi’an 2: 20–23. 316 Another Ming physician, Li Shizhen, is not convinced about the morality of such treatments. He writes, ‘The ancients considered it benevolent to cover exposed bones and often received preternatural rewards for doing so. But now wonder-workers, whose hearts are set on proﬁt and the satisfaction of craving, collect human bones to make medicines. Can [medicine] the “art of benevolence” actually be concerned with this sort of thing? And dogs do not eat the bones of dogs; can it be permissible for men to eat the bones of men?’ Bencao gangmu. 1993. Volume 4, fascicle 52, p. 104. I have followed the translation found in Cooper, William and Nathan Sivin. 1973. ‘Man as a medicine; pharmacological and ritual aspects of traditional therapy using drugs derived from the human body.’ In Shigeru Nakayama and Nathan Sivin eds. Chinese science: explorations of an ancient tradition. Cambridge, Mass., and London: MIT Press, pp. 203–272. 317 Shishan yi’an 2: 24.

180

NOTES

318 This refers to the practice of writing charms on paper, ashing them, dissolving the ashes in water, and taking them as a medicine. 319 Shishan yi’an 1: 16–17. 320 Shishan yi’an 3: 29–32. 321 Shishan yi’an 3: 17–18. Wang Ji does not identify the physician in this case. However, the case is also quoted in a slightly different form by the late Ming physician, Zhang Jiebin in his Zhangshi leijing ! [‘Mr Zhang’s classics arranged by subject’]. He attributes the case to a Han Shiliang. I have followed the translation in Unschuld, Paul. 1985, p. 331. 322 Shizheng lu [Writings on practical government]. Lü Kun . 2: 51a. Quoted in Leung, Angela Ki Che. 1987, p. 153. More evidence for this preference of women for female healers is also found in the Ming dynasty novel Jin ping mei. See Cullen, Christopher. 1993, pp. 126–132. For other information on female healers, see Cass, Victoria. 1986. ‘Female healers in the Ming, and the lodge of ritual and ceremony.’ Journal of the American Oriental Society 106: 233–240. There is even evidence in this period of women penetrating the male domain of the literati physician, as in the case of Tan Yunxian, the female healer who authored her own set of case histories and was honoured as a famous physician (ming yi ). See Furth, Charlotte. 1999. Chapter 8. 323 Additional evidence for the ability of laymen to understand complex medical concepts can be found in the Jin ping mei. See Cullen, Christopher. 1993, p. 120. 324 For a discussion of the wide variety of explanatory models of illness employed by individuals in the context of modern-day Taiwan, see Kleinman, Arthur. 1980. 325 See Needham, Joseph and Lu Gwei-Djen. 2000, pp. 32–34. 326 The validity of these general observations is reinforced by the fact that many of them were also noted by Charlotte Furth in her study of the late Ming physician Cheng Maoxian. Cheng Maoxian and Wang Ji both came from the same region and were both advocates of warming and replenishing remedies such as ginseng and astragalus root, although Cheng was practising almost a century later. Cheng’s patients were similarly knowledgeable about medicine, often treating themselves and their families using standard prescriptions; they were ﬁckle, often using more than one physician in the course of an illness; and they were conservative, showing considerable reluctance to embrace Cheng’s favoured drug combination of ginseng and astragalus root. Like Wang Ji, it seems, Cheng was critical of other physicians and their treatment strategies but could not always manage to persuade his patients to take the same view. See Furth, Charlotte. 1999. Chapter 7. 327 That is, three more cases than are to be found in the Siku quanshu edition of the text, which omits the section on dysentery (li ) from the ﬁrst fascicle. The two editions are almost identical in all other respects, and any quotations, except those relating to the omitted cases, are taken from the Siku quanshu edition.

181

NOTES

328 Excepting gynaecological complaints of course. 329 The Ming dynasty writer, Lü Kun , comments that women would initially seek out the services of female healers. See Shizheng lu [‘Writings on practical government’]. Lü Kun. 2: 51a. Quoted in Leung, Angela Ki Che. 1987, p. 153. 330 Women’s preference for female healers can be clearly seen in the Ming dynasty novel Jin ping mei. See Cullen, Christopher. 1993, pp. 126–132. 331 Dean-Jones, Lesley Ann. 1994, p. 34. 332 Dean-Jones, Lesley Ann. 1994, p. 225. 333 Dean-Jones, Lesley Ann. 1994, p. 119. 334 Shishan yi’an 1: 29. 335 Shishan yi’an 2: 20. 336 Shishan yi’an 2: 37. 337 For example see Shishan yi’an 1: 20, 35; 2: 30. 338 For example see Shishan yi’an 2: 14–15. 339 Shishan yi’an 2: 19, 26. 340 Shishan yi’an 2: 25. 341 Charlotte Furth similarly ﬁnds that menstrual regularity was an insigniﬁcant feature of the casebook of the Cheng Maoxian. She attributes this to the normal home management of such matters by the family. See Furth, Charlotte. 1999, p. 256. This explanation, while entirely plausible, does not fully account for the importance given to menstrual regularity in texts on women’s disorders. 342 Shishan yi’an 2: 5–6. See also 2: 8–9, 17–18; 3: 9–10. 343 This point is located on the lung channel, near the wrist. 344 Shishan yi’an 2: 38–39. See also 3: 29–32. 345 These two acupuncture points are located on opposite edges of the wrist. 346 Shishan yi’an 2: 39. 347 Bencao yanyi ! [‘An exposition of materia medica’]. Kou Zongshi . 1116. The passage is paraphrased in Furen daquan liangfang !"# [‘Good prescriptions from the compendia of gynaecology’]. Chen Ziming . Author’s preface dated 1237. This edition, Beijing: Renmin weisheng chubanshe. 1985, pp. 64–65. 348 See Furth, Charlotte. 1999, pp. 139–142. 349 From Chanke baiwen ! [‘Hundred questions on obstetrics’]. Min Qiji . 1640. I have followed the quotation in Ma, Kan-wen. 1983. ‘Obstetrics in ancient China.’ In Teizo Ogawa ed. History of obstetrics: proceedings of the seventh international symposium on the comparative history of medicine – east and west. Osaka: Taniguchi Foundation, Division of Medical History, p. 166. 350 Shishan yi’an 3: 18. For the original quotation, see Hanshi yitong. 1794. Volume 5, fascicle 1, p. 10. 351 Shishan yi’an fulu [Appendix]: 37. 352 Shishan yi’an 3: 1–3. 353 Shishan yi’an 2: 18–19. 354 Shishan yi’an 2: 37–38.

182

NOTES

355 356 357 358 359

360

361 362 363 364 365 366 367 368

369 370 371 372

Shishan yi’an 1: 33. Shishan yi’an 3: 27–29. Shishan yi’an 2: 27–28, 29. See Furth, Charlotte. 1999, pp. 245–257. See Huangdi neijing su wen !"# [‘Inner canon of the Yellow Lord – Basic questions’]. Fascicle 1, section 3. ‘Shengqi tongtian lun’ !" [‘Treatise on the union of human life and heaven’]. This anonymous text is thought to date to the ﬁrst century bc. I have used the Siku quanshu edition, which was edited by Wang Bing in 762. See Siku quanshu. Volume 733, pp. 15–19. See Pi wei lun [‘Treatise on the Spleen and Stomach’]. Li Gao . Section 1. ‘Pi wei xushi chuanbian lun’ !"#$ [‘Treatise on the transformations of depletion and repletion of the Spleen and Stomach’]. This text was completed in 1249. I have used the Siku quanshu edition. See Siku quanshu. Volume 745, pp. 403– 405. See Furen daquan liangfang. 1985, p. 63. See Furen daquan liangfang. 1985, pp. 63–64. See, Li Xun. ‘Shishan jushi zhuan.’ Shishan yi’an fulu [Appendix]: 21–46. Shishan yi’an 1: 36–37. Shishan yi’an 1: 13–14. Shishan yi’an 1: 29–30. Shishan yi’an 2: 9. See also 1: 18; 2: 14–15. Shishan yi’an 2: 20–24. The use of the word ‘licentious’ (yin ) in this context, with its connotations of illicit or adulterous intercourse, is interesting as it would seem to imply some kind of moral judgement being cast by the physician on the disease syphilis and its sufferers. The usual terms used in the text to allude to sexual activity, se (colour, beauty, sexual attraction, sexual intercourse) and xingfang (to engage in bedroom activities), are rather less derogatory. The correspondence between the disorder described by Wang Ji and both primary and secondary syphilis is discussed in Chapter 3, Note 279. Shishan yi’an 1: 34–35. Shishan yi’an 1: 33. Shishan yi’an 1: 24–25. Women did, however, at least drink alcohol, if not in the same quantity as men. For example, a late Yuan dietetic text has a passage on distilled spirits which warns of their harm when drunk to excess, and advises pregnant women against imbibing them. The need for a warning against drinking distilled spirits would suggest that not only women, but also pregnant women, did indeed drink alcohol. See Yinshi xuzhi ! [‘Essential knowledge about eating and drinking’]. Jia Ming . First published in 1367. Quoted in Mote, Frederick. 1977. ‘Yuan and Ming.’ In K.C. Chang ed. Food in Chinese culture: anthropological and historical perspectives. New Haven, Conn., and London: Yale University Press, p. 231. Charlotte Furth also mentions warnings against drinking during

183

NOTES

373 374

375 376 377 378 379 380

381

382

383

384 385 386 387 388 389 390 391

pregnancy and nursing found in Qing texts on women’s disorders. See Furth, Charlotte. 1987, pp. 14, 22. Shishan yi’an 2: 11–12. For example, Frederick Mote notes the contrast to be found in the late Ming novel Jin ping mei between a Daoist ritual which turned into a night of drinking, feasting and sensual excess which was attended by the males of the household, and a meal held by the women on the same night to entertain some Buddhist nuns which was both vegetarian and restrained. See Mote, Frederick. 1977, pp. 221–225. Shishan yi’an 3: 3–5. Shishan yi’an 1: 31. Shishan yi’an 1: 29; 2: 9–10. Shishan yi’an 2: 1. Shishan yi’an 1: 32–33. Shiji [‘Records of the historian’]. ‘Bian Que Cang Gong liezhuan’ !"# [‘The biographies of Bian Que and Cang Gong’]. Sima Qian . Fascicle 105. The Shiji is thought to have been completed around 99 bc. I have used the following edition: 1962. Beijing: Zhonghu shuju. Volume 9, pp. 2785–2820. Huangdi neijing su wen. Fascicle 1, section 1, ‘Shanggu tianzhen lun’ !" [‘Treatise on the heavenly endowments from remote antiquity’]. Siku quanshu. Volume 733, p. 9. See also fascicle 1, section 3, ‘Shengqi tongtian lun’, p. 18, for another example of the juxtaposition of sex, alcohol and diet as factors which are harmful to health when moderation is not observed. For the Qing dynasty, see Furth, Charlotte. 1987, pp. 14–15. For the late Ming, see Leung, Angela Ki Che. 1984. ‘Autour de la naissance: la mère et l’enfant en Chine aux XVIe et XVIIe siècles.’ Cahiers internationaux de sociologie 76: 58, 64. Fu Qingzhu nannu ke !"# [‘Fu Qingzhu’s medicine for men and women’]. Fu Qingzhu . Fu Qingzhu (1607–84) lived in the late Ming and early Qing periods. This text was compiled from his writings by later scholars and the preface is dated 1827. This edition: 1994. Beijing: Zhongguo Zhongyiyao chubanshe, p. 7. T’ien Ju-k’ang. 1988, p. 207. See Jiyuan jisuo jiche lu !" [‘Transmissions from the abode at Ji garden’]. Zhao Jishi . Quoted in Zurndorfer, Harriet. 1989, p. 51. See Yixian zhi [‘Yi county gazetteer’], fascicle three, ‘Geography’. Quoted in Fu Yiling. 1956, p. 67. Wang Ji. ‘Bian Mingyi zazhu jiyong shen zhulun.’ Shishan yi’an fulu [Appendix]: 7–13; and Cheng Tingyi. ‘Bing yong shenqi lun’. Shishan yi’an fulu [Appendix]: 1–7. Shishan yi’an fulu [Appendix]: 21–22. Shishan yi’an fulu [Appendix]: 14. Shishan yi’an fulu [Appendix]: 19. It is unclear exactly what Wang Ji means by the terms ‘selfcultivation’ (xiushen ) or ‘nourishing life’ (yangsheng ). He

184

NOTES

392 393 394 395 396 397

398

399

400

401 402 403

makes no explicit references to any particular rituals beyond moderating one’s behaviour and does not expressly align himself with any speciﬁc philosophy, be it Confucian, Daoist or Buddhist, let alone a particular faction or movement, such as Song Neoconfucianism. See Shishan yi’an 1: 32, 32–33; 2: 1, 2–4, 11–12, 20–24; 3: 1–3. Shishan yi’an 2: 2–4; 3: 1–3. Shishan yi’an 1: 9–10. Shishan yi’an 3: 1–3. Shishan yi’an 2: 2–4. In another example, which links moral virtue with health, but which does not involve sexual activity or alcohol, Wang Ji sees three men with similar disorders. Two of the men are deemed to hunger after fame and virtue, whereas the third is credited with possessing a liberal heart and so of the three he is the only one able to be treated, whereas the other two die after a year. See Shishan yi’an fulu [Appendix]: 39. Private communication from Cynthia Brokaw, author of The ledgers of merit and demerit: social change and moral order in late imperial China. She also commented that there was a contrast between late Ming morality books which mainly emphasized the need to refrain from such behaviour, and those of the early Qing which perceived them as symptoms of a deeper problem requiring moral reﬂection as well as behavioural change. Wang Ji certainly ﬁts into the late Ming pattern, not appearing to require more than restraint from his patients. Shishan yi’an 1: 31–32. These two women ultimately die as a result of giving birth. The extent to which giving birth was a sign of not having restrained one’s desires is unclear. It may be that, as in the case of men, the act of sex was harmful in itself, or it may simply be that the depleting nature of the resulting pregnancy and birth was instrumental in bringing about their deaths. Private communication from Cynthia Brokaw. Biographies of exemplary women (Lienü zhuan ) and the cult of female chastity are further examples of means by which women were encouraged to practise sexual or moral restraint more on a societal than a personal level. There were, however, Buddhist and Daoist traditions of female self-cultivation which did centre on issues of life enhancement and immortality for women on a personal level. For further information, see Despeux, Catherine. 1990. Les immortelles de la Chine ancienne: taoïsme et alchimie féminine. Paris: Pardès; and Mann, Susan. 1997. Precious records: women in China’s long eighteenth century. Stanford, Calif.: Stanford University Press, pp. 69–75, 178–200. See Furth, Charlotte. 1987; and Leung, Angela Ki Che. 1984. Carlitz, Katherine. 1986, p. 46. The evidence from the cases in the appendix, and from the cases Wang Ji selects for the discussion on emotions in the third fascicle, also gives the impression of an association between women and emotion.

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404 See for example Huangdi neijing su wen. Fascicle 11, section 39. ‘Jutong lun’ [‘Treatise on the differentiation of pain’]. Siku quanshu. Volume 733, pp. 126–127. Or Zhubing yuanhou lun [‘Treatise on the origin and symptoms of all illnesses’]. Chao Yuanfang . Completed in 610. I have used the annotated version, published by the Renmin weisheng chubanshe in 1991, p. 389. 405 Shishan yi’an 3: 14–15. See also 1: 3. 406 Beiji qianjin yaofang !"# [‘Essential prescriptions worth a thousand for urgent need’]. Sun Simiao . Fascicle 2. ‘Furen fang’ [‘Prescriptions for women’]. Completed between 650 and 659. This edition: Siku quanshu. Volume 735, pp. 37–38. 407 For a Song example see Furen daquan liangfang. 1985, pp. 63– 64. 408 Although the other side of the coin from this image of the apprehensive and grieving woman is the woman whose ﬁerce nature causes her to miscarry. See Shishan yi’an 3: 29 –32; Shishan yi’an fulu [Appendix]: 40–41. 409 Shishan yi’an 2: 20. 410 Shishan yi’an 1: 39. 411 Shishan yi’an 1: 40–41. 412 Although there is one case where widowhood is credited with being beneﬁcial because it meant ‘she lacked that which harms the blood’. This seems to be reference to the depleting nature of childbirth. See Shishan yi’an 1: 31–32. 413 For this discussion, and a number of examples taken from past medical works, see Shishan yi’an 3: 14–18. 414 One case in the appendix details the illness of a woman who had become depressed after her husband had taken a concubine. She is deemed to have melancholy and pensiveness harming her spleen, is treated with ginseng and astragalus root, and recovers. At no point is there any suggestion of removing the cause of the problem, namely the concubine. See Shishan yi’an fulu [Appendix]: 32. 415 Shishan yi’an 2: 4–5. 416 Shishan yi’an 2: 1, 2–4, 7. 417 Shishan yi’an 2: 11. 418 For explanations of these terms, and an introduction to the basic concepts of traditional Chinese medicine, see Sivin, Nathan. 1987. Other general reference works worth consulting on this subject include Porkert, Manfred. 1974; and Kaptchuk, Ted J. 1983. 419 See, for example, Furth, Charlotte. 1986. 420 One could say that all depletion is yin relative to disorders of excess which are yang, and that therefore all the female depletion disorders are yin depletion. However, Wang Ji is often quite speciﬁc in his diagnoses: for example, he discusses cases of yang depletion where yin is ﬂourishing; or will argue why a certain illness belongs to yang, not yin, depletion, and therefore needs replenishing with qi tonics as opposed to blood tonics. As a result, my analysis is based

186

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421 422 423 424 425 426 427 428 429 430

431 432 433 434 435 436 437 438

439

440 441

not on what I can deduce from the text using my own knowledge of traditional Chinese medicine in diagnosing whether the symptoms constitute a yin disorder, but on the actual words Wang Ji uses when giving his diagnosis; so a disorder is only included as yin depletion if Wang Ji speciﬁcally terms it thus. Shishan yi’an 2: 1–2, 9–10. For further comment on the seriousness of these ‘depletion and wasting’ disorders, see Furth, Charlotte. 1986, pp. 60–61. Shishan yi’an 2: 5. Shishan yi’an 3: 24–25. Shishan yi’an 2: 18–19. See also 2: 31–33. Shishan yi’an 1: 34–35. See also 2: 26–27. Huangdi neijing su wen. Fascicle 1, section 1. ‘Shanggu tianzhen lun’ Siku quanshu. Volume 733, pp. 10–11. Shishan yi’an 2: 37–38. Shishan yi’an 2: 34–35, 35–37. Shishan yi’an 2: 37–38, 34–35. Comparisons between the Greek and Chinese traditions, particularly in relation to issues of knowledge, can be found in the articles by Francesca Bray and Lesley Dean-Jones in Bates, Don ed. 1995, pp. 41–59 and 235–250. Dean-Jones, Lesley Ann. 1994, p. 85. Dean-Jones, Lesley Ann. 1994, p. 119. Dean-Jones, Lesley Ann. 1994, p. 124. Dean-Jones, Lesley Ann. 1994, p. 119. Dean-Jones, Lesley Ann. 1994, pp. 225–226. For example, the ﬁrst article by Charlotte Furth discusses the various repercussions of the association of women and blood. See Furth, Charlotte. 1986. See Furth, Charlotte. 1994a, pp. 239–245. See also Bray, Francesca. 1995, pp. 235–237. Although women may have been more likely to suffer from an illness which was induced by emotion, this would not affect the actual process of whatever illness it was they had contracted. For example, pensiveness harms the Spleen, but the actual understanding of the mechanism of Spleen depletion, and the way in which this disorder affects other parts of the body, is the same regardless of whether the patient is a female whose illness was induced by pensiveness, or a male whose illness was induced by exhaustion. Interestingly, though, Chinese angelica root, which is perhaps the herb most commonly associated with women, menstrual disorders, and blood and yin depletion, is given to a higher proportion of men than women in the Shishan yi’an, and its use among the women is evenly distributed across all three groups. Perhaps it is its strong association with depletion disorders that accounts for it being prescribed to so many men, given that Wang Ji perceived men as being depleted. Beiji qianjin yaofang. In Siku quanshu. Volume 735, pp. 37–38. Furth, Charlotte. 1994a, pp. 246–247.

187

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442 Zurndorfer, Harriet. 1989, p. 189. Although the number of deaths recorded in the Shishan yi’an are not really sufﬁcient to make generalizations about the comparative ages at which men and women died, it is noticeable that if all the cases are taken, regardless of the eventual outcome, the women appear to be older on the whole, with the distribution being evenly spread between the ages of thirty and ﬁfty, whereas the majority of the men are said to be aged thirty, with a much lower proportion being said to be aged between forty and seventy. That more men fall ill at a younger age again does not seem to indicate that women were the sicklier sex.

188

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199

CHARACTER GLOSSARY

CHARACTER GLOSSARY

ajiao an Anhui bagang baizhu baizhuo bei Beiji qianjin yaofang ben bencao Bencao beiyao ! Bencao gangmu ! Bencao huibian ! Bencao jiyao ! bianzheng biao bingyuan Bo’ai xinjian ! Chanke baiwen ! Chao Yuanfang Chen Jiamou Chen Jue Chen Ziming Cheng Maoxian Cheng Tingyi Cheng Yandao Cheng Zeng chenghun chenpi chuanxiong Chunyu Yi congshu

!

da Dakeng Dai Qizong Dai Yuanli daoliu Douzhi libian ! Du Suwen chao ! duan’an erke Fang Youzhi fangji fangshi fen feng fengjian fu Fu Qingzhu Fu Qingzhu nannu ke fuke fuling fulu Furen daquan liangfang fushui fuzi lizhong tang !" fuzi tang gancao ganjiang ganmen gong’an gu jingwan

200

!

CHARACTER GLOSSARY

guan guishen Gujin yitong daquan

Kong Zi Kou Zongshi

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han Han Mao Hanshi yitong ! hao hong hsien hua Hua Shou Huang Gutan huangbai Huangdi neijing ! Huangdi neijing lingshu ! Huangdi neijing suwen ! Huangdi neijing suwen Wu zhu !"#$% huangqi A huangqin Huizhou huo huo yue Jiajing jianchuang Jiang Guan Jiang Yingsu Jiangsu Jiangxi jiangxia Jin ping mei jinshi jing jing jing yue Jingdezhen jingluo Jiqi Jiyuan jisuo jiche lu juan kesou kong

lao leishu li Li Dongyuan Li Gao Li Qianhu Li Shizhen Li Xun Lienü zhuan lieque Lin Hanzhang Liu Wansu liufu liuyin Lü Kun Lüshi chunqiu Lun yu

!

Maijue kanwu ! maimendong Min Qiji Mingshi mingyi Mingyi lei’an ! Mingyi zazhu ! Nanjing neike neishang zhuzheng nu nüwu nüe Pi wei lun pi wei xu pianli Pushu

qi Qimen Qimen xianzhi ! qi qing qi xue liang xu ! qian qie

201

CHARACTER GLOSSARY

qing shu yi qi tang qingfen

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re ren renshen ru ruyi se Shaanxi shancha shanghan Shanghan lun Shanghan lun tiaobian ! Shanghan xuanlu ! Shanxi She shengzhi shi shi Shi ji shiqin Shishan Shishan jushi zhuan !" Shishan yi’an ! Shizheng lu shu si si junzi tang ! si wu tang Siku quanshu ! Sima Qian sizhen Sun Simiao Sun Wenyuan yi’an !" Sun Yikui taiyiyuan Tan Yunxian Tianshun tiaojing Tuiqiu shiyi ! waike Waike fahui ! Waike lili ! Waike xinfa !

Waitai miyao ! Wanli wang Wang Ang Wang Bing Wang Chen Wang Daokun Wang Daoyu Wang Fuhu Wang Gui Wang Hui Wang Ji Wang Lun Wang Lun Wang Qian Wang Wei Wang Xinyi Wangshi yixue qishu wei Wei Guiyan weiqi wen wen Wu Wu Hezhong Wu Kun Wu Mianxue Wu Pingzhong Wu Qiao Wu Yang Wu Zhenglun wuli wuxing Wuyuan wuzang xi xi xian xiangfu Xie Xie Zhaozhe Xin’an xingfang xingji Xiuning xiushen xu

202

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Xu Chunfu Xu Zhong xulao xue hai xue Xue Ji yang yangmei yangmei chuang yangqi yangsheng Yi yi’an Yifang kao Yifang tangtou gejue Yixian zhi Yixue yuanli ! Yizong jinjian ! yin yin xu yinfu yinfu yingqi you Yu Wuting Yu Zhaoling

Yuezhen Yunqi yilan

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zao Zhang Jiebin Zhangshi leijing ! Zhang Zhongjing Zhao Jishi Zhejiang zhenjiu Zhenjiu wendui ! Zhengde zhenghou zhi zhi guai zhifangshu zhimu zhishi Zhou li Zhou Chen Zhou Zhigan Zhu Zhenheng Zhubing yuanhou lun zi zouqi Zuo zhuan

203

INDEX

INDEX

acupuncture and moxibustion (zhenjiu) 37, 44, 46, 82–84, 92, 96, 246n aetiology 53, 73, 77–78, 117–118; alcohol consumption 78, 119–120, 124–125, 126–137, 159; childbirth 78, 119–120; diet 78, 119–120, 125–137, 159; exhaustion 77–78, 119–120; external factors 13, 78, 117, 119–120; in fuke texts 130–131; sexual activity 78, 119–120, 121–124, 126–137, 159, 70n; in the Shishan yi’an 118–128; and social status 128; see also emotion alcohol see aetiology; women anemarrhena rhizome (zhimu) 63 astragalus root (huangqi) 5, 43, 44, 46, 57, 63, 70–71, 80, 81, 87–88, 92, 93, 94, 131, 142, 147, 157; see also treatment bencao 30, 33, 35, 37, 42, 46, 48 Bencao beiyao [‘The comprehensive essentials of materia medica’] 31, 35, 36 Bencao gangmu [‘Systematic materia medica’] 30, 42, 45, 48 Bencao huibian [‘The collected and arranged materia medica’] 42, 48

Bencao jiyao [‘Collected essentials of materia medica’] 48 Blood (xue) 69, 88, 93, 140; depletion 70–72, 79, 83, 140, 141–142 Bo’ai xinjian [‘Reﬂection of the universal love in my heart’] 44, 46 bookstores 34, 36, 110n; Huanduzhai bookstore 3, 31, 36 brothels 27, 135 case histories 6–8, 15–16, 62–63, 67–68; as a genre 52–54; purpose 54–60; as source material 6–8, 60–65; structure 4, 62–63, 73–75 Chen Jiamou 30, 35 Chen Jue 36, 39, 41, 43, 45, 48, 51, 59, 61, 138n Cheng Maoxian 7, 83, 115–116, 191n, 326n, 341n Cheng Tingyi 43, 45, 48, 52 Cheng Yandao 37 Cheng Zeng 39, 41, 53 childbirth 14, 84–85, 108, 146, 148; association with Blood/yin depletion 85; see also aetiology Chinese angelica root (guishen) 63, 80, 81, 147, 439n chuanxiong 80 Chunyu Yi 52, 107, 128–129, 159n

204

INDEX

civil service: examinations 25, 31–32, 38, 49, 54, 57, 156; reduction in number of posts 22, 26, 33 cold damage disorders (shanghan) 46, 48, 89 concubines 110, 122–124, 414n Confucian benevolence 32, 38, 41, 46–50, 156 cyperus tuber (xiangfu) 147 Dai Qizong 47 Dai Yuanli 47 death 84–85; in childbirth 84–85; gender 149; resulting from depletion disorders 142; resulting from overindulgence 127 Decoction of Four Gentlemen (si junzi tang) 81 Decoction of Four Ingredients (si wu tang) 81 depletion 18, 70, 79, 81, 83, 95, 158–159, 420n; and gender 140–143 diabetes 126 diagnosis 73–80; by correspondence 7, 74, 75, 77, 90–91, 157, 227n; four examinations 76–77, 78–79, 91, 109–116, 157; and gender 109–116; through intermediary 7, 75, 77, 90–91, 115, 157; pattern diagnosis (bianzheng) 78, 140, 230n; physician/ patient dialogue 74–78, 87–89, 112; symptoms 73, 78, 79; see also pulse diet see aetiology; women disciples 34, 36, 39, 42–43, 49, 51, 58–59, 61, 76, 138n, 142n donkey-hide gelatin (ajiao) 147 Douzhi libian [‘Differentiating theories regarding the treatment of poxes’] 44, 46, 47 dried ginger (ganjiang) 63 Du Suwen chao [‘Notes on reading the Basic questions’] 47

economy: commercialization of 2, 22, 36, 155; monetarization 22, 29 eight rubrics (bagang) 78 emotion 78, 117; and ﬁve-phase theory 7, 56, 98, 137, 138, 173n; and gender 118, 119, 137–139, 439n; treatment of 56, 98–99, 138 erke 13, 37 exhaustion see aetiology external medicine see waike Fan Wenzheng 41, 134n Fang Youzhi 31, 32, 35, 36 female healers 7, 14, 84, 99, 107–108, 149, 246n, 322n, 329n, 330n ﬁlial piety 33, 41, 46, 49, 54, 156 ﬁve revolutions and six climatic factors (wuyun liuqi) 47 ﬁve-phase theory (wuxing) 7, 13, 56, 98, 137, 138, 140 frugality 28, 40, 131, 132–133, 136 Fu Qingzhu 130 fuke 13, 15, 37, 129–130, 135, 141–142, 146, 148 Furen daquan liangfang [‘Good prescriptions from the compendia of gynaecology’] 118 ginseng (renshen) 5, 43, 44, 46, 57, 63, 70–71, 80, 81, 87–88, 92, 93, 94, 131, 142, 147, 157; see also treatment Great Medical Ofﬁce (taiyiyuan) 30 Greek medicine 12, 107–109, 146 Gujin yitong daquan [‘Complete synthesis of medical knowledge past and present’] 30, 35, 39, 42, 45 gynaecology see fuke Han Mao 35, 43–44, 45, 52, 53, 57, 95, 114

205

INDEX

Hanshi yitong [‘Mr Han’s comprehensive survey of medicine’] 44, 45, 52, 53, 57–58, 114 hawthorn fruit (shancha) 63, 80 healing practitioners 6, 8, 97–101; see also female healers Huang Gutan 31, 32, 34, 43, 45 Huangdi neijing [‘Inner Canon of the Yellow Lord’] 14, 47, 78, 83, 100, 117, 129, 138, 144 Huangdi neijing suwen Wu zhu [‘Wu’s annotated version of the Inner canon of the Yellow Lord – basic questions’] 37 Huizhou 2, 4, 21, 23; geography 23; natural resources 23, 25; see also land tax; merchants illness syndrome (zhenghou) 73, 78; and gender 140–146 immature bitter orange (zhishi) 63 internal medicine see neike Jiang Guan 30, 35, 37, 39, 42, 45, 53, 59 Jiang Yingsu 30, 36 Jin ping mei [‘Golden Lotus’] 8, 27, 135–136 Jingdezhen 23 Kou Zongshi 114, 116 land tax 22–23, 27, 28 Li Gao (Li Dongyuan) 47, 69–72, 93, 117, 132, 141, 157, 200n Li Qianhu 34, 44, 46 Li Shizhen 30, 34, 42, 45, 48, 316n Li Xun 39, 40, 41, 43, 45, 52 Lin Hanzhang 34, 44, 46 liquorice (gancao) 63, 80, 81, 147 literacy 2, 25, 36–37; see also publishing Liu Wansu 58 Lü Kun 322n, 329n Lüshi chunqiu [‘Spring and autumn annals of Mr Lü] 53

Maijue kanwu [‘Correcting the errors of the pulse in verse’] 47, 49 materia medica see bencao meat 28, 126, 131 medical knowledge: limits to 85; transmission of 2, 30–31, 34–38, 42–44, 49–50, 156 medical texts: increased circulation 2, 35; motivation for writing 46–49; types 2, 36–38, 46–49, 54, 60 men: focus of medical concern 18, 131, 136–137, 152, 159; similarities with women 16, 17–18, 104, 143–146, 147–148, 151–152 menstruation 108–109, 111–112, 145 menstrual regularity (tiaojing) 12, 80, 111–112, 147, 233n, 341n merchants: afﬂuence 24; decadent lifestyles 2, 27, 29, 40, 126, 135–136, 156; elite values 24–27, 36; emergence as a class 2, 23, 156; Huizou 23–29, 44, 156; marriage 25; patronage 2, 24, 29, 36; philanthropy 24–25; social mobility 29, 32, 156 Mingshi [‘Ming History’] 42, 45 Mingyi lei’an [‘Cases of famous physicians arranged by catetgory’] 30, 35, 36, 37, 39, 40, 42, 45, 53, 59 Mingyi zazhu [‘Miscellaneous writings of illustrious physicians’] 44, 46, 58, 71, 92, 93–94 moderation: as a treatment 84–85, 133–136, 248n; as a virtue 40, 132–133 modesty 16, 90, 109, 110–111, 113–116 monks 27 moral exhaustion 132, 136, 143, 150, 157, 159 morality books 25, 28, 59n, 398n

206

INDEX

Nanjing [‘Canon of problems’] 47 neike 37, 83 ophipogon root (maimendong) 63, 80 outcome 73, 85–86; and gender 148–151, 442n paediatrics see erke patients 86–91; loyalty 6, 91–92, 96–97, 100–101, 158; medical knowledge 87–89, 99; resistance from 70, 87–89; self treatment see treatment; social status of 16, 86–87 perception of moral decline 27–28, 29, 128, 132, 135–137, 143, 156 pharmacies 33, 34, 81, 238n phellodendron bark (huangbai) 63 physicians 5–6, 91–97, 156; authority of 88, 89, 91, 96, 101, 304n; competition between 5–6, 54, 57, 74, 89, 91–97, 100–101, 266n; hereditary 31–32, 35–36, 41–42, 49; lineage afﬁliation 59; links between 2, 30, 33–36, 38, 156; as moral advisers 89, 127–128, 133–135; motivation 32–33, 38, 49; non-elite healers see healing practitioners; professionalization 4, 38–39; remuneration 32–33, 73; selfpromotion 57–59 Pi wei lun [‘Treatise on the Spleen and Stomach’] 117 poria (fuling) 80 poxes 46, 48 pregnancy 14, 80, 84, 105, 108, 112, 114, 118, 134–135, 250n prescriptions (fangji) 33, 37, 81 publishing 25–26, 34, 36–37; changing readership 36–37; increased circulation of texts 25, 34–35, 38, 43–44, 156 pulse 85; as diagnostic tool 63, 73, 77, 79–80; and gender 113–114; in pregnancy 80, 113

qi 13, 69–70, 140; depletion 5, 79, 85, 87–88, 112, 141–142; protective qi 69–70, 198n; replenishing of 69–72, 81; structive qi 69–70, 198n Qimen 21, 30, 39–40, 43 Qimen xianzhi [‘Qimen gazetteer’] 39, 42 qingfen 89, 95, 279n reproduction 111–112: and depletion disorders 142; disorders of 108–109; 144–146; site of difference between men and women 13, 104, 144–146 salt trade 22–23 scutellaria root (huangqin) 80 self-cultivation 133–136, 391n; and women 134–135, 400n seminal emission 112, 123, 134 sexual activity see aetiology Shanghan lun [‘Treatise on cold damage disorders’] 31, 35, 70 Shanghan lun tiaobian [‘Treatise on cold damages disorders: systematic critical examination’] 31 Shanghan xuanlu [‘Selected notes on cold damage disorders’] 43, 45, 48 Shi ji [‘Records of the historian’] 52 Shishan yi’an [Stone Mountain medical case histories’] 48; authorship 61; purpose 54–60; ratio of men to women 105–108; as source material 60–65; structure of the text 51–52, 105–106 Shizheng lu [‘Writings on practical government’] 322n Siku quanshu [‘Complete books of the four treasuries’] 62 silver 22 Sima Qian 52 social mobility 2, 21, 26, 29, 32, 156

207

INDEX

Spleen and Stomach 117: depletion 79, 113, 140, 141 Sun Simiao 7, 137, 148 Sun Wenyuan yi’an [‘The medical case histories of Sun Wenyuan’] 31 Sun Yikui 31, 32, 34, 35, 43, 45, 53 surgery see waike syphilis 74, 95, 97, 123, 279n Tan Yunxian 7, 83–84, 322n tangerine peel (chenpi) 80 tea 23, 24, 38n theory-practice dichotomy 5, 68–69, 72–73, 101, 157 transportation: impact of improvements in 22, 25, 29–30, 34, 38, 44, 156 treatment 53, 80–86, 158–159; drug therapy 80–83, 92, 147–148, 157; by family members 90, 157–158; and gender 147–148; self treatment 89; see also acupuncture and moxibustion; prescriptions Tuiqiu shiyi [‘An examination of the ideas of my master’] 46, 47 urbanization 22, 29 Victorian medicine 10–12 waike 37, 46, 82, 299n; practitioners 94, 96; treatment 82–83 Waike fahui [‘An elaboration of external medicine’] 43, 45 Waike lili [‘Surgical principles and examples’] 43, 45, 47, 49, 82, 107 Waike xinfa [‘The inner essence of external medicine’] 43, 45 Waitai miyao [‘Arcane essentials from the imperial library’] 37 Wang Ang 31, 35, 36, 37 Wang Bing 47 Wang Chen 30 Wang Daokun 26

Wang Fuhu 43, 45 Wang Ji: biography 39–42; Confucian benevolence 40–42, 46; clinical encounter 62–64, 73–86, 157–158; disciples 43; ﬁlial piety 41, 46; interaction with non-elite healers 97–101; interaction with other physicians 91–97; itinerant nature of medical practice 75–76, 157; motivation 41–42, 46–50; oeuvre 46–49; participant in Xin’an medical culture 39, 42–44, 49–50; patient/physician dynamic 86–91; theoretical framework 5, 18, 57, 68–73, 141, 157, 158–159; transmission of medical knowledge 42–44; treatment strategies 57, 60, 70–72, 80–86, 92–94, 132, 141 Wang Lun 35, 43–44, 46, 48, 71, 92 Wang Wei 30, 39, 40, 52, 132–133 Wangshi yixue qishu [‘The seven medical books of Mr Wang’] 36, 43, 59 Wei Guiyan 35, 43–44, 46, 48 white atractylodes rhizome (baizhu) 63, 80, 81, 88, 147 widows 85; and chastity 28, 131; and illness 130, 137–138, 412n women: and alcohol 129–140, 372n; association with Blood and yin 141–142, 144–146, 148–149, 251n; chaste reputation 28, 131, 136, 143; and depletion 141–143, and diet 28, 374n; differences between women 9, 14, 16–17, 104, 108, 141–142, 147–148, 151–152; difference from men 9, 10–12, 104; and sexual activity 122–124, 129–131; similarities with men 9, 17–18, 111, 113, 143–146, 147–148, 151–152; see also emotion

208

INDEX

women’s disorders see fuke Wu Hezhong 30 Wu Kun 31, 34, 35 Wu Mianxue 36, 45, 48, 49 Wu Pingzhong 30 Wu Qiao 30 Wu Yang 30, 43, 45 Wu Zhenglun 31 Xie Zhaozhe 23, 27 Xin’an: medical culture 21, 29, 30, 33, 35, 38 Xu Chunfu 30, 32, 34, 35, 39, 45 Xu Zhong 42, 43, 45, 52, 58, 59, 138n Xue Ji 35, 42, 43–44, 45, 47, 59, 70 yang 13, 69; depletion 51, 58, 79, 85, 87–88, 142 Yifang kao [‘Studies of medical prescriptions’] 31, 35 Yifang tangtou gejue [‘Medical prescriptions in verse’] 37 yin 13; yin depletion 44, 51, 58, 70, 88, 131, 141–142, 148–149, 420n; replenishing of 69–70

Yixue yuanli [‘Medicine from ﬁrst principles’] 45, 49 Yizong jinjian [‘The Golden Mirror of Medical Orthodoxy’] 13 Yu Wuting 31, 34, 35 Yu Zhaoling 35 Yunqi yilan [‘The (ﬁve) revolutions and the (six) climatic factors at a glance’] 47 Zhang Jiebin 56, 321n Zhang Zhongjing 70–71 Zhangshi leijing [‘Mr Zhang’s classics arranged by subject’] 56 Zhenjiu wendui [‘Questions and answers on acupuncture and moxibustion’] 47, 83 Zhou Chen 42, 43, 45, 52, 58, 59, 138n Zhou li [‘Rites of Zhou’] 53 Zhou Zhigan 53 Zhu Zhenheng (Zhu Danxi) 42, 47, 51–52, 56, 59, 69–72, 83, 132, 141, 157, 156n Zuo zhuan [‘Zuo commentary of the spring and autumn annals’] 53

209