2012年6月12日 星期二

Black Death in China: Problems faced by Chinse medicine in the early 20th Century


While it is commonly believed that Black Death was a European calamity, the reach of the plague bacteria had played its role in decimating human populations throughout the globe.  In our modern times, antibiotics can treat the disease with relative ease; however, this was not always the case even in the 20th century.

To prevent an invasion and reduce casualties, the Chinese government immediately deployed Wu Lien-teh to Manchuria to handle the catastrophe. He arrived in 1910 where he promptly began researching pathology of yersenia pestis, the bacteria responsible for all forms of plague, and supervising the measures utilized to thwart further deterioration.  One of his foremost concerns was reliving the police from their duties of treating patients with students from the medical college.  Moreover, he implemented quarantine upon the ailing patients and their families to obviate the growth of the disease.  Yet, his most notable contributions were his persuasion of the Chinese population towards using cremation as the dominant mortuary service instead of burial. 
Pneumonic plagues had influenced Chinese historical development since the beginning of Qing Dynasty, and Chinese scholars have recorded precise data regarding the rat-borne disease circa the 18th century.  By the 19th century, the mounting frequency of pneumonic plague and the consequential mortality rates had overwhelmed the China’s rudimentary Traditional Chinese Medicine (hereon referred to as TCM).  In 1909, pneumonic plague ravaged China again, and the severity of the outbreak in human lives was appalling.  Fortunately for Beijing, they, previously, had employed epidemiologist Wu Lien-teh (1879 – 1960) as the Vice-Director of the Imperial Army Medical College to educate its medical corps.   Wu had acquired world-wide fame as the first Chinese graduate from the prestigious University of Cambridge.  With Wu’s assistance, the dispersion of the pneumonic plague was hindered then restrained swiftly thereafter.  The pestilence, due to its lethalness, reallocated the focus of the population from superstition and TCM into a modernized western medical science predominantly revolving around the implications of the sanitation, pathogens and hygiene.


        The plague began its onslaught in the Northeastern China (also known as Manchuria) in the first winter of Xuantong (dynastic imperial Chinese dates use the era name of their reigning emperor which, in this case, was Puyi whose era date was Xuantong.), and in mere days, the disease had slain fifty thousand people in the sparsely-populated stretch between Manchuria and Siberia.  Despite the lack of (undisputable) figures, Dr. Dugald Christie or Christie of Mukden, a missionary doctor who founded Mukden Medical College, asserted that out of 43,942 cases, none survived.  Besides the atrocious mortality rates, there were also ominous political undertones for Beijing – the plague had threatened the regional imperial powers, including Russia and Japan, who threatened military incursions to desist the outbreak. 

(A Russian photograph of the dead from the 1910 outbreak - Source: Thmoas H. Hahn) 

Governmental Intervention:

Bust of Dr. Wu Lien-teh - Source: channelnewsasia

Initially, prior to Wu’s intervention, vast amounts of caresses were exposed in the open leading to hygienic problems which encumbered the medical efforts.  To mitigate the contaminative impacts, Wu beseeched Beijing for an imperial decree to mandate cremation.  His petition was not nonsensical as there were over two-thousand infected corpses in open air without due concern thus ameliorating the probability of further promulgation of the plague.  The imperial court reached a decision in three days and acknowledged the necessity of cremation, and Wu immediately invited government officials to partake in the first Chinese mass incineration of bodies.  The ashes were then interned in a mass grave and from that day onwards, all cadavers of plague victims were cremated.  Wu’s avant-garde approach to burial endowed China with the first positive outlook towards disease contro and the infection rates began a steadfast decline.  Wu’s efforts were initiated in the end of January, 1911, and by early March, the plague had been ceased although some isolated clusters carried on their path of destruction for another four months.   By the end of this pandemic, the cost in human lives were estimated to be around 60, 000 people; however, it also brought modernization upon the initially primeval medical system.

Prior to the Manchurian pneumonic plague, the Chinese government was oblivious to outbreak-halting techniques.  As early as 1894, the pneumonic plague had devastated the Guangdong region of China as well as the British of Hong Kong, but at the time, the TCM doctors were unconscious of the plague’s implications.  Cen Chunxuan, a politican, commented that “with an increase in population, the number of infected increases and its peculiar symptoms have rendered both existing and ancient doctors ineffectual.”  (I translated this myself, his original words, for those who can read Chinese, were 人事愈繁, 診癘之氣亦與之俱進. 發為奇疾異微, 往往為昔人所不及知. 傳染之烈,乃至城市為墟. 若鼠疫者, 尤其甚矣)  The observations from the contemporaries of the time illustrates that TCM doctors were incompetent and inexperienced in handling bacterial mutation and other new diseases.  Because of this, the outbreak of certain anomalous diseases often brought along chaos and vulnerability in Chinese medical services.  Without satisfactory scientific infrastructure or proficient human resources, epidemics proliferated through China without resistance.  However, the severity of the Manchurian plague engraved the vitality of disease prevention and control into the government’s mind.  With Manchuria’s devastation fresh in mind along with the experience garnered, the Chinese medical service was able to dampen the repercussions of later diseases and limit their contagiousness.  This was highlighted by the effectively at the containment of the Second Manchurian outbreak of pneumonic plague. 

President Xu Shichang - Source: lishi.net
With heightened awareness as the epidemic’s consequence, the government implemented wide-scale procedures for its containment and treatment.  In early 1911, Beijing, with Wu’s contributions, had established the earliest modernized public health agency, the North Manchurian Plague Prevention Service.  There were five functions of the organization: vermin-extermination, diagnosis, treatment, quarantine and vaccinations.  All suspected cases of pneumonic plague virus were sent to the medical teams and then quarantined where their development will be monitored by the staff.  Moreover, soldiers were deployed alongside doctors to advise the public on hygiene, and anyone who impeded their progress or disregarded their orders was dealt with harshly.  Yet, these advances came at a turbulent time as the Qing despots were near their demise after 269 years.  Medical services were not prioritized during the tumultuous era as Beijing changed hands frequently between the years 1911 – 1918.  But by the time Xu Shichang (1855 – 1939) became president in 1918, the significance of disease prevention had been reinforced by the Spanish Influenza.  Xu then ordered Qiang Nengxun (1869 – 1924), Minister of Interior, to establish the Central Epidemic Prevention Bureau for the manufacture and distribution of serum and vaccines.

From the aforementioned, it becomes conspicuous that the plague had instilled an enhanced determination in the now-experienced government towards hampering the disease.  Despite the end of the plague, the government vigilant approach to the medical services had not been forsaken and had progressed further than the pioneering efforts to halt diseases but instead to prevent their occurrences through vaccination.  This sparked a turning point in Chinese medical history and instituted a foundation for future modernization processes as China now has a qualified medical force with plague experience.  Consequently, the desolation of the Manchurian pneumonic plague of 1910 – 1911 was not repeated when it returned to Manchuria in 1920.  The death tolls were obviously decreased with only around 8000 deaths which despite tragic, was not the same astronomical number it was during the first outbreak.

Despite contributions by specialists, modernization of medical sciences is influenced by people’s attitude as any endeavors in disease prevention rest upon the acknowledgement and participation of the population.  Prior to outbreak of plague in 1909, the population was not keen in tolerating western medical advances but the terror manifested in people disease’s lethalness compelled their endorsement of westernized treatments.  Even during the midst of the plague, the effectiveness of modernized medicine was still under scrutiny, but the population was convinced by the conclusion of the 1911 outbreak.  In this sense, the first plague was beneficial to revolutionizing the perspective of the Chinese public towards disease prevention and public hygiene. 

Initially, the fatalities of pneumonic plague’s outbreak overwhelmed the population’s burial services and bodies were simply buried in shallow earth without coffins.  However, as the situation further deteriorated, the people did not even bury their dead, and instead left the cadavers on the snowy earth.  This effectively demonstrated people’s obliviousness towards hygiene and failure to realize that the corpses on the streets were escalating the contagiousness of the plague.  As the pathogens responsible for pneumonic plague, unlike bubonic plague bacteria’s pure vector-borne nature, yersenia pestis could aerosolize from corpses and threaten more casualties but fleas from cadavers deal identical damage.  When Wu saw the circumstances of the time, he insisted upon cremating the bodies of pneumonic patients.  Yet, the incineration of one’s ancestors’ body was considered to be extremely disrespectful in the filial pietous Chinese Confucian values.  According to the Analects, “we owe our parents our body, hair and skin; therefore, the highest principle of filial piety is ensuring no ill happens to us.”  (I translated this myself, the original words I am citing, for those who can read Chinese, are身體髮膚,受諸父母,不敢毁傷,孝之始也) With such explicit philosophy upon the significance of one’s body, the destruction of an ancestor’s remains would cause him/her to be un-filial piteous which, in turn, would mean that the cremator can be accused of the same blasphemy.
Moving Bodies for Cremation - Source: Dr. Richard Pearson Strong
However, as Wu had acquired an imperial decree from Beijing, the population was coerced into cremating the deceased, and with the application of cremation, the outbreak slowed.  Cremation as a way of handling the dead became appealing to the Chinese population after the Manchurian Pneumonic plague as it was proven apposite both sanitarily and economically.  In ensuring epidemics, cremation of contaminated bodies was no longer enforced as a regulation but instead a voluntarily practice.  This demonstrated a revolution in the Chinese mentality with an embrace of hygiene and personal wellbeing over blind obedience to cultural philosophy after comprehending the dangers of plague.

The Limitations of Traditional Chinese Medicine

Moreover, the concept of pathogens and personal hygiene harming physical health was also foreign to the early 20th century Chinese, but with confidence in TCM utterly destroyed, westernized medical science was embraced.  TCM theorized in the interactions between the ‘qi’, a concept similar to Aristotle’s philosophy of energeia or Henri Bergson’s notion of vital impetus, and the ‘five elements’ which are wood, fire, earth, metal and water respectively.  According to TCM, a person’s health depends upon the qi travelling unobstructed within his meridians and organs.  Yet, homeostatic imbalances (this can understood as a blockage of one’s qi that disrupts or reverses the flow of flow which in turn would negatively impacts one’s health or the unbalance of the contradictory unity of the five symbolic elements would distress one’s health. 

This demonstrates the extreme need for western science to enter China to prevent further disaster.  Being misinformed, TCM doctors, initially, used treatment called ‘warm-cure’ or ‘cold-cure’ to restore phsyical balance based on yin-yang demonstrating the originally rudimentary nature of disease prevention.  Yet, as parts of TCM is undoubtedly superstition, their methods of treatment proved highly ineffective. 

However, TCM was already comparatively superior the other traditional Chinese alternative ‘medicine’.  In China, superstition with religious overtones can sometimes influence medical decisions.  A belief in the ability of folk heroes’ apotheosis formed a large part of Chinese culture and its influences seep even into medicine.  An example would be Guan Di, or other deities’, portraits placed on the doorway to ward off the ‘god of plague’ believed to have precipitated the epidemic.  They would also put words like “the gods have left” to convince the disease-bearing god to leave alongside his peers.  The contributions of TCM towards plague-control were infinitesimal and superstition certainly did not help and therefore the epidemic continued its deadly course through Manchuria.

Wu’s westernized ideas were the final resort for the population thus was compelled to accept these foreign proposals.  Even the suggestion of autopsy, shortly after the imperial decree for cremation, fell on friendly years as the populace was willing to experiment with anatomic methods due to cremation’s relative success.  After the pneumonic plague, the confidence in modernized medical science grew as western disciplines such as anatomy and pathology triumphed where TCM failed.  Chinese anatomy was further strengthened by youngsters’ willingness to volunteer their family’s corpses for autopsy demonstrating a change of perspective in favor of modernization over traditional Confucianism.  Applications of westernized theories not only became widespread in governmental health care schemes, but also the peasants, as those who may come into contact with rodents voluntarily received vaccinations.  As delineated by the effectiveness in limiting the plague of 1920, the epidemic of the early 1910s had been a catalyst for medical modernization thereafter.  


However, TCM’s lackluster performance during the plague did not remove its position as part of mainstream medication in Asia, and also as alternative treatments in the Western world.  Acupuncture, in particular, had been verified by the American College of Physicians as a beneficial treatment alongside physical therapy for disorders such as oosteoarthritis.  Hence, while TCM is a capable alternative treatment prowess, when serving as plague control, it pales when compared with even basic hygienic knowledge or the application of antibiotics.  Despite the invention of modern antibiotic plague treatments not occurring until the 1940s, insecticides for killing fleas as well as vaccines targeting yersenia pestis were already available during the Manchurian outbreak.  If the Chinese government had vaccinated the Manchurian population as other modernized countries had, the effects of the plague may not have been as devastating.  With that being said, one must acknowledge the difference between the education level of our forbearers in China at the time.  Despite the understanding in western sciences, it was fortuntate that the Chinese governmental officials of the time were willing to acknowledge the effectiveness of Wu Lien-teh and the western medical knowledge he possessed.

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For additional information on Chinese Traditional Medicine, you can refer to http://nccam.nih.gov/health/whatiscam/chinesemed.htm