Shang Han Lun’s Role in the Evolution of Chinese Medicine – part 1

The Shang Han Lun was written by Zhang Zhong Jing (150-219), and 2000 years later is still considered to be one of the most important and influential books in Chinese medicine.

In the previous article – Chinese Medicine: Science or Faith? – The following question was raised:

Does the fact that Chinese medicine consider ancient texts to be of practical value in modern times, indicate it has a concept of a faith rather than a science?

The article focused on Zhang Zhong Jing’s vision for medicine, based on the preface he wrote to the Shang Han Lun. In the preface he appealed to the scholars expressing his wish to inspire a medicine based on education, knowledge, critical thinking and clinical observation.

However, in order to fully enable a discussion on the question raised in the beginning, it is necessary to examine the development of Chinese medicine through time. In this article we will continue to assess this issue raising 2 more questions:

1. Was Zhang Zhong Jing’s appeal to the scholars answered?

2. What was the role of Shang Han Lun in the development and transformation of Chinese medicine throughout history?

This article will focus on the period between the time Shang Han Lun was written in the 2nd century, and the historical turning point when it was officially printed by the Song government in the year 1065.

The Song period (960-1279) is without a doubt a major turning point in the perception and development of Chinese medicine. The changes were derived from a combination of the social and political circumstances of this period, which directly affected the status of the literate elite1, combined with a horrific pandemic which exposed the failures and incompetence in the field of medicine.2 Both the ruling class and the elite class, perceiving the threat to the stability of their status, started expressing concerns regarding the level and quality of medicine and doctors. There was criticism that the medical field had become a simplistic process of symptomatic approach, which could not deal with the actual complexity of diseases.3 There was a rising interest in medicine as a profession worthy of the elite and a new class of doctors emerged – the literati-physician.4 These were doctors that defined themselves by their education and knowledge of the classical texts. Acquiring the theoretical basis and assimilating those principles in the form of a systematized well-founded medical practice. These doctors voiced the same criticism and vision that Zhang Zhong Jing expressed in his preface. It is therefore no wonder that they identified themselves as the successors of Zhang Zhong Jing and the other great doctors of antiquity, taking upon themselves to study, preserve, follow and develop the medicine of the Sages.

This was the beginning of a new and exceptional era in the evolution of Chinese medicine, an era which would flourish through the Masters of the Jin-Yuan dynasties, and continues to influence and shape Chinese medicine during modern times.

However, the centuries that preceded this era were very different.

Based on the criticism expressed by Song officials and scholars, the situation of medicine at the time appears to have been very similar to the situation of medicine in 2nd century China during the time of Zhang Zhong Jing: scholars deemed medicine as an unworthy profession and it remained in the hands of uneducated healers, which based their treatments on unfounded practices and belief. This seems to have been the situation during the hundreds of years that followed the writing of the Shang Han Lun. This apparent disrespect towards medicine and those practicing it is recorded in the writings of Sun Si Miao (581-682), who authored highly influential and extensive medical documents. In the preface to his book Formulae Worth a Thousand Gold in Emergencies (Qian Jin Yao Fang 千金要方) he wrote:

“末俗小人,多行詭詐,依傍聖教而為欺給,遂令朝野士庶咸耻醫術之名…可怪也。嗟 乎!深乖聖賢之本意。”

“Decadent and petty men [practicing medicine] usually act deceitfully. They rely upon the teachings of the sages to make a duplicitous profit, thus causing the literati whether of court or county one and all to scorn the name of medical practice… It is puzzling. Alas! This is profoundly contrary to the original intent of the sages and worthies.”5

In fact, from the time it was written and for the hundreds of years that followed, the Shang Han Lun was not a popular book, it was not widely circulated and it had almost no theoretical or practical effect on the character and qualities of the medicine in China.6 It did however succeed where many other texts failed: it survived.

The mere fact that a text that was written hundreds of years before the invention of print, manages to survive the turbulence and obstacles of time, is not something that should be taken casually. There are 2 factors that should be taken into account while dealing with a text of this sort:

1. It is inevitable that the surviving text will include mistakes, changes and later additions. This is most certainly the case when the text was copied by hand, increasing the chance of unintentional errors as well as intentional changes due to personal judgment of the individual copying the text. This is added to the fact that the text was lost during certain periods, collected in fragments and put together again. It is therefore not surprising that until the official publication in 1065 there were several existing versions of the Shang Han Lun.7 The official committee appointed by the Song government to print medical texts, known as the Bureau for Editing Medical Texts, was aware of the different existing versions and decided to print 2 different versions of the text.8 The first version printed, which is considered to be the popular version, is known today as the Song edition 送本. The version we commonly use nowadays in the study of Shang Han Lun is the Zhao Kai Mei version, printed in 1599 and considered to be identical to the original Song version.

The agreement on a unified official version cannot eliminate the disagreements regarding the authentication of problematic parts of the text, but it is an imperative condition for widespread study and discussion of the text. In my opinion, this vagueness of authentication is actually not a shortcoming but rather an advantage. This is due to the fact that it promotes discussion and clinical observation in order to assess the validity of the different claims into the meaning and understanding of the text. This leads to a scientific orientation of medicine, which is based on continuous self-reflection rather than just faithfully following past conceptions.

2. The survival of a text over the span of 2000 years is not just a matter of coincidence or luck. There is most likely an active effort involved to keeping a text extant. This effort is an indication to the importance attributed to the text. Based on various written references dating between the 3rd and 11th century, the Shang Han Lun was indeed considered an important and valuable text, even prior to its official publication.9 It is worth mentioning a few of these references to the text, which demonstrate the admiration towards Zhang Zhong Jing and recognition to his text.

The earliest mention of Zhang Zhong Jing was made in the 3rd century by Huang Fu Mi, a scholar who collected, organized and edited medical documents of importance in his time. In the preface to his book Systematic Classic of Acumoxa  針灸甲乙經, he mentions Zhang Zhong Jing among other admired and inspirational doctors:

“Zhongjing expanded on Yi Yin’s [Classic of] Decoctions and composed several tens of fascicles using his extensive experience.” 10

The early admiration towards Zhang Zhong Jing in his own lifetime is also expressed in the preface of the Song Edition of the Shang Han Lun:

“He first received his [medical] skills from Zhang Bozu, who was from the same prefecture [as Zhongjing]. People at the time said the subtlety of his knowledge and skill surpassed his teacher. In the treatise he authored, his words are concise yet profound, his methods simple yet thorough.” 11

The text continued to be highly regarded in the generations that followed, evidenced by mentions such as the one by Tao Hong Jing in his book from the 6th century:

“昔南陽張機依此諸方,撰為《傷寒論》一部,療治明悉,後學咸尊舉之。”

“Formerly, Zhang Ji of Nanyang relied on these formulae to write the Treatise on Cold Damage. The treatments [it describes] are clear and thorough. Later scholars all reverently refer to it.”12

In addition to these mentions, there were actions taken in an intentional effort to preserve the text. One of the most important of these actions was done by Wang Shu He (210-285), a high ranking doctor in the palace of the Wei dynasty (220-285).13 Wang collected parts and fragments of the original text named Shang Han Za Bing Lun, which was already in danger of becoming lost to future generations. He copied, organized and edited the text, while dividing it into the 2 separate texts we use untill this day:

♦ Shang Han Lun

♦ Jin Gui Yao Lue

It is impossible for us to know the exact intention behind dividing the original text. We do know that Wang experienced the social and political chaos of China following the fall of the Han dynasty, a chaos which inevitably led to tragic loss of human lives as well as precious documents of human knowledge. It is therefore possible his decision was derived from the notion that the division of a long and complex text into 2 shorter and oriented texts gave it better chance of surviving the turbulent events of history.

Parts of the Shang Han Za Bing Lun were also copied and included in Wang Shu He’s own book Mai Jing (The Pulse Canon), Another indication of the importance Wang felt towards preserving the knowledge in Zhang Zhong Jing’s text.

Another interesting testimony to the high regard of the Shang Han Lun and a significant contribution to it’s preservation comes from the afore mentioned Sun Si Miao from the Tang dynasty period (618–907). In his book Qian Jin Yao Fang (Formulae Worth a Thousand Gold in Emergencies), Sun Si Miao complains that he is unable to obtain a copy of the Shang Han Lun:

“江南諸師,秘《仲景方》不傳.”

“The teachers of Jiangnan keep Zhongjing’s Formulae (Zhongjing fang 仲景方) secret and do not transmit it “14

It is evident from his complaint that there were known circulating copies of the Shang Han Lun, but they were rare. Those who had possession of a copy were well aware of its value and subsequently reluctant to share them. Although he had not yet succeeded in obtaining the actual text, Sun Si Miao praises the text, proof of the reputation surrounding the knowledge it contains. Sun Si Miao did not give up, and was ultimately successful in this endeavor. In his book which was written 30 years later Further Formula Worth a Thousand Gold, he included a nearly complete version of the Shang Han Lun. His effort not only contributed to the preservation of the text, but also to its circulation and influence. Sun Si Miao expresses his own appreciation to text in the preface to the chapters which included the Shang Han Lun:

“ 致於仲景,特有神功…”

“As for Zhongjing, [his methods] have a particularly divine efficacy… “15

The version in Sun Si Miao’s book is now known as the Tang edition 唐本. It is very similar to the Zhao Kai Mei edition used today, both in content as well as in style. The main differences are in scope and in the order of the lines:16

♦ 327 lines in the Tang edition, compared to 381 lines in the Zhao Kai Mei edition.

♦ 105 formulas in the Tang edition, compared to 113 in the Zhao Kai Mei edition.

♦ In the Tang edition lines are arranged according to referenced formula, while in the Zhao Kai Mei edition the lines are arranged in according to conformation.

Thanks to the efforts of all the authors and physicians who sought to save the contents of the Shang Han Lun from disappearing, Zhang Zhong Jing’s appeal to the scholars calling them to take upon themselves the responsibility of developing high quality medicine, was finally answered in the 11th century.

Was the Shang Han Lun a critical element in enabling the change in attitude towards medicine? Or was this change a sole result of the circumstances and of the natural development of medicine in China?

The opinions differ among researchers of the development of Chinese medicine. There is the opinion that the circumstances are the reason for the change, while the Shang Han Lun profited from the change itself, gaining recognition following hundreds of years of being neglected and nearly forgotten. According to this assertion, the underlying reason for choosing the Shang Han Lun to be among the few texts published by the Song government, was not appreciation for the text, but rather a need to display some sort of response to the ravaging pandemic, a problem which the Shang Han Lun was committed to solve.17 Researchers offering a different opinion, suggest that the text was recognized and highly regarded throughout history. When the right circumstances appeared, the mere existence of the text was a significant factor that enabled the scholars to connect to medicine by providing the necessary foundation for developing medicine as a respectable profession worthy of scholars.18

Either way, all researchers agree on 2 things:

1. The Shang Han Lun was a unique text for its time. Other known clinical texts from the period that pre-dated its publication were composed of a symptomatic approach to medicine. This diagnostic and treatment method led to the ever-increasing addition of more and more formulas to account for the endless clinical possibilities. The result was an accumulation of an enormous amount of formulas, reaching tens of thousands. This meant it was virtually impossible to learn and apply medicine in an organized and structured manner.19

The Shang Han Lun, however, offered the scholars of the Song dynasty a completely different approach to medicine.20,21 It was written as a clinical guide for the educated doctor, well versed in the classical canons with a thorough understanding of the theoretical models. It offered a systemic clinical approach of implementing the yin-yang theory in practice, enabling profound understanding into a wide range of clinical situations, while using a limited number of formulas.

“It was through the understanding of the Treatise (ie. Shang Han Lun) that Song physicians built both practical and theoretical bridges between the symptom-centered practice and Classical Medicine.” 19

2. The Shang Han Lun received a major role in the change that evolved during the Song dynasty.22,23 The perception that a skilled and qualified doctor needed to be proficient in the Shang Han Lun was increasingly accepted. As soon as the 11th century, shortly after the official publication, books dedicated to the clinical implementation of the Shang Han Lun started to appear. The Shang Han Lun became a tool in the hands of the literati physician as an authority for arguing cases and a foundation for establishing status of supremacy over the common doctors.24

As a practitioner of Chinese Medicine who relies on the insights and the formulas of the Shang Han Lun in my daily practice, it is easy for me to understand why the scholars of the Song dynasty were drawn to the Shang Han Lun: They were drawn to its organized systemic approach, which offered practical tools for resolving the complexity of diseases. They were drawn to the diagnostic model which bridges the theoretical foundation of Chinese philosophy and medicine to the clinical reality, a model which allows for further development in accord to clinical observation and experience. They were drawn to the vision that was expressed in the preface of the text, calling upon a medicine based on the principles of education, critical observation and creativity. The scholars of the Song dynasty needed the Shang Han Lun just as much as the Shang Han Lun needed them. It enabled them to develop medicine as a sophisticated, challenging field of thought with practical aspects allowing them to attain an honorable contribution to society. They, in return, established the Shang Han Lun as a central text, vital to the development of Chinese medicine to this day.

The exact character and extent of its effect on the development of Chinese medicine from the Song dynasty until modern times, will be discussed in the next article.


References:

1. Hymes RP, Not Quite Gentlemen? Doctors in Sung and Yuan
2. Goldschmidt Asaf, Evolution in Chinese Medicine: Song Dynasty, 960-1200: p. 84-87
3. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 78-97
4. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 119-170
5. Translated by Boyanton in: Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 83
6. Goldschmidt Asaf, Evolution in Chinese Medicine: Song Dynasty, 960-1200: p. 95-99
7. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 39-48
8. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 126-130
9. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 30-37
10. Translated by Boyanton in Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 7
11. Translated by Boyanton in Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 7
12. Translated by Boyanton in Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 32
13. Goldschmidt Asaf, Evolution in Chinese Medicine: Song Dynasty, 960-1200: p. 97
14. Translation by Boyanton in Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 33
15. Translated by Boyanton in Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 34
16. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 42
17. Goldschmidt Asaf, Evolution in Chinese Medicine: Song Dynasty, 960-1200: p. 87-102, 171–172
18. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: 116-170
19. Goldschmidt Asaf, Evolution in Chinese Medicine: Song Dynasty, 960-1200: p. 145
20. Goldschmidt Asaf, Evolution in Chinese Medicine: Song Dynasty, 960-1200: p. 142–146
21. Unschuld PU, Medicine in China, A History of Ideas: p. 169
22. Goldschmidt Asaf, Evolution in Chinese Medicine: Song Dynasty, 960-1200: p. 141–146
23. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: 116-170
24. Boyanton S., The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 134-162

 

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