Ancient Formulas to Strengthen the Nation

In modern China, the revolution was always, and perhaps continues to be, about the body. In 1896, when the North China Daily News declared China to be the “Sick Man of Asia,” the author may have been innocently extending a metaphor for the crumbling Ottoman Empire to the political future of the Qing Empire. But Chinese revolutionaries took the charge literally. For example, Mao Zedong’s first publication in 1917, “A Study on Physical Education 《體育之研究》,” his only known publication that pre-dates his encounter with Marxism, endorsed exercise as a means of transforming society. Challenging the religious and philosophic proclivities towards the stillness of mediation and the social preference for flowing gowns not suited for vigorous activity, Mao exhorted his readers to embrace the slogan: “civilize the spirit by making savage the body 欲文明其精神, 先自野蠻其體魄.”. Chiang Kai-shek, who would become Mao’s political nemesis, lamented the inadequacies of the Chinese physique in his address to the Fourth National Games in 1930.

The Chinese nation’s status in the world, its international ranking, is not even third class. This is our Chinese nation’s greatest shame. And the reason is that our national physique is weak, causing people of other nations not to take us seriously.¹

It may have been this equation between the individual and national body that inspired Mao Zedong to later demonstrate his physical prowess and fitness to lead by swimming the Yangtze River, most notably at age of 73 on the eve of launching the Cultural Revolution.

In this article, I argue that fears about physical degeneration among Chinese elites in the early 20^th century not only dominated political discourse, but also animated debate among medical practitioners. In the Jiangnan region, China’s cultural center in the Republican era, a small but influential group of doctors believed themselves to be besieged by a culture of weakness and an embrace of physical frailty. These concerns were central to the program for medical reform they promoted, which eschewed centuries of late imperial medical scholarship and called for a renewal of the medical profession based on the Han dynasty medical classic, Zhang Zhongjing’s The Treatise on Cold Damage. In promoting their vision of a strong, reformed medicine, they were informed by a mixture of Confucian evidential scholarship, Japanese Kampo medicine, and “Western medicine” (the term for biomedicine in China).

Today these doctors are remembered as innovative thinkers, but their reformist vision has been forgotten. Contemporary scholars usually place the doctors discussed in this paper, figures such as Yun Tieqiao, Lu Yuanlei, and Zhu Weiju, as followers of the Convergence School 中西醫匯通派, a current of medical practice in the late 19^th and early 20^th century that blended elements of Chinese medicine and Western medicine. They are considered pioneers, albeit misguided ones, who paved the way for the more sophisticated integration of Chinese medicine and Western medicine that we have today.² In this paper, I argue that these reformers were not particularly interested in the hybrid, cosmopolitan medicine of the future, but deeply invested in the pure roots of medicine, particularly as found in The Treatise. Only through a renewal of the past, they believed, could one strengthen medical practice, overcome weakness, and reinvigorate the nation. Their vision of renewal ultimately failed to win the battle for the future of Chinese medicine. Following the Communist Revolution, fears about national weakness and physical deficiency gave way to a desire to define national uniqueness and the special characteristics of Chinese medicine. As the new state pushed doctors to come to a consensus about professional standards, The Treatise was recognized as one of the four canons of Chinese medicine but not its central text.

Medicine for frail bodies

In the early 20^th century, diseases of depletion seemed to be rampant in Chinese society. Old diseases, such as spermatorrhea, became ubiquitous in the mainstream press; new diseases, such as neurasthenia, were embraced by medical professionals, the latter becoming a mainstay of neuropsychiatry for decades in China, long after this diagnosis had fallen out of favor in the West.³ There were also many prescriptions – medicinal, political, and otherwise – for these weak constitutions. The famous Daoist innovator, Chen Yingning 陳攖甯, advocated a form of Daoist practice, The Immortals Learning 仙學, that he developed in response to his own struggles with consumption. Stressing activism, practice, autonomy, innovation, Chen promoted The Immortals Learning techniques of self-cultivation to create a robust body strong enough to repel foreign influences.⁴

In elite medical practice, concern over weak bodies in the Republican period had a transformative effect on medical discourse. Leading doctors in the Jiangnan area challenged the deeply held beliefs in the delicacy of southern constitutions and argued for a more robust form of medical practice. Marta Hanson has argued a strong sense of regional uniqueness had emerged in Jiangnan during the Qing dynasty, particularly as the Qing state was weakened by the disruption of the Taiping Rebellion (1853-1864) and the strain of European imperialist encroachments in the late 19^th century.⁵ By the late Qing period, a distinct form of medical practice had emerged in the Jiangnan region based on the belief that Jiangnan bodies were frail, especially in comparison to robust northerners. This conviction was deeply intertwined with the emergence of the Warm Illness current of medical practice, a school of medical practice that focused on epidemics and febrile conditions thought to be outside the canonical Cold Damage tradition. Early formulators of Warm Illness therapies, who happened to all be from Jiangnan, originally portrayed their work as supplementing the canonical formulas of The Treatise of Cold Damage. But by the late 19th century, Warm Illness treatments had emerged as alternative system of treatment, one that relied on purportedly gentle herbs and formulas, in contrast to the supposedly harsh therapies of The Treatise of Cold Damage.⁶

Volker Scheid’s authoritative study of doctors from the Jiangnan city of Menghe, home to some of the best-known medical lineages in 19th century China, illustrates the broader regional concerns about delicate southern bodies that go beyond the Warm Illness current. Fei Boxiong 費伯雄, the most famous doctor from Menghe, argued that one must achieve big results with gentle therapies.

Even during his lifetime, Fei Boxiong was renowned for his gentle approach to treatment…. [One gazetteer] of 1888 noted, ‘In treating [medical] disorders, [Fei Boxiong] did not like to use fierce and harsh prescriptions. He [held instead that] the right [way was for them] to be governed [by the principles of] harmonization and gentleness.’… He did not invent this method, however, but merely followed a style of prescribing that had become popular throughout the Jiangnan area during the Qing. Its mode of drug usage responded to, and in turn amplified, long-established local beliefs that attributed to Jiangnan southerners a more delicate constitution than to the robust northern Chinese. Jiangnan people thus had become increasingly suspicious of taking drugs like Ephedrae Herba 麻黃, Aconiti Radix lateralis praeparata 附子, or Rhei Radix et Rhizoma 大黃 that were associated with potent effects, fearing that these might kill rather than cure them.⁷

Fei Boxiong’s approach not only suited southern sensibilities, it may have been even more perfectly tailored, as Scheid argues, to his wealthy, upper-class clientele that considered themselves to be more delicate than the average southerner. Their complaints, often psycho-emotional conditions such as “exhaustion 虛勞” or “damage from the seven emotions 七傷,” seemed particularly amenable to Fei’s principles of “harmonization and gentleness.” But Fei Boxiong’s mild-acting prescriptions were not just for the rich. They were generally inexpensive, appealing to both wealthy patients whose chronic conditions needed long-term treatment and local peasants who could only afford a short course of treatment.⁸

Shanghai reformers in the early 20th century bristled at the apparent embrace of weakness that was so popular throughout the region. The following passage by Yao Shichen 姚世琛 captures the frustration of a Cold Damage advocate, feeling surrounded by timid Jiangnan colleagues. In the preface to Records of Experiments with Canonical Formulas 《經方實驗錄》, the influential Republican era book by Cao Yingfu 曹穎甫 on clinical applications of The Treatise, he directs his vitriol at the key Warm Illness innovators and their pampered patients.

By the time the history of medicine got to the Qing dynasty, ancient formulas had already been gradually overturned and the “Light and Nimble School” had emerged. Developing the theory that “warm pathogens enter from above, first violating the lungs, then adversely transmitting to the pericardium,” Mr. Ye Tianshi became known for his “light touch,” as can be fully seen in his Guide to Clinical Practice.

Then Mr. Wu Jutong appeared. Because of his devotion to Ye, he momentarily brushed aside the “Six Jing Theory” of the sage Zhang Zhongjing, cleverly promoted his “Triple Burner Treatment,” and produced A Systematic Differentiation of Warm Illness. Subsequently, China from Jiangsu, Zhejiang, Anhui, and Fujian to the border provinces, one after another began to use these formulas, teacher transmitting to discipline, father instructing son, until a world of “mint and burdock seed” had been created!

But is all of this the crimes of Ye and Wu?… Because Mr. Ye lived in the dynamic city of Suzhou, and Mr. Wu hung his shingle in the south-central city of Huaiyin, the patients they saw were princes, aristocrats, and wealthy businessmen. These people enjoyed high position and lived in comfort, indulging their appetites and lusts. Their discomforts were slight, nothing more than an occasional cold or mild exhaustion. Thus ephedra and cinnamon twigs were not needed to dispel Cold and Wind…. As a result, the sage’s superb text was mocked to the point that no one dared mention it.⁹

Although tension between Cold Damage and Warm Illness proponents had been simmering for a long time, the former celebrating Zhang Zhongjing as the one true sage of medicine, the latter proclaiming Ye Tianshi as a second sage, Yao’s diatribe seems to have a new urgency to it: as if to say, in these troubled times, weak bodies and weak medicine can only perpetuate national weakness. Although Yao Shichen’s critique does not explicitly refer to the geopolitical context of his times, another famous voice for reform in this era did. Like Yao Shichen, Lu Yuanlei 陸淵雷 was dismayed by the great popularity of the Warm Illness approach. For him, the future of Chinese medicine lay in the return to The Treatise. Writing in 1929 as a major political crisis with Western medicine was coming to a head, Lu Yuanlei reminds his readers of the importance of The Treatise in the struggle with this new competitor.

I often hear of doctors of Western medicine attacking Chinese medicine, but I have been unwilling to acknowledge their insolent assaults, believing them too vulgar to debate. So I have usually mocked them with a few ludicrous words, not wanting to waste a day on these types, nor eager to protect the rice bowls of today’s so-called doctors of Chinese medicine. The reason Chinese medicine is superior to Western medicine is its treatments, and in treatment there is nothing greater than [Zhang] Zhongjing…. Today’s so-called doctors of Chinese medicine all follow Ye [Tianshi], Wu [Jutong], and Wang [Shixiong]. They don’t read Zhongjing’s book; they don’t use Zhongjing’s methods. This is heresy and not the great lineage of Chinese medicine.¹⁰

We should be cautious about accepting polemical attacks, such as these, at face value. Indeed, the Warm Illness current was a scholarly enterprise that emerged in response to perceived limitations of the Cold Damage approach, and we will explore the rationale behind its development below. But the polemics here do point to deeper political concerns, which we can only grasp by first trying to understand the perceived danger of gentle therapies. If Warm Illness treatments were so mild, how could they also be so dangerous?

The perils of mildness

“The world of ‘mint and burdock seed’” irritated Republican era reformers like Yao Shichen for its apparent meekness. But the greater concern and most damning charge against Warm Illness treatments was that they could have perilous, life-threatening side effects. The two camps were equally fearful of the other’s treatment, but they perceived the dangers differently. For the Warm Illness proponents, Cold Damage herbs and formulas were too powerful for frail, southern bodies. According to the popular expression, most Jiangnan physicians viewed “Ephedra and Cinnamon twigs like they were snakes and scorpions.”¹¹ In contrast, the Cold Damage advocates saw Warm Illness treatments as pernicious not because they were toxic in their own right, but because they frequently exacerbated the illness process, driving it deeper into the body. In a passage from A Collection of Insights from Discussing Medicine in the Reading Room 《籀簃談醫—得集》, Zhang Shanlei 張山雷 provides a typical example of this sort of claim.

When the warm heat theory of Ye Xiangyan [Tianshi] became popular, there was the possibility that some of the inspirations of these later scholars could slightly augment that which was missing in Zhang Zhongjing’s Treatise. But who could have imagined that Old Ye [Tianshi], the first to propose this theory, and [Wu] Jutong, the first to write a treatise about it, would both shun Zhang Zhongjing's established principles, erroneously creating new formulas, using cloying herbs that trap the pathogen, causing innumerable harms without a single benefit. Everyone has followed in this path without reflection, adopting habits that completely mislead the people, devoting one's entire life [to this mistaken approach] without ever awakening.¹²

Lu Yuanlei echoed this sentiment in an unsolicited preface he wrote for a book by Qin Bowei 秦伯未, the well-known physician and educator who was influential in shaping the Chinese medicine profession in both the Republican and early Communist eras. Qin Bowei was a student of Ding Ganren 丁甘仁, a Menghe physician who opened the first modern school of Chinese medicine in Shanghai. His new book, The Best Medical Cases of Famous Qing Dynasty Physicians 《清代名醫醫案精華》, was a tribute to many doctors in his teacher’s lineage as well as other important figures in the Warm Illness current, such as Ye Tianshi, Xue Shengbai, and Wu Jutong. Without having even seen the manuscript, Lu Yuanlei wrote a preface for this new book that was deeply critical of the Warm Illness current. It was and remains commonplace for authors to promote their works by inviting individuals of significance to write a preface. Lu Yuanlei’s breech of etiquette, submitting an unsolicited preface hostile to the very themes of the book, must have been extremely awkward, particularly since the two physicians traveled in the same social circles. But it also demonstrates the level of alarm that Lu felt regarding the dangers of Warm Illness therapies. (It was testament to Qin Bowei’s equanimity that he actually included this preface in the publication with some minor editing.) Lu Yuanlei cautioned the reader:

Warmth and heat are not the cause of serious illness. With two or three doses of medicine, in five or six days, these problems are gone in a flash. But today no one is happy until nine out of ten [patients] are dead [from the Warm Illness approach]. These are the errors caused by Mr. Ye, a poison that has flowed for three hundred years without end.¹³

How is it possible that the cooling herbs of the Warm Illness current could be both gentle and dangerous? The opposing argument against the warming herbs of the Cold Damage current was very straightforward: strong herbs would overwhelm fragile bodies. For the reform-minded Cold Damage advocates, the dangers of cooling herbs were more pernicious: they worked to hasten the natural progression of a disease, masking their dangers behind more familiar clinical presentations, but inevitably leading to death. Zhu Weiju 祝味菊, one of the most respected clinicians from this period, gave a detailed accounting of this process.

In 16th year of the Republic [1927], I came to Shanghai to escape political turmoil. I often heard that people’s constitutions were different due to the environment here. When traveling to a new country, one must ask about the customs, so I didn’t dare to impetuously hang up my shingle. I kept a low profile in Shanghai for a year, hanging around the clinics of famous physicians and the preparation counters of the pharmacies. Sure enough, the illnesses were the same as the Three Xiang [Hunan] but the treatments were very different…. Why were the symptoms the same, but the treatments different? Could it really be due to the environment? I decided to humbly study with a famous physician, a Mr. Zhu [no relation]. After three months, I was in awe of his ingenuity and incredible skill at predicting the course of a disease. The illnesses usually went from mild to serious, ending in death, the doctor predicting every step in the process but unable to prevent the fatality. The doctor would take every appropriate action – from releasing the Exterior with pungency and coolness and driving out dampness with sweetness and blandness, to transmitting heat through the Qi sector, to clearing the Ying sector and dispersing the Blood sector; or from dispersing dampness and turbidity, to nourishing yin and clearing heat, to cleansing phlegm and opening the orifices, to settling the Liver and extinguishing wind – but could not halt this progression. To my disbelief, I quietly realized that famous doctors became famous for predicting the course of an illness, not from stopping it and saving a life. Alas! What’s the point of being a famous doctor if you know the progression of an illness but you can’t do anything about it! And the patients, believing the disease to be beyond a cure, not faulting the murderous actions of the medicine, die without a regret…. Although I had a desire to reform medicine, how could a solitary tree stand when heretical ideas are flowing all about?… Who will be the companion of the one sober man in a crowd of drunks?…¹⁴

In this passage, “the crowd of drunks” is indisputably the Warm Illness practitioners, easily identified by the long list of therapies, usually applied more or less in the order in which Zhu Weiju recounts them. The Warm Illness current, like the Cold Damage school, had a theory of how diseases, particularly externally contracted diseases, progressed through stages of increasing severity. Zhu’s critique, echoed widely amongst his reformist colleagues, was that the Warm Illness therapies, the “appropriate actions” listed above, did not treat the illness at these various stages, but rather accelerated or actually caused the disease to progress through these stages, until death became the inevitable outcome.

The problem of orthodoxy

Reading these attacks, one might reasonably ask, if Warm Illness therapies were so dangerous, how did they ever become so popular? The answer that major figures of the Warm Illness movement have given was straightforward: the inadequacies of the Cold Damage therapies necessitated these innovations. Wu Youke 吳又可, the late Ming physician who is generally considered the first scholar of the Warm Illness current, makes this point emphatically. In his Treatise on Febrile Epidemics 《瘟疫論》, he argues that febrile epidemics 瘟疫, a concept that later merges with “warm illness 溫病,” are actually far more prevalent than Cold Damage.¹⁵ Wu Youke’s critique of the Cold Damage tradition was only slowly taken up, his therapeutic innovations generally considered too piecemeal to constitute an alternative tradition. The next major innovator in the Warm Illness current, the famous Qing dynasty physician, Ye Tianshi (1667-1746), was actually a careful reader of Ke Qin, one of the great Qing scholars of The Treatise on Cold Damage.¹⁶ An eclectic practitioner and virtuoso clinician, Ye Tianshi also read Wu Youke’s treatise and adopted some of his ideas.¹⁷ In his brief but seminal essay, The Treatise on Warmth and Heat 《溫熱論》, published posthumously in 1777 by his students, it is unlikely that Ye Tianshi imagined himself founding a new current of medical practice. As Marta Hanson has shown, it was only subsequent scholarship – Wu Jutong’s, A Systematic Differentiation of Warm Illness 《溫病條辨》 in 1813, and Wang Shixiong’s 王士雄, The Warp and Woof of Warmth and Heat 《溫熱經緯》, published in 1852 – and an emerging Jiangnan regionalism that allowed Warm Illnesses therapies to become a medical current that stood in opposition to Cold Damage.¹⁸

Ironically, if there were one point on which Republican era Cold Damage advocates could agree with their Warm Illness adversaries, it would have been on the historical failures of the Cold Damage tradition. But whereas Warm Illness scholars tended to see gaps and limitations in the Cold Damage perspective that called for a fresh approach, adherents to the Cold Damage current saw a decaying scholarly tradition that was plagued by errors of transmission and philosophical distortion. The great allegiance to The Treatise on the part of Republican era reformers – Warm Illness advocates claimed a more limited allegiance – cannot be understand outside of emergence of the late imperial trend within Confucianism known as evidential scholarship 考證學. This movement grew out of seemingly minor developments in the field of philology in the late Ming, which began to question the authenticity of certain texts considered foundational to Neo-Confucian scholarship, the major philosophical trend within Confucianism since the late Song. Following the conquest of China by the Manchus and the shock of “barbarian” rule, many scholars began to further question the correctness of Neo-Confucian orthodoxies, criticizing them as speculative and solipsistic, too focused on the cultivation of moral perfection and complex cosmological systems of thought to permit pragmatic action. Evidential scholars turned towards Han dynasty writings as the only reliable sources for renewing Confucianism.¹⁹

In medical scholarship, evidential scholarship compelled a reconsideration of centuries of medical discourse. For example, the “great masters” of the post-Song period came under critical scrutiny. In the Ming, Zhang Zhongjing was considered to be one great doctor among four, the progenitor of one important branch of medicine that was complemented by the three great Jin and Yuan innovators (Liu Hejian, Li Dongyuan, and Zhu Danxi). During the Qing, evidential scholarship elevated Zhang Zhongjing to the great sage of medicine, the progenitor of all that was great in China’s medical traditions. Xu Dachun 徐大椿 (1693 – 1771), a rough contemporary of Ye Tianshi, exemplified the influence of this movement in medical discourse. In Treatise on the Origin and Development of Medicine 《醫學源流論》, he rejected the Ming dynasty celebration of the four masters in emphatic terms.

The way of medicine has long been obscured. The Ming people spoke of four great masters: Zhang Zhongjing, Liu Hejian, Li Dongyuan, Zhu Danxi, who were considered the ancient forefathers of medicine. This was truly ignorant nonsense. Zhang Zhongjing is the sage that compiled [the wisdom of] antiquity, just as Confucius is the forefather of Confucianism. The knowledge of Liu Hejian and Li Dongyuan is but one aspect [of medicine]. Zhu Danxi merely deliberated on the claims of various masters, selecting and discarding to provide a convenient approach for the novice. These are the so-called famous physicians? The three masters don’t amount to one ten thousandth of Zhang Zhongjing, How ludicrous to lump them all together?²⁰

The apotheosis of Zhang Zhongjing began to reach dizzying heights in the Republican period as reformers sought a new path forward out of China’s colonial situation. The work of the brilliant Zhang Taiyan 章太炎, one of the leading evidential scholars of his times, a major figure in the 1911 Revolution, an accomplished doctor in his own right, and a mentor to many of the reformist doctors of the Republican period offers a great example of this trend. Zhang Taiyan considered The Treatise to be China’s greatest medical text and the basis for a flourishing medical tradition that could withstand the challenge of Western medicine. “The only reason that Chinese medicine is superior to Western medicine is The Treatise on Cold Damage.”²¹ But he was also dismayed by the scholarship on The Treatise, which he expressed in a preface to Lu Yuanlei’s opus, A Modern Interpretation of the Treatise on Cold Damage.

Since the Jin, there have been many commentators on The Treatise on Cold Damage. They can be divided into three groups: the ugly like Tao Hua, the reckless like Shu Zhao, and the heterodox like Huang Yuanyu…. Cheng Wuji used ancient canons to discourse systematically [on The Treatise] but he did not understand Zhongjing’s intent. Fang Youzhi and Yu Chang rearranged the original text and cleverly defended their uses [of The Treatise] and occasionally explained their forefather’s views but often went too far. Zhang Zhicong and Chen Nianzu borrowed the doctrine of five evolutive phases and six climatic factors, mistakenly applying the Suilu Chapter [of The Inner Canon], and making an efficacious text into mystical blather. Who has been able to avoid these three errors and brilliantly stand on his own, establishing and explicating the great principles? There is no one greater than Master Ke, from Zhejiang. Who has been able to analyze clearly and insightfully? There is no one greater than Master You from Suzhou. Alas! After more than one hundred commentators, there are no more than two that can stand on their own. What a tragedy!²²

The techniques of evidential scholarship were essential for Zhang Taiyan and his colleagues in recovering (what they considered to be) the original meaning of The Treatise. This commitment to evidential scholarship further pre-disposed these Republican reformers to oppose the Warm Illness current, which fit perfectly with their narrative of the late imperial decline. As Zhang Taiyan bluntly remarked, “the superficial writings of Ye Tianshi and Wu Jutong are not worthy of respect.”²³ But it was easier to dismiss the scholarly trend than the disease conditions that supposedly gave rise to it. As a result, Republican reformers had to demonstrate that Cold Damage approaches could handle the sorts of problems that most Jiangnan doctors recognized as Warm Illness conditions. Zhang Taiyan tackled this problem in an essay, entitled “Yangming Illness Is Warm Illness” 《論陽明病即溫熱病》, arguing that the section of The Treatise on the Yangming jing already contained an analysis of and therapeutic approach for Warm Illnesses.²⁴

Yun Tieqiao, one of the leading scholars and clinicians of the Republican period, adapted this same strategy. In 1925, Yun Tieqiao opened a Chinese medicine correspondence school, using a series of textbooks that he wrote himself. One textbook, Clarifying the Principles of Warm Illness 《溫病明理》, was written explicitly to address confusions that he believed were caused by Warm Illness current. Like Zhang Taiyan, with whom he had a very close relationship, he dismissed Warm Illness scholarship.

My humble ambition is to help Chinese medicine flourish, and therefore I cannot avoid to correct false theories…. The books of Wang Mengying, Wu Jutong, Ye Tianshi are filled with flaws and errors. If I were to correct each one, the stack of papers would be as high as me…²⁵

Yun Tieqiao also argued that treatments for Warm Illnesses are already present in Zhang Zhongjing’s work. He directed his students to passages from Zhang Zhongjing’s other text, The Synopsis of Formulas from the Golden Casket 《金匱要略》, where the second chapter contained therapies for dampness 濕 and heatstroke 暍, conditions that he considered to be true Warm Illnesses.²⁶ Perhaps more importantly, he believed that only a small number of diseases fell into the Warm Illness rubric. If his contemporaries would stop misdiagnosing so many conditions as Warm Illnesses, they would soon recognize that Zhang Zhongjing’s work already contained the treatments they needed.²⁷

Removing speculation, borrowing from Japan

Republican era reformers were considerably more radical than Qing evidential scholars, such as Xu Dachun, in their critique of speculative philosophy. This radicalism was spurred in part by their access to Japanese scholarship on The Treatise. Although Japanese scholars and monks had been travelling to China to centuries, bringing the innovations of Chinese civilization back to Japan, Chinese literati were essentially unaware of intellectual developments in Japan until the rise of Japan as a military power in the late 19th century and the establishment of modern diplomatic relations between the two countries in 1873.²⁸ Yang Shoujing 楊守敬, one of the first Chinese political envoys to Japan, played an important role in this new intellectual exchange, collecting more than 30,000 Japanese texts. His 1884 publication of thirteen Japanese medical texts in a volume called The Medical Collection of the Ancestral Virtues Hall 《聿修堂醫學叢書》 marked the first time Japanese Kampo medical texts became available for a Chinese audience.²⁹ Despite these efforts, there was not a large audience for Japanese Kampo scholarship during the early years of this new diplomatic relationship. Indeed, following the Sino-Japanese War of 1895, Japan was better know as a source of biomedical knowledge, attracting numerous students to Japan’s biomedical schools in the early 1900s. One of the leading figures of the Chinese publishing world from this period, Ding Fubao, also exemplified this trend. From 1909 to 1921, he translated and published at least 83 titles, the majority of which were Japanese works on Western medicine.³⁰

Chinese interest in Japanese Kampo writings developed a little later in the 1920s, in part due to the Kampo revival movement that was gaining momentum at just this moment. Kampo medicine in Japan had been in decline since 1874, when the Meiji government passed licensing legislation that vigorously promoted biomedicine and curtailed the practice of Kampo medicine. In 1911, Wada Keijuro launched the revival movement with a vigorous defense of Kampo medicine in his treatise, The Hammer of the Medical World. As Chinese doctors began to encounter this literature, they could not help but admire its rigor, as well as its usefulness in furthering a reformist agenda. Working on his textbook, Research on the Treatise on Cold Damage 《傷寒論研究》, in 1924, Yun Tieqiao described how he first encountered Japanese medical scholarship:

I had long heard that two hundred years ago in the Eastern Country [Japan], Chinese medicine was extremely popular. There was a scholar named Yoshimasu Todo, exclusively studying the works of Zhang Zhongjing, rejecting the popular theories of Zhu Danxi, declaring [his own approach] a return to the ancients, and achieving remarkable clinical results. He was considered an outstanding doctor in Japan. I have been eager to read his writings but couldn’t find them. Shortly before finishing my manuscript Research on the Treatise on Cold Damage, I encountered an antique dealer selling dozens of old Japanese books, including more than 20 about The Treatise. I bought them all, in order to glimpse the origins of Eastern Medicine 東洋醫學. I found them clear and straightforward, superior than our various commentators, such as Chen [Xiuyuan] and Yu [Chang]….³¹

Yun Tieqiao’s writings also demonstrate some of the early influences of Japanese scholarship on its Chinese medicine readers. Yun was particularly impressed with Kitamura Tadahiro 喜多村直寛, who he believed had surpassed all Chinese writers in articulating a solution to one of the thorniest and most important theoretical questions surrounding The Treatise: what are the six jing 六經? Yun Tieqiao notes that Chinese commentators have generally been in agreement about the nature and the location of the three yang jing - Taiyang corresponds to the exterior, Yangming to the interior, and Shaoyang to the half-exterior, half-interior - but have been almost silent on the three yin jing. Citing Kitamura Tadahiro’s discussion of the six jing from Commentaries on the Treatise on Cold Damage 《傷寒疏義》 at length, Yun Tieqiao says his “discussion of the six jing is extremely clear and straightforward, beyond what our nation’s commentators have never been able to express.”³² I cite the following passage at length because this topic was debated throughout the Republican period.

Kitamura states: “The Treatise never uses the words six jing. Rather it discusses the three yin and three yang to mark exterior and interior, cold and hot, deficiency and repletion. Therefore it has nothing to do with the organs or the meridians… Whenever an illness is yang, hot, and replete, it is referred to as one of the three yang. Whenever a disease is yin, cold, and deficient, it is referred to as one of the three yin…. As for their transmission, taiyang and shaoyin are exterior and interior to each other, shaoyang and jueying are exterior and interior to each other, yangming and taiyin are exterior and interior to each other…. I do not dare to say that the order of the three yang and three yin in The Treatise does not originate from the ‘Discourse on Heat’ of The Inner Canon. The meaning could not possibly be otherwise. But regarding the transmission of disease, one must not be constrained by the order of their appearance in the text. Our predecessors were not clear about this point, causing people to feel for shadows in the dark. Was this not careless?”³³

Yun Tieqiao notes that Ke Qin, the great evidential scholar and Chinese physician, came closest to making similar claims. But he scornfully dismisses the whole history of Chinese commentary on The Treatise for its muddle-headedness. “Since Cheng Wuji and Pang Anchang to all the commentators of the Yongle and Qianlong reigns, who can escape censure for feeling for shadows in the dark.”³⁴

The encounter with Japanese Kampo scholarship expanded rapidly over the next few years, becoming inspiration for more radical thought in China. Soon Yun Tieqiao’s embrace of Kitamura would be dismissed as too conservative. This radicalization was strongly shaped by Yumoto Kyushin’s 湯本求真 influential book, Sino-Japanese Medicine 《皇漢醫學》, published in 1927 (translated into Chinese in 1928). This text was a major event in the revival of Kampo medicine in Japan and became the most widely read Japanese medical text in China. This work was also significant because it promoted one particular current of Japanese scholarship, the Ancient Formula School kohoha (Jp.) 古方派, founded by the 18^th century physician, Yoshimasu Todo. Because of Yomoto’s influence, Chinese readers soon began to see the Ancient Formula School, with its exclusive focus on the clinical applications of The Treatise, as representative of Kampo medicine as a whole.

Some reformist doctors, such as Lu Yuanlei, a student of Yun Tieqiao, were inspired by Yumoto and the Kampo revival movement. He celebrated Yumoto’s work, both to challenge biomedical doctors who looked to Japan as a model for the abolishment of traditional medicine and to remind the Chinese medicine profession that its most valuable legacy was based on The Treatise.³⁵ In his two major works, A Modern Interpretation of the Treatise on Cold Damage and A Modern Interpretation of the Synopsis of the Golden Chamber, Lu Yuanlei cited Japanese scholarship on Zhang Zhongjing 674 times and 629 times, respectively.³⁶ He was particularly enamored of the Ancient Formula School and its iconic progenitor, Yoshimasu Todo. In 1928, he wrote,

In the past, The Danxi current was very popular in Japanese medicine. But then Yoshimasu Todo came along. He advocated a return to the ancients and allegiance to Zhongjing. He rejected the writings before Zhongjing, such as The Simple Questions, The Divine Pivot, and The Classic of Difficulties. He also rejected the writings after Zhongjing, such as the masters of the Jin and Yuan. Even the terms in Zhongjing’s text, such as cold damage 傷寒, wind attack 中風, the six jing 六經, and so on, Todo believes are not the terms of a clinician nor the words of Zhongjing. The lesson Todo takes from Zhongjing is to base all herbal formulas on symptoms alone, to measure the symptoms with the formula. In China today, these proposals would be scandalous, since ancient formulas are thought to be inappropriate for modern diseases. But Todo’s clinical results were surprisingly good, truly bringing the dying back to life….³⁷

Trying to eliminate the influence of all speculative philosophy from his research on Zhang Zhongjing, Lu Yuanlei’s vision of the human body began to emulate Yoshimasu, expunging the organs, the meridians, even the six jing. By 1940, when Lu Yuanlei was producing a new textbook for his course on The Treatise, he argued that the six jing were simply six major constellations of symptoms, rejecting the explanation of Kitamura Tadahiro that his teacher Yun Tieqiao had found so apt just 15 years earlier.

The names of the six jing of The Treatise of Cold Damage come from “The Discourse on Heat” of The Inner Canon, but their reality is different than “The Discourse on Heat.” … The six jing of “The Discourse on Heat” are different still than the twelve meridians (where they are divided into hand and foot meridians to make a total of twelve) of The Divine Point. The six jing of “The Discourse on Heat” and the twelve meridians of The Divine Point are different still than qi transformations of the Taiyang cold water and Yangming dry metal, etc….

It is a mistake to use “The Discourse on Heat” to interpret The Treatise on Cold Damage. It is a mistake on a mistake to use “the meridians” to interpret The Treatise…. To use qi transformation to interpret The Treatise is make another mistake on top of the previous mistakes…. And to use exterior and interior, depletion and repletion to explain The Treatise, like Kitamura Tadahiro 喜多村直寛, who says repletion is in taiyang, depletion in shaoyin, repletion is in yangming, depletion in taiyin, and repletion is in shaoyang, and depletion in jueyin, is to still rely on qi transformation and the transmission between meridians. You will still not see the truth of The Treatise.³⁸

Lu Yuanlei’s pursuit of the truth, however, was not limited to the techniques of evidential scholarship, as he found them in Qing scholars and the Japanese Ancient Formula School. He is perhaps most famous for his vast knowledge of biomedicine. Although the 1930s were a period of sharp political tensions between the Chinese medicine and Western medicine professions, reformist doctors enthusiastically embraced biomedicine as an essential tool in the transformation of traditional medicine. Lu Yuanlei’s use of biomedicine in his scholarship was perhaps unmatched, except by his friend and colleague Zhu Weiju 祝味菊. In the following section, I turn to Zhu Weiju’s medical writings to explore the unique role of biomedicine in the Chinese medicine reformist agenda of this period.

Discovering the truth of The Treatise

In 1950, Zhu Weiju published his major opus, Interrogating Difficulties Concerning the Treatise on Cold Damage 《傷寒質難》. It was the last and perhaps most radical book by an elite Republican era medical reformer. Zhu Weiju (1884-1951) was a legendary clinician, the anecdotes about his clinical achievements suggesting that he may have been even more skilled than his very talented colleagues. As a young man in Sichuan, he was exposed to a variety of medical influences, first learning Chinese medicine with his father, later studying Western medicine at a military medicine academy for two years, and ultimately travelling to Japan for one year to learn about their medical system. He came to Shanghai in 1917, and, as described above, was initially perplexed by the medical conventions he encountered.

His boldness, his skill in using the warming herbs and formulas from The Treatise, his notoriety for defying the Jiangnan predilection for gentle, cooling therapies, earned him much acclaim. His reputation – and the issues that motivated his reformist comrades – are captured in a memorable encounter with the famous pediatrician, Xu Xiaopu 徐小圃. A Warm Illness advocate, Xu Xiaopu believed that the “pure yang 純陽” of the child must not be disturbed by the use of warming herbs. Zhu and Xu’s competing medical philosophies were put to the test when Xu’s son, Xu Boyuan 徐伯遠, became gravely ill (perhaps with typhoid fever) at the age of nineteen. Despite meticulous medical attention from the father, Boyuan grew sicker each day, until he was in critical condition. As the son’s condition deteriorated, friends and family urged Xu Xiaopu to invite Zhu Weiju for a consultation. Xu was reluctant. Believing his son was dying of a Warm Illness and knowing Zhu Weiju’s proclivity for Cold Damage formulas, he feared that Zhu’s treatment would be the final blow. But with his son’s life seemingly beyond hope, he finally agreed. True to his nickname, Aconite Zhu’s first prescription contained a large dose of the very hot and toxic herb, Aconiti Radix lateralis praeparata 附子. Zhu Weiju stayed by Xu Boyuan’s side throughout a difficult night. By the next day, Boyuan had stabilized; a week later his fever was gone; one month later he had made a full recovery.³⁹ In the aftermath of this case, Xu Xiaopu was so awed with Zhu Weiju’s clinical abilities and disappointed with his own failures that he effectively “converted” to the Cold Damage school. Both of his sons became disciples of Zhu Weiju, and he went on to become one of the most respected pediatricians in Shanghai, skillfully marshaling the very Cold Damage formulas he had once feared, helping countless children with yang warming herbs that he had once believed anathema to pediatric medicine.

Zhu Weiju was deeply committed to reforming Chinese medicine, particularly through the integration with biomedicine. In his writings, we can observe the unique perspective of Republican reformers toward biomedicine and the radical implications it had for their vision. In the preface to his book, written in 1947, Zhu calls for a unification of Chinese medicine and Western medicine.

I hope this simple and unavoidably superficial small volume can help make doctors of Chinese medicine more receptive to science and encourage doctors of Western medicine to reflect on Chinese medicine. I would be even more delighted if doctors of Western medicine used the theories in this book to study the entirety of Chinese medicine and Chinese herbs…. If we can eliminate all prejudices against the old and new, unite Chinese and Western [medicine] in one family, I believe we could make great progress.⁴⁰

These words seem strikingly contemporary, as if spoken by one of today’s numerous advocates for the “integration of Chinese medicine and Western medicine 中西醫結合.” But the context is different, and so is his intent. Today’s doctors advocate the integration of two medical systems, because they hope to bring together the best of two distinct and fundamentally different medical systems. Republican era reformers, however, did not perceive a profound epistemological divide between Chinese medicine and Western medicine. They believed that the two medical practices described the same, underlying body.⁴¹

These epistemological considerations meant that Zhu Weiju and other Replubican reformers considered biomedicine to be an essential tool for expunging centuries of speculative philosophy from the Chinese medicine corpus and rediscovering its empiricist core in The Treatise. If reformist doctors found that Japanese Kampo writings offered rigorous scholarship and lent an ineffable aura of strength from China’s imperialist neighbor to their project, drawing on “Western medicine” represented an even more strategic power move to ground their claims in science and the ultimate imprimatur of authority. As we will see, the reformist use of biomedicine sometimes led to surprising theoretical innovations and often had radical implications. For example, Zhu Weiju argued that The Treatise was a guide to the treatment of “externally contracted 外感” diseases, in particular typhoid. Qing evidential scholars, like Ke Qin, had critiqued this kind of narrow interpretation of The Treatise, arguing that its formulas were useful in the treatment of all diseases. In spite of their debt to evidential scholarship, Republican reformers generally took a narrower interpretation of the applicability of The Treatise, perhaps because their interest in biomedicine trumped their concerns for evidential scholarship. In this instance, their thinking was shaped by the biomedical disease of typhoid, which happened to be translated into Chinese as shanghan 傷寒, precisely the same term as “Cold Damage.” While Republican physicians clearly recognized the significant differences between the two uses of this term, reformist scholars such as Zhu Weiju, Yun Tieqiao, and others were also inclined to emphasize their similarities, particular since the disease course of typhoid has certain parallels with the theory of disease transmission found in The Treatise. Zhu Weiju took this effort to find equivalences between The Treatise and biomedical disease conditions a step further, naming the first four chapters of his book, Interrogating Difficulties Concerning the Treatise on Cold Damage, after the biomedicine stages of infection: incubation stage, prodromal stage, illness stage, and convalescence stage.

Zhu’s most important innovation in this text are his two guides to clinical practice: “the five stages and eight principles 五段八綱.” Zhu’s “eight principles” has become a standard feature of textbook Chinese medicine and is now called “eight principles pattern differentiation 八綱辨證.” Although the name is new, the eight principles – yin-yang, exterior-interior, cold-hot, and depletion-repletion – are not much different than the diagnostic techniques that were emphasized in late imperial medicine. Zhu’s “five stages,” however, captures his radical reinterpretation of The Treatise. Building on Lu Yuanlei’s analysis of the six jing from A Modern Interpretation of the Treatise on Cold Damage, Zhu Weiju’s five stages takes the reformist debates on the six jing to their logical conclusion. Zhu critiques Lu Yuanlei for not going far enough in his discourse on the six jing, for lacking “innovation ” and failing to free himself from the “constraints of the six jing 六經藩籬.” Lu Yuanlei’s analysis, itself built on a critique of Yun Tieqiao and his adoption of Kitamura Tadahiro’s explication of the six jing, had been an attempt to expunge all speculative philosophy from this debate. He had argued that the six jing of The Treatise had no underlying reality, rather they merely represented six fundamental constellations of symptoms that one observes in externally contracted illnesses. But Zhu considered this allegiance to the number six arbitrary, arguing that there are only five basic pathological responses to contagious disease. He then goes one to provide an explanation for how the “stages” are related to the relative strength of the patient’s “orthodox qi 正氣” and the pathogen’s “heterodox qi 邪氣.”

For all externally contracted diseases, orthodox qi must mount a response, as long as there is excitation caused by some organic pathogen 有機之邪. The tendency of that response will never fall outside five stages. The symptoms of the so-called six jing also never exceed the boundaries of the five stages. What do I mean? My so-called six jing are represented by the five types of response processes. Taiyang is the initial response; shaoyang is an unhelpful response; yangming is an excessive response; taiyin and shaoyin are both an insufficient response; jueyin is the last response. All externally contracted diseases, as long as they produce a response by “orthodox qi,” will not exceed these five stages. These are the fruits of my research. I dare say they have never been expressed before.⁴²

Republican era medical reformers attempted to systematically expunge Chinese medicine of all speculative philosophy. In the process, they abandoned the foundational entities of the body – the organs, the meridians, qi transformation – reducing them to the six jing. With Zhu Weiju’s five stages, this last vestige of traditional theory, the enduring depiction of the inner topography of the body that originates with The Inner Canon, was swept away.

The Treatise with Chinese characteristics

With the success of the Communist Revolution in 1949, a century of imperialism and decades of war and political chaos came to an end. The survival of the nation was no longer in doubt. If frail bodies were not healed immediately, Communist policies at least promised an egalitarian, homogenous body for all, strengthened through the labor regimens of workers, peasants, and soldiers.⁴³ The attempt to reform Chinese medicine based on a robust reading of The Treatise also came to an end. In part, these reform efforts were superseded by the work of the state to create modern health care institutions. The Communist government, unlike its Nationalist predecessors, now had the political control and resources to invest in the institution building necessary to a modern state. But these reform efforts also faded away because frail bodies no longer endangered the nation. China no longer needed a strong medicine to save the nation but a uniquely Chinese form of medicine to highlight the nation’s special characteristics.

For the Chinese medicine profession after 1949, the most significant effect of state health care policy was to alter its relationship with the Western medicine profession. Although the Chinese Communist Party (CCP) came to power espousing “the unity of Western medicine and Chinese medicine 中西醫團結,” its policies in the early 1950s focused primarily on the rapid expansion of the biomedical profession.⁴⁴ It wasn’t until the mid 1950s that the CCP began to build institutions for the Chinese medicine profession. The resources for these efforts, already considerably less then what was being budgeted for Western medicine, were divided between developing medical schools and hospitals for Chinese medicine while also pursuing Mao’s vision of an “integrated medicine 中西醫結合,” a program in which doctors of Western medicine would receive training in Chinese medicine to help create a “new medicine.” Interviews with doctors from this period suggest that by the late 1950s, the eventual political and social dominance of Western medicine was probably already recognized by most doctors of Chinese medicine.⁴⁵ By the end of the Cultural Revolution, it had become unalterable fact.⁴⁶ According to Lu Bingkui 呂炳奎, there were roughly ten times as many doctors of Chinese medicine to doctors of Western medicine in 1949. By the end of the Cultural Revolution in 1976, the two professions were at numerical parity. But due to political biases of the times and other social factors, the number of doctors and institutions that actually cared for patients entirely or even mostly with Chinese medicine was a fraction of what the numbers suggested.⁴⁷

With these rapidly changing social conditions in the Communist era, doctors quickly recognized that the threat to Chinese medicine was no longer doctrinal dispute from within the ranks but the challenges from without. By the mid 1950s, the Republican era animosity between the Cold Damage and Warm Illness camps was subsiding as some scholars argued that the two bodies of knowledge were actually complementary not oppositional.⁴⁸ Moreover, the growing power disparity between Chinese medicine and Western medicine altered the epistemological grounds upon which one might practice Chinese medicine. During the Republican era, Zhang Taiyan, Zhang Shanlei, Yun Tieqiao, Lu Yuanlei, Zhu Weiju and others sought to discover a single truth that united the two professions. As Yun Tieqiao remarked, “with regards to the reform of medicine, there is no other path than the mixing [of Chinese medicine] with Western medicine.”⁴⁹ In the Communist era, thanks in considerable measure to the program for the “integration of Chinese medicine and Western medicine 中西醫結合” that was launched in the 1950s, Yun Tieqiao’s call to blend the two medical system now unquestionably represents mainstream opinion in the Chinese medicine community.

But as noted above, contemporary efforts at integration represent a very different project the Republican era agenda for medical reform. Integration today is focused on using the two medical systems together in clinical practice. It is predicated on the assumption of epistemological differences – not equivalences – between the two systems of medicine. Republican era reform efforts sought to produce one unified body of medicine. Today’s doctors consider that project contrived and naive, because the body of Chinese medicine is unique and epistemologically distinct from the anatomical body of biomedicine. A clear example of this contemporary perspective can be seen in the national textbooks. First published in 1960 and then updated in 1964, 1972, 1978, 1984, and 1996, the national textbooks have been one of the great achievements of the Chinese medicine profession in the Communist period, creating a standardized curriculum for the state-run colleges of Chinese medicine. As Lecture Notes for The Treatise on Cold Damage 《傷寒論講義》, the textbook for The Treatise illustrates, the editors have been cautious about making overt comparisons between Chinese medicine and Western medicine. But at times, they have clearly been in dialogue with Republican era reformers from the Cold Damage camp. For example the fifth edition, the most highly regarded of all the editions, adamantly rejects any attempt to equate typhoid fever with Cold Damage.

The Cold Damage 傷寒 referred to in The Treatise on Cold Damage 《傷寒論》 has a completely different connotation than the Western medicine term “typhoid fever 傷寒.” We must be clear about this point.⁵⁰

Likewise, the editors have emphasized a more conservative definition of the six jing, rejecting biomedical explanations and emphasizing the links to The Inner Canon.

The six jing are the framework for pattern recognition and treatment determination with regards to The Treatise on Cold Damage. It is based on the six jing differentiation of patterns found in “The Discourse on Heat” in The Inner Canon, but it represents an advance over them.⁵¹

Chen Yiren, chief editor of the authoritative study of The Treatise by the Nanjing College of Chinese Medicine, provides additional examples of this pursuit of uniqueness. In Interpretation and Explication of the Treatise on Cold Damage, Chen rejects the Republican era narrowing of The Treatise to externally contracted disease (particularly typhoid fever) and emphasizes Qing claims about its applicability to “the hundred diseases 百病” or all diseases. He carefully examines the major explanations about the nature six jing, adjudicating the pros and cons of each position, staking out a neutral and seemingly reasonable position. He acknowledges the important connections between the six jing and the 12 major meridians, the viscera (or organ) system, and to a lesser extent the eight principles, rejecting the most speculative claims – that the six jing are the Six Climatic Qi – and the most empirical – Lu Yuanlei’s assertion that they correspond to six fundamental syndromes.⁵² Throughout this discussion, Chen carefully defends the uniqueness of The Treatise and its conception of the body based on the six jing. Not only is it distinct from the anatomical body of Western medicine, but it doesn’t correspond exactly to other conceptions of the body found in Chinese medicine theory.

These seemingly small points capture one of the fundamental differences of the two eras. In the Republican era, reformist doctors were in pursuit of a single truth and single body. Concepts and theories from biomedicine could be illuminating for this purpose, even if they seemed to strain the meaning of the original text. In the Communist era, Chinese medicine doctors have sought to highlight the uniqueness of their practice, vis-à-vis Western medicine, privileging difference over sameness. In a world where biomedicine has become hegemonic, if there is only one medical body and a single truth about how that body works, Chinese medicine is redundant. But if Chinese medicine is based on another body, distinct from the anatomical structures of Western medicine, but encapsulating an alternative truth about how the body works, than a space is opened up for its role in modern Chinese society. Although doctors no longer revere The Treatise as some of their Republican predecessors once did, they nonetheless consider it invaluable for thinking about the nature of Chinese medicine and its future role in Chinese society.