This article explores the founding of the Suzhou Hospital of National Medicine in 1939 during the Japanese occupation of Suzhou. We argue that the hospital was the culmination of a period of rich intellectual exchange between traditional Chinese and Japanese physicians in the early twentieth century and provides important insights into the modern development of medicine in both countries. The founding of this hospital was followed closely by leading Japanese Kampo physicians. As the Japanese empire expanded into East Asia, they hoped that they could revitalize their profession at home by disseminating their unique interpretations of the famous Treatise on Cold Damage 傷寒論 abroad. The Chinese doctors that founded the Suzhou Hospital of National Medicine were close readers of Japanese scholarship on the Treatise and were inspired to experiment with a Japanese approach to diagnosis, based on new interpretations of the concept of “presentation” (shō / zheng 證). Unfortunately, the Sino-Japanese War cut short this fascinating dialogue on reforming medicine and set the traditional medicine professions in both countries on new nationalist trajectories.
In December of 1939, a new journal of Chinese medicine, based in the city of Suzhou, opened its inaugural issue with this remarkable preface.
The observant long ago recognized the difference between the great civilizations of East and West. Eastern civilization excels at the metaphysical; Western civilization excels at the physical. How can medicine be any different? Eastern medicine 東洋醫學 is synthetic, inductive, and best at internal medicine. Western medicine is analytic, deductive, and superior at surgery. If the two could be forged into one, then they would make an incomparable new medicine for the world. . . . The first step is to revive and develop the withering and ailing Eastern medicine. . . . Today my comrade Dr. Tang Shenfang . . . has given medicine something truly valuable in the launching of the Journal of the Suzhou Hospital of National Medicine 蘇州國醫醫院院刊. (Yumoto 1939)
This article explores the contours of medical reform that inspired the Suzhou Hospital of National Medicine and its significance for contemporary practitioners in China and Japan. Although the hospital survived for only two years and unfortunately published just one issue of its journal, it nonetheless provides crucial insights into the modern transformation of traditional medicine in East Asia and reminds us of other futures that might have been.
Imperialism and Civilization
As European and Japanese imperialist forces were redrawing the political boundaries of East Asia and transforming the social, economic, and intellectual landscape of the region, medicine was at the center of debates about modernity and tradition. It was both an arena of social change and a force for change itself. Thus, biomedicine, a tool of nineteenth-century religious missionizing, became an essential component of twentieth-century statecraft in East Asia (Iijima 2005; Rogaski 2004). Traditional medicine, which had been an integral part of the social fabric of both rural and urban life in nineteenth-century East Asia, was also transformed by these twentieth-century social and political changes. Indeed, the names we are using for traditional medicine in China and Japan, “Chinese medicine” and “Kampo medicine,” respectively, emerged through the encounter with biomedicine in the nineteenth and twentieth centuries (Kosoto 1999: 2–4; Lei 2014: 121–40).
Changes were most dramatic in Japan, where the policies of the Meiji government followed the German model of Staatsmedizin, or “state medicine,” implementing an integrated, authoritarian, state-controlled system of biomedical institutions and Western-style public health policies, while simultaneously excluding Kampo practitioners from the new medical licensing system. State-centered biomedicine and public health became the basis for colonial medical policies in Taiwan and Korea following victories in the Sino-Japanese War (1894–95) and Russo-Japanese War (1904–05), respectively (Iijima 2005: 130–38; Liu 2009: 19–46). Changes came more slowly to China, which was politically fragmented in the early twentieth century and struggling to stave off imperialist encroachments from Western European states and Japan. Almost all Chinese political reformers believed that biomedicine should be an integral feature of the new Chinese nation state, but some wished to follow the Japanese lead and ban the practice of Chinese medicine in order to achieve this goal. Despite this complicated political terrain, the Chinese medicine profession continued to grow and evolve vigorously in the 1920s and 1930s, and the establishment of the Suzhou Hospital of National Medicine in 1939 is just one example of the many interesting developments during this period.
One of the important effects of the nineteenth- and twentieth-century imperialism in East Asia was that it created tenuous prospects for a new regional unity under a notion of Eastern civilization (東方文明 or 東洋文明), a unity that was ultimately destroyed by war and later superseded by competing nationalisms. Conquering Europeans justified their new dominance in the region in part through the notion of civilization and the advantages their advanced society would bring to the peoples of East Asia (Hevia 2003). Following the establishment of diplomatic relations between China and Japan in 1870, an implicit recognition of the new importance of European style diplomacy, intellectuals from both countries also began to explore their shared cultural heritage, referring to each other as nations with “shared writing” 同文 (Howland 1996: 54). The notion of shared writing, referring to a complex of shared values, practices, and knowledges, ultimately evolved into a grander discourse of Eastern civilization, the term Yumoto used in his preface. This process was slow and fitful as the “shared writing” of the premodern Sinocentric world was gradually reimagined through the concepts of race, geography, and the struggle against Western imperialism (Saaler 2011: 10). The brutality of the Great War contributed to this process by undermining the notion of a universal civilization, belonging only to the West, as writers such as Oswald Spengler and Arnold Toynbee began to formulate a new discourse of multiple civilizations, expressions of the achievements and virtues of a people, not of all humankind. These ideas found a receptive audience in Japan and soon spread to China, in part through the writings of Taisho intellectuals (Duara 2003: 89–103). The notion of Eastern civilization was an attractive concept to both Chinese and Japanese thinkers, validating the achievements of East Asian society, even elevating them over the West because of its seemingly peaceful and spiritual values, while at the same time being ambiguous enough to encompass a range of different political agendas.
One expression of this sort of regionalism that had some more troubling political implications was pan-Asianism, the call for the unity of Asian peoples in order to cast off European imperialism. There were many enthusiasts for this ideology in Japan. In its earliest forms its relatively small number of adherents, sometimes referred to as romantics, promoted egalitarianism in East Asian and often associated with opposition leaders in China and Korea. During the early Taisho period, as Japanese military strength grew, the small movement of pan-Asianism became linked to government policies to unify Asia under Japanese hegemony (Saaler 2011). Wary of this emerging imperialist agenda, Chinese political reformers denounced this new version of pan-Asianism, although they seemed to also accept the premise of a need for a unified Asia. Li Dazhao decried pan-Asianism for using “the intimate words of ‘shared writing, shared race’” as a pretext for “swallowing up China,” calling instead for a “New Asianism” of liberated peoples (Li 1919). Sun Yat-sen in his 1924 speech on pan-Asianism both celebrated Japan's achievement in being the first Asian nation to cast off European imperialism and admonished Japan to take the “kingly way,” to lead by moral example, not military strength (Sun 1930). Today, in the aftermath of the bitter Sino-Japanese War, it is hard not to view pan-Asianism and the notion of Eastern civilization as anything other than a mere fig leaf for Japanese aggression in East Asia.
In its time, however, various forms of Asian regionalism, whether under the banner of “shared writing” or the later notion of Eastern civilization, appealed to many constituents across East Asia and was a far more powerful force in the region than is generally recognized today (Duara 2003: 99). In the world of medicine these discourses were less attached to questions of political hegemony. As we will see in the case of the Suzhou Hospital of National Medicine, Japanese and Chinese doctors could unite around their shared heritage and the urgency of preserving it, even in the midst of the hostilities of the Sino-Japanese War. Both groups revered Zhang Zhongjing's 張仲景 Treatise on Cold Damage 傷寒論 (ca. 220 CE; Shanghanlun in Chinese, Shōkanron in Japanese; hereafter the Treatise), which they saw as the basis for restoring a “decaying” form of medical practice to its original greatness.
Historian Cao Lijuan has argued that the Suzhou Hospital of National Medicine was unique in numerous respects (Fig. 1): it was a relatively complete institution, particularly when compared with other “hospitals” of the day, with an inpatient ward of more than fifty beds, its own training center for nurses, carefully kept medical records and statistical charts, and its own journal publication (Cao 2005). In this article, we argue that the significance of the hospital goes far beyond these technical achievements. It also represented the high point of a particular moment in medical reform. Under the banner of “Eastern civilization,” certain strands within the scholarly medical traditions of China and Japan seemed as if they might merge together and produce a new form of traditional medicine.
Mutual Support in the Context of War
The Suzhou Hospital was established on 16 April 1939, and the first significant fact about this event was that it happened in postinvasion Suzhou, where medical services were collapsing. Although it is probably impossible to know precisely how traditional practitioners were affected by the Japanese offensive on Suzhou, the war was clearly responsible for the closure of most biomedical institutions in Suzhou. According to the Suzhou Gazetteer, there were thirty-four hospitals and clinics of Western medicine in Suzhou city in 1936, both public and private. After the invasion in 1937, however, only Boxi Hospital 博習醫院, the oldest hospital in Suzhou, established in 1883 by American Methodists missionaries, continued to operate (Suzhoushi difangzhi bianzuan weiyuanhui 1995: 1048–49). Following the Japanese military offensive, which drove the Kuomintang (KMT) government from its capital in Nanjing, the Japanese Central China Expeditionary Army set up the Reform Government of the Republic of China 中華民國維新政府 (28 March 1938–30 March 1940) to administer the provinces of Jiangsu, Zhejiang, and Anhui as well as the two municipalities of Nanjing and Shanghai (Chūkaminkoku ishinseifu gyōseiin sendenkyoku 1939; Hori'i 1995a, 1995b, 2000; Brook 2007). However, due to its administrative weakness and anti-Japanese guerrilla fighting, the medical services of the Reformed Government did not go beyond the “minimum required” (Ishinseifu gaishi hensan-iinkai 1940: 145–55). Under these circumstances, the opening of the Suzhou Hospital of National Medicine was a striking event.
It was all the more unusual because Japanese colonial medical policies, particularly as established in Taiwan and Korea, had more or less adhered to its domestic Staatsmedizin philosophy, actively promoting biomedicine while repressing traditional medicine (Liu 2009: 47–85). After the Manchurian Incident in 1931, which led to the invasion of Manchuria and later war with China, there was a growing recognition that some accommodations to local conditions would be necessary and traditional practitioners were tolerated and even used by colonial administrations at times (Yakazu 1988: 48–50; Shin 2003). Although the medical policies of the Reformed Government would have officially followed this late colonial trend, its embrace of Chinese medicine is still notable. This more tolerant orientation may be reflected in the fact that the government registered 251 doctors of Chinese medicine along with 64 doctors of Western medicine between February and November 1939 (Ishinseifu gaishi hensan-iinkai 1940: 147).
Perhaps the second important fact about the founding of the Suzhou Hospital of National Medicine was that Suzhou happened to be home to an important group of reform-minded doctors, innovators in pedagogy, research, and clinical practice. The origins of the hospital go back to 1926, when the young physician Wang Shenxuan 王慎軒 established the Suzhou Gynecology Association 蘇州女科醫社 in 1926. With an expanded curriculum, the school was officially renamed the Suzhou School of National Medicine 蘇州國醫學校 in 1934, and Tang Shenfang 唐慎坊 was invited to be the president (Deng 1999: 203). The college established an affiliated clinic in 1935, but both school and clinic were closed down with the outbreak of the Sino-Japanese War in 1937 (Suzhoushi difangzhi bianzuan weiyuanhui 1995: 1048–49). Led by Tang and Ye Juquan 葉橘泉 (1896–1989), this group was able to continue their educational work and clinical research in postinvasion Suzhou. Six out of fourteen full-time staff members that founded the Suzhou Hospital of National Medicine were either professors or students at the original college (Suzhou guoyi yiyuan 1939: yuanwu 9).
The unique composition of these doctors is also clearly reflected in the stated goals of the hospital: to demonstrate the efficacy of Zhang Zhongjing's “classic formulas” 經方 through the institutional framework of a modern hospital and the collection of statistics (Suzhou guoyi yiyuan 1939: yuanwu 1, zhiliao shili 1). This focus on clinical efficacy is consistent with the general evolution of hospitals in China, which were shifting their emphasis from philanthropic to professional objectives during the first decades of the twentieth century (Renshaw 2005: 187). The journal also reports statistics about the makeup of its patients and their disease profiles, providing rich material on the nature of medicine in urban China at this moment in history (see Figs. 2 and 3). Chinese medicine therapies were used for all treatments, and, true to the hospital's mission, “classic formulas” were used in 75 percent of all cases (see Fig. 4).
Despite the weakness of the Reformed Government, its support was indispensable to the opening of the Suzhou Hospital of National Medicine. The key player in this process was Chen Zemin 陳則民 (1881–1951), governor of Jiangsu. Born in Wu County 呉県, he had traveled to Japan for higher education, like many of the elite students of his generation, earning a law degree from Nihon University. Chen's personal interest in the hospital is evident in the introduction to the Journal of the Suzhou Hospital of National Medicine, where he celebrates classic formulas as “the unchanging standard of ten thousand generations” and can only sigh in profound admiration at Kampo scholarship on the Treatise (Suzhou guoyi yiyuan 1939: yuanwu 1). We also know that Ye had considerable faith in Chen and stated so in a letter to Ōtsuka Keisetsu 大塚敬節 (1900–1980), one of the leading Japanese Kampo physicians of this period.
Dear Dr. Ōtsuka . . . Governor Chen wholeheartedly supports Chinese medicine and the establishment of its administrative status. However, it is a pity that the Department of Health of the Reformed Government in Nanjing is strongly influenced by Western medicine. I have been struggling against them. (Ōtsuka 1940: 3)
Chen's personal connection with the Suzhou Hospital of National Medicine was further mediated by his nephew, Chen Kangsun 陳康孫, who worked in the Secretariat of the Reformed Government and was known as a “Confucian who studied medicine” (Ōtsuka 1939b: 2). Chen Kangsun was interested in the reformist ideas being promoted by Ye and helped him publish one of his major early works, Collection of Contemporary National Drug Formulas for Internal Medicine 近世内科國藥處方集. When the Suzhou Hospital of National Medicine was established, Chen Kangsun became its assistant director.
Medical Revival and the Promise of Imperialism
While it is hard to know with precision the micropolitics that enabled the founding of the Suzhou Hospital of National Medicine, this event was greeted with genuine enthusiasm by many leading Kampo physicians, such as Yumoto Kyūshin and Ōtsuka Keisetsu (Anonymous 1940: 4). What connected these Japanese doctors with this group of physicians in Suzhou? Ultimately, it was the shared problem of political weakness. Both groups faced hostile political establishments and intellectual elites. The political vulnerability of doctors of Chinese medicine in the early twentieth century was ameliorated by their numerical preponderance over doctors of Western medicine. But with the establishment of the Nationalist government in 1928 and the entrenchment of biomedical doctors in the machinery of the state, the threat to the profession grew, although ultimately political actions were limited (Lei 2014; Croizier 1968).
By contrast, Kampo physicians had been politically marginalized for more than half a century. The decline of Kampo in Japanese society began in the late nineteenth century, when the Tokugawa government was overthrown by political reformers who revered the emperor, leading to the Meiji Restoration of 1868. The Meiji and post-Meiji governments were driven by a fear of Western imperialism and pushed Japanese society to embark on a rapid modernization program that included an aggressive promotion of Western medicine. When the Medical Licensing Act (Isei 醫制) was implemented in 1875 to institutionalize educational standards, all examination subjects consisted of Western medicine. Although the system actually had a few loopholes that enabled most Kampo doctors to continue their medical practice, the training of new Kampo doctors was strongly discouraged because anyone who wanted to become a qualified doctor had to master Western medicine first (Kosoto 1999: 176–77).
In the early twentieth century, however, several dynamic Kampo physicians led a revival movement that not only struck a chord in Japanese society but also had considerable influence in China. The seminal text of this revival movement was The Hammer of Medicine (醫界之鐵椎, 1910) written by Wada Keijurō 和田啓十郎 (1872–1916). Wada's mission was to demonstrate the clinical value of Kampo medicine and defend its merits against the supposed advantages of Western medicine. In this task, he drew heavily on the writings of Yoshimasu Tōdō 吉益東洞 (1702–73), whose innovative interpretations of the Treatise had helped to found a new current of medical practice, Kohōha 古方派, or the Ancient Formulas School, in eighteenth-century Japan. Wada celebrated Tōdō's work, elevating it over competing schools of medicine for its apparent empiricism and clinical efficacy, which he believed rivaled that of Western medicine. He also praised the Ancient Formulas School as “no longer Chinese medicine but a unique form of Japanese medicine” (Wada 1910: 8). Wada's writings and teachings inspired other influential doctors such as Yumoto Kyūshin and Nakayama Tadanao 中山忠直 (1895–1957), helping to spur a Kampo revival movement.
The efforts of Kampo revivalists began to bear fruit in the 1930s: the Japan Kampo Association (Nihon Kampo igakukai 日本漢方醫學会) was founded in 1934; public lectures on Kampo medicine were offered at Takushoku University (Takushoku Daigaku Kampo igaku kōza 拓殖大學漢方醫學講座, 1937–49); and the Association of East Asian Medicine (Tōa igaku kyōkai 東亜醫學協会) was established in 1938. A new generation of students—such as Ōtsuka Keisetsu and Yakazu Dōmei 矢数道明 (1905–2001)—emerged to carry forward the revivalist vision. Concomitant with these developments, leading Japanese Kampo doctors began to imagine Japan's new military power in East Asia as a means to fulfill their professional aspirations. Perhaps because many Kampo revivalists were certified in Western medicine and understood the centrality of biomedicine to Japanese imperial aspirations, they also imagined new possibilities for Kampo medicine in these colonial spheres. Their slogan was “Kampo, baptized by science, to the continent” (Ōtsuka 1939a: 1). They quite self-consciously believed that their two most unique features—the understanding of the Treatise derived from the Ancient Formulas current and their professional training in Western medicine—gave them a special role to play in Japan's imperial project.
Now it is time for Kampo medicine to make a remarkable step forward under the collaboration of three nations (Japan, China, and Manchukuo). This will be realized by the expansion of institutions of medical education, the establishment of Kampo hospitals and Kampo libraries, the experiments and cultivation of Kampo drugs, and so on. Through these works, we must push forward toward the fulfillment of a true Eastern medicine (Shin no Tōyō igaku 真の東洋醫學) that will lead the new era in East Asia after the Second Sino-Japanese War. (Anonymous 1939: 1)
Although Kampo doctors hoped to demonstrate their relevance to Japan's growing empire, their social and political weakness meant that they could only hope that their colonial counterparts would embrace their vision of true Eastern medicine. Since Kampo physicians had failed to even establish a hospital for Kampo medicine within Japan (Yakazu 1988: 35–6), they were delighted at the opening of the Suzhou Hospital of National Medicine, particularly since the hospital was founded on principles remarkably similar to those espoused under the banner of “true Eastern medicine.” One excited Japanese commentator wrote:
[At the Suzhou Hospital of National Medicine] they lead and enlighten the common people who fear rhubarb 大黃 and gypsum 石膏 as if they were deadly poisons and look at dried ginger 乾姜 and aconite 附子 as if they were snakes and scorpions. They are determined to prescribe Zhang Zhongjing's formulas and have shown great achievement. Policies like these will dispel the superstitious illusions in Chinese medicine that have continued for more than a millennium. (Anonymous 1940: 4)
Reforming Chinese Medicine
That the Kampo revival movement would find an audience in China was by no means guaranteed. It is likely that Kampo scholarship reached only the most educated, elite, urban doctors in China. Even within this select group, the focus on the Treatise would have seemed unnecessarily narrow for most Chinese doctors who considered Zhang Zhongjing to be but one of many important figures in the history of Chinese medicine. An example of this kind of resistance can be found in the Tianjin-based journal Authoritative Words about National Medicine 國醫正言, which published an exchange between Wu Hanxian 吳漢僊 and Yumoto Kyūshin. Yumoto had criticized Wu's new book, Alarm Bell of the Medical World 醫界之警鐸, for recommending the use of Li Gao's 李杲 famous twelfth-century formula, Tonify the Middle to Augment the Qi Decoction 補中益氣湯, to treat fever caused by internal damage. Yumoto's view was that “Treatise formulas can be used to treat all diseases.” In an open letter, Wu responded with incredulity that Yumoto refused to recognize the basic divide between disorders due to external causes 外感 and those caused by internal damage 內傷, for which “contemporary formulas” 時方 developed in the late imperial period are more appropriate. In Wu's view, it was dangerous to use Zhang Zhongjing's formulas for anything other than disorders with external causes (Wu 1935).
The debate between Wu and Yumoto turned on one key point: whether the Treatise can be used to treat all diseases or just a subset of disorders due to external causes. In China, Wu's position represented the majority view, a consensus that emerged during the Ming. Nonetheless, a small, influential group of reformist doctors in China were attracted to Yumoto's perspective. In 1929, Lu Yuanlei 陸淵雷, who later taught at the Suzhou School of National Medicine, captured some of their sentiments:
I've recently read the works of the Eastern doctor, Yoshimasu Tōdō, such as Formulas by Categories 類聚方, Formula Standards 方極, and Drug Presentations 薬徴, which coincidentally match my views. Treating disease according to his recommendations is very effective. . . . If there had never been a Tōdō, then Kampo medicine would not be enjoying today's revival but would have perished in the Meiji Restoration. Why? Because the therapies of the Danxi School are inferior to German medicine. Today's so-called doctors of Chinese medicine in China are different. They don't follow the lineage of Zhongjing. They just clutch the books of Ye Gui (Tianshi) and Wu Tang (Jutong), believing this is the locus of Chinese medicine, sinking again into the doctrines of Five Evolutive Phases and Six Climatic Qi to perish without ever knowing why. (Lu 2008: 83–84)
In order to understand Lu and the Chinese reformist embrace of the Treatise and rejection of late imperial medicine, it is crucial to understand their training in evidential scholarship. This intellectual movement began with small innovations in philology during the Ming and became a full-blown critique of neo-Confucianism by the end of the Qing. For scholars of this persuasion, neo-Confucian thought was speculative, mystical, and abstruse. Only a return to the established verities of the Han Dynasty could rectify the corruption of late imperial Chinese society (Elman 1984). The most dangerous development in the post-Song medicine, to their eyes, was the Warm Disorder current. This unique trend in Chinese medical practice, which was less known in northern China and had little influence in Korea and Japan, was popular in the Jiangnan region because of its repertoire of gentle, cooling formulas that were thought to be well suited to the supposedly delicate constitutions of southerners (Hanson 2011; Scheid 2007). For reformers like Lu, the Treatise with its pithy, time-tested formulas, its use of potent, frequently warming herbs, its relative absence of philosophical speculation, and its Han dynasty pedigree, was the perfect antidote to contemporary doctors such as Wu.
An exemplar of the role of evidential scholarship in medical reform in China was Zhang Taiyan 章太炎 (1868–1936). Zhang was widely recognized as perhaps the leading evidential scholar of his generation and revered by many for his prominent role in the 1911 Revolution. But Zhang was also an accomplished physician of Chinese medicine. In his later years, he devoted much of his scholarly efforts to research on Chinese medicine and was a mentor to many of the leading Chinese doctors in reformist circles. Writing in the preface to Lu's opus, A Modern Interpretation ofthe Treatise on Cold Damage 傷寒論今釋, Zhang gives us a classic statement of the evidential scholarship perspective on late imperial medicine:
Since the Jin, there have been many commentators on the Treatise. . . . 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 [Qin], from Zhejiang. Who has been able to analyze clearly and insightfully? There is no one greater than Master You [Zaijing] from Suzhou. Alas! After more than one hundred commentators, there are no more than two that can stand on their own. What a tragedy! (Lu 2008 : 1)
With the spread of the Treatise to Japan, there have also been dozens of commentators. Their commentaries follow the text closely and are considerably more circumspect than ours. Their treatments demonstrate an ability to modify formula with virtuosity, unimpeded by past orthodoxies, and moreover with frequent clinical success. In terms of making Zhongjing [come to life in the] present, we must state: our Way has gone to the East. (Lu 2008 : 1)
Although he died in 1936, Zhang's influence on the Suzhou Hospital of National Medicine was palpable when it opened three years later. In the opening section of the Journal of the Suzhou Hospital of National Medicine, Ye Juquan reiterates Zhang's message that Japan is now the center of “our Way”:
[The medical traditions of China] . . . truly have undeniable value, especially the classic formulas of [Zhang] Zhongjing. . . . Unfortunately, due to the recent trends in medicine, cunning physicians often don't understand the patient's presentation. They prefer the gentle over the strong [treatments] and have developed the “contemporary formulas” 時方 as a result. Deluding with gentle treatments and ineffective prescriptions, these doctors are irresponsible. They delay the recovery from mild illnesses and bungle the treatment of serious ones. . . . Ever since the rise of Yoshimasu Tōdō, Japanese Kampo medicine has championed the classic formulas of Zhongjing, curing serious illnesses and the hard-to-treat. This brought about a great resurgence in the popularity of medicine. As a result, Mr. Zhang Bingling [Taiyan] has said, “Our Way has gone to the East. We should emulate the East and not fear the Far West.” (Ye 1939: zhiliao shili, 1)
Emulate the East and do not fear the Far West. Learn from the itinerant drug peddler below; do not privilege the Confucian physician. The worst physicians are those who claim to know the resonances of Heaven and Man and blather about the Five Phases. Their words are many; their successes few. They may appear to be right but are often wrong. The Way is always nearby; let the body of your patients be your teacher. Do not illicitly seek fame; let the words of the cured be the proof of your efficacy. (Suzhou guoyi yiyuan 1939: zhiliao shili 58)
In their mission to create a “true Eastern medicine” Kampo doctors made a virtue of their decades-long struggle with the Western medicine profession in Japan, proudly proclaiming that they had been “baptized by science.” What did this “religious experience” mean, and how could it be brought to the colonies? One important result of the encounter with biomedicine can be found in the philosophical inquiries into the relationship between Kampo medicine and Western medicine. Through the writings of the Kampo revival movement, Japanese physicians had begun to see the two medical systems as ontologically distinct (Shin 2011). Table 1, excerpted from an article published in East Asian Medicine 東亜醫學 in 1940 by Yakazu Dōmei, presents a well-developed list of comparative traits, each characteristic of one medical system matched to an opposing characteristic of the other.
Although other Japanese scholars would debate the specifics of these terms, they were in general agreement that the two medical systems existed in binary opposition to each other (Shin 2011). Among scholars of Chinese medicine at this time, these sorts of oppositional comparisons were only just emerging (Karchmer 2005), and possibly through the influence of Japanese scholarship. Chinese doctors, particularly reformist scholars such as Zhang, Lu, Zhu Weiju, and others, tended to emphasize the strong convergences between Chinese medicine and Western medicine. Whereas Chinese reformist doctors envisioned epistemological compatibility (Karchmer 2015), Kampo physicians were constructing ontological divides. In short, Kampo doctors were not just trained in biomedicine; their “baptism by science” meant that their own understanding of Kampo medicine had been framed by their knowledge of biomedicine.
For the doctors of the Suzhou Hospital of National Medicine, it was Japanese scholarship on the different characteristics of diagnosis in Kampo medicine and biomedicine that was the most influential such comparison. Japanese scholars focused on the key term shō (Japanese) or zheng (Chinese), which has historically referred to the “presentation” of an illness but was written with two more or less interchangeable characters in the late imperial period. In the early twentieth century, Kampo scholars began to argue that these two characters were distinct terms, emblematic of the diagnostic differences between Kampo medicine and biomedicine. A translated excerpt from Ōtsuka's 1932 book, The Key to Classifying and Discriminating Clinical Presentations in Kampo Medicine 類證鑒別漢醫要訣, published in 1934 in the Suzhou Journal of National Medicine, the journal affiliated with the Suzhou School of National Medicine, provides an example of this scholarship. In the following passage, Ōtsuka argued that the homonyms (in both Japanese and Chinese) of shō / zheng 證 and shō /zheng 症 referred to radically different concepts:
Shō / Zheng 證 presentation means evidence, verification, confirmation. It also means proof. It is completely different than shō / zheng 症 symptoms. . . . If you are examining a patient with pneumonia who has fever, chills, floating and tight pulse, absence of sweating, and panting, then this is called the Ephedra Decoction presentation (shō / zheng 證). If the patient has only a fever or wheezing, then this is a symptom, not a presentation. (Ōtsuka 1934; emphasis added)
What makes this small point in Ōtsuka's writing so significant is that it captures a moment of emergence, the “baptism by science,” as it is transpiring. We can further appreciate this emergent process by examining the writings of Yumoto Kyūshin, Ōtsuka's teacher, who had addressed the same topic a few years earlier. In Sino-Japanese Medicine 皇漢醫學, published in 1927 and translated into Chinese in 1928, Yumoto made a similar ontological distinction in the therapeutic approaches of the two medicine systems. He doesn't explicitly remark that there are fundamental semantic differences between the two characters for shō / zheng, but it is implicit in his claims, and we use the glosses of presentation and symptom accordingly.
The symptomatic therapy 對症療法 of Western medicine and the “adjust the therapy to the presentation” 隨證治之 approach of Kampo medicine look similar but are different. The former focuses on the patient's uncertain self-reported symptoms 自覺症狀 and seeks to repress them. This approach is called treating the branch in Kampo medicine and is completely different than the “adjust the therapy to the presentation” approach. Kampo medicine combines the self-reported symptoms with the observed symptoms 他覺症狀 to discover the confirmed and unchanging symptoms 症狀 and treats that. For Kampo medicine, treating the presentation 證 is a causal therapy 原因療法 and a treatment of special efficacy 特効劑. (Yumoto 1927 : 60; emphasis added)2
To appreciate the newness of Yumoto's and Ōtsuka's claims and how they transformed the understanding of shō / zheng for Kampo and Chinese practitioners, we can compare the definition of zheng 證 found in the highly regarded Comprehensive Dictionary of Chinese Medicine, the first dictionary of Chinese medicine, edited by Xie Guan and published in 1921. The entry reads: “Zheng: the external expression of an internal disorder, like the evidence of an event” (Xie 1994 : 612).3 In this definition, the exterior is inseparable from the interior of the body. Zheng is the manifestation of the unseen disease; the physician interprets the presentation in order to treat the underlying disorder. But just eight years after the publication of Xie Guan's dictionary, Lu proposed a radically different understanding of this concept that helped to put the new Japanese interpretations of shō / zheng in circulation in Chinese medical discourse (Scheid 2014). In a series of four essays published in 1929, Lu argued that the presentation, not the disease, is the object of treatment in Chinese medicine (Lu 2010 [1929c]: 1439). Drawing on the work of Odai Yōdō 尾台榕堂 (1799–1871), a follower of Yoshimosu Tōdō, and Yumoto, he illustrated this point with a well-known formula from the Treatise, Five Ingredient Formula with Poria 五苓散. Lu argued that Chinese medicine treats the presentation associated with the formula, the “formula presentation” 方證, which in the case of Five Ingredient Formula with Poria is “great thirst, but restricted urination; or thirst with the desire to drink, vomiting as soon as water is consumed, floating pulse, slight fever” (Lu 2010 [1929b]: 1443). By focusing exclusively on this cluster of clinical facts and treating it with the indicated formula, he argued that it was possible for one formula to treat two distinct and apparently unrelated biomedical diseases, early-stage renal failure and early-stage cholera (Lu 2010 [1929a]).
It is precisely this approach to diagnosis and treatment that we can observe ten years later in the Suzhou Hospital of National Medicine clinical cases, through a new but related term—“presentation diagnosis” 證候診斷. Using the binomial zhenghou to refer to presentation, the editors of the hospital's journal highlight the importance of this diagnostic practice in a box insert:
To study practical medicine and treatment techniques, to focus on presentation diagnosis 證候診斷 and the uses of formulas and drugs, to absolutely refuse to do speculative research and empty theorization. Although our national medicine has accumulated thousands of years of history and can truly cure illnesses, it still can't take its place among the sciences of the world, because it has been influenced by mysticism. We should clarify our goals, not cling to the empty words of Five Phases and Qi transformation, and select the best from the ancient books. The Editors. (Suzhou guoyi yiyuan 1939: Zhiliao shili, 24)
Ye indicated that he is privileging the presentation over other diagnostic approaches in one case with a reference to Yoshimasu Tōdō. The patient, Zhang Yuyi 張郁義, suffered from “a cough with blood, nocturnal emissions, distention in the left flank, twitching when sleeping on the left side, fever in the afternoon, red face, strong heart palpitations.” He also noted the patient claims to have tested negative for tuberculosis elsewhere. Ye's diagnosis is “neurasthenia, flu-like symptoms, coughing up blood, and the presentation of Buplureum Dragon Bones and Oyster Shell Decoction 神經衰弱,感症咳血, 而呈柴胡籠牡證” (Suzhou guoyi yiyuan 1939: Zhiliao shili, 3). In the treatment section of this case, he explains:
According to the method of Zhang Zhongjing, one doesn't ask the cause of the illness. [Rather] one uses the method that corresponds to the presentation. This is the treatment philosophy espoused most forcefully by the Japanese doctor, Mr. Tōdō. As a result, I administered the Buplureum Dragon Bones and Oyster Shell Decoction and after seven to eight doses the patient was cured. (Suzhou guoyi yiyuan 1939: Zhiliao shili, 3)
Returning to the case of Chen Zhenhua, we observe Ye using a similar approach in a case of typhoid fever, complicated by intestinal bleeding. Instead of one treatment for one disease, as one would expect with biomedicine, he uses a series of different formulas (all from the Treatise except one) to negotiate the perils of this complicated condition and guide the patient back to health. As he sums up, he alternately used “Unripe Bitter Orange Decoction to Drain the Epigastrium 枳實瀉心湯, Major Bupleurum Decoction 大柴胡湯, Reach the Source Drink 達原飲, Regulate the Stomach and Order the Qi Decoction 調胃承氣湯湯, Pulsatilla Decoction 白頭翁湯, Polyporus Decoction 豬苓散, Five Ingredient Formula with Poria 五苓散, and Ginseng, Aconite, Astragalus, Atractolydes and so on 參附耆朮等 using [each formula] according to the presentation 對症施治” (Suzhou Guyoi 1939: Zhiliao shili, 13). Although the hospital never published another journal issue and eventually closed in 1941, this single journal issue provides a fascinating glimpse of an emergent style of medical practice based on Zhang Zhongjing's classic texts and the new concept of presentation diagnosis. Had it not been for the devastation of war, perhaps it would have been a first step toward the creation of a “true Eastern medicine.”
Building National Medicines
In the aftermath of the Sino-Japanese War, medical developments in China and Japan diverged. The burgeoning intellectual synergies between Chinese and Japanese doctors in the 1920s and 1930s that ultimately led to the founding of the Suzhou Hospital of National Medicine were cut short, as indicated by the precipitous drop in the number of Japanese medical texts published in China (Mayanagi 1999). At the same time, the discourse of Eastern civilization and other regionalism that had inspired both medical reforms and Japanese empire building dissipated, not just from the bitterness of war, but due to the emergent new discourse of nationalism. In the space of a few short years, the aspiration for a unified form of traditional medicine in East Asia based on the Treatise was replaced by the promotion of unique nationalist forms of traditional medicine across the region.
As Japanese and Chinese traditional doctors began to embark on new paths of national development, they did so nonetheless from a crucial shared starting point. Both professions now considered the concept of “presentation” (shō / zheng 證), as distinct from “symptom” (shō / zheng 症), to be central of their respective practices. While shō 證 as “presentation” was already well established in the Kampo revivalist literature, the meaning of the term began to evolve in China as the profession underwent dramatic changes with the establishment of the People's Republic of China in 1949. For a confluence of reasons related to the new role of the Chinese state in creating modern health care institutions, Chinese medicine scholars began to define their practice around the term bianzheng lunzhi 辨證論治. This new expression—the phrase is not found in the literature from the Republican era—was indeed centered on the concept of zheng, but its meaning was open to competing interpretations. Writing in the Journal of Chinese Medicine in 1958, Ye defined its meaning as strikingly similar to the method of presentation diagnosis that he practiced almost twenty years earlier in Suzhou. “So-called bianzheng lunzhi does not mean just anything. . . . [We must] determine which formulas match which presentations” (Ye 2014 : 1). Eventually other views prevailed, however, most significantly through the publication of the second edition of the national textbooks in 1964 (Karchmer 2005). In textbook medicine, zheng 證 became a reference for the underlying pathological mechanism of a condition, which is now most often glossed as “pattern.” As the methodology of bianzheng lunzhi was spread through the new unified educational system, the nascent Japanese-inspired Republican use of zheng as “formula presentation” fell out of favor.
The radical politics of the Maoist era isolated China and increased the divergence between the traditional medicine professions in China and Japan. It wasn't until the reforms of Deng Xiaoping in the early 1980s that meaningful intellectual exchange recommenced. This exchange has yet to achieve the intensity and richness of the early twentieth century and is often truncated by nationalist sentiments. For example, today the methodology of bianzheng lunzhi is now well known in Japan. In fact, most Kampo practitioners learn it alongside Ancient Formulas School methods, now called “match the formula to the presentation” method (hōshōsōtai 方証相對). According to Yasui Hiromichi, some practitioners use bianzheng lunzhi, others prefer hōshōsōtai, and still others use both on a case-by-case basis (Yasui 2007: 178). Interestingly, some Japanese practitioners have argued that the 後世派 Goseiha, or Later Masters Current, founded by Manase Dōsan 曲直瀬道三 (1507–94), anticipated bianzheng lunzhi with its methodology of “presentation examination and treatment determination” (sasshō benchi 察証弁治), prescribing formulas based on disease cause 病因, pathological mechanism 病機, four qi 四気, five flavors 五味, and channel affinity 歸經. Although this methodology was later forgotten, Yasui writes, “it is amazing that Dōsan developed this method four hundred years ago, much earlier than contemporary Chinese medicine” (2001: 848).
Japanese hōshōsōtai was almost unknown in China until the early 2000s. Since then its popularity, together with a renewed interest in the Treatise, has spread rapidly. The most influential scholar in this field has been Huang Huang 黃煌, a professor at the Nanjing University of Chinese Medicine, who discovered Yoshimosu Tōdō's Drug Presentations in the mid-1980s and then went to Japan in 1989 to spend a year studying traditional medicine. Since the turn of the century, his scholarship has focused exclusively on Zhang Zhongjing and his “classic formulas” 經方. Today he runs a popular website, Huang Huang's Classic Formula Salon, and has published numerous books on Zhang Zhongjing's classic formulas. While he acknowledges the influence of Kampo medicine on his thinking, he does not embrace Japanese medical scholarship with the same enthusiasm as his Republican predecessors; rather, he tends to portray himself as transmitting “the treasures of traditional Chinese culture” (Huang 2012: preface). It is fascinating to observe that decades after the closing of the Suzhou Hospital of National Medicine, medical dialogue between the two countries is finally flourishing again. It remains to be seen whether latent nationalist impulses of both sides will prevent a richer dialogue from emerging.
Keiko Daidoji and Eric I. Karchmer have contributed equally to this article. Its research and writing were carried out as part of the project Beyond Tradition: Ways of Knowing and Styles of Practice in East Asian Medicines 1000 to the Present, funded by a Wellcome Trust Senior Researcher Grant in the Medical Humanities (097918-Z-11-Z) to Prof. Volker Scheid, EASTmedicine, Faculty of Science and Technology, University of Westminster, London. Keiko Daidoji would also like to acknowledge Japan Society for the Promotion of Science KAKENHI grant JPMKK541J (Keiko Daidoji) for additional support in 2015–16.
Shō / zheng 症 was a late sixteenth-century neologism and considerably less common than the original character shō / zheng 證. In contrast to Mayanagi (1998) and Li (1997), Scheid (2014) has argued that semantic distinctions between the two characters were already observable in the late imperial period. Because doctors at the Suzhou Hospital of National Medicine used the two characters interchangeably, we have privileged Mayanagi's and Li's claim in our argument. Irrespective of these competing claims, we believe that the most significant issue for early twentieth-century Japan and China was that the semantic divergence between the two characters was driven by the encounter with biomedicine. A third character, chō / zheng 徵, was also affected by the influence of biomedicine. Although not an orthographic variant of shō / zheng 證, it could serve as substitute. In the twentieth century, it became the term for the biomedical concept of “sign” as in the expression taichō / tizheng 體徵
While Yumoto is very careful in his use of the two orthographic variants for shō / zheng, the Chinese translator Zhou Zixu 周子敘 is not. Zhou uses the same character 證 for both expressions, suggesting that a semantic distinction between these two characters had not been established in Chinese medicine discourse at this point in time (Yumoto 2007 : 22).
As Li Zhizhong has pointed out, the alternate form of zheng 症 is not included in Xie Guan's dictionary, indicating its relative insignificance in Chinese medical writings of the time. Moreover, he notes that the famous Chinese dictionary Sea of Words 辭海, compiled between 1915 and 1936, also adopted Xie Guan's definition of zheng (see Li 1997).