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In the case of the establishment of medical schools, a medical examination, and medical officials, surviving evidence indicates that the government’s intention was indeed to raise the status of medicine in order to attract elite men to its practice. Fan Zhongyan, under whose auspices the medical schools were first established, mentioned the deplorable state of doctors in
the memorial suggesting their establishment:
At the present, the capital’s population is one million, [with only] a thousand some-odd physicians. Most of them learned their skills informally, and have not undergone instruction by a teacher. Their errors, harming human lives, occur on a daily basis.162 今京飾生人百萬，醫者千數，率多道聽，不經師授，其誤傷人命者，日日有之。 Furthermore, from its inception, application to the medical school required an official statement on the applicant’s family background. Although the exact purpose of this statement is not specified, a similar system was used in the civil service examination to exclude sons of Ibid., 31–40, 46–57; Miyashita Saburō, “Sō Gen no iryō,” 134–157.
The medical reforms were actually instituted by activist regimes and were opposed by the conservative faction at the time; nevertheless, since the medical reforms were among the few reforms which were not completely dismantled under conservative regimes—perhaps due to their appeal to emperors and regents alike—I will consistently refer to these reforms as the actions of the Song imperial government as a whole.
Fan Wenzhenggong ji, zhengfu zouyi xia, 40a, in Sibu Congkan.
merchants, peasants, and criminals.163 The medical schools were therefore not created to improve the status of existing non-elite physicians, but rather to encourage elite men to become physicians. By the late Northern Song, the government’s desire to attract literati to the study and practice of medicine is even more apparent. A number of changes in the schools were introduced to ensure that their structure and position within the administrative hierarchy were as close as possible to the more prestigious schools associated with the civil service.164 The Song government was not alone in its concern about the poor quality of physicians.
Complaints about doctors’ errors abound in Song dynasty literature. The claim that an author became interested in medicine due to watching an incompetent physician kill a relative is so frequent in the prefaces of Song medical works that one would be tempted to discount it as a literary motif were it not for the extreme personal detail in which these stories are often told. The
story Wang Gun (王袞, fl. 1047-1082) included in the preface to his formulary is typical:
In the past, I accompanied my father, (Wang) Ren, who, on the road to Huatai, became ill at a stopover. He encountered a vulgar physician who, without investigating the pattern of his pulse, recklessly prescribed a medicinal decoction, and ultimately he did not recover from the illness. Also, my mother was frequently sick. Since this went on for many years, I devoted my leisure time to the study of medical techniques.165 袞曏侍家君任，滑台道次得疾，遇醫之庸者，不究其脈理，妄投湯藥，而疾竟不瘳。 復又母氏多病，續有年所，袞遂因公暇潛心醫術。 It is not medicine as a field of knowledge that elicits Wang’s concern. On the contrary it is precisely the complexity and subtlety of medicine that makes “vulgar physicians” so
problematic. As Wang had already observed:
Thus, people’s illnesses being many and varied, the Way of medicine cannot be grasped by means of one path alone either… Those who are ignorant of the Way [of medicine], Goldschmidt, Evolution, 48; Chaffee, Thorny Gates, 53, 60–61; Hymes, “Sung Society and Social Change,” 641– 650.
Goldschmidt, Evolution, 51–57.
Boji fang 博濟方, author's preface, in Siku Quanshu, 6.
do not meticulously grasp the symptoms. When using [medicine] clinically, they are always mistaken.166 然人之疾狀多端，醫道又不可一途取也… 昧於道者，乃不詳其證候，迨乎臨用，有誤 十全。 For both the Northern Song government and members of the elite with an interest in medicine, the problem was not that medical knowledge itself was inadequate, but that the wrong kind of people were learning and practicing medicine in the wrong way.
The Status of Physicians through the Northern Song The treatment of illness in China was never monopolized by any one group of healers or any single therapeutic method. Home remedies, often under the direction of senior household women, were usually the first resort of a sick person. Various forms of ritual healing, whether performed by spirit-mediums, unordained specialists in various Daoist or Buddhist ritual techniques, or officially ordained clergy, remained popular among both commoners and elite in spite of the odium they occasionally attracted from the government and its representatives. A plethora of itinerant healers practicing a variety of therapies were also in regular demand. At the top of the medical status hierarchy, however, was textually based medicine (yi 醫), which claimed descent from the legendary sage-kings of antiquity and had a textual tradition of its own to bolster its respectability.167 Throughout imperial Chinese history, however, the status of medicine as an occupation was at best debatable. Before the Song dynasty, the vast majority of the elite considered the practice and study of medicine beneath their dignity. Even learned medicine, in spite of its “classics (jing 經)” and “treatises (lun 論),” remained overwhelmingly the province of Boji fang, author’s preface, in ibid.
Christopher Cullen, “Patients and Healers in Late Imperial China: Evidence from the Jinpingmei,” History of Science 31 (June 1993): 100–104.
commoners. Medical texts written by literati during this period, almost the only medical texts that have survived, serve only to confirm the rarity of their authors’ interest in medicine. The preface to the Treatise on Cold Damage opens with regret and puzzlement over the elite’s lack of
interest in medicine and their resulting reliance on common physicians:
I am puzzled that the literati168 living in the world today never pay attention to medicine or thoroughly study the art of [prescribing] formulae … They take their hundred years of life, the most valuable of the important things they hold, and entrust it to common physicians who are reckless in what they do. Alas!169 怪當今居世之士，曾不留神醫藥，精究方術 … 齎百年之壽，持至貴之重器，委付凡 醫，恣其所措，咄嗟嗚呼！
The famous Tang dynasty literati medical author, Sun Simiao, complained of the same situation:
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.170 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。 Like their Song counterparts, literati medical authors before the Song harbored a tremendous antipathy toward common physicians, but unlike Song medical authors, their interest in and desire to reform medicine were shared by few among their contemporaries.
In the Northern Song, common physicians were part of a social stratum that Robert Hymes has termed the lumpenliterati. This stratum formed as a result of profound social and technological changes occurring during the Song. As printed books became more readily available and less prohibitively expensive, a wider audience than before was able to afford both literacy and at least some books. In part this allowed the rapid expansion of the literati social The translation “literati” may not be appropriate for the term shi 士 in the Han dynasty, but even at that time it referred to a social elite who this dissertationicipated in government. Song elite readers, at any rate, would have read it as referring to people like themselves.
Shanghan lun 傷寒論, author's preface, in Zhang Ji, Zhongjing quanshu, 6.
Qianjin yaofang 千金要方, author's preface, in Sun Simiao, Sun Simiao yixue quanshu, 11.
stratum, but it also allowed for the development of a new social stratum comprising individuals who were literate and made their living by means of literacy, but to varying degrees lacked the culture, learning, and social networks of the elite. Hymes has pointed to religious specialists, litigation masters, and common physicians as examples of this stratum. As a group, they aroused anxiety on the part of the literati, who saw them as destabilizing forces with the potential to encroach on literati privileges and powers.171 Unlike other members of the lumpenliterati, doctors were able, under the right circumstances, to mingle with and befriend the elite, many of whom demonstrated a new-found amateur interest in medicine.172 Su Shi’s (蘇軾, 1037-1101) friendship with and admiration of Pang Anshi is well known from Su’s own jottings (biji 筆記),173 and Su’s medical writings were posthumously collected together with those of Shen Gua to form the Excellent Formulae of Su and Shen. Numerous other members of the elite also produced medical books or made extensive notes on medical matters in their jottings.174 In spite of this increasing openness to medicine as a field of study, a willingness to associate with suitably cultured physicians, and even increasing numbers of literati men practicing medicine, it remained a largely undesirable choice of profession for the literati throughout the Song. Robert Hymes’s research on Fuzhou demonstrates that medicine as a literati career remained rare there until the Yuan dynasty. Chen Yuanpeng has questioned the general applicability of this conclusion, noting that this research was focused on only one prefecture.175 However, Hymes’s argument is supported by the disparaging attitudes towards medicine found in the jottings literature and popular drama as well as the very efforts Hymes, “Sung Society and Social Change,” 557–562.
Ibid., 558–559; Chen Yuanpeng, Liang Song de “shangyi shiren.” E.g., Su Shi, Su Shi sanwen quanji (Jinri Zhongguo Chubanshe, 1996), 1702.
Chen Yuanpeng, Liang Song de “shangyi shiren,” 133; Tao, Biji zazhu yishi bielu.
Chen Yuanpeng, Liang Song de “shangyi shiren,” 32–33.
made by those seeking to increase the status of medicine, whether private individuals or government officials.176 The Northern Song Crisis of Trust Medicine was not the only field in which Northern Song thinkers displayed anxiety, doubt, and a sense of a need for new principles and practices in a changed world. The elite of the Northern Song were aware of many of the transformations discussed in Chapter 2, and some of its memebers sought to develop new responses to the new situations in which they found themselves. They recognized the differences separating them from their Tang dynasty forebears which made a return to the institutions, policies, and customs of the past impossible. Though often looking to the past for inspiration and guidance, they argued against slavishly imitating past solutions when dealing with present problems and actively put forward new solutions to the difficulties of their times.177 The activist mentality and the many innovative reform efforts of the Northern Song have rightly been seen as indicative of an optimistic sense of the possibility of making the world better, but the roots of that mentality and those efforts lay in an anxious awareness of the presence of new and unprecedented challenges to both state and society.178 This awareness of something fundamentally new in their era is reflected most clearly in Northern Song elites’ concerns regarding their identity. As discussed in chapter 2, the changing nature of the literati social stratum destabilized elite identity, raising questions about what it meant to be a literatus and what his appropriate role was within society. Peter Bol has argued that Hymes, “Not Quite Gentlemen?,” 51–56. My own research, as seen in this chapter, has revealed further confirmation of the Northern elites’ distrust of common physicians.
Bol, Neo-Confucianism in History, 7–8; Robert Hymes and Conrad Schirokauer, eds., “Introduction,” in Ordering the World: Approaches to State and Society in Sung Dynasty China (Berkeley: University of California Press, 1993), 40; Thomas H. C. Lee, ed., “Introduction,” in The New and the Multiple: Sung Senses of the Past (Hong Kong: Chinese University Press, 2004), xxi–xxiv.
Hymes and Schirokauer, “Introduction,” 1–3.