1. Introduction
In a civilized society, people habitually believe that it is natural for human beings to consciously seek treatment from others when they are sick. John Burnham went so far as to argue that the use of third-party therapy is a fundamental difference between humans and animals, as “animals lick wounds, rest, drink, and perform other therapeutic activities. Humans are unusual in that they bring in a third party to care for and manage the patient -- the healer (Burnham, 2005: 10).” Proceeding from this logic, it is natural for people to think that the increasing popularity of seeking medical treatment and the continuous development of medicine are the important embodiment of the progress of human civilization. In other words, there is a fundamental tension between self-treatment and the advancement of medicine. Generally speaking, the progress of medical technology and the abundance of medical resources mean that the phenomenon of self-treatment is reduced. However, in our study of Chinese medical history, especially when looking through historical materials such as medical books, local chronicles, genealogies, notes and anthologies, the author found that the self-treatment phenomenon in the Ming-Qing dynasties had quite significant characteristics compared with the previous dynasties, mainly reflected in: Before the Song Dynasty, the imparting of medical knowledge was closed and inaccessible to ordinary people, while after the Song-Yuan Dynasties, medical knowledge was in an open state, especially in the Ming-Qing dynasties, the trend of popularization and socialization was particularly obvious. Along with this, self-treatment was becoming increasingly common during this period. This creates a paradox that was not common in the pre-Song dynasties -- Although medical advances were evident, the phenomenon of self-treatment was even more prominent. This seemingly contradictory phenomenon can not help but make us think about what causes this contradiction and what is the logic and root behind this seemingly contradictory phenomenon? The author thought deeply about this and found that the more fundamental reason lies in the disharmony between the high degree of life-oriented of traditional medical treatment and the low degree of specialization in Ming-Qing Dynasties. So, is this incongruity a historical norm or a product of a certain historical stage? Answers to these theoretical questions may shed light on the life-oriented trend that are being encouraged in medicine today. Besides, the concept of self-treatment is not very clear, so it is necessary to define it: self-treatment mentioned in this paper refers to a treatment method that was widely sought by people from the scholastic class to the ordinary people, that is, to treat themselves with available resources, rather than relying on medical experts. This is a proactive attitude in the face of illness. The practice of abandoning medicine and relying just on the healing power of the body are not included.
Since the 1980s, with the rise of medical social history in China, issues such as the doctor-patient relationship and disease responses have also been paid attention to by historians, and a series of research achievements have been made(Qiu, 2013: 315-349; Christopher, 1993: 99-150; Jiang, 2006: 181-212; Lei, 2005: 45-96; Zhu, 2010: 1-50; Yu, 2007: 248-257; Ma, 2016; Tu, 2010: 149-169; 2017: 1-50). These studies are helpful for us to understand the medical resources and level at that time, the doctor-patient relationship and people’s overall disease response, etc., but the phenomenon of self-treatment is basically only mentioned in the study of patients’ doctor-seeking behavior, lacking special attention and discussion. Only Liu Xiyang and Yang Yong specifically discussed this phenomenon. Using solid historical materials, Liu Xiyang mainly focused on the self-treatment and self-maintenance of the literati and bureaucrats in the Ming Dynasty from the perspective of daily life history. In terms of the choice of self-maintenance methods, they preferred the Confucian method of self-cultivation and the Taoist method of meditation guidance (Liu, 2016: 131-143). Yang Yong mainly explored the historical root of this self-treatment behavior, which was particularly prominent after the Song and Ming Dynasties(Yang, 2020: 145-154). According to the unearthed documents, he traced it back to the Warring States period, and analyzed the forms of this behavior in that time. In addition, some studies occasionally involved the topic of self-treatment when discussing the motivation of medical learning and the mechanism of medical knowledge diffusion(Xue, 1999: 5-9; Yan, 2009: 480-481). Although these studies have provided a good research basis for our understanding of the origin, connotation and motivation of self-treatment during the Ming-Qing Dynasties, it is undeniable that on the one hand, research on self-treatment behavior which was common in traditional China is still in its infancy, and on the other hand, in the only two papers devoted to this phenomenon, they did not discuss it as a historical phenomenon in the context of the whole medical history of China, nor did they explore the unique historical medical experience of the Ming and Qing Dynasties and the logic and root of the experience from a series of seemingly contradictory phenomena.
Therefore, this paper regarded the phenomenon of self-treatment in the Ming-Qing Dynasties as a whole, starting from a seemingly contradictory phenomenon--despite the obvious progress in medical treatment, the phenomenon of self-treatment was even more prominent, and summarized the reasons behind this contradiction. On this basis, the author excavated the deep logic and basis of this contradictory phenomenon through further thinking. So, it is necessary to make an overview of medical technology and resources in Ming-Qing Dynasties in the first step of this study.
2. An overview of medical skills and resources in Ming-Qing Dynasties
Influenced by popular concepts such as “Social Stagnation Theory of Ming and Qing Dynasties” and “Needham’s Problem”, some researchers are used to using words such as “stagnation” and “trough” to evaluate the level of medical development in Ming-Qing Dynasties from the perspective of modern science(Li, 2004: 88; Liu, 2011: 114). However, if it is placed in the context of Chinese historical development, the development of medicine in Ming-Qing Dynasties has much to be noted, such as the rise of febrile disease theory, the observation of occupational diseases in pathology, the suspicion of previous statements in anatomy, the invention of human pox vaccination in preventive medicine, the first invention of Kun agent to drive plum in therapeutics, and so on(Fan, 2016: 272-273). In particular, the rise of the doctrine of februarism and the invention of varia-pox are widely recognized achievements in the history of Chinese medicine. The proposal and development of the “Doctrine of evil Qi(戾气说)” not only greatly promoted the development of medicine in Ming-Qing Dynasties, but also contributed to the introduction and acceptance of the Western germ theory in the late Qing Dynasty. The inoculation of human pox started the beginning of effective artificial immunity with far-reaching effects.1) In view of these remarkable achievements in the Ming-Qing Dynasties, even Mr. Fan Xingzhun, who believed that the medical theories in Ming-Qing Dynasties were in a weak state, seemed to have no sufficient reason to deny it. Therefore, he added that the development of medicine had two sides—weak and leaps, and in his paper, leap and development were more described in detail, not weak(Fan, 2016: 196).
There is no doubt that the medical theories and skills of the Ming and Qing Dynasties have made very important developments, which would undoubtedly contribute to the improvement of the level and effect of clinical treatment. At the same time, medical resources more relevant to people’s daily care have also been greatly improved. Yu Xinzhong discussed in detail the increasing enrichment of medical resources in Qing Dynasty from four aspects: the popularization of medical knowledge, the increasing openness of doctors’ profession, the prevalence of shamans and divinity, and the development of medicinal industry(Yu, 2014: 269-278; Li, 1999: 605-609). While other more specific studies have further demonstrated this understanding from different aspects. For example, Angela Ki Che Leung illustrated the development of medical resources in the Ming Dynasty from the perspective of doctor training. She pointed out: “In the Ming Dynasty, there was a big change compared with previous dynasties in terms of doctors. The government did not actively promote the training of local doctors, nor did it pay much attention to the allocation of local medical resources. However, this did not necessarily mean that there would be fewer local medical resources or a lower level of medical services available to the general public. In terms of the training of doctors, it seems that the Ming society was more capable of producing high-quality and large numbers of doctors, rather than necessarily relying on government cultivation. In other words, the Ming society cultivated and produced good doctors more effectively than the Song and Yuan societies(Leung, 2012: 149-150).” Liu Xiyang’s research showed that practical prescriptions were widely used in the Ming and Qing dynasties (Liu, 2020: 85-99), and the researches of Bian he(Bian, 2017) and Zhu Shaozu(Zhu, 2019) showed the rapid development of the medicinal herbs market in Ming and Qing Dynasties. All these studies showed that in the Ming and Qing dynasties, with the increase of population and the development of social economy, the medical market continued to expand and medical resources were also increasingly popularized and socialized, which made it easier for people to obtain medical resources than before.
To sum up, it can be seen that the medical level of the Ming-Qing society was more developed than the previous generation, the local medical resources were more abundant, and the accessibility of people to seek medical treatment was also greatly improved. So, does this mean that the self-treatment tradition in the Ming-Qing society would shrink with the increase of medical resources? Following this question, the author began to systematically sort out relevant literature and historical materials in the Ming-Qing Dynasties.
3. On the phenomenon of self-treatment in Ming-Qing Dynasties
Self-treatment is a phenomenon that exists in all times. Generally speaking, people are more likely to seek self-treatment under the condition of low medical skills and lack of medical resources. However, when reading medical books, local Chronicles, genealogies, anthologies and other historical materials, the author was deeply impressed by the phenomenon of self-treatment and felt that this phenomenon seemed to be more common in Ming-Qing dynasties, no matter the relatively rich literati class, or the poor ordinary people. Here are two aspects of this phenomenon.
1) For the elite, the close relationship between traditional medicine and ancient philosophy made them have higher medical literacy than most professional doctors, which prompted them to switch from other-treatment to self-treatment
Many reports have pointed out that traditional Chinese medicine was born out of ancient philosophy and has an inseparable relationship with ancient philosophy. Further, in the field of ancient philosophy, some scholars have even proved that philosophy and medicine are one from the two dimensions of “philosophy is another medicine” and “philosophy is medicine of medicine” by philosophical speculation (Dai, 2011: 60-64). Such a view has become popular in the current philosophical research field, as evidenced by the trend of “philosophical consultation” and “ideological consultation.” Because of this, for the elites who had been educated by Confucianism for many years, the study of medicine had a unique advantage: Compared with a considerable number of practitioners, they had more ability to study medical classics, which was precisely the key link of syndrome differentiation and treatment of traditional medicine. As a result, many of them did not trust medical practitioners in society. Sun Yanzhi, a scholar in the Qing Dynasty, regarded the absence of medical practitioners as a method to explore the origin of a large number of undesirable phenomena(Sun, 1843). And even well-educated doctors tended to be open about it. Wu Tang, a famous febrile epidemiologist in the Qing Dynasty, also said: “How innocent the living people are! Die not from illness, but from medicine. It’s better to have no doctor than to have one(Wu, 2010:8).” In addition, influenced by the ethos of advocating medicine in the Song Dynasty, they often studied medicine as a sideline so as to get effective treatment when they were learning Confucianism or working as officials. In the process of reading historical materials, the author found that such records are very common in historical materials of the Ming and Qing Dynasties. Although the most were individual cases, the universality of self-treatment among scholars in Ming -Qing dynasties could also be indirectly felt through a large number of specific and vivid cases and famous doctors’ attitudes to self-treatment.
Jiang Cui, born in Huizhou in the Ming Dynasty, studied hard at the Four Books and the Five Classics in his childhood and took part in the imperial examinations for many times, but failed. Soon he fell ill and many doctors failed. Thus, he began to study medicine. In ten years, he cured himself every time his condition recurred(Jiang, 2013: 673).” Another example is that Shen Deqian, a scholar in the Qing Dynasty, was ill at the age of 30 with Xue Zheng(血症). Many doctors were invited, but there was no effect. In desperation, he began to read ancient medical prescriptions and learnt that this disease could be treated by children’s urine. However, children’s urine was not easy to obtain, they could also use their own urine instead. So he started taking his own urine, and over time, he recovered. Occasionally relapsed, he took his urine again as before. It had been forty-eight years since the onset of the disease (Wang, 1999: 357). Not only that, there were also people who taught others how to conduct self-treatment with their accumulated self-healing experience. Fang Houshan, born in Huizhou in the Qing Dynasty, was fond of reading medical classics in his spare time. At the beginning, he gave up reading due to illness, and after learning, he cured diseases with books. Years passed and the disease was finally cured. In his later years, he paid great attention to health preservation—— “screened to plump, focusing on light food and occasionally with medicine as an auxiliary.” In addition, he used his medical knowledge not only to cure himself, but also to teach those around him how to cure themselves. The sick tried as he said, and recovered. Hundreds of people were cured every year, but Houshan was not complacent (Fang). Such cases are numerous in the records of the Ming-Qing Dynasties. This self-treatment behavior was advocated by the ideology of Ming and Qing dynasties and became a trend. Some people even regretted their ignorance of medicine. For example, When Cheng Yuan-ji mentioned his father’s sudden sputum disease in the preface to Luo Hao’s Medical Classics, he said regretfully, “Mr. Yichuan said, You can’t be filial without studying medicine(事亲者不可不知医), and every time I uttered the words, I would sweat for it(Luo, 2015: 7).”
It was worth noting that they often did not lack professional doctors around them. On the contrary, they paid much attention to the participation of doctors in the daily circle of friends, and discussed medical theory and skills with them. But when they fell ill someday, they still saw self-treatment as a basic option. However, the limited number of this elite class could hardly represent the situation of the whole society. In order to reveal the prevalence of self-treatment behavior in the Ming and Qing dynasties, the following question is, what kind of narrative will be presented in civil society and remote areas that account for the vast majority of the population?
2) For the ordinary, the imbalanced distribution of medical resources and the unprecedented universality of medical resources made the self-treatment behavior more common in Ming-Qing dynasties
For the ordinary, as mentioned above, although the Ming and Qing dynasties were more able to cultivate high-quality and large number of doctors, high-quality medical resources were still extremely scarce which led to people’s self-treatment, especially for some minor diseases. Taking Haotou township in Hunan province as an example, “During the Ming-Qing Dynasties, the villagers mostly treated themselves when they fell ill, and only when they were seriously ill would they seek medical advice from rural doctors.”2) In the process of self-treatment, medical knowledge mainly came from folk remedies, patent medicines and popular medical prescriptions at that time.
Folk remedies
Folk remedies are often characterized by experience, low cost and convenience. Therefore, such medical knowledge can be seen everywhere in the folk, and it has become the primary source of medical knowledge for people to treat themselves when they get sick. Even in modern rural areas are still spread a lot of folk remedies. For example, in Hangzhou and its suburbs, “for a cold and cough, people often use pears steamed with fritillaria and rock sugar, or use maltose eggs.”3) In Huzhou, “if you have a fever, drink light bamboo leaf soup or reed root soup. Take the former more in mountainous areas, and take the latter more in water towns.”4) Another example was that a man had been to Leizhou before, and he was poisoned on the way. He looked different and claimed to be dead. Fortunately, he recovered from a few inches of Jicai(吉财) which had been just a folk remedy there(Zhao, 2008:820). Folk remedies like these are often no less effective than doctors’ treatment. For example, at the beginning of the Qing Dynasty, Yao Tingling in Shanghai suffered from dysentery. Because the prescription prescribed by the doctor was not effective, he took medicine according to the local method instead. He wrote about this:
Epidemic dysentery has been prevalent everywhere. I have had diarrhea since June 20. . . . . . At the beginning, I used Mr. Du Xinghu’s medicine for a few posts, but it didn’t work. I felt that I have to defecate all the time and extremely upset. I actually used the four decoctions of Angelica, Alisma, Scutellaria, and Mutong. After only one post, the feces in the abdomen were diarrhea, and it was so comfortable(Yao, 1982:127-128).
For such folk remedies, some famous doctors also specially reminded others that they should not ignore the involvement of these remedies in the process of practicing medicine. The natives often have extremely effective remedies, and a doctor should learn from them. If you always hold on your own opinions, you will be ridiculed when your treatment is ineffective(Xu, 1995:802). Although it is effective, local methods are often only targeted at local common and frequently-occurring diseases. For many conditions, patent medicines have to be used.
Patent medicines
With the development of commerce, drugstores producing various types of patent medicines were scattered all over the country, especially in central cities such as Shanghai, Suzhou, and Hangzhou in the middle and late Qing Dynasty(Yu, 2014: 312-313). These pharmacies made medicines for people’s self-treatment either based on doctors’ own secret recipes or proven recipes accumulated. According to the “Six Shortcuts to Medical Introduction”(医学入门捷径六书), the 36 kinds of medicines sold in the “Xu Bao Yuan Tang”(徐保元堂) pharmacy opened by the famous doctor Xu Chunpu were all Xu’s own secret recipes(Tong, 1995: 31). Another notable drugstore is Bao He Tang(保和堂)(Wang, 1999: 92). The reason for its popularity throughout the country might be that according to the regulations of the “Bao He Tang Wan San”(保和堂丸散谱), “the medicines it had been sold were not just made by one or two people in three to five years, but based on the experiences accumulated by all the well-versed people who had studied medical science for many years”. The diseases that each medicine could treat were listed in detail, so even those who were stupid and ignorant could also take them as prescribed. In this way, the geographical limitations of Lu’s medical practice were greatly broken. “Bao He Tang Wan San could reach the places where Lu’s footprint was not reachable”. For better sales, some drugstores were not limited to operating their own secret recipes, but usually spent a lot of time and energy to collect strange recipes or other people’s secret recipes. For example, “Bao Yu Tang Wan San Pu” was a catalog of medicines made in “Bao Yu Tang”(胞与堂) drugstore founded by Hong Ji in the Ming Dynasty. When talking about the origin of Wan San Pu, Hong Ji said that he preferred medicine, and in his spare time studying Confucianism, he studied medical classics. After years of traveling, he came to realize that medical theory was nothing more than a prescription. Later, he hung a sign at the door, saying: “Exchange strange prescriptions. As long as any person has a strange prescription, I will humbly ask for it”. Through 20 years of hard work, he had obtained tens of thousands of prescriptions, among which the most magical and useful ones had been selected and made into medicines(Wang, 1999: 273).
Although medicines sold by these drugstores became a standing item for some families at that time(Yu, 2007: 256), due to the difference in the financial affordability of individuals, a considerable number of people could not afford. In view of this, some institutions or families or individuals often distributed such drugs for charitable purposes. For example, it was stated in the “Rules of Xu’s Righteous Warehouse”(《徐氏义仓规条》) stipulated in the tenth year of Guangxu: “The plantain fan for heatstroke prevention, as well as Sha medicine, and diarrhea medicines are scheduled to be delivered after the Dragon Boat Festival until the Mid-Autumn Festival. Traumatic medicines, such as hemostasis Qilisan for repairing wounds, medicines for bites from dogs and snakes, can be given at any time, regardless of the family’s surname”(Yu, 2007: 256). These medicines were easy to obtain, so they were often used for self-treatment. For example, on the second day of August in the first year of Tongzhi (1862), Wang Cuiyuan in Shanghai fled with his family. In the early morning, his cousin Zhang Yueqiao suddenly broke out with cholera which was quite serious. Fortunately, he had some Sha medicine with him. After taking it one after another, he recovered(Wang, 1989: 54).”
Medical prescriptions
Illnesses are diverse and different in severity. It is far from covering all diseases by solely relying on folk remedies and patent medicines. Therefore, some literate people used their leisure time to copy or collect daily prescriptions for themselves or their family members. Qi binghui was sickly in his childhood and became increasingly frail. Later, when he went to Shanghai and Chongqing to do business, he obtained the book “Xue’s Medical Case”(《薛氏医案》) by chance, in which he chose a prescription and bought medicine to cure himself. After two or three years, he recovered unexpectedly.5) Moreover, some people were not limited to copying prescriptions at ordinary times, but paid great attention to the dabbing of medical knowledge. For example, Li Yongyi went to Guixi County, Guangxin Prefecture, Jiangxi province to do business at the age of 14. At his leisure time at night, he read medical books by stealing lights, tirelessly for several years.6)
From the above discussion, it is not difficult to see that at that time, self-treatment behaviors were widespread and most of them were taken independently after possessing certain medical resources. Such behavior would inevitably affect the demand for doctors in the medical market, thus causing criticism from medical practitioners. In medical records, there were quite a lot of cases of self-treatment, but they were generally recorded as objects of criticism and “mostly ended up with recourse to doctors(Liu, 2015: 131-143).” A famous doctor named Wan Quan criticized those patients who claimed to be familiar with medical knowledge: “I have seen patients who claimed to know medicine. When doctors wanted to use medicine, they said, ‘What the use of this medicine is! It is tantamount to instructing those who have specialized in carving jade to carve jade. If the medicine is effective, then tell others that it is the result of their own success. If there is not effective, blame on the doctor. How can you expect him to cooperate with doctor in treating diseases?” (Wan, 1999: 23) Wang Shaolong, who was born in a medical family, even regarded those claimed to know medicine as one of the three bad habits of patients(Wang, 1990: 9). For this phenomenon, it was not surprising that medical practitioners generally opposed self-treatment from the standpoint of safeguarding their own authority and interests. However, from the opposite side, this is also an evidence of the popularity of self-treatment behaviors.
According to the above analysis, medical skills in Ming-Qing dynasties were more developed than that in previous and the local medical resources were more abundant. However, from ordinary people in remote areas to elite groups such as literati and officials, no matter whether they had the ability or the opportunity to delay medicine, they often regarded self-treatment as a basic choice when they or their family members fell ill. This is obviously not in line with the cognitive model that people are accustomed to -- the more opportunities to seek medical treatments, the more marginalized the self-treatment behavior is. So, what accounted for this seemingly contradictory phenomenon?
4. The reasons for this paradox
With the development of medical skills and resources in the Ming-Qing Dynasties, the phenomenon of self-treatment increased rather than decreased which seems to be counterintuitive and makes people feel contradictory and even confused. But in a historical context, such phenomena are natural. There are probably the following main reasons:
1) Low barriers to entry and high rewards, coupled with the fact that good doctors were scarce, drived people of varying qualifications into the medical profession, which caused self-treatment no worse than the alternatives
Traditional Chinese rulers focused only on political and military security, with little interest in the welfare of the masses. Although official measures such as famine relief were common, the main reason was that famine was prone to rebellions that threatened the imperial government. Even in Song and Yuan dynasties, which had the most official medical support, official medical care was only the tip of the iceberg in the social medical system (Leung, 2012: 159). Compared with the Song and Yuan dynasties, the Ming-Qing dynasties paid less attention to medical care (Leung, 2012: 155-179). At present, the academic community has been unthinkingly studying in this framework, and no one has thought about why the Ming-Qing governments were more indifferent to medical treatment, which provides room for further research.
During the Ming-Qing dynasties, in the absence of government intervention, private medical care was a free competitive market. A doctor could become a practicing doctor or even a famous doctor as long as there were enough patients; The development of commodity economy stimulated people’s profit-seeking behavior to a certain extent, and the income of medical practitioners at that time was often more than 10 times that of teachers which had been another major outlet for those who failed in the imperial examination(Xiong, 2018: 114); The publication of a large number of medical books had made medical learning no longer limited to mentor-disciple transmission or family transmission. As long as one had the ability to read, he could obtain relevant knowledge from it (Leung, 2012: 179-189). As a direct result of all these factors, a large number of people with little or no medical knowledge were competing to enter the medical market and practice medicine openly. Huang Kaijun, a famous doctor in the Qing Dynasty, attributed the large increase in doctors to the fact that most of the so-called “doctors” were those who “failed to pass the imperial examination, lacked capital for business, lacked the strength to engage in agriculture, and disdained to engage in technology. So they switched to medicine, starting to learn in Spring and to treat people in Summer(Huang, 1996: 400-401).” Those, who did not know what “Huangdi Nei Jing” was and what Wang Shuhe said, just relied on the memory of a few lines of concise medical knowledge and began to treat people. Traffickers, village wives, refugees, and wild monks were all healers. In contrast, the proportion of good doctors was very small. Wu Kun, a doctor in Huizhou in the Ming Dynasty, estimated the ratio of quacks to good doctors after traveling around the country for several years, which was roughly 10 to 1(Wang,1999: 227). Although this ratio was not an accurate statistical result, it could reflect the reality that the overall quality of doctors at that time was relatively low. Even A. Tatapnhob, a nineteenth-century Russian scholar, attributed one of the motives for Chinese people to practice medicine to the fact that “there is no better way to conceal one’s ignorance than the title of doctor(Cao, 2004: 430-431).”
For such medical chaos, although some famous doctors constantly formulated and appealed to abide by various ethical norms to ensure the quality of medical care, there was no mandatory. The cultivation of medical ethics mainly depended on the self-discipline of individuals (Zhu, 2010). The result of moral indoctrination only by some doctors was: On the one hand, the moral standards put forward by some doctors deeply influenced by Confucian traditional morality have being talked about by people even today. On the other hand was the emergence of a large number of negative phenomena of medical ethics coexisting with these ethical standards(Ma, 2008: 113-118). This worrisome medical situation also directly reduced the trust of the patients in the doctors. In such a medical situation, for many people, in the absence of good doctors, it was better to take advantage of popular prescriptions to cure symptoms by themselves than to hand over their lives to others, and even regarded it as extremely dangerous to obey people when they were ill.
2) In the Ming-Qing dynasties, Confucian physicians tended to write more practical prescriptions, which gave many people the opportunity to improve their own medical knowledge and provided great convenience for self-treatment
He Bingdi once estimated the number of people who passed the imperial examination in the late Qing Dynasty: about 500,000 Shengyuan (生员), 40,000 Juren(举人), and 4,000 Jinshi(进士). Taking 1750 as an example, Shengyuan accounted for about 0.01 of the total adult male population, about 0.001 of Juren, and 0.0001 of Jinshi(Ho,1962:173-189). For the children of ordinary families, it was a far-fetched myth to pass the imperial examination. For those who failed, many families showed them the way to make a living. The Family Instructions in the Seventh Revision of The Genealogy of the Qian Family of Wu Yue (《吴越钱氏七修流光宗谱》) specifically mentioned: “If a person has no property, he must pursue a career. Of all careers, the best is reading. If reading is not good, go to be a teacher to teach his fellow children. If not, study medicine so that many people can benefit”. It can be seen that studying medicine had become an important way out for those who could not pass the imperial examination.
When studying medicine, this group of intellectuals with Confucian background compiled and published the most practical parts for the masses under the influence of the concept of benefiting others that Confucianism especially paid attention to while carrying out theoretical interpretation of texts. This practical medical knowledge therefore accounted for a large proportion of all writings. Taking Huizhou as an example, the “Textual Research on Medical Books of Xin ‘an” (新安医籍考) (Wang, 1999) contained more than 800 medical books written by Xin ‘an physicians before the end of the Qing Dynasty. It not only made a very detailed textual research on the existing medical books, but also explored the missing documents. It should be said that it could basically present the overall appearance of Xin ‘an medical records. According to the author’s statistics, among 766 medical books in the Ming and Qing dynasties, medical classics accounted for 13.3%, while prescriptions 46.4%. When we look through the prefaces or legends of these medical books, most of them were written to encourage people to help themselves if a doctor was not available quickly.
This kind of practical medical knowledge, on the one hand, conformed to the ideal of Confucian physicians that everyone could benefit, on the other hand, it also had great social demands in reality. Especially in the late Ming Dynasty, a large number of such prescriptions emerged, and in the Qing Dynasty, the number of such prescriptions exceeded the sum of all previous dynasties(Liu, 2018: 127). This made underprivileged rural communities, who had little or no access to books in the past, the main consumers and beneficiaries (He, 2019: 329), and had played a considerable role in advancing people’s medical knowledge. As Edward H. Hume (1876-1957), a missionary physician who came to China at the end of the Qing Dynasty, described in his memoirs, “Chinese patients would question him with the knowledge of medical books, and even women could communicate with him about rehabilitation with the knowledge of classical medical books, including drawing pictures of the viscera to explain their own conditions(Edward, 2011: 39-40).” They had different degrees of practical medical knowledge, which provided great convenience for self-treatment.
3) Since the mid-Ming Dynasty, the high medical price had caused serious difficulties for the ordinary
Since the mid-Ming Dynasty, the commodity economy was booming and the marketization tendency of the medical profession was quite obvious. Seeking medical treatment required payment of medical fees, which gradually became a natural principle, and even the practice of making a living or even getting rich with medicine also appeared(Xue, 2014: 144). Qiu Zhonglin(Chang, 2009) and Zhang Tiansheng (Zhang, 2015: 144-153) have done excellent researches on medical prices in Ming and Qing dynasties respectively. On the basis of their research, it could be learned that the fees charged by doctors in many areas were not affordable for ordinary people. At that time, doctors’ fees were made up of consultation fees and prescription fees, and if a doctor made a home visit, the fees were added. Among them, compared with the medical fee, doctors’ home-visiting fees and drug cost constituted an important part of the high medical price. In traditional Chinese society, if the illness was serious, in most cases, the sick would invite a doctor to his home. If there were no special circumstances, the doctor would not stay overnight at the sick home. As a result, serious illnesses often required multiple treatments from start to finish, and each visit was paid for by the patients. How much did it cost? We can’t see the exact amount due to the lack of historical data. However, we can speculate from the fee for doctor visits in Henan, which was indirectly mentioned in the late Qing satirical novel The Appearance of Officialdom (官场现形记) (Li, 2000: 347-348). In the 23rd chapter of the novel, Jia Liantai interrogated a young woman who had been suspected of murdering her husband. The young woman denied her crime and believed that the doctor Zhang Dachun had killed her husband. Zhang was brought to court and confronted the young woman. The young woman described the high medical fees charged by Zhang:
All the doctors in our town had bad conscience. Other doctors charged us 4 cents a visit, but he was different—24 cents a visit. For each patient’s house, when he entered the front door and passed through the courtyard, he would need 48 cents more. He lived in the south of the city and I lived in the north, and when he crossed the city, he had to cross two drawbridges, each of which cost two cents more. His conscience, my Lord!
Although there are many fictional elements in novels, the social background and medical mentality it reflects are often true. In this sense, it has also become an important source of medical history research. In this section, there might be exaggerations of Zhang Dachun’s medical price, but the behavior of raising fees should be consistent with the medical environment at that time. Compared with the high cost of home-visiting fee, the cost of medicine fee was even higher because patients often needed to take several posts. Even official families often grudged money for medicine. During the Jiajing period, when Tu Yingxun (? -- 1529) returned to Jiaxing, he was seriously ill and asked for medical advice. A doctor said that if he got frankincense, he could be cured. Tu asked about the price, and the doctor answered that he needed one silver. Due to the high cost, he died a few days later(Zhang, 1985:109). With the economic capacity of an official, they were still stingy with medicine expenses, not to mention ordinary people. In recent years, in my reading of Huizhou documents and other relevant historical materials, I often came across the cruel reality of selling land, selling mountains and even selling wives to buy medicine for his family.
It can be seen that the rising medical prices in Ming-Qing Dynasties should not be a big problem for rich families. However, for the lower and middle class patients who accounted for the vast majority of the population, the high price of medical treatment caused serious difficulties for them. Rather than dying without professional help, it was better to carry out self-treatment in the way they could.
5. Discussion: The contest between life-oriented and specialization
It can be seen from the above discussion that during the Ming-Qing Dynasties, from the ordinary people in remote mountainous areas to the literature-official class, regardless of whether they could afford to ask a doctor, self-treatment had been a basic choice. Moreover, with the development of medicine and the increasingly abundant medical resources, the territory of self-treatment did not shrink but became more common. This seemingly contradictory phenomenon was mainly attributed to the lack of high-quality doctors, the emergence of practical prescriptions and high medical prices. But if thinking further, the deeper logic and root-cause lies in the disharmony between the high degree of life-oriented of traditional medical treatment and the corresponding low degree of medical specialization and professionalization.
During the Ming-Qing Dynasties, medical care was highly integrated into the daily life of individuals or families. As the topic of life-oriented in medicine is closely connected with the current theory of daily life, we can draw lessons from the analysis of the traditional Chinese social structure made by the academic circle using the theory of daily life. According to modern common sense, for any medical system, with the emergence of groups specializing in medical treatment activities, the professionalism of this medical system and the legitimacy of its activities belonging to non-daily life field are self-evident. However, the daily life field of Chinese traditional society was surprisingly developed, so it penetrated, controlled and influenced the non-daily life fields to a considerable extent (Yi, 2004: 250-266). Medical care, which should have belonged to the non-daily life field, was “embedded” in people’s daily life to a great extent in the Ming-Qing Dynasties, and became a part of individual and concrete daily life. From medical training to disease curing and nursing, they were basically carried out in the family space. When a member of the family was ill, the doctor would be called if possible, but the care of the sick were the responsibilities of the rest of the family. Even innovative activities of medicine were no exception. For example, Huang Lvxian, one of the four ingots of Huizhou merchants, had a tenroom garden in his family. He invited the famous doctor Ye Tianshi to his home to test the properties of medicine with Wang Jinsan, Yang Tianchi, and Huang Ruiyun.”7) However, regional differences in climate, physical fitness, etc. often lead to a considerable distance between medical theory and medical practice. Therefore, although many doctors chose to travel around after studying medical theories and entered a non-daily life world dominated by interpersonal rather than human relations, the reason why they could travel to an unfamiliar space to study and apprentice was still rooted in family or the basic security provided by people from hometown. Wherever Xin ‘an physicians went, there would be Hui merchants who provided food and lodging (Tong, 1989: 47-49). In the medical form that medicine and daily life are integrated without distance, the richer the medical resources, the more convenient it is for people to resort to self-treatment.
It can be seen that the high degree of life-oriented of medical treatment in the Ming -Qing Dynasties led to the legitimate significance of medical care in family space, which abided by the natural and spontaneous cultural factors such as emotion, kinship and human feelings based on blood relationship in traditional Chinese society, as well as the corresponding customs, experiences and so on. Therefore, the traditional medical care that attached to this space also had a strong randomness, but lacked institutional regulations and requirements. Until the late Qing Dynasty, with the increasing localization of Western culture, a series of efforts aimed at reshaping the national spirit came one after another. The traditional family space had been transformed from the source of value to the source of evils and diseases, creating a new moral structure. This new moral structure, on the one hand, made people feel threatened and alienated from their previously close family members and acquaintances, and on the other hand made them feel a sense of responsibility for the unfamiliar “non-specific individuals”. As an important part of the social innovation, medical care also took this path. With the implantation of the closed and monopolized medical knowledge, the corresponding licensing system, ethical standards and other measures in Chinese society, medicine was gradually separated from the family space, thus becoming more independent and professional in the modern sense. With the takeover of the body by modern medicine, the advent of today’s medicalization era and the expansion of state welfare, even though the vast majority of people have the opportunity to see a doctor, there are still a large number of self-medicating people. Instead of being marginalized, self-treatment is still a common response to diseases, especially minor ones. Since this paper focuses on the phenomenon of self-treatment in the traditional Chinese period, the author has not yet explored further questions such as how does hospital-treatment and self-treatment interact in daily life? In modern society, what is the new appearance of self-treatment different from that in the Ming and Qing Dynasties? This is also one of the important issues to be discussed in the future.
On the basis of the above analysis, specialization will be examined. Because it is a gradual historical development process rather than a stagnant social pattern (Rueschemeyer, 1983: 38), it cannot be simply judged as yes or no, but what should be considered is the level of specialization. In this sense, we can evaluate the degree of medical specialization during the Ming-Qing dynasties through the following criteria. Zhao Yuanling discussed the standards of doctor professionalization and specialization, and believed that to judge the level of medical specialization, there were several criteria: the separation of the physicians’ healing function from that of other groups, the establishment of boundaries restricting membership, and the development of specialized knowledge that separated the laymen from the specialist (Chao, 1995: 276). Jen-der Lee further outlined the scene of medical specialization: “In a specific space (medical institution), doctors and nurses have licenses and perform their respective duties without mutual violation, and people without professional licenses are not allowed to engage in it. People should seek medical advice as soon as possible if they have any illness or pain(Lee, 2008: 343).” According to the above criteria, combined with the above disclosure of the universality of self-treatment behavior and its social background in the Ming-Qing Dynasties, it can at least be considered that specialization in this sense was a relatively missing content in Ming-Qing medical care.
This may stem from the social reality that traditional Chinese rulers focused only on political and military security, with little interest in the welfare of the masses. As for health care, the state was “absent” not only in terms of individual treatment and care, which were directly related to people’s well-being, but also in terms of regulating the quality and quantity of medical groups so that people could have some degree of access to medical professional services. Even in the Song Dynasty when the state’s emphasis on medical care was unmatched in the entire history of China, the emperors and their ministers pursued the political benefits brought by medicine, not medicine itself (Volker, 2016: 28). In addition, in a self-sufficient natural economic society, labor input was the most effective way to expand reproduction and increase material wealth, and the largest and most direct beneficiaries of good health were individuals and families, not the state. Thus, the State placed the responsibility for maintaining health on individuals and families, even for infectious diseases that were far beyond their capacity to respond. The imperial court was more active than usual in dealing with the plague and would take many measures. Even so, most individuals and families had no choice but to self-medicate when the plague stroke. For example, in the first year of Daoguang, there was a great plague. Some people took ginseng, cinnamon and ginger, some took watermelons and cold water, and some rubbed hands and feet with wine. This was the case in all provinces.8) With the continuous advancement of socialized mass production in modern times, personal health, as an important human capital, has played an increasingly important role in social and economic development and national prosperity. In particular, the establishment of the right to health has pushed the country to the front of the medical and health care field.
To sum up, it is not difficult to see that the relationship between specialization and the life-oriented naturally opens up a broader space for us to think further. During the Ming-Qing Dynasties, in the macro trend, the two showed a competitive relationship. However, in the context of a broader and more microscopic time and space, whether such a competitive relationship is valid? Especially at present, chronic non-communicable diseases are the biggest killer of human health. With the professional development of medical technology, the trend of lifeoriented in medicine has also become a reasonable path for people to shorten the distance from the highly authoritative medical treatment and shoulder their own health responsibilities. This kind of medical specialization and the life-oriented seems to be developing in parallel. If thinking further, what kind of complex social and cultural features will be presented? This is an issue that needs to be resolved in the future.
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