Old and New Diseases

The sixteenth century can be considered a watershed in China's disease history. With the coming of European traders to China's southeast coast and the intensification of international commercial activities in South and Southeast Asia, China entered the world community and a few new epidemic illnesses entered China. Scarlet fever, cholera, diphtheria, and syphilis are the more important ones to be added to the reservoir of older diseases that had been ravaging China for centuries. Among the latter were smallpox, pulmonary diseases, malarial-types of fevers, other febrile illnesses, dysentery, and possibly plague. However, the social and demographic impact of the new diseases on China after the sixteenth century is a field largely unexplored despite its important historical implications.

Smallpox is one of the oldest diseases known to China. An early sixth-century medical work claimed that the malady (then called luchuang, "barbarian boils") was introduced around A.D. 495 during a war with the "barbarians" in northern China (Fan 1953; Hopkins 1983). Little is known of the development of smallpox thereafter, until the late eleventh century (Northern Song period) when treatises on the disease written by pediatricians first appeared.

That pediatricians wrote of smallpox suggests that by this time it had developed into a childhood illness among the Chinese population (Leung 1987b). The technique of variolation using human pox was first practiced in the lower Yangtze region not later than the second half of the sixteenth century, and vaccination became popular in the early nineteenth century, when Jennerian vaccination techniques were introduced through Canton. Yet, despite the early practice of variolation, smallpox was rampant in China, especially in the north (the Manchus and the Mongolians were the most vulnerable, and two of the Manchu emperors died of the disease) where variolation was much less practiced than in the south (Leung 1987b).

Malarial-types of fevers {nue or zhang) first appeared in medical texts in the seventh century, when the economy of the subtropical regions south of the Qinling Mountains became of great importance to the northern central government. From the twelfth century on, after northern China was occupied by the Jurchens and the Song government fled to the south, specialized medical books on malarial fevers and other subtropical diseases believed to be caused by the "miasma" {zhangqi) of these regions appeared in increasing number (Fan 1986). Some scholars believe that temperatures during the Tang period (A.D. 618-907) were probably higher than those of today, which suggests that the northern limits of diseases associated with the southern climates (malaria, schistosomiasis, and dengue fever) were further north than they are today (Twitchett 1979). The number of victims of these diseases was therefore likely to be larger than previously thought. In fact, malaria was still a major killer in South and South east China during the early twentieth century (Chen 1982).

The history of plague in China is a controversial subject. Some believed that it arrived in China in the early seventh century (Twitchett 1979), whereas others date the first appearance in the 1130s in Canton (Fan 1986). Yet both of these views are based at least in part on simple descriptions of symptoms (appearance of he, "nodes"; or houbi, "congestion of the throat"), which is far from conclusive evidence. By tracing the development of plague epidemics in the Roman Orient, and in Iraq and Iran from the mid-sixth century to the late eighth century, D. Twitchett (1979) has argued that at least some of the epidemics that struck China from the seventh and eighth centuries were those of bubonic plague. By contrast, those who feel that plague burst out as devastating epidemics only in the early thirteenth or fourteenth century (McNeill 1976; Fan 1986) suggest a possible relationship to the European Black Death of the same period.

Unfortunately, there is no direct evidence to support either of the above hypotheses. Even as late as the seventeenth century, when China was again struck by a series of epidemics, it is impossible to prove that these were outbreaks of plague (Dunstan 1975). The first epidemic in China, which we have substantial reason to believe was plague, was that first striking Yunnan in 1792. It then spread to the southeastern provinces of Guangdong and Guangxi, up the Chinese coastline to Fujian and to the northern part of China (Benedict 1988). But it was only in the late nineteenth century that medical works on the "rat epidemic" (shuyi) began to be published (Fan 1986).

In addition to the epidemic diseases discussed above, several endemic ailments were likely to be equally devastating. Among these were pulmonary diseases (probably pneumonia and tuberculosis), dysentery, various fevers (the shanghan category of fevers), which probably included typhoid fever, typhus, and possibly meningitis, cerebrospinal fever, influenzas, and the like. Most popular almanacs and family encyclopedias of the Ming-Qing period that contained chapters on common illnesses and their treatment mentioned dysentery, the shanghan diseases, and coughs. Skin diseases, huoluan (prostrating fever with diarrhea), beriberi, and nue (malarial-type fever) were also frequently discussed (Leung 1987a).

Perhaps some notion of the relative importance of these endemic diseases, especially in southern China, can be gleaned from surveys done in Taiwan during the Japanese occupation period (1895-1945). The disease that caused the highest mortality in Taiwan from 1899 to 1916 was malaria. In 1902, it accounted for 17.59 percent of mortality among the native Taiwanese, causing 4.62 deaths per 1,000. Malaria was followed by dysentery and enteritis until 1917, after which "pneumonia" became the region's biggest killer (4.42 deaths per 1,000 in 1935). Next in importance was dysentery (2.55 deaths per 1,000 in 1935), whereas other contagious diseases including parasitic ailments accounted for 1.5 deaths per 1,000 in 1935 (Chen 1982).

That pulmonary diseases and dysentery persisted as the major fatal diseases among southern Chinese from the premodern period to the early twentieth century seems obvious. The secondary place that Ming-Qing almanacs accorded to the malarial-type fevers, despite the fact that malaria was the principal killer in nineteenth-century Taiwan, can be explained by the fact that few, if any, of these almanacs were written by authors from subtropical and frontier regions. It is also possible that malaria was confused with some of the shanghan diseases in almanacs.

Parasitic diseases, which ranked third on the list of high-mortality diseases in Taiwan in the 1930s and 1940s, were rarely mentioned in the almanacs. But their importance was emphasized by Western scientists who came to China in the early twentieth century. Thus G. F. Winfield claimed that feces-borne diseases caused about 25 percent of all deaths in China, especially among peasants in the rice and silk regions of the south (Winfield 1948).

Syphilis was one of the first "new diseases" that reached China. It was probably first introduced to Guangdong through Portuguese traders in the early sixteenth century, as a 1502 medical work recorded that syphilis was called the "boils of Guangdong" (guangchuang) or "plum boils" by the people of the lower Yangtze region. The disease was already much discussed in sixteenth- and seventeenth-century medical texts, some of which clearly stated that it was transmitted through sexual intercourse (B. Chen 1981; Fan 1986). Along with gonorrhea, syphilis probably accounted for 2 to 5 percent of all Chinese deaths in the 1930s (Winfield 1948).

Cholera probably arrived after syphilis. The modern term for the disease - huoluan — was in the past a name for any disease that caused sudden and drastic vomiting and diarrhea. Reliable records date the first real cholera epidemics in China from the 1820s. Like syphilis it also was first introduced in Guangdong and spread from there along the south eastern coast up to Fujian and Taiwan. It usually struck in the months of August and September.

Some scholars suspect that an epidemic in 1564, which had reportedly killed "10 million people," may have been cholera. But regardless of the possibility of cholera's presence at an earlier date, there is no question about the devastating effects of cholera in nineteenth-century and early twentieth-century China, especially in crowded urban centers (B. Chen 1981; S. Chen 1981; Fan 1986).

Scarlet fever and diphtheria came to China in the early and late eighteenth century, respectively. Scarlet fever was epidemic in the lower Yangtze region in the 1730s during the winter-spring transition and was then called "rotten-throat fever" (lanhousha). The contemporary epidemiologist Ye Gui (1665-1745) noticed that the illness struck all age groups and that the victims were covered with dense red spots and had red sore throats. The disease seemed to be more devastating in the north. In the Peking area of the 1930s, the estimated mortality of scarlet fever was 80 per 100,000 (S. Chen 1981).

Diphtheria was confused with scarlet fever when it first reached China in the late eighteenth century. It became widespread and epidemic in the decades of the 1820s through the 1850s, spreading from the lower Yangtze region to southwestern China and to the northeastern regions before it reached the northwest in the late nineteenth century. The first medical work on diphtheria (then called "white-throat disease," baihoulong or baichanhou) was also published in the mid-nineteenth century (Fan 1986).

It is difficult to estimate quantitatively the mortality caused by the new diseases. Their older counterparts seemed to remain on the top of the list of high-mortality diseases into the early twentieth century. However, as scarlet fever was the tenth leading cause of mortality in the Peking area between 1926 and 1932 (S. Chen 1981), and as syphilis (with gonorrhea) accounted for 2 to 5 percent of all deaths in China, their roles cannot be underestimated. Perhaps the reason why the impact of cholera and diphtheria epidemics in the premodern period was not quantified was that the former was too seasonal and the latter basically a childhood disease.

According to local gazetteers of the southern provinces, epidemics usually struck during the spring-summer and the summer-autumn transitions. This seasonability of disease prevalence was confirmed by the 1909 Foochow Missionary Hospital Report, which recorded 2,004 patients treated in May, 1,943 in June, and 1,850 in October - equaling about one third of the 17,456 patients treated during the entire year (Kinnear 1909). Dysentery was generally the biggest killer in the summer, whereas cholera did its most important damage in October.

Unlike Japan whose isolation from the important world trade routes kept major diseases away from its shores during premodern times (Jannetta 1987), China was always exposed to epidemic disease. Trade through the old silk route, war with the northern "barbarians," travel to and from India and Indochina - all brought the "old" diseases to China, whereas the coming of the Europeans by sea from the sixteenth century onward brought a few "new" ones.

The low mortality rate resulting from diseases in premodern Japan preceded a period of low fertility, all of which shaped Japan's demographic development (Jannetta 1987). Comparison with Japan in turn raises the question of the extent to which epidemic diseases in China may have been an important factor in its population growth. For example, did China ever experience something similar to the Black Death, which struck Europe in the fourteenth and fifteenth centuries, or the smallpox epidemics that paralyzed the Amerindian communities in the sixteenth century?

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