Geography, History, and Background
Much of Korea’s epidemiological past has been shaped by its geography. The country occupies a peninsula south OfManchuria that is separated from the Chinese mainland to the west by the Yellow Sea, and from nearby Japan to the east by the Korean and the Tsushima Straits.
Forming a land bridge between northern Asia and the islands of Japan, Korea has time and again been subjected to invasions by armies from the Asian mainland intending to attack Japan, or by Japanese armies establishing a base from which to attack the Asian mainland. Undoubtedly, these contacts must have brought infectious diseases to Korea.To discuss diseases of antiquity in Korea means to discuss those illnesses that occurred during the Old Choson Period (traditionally dated 2333 B.C. to A.D. 562), and the Three Kingdoms Era encompassing the Kingdoms of Koguryo (37 B.C. to A.D. 688), Paekche (18 B.C. to A.D. 660), and Silla (57 B.C. to A.D. 935), as well as the Koryo Era (918-1392). By the ninth century B.C., rice-cultivating Bronze Age cultures had been established on the Korean peninsula. During the Three Kingdoms Era, the Chinese writing system was adopted by the courts in order to ensure the writing down of state chronicles. Only fragments of these texts have survived by being incorporated in the Samguk sagi (History of the Three Kingdoms), which was compiled in 1145 and constitutes the oldest preserved history of Korea.
The introduction of Buddhism to Korea from China during the fourth century A.D. increased contacts with the Asian mainland. Particularly during the Three Kingdoms Era, many Korean Buddhist monks studied in China and were responsible for the influx of many aspects of Chinese culture to the peninsula. When, after long periods of warfare, the Three Kingdoms were unified in 661, the resulting Kingdom of Unified Silla extended cultural and economic contacts with China.
Besides an increasing number of Buddhist monks, students interested in Confucian learning went to China. Some Buddhists even reached India, endeavoring to study their religion at its source. This period also saw increasing cultural and economic exchange with Japan, and commercial intercourse with Arab traders.Although Korea was epidemiologically not as isolated as Japan, and the development of immunities within the population must have set in earlier and more intensively, the long periods of unrest, poverty, and famine during the wars of unification must have favored the outbreak of epidemics and famine- related diseases. Social reforms during the Koryo Era (918-1392) may have improved this situation. Relief programs, sponsored by the government and by the Buddhist church, were implemented; granaries were built as a precaution against years of drought; infirmaries were created; and a system of medical care in the countryside was established. Despite all these efforts, however, the vast majority of the population stayed in poverty and, consequently, remained particularly vulnerable to contagious diseases.
Textual sources relevant to the study of diseases in the early history of Korea are scarce. The Shin Jip Ban (Anthology of Paekche Prescriptions) and the Bup Sa Ban (Prescriptions of the Masters of Silla), medical texts compiled in the states of Paekche and Silla, respectively, are lost. Only some passages and prescriptions have survived by being incorporated into Chinese and Japanese texts. The Ishinpo, a collection of mainly Chinese medical texts, compiled by the Japanese scholar Tamba Yasuyori in 984, refers to the Shin Jip Ban in a discussion concerning abscesses.
Korean physicians were very much influenced by Chinese medical thinking, and adopted Chinese medical terminology. But they also reinterpreted Chinese material in their own way and added information obtained from Indian sources.
Owing to the lack of genuine medical literature of that period, we have to rely on historical literature for information regarding diseases.
The Samguk sagi mentions a first occurrence of an epidemic during the reign of Onjo, king of Paekche, in 15 B.C. There are a great number of different terms for epidemic diseases in ancient Korean writings such as “poison epidemic,” “evil epidemic,” “epidemic of the time,” “epidemic of disease,” and others. Identifications of these terms are, however, difficult. Thus, the Chinese character that could be translated “leprosy epidemic” might simply refer to a widespread disease of a very severe nature.Diseases were discussed in terms of their major symptoms. However, often no clear distinctions were made, and death from famine was recorded with the same wording as death from an epidemic. No need for precision may have been felt in a society that attributed misfortune, disease, and death to the action of ghosts, devils, and demons. Although the more rational principles of Chinese medicine were known to the physicians, they rarely made distinctions solely based on these criteria.
The only complete extant medical book of the Koryo Era is the Hyang-yak kugup pang (Emergency remedies of folk medicine). This collection of simple relief measures and preparations was compiled during the reign of King Kojong, in 1236. It deals mainly with emergency measures such as employed in accidents; injuries; bites by insects, reptiles, and other animals; drowning; sunstroke; food poisoning; drunkenness; and toothache. It describes, however, also symptoms of diseases and their treatment. This book may be considered to reflect the scholarly attitude toward health care because it leans strongly on the tradition of Chinese medicine. Thus, symptoms such as hemorrhages, blockages of the throat, loss of consciousness, and sudden death from various infectious diseases are discussed. A combined study of the Hyang-yak kugup pang and official annals such as the History of Koryo would provide more insights into the epidemiology of that period. It must be noted, however, that the official historical writings expressed little awareness of medical problems in the country except in case of extended and devastating epidemics, those that involved the capital city or its environs, or cases of illness within the royal family.
The following represents a survey of diseases or groups of diseases, endemic or epidemic, the occurrence of which can be inferred from miscellaneous textual sources:
Smallpox
Historians generally agree that smallpox originated from India. According to the Tongui pogam (Exemplar of Korean Medicine 1610), smallpox had appeared in China already at the end of the Zhou dynasty and the beginning of the Han dynasty (i.e., during the late third century B.C.). A first mentioning of smallpox in a Chinese source suggests a later date (Zhou-hou bei-ji fang by Ge Hong, first half of the fourth century A.D.), whereas a first documented smallpox epidemic can be dated A.D. 495.
A terminus antequem for the arrival of smallpox to Korea may be deduced from the fact that Korean envoys of King Song (523-54) of Paekche, who brought Buddhist scriptures and statues to Japan, transmitted the disease to that country in 552. Shortly after Emperor Kimmei legalized Buddhism, an epidemic of smallpox broke out, and led to the immediate abolition of the new religion. In 584, Japanese officials visited Korea and brought back to Japan the disease together with two images of Buddha. Emperor Bidatsu himself became a victim of the ensuing epidemic the following year. Two years later, with the epidemic still raging, Emperor Yomei (585-7) died of the disease, too. Also the epidemics of 735-7 and of 763 are supposed to have been transmitted to Japan from the Korean peninsula. At any rate, during the Three Kingdoms Era, Korea was a frequent victim of the disease; two kings, Sondock (780-5) and Munjong (839-57), died of smallpox.
For the Koryo Era there is no evidence for the occurrence of smallpox epidemics. Yet, the Hyang- yak kugup pang refers to eruptive diseases in the chapter “Various Childhood Diseases”; the text speaks of “pea-sized boils” and '⅞ean-sized boils in the child.” This could well be a reference to smallpox. If we correctly interpret this passage, and if smallpox had become one of the common children’s diseases, then it would have been firmly established in Korea at this period.
It should, however, be noted that measles was apparently not distinguished from smallpox until the beginning of the Yi dynasty (1392-1910).Other Febrile Illnesses
There can be little doubt that malaria was epidemic on the Korean peninsula from time immemorial. A first mentioning of the disease, however, is as late as the History of Koryo. The Hyang-yak kugup pang contains a passage on “malaria disease” and its therapy. Although not always strictly differentiated from other febrile illnesses, the symptoms of the “3-day fever,” as it was usually called, are sufficiently distinct to recognize it with some degree of certainty; various drugs were employed to obtain relief during the attacks (Miki 1962). Although typhoid fever may have been subsumed under and classified together with other febrile diseases, when one considers the social and hygienic conditions of the period, there can be little doubt of its role in Korean medical history. The same may apply to diphtheria; perhaps the term “blockage of the throat” refers to this disease.
Respiratory Diseases
The Hyαng-yαk kugup pang refers to illnesses that, in modern terms, would be classified as respiratory diseases. In fact, there seem to be references to asthma, pleurisy, and hydrothorax. Whether or not pulmonary tuberculosis and pneumonia, frequent diseases in many premodem societies, were recognized as individual diseases cannot be ascertained from the text.
Parasitic Infestations
The texts mention a disease with bloody saliva. This symptom is characteristic of pulmonary distomato- sis, an infestation with Paragonimus westermani, which is still prevalent in East Asia, particularly in Korea.
Diarrhea and Dysentery
Taking the minute categorization of diseases accompanied by diarrhea, as found in the Hyαng-yαk kugup pang, as an indicator, this group of illnesses appears to have been common and well known. Whereas the official chronicles omitted these, the Hyang-yak kugup pang gives a description of an epidemic with precise details of its symptomatology, including the twisting stomachache and bloody stools.
Besides, this book mentions “cold dysentery,” “dysentery with blue color,” “hot dysentery with reddish-yellow color,” “red dysentery with stomachache,” and others.Venereal Diseases
One of the main symptoms of advanced gonorrhea, difficult urination, is mentioned in the Hyαng-yαk kugup pang. Besides this book distinguishes five types of gonorrhea. That the nature of contagion of this disease was understood is implied in the following passage in the History of Koryo:
One night Mr. Hong took the previous King Chunghye (1330-1332) to his house and they feasted. The King ordered a priest-doctor to cure Mr. Hong’s gonorrhea. The King always took a fever drug and visited many ladies. As a result he had disease. The King and Mr. Hong received curing methods from the priest. The King... used the fever medicine to increase his stamina. (Miki 1962)
Diseases due to Nutritional Dehciencies
In a largely agricultural society, only sufficient local harvests could avert famine and famine-related diseases. In the early Three Kingdoms period, the king of Paekche was held responsible for crop failure and, in such cases, removed from the throne or even killed (Lee 1984). One of the most common nutritional diseases in rice-growing societies up to recent times has been beriberi, that is, thiamine or vitamin B deficiency. Although there is no description of the symptoms in Korean sources prior to the Yi dynasty (1392-1910), we may assume that this disease was common, whenever rice was polished and the husk, which contains this vitamin, was stripped from the grain.
Skin Diseases, Tumors, and Leprosy
The Hyαng-yαk kugup pang contains a section on tumors. However, whether these refer to abscesses, carbuncles, and other inflammatory swelling remains uncertain, particularly because these descriptions are mixed with those of other skin diseases such as furunculosis, dermatitis, scabies, and erysipelas; erysipelas of the head and face is emphasized in the text. Another skin disease marked by boils that is mentioned in this text most probably refers to leprosy. The History of Koryo frequently refers to leprosy as the “bad disease” which is widespread, malignant, and hard to cure. That persons stricken with this disease not only spread horror to the healthy population but also tended to elicit pity and gave rise to benevolent deeds is shown by a
passage from the History of Koryo in which a devoted son cut off a piece of his own flesh in order to cure his father’s disease.
Miscellaneous Diseases and Conditions
The Hyαng-yαk kugup pang gives a clear-cut definition of tetanus by stating that a spear wound will be fatal if it has caused lockjaw and spasms. Similarly, brief descriptions are given for rabies, stroke, epilepsy, hemorrhoids, prolapsed anus, and diabetes mellitus. The latter is defined as causing much urine, being unrelated to gonorrhea, and resulting in very thin patients. Somewhat obscure is the category of “water-swelling” diseases. Obviously referring to edemas, this term may include not only primary heart or kidney disease but also edemas of wet beriberi; consequently, the symptoms of “waterswelling” diseases are also listed in this book under the heading of “paralysis,” this being one of the cardinal symptoms of dry beriberi.
Finally, the Hyang-yak kugup pang has a section on insanity, termed “uneasiness of mind,” “unusualness of mind,” or, in the case of psychosis, “true madness.” However, insanity was a health problem that was considered outside the confines of scholarly medicine; treatment called for the mudang (shaman) rather than the physician.
Lois N. Magner