Leprosy in China

A History

Angela Ki Che Leung

• Publisher: Columbia University Press
• Year: 2009
• ISBN:
  9780231517799
• Topic: Historia
• Subtopic: Historia de China

Angela Ki Che Leung's meticulous study begins with the classical annals of the imperial era, which contain the first descriptions of a feared and stigmatized disorder modern researchers now identify as leprosy. She then tracks the relationship between the disease and China's social and political spheres (theories of contagion prompted community and statewide efforts at segregation); religious traditions (Buddhism and Daoism ascribed redemptive meaning to those suffering from the disease), and evolving medical discourse (Chinese doctors have contested the disease's etiology for centuries). Leprosy even pops up in Chinese folklore, attributing the spread of the contagion to contact with immoral women.

Leung next places the history of leprosy into a global context of colonialism, racial politics, and "imperial danger." A perceived global pandemic in the late nineteenth century seemed to confirm Westerners' fears that Chinese immigration threatened public health. Therefore battling to contain, if not eliminate, the disease became a central mission of the modernizing, state-building projects of the late Qing empire, the nationalist government of the first half of the twentieth century, and the People's Republic of China.

Stamping out the curse of leprosy was the first step toward achieving "hygienic modernity" and erasing the cultural and economic backwardness associated with the disease. Leung's final move connects China's experience with leprosy to a larger history of public health and biomedical regimes of power, exploring the cultural and political implications of China's Sino-Western approach to the disease.

Li/Lai/Dafeng/Mafeng	ONE
History of the Conceptualization of a Disease/Category

In the early twentieth century, when China was obsessed by its leprosy problem, medical doctors and historians alike looked back in history in order to identify evidence of true leprosy in ancient classics and medical texts.¹ The mentions of dafeng/lifeng (big Wind, Wind of li) in the Huangdi neijing (The Yellow Emperor’s Inner Canon), the most important medical classic in China,² and the famous episode in the Lunyu (Analects) on Confucius lamenting the “malignant ailment” (eji) of his disciple Ran Boniu were probably the most quoted examples in modern articles written on the Chinese history of leprosy to illustrate the early existence of the disease. These mentions were made famous in Western literature by Joseph Needham and Lu Gwei-djen in the 1960s in their effort to show the occurrences of true leprosy in ancient China.³ The approach of describing the history of leprosy by equating certain early terms with Hansen’s disease, or taking as proof of its existence the mention of a few suggestive symptoms seems outdated nowadays. This approach was legitimately challenged, notably by Nathan Sivin, already in the 1970s.⁴ As it is practically impossible to judge from texts if a recorded case was indeed true leprosy, determining the moment when leprosy first appeared in China is doomed to be futile and controversial. What is of greater interest to today’s historians is the historical development of the conceptualization of the disease, or rather, a category of diseases called dafeng or li/lai⁵ in early China that late imperial doctors reanalyzed as a single category called mafeng (numb Wind), a name that is still used today to translate Hansen’s disease. This approach would at least reveal the complexities of old Chinese disease categories, which are not easily analyzable by familiar modern biomedical ones. The historical conceptualization of dafeng/li/lai/mafeng would also provide a concrete case of the historical construction of medical knowledge in China in the past. In other words, by avoiding imposing modern biomedical meanings onto old Chinese disease names, I attempt to reveal the rich history of old Chinese disease categories on their own terms, a better way to grasp the nature of the old Chinese nosological system. The history of mafeng provides an excellent example for such an understanding.

Ancient disease names in China were of two broad types: those describing symptoms, and others that refer to broad configurationist etiological patterns that were considered to be responsible for producing disorders. These patterns were mostly cosmological or environmental, such as yin/yang, the five phases (wu xing) that constituted the basis of ancient Chinese thought,⁶ and the six qi (atmospheric influences, or “energetic configurations”⁷): Wind, Cold, Summer Heat, Dampness, Hot Dryness, Fire, a notion derived from the five atmospheric influences described in the Inner Canon.⁸ These six qi were later sometimes also called the six excessive influences or external pathogens (yin). The terms dafeng or lifeng thus designated disorders caused by the intrusion of Wind as a cosmic or atmospheric influence. Li⁹ or lai, on the other hand, were names describing symptoms: essentially sores on the skin. Throughout the ancient and medieval periods, ailments with symptoms suggestive of leprosy were described in either symptomatic or configurationist terms in a variety of eclectic combinations: dafeng, li, lai, lifeng, efeng (malignant Wind), zeifeng (vicious Wind), and so on. In the later imperial period, after the eleventh century, there was the gradual emergence of a term combining a single new symptom-related descriptor, ma (numb), with the configurationist concept of Wind in the more modern compound terms mafeng and damafeng (big numb Wind). Along with the new, stable nomenclature gradually emerged new images and conceptions of the disease. In the same period, speculations about the transmission of the disorder by human contact, that is, a medical model of contagion, also came into place.

ETIOLOGY OF THE DISEASE CATEGORY: A HISTORY

The Early Imperial Period (Fourth Century B.C.—Eleventh Century A.D.)

A Wind-Induced Disorder: Dafeng/Efeng

In the Inner Canon, feng (Wind), the first of the five atmospheric influences, the other four being Cold (han), Dampness (shi), Hot Dryness (zao), and Fire (huo), was described as the “origin of the hundreds of disorders.”¹⁰ Since then Wind was indeed considered the cause of many serious and dramatic ailments that constituted the dominant class of disorders in subsequent mainstream medical texts.¹¹ One such disorder occurred when Wind and Cold resided inside the circulation channels of the human body. In section 42 of the “Suwen” (Plain Questions) part of the Inner Canon (see n. 2), where the various detrimental effects of Wind are explained, the disorder called lifeng (Wind resulting in the li disorder), also known as Cold Heat (han re), is described as having the following sequence and symptoms: “The [Wind-] heated constructive energy digresses [from the channels deep in the body’s interior] into the skin, polluting the [patient’s] qi, leading to the degeneration of the bridge of the nose, and the deterioration of the color of the skin that would eventually erupt into sores.”¹² In the same section, various disorders caused by Wind entering into or stagnating inside different parts of the body are described as having common symptoms such as numbness, paralysis, corruption of the complexion, loss of appetite, sweating, fatigue, and so on. In other words, there are a number of symptoms shared by various Wind-induced disorders. Terms like dafeng or malignant, vicious Wind (efeng, zeifeng), not necessarily names of specific disorders, also appear in different sections in the Inner Canon usually referring to serious cases of Wind intrusion with various clusters of symptoms.¹³

In section 55 of the Lingshu (Divine Pivot) in the Inner Canon, dafeng is described as causing symptoms such as “the swelling of bones and joints, and the falling out of hair and eyebrows,” curable by acupuncture, first applied on the flesh, then on the bones.¹⁴ The compilers of the Inner Canon were apparently describing what were for them two categories of pathogens, lifeng and dafeng, in two distinct sections, one affecting essentially the skin, the other, the bones. From the brief descriptions in the medical classic, it is difficult to tell if these two broad types of Wind-induced symptoms were considered by the compilers as related. Also hard to fathom is the range of these two types, as the symptoms described could be common to various Wind-induced disorders. Nonetheless, due to these two passages, li, in lifeng (which could in fact be pronounced as lai in this case), and dafeng have frequently been cited by modern historians of medicine as early terms for leprosy, as well as proof that true leprosy existed in China before the first century A.D.

The discussions on Wind-induced disorders in the Inner Canon were elaborated more systematically in the seventh-century classic on etiology by Chao Yuanfang (550–630), Zhubing yuan hou lun (General Treatise on the Origins and Symptoms of Disorders [ca. 610]). In this medical classic, names and categories of disorders are expressed and discussed more methodically and in more concrete terms. Chao begins the book with two chapters on Wind-induced disorders, fully indicating their dominant position in the nosological hierarchy already implied in the Inner Canon.¹⁵ The two chapters listed fifty-nine types of symptoms caused by the effect of Wind. Of these, the last eleven types, beginning with type forty-nine, were related to the dafeng category as described in Divine Pivot of the Inner Canon. In brief, Chao labeled this group of symptoms the “falling out of the beard and eyebrows caused by efeng” and discussed in detail different symptoms caused by Winds “from the eight directions.”¹⁶ In general, the author considered these as the results of “Wind, Dampness, and Cold” entering the skin and flesh and into the viscera. In this context, Chao provided more concrete interpretations of the causes by saying that the disorder was “caused either by water entering the body of a sweating person, or cold water entering into his skin and flesh.” He went on to explain, “[Someone could catch the disorder by] lying on wet ground after having taken alcoholic drinks, or confronting wind, or sitting under a tree, or on wet grass. [He could also catch this] by scratching his itchy body, which slowly develops sores. If not cured, [the ailment] will turn into the feng disorder after a few years.”¹⁷ Clearly the opening up of pores under the effects of alcohol and scratching was considered the immediate cause of the introduction of Wind and other bad atmospheric influences into the body.

The final three types of Wind-induced disorders caused by efeng, types fifty-seven through fifty-nine, were called lai (for a more detailed discussion of lai in this text, see the following section), clearly defined by the skin symptoms. In fact, most of the efeng and lai symptoms were related to the skin, including itchiness, eruption into sores, deterioration of the complexion, and loss of sensitivity of the skin, but there were also other serious symptoms, such as the falling out of hair, collapse of the bridge of the nose, hoarseness of the voice, deterioration of eyesight and hearing, and death. Chao explained the more serious lai symptoms and elaborated on the complex nature of the disorder by evoking the five Winds attacking the five viscera, causing the five main symptoms of the falling out of the eyebrows, the collapse of the bridge of the nose, the voice becoming hoarse, a ringing or roaring in the ears, and, finally, death.¹⁸ Even though the author repeats many similar symptoms in the last eleven types of Wind-induced disorders, he nonetheless deems it necessary to distinguish the dafeng from the lai category, with emphasis on skin symptoms for the latter.

The ambiguous relations between the two categories of related disorders, with one highlighting the Wind factor and the other skin symptoms, persisted in Tang medical texts, as shown notably by Sun Simiao’s (581–682) Beiji qianjin yaofang (Essential Recipes for Urgent Use Worthy of a Thousand Gold Pieces [ca. 650–659]),¹⁹ and Wang Tao’s (670–755) Waitai miyao fang (Secret Essentials from the Imperial Collections [ca. 752]),²⁰ the most important medical texts of the period. Sun discusses lifeng and ej/dafeng in two separate chapters. Lifeng is discussed in chapter 8 as a serious category of Wind-induced disorders, whereas ej/dafeng is described, more lengthily, in chapter 23, together with disorders such as hemorrhoids and tinea. In chapter 8, Sun elaborates on the various symptoms of and especially the recipes for disorders caused by the intrusion of Wind, which he called lifeng or efeng, into the skin and flesh, including those with symptoms such as itchiness, deafness, and the loss of eyebrows. The ej/dafeng category, with multiple symptoms, is described more lengthily in chapter 23, where other skin disorders are also described.²¹ In his account of eji/dafeng, Sun specifies that a patient may have some but not all the symptoms, including the falling off of the limbs’ extremities, sensation of extreme cold or heat in the body, dehydration or constant sweating, dry itchiness, white flakes or painful sores on the skin, or total anesthesia, and so on. The colors on the deteriorating skin also varied. According to his own experience as a doctor, people affected by the disorder would usually die in no more than ten years, or even in five or six years. Sun never uses the term lai for the eji/dafeng category. In another work, he uses the term ebing (malignant disorder) to indicate the same symptoms.²² It is in fact difficult to distinguish clearly between the disorders he describes in chapters 8 and 23, as both were considered Wind-induced and shared many similar symptoms. Wang Tao, on the other hand, basically combined Chao’s and Sun’s descriptions. Chapter 30 of his synthesis begins with a section called ej/dafeng, repeating almost word for word Sun’s account under ...