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The southward migration of the Song population has been long recognized,121 but it is only more recently that the potential epidemiological significance of this shift has been fully explored. Southern China—usually defined as the region south of the Huai and Han rivers—has a far warmer and wetter climate than North China. The summer monsoon brings warm moist air up from the South China Sea, resulting in high levels of rainfall across the Yangtze delta and other parts of South China. The mountainous nature of most of South China ensures that little of this moisture reaches North China, resulting in a sharp climatic divide between the two regions.
The differing climates produce very different disease profiles as well. Southern China is characterized by far higher levels of febrile illnesses than northern China, and illnesses such as malaria were historically much more common there.122 The Song Chinese were well aware of the higher disease burden of South China. From very early times, a divide between the north and south or northwest and southeast had been part of the Chinese geographical imagination. One of the earliest versions of this divide tells how Goldschmidt, “Epidemics and Medicine”; Goldschmidt, Evolution, 69–102; Miyashita Saburō, “Sō Gen no iryō.” Hartwell, “Demographic, Political, and Social Transformations of China, 750-1550,” 365–366.
Goldschmidt, Evolution, 70, 85; William H. McNeill, Plagues and Peoples (New York: Anchor, 1977), 102–103.
during a mythical battle, the northwestern pillar of heaven was broken causing the earth and heaven to come closer together in the northwest and grow farther apart in the southeast. In the Inner Cannon, the resulting tilting of the earth was used to explain the different types of illnesses that characterized the northwest and southeast.123 During the Northern Song, the far south was a place of exile. It was characterized by strange diseases, strange peoples, and strange customs.
Exile to the distant south was the most extreme punishment an official could receive, in part because of the number of northerners who succumbed to disease while there.124 In spite of the awareness of the risks of living in the south, from the 8th century onward a steady stream of migrants relocated there from the north. At the outset of the dynasty, roughly two-thirds of the Song population lived north of the Huai and Han rivers. By the end of the 11th century—prior to the loss of north China, but during a period of escalating conflict with the Jurchen forces—fully 75% of the Song population lived south of them. As the population of North China recovered, this ratio decreased, but from this point up to the end of the empire, roughly two-thirds of China’s population lived in South China.125 The dramatic rise in southern population that occurred in the Song meant far more people were exposed to the diseases prevalent there. Furthermore, as the population increased, so did interregional commerce and transportation. Water transport—common in the south—was far faster than land transport, making it easier for diseases to spread from region to region. Taken together, these two factors offer a compelling explanation of the increased disease burden of the Song population, but a second factor has long been ignored: the absolute increase in population Marta Hanson, Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China (Routledge, 2011), 30–35.
T.J. Hinrichs, “The Medical Transforming of Governance and Southern Customs in Song Dynasty China (960-C.E.)” (PhD Dissertation, Harvard University, 2003), 64–72; Ari Daniel Levine, Divided by a Common Language: Factional Conflict in Late Northern Song China (University of Hawaii Press, 2008), 21–22.
Dieter Kuhn, The Age of Confucian Rule: The Song Transformation of China, 2011, 73–75; Hartwell, “Demographic, Political, and Social Transformations of China, 750-1550,” 365–366.
during the Song. By the early 13th century, the combined population of the Southern Song and Jin is estimated at 120 million, meaning that somewhere between one-third and one-half of the world’s population lived in China at this time.126 Absolute population is a critical factor in determining the spread of epidemic diseases. In small populations, epidemics appear and cause high levels of mortality. Individuals either survive the illness, becoming immune to it, or die.
After exhausting the supply of susceptible individuals, the disease itself disappears. After a generation or two, the majority of resistant individuals have died of other causes, and if the disease is reintroduced, the cycle repeats itself again. In a sufficiently large population, on the other hand, even a highly virulent disease can sustain itself indefinitely by cycling through the population region by region, generation by generation. Under these conditions, not only do many diseases become endemic diseases of childhood—so that all individuals who survive to adulthood are immune—but the capacity of the population to generate and sustain large-scale epidemics also increases dramatically. Using the catalogue of major epidemics prepared by Joseph H. Cha and included in the appendix to William McNeil’s Plagues and Peoples,127 the epidemiologist, Alfredo Morabia, has recently demonstrated that the pattern of epidemics seen in Chinese history matches that predicted by current epidemiological models for a growing agricultural population. Of particular interest for this study, his work reveals a sharp climb in the frequency of epidemics as the population begins to increaase dramatically in the Song dynasty.128 During the Song dynasty the population of China thus crossed two important epidemiological frontiers. The first was geographical, the shift of the center of population density Kuhn, The Age of Confucian Rule, 73–75; Valerie Hansen, The Open Empire: A History of China to 1600 (New York: Norton, 2000), 411.
McNeill, Plagues and Peoples, 297–306. As the authors admitted, this list is not without flaws. It is undoubtedly incomplete and spotty in its coverage. It was produced by checking and correcting an earlier list based on Sima Guang’s Comprehensive Mirror for Aid in Government (Zizhi tongjian 資治通鑑 and the Qing Imperial Encyclopedia (Gujin tushu jicheng 古今圖書集成).
Morabia, “Epidemic and Population Patterns in the Chinese Empire (243 BCE to 1911 CE).” to southern China, the second was demographic, the increase of the absolute population to a level capable of sustaining more frequent epidemics. As a result, an upsurge in epidemics occurred that prompted doctors, officials, and even emperors to seek means of improving the situation.
Many of the medical reforms attempted by both the government and private individuals were explicitly aimed at improving the treatment of epidemic febrile illnesses, but it is likely that many of their other activities—such as the condemnation of common physicians129—were also driven in part by these epidemiological shifts.
SECTION THREE: Medical Change in the Song As in other areas of Chinese culture, the Song Dynasty witnessed important changes in
medicine and healing. Recent research has highlighted a number of important areas of change:
the rise in status of the Treatise on Cold Damage; increasing elite involvement in medicine;
efforts on the part of the Song state to use medicine as a tool of government; and new patterns of knowledge transmission largely due to the growing printing industry. The first of these areas— the changing place of the Treatise in textually based medicine—is the topic of this dissertation as a whole. The remaining areas of change are discussed below.
Elite Involvement in Medicine One of the earliest changes scholars noticed in Song-Dynasty medicine was the
increasing participation of members of the literati elite. Writing in 1935, Xie Guan (謝觀, 1880observed:
In Chinese medical arts, the Tang and Song should be taken as an important boundary.
Up through the Tang, most doctors clung to specialized learning transmitted [from master
See Chapter 3.
to disciple]. The literati among them who loved the study of formularies … numbered only a few. From the Song onward, medicine suddenly became a job for the literati. If [a doctor] was not a scholar physician, he was not worthy of recognition in the world.130 中國醫術，當以唐宋為一大界。自唐以前，醫者多守專門授受之學，其人皆今草澤 鈴醫之流，其有士大夫而好研方書 … 代不數人耳。自宋以後，醫乃一變為士大夫 之業，非儒醫不足見重於世。 More recent research by Robert Hymes has shown that the transformation was not as sudden as Xie presents it, but it was nevertheless quite striking. Examining Fuzhou prefecture from the Northern Song to the Yuan, Hymes shows that few elite men took up medicine as a career during the Song, but a large number did so in the Yuan. 131 Chen Yuanpeng 陳元朋 suggests that Hymes is overly conservative in his evaluation of the number of elite doctors, but the examples he cites are all famous doctors of the Song who authored well-known texts. His data-set is far too limited to evaluate the behavior of ordinary elite living away from the capital.132 Hymes argues convincingly that the rise in the number of elite physicians was caused by the disappearance of the civil service examinations—which were temporarily suspended under the Yuan—and the resulting decrease in demand for teachers—traditionally the fall-back job for elite men unable to pass the exams.133 Reiko Shinno, examining the Yuan Dynasty’s medical policies—which continued and expanded upon those of the Song—contends that it was the Yuan government’s valuation of doctors, an attitude derived from Mongol culture, that was most influential in encouraging elite men to consider medical careers.134 Shinno fails, however, to present comparable local data to demonstrate how the administrative changes she has discussed were actually impacting the elite away from the capital. All of her examples are drawn from Origins and Development of Medicine in China (Zhongguo yixue yuanliu lun 中國醫學源流論, 1935), lingyi mifang, in Xie Guan, Zhongguo yixue yuanliu lun (Fuzhou: Fujian Kexue Jishu Chubanshe, 2003), 101.
Hymes, “Not Quite Gentlemen?” Chen Yuanpeng, Liang Song de “shangyi shiren,” 31–33.
Hymes, “Not Quite Gentlemen?” Reiko Shinno, “Promoting Medicine in the Yuan Dynasty (1206-1368): An Aspect of Mongol Rule in China” (PhD Dissertation, Stanford University, 2002), 198–204.
high-ranking officials and places intimately associated with them. While she provides persuasive evidence that Yuan government actions contributed to the rise in elite involvement in medical practice, she does not show that this influence was decisive. Moreover, the lack of access to official positions and teaching jobs would have directly and rapidly affected the vast majority of the literati-elite. The Yuan administrative changes were more limited in scope, and it remains unclear how long they were in effect, given the short period of time during which the Yuan wielded effective control over all of China.
Regardless of its timing or causes, however, all of these researchers agree that a major shift in elite occupational strategies occurred between the Song and Yuan dynasties. By the end of the Yuan, a large number of elite men were practicing medicine as a career and medicine was widely seen as a field only a literatus could properly master.
Medical Governance No doubt tied to the growing sense that only the educated elite could practice medicine correctly, the Song government also took a far greater interest in medicine than had previous dynasties. Apart from providing medical care to the imperial family and high officials, previous dynasties, involvement in medicine had been limited to distributing medicine during epidemics.
Under the Song, however, the government took a more activist stance regarding medicine. Not only was it concerned to provide both qualified doctors and effective medicines to the empire, but it made use of medicine in its efforts to transform the customs of the people. T.J. Hinrichs has coined the term “medical governance” to refer to the numerous ways in which medicine became a tool of government during the Song. The key components of Song medical governance were establishing medical schools and imperial pharmacies, using medicine to transform southern customs, and publishing medical texts.135 The Medical Schools In its early years, the Song government maintained Tang Dynasty medical institutions such as the Imperial Medical Office (Taiyi shu 太醫署) which was primarily responsible for the health of the imperial family, but they rapidly broadened the responsibilities of this office. In 992, the Imperial Medical Office was renamed the Hanlin Physician Service (Hanlin yiguan yuan 翰 林醫官院). The use of the prestigious name “Hanlin”—long associated with the imperial academy for the study of literature and the classics—reveals that even at this early point in the dynasty, the Song government was acting to strengthen the reputation of medical practice among the elite.
An important front in the Song effort to raise the status and improve the quality of medical practice was medical education. Education of physicians to serve the imperial family and officials was the responsibility of the Imperial Medical Bureau (Taiyi ju 太醫局). Students treated soldiers, fellow students, and the people of the capital and were evaluated on the basis of their success rate. During the Qingli Reforms of the 1040s, an attempt was made to establish medical schools throughout the empire, though it is unclear how successful these efforts were.
Under the New Policies reforms of 1069-1085, the system of medical schools was further expanded. At its height, the Imperial Medical Bureau in the capital was training 300 physicians, divided into three “halls.” The curriculum included a combination of famous older texts, more recent materia medica compilations and formularies, and texts determined by a students
T. J. Hinrichs and Linda L. Barnes, eds., Chinese Medicine and Healing: An Illustrated History (Cambridge:
Harvard University Press, 2013), 99–100.