Perhaps the most significant shift in the history of Korean medicine was the popularization of medicine that started during the latter half of the seventeenth century and continued in the nineteenth century. As a result of this process, a Korea equipped with a naturalistic and rational medical system was, for the first time in Korean history, no longer monopolized by a minority of the ruling class. The use of medicine in this period expanded nationwide, even to the level of small towns in terms of geography and even to the general populace in terms of socioeconomic class. In what follows, I examine changes in medical practices and explore the process of and factors behind the popularization of medicine. Given the sources, it is not possible to compile time series data to show at a glance the great changes that took place in medical practices during the latter half of the Chosŏn Dynasty by era, region, gender, and class. The closest we can get to such data comes from a comparison of diaries. However, it is impossible to understand the mechanisms of development and change for each period solely based on such a comparison of diaries. To overcome this drawback, I make use of a different form of example. The case concerns the long-lasting Kangnŭng medical mutual aid society 江陵藥契, which was initiated in 1603 and lasted until 1842.
Perhaps the most significant development in the history of Korean medicine was the popularization of medicine that started during the latter half of the seventeenth century and continued into the nineteenth. Through this gradual process, for the first time in Korean history, a Korea equipped with a naturalistic and rational medical system was no longer monopolized by a minority of the ruling class. The use of medicine in this period expanded nationwide, even to the level of small towns in terms of geography and even to the general populace in terms of socioeconomic class.1
According to written records, the tradition of Korean medicine is of considerable length and continuity. Indeed, the tradition of the ideology that medicine must be practiced on behalf of the populace is evident even in a national foundation myth. We have references to practicing physicians from the fifth century ad, and in 692, a medical school was established to train them. In the tenth century, during the Koryŏ Dynasty 高麗王朝, an institution, the Tongsŏ Taebi-won 東西大悲院, was established to take care of patients, indigents, orphans, aged people, and those suffering from hunger in the capital based on the concept of “great compassion.” In 1109, in imitation of the Song Chinese tradition of treating the illnesses of the populace in which the “monarch bestows medicine as a virtuous deed for the populace,” the Hyemin-guk 惠民局 was established to provide medicine to the inhabitants of the capital. This ideology of providing medical service to commoners was subsequently transmitted to the Chosŏn Dynasty 朝鮮王朝, founded in 1392. At that time, the Hyemin-guk was renamed the Hyemin-sŏ 惠民署, while the Tongsŏ Taebi-won continued to exist as the Tongsŏ Hwarin-sŏ 東西活人署, with the Buddhist term “great compassion (taebi)” being replaced by the Confucian name “saving people (hwarin)”.
Despite the existence of such institutions, however, medicine was monopolized by the ruling class. Hendrick Hamel (1630∼1692), who was shipwrecked on his way to Nagasaki, Japan and detained in Korea during 1653–1666, thus wrote of the medical situation in the country as he observed it.
They [Koreans] use indigenous drugs when they are ill. Commoners are ignorant of the drugs. The medical doctors serve only the upper class. The poor, who do not have access to medicine, depend on blind fortunetellers or diviners (Hamel 1981).
Surprisingly, the eyewitness accounts of foreigners in the late nineteenth century are strikingly different from those of Hamel. In 1884, George Woods, a US navy surgeon, said “The Coreans, just like Chinese, are medicine consumers, and drug-stores are numerous...As a conclusion, it must be mentioned that superstitious practices are less common among Coreans than among Chinese. The people of the `Hermit Kingdom' are disposed to follow the Japanese in an almost complete indifference to religious matters” (Bohm and Swartout 1984). In 1888, Shouziki Koike 小池正直, a Japanese army doctor who served in a Japanese hospital in Korea, reported: “In many cases, physicians originated from sons of government officials. People respect them. Physicians only give their patients prescriptions without supplying drugs by themselves, and the pharmacists compound medicines according the physicians' prescriptions. But, these phenomena can only be found in the capital, Seoul. In rural areas, medical practitioners manage drugstores and give prescriptions by themselves, and patients do not respect them... Everybody who wanted to be medical practitioners can obtain the occupation because there is no government license system” (Koike 1888).
What, then, occurred in Korean medicine during these 200 years? Although eyewitness accounts should not be accepted uncritically, these records demonstrate that, in the mid-seventeenth century, according to the patient's economic circumstances, the upper class made use of medicine while the lower class depended on divination. But, during the latter half of the nineteenth century, both classes relied little on superstition and made a broad use of medicine, as medicine extended even to rural areas. By this time, physicians in Seoul boasted high status and standards and even managed pharmacies, while those in the provinces were of low standards. Here, I use a term “medicine” as “naturalistic” medicine in a limited sense, which is distinguished from “supernatural” treatments such as shamanic rituals and Buddhist incantations. In this paper, I examine changes in medical practice and explore the processes and factors behind these changes. Such changes, however, do not imply a full adaption of medicine and rejection of supernatural methods entirely. Many Koreans, especially of the lower class, had increasing access to naturalistic medicine as consumers while at the same time continuing to employ supernatural treatments.
Below, I have chosen the case study method. This is because there is no time series data whatsoever that shows at a glance the great changes that took place in medical practices during the latter half of the Chosŏn Dynasty by era, region, gender, and class.
As examples, I have chosen two diaries. The most important reason behind this decision is that they were written over an extended period and, from among diaries known to this day, exhibit the richest information on medical life during each era. To compare two eras, I have selected two diaries from the end of the sixteenth century and two from the latter half of the eighteenth century. I have thus chosen one diary per era to better represent individual and regional characteristics. Miam Ilgi (眉巖日記 1567–1577), penned by Yu Hŭi-ch'un (柳希春 1513–1577) during the latter half of the sixteenth century, well demonstrates the medical situation for the highest social class in both Seoul and the provinces. Hwang Yun-sŏk's (黃胤錫 1729–1791) Ijae Nan'go (頤齋亂藁 1739–1791) richly reflects the medical life of a representative aristocrat who held low-ranking posts in both Seoul and the provinces.
However, it is impossible to understand the mechanisms of development and change for each period solely based on such a comparison of diaries. To overcome this drawback, I make use of a different type of example. The case concerns the Kangnŭng medical mutual aid society 江陵藥契, which was initiated in 1603 and lasted until 1842. Kangnŭng is a large town located along the east coast in a latitude similar to that of Seoul. Because this mutual aid association existed for no less than over 240 years, its records reflect the association's emergence, expansion, and extinction. In addition, because, from the standpoint of Seoul, the area concerned could be reached only after crossing the most perilous mountains in Korea, these records reflect the conditions far away from the economic and political center.
In Korea, the history of research on the “popularization of medicine” is relatively sparse. Nonetheless, previous studies across the history of medicine in general provide a basis for the medical systems, theories, and publications that form the foundation for the popularization of medicine. In the History of Korean Medicine and of Diseases in Korea 朝鮮醫學史及疾病史, Miki briefly noted that late-Chosŏn medicine was characterized by the popularization of medical science and the publication of simple medical manuals.2 In my doctoral dissertation, “The Formation of a Modern Healthcare System in Korea: 1876–1910” (1996), I proposed a comprehensive hypothesis on the popularization of medicine in Chosŏn society from the latter half of the seventeenth century to the nineteenth century (Shin 1996). The hypothesis ran as follows: “The upheaval of the caste system in the late Chosŏn period contributed to an increase in the number of physicians; the vitalization of medicinal markets, exemplified by the Yakryeong Market, led to the formation of a nationwide supply network for medicinal ingredients; the emergence of medical “gye” (契, local financial clubs in which members pooled funds and received lump sums in a predetermined order) diffused the economic burden involved in the purchase of medicine; and, ultimately, the establishment of pharmacies made it easier to use medicine in everyday life.”
Not long after my dissertation, empirical studies that provided a degree of support for this hypothesis began to appear. In “The Growth of Private Medicine in the 18th Century” (1998), Kim Dae-won delineates the popularization of medical knowledge, the increase in the number of doctors, the expansion of medicinal supply, and the spread of simpler and more economic single-ingredient prescriptions that took place during the late Chosŏn period (Kim D. 1998). In “The Hygiene and Medical life of Sajok 士族 who lived in Seoul in the Late 18th Century of the Chosun Dynasty” (1998), another Kim Ho provides a detailed account of the medical community in Seoul during the period (Kim H. 1998). He demonstrates that numerous pharmacies had formed a medicinal market in the capital and that there was fierce competition among doctors in the private sector.
The recent interest in the “popularization of medicine” shown by those studying the history of medicine in Korea, including myself, is influenced by studies that actively emerged in Western academic circles from the 1980s onward. Even in the West, the social history of medicine was a largely overlooked field until the 1970s—traditionally, historical research had tended to focus on the composition of medical chronologies, the accomplishments of renowned medical scientists, clinical achievements in the field of medicine, and the history of notable medical institutions. In the 1980s, such studies began to be criticized for their “Whiggist” view of history, and diverse new research trends advocating an internal approach to the history of medicine—including new historicism, historical sociology, socio-historicism, feminism, and the sociology of knowledge—began to emerge. Although they differed in their areas of interest and scholarly methodologies, these new approaches shared a common interest in the social nature of medicine, as shown through everyday medical activities, the social and cultural formation of medical knowledge, and the ideological underpinnings of medical theories and practices, while eschewing the conventional focus on dramatic medical achievements. Among such studies, those by Roy Porter are particularly relevant to my own dissertation topic. Porter pioneered the socio-historical study of medicine in a series of influential books and anthologies, including Patient and Practitioners (1985), “The Patient's View: Doing Medical History from Below” (1985), Patient's Progress, Doctors and Doctoring in Eighteenth-Century England (1989), and The Popularization of Medicine, 1650–1850 (1992) (Porter 1985; Dorthy and Porter 1989; Porter 1985; Porter 1992). In the latter, in particular, he examined the various forms the popularization of medicine took in England, the USA, Hungary, Spain, and France during a common time span.
This new trend had a powerful impact on the study of East Asian medical history, as demonstrated by the numerous studies that have been published in China, Taiwan, Japan, and Korea since 2000. Notable examples include Ki's “Medical Instruction and Popularization in Ming-Qing China” (2003), which deals with the Ming and Qing dynasties in China's history, and Suzuki's “Medicine, State, and Society in Japan, 500–2000” (2007), which examines the changes that affected Japanese medicine over the centuries from the perspective of the expansion of medical science (Leung, Late Imperial China, 24(1), 130–152; Suzuki 2007). Comparing the popularization of medicine that took place during contemporaneous time periods in various regions of East Asia is a fascinating endeavor, especially since it reveals numerous areas of overlap such as the commercialization of medical practice, the geographical expansion of medicine, and the popularization of medical books. Both the dramatic drop in the price of imported medicine caused by the growth of medical trade among Korea, China, and Japan, and the knowledge of medical expansion in neighboring countries experienced and reported by foreign envoys indicate that such overlaps are not merely coincidental but intricately connected. Although this is an engaging topic, an intensive comparison of the popularization of medicine in Korea, China, and Japan is beyond the scope of the current study, since research into the social history of medicine is still in its early stages in all three countries. The purpose of this paper is to verify the expansion of medicine that took place on a national level in late-Chosŏn society and examine its causes. My use of the term “medicine” inherits the meaning of the word “uiyak” 醫藥, which appears in primary texts from the period as a compound of “ui” (medical science or doctors) and “yak” (drugs and medicine). In late-Chosŏn texts, “medicine” is clearly differentiated from other forms of therapeutic activity, such as shamanist rituals and fortune-telling. Thus, “medicine,” in this context, is synonymous with what we know today as traditional medicine. When defined according to general medical concepts, “medicine” signifies medical practices that employ naturalistic theories, medicinal herbs, acupuncture, and poultices rather than relying on supernatural forces. In Chosŏn during the seventeenth and eighteenth centuries, such naturalistic medical practices, which had been relatively insignificant in earlier periods, increased dramatically. My aim in this study is to verify this phenomenon and explore its process and contributing causes.
2 The Medical Situation in Korea at the End of the Sixteenth Century as Seen through the Diary of a High-Ranking Official
Miam Ilgi 眉巖日記 is the diary of Yu Hŭi-ch'un, a Confucian scholar from the mid-Chosŏn Dynasty who was at one time the monarch's teacher. Although he passed the civil service examinations and entered government service in 1538, he was soon involved in politically motivated factional strife, consequently being exiled to a remote corner of Hamgyŏng Province in the northernmost area of the country, for 22 years. Following the enthronement of the new monarch, King Sŏnjo 宣祖, in 1567, Yu Hŭi-ch'un was pardoned and released, subsequently serving as a taesasŏng 大司成, junior academician, and governor of Chŏlla Province 全羅觀察使 before retiring to his hometown. In particular, as King Sŏnjo's teacher and a Royal Lecture official, he devoted himself to discussions during Royal Lectures. Begun in the year of his release and written in his own hand, Miam Ilgi starts in the year of his release and ends on the day before his death in 1577, covering nearly 10 years. Entries concerning medicine appear on the very first day and last until the end of the diary.
From Miam Ilgi, I chose approximately 570 entries on medicine. Of these, 223 concern patients. A breakdown of these entries is as follows: sixty-nine on Yu Hŭi-ch'un's own illnesses; fifty-one on his immediate family; eighty-four on his extended family and close friends; five on his slaves; six on his horses; and eight on others. Included here are forty-five entries on the illnesses of both family members and strangers, who encompass members of his wife's family, relatives, friends, students, and subordinates. These figures show that Yu Hŭi-ch'un diligently took care of the health not only of himself, his family, and slaves, but also of his extended family and friends.
Entries recounting the treatment of illnesses amount to 104. A breakdown of these entries is as follows: eighty on the intake of medicine; seven on acupuncture; one on moxibustion; nine on bathing in water in which dried safflowers had been boiled; one on bathing in the water from Ch'ojŏng Spring; one on fomentation; two on washing away medicine (from the wounded and the killed); and two on treatment through a shaman's rituals. Apparently, with treatment based on medicine forming the majority, acupuncture, and bathing were used as auxiliary means. There are only two entries on treatment through a shaman's rituals, and even these cases were initiated by female members of the family. There are no fewer than 57 entries on medical texts, most of which concern Yu Hŭi-ch'un's acquisition or transcription of books that he wished to refer to after retiring to his hometown. Eleven entries concern methods for preserving health, and Yu Hŭi-ch'un was especially interested in dietary methods for the preservation of health.
In Miam Ilgi, 203 entries concern physicians, and the names of 30 of them are presented. When classified according to their respective fields, these physicians are: 23 who cure illnesses with medicine; one acupuncturist; three female physicians; and three horse doctors. In addition, among the unnamed physicians is an abscess doctor. Judging from these names, medicine was a professional field in contemporary Korean society. As for their respective regions, out of 30 physicians, 23 were residents of Seoul, and, even among provincial physicians, four medicinal ingredient inspectors had been dispatched from the capital. Consequently, there were only three true provincial physicians, and, to them, those in the provinces who were responsible for the presentation of medicine to the central government can be added.
One hundred ninety-six entries show the ways in which medicine was transacted. From among these, 119 reveal the sources of the medicine that Yu Hŭi-ch'un obtained. These sources were: (1) 27 occasions of offering and bestowing medicine between individuals; (2) 52 occasions involving organs in charge of medicine and physicians attached to the central government such as the dispensaries attached to the State Council 議政府, Privy Council 中樞府, Board of Rites 禮曹, and Board of Honors 忠勳府 as well as Public Dispensary 惠民署; (3) 30 occasions of medicine received from government offices and individuals in the provinces; and; (4) ten occasions involving Hŏ Chun 許浚, who was Yu Hŭi-ch'un's friend and de facto family doctor. Seventy-two entries concern Yu Hŭi-ch'un's dispatch of medicine. Among these entries, 28 apply to cases where medicine was requested from or dispatched to the provinces from Seoul, 17 involve requests from and dispatches from one province to another, and 27 concern requests from and dispatches to Seoul or unknown locations from the capital. Out of these, ten entries indicate that the charge for the medicine was paid.
In October 1567, Yu Hŭi-ch'un was appointed as a lecturer, who would then participate in the monarch's Royal Lectures. Involved in the literati purge of 1545 and dismissed from government service, however, he was exiled to Ŭnjin, only to be rehabilitated and to return to the capital 22 years later. After staying in Seoul for some 20 days to receive his official appointment letter, Yu Hŭi-ch'un left for his hometown to notify the spirits of his ancestors of his rehabilitation. During his brief stay in the capital, his friends provided him with the medicine to treat his ailments:
November 3, 1567 Official Kang Chi sends Ch'ŏngsim Yŏnjaŭm 淸心蓮子飮.3
November 16, 1567 Han Sa-sin brings medicine.4
November 16, 1567 (判書 Minister) Hong Tam sends the medicine requested.5
November 17, 1567 Ki Tae-sŭng (前銜 former title) Ki Tae-sung brings the medicine.6
Found at the beginning of the diary, the commonplace provision of medicine among friends was in accordance with the general method of circulating medicine in Korea in the seventeenth century. Subsequently, his diary demonstrates different forms of transaction, depending on the parties' kinship, provincial affiliations, educational ties, official ranking, and social class.
Between 1568 and 1569, when Yu Hŭi-ch'un held major government posts, he did not lack medicine. This was because he could, with relative ease, use the medicine at the government office to which he belonged. On August 6, 1568, Yu Hŭi-ch'un was appointed a prosecutor (檢詳 正五品class 5A) in charge of the practical business of the State Council, and, from this day onward, freely used the medicine at the dispensary attached to the organ as long as he worked there.7 This held true also when he belonged to other government organs such as the Office of Special Advisers or the Office of Royal Decrees 司憲府. In the early days of the Chosŏn Dynasty, not all organs in the central government were equipped with pharmacies so that even officials had to obtain medicine, if need be, through medical organs such as the Palace Pharmacy, Palace Medical Office, and Public Dispensary. Later, however, pharmacies were installed, and physicians were dispatched to diverse organs in the central government such as the State Council, Office of Royal Pedigree 宗親府, Board of War 兵曹, Board of Rites, Five Military Commands Headquarters 都摠府, Board of Honors, and Privy Council (Sŏng-su 2006). Becoming a high-ranking official in the central government of Chosŏn meant innumerable privileges of which provision of medicine was one.
Yu Hŭi-ch'un sent the medicinal ingredients that he obtained through government organs or friends to his relatives and friends instead of limiting them to the treatment of his illnesses. For example, he sent: medicine to Ŭn-yu's mother and Yi ŏk-pok,8 probably close relatives; Ch'ŏngsim-hwan 淸心丸, Sohap-hwan 蘇合丸, and the Coptis japonica 黃蓮 that the Vice Minister of the Board of Rites had given to him to Na Sa-ch'im in Naju, with whom he enjoyed a close relationship9; and first-aid medicine such as Ch'ŏngsim-hwan, Sohap-hwan, Onbaek-hwan 溫白丸, and Manbyŏng-hwan 萬病丸 to Master T'oegye 退溪 李滉 Yi Hwang, his mentor.10 In addition, friends in the provinces often asked him for medicine, examples of which include the request of Kim Ch'ŏn-il in Naju for Sŏngsim-san 醒心散, and of Chŏng-gon's elder brother for medicine for eye diseases.11 This is because he held a key position which allowed him to obtain physians and medicine easily in the medicine-rich capital.
On some occasions, Yu Hŭi-ch'un purchased and recommended medicine. At such times, he paid for the medicine with rice. He discussed preparing Ch'ŏnp'o-hwan 天疱丸 with Kim Yŏng-guk, assistant curator of the Palace Medical Office 典醫監, and paid two pecks of rice for the medicine.12 In addition, the Wiryŏng-t'ang 威靈湯 that he sent to Na Sa-ch'im's son cost three pecks of polished rice,13 and that friend sent 12 pecks of rice to Seoul as payment for previously used medicine.14 Judging from this, payments for medicine seem to have depended on the degree of closeness and the nature or quantity of the medicine involved.
In Seoul, Yu Hŭi-ch'un came in contact with numerous physicians. Because he was a high-ranking official and a king's teacher, renowned physicians including royal physicians participated in diagnosing and treating Yu Hŭi-ch'un and his family and friends. Royal physicians and palace physicians alike responded to Yu Hŭi-ch'un's requests. Famous later for his Dongŭi Bokam 東醫寶鑑, as a young man, Hŏ Chun 許浚 served as Yu Hŭi-ch'un's family doctor. The latter asked Hŏ Chun to examine the pulse of his close friend Na Sa-hwon to determine the existence and degree of palsy.15 Consequently, Yu Hŭi-ch'un delegated to Hŏ Chun the diagnosis and treatment of his wife's abscess on the tongue and the abscess on his own face, and also had him examine the pulse of his friends Sin Hŭn and Song Sun.16 In the course of these events, Yu Hŭi-ch'un seems to have esteemed Hŏ Chun's medical skills highly, even to the extent of presenting, in June 1569, to the Minister of the Board of Personnel 吏曹 a letter recommending Hŏ Chun as a medical official at the Palace Pharmacy.17 While it is unclear whether this recommendation took effect, Hŏ Chun was indeed appointed to the class 4B post of a manager not too much later.18 Hardly noticeable is direct material recompense for diagnoses and treatment by physicians such as Hŏ Chun and Kim ŏn-bong. Nevertheless, seen more broadly, there was some reward: after all, as a reward for diagnoses and treatment, uintangible recompense such as requests concerning government posts were made.
Also noteworthy among medical practitioners in Seoul are women medical practitioners, who were female physicians 醫女 attached to government institutions. When, between August and September 1568, Yu Hŭi-ch'un's daughter suffered from furuncles on the face, Sŏn-bok 善福, a female physician, visited the family home and performed acupuncture.19 In addition, when his wife was afflicted with acute rheumatoid arthritis, Sarangbi, an elderly female physician, came and treated the illness.20 As such examples show, the illnesses of women in Yu Hŭi-ch'un's household were treated by female physicians. This female physician system is an institution created in response to aristocratic women's tendency to avoid male physicians after the emergence of a strict Confucian sense of morality that sought to keep a distance between the two sexes as a result of the adoption by the Chosŏn Dynasty, newly established in the fifteenth century, of Confucianism as the state ideology. As a consequence, intelligent female slaves, whose low social class allowed them to face men, were selected and trained at the Public Dispensary to become female physicians. These female physicians belonged to the Palace Pharmacy and the Public Dispensary. The former group treated women in royal and high-ranking aristocratic families, while the latter group treated women in all other, more ordinary aristocratic families (Shin 2004). However, there is no mention of these female physicians when Yu Hŭi-ch'un was in his hometown.
Yu Hŭi-ch'un's diary mentions Confucian scholar–physicians 儒醫. He states, “(Privy Councilor) Won gon's medical skills exceed those of mediocre physicians.”21 A privy councilor is one of the highest government posts in class 1B and available to both civil and military officials. Here, “mediocre physicians” generally designated physicians from the non-aristocratic class of technical officials and local government functionaries, and the comment implies that Won gon's medical skills had already surpassed their level. Such people were called “Confucian scholar–physicians” in Korea. Confucian scholar–physicians differed from professional physicians from among technical officials because, first and foremost, they were Confucian literati and civil or military officials. Before the sixteenth century, there was no class of non-aristocratic technical officials or local government functionaries specializing in medical services so that medicine was still a field belonging to the aristocracy or Confucian scholar–physicians. From the sixteenth century onward, illegitimate offspring of aristocrats were designated as belonging to the same class as non-aristocratic technical officials and local government functionaries, thus restricting their entry into government service to professional technical posts. It is at this moment that medicine became one of the professions allowed to this class.22 Of course, this did not mean that aristocrats were now renouncing medicine altogether. On the contrary, in accordance with the Confucian ideology of stressing filial piety, aristocrats studied medicine to take care of the health of their parents and to manage their own health. Unlike professional physicians, however, they did not practice medicine as a means of livelihood.23 In this respect, Korean Confucian scholar–physicians differed from their counterparts in China and Japan.24
Yu Hŭi-ch'un, too, may very well be classified as a Confucian scholar–physician. Highly interested in medicine, he acquired or transcribed medical texts including Kŏga P'iryong 居家必用,25Singmul Ponch'o 食物本草,26Iryong Ponch'o 日用本草,27Kugŭp Kanibang 救急簡易方,28Chikchi-bang 直指方,29T'aesan Yorok 胎産要錄,30Ŭiga Kagam 醫家加減,31 and a printed edition of Ch'on'ga Kugŭp-pang 村家救急方.32 When the monarch suffered from an illness of the spleen and the stomach, Yu Hŭi-ch'un selected dietary treatment methods from works including Yŏnsusŏ 延壽書, Such'in Yangnosŏ壽親養老書, San'gŏ Sayo 山居四要, Ŭibang Yuch'wi 醫方類聚, and Singmul Ponch'o 食物本草, edited them into a book, and presented it to the king.33 In March 1573, he explained the meaning of a passage in Tŭkhyo-bang 得效方 to Kim ŏn-bong the physician,34 and, in his old age, made out prescriptions himself. He even diagnosed his illness as a result of the loss of stamina and wrote out a prescription35 and made out a prescription when his nephew's wife was afflicted with a stomach ache.36
When not working as an official in Seoul, Yu Hŭi-ch'un stayed at Tamyang, his hometown. In addition, because his concubine lived in Haenam and his relatives were evenly spread out throughout Chŏlla Province, Miam Ilgi comprehensively depicts medical life in diverse areas in the province. Moreover, because Yu Hŭi-ch'un toured the province while serving, for 7 months, as its governor, Miam Ilgi reflects medical life as the highest ranking official in Chŏlla Province.
In his hometown, Yu Hŭi-ch'un and his family generally took medicine instead of relying on acupuncture when they were ill. On the contrary, Kim Ryang, his friend who eventually died from a severe illness, received as treatment a blind man chanting a sutra.37 As this example shows, even among provincial aristocrats, sutra chanting was attempted when treatment using medicine was utterly ineffective.
The physicians whom Yu Hŭi-ch'un met in Chŏlla Province were far fewer than those he had met in Seoul. They included: medicinal ingredient inspectors 審藥, class 9B officials who were in charge of paying, as tribute tax to the central government, local medicinal ingredients; physicians Pak Han-mu and Pak P'aeng-jo, who belonged to the local government of Chinwon; and physicians belonging to Tamyang.38 All of these four categories belonged to government organs. Yu Hŭi-ch'un was diagnosed and treated by these men or delegated to them the treatment of his friends and the preparation of his own medicine. Likewise, in his hometown, he received and sent his medicine from and to his family and friends.39 In his hometown, Yu Hŭi-ch'un used his own medicine, medicine obtained through friends, medicine obtained from government organs, and medicine purchased in Seoul. Although the process was time-consuming and complicated, even in such a system, he never complained of the difficulty of procuring medicine.
When working as the governor of Chŏlla Province for 6 months from March 1571, Yu Hŭi-ch'un toured counties and prefectures in the province together with a medicinal ingredient inspector 審藥. Dispatched by the Public Dispensary, these medicinal ingredient inspectors took care of the governor's health and, together with him, verified the quantity and quality of medicinal ingredients to be presented to the monarch as a tribute as allotted to each county and prefecture.40 Indeed, hundreds of medicinal ingredients including ginseng and the velvet of young deer horn were allotted to their production centers, which were counties and prefectures nationwide, and each provincial governor was responsible for collecting taxes in counties and prefectures under his jurisdiction and presenting medicinal ingredients to the monarch in the capital. The Korean medicinal ingredients gathered or grown in each county and prefecture were dispatched to Seoul and formed a medicinal ingredient pool together with the Chinese medicinal ingredients imported through official trade with China (Sõ 1982).
In fact, the medicinal ingredients used at the Palace Pharmacy, Palace Medical Office, Public Dispensary, and each government organ had all been collected thus. Because the form of presentation to the monarch was adopted and only official trade was allowed, all manner of medicinal ingredients used to treat diverse illnesses were available only in Seoul. In the provinces, it was difficult to make up prescriptions unless medicinal ingredients arrived from Seoul. This was because even ingredients such as licorice, an ingredient of all medicine, had to be imported. It was after the implementation of the Uniform Land Tax Law 大同法, which replaced various tribute taxes and corvée with the collection of rice in 1608–1708, that such direct presentation to the monarch changed. Consequently, medical centers in Seoul could now purchase medicine nationwide with the taxes levied, and members of tribute agencies organized medical mutual aid associations to provide medicine to institutions in the central government. In addition, the resulting surplus led to the formation of non-governmental medicinal ingredient markets.
3 Medical Life in Seoul and the Provinces through the Diary of a Provincial Aristocrat during the Latter Half of the Eighteenth Century
The diary of Hwang Yun-sŏk (1729–1791), who was dubbed the “foremost Confucian scholar in Chŏlla Province” during the latter half of the eighteenth century, Ijae Nan'go 頤齋亂藁 is quite voluminous. For over 50 years from the age of 9 years until his death at 62 years, he recorded in his diary everything he heard, saw, learned, and thought concerning a wide variety of subjects ranging from diverse academic disciplines to daily life. His diary includes a wealth of information related to medicine, and, from among extant documents, remains the best record of the medical life of Confucian literati in Korea during the latter half of the eighteenth century. He had great expertise on astronomy and mathematics, compiled a voluminous book titled Lisu Sinp'en 理數新編 which included information derived from the Jesuits in 1774, but was not well-versed in medicine. After passing the literary licentiate examinations in 1759, he was, as a Confucian scholar without an official title, appointed to some low offices in the government from 1766 on. After 1779, he was appointed as the prefect of small towns such as Mokchŏn 木川 and Chŏnŭi 全義. Because of this background, he often traveled to and from Hŭngdŏk, Ch ŏlla Province, his hometown, and Seoul, and also stayed for some time at Changnŭng in P'aju near Seoul, and, as a provincial magistrate, lived in Mokch'ŏn and Chŏnŭi, both in Ch'ungch'ŏng Province. All of this is meticulously recorded in his diary, thus depicting life in diverse areas of Korea during the latter half of the eighteenth century.
The 558 entries that I have selected from Ijae Nan'go recount in detail the illnesses of Hwang Yun-sŏk himself, his family, and neighbors by time and area and the physicians, pharmacies, and treatment through prayers for good fortune to which they resorted. To treat illnesses, Hwang Yun-sŏk visited physicians and took medicine prepared according to their prescriptions. The medicine was paid for with currency. These aspects are apparent throughout his diary.
Ijae Nan'go mentions a case where recompense for a prescription was remitted with money.41 Moreover, this honorarium was considerable, amounting to no less than two taels. It is unclear whether this was because Secretary 都事 Hong, who wrote out the prescription, was highly skilled, the illness was intractable, or the payment included the fee for the medicine. Judging from the use of the title “secretary” (class 5B), Secretary Hong, who made out the prescription, seems to have held this post or had done so previously. The fact that Hong Il-sŏng, who, judging from his title, would have been an aristocratic physician, received money as recompense for his practice of medicine implies that contemporary medicine was now firmly settled as a commodity instead of a “benevolent art” 仁術 that received recompense as a token of appreciation for successful treatments (Fig. 1).
Hwang Yun-sŏk at times complained of the economic burden of purchasing medicine. Generally, he purchased comparatively affordable medicine. What he purchased at pharmacies generally did not exceed ten maces.42 Nevertheless, he received from Mun Pok-kwang, a Seoul physician, a prescription stating that Hasuo-hwan 何首烏丸 was good for his chronic illness. However, he could not purchase this medicine because he did not have the money for the payment: one tael, one mace, and three candareens.43 Here, the difficult life that Hwang Yun-sŏk, a stranger, led in Seoul because of his low rank is palpable. In addition, the plain truth that prices are decisive factors behind the purchase of medicine can be confirmed once again.
The medical skills that greatly interested Hwang Yun-sŏk in Seoul were possible treatments for his younger brother's wen. He was on the watch for renowned physicians in this area who could cure his brother and asked for treatments whenever he met famous physicians. He discussed his brother's illness with Yi Chin-hŭi, an abscess doctor from Kuryong-dong in Hamp'yŏng who happened to visit him.44 In addition, he was advised to seek out Doctor Im T'ae-hŭi, a physician supposedly skillful in treating wens.45 He sought eagerly to collect information on physicians who might be able to cure his brother in Seoul, an urban center, and the information involved covered the entire nation.
With age, Hwang Yun-sŏk's eye disease became chronic. Indeed, when he traveled to Seoul to take the civil service examinations in 1764, the ailment relapsed so much as to hinder his ability to take the test. Consequently, he diligently sought out physicians well-known for treating eye diseases. Hwang Yun-sŏk sought to cure his disease with acupuncture and, sought out the “document manager” 主簿 (with a position in the government medical institutions) Han, a physician living in Hŭngdŏk-tong, but was unable to meet him. Hwang Yun-sŏk sought out many physicians to cure his eye disease and was prescribed diverse treatments such as acupuncture, refined Borneo camphor, and alum.46 The fact that he desperately sought Document Manager Han as a physician implies that the latter was a capable ophthalmologist. Hwang Yun-sŏk's diary thus shows that even ophthalmology was considerably specialized by now, a phenomenon not found in diaries from the sixteenth century.
The most noteworthy medicine that Hwang Yun-sŏk used in Seoul is the abscess medicine from Beijing. When an abscess developed in his armpit, a subordinate official “presented white and black medicine sold at the medical mutual aid association in Beijing.” This medicine had been obtained from a medical mutual aid association that specialized in medicine from Beijing.47 In Sŏngho Sasŏl, Yi Ik criticized the contemporary practice of “loading carts with an endless quantity of medicine” in Beijing and selling it in Korea and pointed out that the silver coins of Korea were being wasted in volume on medicine from Beijing.48 Nevertheless, the increased import of Chinese medicinal ingredients by Korean pharmacists must have contributed decisively to the expansion of medicine in Korean society. This is because the purchase of Chinese medicine, which hitherto had been a hurdle to the composition of medical prescriptions, was no longer viable among the public.
Entries recording Hwang Yun-sŏk's life outside his hometown as a local magistrate—i.e., in Mokch'ŏn from December 1779 to June 1780 and in Chŏnhŭi from July 1786 to April 1787—are valuable because they reflect that he experienced and understood as a provincial local.
In Mokch'ŏn, where Hwang Yun-sŏk served as magistrate, there was no physician and only one pharmacy operated by Doctor Chin.49 Consequently, he made use of the physicians in neighboring areas. The physicians whom he summoned included Hong I-p'ung from Chŏnŭi, 50 Pak Chin-hwan from Chiksan,51 renowned physician Yi Se-ju from Ch'ŏnan,52 governmental physician 醫官 and document manager Chu from Ch'ŏnan,53 Doctor Chŏng, a neighbor well-versed in medicine,54 and Mo Ch'un-jŏng, a female physician belonging to the government organ in Ch'ŏnan.55 To cure himself and his family, Hwang Yun-sŏk made use of all capable physicians around him. Of course, all of this was possible because of his prefectural magistracy. According to the list of physicians above, there were in Ch'ŏnan at least two physicians, one belonging to government organs and one renowned among the public. As for physicians from Chiksan and Chŏnŭi, those listed here are likely to have been the sole physicians in their respective areas and were non-governmental physicians. Well-versed in medicine, Doctor Chŏng seems to have been an aristocrat not formally acknowledged as a physician. Hwang Yun-sŏk obtained all of his medicine from Chin's Pharmacy. The price of all of the medicine that he obtained from Chinsaeng Pharmacy up to his departure from Mokch'ŏn amounted to nine taels and five maces and that of separately prepared medicine amounted to nine taels. All of these expenses were remitted by government organs.56 What is noteworthy is that Hwang Yun-sŏk's terms as a magistrate saw the creation of a second pharmacy. This was founded by Sin Se-uk.57
Six years later, Hwang Yun-sŏk arrived in Chŏnŭi, which was close to Mokch'ŏn, to take up his duties as its prefectural magistrate. Diary entries from this period mention new figures including Kim Tu-ch'u, who had a special prescription against chronic headache, and Yi Hyŏng-ŭi, an itinerant physician, in addition to Hong I-p'ung, Yi Se-ju, and Mo Ch'un-jŏng.58 As is apparent from the title “itinerant physician,” Yi Hyŏng-ŭi was not a physician native to the area but an itinerant adept at acupuncture.59 Hwang Yun-sŏk continued to seek out Hong I-p'ung, a physician in Chŏnŭi, the area that he governed, with the greatest frequency, and occasionally visited Yi Se-ju. The female physician from Ch'ŏnan treated his concubine's illness. The illnesses of Hwang Yun-sŏk's mother, concubine, and daughter were treated by the female physician Mo Ch'un-jŏng. Retired from the Palace Pharmacy, she now belonged to the government office in Ch'ŏnan. As recompense for curing illnesses, Mo Ch'un-jŏng received two pecks of rice, five jars of fermented soybeans, and one catty of beef.60 Except for the period in which Hwang Yun-sŏk was the prefectural magistrate of Chŏnŭi, female physicians were not used. These facts imply that provincial aristocrats made use of female physicians only when they were in the same area and the aristocrats were in a position to use them.
When Hwang Yun-sŏk was the prefectural magistrate of Chŏnŭi, medicine was supplied in most cases not by the local pharmacist but by Kim Kyu-jin, a pharmacist in Seoul.61 He was “one who understood the principles of medicine and pharmacy.”62 Judging from the title “pharmacist,” Kim Kyu-jin seems to have sold medicine from Seoul to the provinces. In addition, Hwang Yun-sŏk's diary mentions an itinerant pharmacist who lived in Ubal-li, Puan, and made money by selling medicine in Seoul, Kimp'o, Chŏnju, and Puan.63 They were thus constructing a network for circulating medicinal ingredients in Seoul and the provinces. Such a phenomenon could not be found in Miam Ilgi diaries from the end of the 16th century.
Because Hwang Yun-sŏk's life in his hometown spanned nearly 40 years, with the exception of departure for studies, civil service examinations, or official posts from 1754 to 1791, it is possible, to a certain extent, to read changes in the medical conditions of a particular area through his diary.
First, there are seven entries on his life in Hŭngdŏk from April 1754 to July 1758. There is no noteworthy information.
Second, from among entries covering his sojourn in Hŭngdŏk from September 1760 to April 1764, there are eight on medicine. As physicians, Doctor Kim from Songch'on, a doctor from Changsŏng, Doctor Chin Kyŏng-a, Kim Hoe-ju, and Yi Sang-sa are mentioned. Kim So-myŏng is alluded to as having prepared pills.
Entries on Hwang Yun-sŏk's third stay in Hŭngdŏk cover the period from July 1771 to April 1778 and amount to 25. At this time, he resigned from his post in Seoul and returned to his hometown due to his father's illness. As physicians, Kim Kyŏng-gan, Pak Sa-han, and renowned physician Im Ŭng-hŭi are mentioned. From among them, only Kim Kyŏng-gan was not native to the area. Although from an aristocratic family, he had come to make use of his medical skills due to poverty. He subsisted on his work as a physician.64 This record confirms that “fallen” aristocrats served as provincial physicians.
During his fourth stay in Hŭngdŏk from January 1781 to March 1786, Hwang Yun-sŏk left 108 entries on medicine. This was because the period saw frequent illnesses in his family such as his aged mother's critical condition and death and his pregnant daughter's critical condition. In particular, to cure his aged mother's fatal illness and his pregnant eldest daughter's serious ailment, Hwang Yun-sŏk did his utmost to find good prescriptions and medicine. To treat his aged mother's illness, he even went to Changsŏng, which was somewhat distant, to invite Hwang Mong-il, a renowned physician.65 Following his aged mother's death, the pregnant eldest daughter was seriously ill at one point and Hwang Yun-sŏk actively sought to cure her. He sought out no fewer than eight physicians and searched even farther and wider than before.66 Hwang Yun-sŏk sought out so many physicians because there were more physicians in the provinces than before and also because he wished to find even better medicine and physicians from among them. This must have been due to a low level of trust of provincial physicians. Consequently, the range of area to be searched to find good physicians and good medicine was inevitably broad. Moreover, professional pharmacists who came from afar broadened the range even further. From the standpoint of the physicians themselves, competition was that much fiercer.
From 1783 onward, many changes occurred to the physicians and pharmacies used by Hwang Yun-sŏk. In addition to Kang Chu-jik, Doctor Kim, and Pak Hwang-jung, whom he had originally patronized, Doctor Kim Hoe-ju newly opened a pharmacy and Sŏ Chong-sang, a new physician, emerged in Koch'ang.67 In addition, this period saw the noteworthy existence of itinerant physicians at official organs.68 Also mentioned is Kim, an itinerant pharmacist from T'aein and Tuwol.69 The establishment of new pharmacies, influx of new physicians, relocation of physicians, and itinerancy of pharmacists all signify that the purchase and supply of medicine in the provinces was active at this period.
All entries on medicine that Hwang Yun-sŏk left from May 1787, when he returned to his hometown from his final government post, and January 1791, when he died, amount to 90. Although he had been absent for only 1 year and 2 months, nearly all of the physicians whom he had often sought out were gone. Except for pharmacist Pak Kwang-won, all physicians were new.70 Among them, Yun Kwang-hŭp was an itinerant physician; Ch'a Tong-ji was a physician from Seoul, and Cho Hae-su had returned from the east.71 Though it is difficult accurately to explain the factors behind the great changes that took place in the 1780s among the physicians whom Hwang Yun-sŏk sought out, it is at least clear that medical circles in the provinces were dynamic enough so that users could change so dramatically.
4 Changes in Provincial Medical Service during the Latter Half of the Chosŏn Dynasty
The growth of medicine in the provinces from the latter half of the seventeenth century to the eighteenth century can be confirmed through far more consistent data. The medical mutual aid association of Kangnŭng 江陵藥契 was maintained for 240 years from 1603 to 1842. It was first organized in 1603, with management by local aristocrats and support from the city of Kangnŭng. The organization then exhibited considerable external growth until approximately 1691, became merely nominal around the nineteenth century and was completely abolished in 1842.
A remote area that could be reached from Seoul after a 7-day trip on horseback, Kangnŭng was an important administrative region from before the Three Kingdoms period to the Chosŏn Dynasty. Despite its administrative importance, however, the area was underdeveloped in terms of transportation because, when starting out from Seoul, one had to overcome the considerably high Taegwallyŏng 大關嶺. The complaint that “this area utterly lacked medicine” (Fang 1989) was cited as one of the reasons for the establishment in 1603 of a medical mutual aid association in Kangnŭng. Hence, it may very well be possible to see this region as completely isolated medically. P'yŏnggang was located in Kang'won Province making it possible to infer the situation in Kangnŭng.
It was amidst such circumstances that the Kangnŭng medical mutual aid association was formed. “Yakkye Ibŭi 藥禊入議” thus records the time and philosophy of the mutual aid association:
It is difficult for human beings to avoid illnesses. Consequently, to save people from sudden death, ancient sages created medical science and medication, both of which have established a glorious tradition. However, our city of Kangnŭng is located in a remote area beyond Taegwallyŏng so that there is neither physician nor medicine, with the result that even filial sons who are devoted to their parents have been powerless and had no choice but to await the completion of [their parents' and elders'] allotted life spans when illnesses develop, unable to discuss anything. We comrades therefore have agreed and come together to establish a pharmacy to save human lives. The explanatory notes are as follows.72
It is noteworthy that the practice of filial piety is stressed here. This was more than simple rhetoric. Indeed, at the beginning, the Kangnŭng medical mutual aid association limited the beneficiaries of its financial support to parents. Because the endeavor to cure one's parents' illnesses is the noblest action, helplessness at parents' illnesses due to the inability to obtain medicine would very well have been seen as unbearable unfilialness. Espousing Confucianism as its ruling ideology since its foundation, the Chosŏn Dynasty stressed above all the practice of the three bonds and five human relationships, and the practice of filial piety was the greatest value. Although the management of a pharmacy required considerable financial resources and the effectiveness of the pharmacy in terms of its investment costs was vague, the aristocracy of Kangnŭng nevertheless established a medical mutual aid association, to a large degree because of the ideology of filial piety. In other words, even though this may be a rather extreme interpretation, the force that led to such immense changes in an otherwise unchanging medical system may very well have been the Confucian emphasis on the practice of filial piety.
The Kangnŭng medical mutual aid association consisted of 25 members.73 These members were mostly influential local aristocrats. Upon analysis, with the range restricted to 90 members from those who first established the medical mutual aid association to those in 1692, 57 of them held titles such as inspectors 監察, teachers of Confucianism 司藝, overseers 察訪, and colonels 護軍; there were fifteen classics licentiates 生員 or literary licentiates 進士; twelve students 幼學 without official titles; and six obscure members (Yi 1988). They also encompassed noteworthy clans living in Kangnŏng at the time: Kangnŭng Ch'oe clan; Kangnŭng Kim clan; Kangnŭng Pak clan; Samchŏk Sim clan; and Andong Kwon clan. Even when a member died, his membership was automatically transferred to his brothers or descendants. The medical mutual aid association subsisted on the rice submitted by these members, and the interest incurred and non-members' payments for using the pharmacy were used to maintain the association.
The fact that 25 aristocrats representative of Kangnŭng came together to manage a mutual aid association shows that the operating expenses of this mutual aid association were by no means low. This is because, to manage a pharmacy in a situation without a circulation structure, or a market, for medicinal ingredients, pharmacies themselves had to acquire in advance the innumerable Korean and Chinese medicinal ingredients used in countless prescriptions. Consequently, it was difficult to establish pharmacies in the provinces. The case of the Kangnŭng medical mutual aid association in the early seventeenth century implies that influential aristocrats in a region could overcome such economic restrictions only by coming together and not without difficulty.
To run a pharmacy, it was indispensable to secure the medicinal ingredients that could be used in prescriptions. The Kangnŭng medical mutual aid society directly cultivated medicinal ingredients in their own gardens or gathered medicinal ingredients available in the area. Because nearly 100 types of medicinal plants were produced in Kangnŭng, medical practitioners harvested them each season without missing the right time for collection. In addition, all medicinal ingredients acquired by members and non-members alike of this medical mutual aid association were to be sent to pharmacies. Chinese medicinal ingredients and medicinal ingredients not produced in or around Kangnŭng were purchased in Seoul. As for the prices of the goods to be used in trades for Chinese medicinal ingredients and of the work horses used, they were weighed and paid in return with the rice and cloth housed in pharmacies. Medicinal ingredients to be obtained in China were secured by meeting and pleading with envoys on their way to China.74
Securing physicians, too, was an important task at hand. At the Kangnŭng medical mutual aid association, local aristocratic members who were well-versed in medicine were appointed as the group's physicians.75 Aristocrats assumed this duty because professional medical officials were only in Seoul, and the provinces had no such physicians. This differs somewhat from the increasing percentage and presence of “middling men” ” among physicians in Seoul, which became full-fledged in the seventeenth century. Designating the illegitimate offspring of aristocrats, “middling men” were a class of men prohibited from advancing to aristocratic posts including the civil and military services alike and, instead, allowed only to accumulate professional and technical knowledge such as “miscellaneous learning 雜學”—i. e., medicine, astronomy, arithmetic, and law—and to hold offices related to it. They were called “middling men” because they were sandwiched between the plebeians and the aristocrats. They began to form in the sixteenth century, and, up to the first half of the seventeenth century, approximately 50% of the families of these “middling men” throughout the nation were formed (Kim Y. 1999). However, medicine originally was one of the disciplines to be mastered by the Confucian literati to practice filial piety and consequently, until the seventeenth century, aristocrats' practice of medicine was not seen as beneath their class in the provinces. This can be verified in the record of the Kangnŭng medical mutual aid association also: “In the past, yi had medicine so that everyone correctly desired it...”76 Physicians belonging to medical mutual aid associations were called “medical officials 醫官,” a title that reflects the wish to elevate the position of medical duties within these associations. These medical officials were paid out of consideration only when profit was made in the management of pharmacies attached to medical mutual aid associations.77 This fact signifies that medical officials were not occupationally tied to the medical profession even though they made out prescriptions.
Although it followed the curricula of the medical service examinations and medical tests administered to select talented individuals (promotion tests) of the central government, the medical knowledge necessary for the Kangnŭng medical mutual aid association took on a simpler form. In 1603, the pharmacy of the medical mutual aid association obtained for its physicians medical texts including Ponch'o 本草, Uihak Chŏnchŏn 醫學正傳, and Hawache Kukbang 和劑局方. Texts unavailable in Kangnŭng were acquired in Seoul and brought back. Here, Ponch'o designates Dagwan Kyengsa Cheungryu Ponch'o 大觀經史證類備急本草, which had been revised and enlarged during the Song and Ming Dynasties, and was a basic text of medicinal plants. A comprehensive medical and clinical text in eight fascicles authored by Yu Tuan 虞摶 of the Ming Dynasty in 1515, Uihak Chŏngchŏn presented the symptoms of illnesses, pulse examination methods, and prescriptions. The official collection of prescriptions for the people published by the Song Chinese government, Hawache Kukbang was a practical text because the number of medicinal ingredients for each prescription was minimal. These three works were all included among the nine medical texts in the curricula of the medical service examinations and medical tests administered to select talented individuals as stipulated by the National Code 經國大典 (1484), the most important code of laws during the Chosŏn Dynasty.78 The Kangnŭng medical mutual aid association considered the three medical texts Ponch'o, Uihak Chŏnchŏn, and Hawache Kukbang as indispensable and saw other texts as supplementary; in the provinces, in most likelihood, the standardized texts for the medical service examinations were followed but a simpler form of medical knowledge was used.
The publication in 1613 of Dongŭi Bokam 東醫寶鑑, which went on to become the representative medical text of Korea, affected provincial medical circles considerably as well. Indeed, at some point, medical mutual aid associations that had obtained Tongŭipokam started, in writing, to prohibit members from taking the work out of the association building. When this stipulation was violated, the personnel in charge could even inflict strict punishment on the offending member.79 Such measures were taken, in most likelihood, because Tongŭipokam was so popular and frequently checked out that it could not be referred to in the process of preparing medicine. These facts plainly demonstrate how deeply Korean medical circles adopted Tongŭipokam.
From its initial purpose as a means of practicing filial piety, the medical mutual aid association changed into a means of providing affordable medical service to members and their families. At first, the primary recipients of the medical mutual aid association were members' parents in addition to officials who aided the operation of the association. Indeed, the medical mutual aid association provided one dose of medicine to members' parents.80 At the same time, however, from the very beginning, the medical mutual aid association allowed its use by non-members and by members irrespective of regulations to secure financial resources. In such cases, medicine was provided at prices higher than when supplied through the medical mutual aid association. Such differences in the pricing were applied also to the use of the association by members' families and non-members.81 By 1648, 45 years after the foundation of the medical mutual aid association, however, the recipients of medicine from the association expanded from members' parents to their immediate families as well as members themselves.82 Such expansion of the recipients qualified to receive medical service through the medical mutual aid association implies changes in the basic ideology buttressing the association. Despite the stress placed on the practice of filial piety, the provision of affordable medical service to members and their families became increasingly important.
Because they performed the function of socially controlling non-members in the local society through medicine, medical mutual aid associations served as an instrument of domination by aristocrats. Created by 25 aristocrats encompassing all influential clans in Kangnŭng, this medical mutual aid association did not stop at merely aiding close members of the aristocracy in times of illness. In light of the fact that it divided the entire city of Kangnŭng into four areas and ruled them, the medical mutual aid association was a total non-governmental medical system as well as the only medical institution in the region. In other words, it was the sole means of satisfying the medical needs of all residents of Kangnŭng. Indeed, these people had no choice but to depend on this medical mutual aid association and to make high payments. Unprecedented, this kind of medical system can be seen as an expansion into medicine or the “benevolent art,” of the growing aristocracy, with the slogan of practicing filial piety. In terms of the developmental history of provincial medical institutions during the Chosŏn Dynasty, this can be seen as the fall of a makeshift system managed on the basis of bureaucratic connections and acquaintance and the subsequent establishment of a new form of stable provincial medical system based on aristocrats' ideology, economic power, and medical knowledge.
Founded in 1603, the Kangnŭng medical mutual aid association operated for some 200 years without problems but became merely nominal at one point around the nineteenth century and was finally abolished in 1842. A document entitled “Sinsu Ch'amdong-gyech'ŏp Chŏnmal 新修參同契帖顚末” thus explains the background.83 There, two reasons are cited for the dissolution of the medical mutual aid association: with the continued emergence of privately managed pharmacies, it had become easy to obtain medicinal ingredients; and pharmacies had come to be considered lowly, suitable to plebeian men and beneath the Confucian literati. For these reasons, medical mutual aid associations, which, like village codes, were highly ideological and class-oriented organizations focusing on aristocrats, disintegrated. Their place was filled by private pharmacies, which were organizations seeking profit, the object solely of the economic activity of consumption. In 1913, all provincial physicians were registered for the first time. According to the Official Gazette, the number of registered physicians nationwide amounted to 5,887, with those in Kangnŭng reaching 32 years.84 Through these statistics, it is possible to estimate the expansion of medicine starting in the eighteenth century. However, these figures do not include medicinal ingredient sellers (according to 1,914 statistics, approximately 7,500 nationwide), who also sold medicine.85 When this omission is taken into consideration, it is possible to infer that, in Kangnŭng, there were far more than 32 medical practitioners. (Fig. 2)
Just how commonplace, then, were medical mutual aid associations like the Kangnŭng medical mutual aid association? First, the existence of a medical mutual aid association formed, probably in 1680, in the northernmost regions of Hamgyŏng Province, by 50 individuals including Yu Chi-jae and Kyŏng Wol-lo has been verified (Hong 1782). Because it was “very difficult to obtain medicine in the impoverished countryside,” these people organized a medical mutual aid association so that, by purchasing in advance diverse kinds of medicine with the grain submitted by the members, it would become possible to provide this medicine to those who later fell ill and use it in a timely manner. The idea and method of responding to illnesses by obtaining medicine through a medical mutual aid association in a remote area are identical to those of the Kangnŭng medical mutual aid association. However, the composition of the 50 members of this medical mutual aid association, founded approximately 70 years after its predecessor in Kangnŭng, is unclear, and, most importantly, it did not openly espouse filial piety.
An entry in the Log of the Royal Secretariat 承政院日記 in 1659 reports not of the organization of medical mutual aid associations in a particular area but of their nationwide proliferation during the mid-seventeenth century. The entry reads as follows:
According to an official report, “It is said that, in innumerable cases, private businesses have become so rampant lately that official operations have been nearly discontinued. For example, private medical mutual aid associations in each market and village are full of those who seek profit through fraudulence so that the regulations by which the Public Dispensary and the Palace Medical Office sell medicine have come to be nearly abolished. Consequently, the prices of medicine have risen sharply, the harmful effects of which are unfathomable. We therefore beseech Your Majesty to prohibit all private medical mutual aid associations except pharmacies attached to government organs” and His Majesty stated, “Implement the suggestions in the report.”86
The entry above reveals two things. First, the proliferation of private medical mutual aid associations has led to the near extinction of the sales of medicine by the Public Dispensary and the Palace Medical Office. Indeed, private medical mutual aid associations now abounded so that there was one in each market and village. Second, these private medical mutual aid associations pursued profit. When these two facts are considered, it becomes possible to infer that, with the growth of non-governmental medical mutual aid associations in the mid-seventeenth century, the monopoly on the sales of medicine enjoyed by the Palace Medical Office, Public Dispensary, and pharmacies attached to organs in the central government and maintained since the instatement of the Chosŏn Dynasty was crumbling. In particular, in the case of Seoul, non-governmental pharmacies proliferated by the latter half of the eighteenth century.87 In all likelihood, this was a result of the growth of private medical mutual aid associations which had occurred following the entry in the 1659 Log of the Royal Secretariat. With the passage of time, private medical mutual aid associations would have changed into pharmacies.
The private medical mutual aid associations recorded in the Log of the Royal Secretariat and medical mutual aid associations in isolated areas such as Kangnŭng were similar yet different. In remote areas, while business activities had been performed at times, there was a strong desire to establish and practice a “benevolent art” to overcome the unfavorable situation in the area. Private medical mutual aid associations did not clearly espouse the practice of a “benevolent art” and were devoted to making a profit through the sales of medicinal ingredients. While it is unclear which of these two medical mutual aid associations first emerged, there is a commonality. The former, in Seoul and other cities, and the latter, in isolated areas, both functioned as the agents behind the reorganization of the medical system in seventeenth-century Chosŏn. As a result, medicine in Seoul came to be diversified and specialized, and a medical system absent in remote areas came to be established. Now, in Seoul and the provinces alike, medicine changed from a class-dependent commodity that could be obtained through organs of the central government or bureaucratic connections to one that could be purchased at the market according to one's economic ability.
The Kangnŭng medical mutual aid association is a good example of the construction in remote areas of a non-governmental medical system led by the aristocracy in the early seventeeth century and the subsumption, in turn, of this system around the nineteenth century in a nationwide system focusing on sales. It agrees with numerous accounts of the medical situation in the provinces in works such as Hwang Yun-sŏk's Ijae Nan'go. As a logical extension of such discussions, the following question must be posed: what are the major factors behind the fundamental transformation of the medical system in Kangnŭng and the entire nation starting in the seventeenth century? Through an analysis of four diaries and the case of the Kangnŭng medical mutual aid association, I focus on the following as the factors behind such changes: formation of the social organization of the mutual aid association; expansion and intensification of Confucian ideology regarding medicine as a “benevolent art”; economically, a surplus in medicine following the implementation of the Uniform Land Tax Law 大同法, pursuit of profit, and increase in international trade; and the rise of new intellectuals such as village schoolmasters and physicians amidst radical changes in the class system.
However, these changes would have been utterly impossible without the special form of organization called mutual aid associations. In the history of Korean medicine, one must obtain hundreds of medicinal ingredients before writing out prescriptions. While it was difficult thus to gather Korean medicinal ingredients, securing foreign medicinal ingredients was even more difficult. This is why it was such a challenge to establish and operate pharmacies in the provinces, in contrast to Seoul. During the first half of the Chosŏn Dynasty, the procurement of medicinal ingredients was possible only for professional medical organs such as the Palace Pharmacy, Palace Medical Office, and Public Dispensary. Later, pharmacies were gradually extended to diverse types of organs attached to the central government and even large government organs in the provinces. In remote rural areas, the locals founded medical mutual aid associations to overcome the economic limitations of pharmacies.
Why the particular organization of the mutual aid society was applied to medicine requires an explanation. “Why must one resort to medicine when ill?” Hamel records the custom that the “provincials rely on shamanism or fortune-tellers instead of medicine.” Amidst such an atmosphere, numerous Confucian scholars, including Yi Ik, steadily argued that “one must resort to medicine when ill.” With the expansion of the Neo-Confucian order, the government accordingly sought to prohibit superstitious cures including shamanistic rituals and, on several occasions, expelled shamans from the capital city. At the same time, village codes and various mutual aid associations, which governed the local society of Korea, intensified such an ideology. Dominated by aristocrats, the Kangnŭng medical mutual aid association was related to these trends. Indeed, stressing the urgent need for medicine in terms of the practice of filial piety, this medical mutual aid association started as one focusing on one's parents and elders. The view that remote areas, too, require medicine and that medical mutual aid associations therefore are necessary can then be understood as the result of such education.
However, these two factors alone are inadequate for explaining the great change. Because medical mutual aid societies were not restricted to specific areas, the material basis of the overall circulation of medicinal ingredients must be discussed. How were the countless medical mutual aid associations in both Seoul and the provinces able to procure so many medicinal ingredients, whether for profit or for the realization of Confucian ideology? What were the circumstance surrounding imported Chinese medicine as well as Korean medicine? Although future research must determine the quantity of medicinal ingredients in surplus of the amount to be presented to government organs and the channels through which these excess medicinal ingredients became available to the public, medical mutual aid associations undeniably flourished based on this very surplus. At least from a medical standpoint, increased consumption of medicine nationwide from the seventeenth century to the nineteenth century clearly gave rise to a structure of a virtuous circle characterized by active circulation and lower prices. In light of the fact that the Uniform Land Tax Law, which replaced most medicinal ingredients to be presented to the monarch with rice, was implemented in the seventeenth century, it probably is no coincidence that the prevalence of medical mutual aid associations and the implementation of the Uniform Land Tax Law occurred at the same time. Moreover, in light of the fact that the medicinal ingredient market was related to the massive import of Chinese medicinal ingredients during the latter half of the Chosŏn Dynasty, this issue may require an understanding of the situation in East Asian and even global medicinal ingredient markets. In addition to an increase in the supply of medicine, an increase in medical human resources, too, requires attention. This is because medicine and pharmacy are linked to a special form of knowledge. During the latter half of the Chosŏn Dynasty, the intelligentsia increased explosively while the number of government posts was extremely limited. Consequently, intellectuals who failed to be appointed to such posts were prompted to sustain themselves by working as legal scriveners, village schoolmasters, and physicians—all of these occupations requiring specific knowledge.
Finally, what does the continued development of medicine from the seventeenth century to the nineteenth century signify for our understanding of Chosŏn society? With the emergence of the Kangnŭng medical mutual aid association in 1603, aristocratic medical service came to supplant a medical system based on feudal relations, and, around the nineteenth century, commercial medical mutual aid associations pursuing profit came to replace this aristocratic medical service. The field of medicine, at least, saw steady expansion from the seventeenth century to the twentieth century. Unlike other commercial fields, however, medicine concerns rational knowledge of nature and the human body. The expansion of medicine signifies the gradual liberation from shamanistic and religious medical services. If so, would it be an exaggeration to say that, in consideration of the commercialization of medicine that transcends the shackles of class and the expansion of medicine based on the knowledge of nature, the growth of medical mutual aid associations examined in this paper signifies the greater rationalization of Chosŏn society in both the economy and knowledge starting in the seventeenth century?
Appendix. The places in this article
This paper combines two previous papers I published in Korean. For this paper, I have rewritten and shortened the article “The Transformation of Everyday Medical Life between the Late 16th Century and the Late 18th Century: From `Gift' Economy to Market Economy (Yuksa Bipyeng 歷史批評 75, 2006, 344–391)”. I have also incorporated material from my article “Three Major Phases in the Development of the Local Medical System of the Chosŏn Dynasty (Hankuksa Yŏnku 韓國史硏究 135, 2006, pp.1–29). The translator of this paper is Kim Yusŏk.
Miki (1962). The first edition of this book appeared as a self-publication in 1955.
Miam Ilgi (Miam Ilgi), 1567.11.3(vol. I, p.63. abbreviated as `I-63' below)
Miam Ilgi, 1568.7.16 (vol. I-88)
Miam Ilgi, 1568.7.16(vol. I-88).
Miam Ilgi, 1568.7.17(vol. I-89).
Miam Ilgi, 1568.7.4(vol. I, p.408), 7.8, 8.10(I-463), 8.11(I-463), 8.20(I-480), 9.2(I-494), 10.27(I-568), 10.29(I-570), 1569.6.1(II-22), 6.9, 6.20(II-53), 閏6.18.(II-85).
Miam Ilgi, 1568.9.19(I-521), 1569.7.19.(II-114)
Miam Ilgi, 1568.5.7.(I-323) 1569.閏6.18(II-74∼75), 1568.3.
Miam Ilgi, 1568.8.16(I-472∼473).
Miam Ilgi, 1568.5.25(I-349), 8.11.(I-463)
Miam Ilgi, 1568.3.26.(I-250)
Miam Ilgi, 1570.6.30.(II-439)
Miam Ilgi, 1570.7.6.(II-449)
Miam Ilgi, 1569.6.6.(II-28∼29)
Miam Ilgi, 1569.6.23(II-56), 6.29(II-62), 7.2.(II-96, 97)
Miam Ilgi, 1569.閏6.3.(II-66)
Miam Ilgi, 1571.11.2..(II-281)
Miam Ilgi, 1568.9.26(I-533), 10.11.(I-548)
Miam Ilgi, 1569.6.1.(II-22)
Miam Ilgi, 1576.10.4..(V-427)
Shin, 2004, pp. 216∼217.
Shin, 2004, p.214.
Miki, 1962, p.348.
Miam Ilgi, 5.26(I-350), 9.8(I-505), 10.17.(I-553∼554)
Miam Ilgi, 1569.12.23.(II-243)
Miam Ilgi, 1570.7.3(II-442), 7.10(II-454), 8.4.(II-494)
Miam Ilgi, 1571.5.4.(III-134)
Miam Ilgi, 1571.6.18(III-172), 7.25(III-203), 10.3(III-252), 10.6.(III-254)
Miam Ilgi, 1572.10.4.(III-382)
Miam Ilgi, 1573.8.21.(IV-129)
Miam Ilgi, 1571.5.4.(III-134)
Miam Ilgi, 1573.1.8(III-498), 1.10.(III-500∼501)
Miam Ilgi, 1773.3.6.(III-600)
Miam Ilgi, 1576.4.8.(V-277)
Miam Ilgi, 1576.5.14.(V-131)
Miam Ilgi, 1569.11.28.(II-229)
Miam Ilgi, 1575.11.12(V-123, 124), 11.13(V-125), 11.29(V-138), 1576.3.21(V-262), 3.26.(V-267)
Miam Ilgi, 1575.12.21 (V-160), 1576.1.29(V-201), 6.14(V-336), 7.3(V-362), 7.27.(V-408)
Miam Ilgi, 1571.7.12.(III-192)
Ijae Nan'go 頤齋亂藁, 1759.9.29.(I-236a)
Ijae Nan'go, 1759.9.30(I-236a), 10.3(I-236a), 10.8(I-236b), 10.22.(I-238b)
Ijae Nan'go, 1770.7.8.(III-322a)
Ijae Nan'go, 1769.10.2(II-568b), 5.11.(II-579b)
Ijae Nan'go, 1769.3.16. (II-355a)
Ijae Nan'go, 1764.5.4.(I-350b)
Ijae Nan'go, 1769.6.10.(II-426b)
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Ijae Nan'go, 1780.3.1(VI-212)
Ijae Nan'go, 1780.3.22.(VI-224)
Ijae Nan'go, 1780.5.23.(VI-261∼262)
Ijae Nan'go, 1780.3.22.(VI-224)
Ijae Nan'go, 1780.1.8.(VI-171)
Ijae Nan'go, 1780.4.23.(VI-245)
Ijae Nan'go, 1780.2.3(VI-194), 4.8(VI-235), 6.12.(VI-266∼267)
Ijae Nan'go, 1780.5.17.(VI-258)
Ijae Nan'go, 1780.3.22.(VI-224)
Ijae Nan'go, 1786.7.30(VII-403), 12.27(VII-553), 7.2(VII-369), 8.28(VII-420), 1787.1.16.(VII-579)
Ijae Nan'go, 1786.12.27.(VII-553)
Ijae Nan'go, 1780.2.4.(VI-195)
Ijae Nan'go, 1787.3.2(VII-624), 3.29(VII-642), 4.6(VII-649), 4.11.(VII-656)
Ijae Nan'go, 1787.7.12.(VIII-9)
Ijae Nan'go, 1786.6.13.(VII-336)
Ijae Nan'go, 1772.8.21.(IV-39)
Ijae Nan'go, 1781.5.27.(VI-360)
Ijae Nan'go, 1782.8.5(VI-421)∼10.21.(VI-429)
Ijae Nan'go, 1783.11.26(VI-497), 1785.1.2.(VII-1)
Ijae Nan'go, 1784.閏3.27.(VI-538)
Ijae Nan'go, 1785.6.16(VII-69), 1786.2.18.(VII-169)
Ijae Nan'go, 1790.2.25.(VIII-385)
Ijae Nan'go, 1788.11.17(VIII-164), 1790.4.1(VIII-400), 1789.5.4.(VIII-254∼255)
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