Speaking of Epidemics in Chinese Medicine

Disease and the Geographic Imagination in Late Imperial China

Marta Hanson

• Publisher: Routledge
• Year: 2012
• Print ISBN: 9780415835350
• eBook ISBN: 9781136816413
• Topic: History
• Subtopic: Chinese History
• Index: History

This book traces the history of the Chinese concept of "Warm diseases" (wenbing) from antiquity to the SARS epidemic. Following wenbing from its birth to maturity and even life in modern times Marta Hanson approaches the history of Chinese medicine from a new angle. She explores the possibility of replacing older narratives that stress progress and linear development with accounts that pay attention to geographic, intellectual, and cultural diversity. By doing so her book integrates the history of Chinese medicine into broader historical studies in a way that has not so far been attempted, and addresses the concerns of a readership much wider than that of Chinese medicine specialists.

The persistence of wenbing and other Chinese disease concepts in the present can be interpreted as resistance to the narrowing of meaning in modern biomedical nosology. Attention to conceptions of disease and space reveal a previously unexamined discourse the author calls the Chinese geographic imagination. Tracing the changing meanings of "Warm diseases" over two thousand years allows for the exploration of pre-modern understandings of the nature of epidemics, their intersection with this geographic imagination, and how conceptions of geography shaped the sociology of medical practice and knowledge in late imperial China.

Speaking of Epidemics in Chinese Medicine opens a new window on interpretive themes in Chinese cultural history as well as on contemporary studies of the history of science and medicine beyond East Asia.

Part I

Foundations and Inheritances

In 217 CE, pestilential qi circulated. Every household suffered deaths; in every house [people] wailed and wept in grief. In some cases, [they] closed their doors and died; in other cases, an entire lineage perished and mourned. Some believed that the epidemic was due to demons and spirits (guishen kou zuo 鬼神口作).¹ Those who suffered from it, [however], were children of the destitute who dressed poorly and ate coarse food, people who lived in thatched dwellings and woven shacks. Those families who lived in palatial houses and ate from precious vessels, households with piles of furs and layers of quilts, rarely suffered so terribly. It is because yin and yang lost their proper orientations, and cold and summer-heat [climatic factors] were unseasonable, that the epidemic occurred. Nonetheless, ignorant people [still] hung up talismans to expel them. That is laughable.²

The author of this account of a raging epidemic in the final years of the Eastern Han dynasty, Cao Zhi 曹植 (192–232), the son of a dynastic founder and the brother of an emperor, was a famous literary figure in his own right. He was also a younger contemporary of the famous Han physician Zhang Ji 張機 (150–219).³ In fact, Zhang may well have been treating patients as he grieved the loss of his own relatives during the same epidemic, most likely in the Eastern Han capital Luoyang. Whether or not they were both were in Luoyang during the epidemic or even knew each other – although Zhang would have known about Cao – they shared comparable views about the cause of epidemics. The cosmic imbalance of yin and yang and their climatic correlates (Cold and Summer-Heat), rather than supernatural forces, added to the widespread assault of the epidemic disease on all sectors of society. Cao also brought attention to social and economic factors – differences in wealth, housing, food, clothing, and bedding – that made the destitute and poor suffer most.

In the preface to his most influential medical treatise, the Treatise on Cold Damage and Miscellaneous Disorders (Shanghan zabing lun 傷寒雜病論), Zhang attributed his motivation for writing what amounts to the first Chinese disease monograph to the devastating effects of the epidemics on his own relatives: “My ancestral lineage used to be large, two hundred or so [members]. Since the Jian’an reign (196–220), in less than ten years, two thirds have died, seven out of ten from Cold Damage.”⁴ Zhang focused not on Summer-Heat, but on other climatic factors that he thought had caused these deadly epidemics, namely Cold and Wind. In contrast to Cao Zhi, Dr. Zhang did not mention contributing social or economic factors but rather focused on the range of clinical patterns of epidemics, their transformations over the course of illness, and the appropriate combination of drugs in formulas to treat each permutation.

Just three years after Cao Zhi’s epidemic, however, the Eastern Han dynasty collapsed and Zhang Ji died, perhaps himself a victim of the epidemics that accompanied the political chaos of that final year. The fate of his medical writings, however, is better understood. One of the palace physicians of the Wei dynasty (220–265), Wang Xi 王熙 (210–285),⁵ collected whatever fragments remained of his manuscripts, probably reorganized them, and considerably revised and expanded upon them. Although this early edition would become a considerable source of controversy during the late Ming and Qing dynasties between those who sought to separate the authentic text by Zhang Ji’s hand from Wang’s and later editors’ amendments, it had no major impact on medicine during the Six Dynasties (220–589), Sui (581–618), or Tang (618–907) periods. In fact, it practically went out of circulation. It was not until physicians in the Northern Song imperial medical bureau rediscovered Zhang Ji’s writings and republished them as three separate imperially sanctioned treatises in the mid-eleventh century that physicians outside of the imperial bureaucracy began to take notice of these writings.⁶ Although physicians and scholars alike began to comment on their geographic limitations and narrow focus on Cold Damage nearly as soon as they began to circulate again, nonetheless from then on Zhang Ji’s treatises came to represent one of the most important textual foundations and intellectual inheritances from the Han dynasty of classical Chinese medicine.

In Part I of this book, the first chapter clarifies my positions on three themes related to the literary and medical practice of “speaking of epidemics” (shuoyi 說疫) that Cao Zhi and Zhang Ji initiated – Chinese traditional epidemiology, conceptions of disease and the geographic imagination, and the place of “Warm diseases” in the Cold Damage narrative. The second chapter then provides a deep history of the Chinese geographic imagination from the mythological origins of a northwest–southeast dichotomy and the medical discourse on the five directions, eight winds, and northwest–southeast axis in the Inner Canon (both predating Zhang Ji). It then turns to the critical responses to Zhang Ji’s treatises, and by extension Song medicine, based on skepticism of their universal efficacy and regional relevance that continued through the Jin (1115–1234) and Yuan (1278–1368) dynasties.

1 Medical History in Three Themes

Chinese Epidemiology, the Geographic Imagination, and a Biography of Wenbing “Warm Diseases”

Before the nineteenth century, not one inhabitant of China suffered from plague, cholera, typhoid fever, tuberculosis, or malaria. Millions died, however, from yin deficiency (yinxu 陰虛), foot qi (jiaoqi 腳氣), Cold Damage (shanghan 傷寒), and Warm diseases. Before the late-nineteenth-century transformations in laboratory medicine, physicians neither in China nor in Europe thought in terms of malaria’s Plasmodium protozoa, the tuberculosis bacilli, the comma bacilli of cholera, or plague’s pasteurella pestis. Modern biomedical categories of disease based on laboratory evidence of parasites, bacteria, and viruses do not apply to the pre-modern Chinese experience with illness, disease, and epidemics. Passage through the Petri dishes of the modern laboratory fundamentally changed the definition of all disease concepts shown to involve microorganisms.¹ These microorganisms would sound as strange to the traditional Chinese physician as deviant qi (liqi 戾氣), pathogenic heat (rexie 熱邪), malignant wind-intrusion (efeng 惡風), magical gu poisoning (gudu 蠱毒), and even smoky miasmas (yanzhang 煙瘴) sound to the modern ear. Yet, Western and Chinese historians continue to extend the laboratory-based model of germ theory, bacteriology, and virology spatially into non-Western countries and temporally into the pre-laboratory past.² Imposing biomedical conceptions of disease onto the past – and even onto unfamiliar cultural contexts of the present – precludes understanding the historical and culturally shaped individual experience of disease as well as contemporary medical responses to them.

Somatic disease involves pathological processes. The pasteurella pestis marks its plague victims with scarring mortal lesions and the tuberculosis bacilli irreparably damage the lungs. Nevertheless, defining a disease remains a social act within a given cultural frame that involves both the patient and the practitioner. The biological aspects and epidemiology of somatic diseases may not change significantly from one context to another or from human to human, but their social, political, and cultural meanings do – and with them the possibilities of therapy. These meanings reveal the many roles diseases play in framing social thought, institutional responses, cultural values, and individual identity. This point is not new to the historian of medicine who begins with the premise that diseases in any society encompass a spectrum from the biological and personal to the cultural, social, and political. A given disease is the sum of these dimensions. As the historian of medicine Charles Rosenberg wrote, “A disease does not exist as a social phenomenon until we agree that it does – until it is named.”³

In other words, when medical historians examine diseases as social and cultural phenomena, they pay attention to who named them, when and why; and how the names for, meanings of, and responses to diseases changed over time. Naming a disease creates a disease concept, and like any concept, medical ones are always social products. And because they are necessarily human interpretations, disease concepts have their own unique histories. They also share basic components: the type of suffering or symptoms, who suffers or the patient, what it is called or the diagnosis, its outcome or prognosis, its cause, and how best to prevent or treat it.⁴ The confusion arises when physicians and historians alike mistake the disease concept for a disease entity and treat disease concepts as if they were biological beings in Nature instead of the human constructs they always are and have always been. Even “biological” and “Nature” are concepts humans have deployed to make sense of the observed world. Their meanings have changed considerably over the centuries of their recorded use in European languages. When positivist historians give disease concepts a transhistorical status, confusing them with the phenomena they describe, the result is impoverished understanding.⁵

Retrospective diagnosis – the projection of modern disease concepts onto past disease experiences – remains a common practice despite its anachronism and methodological pitfalls. It justifies ignorance of changes in meanings of diseases over time. By contrast, this book’s approach to the history of disease concepts starts from the premise that diseases are historically situated, socially defined, and culturally meaningful. Not only does the meaning of a disease concept evolve, the disease is inseparable from its definition and interpretation. These two opposing approaches to the history of disease can be summarized according to what Adrian Wilson, borrowing from Ludwig Fleck, called two “thought styles.” The common practice of retrospective diagnosis exemplifies what Wilson calls the naturalist-realist approach. This approach assumes that the modern disease concept mirrors “natural reality” and thereby excludes it from serious historical investigation. Scholarship that takes disease concepts themselves as objects of historical analysis, by contrast, represents the historicalist-conceptualist approach.⁶ From this perspective, the histories of the more obviously somatic modern disease concepts such as plague, cholera, tuberculosis, malaria, leprosy, and syphilis are as varied, variable, and unstable over time as those disease concepts considered to be more psychosomatic – neurasthenia, chronic-fatigue syndrome, allergies, and even asthma – or more obviously socially constructed ones such as hysteria, homosexuality, cholorosis, and most recently, attention-deficit hyperactivity disorder.

The naturalist-realist approach also assumes that scientific and medical knowledge exists somewhere outside society. In this view, the only relevant past meanings of a disease concept are those that fit into a clear trajectory progressing toward its present definition. The naturalist-realist essentially uses teleology to ignore not only past meanings that do not support the present consensus, but also the consensus-building process that stabilized the current disease concept in the first place. The historicalist-conceptualist approach, by contrast, starts from the premise that all knowledge (medical as well as scientific and humanistic) is socially constituted, socially maintained, and changes over time. Even the most stable somatic disease concepts today have complex cultural histories, require strategies that generate and enforce agreement on their current meanings, and change with new medical knowledge, technologies, and consensuses.⁷

Biographies of Disease C...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• List of illustrations
• Chinese historical dynasties
• List of bibliographic abbreviations
• List of library abbreviations
• List of editorial abbreviations
• Acknowledgements
• Introduction
• Part I: Foundations and inheritances
• Part II: New Ming medical boundaries
• Part III: Early modern medical transformations
• Notes
• Bibliography
• Index