THREE    Demonstration of Medical Virtuosity

XU SHUWEI’S LIFE AND HIS OEUVRE

Xu Shuwei practiced medicine as a physician and remained an examination candidate for several decades. At the age of fifty-two, he finally passed the civil service examination and hence became a civil official—he was a member of the ruling class. His life and career were so unique for the Song dynasty that he become something of a celebrity.

Song sources offer several accounts to explain why Xu practiced medicine. The variety of these accounts indicate his fame, suggesting that his life drew widespread attention.¹ Xu himself attributed his vocation to his parents’ death when he was a child.² When he was eleven years old, his father and mother died from successive illnesses within a hundred days of one another. After growing up, Xu studied medicine diligently and became a physician. Hong Mai (1123–1202) offered an alternative version in his Record of the Listener (Yijian zhi), one of the most popular and widely disseminated notebook series in the Southern Song era. Hong declared that Xu chose to become a physician because saving lives enabled him to accumulate good karma and thereby helped him to pass competitive civil service examinations.³ Xu indeed attempted the examinations several times, although we do not know how many. These examinations typically were administered every three years, but it seems that for several decades, Xu aspired to but failed to pass them.

Xu was not the first member of the elite to master the Confucian classics and go on to earn a living by healing the sick. Since at least the sixth century, some members of the classically educated elite staked their claim to fame or their livelihoods on medicine. Treating their parents’ (usually their mothers’) disorders constituted the primary motivation for learning and later comprehending the art of healing.⁴ The ranks of the classically educated elite who chose medicine as an occupation grew conspicuously during the Song dynasty, especially after the eleventh century. Modern scholars have proposed several explanations for this phenomenon. One notes that the proposition that medicine was a knowledge domain worthy of the cultural elite was firmly established in this era. Another argues that public dissemination of medical literature enabled the literati to learn medicine from books.⁵ The Song emperors’ interest in and imperial patronage of medicine enhanced the esteem conferred on it as an occupation.⁶ Facing the increasingly competitive civil service examination, many candidates who repeatedly failed saw practicing medicine as a physician as one of the next best options.⁷ With this in mind, we can better understand how encouraging Xu’s story would be for his educated Song fellows when he eventually passed the examination with flying colors late in his life. It was this late success that made him something of a legend.

The advantageous transport location of Xu’s hometown, in Zhen Prefecture (in Jiangsu), helps to explain why he, as a local physician, was able to access texts that were instrumental in preparing for the civil service examination and in learning medicine. Zhen Prefecture is located at the confluence of the Grand Canal and the Yangzi River. Through the canal, goods that originated in the south were imported to the capital, Kaifeng, and other destinations in northern China. Through the Yangzi River transport network, goods were carried between eastern and western China. Located at the interface of these two central networks, Zhen Prefecture benefited from the transport of large volumes of materials and products across China.⁸ Its location meant that, although his activity was mostly confined to the prefecture, Xu still had ample opportunity to access texts produced outside his home county. This circumstance informs our understanding of his success in the examination as well as of the variety of texts that he discussed in his works.

When Xu was forty-seven years old, the Jurchen Jin state besieged and sacked Kaifeng, ending the Northern Song dynasty. In the same year, the ninth son of Emperor Huizong ascended to the throne, establishing a successor state, known as the Southern Song. This regime waged war against the Jin, joining numerous and often violent engagements from 1127 to 1142 along the middle and lower reaches of the Yellow and Huai Rivers. Zhen Prefecture, which as indicated above was once a prosperous transfer port, now became a border region that was prone to Jin attacks. In addition to the Jin armies, gangs of bandits ravaged the prefecture as well; the leader of one gang of bandits, Zhang Yu, engaged in armed robbery and set fire to regions of it in 1128.⁹ Following these ravages, “conglomeration diseases” (jijia) reached epidemic proportions. Xu Shuwei visited patients who were suffering from conglomeration diseases and healed 70 to 80 percent of them.¹⁰

While living in a turbulent time, Xu eventually passed the civil service examinations at the age of fifty-two and earned a fifth ranking nationally, a distinction of great honor. Varying versions of the story, according to which Xu passed the examinations with such distinction after saving countless lives, spread across the Southern Song region in medical treatises and notebooks. The popularity of anecdotes about Xu renders him one of the most frequently discussed medical writers of the era. Even the Southern Song gazetteer of Xu’s home county, Yizhen Gazetteer (Yizhen zhi), documented Xu’s life.¹¹

Beyond anecdotes regarding Xu’s performance on the examinations, extant Song sources say little about his official career. We know with certainty of only two particular positions that he held. Both were in the capital of the Southern Song state, Lin’an (in Hangzhou city). One position involved serving as a professor at the Lin’an Prefectural School in 1142, when the court assigned him to help with the metropolitan civil service examination.¹² He then became an official in the capital, but his specific title has not come down to us.¹³ The other position was as the “academician of the Hanlin Academy” (Hanlin xueshi), an appointment reflecting great dignity, giving him responsibility for drafting imperial orders and edicts.¹⁴ The latter appointment won Xu the posthumous title of Academician Xu (Xu Xueshi). Xu retired in an unknown year but apparently continued treating the sick.¹⁵

Xu Shuwei was a prolific author. He wrote at least seven medical treatises. As shown by their titles, most concerned cold damage disorders. “Cold damage” (shanghan), to be very brief, was a generic term used by medical authors in imperial China in reference to disorders that covered a wide variety of symptoms that were often ascribed to the invasion of the human body by seasonal or unseasonal cold qi. Some of the symptoms are reminiscent of what we know today as febrile illness. Of the seven treatises Xu wrote, he had already lost three by 1129 as casualties of military conflicts: Diagrams about Zhongjing’s Methods of Palpating the Pulse (Zhongjing maifa sanshiliu tu), Aid to the Treatise on Cold Damage (Yi shanghan lun), and Classified Differential Diagnosis (Bianlei). Of the remaining four, one has been lost and is known only by its title: Methods of Therapy in Eighty-One Sections (Zhifa bashiyi pian). The other three have come down to us. Of those, Xu completed and printed One Hundred Mnemonic Verses on Cold Damage Manifestations (Shanghan baizheng ge) and Subtleties of Cold Damage Revealed (Shanghan fawei lun) around 1135.¹⁶ The last one, The Formulary with Explanatory Historical Contexts, Xu finished and printed after 1143, when he was, in all likelihood, retired.¹⁷ Because references to all seven titles appear in Xu’s own writings, their authorship is certain.

Four other medical treatises were attributed to Xu Shuwei generations after his death. One was entitled Instructions to Save Lives (Huoren zhinan). According to the famous Southern Song scholar-official Lou Yue (1137–1213), this treatise concerned cold damage disorders.¹⁸ The second was Classified Examples of the Efficacy of Classics (Jingxiao leili). The text has been lost, but its title suggests that it may have included healing case narratives as testimony to the efficacy of remedies that were applied according to medical classics. The third treatise was titled Sequel to the Classified and Widely Benefiting Formulary with Explanatory Historical Contexts (Leizheng puji benshifang xuji or Benshifang houji). Although it circulated in the thirteenth century, a Southern Song medical author doubted that Xu was its author.¹⁹

The fourth medical treatise attributed to Xu Shuwei after his death was Ninety Discussions on Cold Damage Disorders (Shanghan jiushi lun, hereafter Ninety Discussions). No surviving book attributed to Xu has attracted more scholarly attention than Ninety Discussions, which is distinguished from other Song medical treatises by its contents. Case narratives constituted its bulk, and those depict the healing practices of a single physician, Xu Shuwei. In contrast, formulas occupy a more central place than case narratives did in medical treatises completed in and before the Song dynasty. The case narratives collected in those treatises often come from both the authors’ own medical cases and others’ cases (as is true of Shen Kuo’s Good Formulas). Some scholars hence regard Ninety Discussions as the forerunner of collections of medical case histories serving as a new genre in China.²⁰ Along the same line of thinking, Xu is the first physician to have written down and published a collection of his own medical case histories.

It is unlikely, however, that Xu was the author of Ninety Discussions. He never mentioned this treatise nor did anyone in the Southern Song talk about it. That Ninety Discussions was never documented in the Southern Song era is baffling, because it conflicts not only with Xu’s fame but also with the popularity of his Formulary with Explanatory Historical Contexts at the time. As a celebrity at the time, Xu was mentioned in numerous medical texts and notebooks; The Formulary with Explanatory Historical Contexts was widely cited and one of the most frequently printed medical treatises in the Song era. In contrast, the earliest fragments of Ninety Discussions appear in a fifteenth-century encyclopedic work, Great Compendium of the Yongle Era.²¹ The Ming court completed this encyclopedia in 1408, some 250 years after Xu’s death.

Comparing an identical case in Ninety Discussions and The Formulary with Explanatory Historical Contexts yields more solid evidence indicating that Xu is unlikely to have been the author of Ninety Discussions. In The Formulary with Explanatory Historical Contexts, there was a case in which Fan Yun (451–503) was subordinate to “Emperor Wu of the Liang dynasty” (Liang Wudi, personal name Xiao Yan, 464–549, r. 502–549). Fan contracted a cold damage disorder very suddenly, and he sought to be cured immediately so that he could attend a ceremony scheduled imminently that would showcase Xiao Yan’s ruling power.²² In Ninety Discussions the plot remained the same, but the figure “Emperor Wu of the Liang” was replaced by “Chen Baxian” (503–559, r. 557–559), who was Emperor Wu of the Chen dynasty.²³ This difference reveals serious gaps in literary and historical knowledge regarding the author of Ninety Discussions and Xu Shuwei.

Xu, in The Formulary with Explanatory Historical Contexts, explicitly documented that he drew the case from History of the South (Nanshi), a standard history completed in 659 that recorded political events occurring between 420 and 589.²⁴ As recorded there, Fan Yun had been friends with Xiao Yan long before the latter acceded to the throne. Xiao Yan, Fan Yun, and six other men of letters were collectively called “the eight companions of the prince of the Jingling” (Jingling bayou), an illustrious group in the world of literary men.²⁵ Their friendship explained why Fan was so eager to attend the ceremony held for Xiao. By replacing “Emperor Wu of the Liang dynasty” with “Chen Baxian,” who flourished after Fan’s death, the author of Ninety Discussions not only made an ahistorical mistake but also misunderstood Fan’s career as recorded in the standard history, History of the South. Given that standard histories were texts that anyone in the Song era attempting to pass the civil service examinations were expected to learn, it would be surprising if Xu, who passed the examination and earned the “advanced scholar” degree, made such basic mistakes. I thus consider those mistakes important evidence indicating that the author of Ninety Discussions was not Xu but rather someone with more limited literary and historical knowledge.

Recent scholarship also suggests that Xu was unlikely to have been the author of Ninety Discussions. Comparison of Ninety Discussions with two medical treatises that were certainly written by Xu—Subtleties of Cold Damage Revealed and The Formulary with Explanatory Historical Contexts—shows that the language used in Ninety Discussions was more colloquial than that in the other two treatises. For instance, Ninety Discussions mentions Emperor Wu of the Chen dynasty with his original name, Chen Baxian, whereas the other two treatises respectfully employ “Emperor Wu of the Liang.” More importantly, some of prescription strategies included in Ninety Discussions directly contradict corresponding ones recommended in Subtleties of Cold Damage Revealed.²⁶ The colloquial language and the contradictions together make it more likely that the contents of Ninety Discussions were based on drafts of medical case records that Xu wrote. It would not be surprising to learn that healers in imperial China developed the habit of recording their successful cures for their own reference without leaking the records to others they did not know. The Western Han physician Chunyu Yi’s “examination records” (zhenji) exemplify this practice. Xu may have kept a log of his clinical practices for his own purposes as well.

Rather than identifying Xu Shuwei as the author of Ninety Discussions, a more plausible scenario is that, based on the rough drafts of his medical case records, which Xu used to compose Subtleties of Cold Damage Revealed and The Formulary with Explanatory Historical Contexts, someone (perhaps disciples of Xu or his descendants) later compiled and edited those drafts into Ninety Discussions between the fall of the Southern Song dynasty and the fifteenth century. Considering the strong possibility that Ninety Discussions was not a Song-dynasty treatise, I do not analyze its case narratives in this study.

Unlike Ninety Discussions, which was apparently unknown in the Song context, The Formulary with Explanatory Historical Contexts received popular acclaim in the Song period. It was printed at least six times in Zhen Prefecture, Yong Prefecture (in Hunan), and Jianyang (in Fujian) in this era by various publishers, including Xu Shuwei himself, local officials positioned in Xu’s home county, and private (or commercial) publishers.²⁷

THE STRUCTURE OF XU SHUWEI’S CASE NARRATIVES

The extant version of The Formulary with Explanatory Historical Contexts consists of ten chapters covering remedies for a wide range of disorders. The chapters include some 362 remedies and 123 medical cases, including both Xu’s and others’ cases that he drew from previous texts or with which he was otherwise acquainted. Xu appended relevant case histories to a given medical formula. For instance, the narrative for the use of the Major Bupleurum Decoction, which we saw at the beginning of this chapter, follows the formula of the decoction. Case histories in The Formulary with Explanatory Historical Contexts vary in length. Some of them are as short as three sentences, whereas others extend over several paragraphs. In general, though, Xu’s own were longer than others’ and were often supplemented with detailed theoretical discussions. This formula-case-discussion trilogy format appears in other Song formularies as well.

Almost all of Xu’s own case histories in The Formulary with Explanatory Historical Contexts follow the same general structure: Each one begins with information about a sick person’s history, such as their surname, locale, occupation, and relationship to Xu. Each then describes the disorders in question, including symptoms, duration, and development over time, as well as the patient’s relevant medical history, such as previous physicians’ misdiagnoses and misprescribed treatments. A typical case ends with Xu’s diagnosis and prescription, and the outcome for the sick person. In most cases, the patient followed Xu’s advice and then recovered. Reporting successful outcomes helped to signal the reliability and enhance the credibility of the remedies Xu recorded. In some cases, a patient was too skeptical or bullheaded to accept Xu’s prescription and subsequently died from their disorder. Their deaths ironically attest to Xu’s amazing predictive skills.

In many cases, Xu included the rationale for his diagnosis and treatment in his replies to questions. Rival healers around sickbeds were not the only group raising such questions, as members of patients’ households also did. Eager to see their loved ones recover quickly, those family members were opinionated and did not hesitate to replace healers they considered unsuccessful with others whom they regarded as more skillful.

After describing successful outcomes of his treatments, Xu sometimes cited or elaborated his analytic opinions of passages from other texts he regarded as relevant to specific disorders. Those passages came from both pre-Song and Song texts, as well as both medical and nonmedical texts, such as The Book of Songs (Shijing), Essential Formulas, and Good Formulas. The wide scope of the citations demonstrated Xu’s familiarity with a great body of textual knowledge accumulated from the past but also extending into his day. In addition to commenting on other medical texts, Xu sometimes ended a case with a theoretical discussion, which encompassed a broad range of topics, from the origins of disorders in question to the rationale behind a diagnosis or prescription. These discussions often presented new medical ideas that Xu had developed over years of clinical practice.

Among the medical case histories included in The Formulary with Explanatory Historical Contexts, those involving treatment for cold damage, which are found in the eighth and ninth chapters, carry special weight. As shown in table 1, the ratio of Xu’s medical cases to remedies is higher in most chapters than the ratio of other peoples’ cases to remedies. The former reaches its peak in the eighth and ninth chapters. In contrast, the latter in these two chapters is the lowest. Xu’s own medical case histories in these two chapters thus offer illuminating sources of information regarding the social and intellectual contexts in which Xu documented his medical cases, and they help us understand what Xu hoped to achieve.

ANECDOTES ABOUT POEMS AND LYRICS

Beginning in the seventh century, medical treatises contained medical case narratives, but Xu Shuwei did not position his Formulary with Explanatory Historical Contexts in the genealogy of medical writing. When discussing the inspiration for his formulary, Xu did not mention the fact that some earlier ones collected medical case histories. Yet Xu was far from ignorant of that. Actually, in the main text of The Formulary with Explanatory Historical Contexts, he cited case narratives from Shen Kuo’s Good Formulas, and thus was aware of precedents in formulary writing.²⁸

Nonetheless, Xu claimed that he found his inspiration for The Formulary with Explanatory Historical Contexts in literary works that gathered narratives of the historical contexts in which a given poem or a lyric was composed or circulated. Xu recalled being inspired as follows:

Now I am approaching the late stages of my life. I desultorily collected medical formulas I have tested and new ideas I obtained, recording them so as to disseminate them to far distances. I entitle this book The Widely Benefiting Formulary with Explanatory Historical Contexts. Meng Qi wrote Poems with Explanatory Historical Contexts. Yang Yuansu wrote Lyrics with Explanatory Historical Contexts. Both of these works contained “facts at that time” [dangshi shishi], so that their readers could see “the twist and unfolding” [quzhe] behind their works [i.e., a poem or a lyric]. Given that I devote my heart to saving living beings, and not requesting rewards, how could I not share this formulary with the public?²⁹

In mentioning Yang Yuansu’s Lyrics with Explanatory Historical Contexts, Xu is referring to A Collection of the Contemporaneously Wise’s Lyrics with Explanatory Historical Contexts (Shixian benshi quziji, hereafter Lyrics with Explanatory Historical Contexts) by Yang Hui (1027–1088; his style name was Yuansu). Xu here analogized the meaning of the term benshi (explanatory historical contexts or original incidents) in his formulary title with that in Meng Qi’s Poems with Explanatory Historical Contexts (Benshi shi) and Yang Hui’s Lyrics with Explanatory Historical Contexts.

Meng Qi completed Poems with Explanatory Historical Contexts in 886. It was the first monograph in China that collected anecdotes about a specific Tang poet (including his love affairs) that accounted for the historical contexts in which a given poem was composed or circulated. Prior to Meng’s work, records of the historical contexts appeared occasionally at the beginning of a poem or in a long poem’s title; corresponding anecdotes were scattered across entries in novels and notebook-style writings. Meng Qi was the first author to place such contexts and anecdotes together into an independent book.³⁰

Scholars have considered Yang Hui’s Lyrics with Explanatory Historical Contexts to be the monograph that ushered in the “lyric remarks” (cihua) genre. Only a dozen entries in this work survive, and most of those record anecdotes about lyric writers and background stories about the composition of a given lyric. Unfortunately, those entries leave us no further information about Yang Hui’s rationale for selecting anecdotes to be recorded. Soon after the completion of Lyrics with Explanatory Historical Contexts, this work was circulated among literati; for instance, Gao Cheng’s Recording the Origins of Things and Affairs (Shiwu jiyuan) already cited it in 1080.³¹

The parallel that Xu Shuwei drew between the abovementioned two literary works and his Formulary with Explanatory Historical Contexts was by no means incidental. Considering Xu’s familiarity with literary genres, evidence of which we see in his advanced-scholars degree, he was in all likelihood aware that Poems with Explanatory Historical Contexts was a pioneering work in the “anecdotes about poems” genre and that Lyrics with Explanatory Historical Contexts was likewise in the “lyric remarks” genre. The parallel thereby indicated that his formulary was also a pioneering early work, if not the first one, in the “explanatory historical contexts of formularies” genre.³²

The parallel served not only to mark The Formulary with Explanatory Historical Contexts as a pioneering work among books that collected medical cases but also to suggest the function and epistemic focus of case narratives in the formulary. Meng Qi and Xu Shuwei both emphasized the pedagogic function and factuality of the “explanatory historical contexts” they documented. Meng believed that these could help readers to understand the meanings or subtle gist of a poem.³³ In the above quotation, Xu declared that the purpose of documenting the historical contexts was to reveal the “twist and unfolding” behind the creation of poems and lyrics. As for medical formulas recorded in Xu’s formulary, the twist and unfolding referred to healing cases narrating the application of a given formula. Xu envisioned that the combination of a given medical formula and a relevant case history would help readers better understand the formula. This pedagogic function of cases that Xu envisioned signals medical authors’ heightened awareness of cases as a form of medical writing, particularly as an epistemic form that was useful for transmitting medical knowledge.

Meng Qi emphasized, when selecting which anecdotes and historical contexts should be recorded, that accounts of strange things that he suspected were not “factual” (shi) and vulgar anecdotes should be excluded.³⁴ Meng was far from the only writer in the ninth century who emphasized not only veracity but also an author’s epistemic autonomy in determining it. Both Duan Chengshi in his Miscellaneous Morsels from Youyang and Duan Gonglu in his Northward-Facing Doors expressed a similar emphasis. Meng Qi’s Poems with Explanatory Historical Contexts reveals that the emphasis on the reliability of a given text and on an author’s epistemic autonomy in notebook-style writings became more pronounced than ever in the ninth century.

In using the phrase “explanatory historical contexts,” neither Xu Shuwei nor Meng Qi stressed whether the contexts they recorded were based on their firsthand experience. They used the term in reference to the historical factuality of the contexts—in Xu’s words, “the facts at that time” (dangshi shishi). One purpose of recording “the facts at that time” was to demonstrate in detail how events took place. In Poems with Explanatory Historical Contexts and Lyrics with Explanatory Historical Contexts, such events could involve the scenario in which a given poem or lyric was composed. In The Formulary with Explanatory Historical Contexts, the events could involve scenarios in which a set of remedies were designed and achieved successful outcomes.

The way in which Xu Shuwei paralleled his formulary with Meng Qi’s and Yang Hui’s works offers an important clue to Xu’s readership targeting. When appealing to the parallel between his composition and Meng’s and Yang’s, Xu provided no further background information about the two literary works; he merely introduced their book titles and the authors’ names. Such a brief introduction implies that Xu assumed that his readers already knew about them and even perhaps recognized them as pioneering pieces conveying anecdotes about poetry and lyrics. Readers with that knowledge would likely have been educated men who were familiar with literary works, such as himself.

In paralleling the three books with explanatory historical contexts, Xu displayed his public persona as an educated figure who was familiar with literary and historical knowledge. This persona implicitly differentiated him from most common physicians. Although Xu had earned his living practicing medicine over several decades, he completed The Formulary with Explanatory Historical Contexts only after passing the civil service examination and attaining a position as a civil official. In other words, when Xu completed this formulary, his social status and cultural reputation were both much higher than those of a common physician.

Other hints at the difference between Xu Shuwei and common physicians come from Xu’s preface to The Formulary with Explanatory Historical Contexts. It began with Xu’s praise of medical knowledge: “the ‘way’ (dao) of medicine” is more than “arts” (yi) and “techniques” (ji), because it could bring the dead back to life. Immediately after offering this praise, Xu then listed the names of eminent physicians from ancient times to the Tang dynasty, such as Sun Simiao, whom Xu regarded as fathoming the way of medicine. Why, Xu wondered, was those physicians’ way of medicine much better than medical skills during his time? He answered that it was because in earlier days, physicians practiced medicine for the purpose of saving lives, and Heaven accordingly gifted the way of medicine to them; in contrast, contemporaneous physicians thought only of profits, and Heaven consequently refused to bestow the way of medicine upon them. Xu then argued that the lack of competent physicians in his home county caused his parents’ deaths when he was a child. “Being anguished by the thought that there was not a single good physician in our village [who could help my parents],” Xu began to learn medicine and “swore wholeheartedly to devote my life to saving all living beings.”³⁵ By narrating his question, answer, and vow in this sequence, Xu implied that his way of medicine was better than that of contemporaneous physicians because he aimed to save lives, while the others aimed to earn money. At the end of the preface, Xu stated again that he saved lives without seeking rewards. This statement reminded his readers of the contradiction between what he regarded as eminent and common physicians that he had mentioned earlier.

Xu’s inclusion of the phrase “explanatory historical contexts” (benshi) in his formulary title merits special attention. This phrasing marks the first time that language referring to medical case narratives, which usually appeared in prefaces and postscripts, was included in a book title. The parallel that Xu Shuwei drew between The Formulary with Explanatory Historical Contexts and the other two literary works had multiple implications. For one thing, the title indicated that his treatise on the collection of medical case histories was a pioneering work, thus attracting educated men as his target audience and fashioning Xu as a learned and benevolent medical expert.

Although Xu’s use of the term “explanatory historical contexts” bore similarities to Meng Qi’s use of the phrase, one of Xu’s remarks in his preface helps us differentiate his formulary from Meng’s works, that is, the inclusion of “new ideas” (xinyi) that Xu acquired over his long career in healing. Meng stressed in his preface his efforts to verify the historical contexts he recorded; he gave no word regarding any his creative labors.³⁶ In contrast, Xu pointed out that his formulary not only collected relevant historical contexts but also presented his new ideas about healing. In this regard, Xu Shuwei demonstrated the more prominent presence of his discoveries and intellectual voice in his formulary compared with Meng’s.

MEDICAL CASES AND PHYSICIANS’ FAME

When Xu Shuwei was writing his medical treatises, the scope and purposes of collecting medical case histories underwent a significant change. The appearance of a particular formulary in the early twelfth century marked this new development. The formulary, Straightforward Rhymes of Medicines for and Syndromes of Children (Xiaoer yaozheng zhijue, or Authentic Rhymes of Medicines for and Syndromes of Children, Xiaoer yaozheng zhenjue, hereafter Straightforward Rhymes), devoted an entire chapter (juan) to presenting a single physician’s case histories. In comparison, from the seventh century onward, a growing number of authors published formularies that contained medical case narratives, but they scattered case records throughout a given book. Those formularies included Essential Formulas, Mr. Cui’s Collections of Essential Formulas, and Passing on Trustworthy Formulas, as discussed in chapter 1.

The sole physician who was subject to depiction in Straightforward Rhymes’ case histories was Qian Yi (ca. 1032–1113), a famous pediatrician. Qian won great fame and served as a medical official at the court after curing Emperor Shenzong’s niece during the Yuanfeng reign (1078–1085). Nonetheless, the author of Straightforward Rhymes was not Qian but one of his patients, Yan Jizhong.

Yan’s preface to Straightforward Rhymes reveals alternative, even contradictory, views on the usefulness of publishing medical case histories that were being expressed by the time of fall of the Northern Song empire. According to the preface, Qian Yi had cured Yan when he was five or six years old and was about to die from multiple diseases. Qian was young at that time and “not willing to transmit his writings casually.”³⁷ Even after Qian became a renowned court medical official—the peak of a physician’s career in the Song era—he still did not complete and publish a medical treatise. Qian’s doubt about the helpfulness of transmitting medical knowledge via a documentary format was reminiscent of Shen Kuo’s belief that one could not fathom medicine only by reading books (a belief analyzed in chapter 1). Regardless of Qian’s doubt, Yan was determined to collect and publish Qian’s notes on pediatric knowledge. He spent decades collecting the relevant materials, such as Qian’s medical essays and formulas, from his own relatives and acquaintances. Yan also found “other versions” (bieben) of Qian’s writings that were circulating in Kaifeng. He then compared them and edited all of the materials he had collected so painstakingly, reorganizing them into Straightforward Rhymes.

Yan Jizhong organized Qian Yi’s materials in the pattern of a discussion-case-prescription trilogy. He structured Straightforward Rhymes into three chapters. The first includes some 47 medical “discussions” (lun) about pediatrics. The second lists twenty-three case-based accounts, identifying them as “Records of Twenty-Three Disorders Qian Yi Once Treated.” The third chapter lists some 114 medical formulas. As modern scholarship has observed, the discussion-case-prescription trilogy format indicates that Qian’s case histories were more likely read as an explanatory chapter supporting the preceding chapter of medical discussions and the following chapter of formulas.³⁸

The general structure and form that some of the episodes among the twenty-three case records take are similar to the that of Xu Shuwei’s cases. Both follow a basic pattern in which a patient’s personal information is related before describing the disorders in question and relevant medical histories, eventually accounting for their diagnosis and prescription before noting the outcome for the patient. This structure is commonplace in case histories in earlier texts, such as Chunyu Yi’s examination records from the second century BCE and Sun Simiao’s Essential Formulas in the early seventh century CE. Like Xu in his case histories, Qian Yi in his acknowledges fierce competition for patient patronage. Qian often had to debate rival healers and persuade opinionated members of patients’ households to earn their patronage. The medical debates and Qian’s successful cures portrayed in the twenty-three cases validated Yan’s assessment of Qian’s extraordinary healing skills.

The appearance of Straightforward Rhymes suggests that publishing formularies in the discussion-case-prescription trilogy format became a means of demonstrating a physician’s medical virtuosity and bolstering his fame as a successful practitioner. Such a trilogy is evident in Xu Shuwei’s own medical case narratives as well, especially those that involve cold damage disorders. The special attention that Xu paid to gathering his cases of cold damage disorders grew out of the development of this medical subfield in his time.

CANONIZATION AND POPULARIZATION

Cold damage medicine rose in salience in the Song era, as indicated by the soaring number of medical treatises that were specific to this medical subfield. Approximately ten of this sort had been published before the Song dynasty, a period spanning seven hundred years, running from the third to the tenth centuries, whereas there were sixty-five in the Song era.³⁹ Modern scholars have proposed various explanations for the rise of cold damage medicine during this period, such as frequent outbreaks of epidemics in China.⁴⁰ Another explanation cites the unusually cold climate experienced between 985 and 1192.⁴¹ One significant contributing factor that scholars have agreed upon is the canonization and popularization during the Song dynasty of a third-century formulary, Treatise on Cold Damage. Beyond this consensus, however, the specific process involved in and the timeline of the canonization and popularization of this formulary are unclear. Issues under debate, for instance, include how the treatise became widely known among medical authors across China, and when medical authors began to acclaim it as a canon of cold damage medicine. Resolving these issues would require comprehensive research into both received and excavated sources in middle-period China, a project deserving of an entire monograph on its own. Here, our focus is on the trajectory over which the treatise was considered a cold damage canon and on the process in which this concept prevailed in the Song era.

The received story about the birth of Treatise on Cold Damage began with its author Zhang Ji’s (150?–219?) great loss of his “kinsmen” (zongzu), who originally numbered some two hundred people. During the Jian’an reign (196–220), two-thirds of his kinsmen died within the span of a single decade. Of those, seven of ten died of cold damage.⁴² This great loss drove Zhang to study medicine diligently and search widely to collect remedies, completing Treatise on Cold Damage and Miscellaneous Disorders (Shanghan zabing lun, hereafter Cold Damage and Miscellaneous Disorders) sometime between 202 and 217. This story about epidemics originates from a preface to it, which is attributed to Zhang Ji. Medical historians have hotly debated whether Zhang was the author of the preface; they have also disputed its accuracy.⁴³ As shown in a recent discussion, this story about epidemics appeared in the Song era, eight hundred years after Zhang’s death. Another issue that has been subject to debate among medical historians is whether Zhang served as the governor of Changsha (in Hunan).⁴⁴ No evidence in the Han dynasty can be found to prove this; however, the Song literati believed that Zhang was the governor.

As signaled in the title, Cold Damage and Miscellaneous Diseases classified disorders into two large categories: one covered cold damage disorders and the other covered all the other types of disorders that Zhang collectively called “miscellaneous disorders.” Along the lines of transmission over the centuries, the two disorder-category parts of Cold Damage and Miscellaneous Disorders became separated from each other, circulating as independent treatises. The one on cold damage disorders is what the Song people called Treatise on Cold Damage.

According to the received view, Treatise on Cold Damage was not circulated widely from the third to the eleventh centuries.⁴⁵ Scholars have reported that, even in the early seventh century, it circulated among only a small group of physicians in Jiangnan, the area south of the Yangzi River; it was not until the Directorate of Education printed this text in 1065 and 1088 that it became widely available and accessible to physicians and literati. Based on this view, the medical historian Asaf Goldschmidt’s research took this understanding a step further and proposed a key change in Song medicine. To simplify Goldschmidt’s argument greatly, the newly available Treatise on Cold Damage stimulated physicians in the Song era to integrate theories in this ancient treatise with contemporary healing practices; their pursuit of this integration fostered the emergence of a great number of treatises specific to cold damage medicine. The integration characterizes the Song era as one of the three turning points in the development of Chinese medicine.⁴⁶ Goldschmidt’s argument has been influential and over the past decade has provoked an intense discussion on the evolution of cold damage medicine in middle-period China.

Recent studies have seriously challenged the foregoing received view. They show that, before 1065, when the directorate printed the entire contents of Treatise on Cold Damage, parts of this book were already circulating widely; medical treatises completed between the third and seventh centuries had drawn formulas from it.⁴⁷ For instance, Sun Simiao had transcribed parts of it in his Supplement to Formulas Worth a Thousand in Gold.⁴⁸ Treatises whose titles contained the term “cold damage” and were attributed to Zhang Ji appeared continuously in other medical texts and bibliographies in the Six Dynasties and Tang eras, such as Discerning Cold Damage (Bian shanghan). Those cold damage treatises that were attributed to Zhang presumably drew their sources from part of the cold damage treatments recorded in Treatise on Cold Damage and Cold Damage and Miscellaneous Diseases.⁴⁹ In other words, the circulation of the former from the third to the eleventh centuries, even though it was not in a complete book version, was wider than previous scholarship has thought. This meant that the contents of Treatise on Cold Damage for physicians in the Song era may not have been as new as the received view suggested.

In addition to challenging the received view, which tended to emphasize the quick and direct influence of the directorate-printed Treatise on Cold Damage as boosting cold damage medicine in the Song era, recent studies have also presented a less linear trajectory of its canonization and popularization in this period. They have pointed out the more limited circulation of the directorate-printed version and the popularity of an easy-to-understand guidebook on Treatise on Cold Damage. The directorate printed the treatise in 1065 and 1088, assigning it as a textbook in government medical education and examinations by 1083.⁵⁰ Beyond that government system, physicians may have encountered difficulties in accessing the directorate-printed version.

Unlike what the rapid spread of Treatise on Cold Damage in government medical education implies, however, not every early Northern Song medical treatise that was completed in private hands and specific to cold damage cited it. One example is Master Tongzhen’s Summary of Cold Damage (Tongzhen zi shanghan kuoyao), which was attributed to Liu Yuanbin (fl. 1076–1090), the assistant magistrate of Shaoyang County in Shao Prefecture (in Hunan). The first half of the extant version of Master Tongzhen’s Summary of Cold Damage drew primarily from the Song court–compiled The Imperial Grace Formulary instead of Treatise on Cold Damage.⁵¹ Beginning in 1088, the second time the directorate printed Treatise on Cold Damage, and running to the end of the Southern Song dynasty, little evidence suggests that this treatise was reprinted as an independent book.

In comparison with the dissemination of Treatise on Cold Damage, an easy-to-understand guide to it, One Hundred Questions on Cold Damage (1107, hereafter One Hundred Questions), circulated more widely. As shown in recent studies, it was instrumental in achieving the canonization and popularization of Treatise on Cold Damage in the Song period. Its author, Zhu Gong, used the question-and-answer format to elaborate the content of the treatise, posing 101 questions about applying it to healing practices. Zhu then appended answers after each question. For instance, the questions involved factors such as when specific symptoms (such as feeling cold limbs) manifested and a specific pulse pattern was diagnosed or what drug therapies could be applied. In answering those questions, Zhu recommended pertinent drug therapies and explained the rationale for each prescription.

Zhu took twenty years to complete One Hundred Questions. He claimed in 1107 that he had written a book that explained the content of Treatise on Cold Damage so that “scholar-officials would easily understand it and subsequently enjoy reading it.”⁵² In the early twelfth century, when Zhu was retired, he moved to West Lake (in Zhejiang) and continued writing the book. He completed his efforts in 1107.⁵³ Four years later, Zhu Gong assigned his son to submit One Hundred Questions to the court and requested that the court print it.⁵⁴ In 1114, when Emperor Huizong’s government was promoting the status of medicine, it appointed Zhu Gong as “erudite master” of the medical academy.

Parts of One Hundred Questions were circulating before Zhu Gong’s son submitted the entire book to the court in 1111. Before then, Zhang Chan, who presumably was a physician, claimed that he had read a treatise entitled Mr. Seeking Nothing’s One Hundred Questions on Cold Damage (Wuqiuzi shanghan baiwen) in what is now the southeast region of Jiangsu.⁵⁵ At that point, Zhang had no idea who the author—Mr. Seeking Nothing (or Mr. Not Seeking Fame and Wealth, Wuqiuzi)—was. When he met Zhu Gong around West Lake in Hangzhou, he found out that Zhu was Mr. Seeking Nothing and that what he read was merely 60 percent of the contents of Zhu’s original One Hundred Questions. Zhang received the entire version from Zhu and edited it. The outcome of Zhang’s editing was a treatise of twenty chapters and some ninety-one thousand words. Zhang named the treatise The Book for Saving Lives from Nanyang (Nanyang huoren shu, hereafter Saving Lives). Nanyang, in this title, as Zhang Chan explained, referred to Zhang Ji and his oeuvre, because Nanyang was Zhang Ji’s home county.

Saving Lives was printed many times across Song China after the early twelfth century. In 1116, Zhu Gong retired and returned to Hangzhou. On his way there, he heard that Saving Lives had been printed in the capital Kaifeng, Chengdu, Hunan, Fujian, and Liangzhe (in Jiangsu); one of the publishers of the printed versions in Kaifeng might have been the Directorate of Education.⁵⁶ It was a pity, his informants complained to Zhu, that those printed versions were not properly edited and were full of mistakes. After returning to Hangzhou, Zhu made some one hundred revisions to Saving Lives and asked a commercial publisher in Hangzhou to print this version in 1118.⁵⁷ In 1176, “the previous versions” (jiuben, perhaps not the version revised by Zhu Gong) of Saving Lives were printed “among laymen” (minjian) in Jian Prefecture (in Fujian) and Rao Prefecture (in Jiangxi); the prefectural office (gongshiku) in Chi Prefecture (in Anhui) printed Zhu’s revised version.⁵⁸

The ample number of printed editions and the wide geographical scope of the printings of Saving Lives attest to its popularity in Song China. This meant that many more readers learned about Treatise on Cold Damage by reading Zhu Gong’s easy-to-understand guidebook. In addition to popularizing the treatise, Saving Lives was the first extant source that explicitly added Treatise on Cold Damage to the “canon” (jing) of cold damage medicine.⁵⁹ Medical authors had praised it before Zhu did. The first surviving reference to Zhang Ji as a sage appeared in the preface to the directorate-printed version, written by civil officials who were in charge of this editing project.⁶⁰ Nevertheless, Zhu was one of the earliest authors to extol it as a contribution to the medical canon. Following publication of Saving Lives, a growing number of medical authors began advocating for including Treatise on Cold Damage in the canon of cold damage medicine.

Xu Shuwei’s treatises likewise contributed to the trend toward canonizing and popularizing Treatise on Cold Damage. Goldschmidt proposed that three cold damage treatises attributed to Xu were probably intended to be read together as a trilogy so as to make Treatise on Cold Damage easier for nonexperts to understand. The first part, One Hundred Mnemonic Verses on Cold Damage Manifestations, consists of one hundred rhymes, each of which summarizes parts of Treatise on Cold Damage. The second, Subtleties of Cold Damage Revealed, consists of twenty-two “discussions” (lun). In each of the discussions, Xu talks about one topic concerning the diagnosis and treatment of a cold damage disorder. The third part, Ninety Discussions, consists of Xu’s ninety medical cases of these disorders. Goldschmidt formulated the trilogy in such a way that each of the three books, in its specific written form (i.e., rhymes, discussions, and cases) popularized Treatise on Cold Damage in a distinct way: One Hundred Mnemonic Verses transformed its contents into easy-to-remember rhymes, Subtleties of Cold Damage Revealed discussed the important but difficult-to-understand medical issues it mentioned, and by documenting Xu’s healing practice, Ninety Discussions merged the ancient medical theories mentioned in the treatise with Xu’s clinical practice, demonstrating how to apply the third-century classic to twelfth-century healing practices.⁶¹ Taken together, the three books made Treatise on Cold Damage more comprehensible to a wider audience.

Although the identification, in existing scholarship, of Xu Shuwei as the author of Ninety Discussions appears to be erroneous, the trilogy that Goldschmidt proposed has inspired the present study to view Xu’s medical cases of cold damage disorders in The Formulary with Explanatory Historical Contexts as contributing to his advocacy of Treatise on Cold Damage as a cold damage classic and as a way of popularizing the book. Findings in recent studies also modify the trilogy, showing that, in addition to Treatise on Cold Damage, another cold damage treatise that Xu’s books promoted was Saving Lives. For instance, although Xu claimed that everything in his One Hundred Mnemonic Verses “originated from Zhang Zhongjing,” two-thirds of its rhymes actually summarized Zhu Gong’s words in Saving Lives.⁶²

The abovementioned studies on the development of cold damage medicine in the Song era focused on progress toward canonization and popularization of cold damage medical treatises and the integration of medical theories and practice. Disputes arose however, over the course of this canonization, popularization, and integration.

MEDICAL DEBATES

Xu Shuwei wrote and published cases involving cold damage in response to disputes over the diagnosis of and prescriptions for these disorders that arose in the course of the canonization and popularization of Treatise on Cold Damage. These disputes manifested in three ways: debates involving clinical encounters with assembled rival healers or members of patients’ households; Xu’s ongoing discussion with a figure whom he did not identify, where it is often difficult to discern whether the discussion took place in a clinical setting; and an intertextual debate between Xu and other contemporaneous authors, which was a relatively new phenomenon in the Song era. The three types of disputes mark The Formulary with Explanatory Historical Contexts as a pioneering treatise in China whose author deliberately marshaled his case histories to support his opinions in medical debates, either in clinical practice or in intertextual space.

The debates involved in Xu’s clinical encounters often began with questions raised by assembled physicians and a patient’s family regarding the justification for a diagnosis and prescription. These ranged from wanting to know the names of disorders to wondering about remedies Xu recommended to puzzlement over seemingly worsening manifestations in a patient who had consumed one of Xu’s remedies. One example of such a debate is exhibited in the case narrative with which this chapter opens. In it, the assembled physicians doubted why Xu chose to use the Major Bupleurum Decoction instead of a honey enema.

If challenges to a prescription came from members of a patient’s household, Xu sometimes did not answer them orally in a clinical setting. Instead, he included the complaints and his justifications in a written case narrative in The Formulary with Explanatory Historical Contexts. Here is a typical example: When examining a patient named Mr. Qiu from Xu’s hometown, Xu said: “Although this is a manifestation type of Ephedra [Decoction], the pulse at the ‘foot position’ (chi) is tardy and weak. Treatise on Cold Damage says: ‘If the pulse at the foot position is tardy, it is because the “nutrient qi” (rongqi) is insufficient and the “blood” (xue) and the qi are very scant. One cannot sweat the patient at this moment.’”⁶³ Accordingly, Xu did not sweat Mr. Qiu. Xu prepared a “Construct the Middle Decoction” (Jianzhong Tang), adding Chinese angelica and astragalus (huangqi), and ordered Mr. Qiu to drink it. Even though Xu explained the rationale for his prescription, the next day, members of Mr. Qiu’s household became impatient and kept urging Xu to administer a diaphoretic drug. Their language even approached rudeness. “I put up with this [abuse],” Xu recalled in his response in the case narrative. Not ingratiating himself with those rude family members, Xu stick to his original prescription plan. After some five days, Mr. Qiu was cured.

Following this successful outcome, Xu in the case narrative cautioned physicians against applying treatments in the wrong sequence. He warned, “I often saw that patients’ household members were impatient. The patient was sick no more than three or four days, and they urged physicians, day and night, to apply sweating treatment.” Once physicians comply with household members’ ignorant opinions, treatments often fail. “Therefore,” Xu noted, “I document this as a special word of caution for physicians.”⁶⁴ Although he claimed that the caution was written for physicians, it could also have been intended simultaneously to educate his readers to heed the proper timing for sweating a patient who suffered similar symptoms.

When replying to rival healers’ questions and justifying his own diagnoses and prescriptions, Xu frequently interpreted medical classics. He also used this method to justify his treatments in other types of dispute. For instance, in one case record, a person suffered from dysentery, his body felt hot, his mind was clouded, he raved, and he could not fall asleep. Xu palpated the patient’s pulse and said, “This was the manifestation type of Minor Order-the-Qi Decoction” (Xiao Chengqi Tang).” Observers were astounded by this diagnosis, asking, “Can prescribing Minor Order-the-Qi Decoction for dysentery be one of Treatise on Cold Damage’s methods?” Xu answered: “This is the method in Treatise on Cold Damage. It says, ‘Patients have dysentery, raved, and have dried excrement. This belongs to the manifestation type of Minor Order-the-Qi Decoction.’ I once read Basic Questions. It says, ‘When the disorder is slight, go against it; when it is strong, conform to it. Going against the pathogen means treating it directly; following it means treating it contrarily.’”⁶⁵ Here Xu cited Treatise on Cold Damage and Basic Questions to legitimize his prescription.

Next to Treatise on Cold Damage, Basic Questions is the second most frequently cited medical classic that Xu used to support his positions in medical debates. Basic Questions and Divine Pivot together constitute The Yellow Emperor’s Inner Canon (Huangdi neijing, hereafter The Inner Canon), which has long been considered the most crucial work in classical medicine in imperial China and, even today, occupies the role of a textbook in curricula on traditional Chinese medicine. The earliest compilation presumably dated from the Han dynasty, though it is not the oldest medical text in China; archaeological excavations since the 1980s have discovered older materials. The Inner Canon is, however, the oldest extant work of literature recognized as a source of canonical medical doctrine in China.⁶⁶

In Xu Shuwei’s medical cases, physicians of his day were less familiar with Treatise on Cold Damage and other medical classics than Xu was; Xu often won debates by drawing references from them. It should not be surprising, though, that Xu exaggerated his rival healers’ ignorance of medical classics to makes his erudition conspicuous. But did he really persuade rival healers and patients’ household members in clinical practice by appealing to medical classics? Or did he construct this plot to promote his own erudition? To what degree and on what grounds can we consider Xu’s medical cases as narrated as accurate depictions of what actually happened in clinical practice? Given the dearth of other evidence, it is difficult to give these questions concrete answers.⁶⁷ What we know for certain is that, in his medical cases, Xu used his success in practice and textual learning as the underpinning of his expertise in medicine.

After describing debates and successful outcomes in clinical practice, Xu sometimes notes that “one may ask” (huowen) or “one may say” (huoyue) regarding a given question, followed by a reply to the question. Considering that passages in this dialogic form often appear following accounts of outcomes and in the absence of questioners’ names or personal information, it seems that Xu had no intention of identifying the participants in dialogues that took place in clinical settings. Instead, they were designed to function more like conversations between Xu and his readers, thus they may be differentiated from medical debates occurring in clinical settings and be counted as the second type of dispute included in Xu’s medical cases. Some discussions of this type are similar to those raised by assembled physicians, which mainly concerned the rationale for a given diagnosis and prescription. Others express confusion of the sort that readers might experience when reading Treatise on Cold Damage, such as that involving paradoxical prescriptions and the meanings of medical terminology. One typical example stems from the case narrative involving the Major Bupleurum Decoction, in which Xu noted questions from unidentified figures: “In discussing Yang Brightness disorder, Zhongjing says, ‘In the case of those with profuse sweating, urgently drain the patient’s bodily fluid downward.’ Many people often say that when the patient is spontaneously sweating and one further drains the patient’s bodily fluid downward, how could the result not be depletion in both the interior and exterior aspects of the body?”⁶⁸ To answer this question, Xu elaborated on his interpretation of Zhang Ji’s words. The successful outcome that preceded this question and answer enhanced the credibility of Xu’s interpretation.

Transmitting knowledge through the question-and-answer form was a long-standing practice in medical literature in China, whereas in the twelfth- century, sources of authority in this form differed markedly from those cited in ancient times. The dialogue form can be traced back to Basic Questions; as shown in its title, this form constitutes the primary means of passing down knowledge. In this medical classic, divine figures, such the Yellow Emperor, asked questions about medical knowledge, and another legendary figure answered at length. The authority of those answers derived not from their authorship, which was often obscured in ancient medical treatises, but from the associated legendary figures. In contrast, in twelfth-century medical treatises, the authors rarely identified questioners’ names or personal information in a dialogue, and sources of the authority supporting the answers were closely associated with the authorship of a treatise. For instance, Zhu Gong, the author of Saving Lives, gained much of that authority from his court appointment as the “erudite master” of the medical academy; Xu Shuwei in The Formulary with Explanatory Historical Contexts based its authority largely on his successful practice and medical erudition.

Xu, when elaborating his interpretation of Treatise on Cold Damage to unidentified questioners, sometimes commented on his contemporaneous cold damage treatises. Intertextual dialogues with contemporaneous medical authors such as this constitute a third type of medical dispute in Xu’s cases. These dialogues seldom appeared in earlier medical literature but proliferated in the Song era. One case in point is Zhang Chan’s 1111 preface to Saving Lives. When praising the book, Zhang hinted that he had also read five other Northern Song authors’ cold damage texts. The dates of the five attest to the short period of time between the publication of a Song cold damage treatise and its entry in intertextual dialogues between contemporaneous writers; they are Classified and Collected Cold Damage Disorders (Shanghan zuanlei) by Gao Roune (977–1055), Alternative Orders of Cold Damage Disorders (Bieci shanghan) by Shen Kuo, Classified Examples of Cold Damage Disorders (Shanghan leili) by Hu Mian (fl. ca. 11th century), Rhymed Instructions on the Pulse Patterns of Cold Damage Disorders (Shanghan maijue) by Sun Zhao (fl. 11th century), and Discussions on Cold Damage and General Disorders (Shanghan zongbing lun) by Pang Anshi (1042–1099).⁶⁹ Those five treatises, Zhang Chan commented, introduced innovations yet were less organized than Saving Lives.

The Formulary with Explanatory Historical Contexts abounds with intertextual dialogues with contemporaneous authors, such as Wang Shi (fl. ca. 11th century), Sun Zhao, Pang Anshi, and, of course, Zhu Gong. In the dialogues, Xu Shuwei sometimes concurred with their opinions but sometimes expressed his disagreement with them very directly. In one case, for example, someone asked Xu about the pathological course of cold damage disorders in the body. Xu replied, in a matter-of-fact tone, that neither Treatise on Cold Damage nor previous or present texts discuss the pathological course; only Pang Anshi proposed a course and a rationale. After reiterating the course and rationale, Xu explicitly refuted it by saying, “I consider it is wrong” and “It is so contrived.” Xu then cited a sentence from Basic Questions to support his refutation.⁷⁰

Pang Anshi was a physician who was active in eleventh-century Hubei and was famous for cold damage medicine. Xu’s refutation of Pang’s views is noteworthy, because it shows that disputes over cold damage medicine arose not only between physicians and laymen or between eminent healers and incompetent ones but also between doctors who specialized in this medical subfield. No one’s medical authority was self-evidently preeminent.

Another example of Xu’s case records involving intertextual dialogues concerns the meaning of cold damage medical terminology. This case record illustrates the difficulty of learning this medicine by reading books without intermediaries. In it, Xu examined a patient who suffered from a cold damage disorder but who did not sweat and had an aversion to wind, and whose neck was bent but rigid. Xu said, “This condition is called ‘neck rigidity and jiji.’ The manifestation type of the Kudzu Decoction (Gegen Tang).” Immediately after recording this diagnosis, Xu writes: “One may ask ‘What is meant by jiji?’ I said: ‘Jiji refers to a condition similar to one when a patient suffers a foot disorder and their feet [or legs] are bent but rigid. Xie Fugu, when he referred to this term, said that it means a condition in which the patient is so sick and feeble that he must lean on a desk to rise. It is wrong.’”⁷¹

Xie Fugu was a Song-dynasty medical author and served as the academician of the Hanlin Academy. Xu did not explain why he objected to Xie’s understanding of the term jiji; perhaps he thought the mistake was too obvious. But at the end of the entry, Xu notes that “there are many points in Treatise on Cold Damage that were difficult to comprehend” and lists five other phrases as examples.

Notably, in this intertextual dialogue, Xu did not bestow greater intellectual authority on the court-commissioned version of Treatise on Cold Damage, which the Bureau for Editing Medical Texts edited and the Directorate of Education printed. Rather, Xu criticized its comments on the treatise. His criticism appears in his reply to an unidentified questioner’s doubt about his prescription: “The patient has already vomited and was then treated by draining his bodily fluid downward; this is a case of internal depletion. How can you apply White Tiger Decoction [Baihu Tang]?” In response, Xu cited two sentences in Treatise on Cold Damage and elaborated their meaning. At the end of his elaboration, Xu criticized the bureau’s comment on the two sentences: “Our dynasty’s Lin Yi, in his critical edition of Treatise on Cold Damage, wrote: ‘Zhang Zhongjing in detailing this method wrote the words “exterior” and “interior” incorrectly.’ I said it was not the case.”⁷² Lin Yi was one of the three civil officials who were in charge of the bureau’s editing project for Treatise on Cold Damage.

Xu went on to explain why Lin was wrong and concluded his criticism of the bureau’s comments on the treatise as follows: “Lin Yi examined only the so-called difference between the interior and exterior aspects of the body and then said there was an error. This was Lin’s error due to not thinking it through.”⁷³

Xu’s criticism here is significant. It shows that the appearance of the court-commissioned version of Treatise on Cold Damage by no means quelled Song authors’ frequent and wide-ranging debates over the diagnosis and prescription of cold damage disorders and over the correct understanding of it. The court-commissioned version, some Song authors believed, was nothing but another voice in those battles.

Although the annotations in the court-commissioned version of Treatise on Cold Damage did not prove to be sufficiently authoritative to quell the heated debates, that version may help in standardizing the treatise’s contents. Recent scholarship has observed that, before the directorate printed the version of Essential Formulas that the Bureau for Editing Medical Texts had edited, medical treatises had asserted various opinions about when menarche would begin, ranging from fourteen to sixteen years of age. After the court-commissioned version of Essential Formulas was issued—which stated that menarche began when a female reached fourteen—other versions of Essential Formulas followed suit.⁷⁴ The court-commissioned version of Treatise on Cold Damage could function similarly in the effort to standardize the contents of this canonical medical work.

AS AN EARLY PIONEERING WORK that groups medical case histories as supportive evidence in medical debates, The Formulary with Explanatory Historical Contexts had multiple inspirations. The core inspiration that its author, Xu Shuwei, claimed was not medical writing but literary works: Poems with Explanatory Historical Contexts and Lyrics with Explanatory Historical Contexts. The analogy drawn in Xu’s preface between those and his formulary had several implications. It illustrated his acquaintance with Tang and Song literary genres, suggesting that his target audience comprised educated men who were familiar with such writings. The analogy meanwhile connoted that The Formulary with Explanatory Historical Contexts was a pioneering work in which medical cases constituted a large proportion of the text. By including the phrase “explanatory historical context” (benshi) in the title of the formulary, Xu displayed a heightened awareness that his medical predecessors lacked the use of cases as an epistemic form for conveying new knowledge.

In addition to Poems with Explanatory Historical Contexts and Lyrics with Explanatory Historical Contexts, two changes in social and intellectual contexts encouraged Xu to marshal medical case histories in his formulary. One was the rising visibility of case narratives in medical literature in the early twelfth century, when formulary authors for the first time devoted independent sections to recording a physician’s case histories. One formulary, Straightforward Rhymes, provided a precedent for using the discussion-case-prescription trilogy format to build up a physician’s fame.

The other change was the diverse and abundant disputes about the understanding of Treatise on Cold Damage and cold damage medicine. These arose over the course of the canonization and popularization of the treatise in the eleventh and twelfth centuries, which made the need to understand its medical terminology and theories all the more acute, as compared with its reception in the preceding centuries. Meanwhile, amplified by woodblock printing, the wider dissemination of Treatise on Cold Damage and other Song-era cold damage texts meant that contrasting understandings of the treatise and cold damage medicine were more visible to readers in this period than they had been before. The ever more acute need to understand the treatise, along with the growing visibility of contrasting understandings, together encouraged closer intertextual dialogues, sometimes even debates, between medical authors than ever before. To convince readers and prospective dialogue participants of the correctness of their understandings, the Song authors creatively applied a range of persuasion strategies. The key strategy, for example, that Zhu Gong adopted was to seek imperial endorsement of his Saving Lives. As for Xu Shuwei, he appealed to the empirical strategy, publishing his collections of case histories. Xu recorded his successful cures and populated his cases with learned remarks. The Formulary with Explanatory Historical Contexts was therefore written for publication and to bolster his fame both as a successful practitioner and as an erudite scholar.

The explanatory function of Xu Shuwei’s medical cases involving cold damage disorders additionally gives us a glimpse into the use of the medical case narrative in a specific medical subfield during the Song period. In this subfield, where consensus over its canonical sets, such as treatises on cold damage medicine, was being reached, the case narrative in general served to illustrate canonical textual knowledge. In stark contrast, in other medical subfields that lacked such texts, medical case histories played more important roles in bolstering the reliability and credibility of a given treatise and new healing knowledge, a phenomenon examined in the next chapter.