Do you treat your patient, or do you treat their disease? Do you establish an underlying pattern of disharmony/diagnosis/constitution, or do you use a tried-and-true formula for different disorders? This dichotomy first appeared during the Sòng dynasty (960-1279CE) because of three key features – ‘Moveable Block Printing’, the government establishing the ‘Pharmacy Service’, plus opening almost 1000 additional places for students to study the medicine. This article will explore the dichotomy, as well as discuss the importance of these three key features, not just for the Sòng dynasty but for our present-day view of Chinese medicine. This article will also look at other interesting developments before, during and after the Sòng dynasty.
‘Treat the Disease’ OR ‘Treat the Person’?
The Sòng dynasty healthcare system was a dream come true for the average Chinese person. They could access chemists/apothecaries/pharmacies for patent herbal formulas, or they could visit a local physician for specific healthcare. What this essentially meant was that virtually every Chinese person could now gain access to treatment anytime they needed/wanted. This was unprecedented in Chinese history prior to the Sòng dynasty.
Any Chinese person could now go into a pharmacy and advise the chemist that they had a complaint, such as a bad cough. The chemist would then consult the ‘Formulary’ and prescribe a patent formula to treat the customer’s cough. This would lay the seeds for ‘treating the disease and not the person’. The customer did not necessarily need to see a specialist physician anymore. This would save the average Chinese person time and money. The physicians were seeing their livelihoods disappearing, so they needed to do something about it, and fast!! This would lay the seeds for ‘I Spy’ or ‘treat the person and not the disease’ (Unschuld 2009, p.117).
In the end, neither the chemist nor the patient knows; only the physician knows! That is the game of ‘I Spy’ and the physicians played it beautifully. Regardless, for the average Chinese person this was a win-win because there was significantly more healthcare available to the community than there ever had been before.
Wood Block Printing – Medical Texts
Wood block printing was established in China around 600CE but did not become popular until around 1050CE when movable block printing was invented. This allowed for a lot of texts to be produced quickly, whereas prior to block printing, every text was laboriously handwritten.
“As a consequence of advances in printing, scholars were able to communicate as never before.”
Cotterell 1990, p.180.
In 1057CE, the Sòng emperor Rén Zōng, took advantage of movable block printing and established the ‘Bureau for Editing Medical Treatises’ (Bureau). In the space of twelve years (1057-1069CE) the Bureau collected, compared, and then produced definitive editions for 11 of their medical classics. Among the list were the Yellow Emperor Classic (Huáng Dì Nèi Jīng/黃帝內經) and the Treatise on Cold Injury (Shāng Hán Lùn/傷寒論).
By the end of the Sòng dynasty (1279CE) the Bureau had reproduced 16 classics and had written/printed 18 brand new medical texts (Hinrichs & Barnes 2013, p.104). To put that into context, only five medical texts were printed in an official capacity prior to the Sòng dynasty.
“The recensions that we have today date to those Song imprints.”
Hinrichs & Barnes 2013, p.107.
Pharmaceutical Trade – Medicine Distribution
The Sòng government established the ‘Pharmacy Service’ which was responsible for founding new chemists/apothecaries/pharmacies outside of city centres. By 1150CE they totalled 70 outlets (Hinrichs & Barnes 2013, pp.101-102). These chemists had two main responsibilities:
- Donating herbal concoctions to the Chinese population during epidemics.
- Selling medicinal drugs to the general population via patented herbal formulas. In 1107CE, the Bureau wrote a Pharmacy Service patent formula text which would lay the seeds for ‘treating the disease and not the person’ (discussed earlier).
Prior to the Sòng, medical schools were primarily dedicated to training physicians to treat the imperial family and for government service. At its peak, the Táng dynasty (618-907CE) had 40 spots available for training medical students. In less than 200 years (1113CE) that number had grown to around 1000 (Hinrichs & Barnes 2013, p.102). In addition, the curriculum had expanded from nine subjects to 13. Included in the new curriculum were women’s and children’s disorders. Graduates started to specialise in different areas of Chinese medicine.
The problem here was the Sòng did not open additional clinical placements (within government circles) for these trained physicians so these new, and highly trained, physicians started to apply their trade within the community. This would lay the seeds for ‘treating the person and not the disease’ (discussed earlier).
Nearly 750 years have passed since the Sòng dynasty was conquered by Kublai Khan (1215-1294CE) and his Mongolian horde, creating the Yuán dynasty (1279-1368CE). Yet my international travels to present workshops, speak at conferences, visit Chinese medicine institutions and chat with practitioners, has suggested to me that we still tend to sit in one of these camps. So, do you treat the person OR do you treat the disease? Perhaps the most crucial thing to consider is this: ‘Does it matter if your patient is getting good results from your treatment?’ A question to ponder on a future occasion!
“Imperial patronage and the appearance of a mass publication industry, combined with a benevolent appreciation of public needs, drove a Song revolution in medicine and medical education, raising the status of medicine as a profession.”
Buck 2015, p.208.
Additional Content
A lot of interesting stuff was happening in China before, during, and after the Sòng dynasty. Let me take you through some of the more fascinating bits.
Please note: I have not included the tone lines for the Pin Yin or Chinese characters for this extension to the main article above.
How the Song Dynasty came into Power
Prior to the Song dynasty there was a period of disunity called the Five Dynasties (907-960CE). Before the Five Dynasties there was a peaceful period of harmony in China called the Tang dynasty (618-907CE). When the Tang fractured there was essentially 53 years of civil war, along with neighbouring countries invading and claiming large slices of China’s fringe regions.
The Five Dynasties has been named because there were five separate ruling houses that controlled the northern parts of China during those 53 years (Cotterell 1990, p.164). Interestingly, there were ten separate states scattered throughout southern China that had no affiliation with any of the five northern dynasties during this period.
Eventually a very smart army general named Zhao Kuangyin (he changed his name to Tai Zu when he became emperor) managed to wrestle control of all the northern states. He celebrated by getting totally tanked and when he woke in the morning his army crowned him the new emperor of the unified northern China. He then did four things that secured his position, and that of the new Song dynasty (Cotterell 1990, pp.169-171):
- He demanded that the current imperial families (and the officials in the palace) were spared their lives.
- That the royal treasury was not pilfered.
- His soldiers were encouraged to resign from the army and retire to ‘large house and land packages’. They were told they (and their future ancestors) would be looked after for future generations.
- He convinced most of the southern states to unite with the northern states, thereby reuniting China.
These four key decisions ensured that he came into power with less enemies (and more friends). It obviously also meant he had money to spend on new infrastructure throughout China; and he took the power away from the army, and instead of employing army generals to important regional outposts, Tai Zu hired intelligent scholarly civil officials instead.
The Song were never expansionist in design and instead tried to shore up what they had. This was relatively successful during the period of 960-1126CE until Northern invaders pushed the Song into the South. There they remained strong from 1126CE until the Mongols invaded all of China and officially took power in 1279. More on that later.
Divide Between North and South
Let us backtrack a bit here. When the Han dynasty came into power in China (206BCE-220CE) they started to streamline and systematise everything in their external environment; and since the Chinese believed that their internal environments were a microcosm of their external surroundings, they did the same with their medicine. This resulted in the Huang Di Nei Jing Su Wen (Yellow Emperors Simple Questions) and Ling Shu (Yellow Emperors Spiritual Pivot) being born and from it came a distinct fracturing of traditional medicine. Those that did not adhere to the new medical model could still practice their style of medicine on the quiet, or by moving to remote rural areas.
The physicians that transitioned into this streamlined medicine tended to remain in urban areas in the northern areas of China. They also referred to themselves as the elite, so by the time the Song dynasty came along nearly 1000 years later, this elitist model had built itself into a distinct entity. As a result, the Chinese elite would refer to themselves as Han Chinese (being descendants of the great Han dynasty). And seeing as they were elite, then the people not living in northern regions (such as those from southern China) were often referred to as barbarians. They also concluded that barbarian medicine must be noxious and the people that practiced this medicine were termed shamans or witch doctors (Wu). Their deities were also considered demonic! The southern people were even considered to be responsible for contagion, epidemics, or plagues.
The medical care provided in northern and southern China was certainly different. Let us look at epidemics as a case in point. The treatment for epidemics in the south was often isolating the patient to reduce the risk of the contagion spreading. However, in the north, they believed that the physician (and the ill patient’s family) should still help the contagious individual, even at the risk of their own health, because to do so was an ethical duty of care (Hinrichs & Barnes 2013, p.112).
What is interesting here is that the Song dynasty Bureau’s block printing of Zhang Ji’s Shang Han Lun (Treatise on Cold Diseases), reminded physicians about the six divisions discussed in the Huang Di Nei Jing. Namely, that external pathogenic factors could spread from a sick person to a healthy person, but only if the healthy person has poor Qi or Jing energies. So, if the physician remained healthy, then they would be able to treat a diseased patient without the risk of getting sick themselves (Hinrichs & Barnes 2013, pp.113-115; Unschuld 1985, pp.171-172).
When the Northern Song was defeated (1126CE) a lot of northern Chinese people fled to the south; this merging of northern and southern Chinese people created a significant melting-pot for transferral of information. But it also contributed to the increase in epidemics as the north merged with the south (Hinrichs & Barnes 2013, p.119). By the 1100’s the cultural centre – previously being in the North had moved its centre to Hangzhou (roughly 200km southwest of Shanghai).
Even though the Northern view of medicine was aligned more with structured Confucian processes (from which the Han text Huang Di Nei Jing was derived), the south had continued to use Daoist traditional medicine dating from pre-Han dynasty times. This included demonological therapy, exorcism movements, and plague spirit cults (not all of these were Daoist). Wu soothsayers or shamans were often responsible for demonic exorcisms or magical healing; this included black contact magic or homeopathic magic (Hinrichs & Barnes 2013, p.119; Unschuld 1985, p.163).
Whilst the northern Chinese would have liked to believe that the old medical ways used by the Daoists had ceased way back in 200BCE, in fact it had not. As I mentioned briefly above, it simply moved out to rural centres and into southern China and not only survived but thrived. So, when the north met the south and discussed their medicines, they were obviously not the same.
Physicians and the Elite Literati
As I touched on earlier, the Song government allowed for more of the population to sit the exams for government positions, including healthcare (roughly 1000 students). Approximately 30 000 men were sitting the exams at the start of the Song dynasty; by the end of the dynasty this number had risen to roughly 400 000 (http://afe.easia.columbia.edu/song/). Unfortunately for most of the men that sat the exam, the number of positions available in the government remained the same, resulting in more people failing the exams and therefore searching for a career in the wings of the government – often that of a physician. This resulted in a much closer association amongst the elite literati and middle-class physician. It was during this time that the two words were merged leading to Ru Yi, literati physician, or scholar physician. Interestingly, the Ru Yi were of the view that you had to ‘treat the person and not the disease’.
“Although most healing skills continued to be transmitted within families, increasing numbers of aspiring doctors studied from purchased books and travelled to study with renowned physicians … In the Jin [Southern Song], however, on the model of contemporary Neo-Confucian practice, some physicians began apprenticing exclusively with a single teacher and formed medical lineages” (Hinrichs & Barnes 2013, p.117).
Confucianism, Daoism and Buddhism
Confucianism was still the state’s philosophy of choice, but Daoism and Buddhism were gaining in popularity. From a medical perspective each of these three philosophies needs a brief discussion:
Daoism
As mentioned above, Daoism medicine was in the more rural and southern parts of China. The medicine included demonological therapy, exorcism movements, and plague spirit cults (Hinrichs & Barnes 2013, p.119; Unschuld 1985, p.163).
Daoist inner alchemy (Nei Dan) continued to gain traction. It emphasised meditative breathing and visualisation, rather than the original external alchemy (Wai Dan), which had emphasised concocting certain elixirs for consumption with the goal being to gain immortality (Hinrichs & Barnes 2013, p.121). What’s fascinating is that one of the original ingredients of these famed elixirs of immortality was cinnabar (Dan); fascinating because cinnabar is deadly mercury sulfide.
Buddhism
Had become extremely popular with the middle to lower class Chinese that found it a philosophy more manageable in their day to day lives than Confucianism was. Therefore, a divide started with the elite Chinese society as they continued to embrace Confucianism. A census showed that Buddhism in the year 1221CE could count 400 000 monks, 60 000 nuns and 40 000 temples as part of their philosophical cause. Having said that, what is surprising is that Buddhism was on the decline (Unschuld 1985, pp.163-164); this was primarily because a new philosophical system termed Neo-Confucianism was emerging (discussed briefly below).
Buddhist medical practices were not necessarily confined to individualist healthcare. It also considered the wider implications of communal healthcare; and for this, they included some of the Daoist shaman practices. These comprised, but were not limited to, rain making, predicting the outcome of wars/military operations, and even divinations (which had long since ceased being an exclusive tool of the Emperor/Tian Zi/Son of Heaven) (Unschuld 1985, p.156).
Buddhist priests from China started visiting Japan (and vice versa) and, because of the explosion of block printing texts into the marketplace, took medical texts with them. As a result, Japanese traditional medicine, which had remained stagnant for the previous 300 years, once again was thrust into the spotlight. Japanese traditional medicine would never be the same again (Hinrichs & Barnes 2013, pp.123-126).
Confucianism
Neo-Confucianism emerged as the philosophy/orthodoxy of choice for Song emperors. It merged traditional Confucian thought with Buddhist doctrine, and in so doing, changed the face of traditional medicine (Cotterell 1990, pp.176-177; Unschuld 2009, pp.113-114).
Confucian ideals/principles were also central to the civil service exams that thousands of Chinese sat each year. If you didn’t know the ‘Four Books’ (‘The Great Learning’ – Da Xue; ‘The Doctrine of the Mean’ – Zhong Yong; ‘The Analects of Confucius’ – Lun Yu; ‘The Mencius’ – Meng Zi) and, to a lesser extent, the ‘Five Confucian Classics’ (‘Classic of Poetry’ – Shi Jing; ‘Classic of History’ – Shu Jing; ‘Classic of Changes’ – Yi Jing; ‘Record of Rites’ – Li Ji; ‘Chronicles of the Spring and Autumn Period’ – Chun Qiu) then you were not going to pass the exams (http://afe.easia.columbia.edu/song/).
This differentiated development of Confucianism [Neo] soon radiated a great intellectual vigor and appeal. The study of the classics once more became a vital topic. The impulse to investigate carefully individual phenomena of nature and in so doing to understand one’s own position in the larger scheme of the universe, culminated in the scientific activities of the period.
Unschuld 1985, p.166.
In the end, all three philosophies contributed to the development of traditional medicine during the Song dynasty, typically as separate entities, but occasionally with similar ideals and treatment protocols (Unschuld 1985, p.167).
Other Song Dynasty Inventions/Achievements
Apart from inventing movable block printing, the Song dynasty also gave us gunpowder (Unschuld 1985, p.163), rockets, flame-throwers, cannons, bombs, mines, fireworks, the compass, porcelain/china, paper money, coal, rainbow bridges, foot binding, and even the dreaded examination. A Song academic Shen Gua (1031-1095CE) hypothesised that the ocean tides were affected by the cycles of the moon. The Song also dramatically increased the number of tea houses and restaurants available to the general population, particularly in the urban centres of China (www.pbs.org/wgbh/nova/ancient/song-dynasty.html; http://afe.easia.columbia.edu/song/).
Interestingly, movable block printing was eventually used by Johannes Gutenberg for the printing of the Bible (www.pbs.org/wgbh/nova/ancient/song-dynasty.html). This didn’t occur until the 1450’s, almost 400 years after the Chinese Song government started using it.
Trade also blossomed throughout China as new inland waterways were built to enhance, and more efficiently, move materials around. New ships were also built to improve trade with foreign lands (Unschuld 2009, p.113), particularly throughout south-east Asia. Having said that, the Chinese also traded with a lot of other countries outside of south-east Asia. These included, but were not limited to, India, Persia, Arabia, and even Africa (east coast).
A census taken in 1083CE suggested over 100 million people were living in China; over 1 million of those in the capital of Hangzhou (by 1270CE) which is located roughly 200km south-west of Shanghai in Eastern China (Cotterell 1990, p.182; www.pbs.org/wgbh/nova/ancient/song-dynasty.html; http://afe.easia.columbia.edu/song/). What is interesting is that from about 2CE until 742CE the population in China was relatively steady at 50 million people. What that essentially meant is that in the space of about 300 years, the population in China doubled (http://afe.easia.columbia.edu/song/). To further put that into context, London’s population at this time was only about 15 000 people. One of the main reasons for the population explosion was the dramatic increase in rice production. Rice was grown in southern China, whereas wheat, millet and sorghum were grown in the north.
“The elite of the city [Hangzhou] often formed clubs. A text written in 1235 mentions the West Lake Poetry Club, the Buddhist Tea Society, the Physical Fitness Club, the Anglers’ Club, the Occult Club, the Young Girls’ Chorus, the Exotic Foods Club, the Plants and Fruits Club, the Antique Collectors’ Club, the Horse-Lovers’ Club, and the Refined Music Society. Members gathered for lively discussions and socializing” (http://afe.easia.columbia.edu/song/).
Marco Polo supposedly visited China around 1275CE and stayed about 20 years. Initially, however, he went to Beijing, which had become part of the Mongol empire. He became a friend and confidante of Kublai Khan, the emperor of the Mongol empire, and soon to be first emperor of the Yuan dynasty of China (1279-1368CE) (http://www.silk-road.com/artl/marcopolo.shtml).
Landscape painting and gardening were also particularly popular:
“… the Song was the most active period culturally in Chinese history … its greatest achievement lay in the visual arts … Chinese art found its perfect mode of expression. That is the painting of the landscape … Interest in gardening as an art ran parallel to that of landscape painting”
Cotterell 1990, pp. 178-179.
Collapse of the Song Dynasty
The Song dynasty collapse did not happen overnight and was essentially set in motion in the first twenty years of the Song dynasty. After Tai Zu regained control of most of southern China, in 979CE he tried to regain control of the northern parts of China near Beijing. It was an epic failure and Tai Zu had to agree to pay tribute to the ruling state (called Liao) to stop them invading the Song territory (Cotterell 1990, p.170). From that point forward, the Song stopped its dreams of expansion and settled on strengthening what they already had.
However, continued unrest in the northern regions of China (and beyond), and the fact that the Song dynasties northern border was not defended by the Great Wall of China, meant that they were continually at threat from those regions. In addition, the western regions were active against the Song, so they had enemies coming from two different directions. So, I guess it was not particularly surprising that by 1126CE (166 years after the Song came into power) the northern and western invaders had driven the Song south and east. With less land to defend, and with the aid of an extremely helpful wartime item called gunpowder, the Song were able to hold on for a further 153 years as the Southern Song.
It is impossible to predict the outcome of the Song had Genghis Khan and his Mongolian horde not taken an interest in conquering China. The Song may very well have thrived for several hundred more years, but of course history does not work that way. Genghis Khan was real, and he was a serious badass. He conquered a large chunk of the known world at the time (see map below) before dying in 1227CE as he was heading into the northern parts of China. Mystery abounds but apparently, he died after falling off his horse; sounds like a rather boring way for such a significant historical figure to die. Wouldn’t it have been way more interesting had he died extremely outnumbered 20-1; Injuries to his face, groin, and abdomen; yet still standing like an inhuman God? Wait, I have a better one, he could have died like the black knight in the historical fiction piece from the Monty Python ensemble called ‘The Holy Grail’. I should probably get serious again … haha!!
Genghis Khan started the invasion of Northern China before dying in 1227CE. His people continued the invasion of the South, but it took them until 1279CE to conquer all of China. Kublai Khan (grandson of Genghis) became emperor of China, moved the capital to Beijing and called his dynasty the Yuan (Cotterell 1990, pp.186-187).
It might seem hard to believe that it took the Mongolian horde 50+ years to defeat the Song dynasty. The main reason it was so difficult for them was hinted at by me earlier – gunpowder! That one item, plus the unfamiliar and unkind terrain for the Mongolian war horses, pretty much guaranteed that the Song were going to hold firm. Unfortunately for them, some of their gunpowder specialists were seized and then forced to use their expertise against the Chinese. From that point on, the Mongolians were irresistible and officially seized power in 1279CE.
“Although scholars often consider the Song Dynasty to have been very weak, its use of gunpowder was the reason it was able to hold off the Mongols for many decades. Eventually, the Mongols were able to capture Chinese artisans and use the latest gunpowder technology against the Chinese. The Mongols used those people who had a special knowledge of technology and employed them in their own armies as engineers. They carried that technology to the West very rapidly because it was very helpful in their conquests” (http://www.pbs.org/wgbh/nova/ancient/song-dynasty.html).
Concluding Thoughts
I absolutely love history! I do not care what culture or what age, and Chinese medical history is one of my special interests, especially for those eras when the medicine has been shaped by historical events.
When events occur in history that alter how people view their health and well-being, well that is where I want to be – fully immersed in it. I want to feel like I was there, learning from the Chinese people, peeking into all the nooks and crannies, searching for any heroes, or perhaps, some skeletons in closets. I want to know what was happening in their world at the time because I feel like this will help me to better understand the changes in their medicine.
I want to thank the Song Chinese (960-1279CE) for so kindly inviting me into their lives. They were such polite guests who treated me with the utmost respect.
The idea for this blog came from a student of mine who was asking me about some of the original Chinese medicine texts such as the Yellow Emperor Classic and the Shang Han Lun. She asked me how old these texts were because she had been given a variety of different dates from different lecturers, and her research had also left her none the wiser. I told her that the Yellow Emperor Classic was probably written somewhere around 100BCE and the Shang Han Lun somewhere around 200CE. This response seemed to be well received by my student and we parted ways as we headed off to different classes.
As I was walking to my next class my brain started to do its funky memory recall thing and I was reminded about the Song dynasty and the fact that they had written/printed definitive editions of a series of classical medical texts. And that, as they say, was it!! When I got home that night, I did a bit of research on the Song dynasty, and I was hooked. Initially I was going to focus solely on moveable block printing but once the Song Chinese started speaking to me it became apparent that they wanted you, the reader, to know about something more important – which was, do you treat the person, or do you treat the disease?
I hope you enjoyed my article even half as much as I enjoyed researching/writing it. What are your thoughts? Please let me know in the comments below.
Love and light to you all
David Hartmann
“The Sung period thus constitutes one of the pinnacles of technological and scientific progress in Chinese history”
Unschuld 1985, p.163
References
Buck, C (2015) Acupuncture and Chinese Medicine: Roots of Modern Practice. Singing Dragon, London.
Chia, L & De Weerdt, H (eds) 2011, Knowledge and Text Production in an Age of Print: China, 900-1400, Brill, Leiden.
Cotterell, A 1990, China: A History, Pimlico, London.
Hinrichs, TJ & Barnes, LL (eds) 2013, Chinese Medicine and Healing: An Illustrated History, The Belknap Press of Harvard University Press, Cambridge.
Unschuld, PU 1985, Medicine in China: A History of Ideas, University of California Press, Berkeley.
Unschuld, PU 2009, What is Medicine? Western and Eastern Approaches to Healing, trans. K Reimers, University of California Press, Berkeley.
http://education.asianart.org/
https://www.britannica.com/biography/Renzong
http://afe.easia.columbia.edu/song/