Warren M. Cochran

The TherapeuticResponse to ContagionThe Influence of Pestilence on Medical Theoryand Practice in Late Imperial China

Warren M. Cochran

AbstractIn the third century before the current era BCE, devastatingepidemics claimed the lives of thousands throughout theChinese empire. The poet Cao Zhi (192 - 232 CE) recordedthe calamity by writing that 'from each room came wailsand cries of sorrow' (Quoted in Kuriyama, 2000). Somethree hundred years later on the other side of the world,the Anglo-Saxon Chronicle of 664 CE noted that 'the suneclipsed on the 5th before the Nones of May, and in thesame year there was great pestilence in the island ofBritain' (Shrewsbury, 1949). However, while much hasbeen written on the socio-economic and religio-philosoph-ical impact of epidemic disease on the apparent frailty ofhuman existence, medical historiography has not alwaysaddressed the issue of how changing disease patternsmay have influenced therapeutic strategies. The theme ofthis paper will focus on this aspect of medical history byconsidering how disease manifestations as perceived byphysicians of Chinese medicine, have helped shape med-ical notions and determine therapeutic response.KeywordsAntiphlogistic, contagion, deleterious, endogenous,enteric, epidemic, exigencies. febrile, infectious, nosology,pandemic, pathogenesis, pestilence, phlebotomy, pldgue,prophylactic, venesection.

10 The European Journal of Oriental Medicine

It is difficult to perceive, in our modern age of antibiotics andscientific medicine, the terror engendered by the impact ofcontagion on human societies. As the medical historianCharles Rosenberg has so succinctly observed 'health or dis-ease results from the cumulative interaction between constitu-tional endowment and environmental circumstance' (Vogeland Rosenberg, 1979). Certainly the deleterious influence ofplague, cholera, typhus, and influenza, has in historical peri-ods, greatly tested this constitutional endowment by exacer-bating environmental circumstances.

Medical historiography affords numerous examples ofsuch deprivations upon the health and well being of humansocieties, both past and present. In 1232, a severe epidemicbroke out in Honan Province, China. The records list 90,000dead in less than fifty days (McNeill, 1976). Just oyer a cen-tury later in 1347, merchant ships carrying the plague mooredat the port of Messina. By 1351 one quarter of the populationof late medieval Europe, being some 20 million souls, hadbeen claimed by the Black Death (Goffried, 1983).

In the century between 1398 and 1495 Arabic sourcesrecord the outbreak of some 17 epidemics in the Nile valley ofEgypt. The victims may have felt some comfort with theirProphet Muhammed, who wrote, 'He who dies of epidemicdisease is a martyr' (quoted in MoNeill, 1976). More recently,

the cholera epidemic of 1831 claimed 250,000 deaths in Hun-gary, while official records confirm 10.2 million victims fromthe same disease in India between 1910 and 1954 (McNeill,1976).

Certainly, as one medical historian recently wrote, 'an epi-demic is almost by definition frightening; numbers of unfortu-nates are seized with grave illness, one after another exhibit-ing similarly alarming and alarmingly similar symptoms'(Rosenberg, 1992). Historically, pestilence has had a pro-found influence on human society, both in China and theWest. Contagious epidemics including cholera, typhoid fever,typhus, and plague have all had disastrous effects on bothhuman demographics and socio-economic institutions.

As a corollary, has disease had any influence in shapingmedical theory and practice? Has the therapeutic response tocontagion, in either China or the West, resulted in any tangi-ble shifts in contemporary medical activities? Some initialefforts to address these issues were explored by Guenter Rissein an earlier volume of the Bulletin of the History of Medicine(Risse, 1979). His academic focus was western medical histo-ry, and in this paper I wish to explore the theme further, withreference extended into the sphere of Chinese medicine.

To a large extent, it could be said that coI;ftemporary med-ical theory and practice has often been seen by medical histo-rians as organised responses to contain, or at best, eradicatethe pernicious influences of epidemic disease. As GeorgeRosen advocated in an earlier paper on the biological elementin human history 'man is a biological organism in a naturalworld containing various physical and biological elements.But man is also a social organism capable of creating a socialenvironment which he interposes between himself and nature'(Rosen, 1957). Medicine may be viewed as a socio-culturalinstitution which forms part of that environment. As such,therapeutic intervention has influenced disease in human soci-eties by lowering both morbidity and eliminating, or at leastreducing, levels of mortality.

This triumph of human enterprise over the deleteriousincursions of infection upon human populations has often, inthe early years of the intellectual history of medical science,been depicted as a growth or expansion of the scientific per-ception of disease. Hence, in the West, the endeavours ofEdward Jenner in isolating smallpox, Louis Pasteur's researchinto both anthrax and rabies, and the pioneering work ofRobert Koch in the discovery of the tuberculosis bacillus in1882 have provided validation for this sense of an historicalexpansion of medical theory and praxis.

This perspective is also reflected in much of the literatureof medical history, both in China and the West. Surveying theevolution of intellectual notions in Europe, Lester King haswritten 'at irregular intervals great discoveries have changedthe whole course of medicine, but the intervening periodshave not been static. They manifest a gestation of new ideasand a struggle between new concepts and the old establisheddoctrines' (King, 1963). His book chronicles the evolution ofthese ideas from Hippocrates to Paracelsus, concluding withthe cell theories of Hermann Boerhaave and Rudolf Virchow.The twenty succinct chapters in Erwin Ackerknecht's A Short

The Therapeutic Response to Contagion

History of Medicine. which incidently includes a section onmedical concepts in early India and China, also give the over-all impression of an episodic journey from what he has termed'primitive medicine' to the therapeutic apotheosis of nine-teenth century scientific biomedicine (Ackerknecht, 1982).Published in 1932, Wong and Lien-Teh's chronicle on the his-tory of Chinese medicine also has this perspective, with mostof the book surveying the introduction and consequent expan-sion of western medical science into late Imperial China(Wong and Lien-Teh, 1932). A more recent work tracing thehistory of acupuncture also has the appearance of an episod-ic, chronicled survey (Eckman, 1996). The issues of the socio-cultural forces which shape medical notions, or the possibleeffects disease itself may have had in determining therapeuticstrategies and outcomes are not really explored in any greatdepth in any of these works. In his seminal publication on theevolution of medical concepts in China, Paul Unschuld doesgive due consideration to the various forces present in the

He who dies of epidemic diseaseis a martyr

social milieu of early China which have impacted on the shap-ing of Chinese medicine as we know it today. This isespecial-ly evident in the sections on the protohisrorical Shang andZhou periods (Unschuld, 1985).

Certainly historians of medicine must take into accountthe 'zeitgeist' or climate of opinion dominant in the historicalperiod under academic inspection. As W. H. R. Rivers wroteas long ago as 1924, medicine should be seen as a social sys-tem and that 'any principles and methods found to be of val-ue in the study of social institutions in general cannot beignored by the historian of medicine' (quoted in Ackernecht,1942). Henry Sigerist was to reiterate this sentiment writingthat 'the medical historian consulting the past will firstendeavour to find out what health conditions were in a givensociety at a given time' (Sigerist, 1951). In the intellectual spir-it of this innovative viewpoint on the history of medicalnotions, a number of more recent works have tried to takeinto consideration this climate of opinion, making an acade-

The European Journal of Orienta! Medicine 11

Warren M. Cochran

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12 The EuropeanJournal of Oriental Medicine

mic departure from a predilection for historical surveys of thecontinued evolution of therapeutic sophistication .

Some studies have ofren made a point of examining thepreconditions for the emergence of disease as a direct corol-lary of human activities in the wake of rapid industrial expan-sion and population shifts from rural settings to urban con-centrations. Such demographic relocation in recent historyhas correspondingly facilitated the origin, spread, and impactof contagion. This thesis has been explored in depth byWilliam McNeill in his rather polemical account of the histo-ry of disease and its impact on social and cultural life(McNeill, 1975).

More recently, medical historians have directed their aca-demic endeavours away from general themes in the emergenceof modern therapeutics, to focus on more specific issues whichaddress medical concepts as they exist within the frameworksof contemporary societies. Recent publications on the historyof western medical science include, for example, ByronGood's study of cultural perspectives in understanding illnessand healing, while Charles Rosenberg's collection of paperson pertinent themes in the history of medical ideas in theWest, have been valuable additions to the growing literaturein this field (Good, 1994; Rosenberg, 1992). The medical his-toriography of China has also been greatly enriched by suchrecent works as Charlotte Furth on gender in Chinese medi-cine, Francesa Bray on woman's health in late Imperial China,and Shigehisa furiyama on cultural comparisons betweenearly Greek medicine and therapeutics during the Handynasty (Furrh, 1999; Bray, 1995; Kuriyama, 1999). Also inrecent decades, historians of medicine have directed theirattention to elucidating the impact of disease on a diverserange of topics including mortality rates, agricultural produc-tivity, population shifts, human nutrition, and the effects ofepidemic disease on the health policies of government agen-cies including famine relief. However, analysis of the possiblelinks between disease conditions and medical theory and prac-tice has often been neglected. This anomaly was addressed tosome extent by the publication of Charles Rosenberg's semi-nal account of the cholera epidemic which ravaged New YorkCity in 1832, making subsequent visitations in both 1849 and1866 (Rosenberg, 1962).

The exigencies of the cholera pandemic, which before1817 had been limited to the Far East, has been paralleledonly by the deleterious impact of influenza in the twentiethcentury. During the epidemic of 1849, 5,017 New Yorkershad perished by May 16 (Rosenberg, 1962). This demograph-ic catastrophe prompted the Metropolitan Board of Health,which was not formed until 1832, into evasive action. Inmany North American cities, pigs, dogs, and less frequentlygoats, still provided the principal means of sanitation. Onetenement in Orange Street, New York was reported to havehoused 106 hogs during the 1832 epidemic. As Rosenbergcommented 'it was almost impossible to separate the poorfrom their pigs, a cheap and reliable source of garbage-fat-tened bacon and hams' (Rosenberg. 1962). Government legis-lation in response to the menace posed by contagious diseasewas to result not only in the establishment of cholera hospi-

tals, but also the appointment of sanitary inspectors withpowers to enforce privy disinfection. Continued police persis-tence resulted in the flushing out of some five or six thousandporkers by the middle of June 1849 (Rosenberg, 1962). How-ever, while the exigencies of the cholera epidemic may haveforced health authorities into evasive action, no common pro-phylactic treatment strategies could be agreed upon by thecurrent medical profession. The new threat to good healthwas combated by some with drug and lancet, while otherphysicians recommended keeping the patient's skin warmwith such substances as cayenne pepper, mercury ointment,and calomel, Hg2 Cl2 (Rosenberg, 1959).

To the pious, who viewed the affliction as divine punish-ment for the living of ungodly lives, the disease was broughtabout by filth, vice, and intemperance. To the current medicalfraternity, indiscretions in food and drink were more likely tobe at the root of the disaster. Hence it was believed that 'apineapple or a melon was a death warrant, a dozen oysterssuicide, and over indulgence in alcohol the most dangerous ofall' (Rosenberg, 1959).

However, although this contemporary dietary advice fromcertain members of the medical profession in early nineteenthcentury America may have been of therapeutic relevance, itdoes not, by itself, constitute the emergence of novel strate-gies, which represent a departure from old treatment princi-ples to deal with the new threats to good health and wellbeing. In the late eighteenth and the early nineteenth cen-turies, both in China and the West, the most widespread andthe most deleterious group of diseases were the fevers. Thetherapeutic exigencies of acute infectious diseases, in bothplaces at a similar time, were to have profound influences oncontemporary medical theory and practice. In the West, it wasto result in the decline of phlebotomy as an antiphlogistictherapy, while in late Imperial China, the emergence of WenBing Xue (Warm Febrile Disease) theory was, to a largeextent, the therapeutic response to incursions of warm, pesti-lential disease widespread in southern China in the late Ming(1368 -1644) and early Qing (1644 -1911) eras. I would nowlike to compare and contrast the role of contagion in the for-mation of new medical theories and therapeutic strategies,both in Great Britain and late Imperial China, interestinglyenough, in about the same historical period.

Eighteenth century Great Britain was to experience severeepidemics of contagious fever, following in the wake of theravages of the Napoleonic wars and the bad harvest of 1816.The impact of contagion was particularly evident on navalships, army camps, and in His Majesty's prisons. Hence theoutbreaks of large reddish or bluish spots on the skin gave riseto its contemporary appellations of ship, camp, or gaol fever.Also known as putrid, petechial, or malignant fever, it rav-aged such cities as London, Liverpool, Manchester, andCarlisle (Wilson, 19(8). The medical profession at the timestill largely subscribed to the influential theories of WilliamCullen, (inO - 1790) professor of theory and practice ofmedicine at the University of Edinburgh from 1773 to 1790.To Cullen, speaking from his prestigious medical chair atEdinburgh, basic fever types could be distinguished as either

The Therapeutic Response to Contagion

full inflammatory or bodily weakness in clinical manifesta-tion, His febrile dichotomy classed the former, with red faceand full pulse as 'synocha'. Bodily reactions were severe, withheavy, laboured breathing, thirst, and sweating. Its opposite,termed 'typhus', represented a type of fever which was pre-ceded by general lassitude and weakness, accompanied byheadaches and the gradual onset of delirium (Risse, 1979).

It is interesting here to parallel medical theory regardingfebrile disease in the West with traditional Chinese medicine.John Huxham, writing before Cullen in 1739, used the terms'inflammatory' and 'low nervous' in his nosology (Risse,1979). The former, with laboured breathing, high body tem-perature, and rapid, full pulse could be viewed in terms of ashi or repletion condition. The weak and rapid pulse of thelatter, with its common clinical manifestations of headaches,restlessness, delirium, and sweating represented the xu orvacuity condition as evidenced by Endogenous Heat in theying and xue levels.

a pineapple or a melon was adeath warrant, a dozen oysterssuicide, and over indulgence in

alcohol the most dangerous of all

Up until this time, the principal means of therapeutic inter-vention had been phlebotomy or the letting of blood. Influ-enced by the theories of Galen of Pergamum, (130·~ 210 eE)venesection was the preferred method of treatment for a widerange of disorders including gout, epilepsy, arthritis, andmelancholy. Although criticised by the Arabic philosopherAverroes (1126 - 1198) for his insistence on bleeding until syn-cope in cases of ardent fever, (see Tempkin, 1973) his declara-tion of phlebotomy as 'an essential remedy' in any severe dis-ease (see Kuriyama, 1999) was to permeate medical opinion inthe West until the early nineteenth century. This therapeuticpredilection for the exsanguination of the sick was evident inmuch of the contemporary medical literature, with MarshallHall writing in his treatise On the Morbid and CurratiueEffects of the Loss of Blood in 1830 that 'bloodletting is notonly the most powerful and important, but also the most gen-erally used of all our remedies' (quoted in Kluger, 1978). Writ-ing in the prestigious medical journal Lancet three years later,

The European Journal of Oriental Medicine 13

Warren M, Codran

James Wardrop, a prominent nineteenth century British sur-geon, advocated that 'bloodletting should be recommended incase of inflammation whenthe disease is in the early stages andthe symptoms are not yet fully developed' (King, 1961).

The Galenic therapeutic legacy of venesection was to bechallenged, however, by the medical exigencies posed by thecontagious febrile diseases of the late eighteenth and earlynineteenth centuries, with the new afflictions prompting therise of alternative strategies. Writing in 1803, John Herdman,a fellow of the Royal College of Surgeons in Edinburgh,viewed the new fevers as diseases of debility, manifesting ingeneral feelings of lassitude. Thus he advocated against theemployment of bleeding and other antiphlogistic evacuations(Risse, 1979). He argued that physicians should 'draw thelancet with utmost hesitation, and having done the deed,sheath it in fear and trembling' (quoted in Risse, 1979).

Wu You Xing advocated thedeleterious effects of pestilential

energy or Ii q; entering thevictims through the mouth, nose,

or the pores of the skin

He was, instead, to parallel the supportive and nutritivetherapies of Ye Tian Shi (1667-1746) and Wu Ju Tong (1758-1836) in China by recommending the use of warm wine, opi-um, and cordial drinks. His novel approach to the treatmentof febrile disease had been echoed by John Millar, who, in hisreview of the prevailing diseases in Great Britain in 1770, wasconvinced that the inflammatory disorders were quite rare,and that 'there are few fevers in this country, in which theantiphlogistic method of cure can be used with safety' (quot-ed in Risse, 1979). James Hutchinson, in his doctoral disser-tation in 1782, also reiterated this therapeutic viewpoint,

. declaring that the pure fonn of 'synocha' was seldom seen,with the low-grade debilitating fever or 'typhus nervosus'being much more common (Risse, 1979).

The decline of venesection and the rise of the therapeuticpre-eminence of stimulants such as opium, cordial drinks, andwarm wine indicates that contemporary British physicianshad felt a shift ill disease patterns and adjusted their medicalresponse accordingly.

In this sense, changing disease patterns had significant

14 The European Journal of Oriental Medicine

influence on contemporary medical theory and practice ineighteenth century England. The therapeutic transition frombelief in the prophylactic benefits of bloodletting in the treat-ment of contagious febrile disease, to the employment of sup-portive therapies in the form of alcohol, opium, and Peruvianbark, represented a major change in contemporary medicalopinion, equating to a large extent, with shifting perspectiveson the theory and practice of medicine in the West. Was therean historical corollary in the Far East? Is there evidence of acorresponding therapeutic transition within the medical pro-fession in response to changing disease patterns in late Imper-ial China? The proponents of the Warm Febrile Disease theo-ry and their subsequent schism with the more traditionalsupporters of the theories embodied in the Shang Han Lun(Treatise on Cold Damage Disorders) seem to indicate thatthere was. I would now like to consider the concept of conta-gion in the traditional medicine of China, and attempt to elu-cidate its impact on developing medical theory and practice.Certainly, in historical periods, the Far East has had its fairquota of epidemics. An epidemic in Shansi and Hopei claimed200,000 lives in 1358, with 78,400 dying in the 1408 epi-demic in Kiangsi and Szechwan provinces. The Shantung epi-demic of 1525 resulted in 4,128 deaths, with outbreaks ofpestilence occurring in some part of the Chinese empirealmost every year from 1733 to 1911 (McNeill, 1976).

But how did contemporary medical literati in ImperialChina view conragion? Kuriyama stated that traditional Chi-nese doctors themselves put no emphasis on the subject(Kuriyama, 2000). He has recently argued that perusal of adozen or so comparatively modern accounts of Chinese med-icine is unlikely to reveal any extended discussion on thetheme of contagionism (Kuriyama, 2000).

Whilst this might be true, physicians in the early modernperiod certainly recognised the possibility of actually 'catch-ing' a disease by contact with those who had succumbed tothe pernicious clutches of pestilence. Chao Yuanfang, writingin the Zhubing yuanhou zonglun (610 CE) for example,advised against a person with open sores mounting a horse.He wrote that 'the sweat, horsehairs, dirt, urine, and saddleblanket all contain poisons. If the poisons enter the sore, theycan cause inflamed swelling, aches, and pains, fevers. If theyenter the stomach, the person may die' (ZBYHL, juan 36,143. Quoted in Kuriyama, 2000).

Writing in the late Ming era, Zhang jiepin (1563 - 1640)advocated the inhalation of noxious elements in causing pesti-lence, suggesting the burning of aromatic incense or the chew-ing of biscuits made from Fujian aromatic tea, if one wasentering an area infested with plague (Kuriyama, 2000). Theearly Qing physician Xiong Lipin warned against touching thebedclothes of people who were suffering from epidemicfevers, urging the relatives to keep a safe distance fromcorpses and the coffins of those taken by the plague (Kuriya-rna, 2000). This therapeutic sagacity is paralleled in the Westat about the same time with the actions of William PulteneyAlison at the New Town Dispensary, Edinburgh, in 1815. Inchecking the spread of fever contagion, he advocated theprompt removal of those afflicted to the Edinburgh Royal

Infirmary, or at least their separation from healthy persons.He also stressed the importance of 'the fumigation, white-washing and cleaning of the rooms, clothes, and bedding inwhich they (ie: the sick or the dead) have lain' (quoted in Wil·son, 1978).

But perhaps it was the early theories of the Ming medicalliteratus Wu You Xing (1582 - 1652) who best exemplifiescontemporary theories of contagious infection in China dur-ing the mid Imperial era. During his lifetime, outbreaks ofplague decimated the provinces of Hebei, Shandong, and Zhe-jiang. In his Theory of Epidemics (1642) he advocated thedeleterious effects of pestilential energy or li qi entering thevictims through the mouth, nose, or the pores of the skin(Kuriyarna, 2000).

Wu You Xing (1582 -1652)

His precursor in this respect, Tao Hua (1369 - 1450)phrased it poetically by writing with regard to the penetrationof polluted breaths 'when the walls and barriers (of a fortress)are not solid, bandits dare to enter. If one's vitality is strong,pathogenic influences have difficulty invading' (quoted inKuriyama, 2000). Wu You Xing's theories of the invasion ofpestilence also parallels the view of Galen and his concept of'pestilential seeds' or 'loirnus spermata'. This early Greekmedical philosopher had argued that plagues were spread bybreathing putrid air. inhaled from corpses left unburnt afterbattles, or from the rotten gases emitted by swamps and poolsin the hot summer months (sec Narron, 1983). In his treatise,On the Different Types uf Fever (e. 178 CE). Galen recordedthat even in apparently well individuals, 'seeds of disease' maylurk, and under certain conditions, a recurrent attack of anintermittent fever could recur (Narron, 1983).

Both Galen's 'pestilential seeds' and Wu You Xing's ii qi.could be seen as an incipient form of 'germ theory' with thelatter's concepts of contagious disease anticipating theresearch of Louis Pasteur (1822 - 1895) by some two centuriesor more. \Vu You Xing's aeriological concepts were to result

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Warren M. Cochran

in the rejection of the earlier theories of Zhang ji as recordedin the Shang Han Lun during the Eastern or Later Handynasty (25 - 220 CE). Traditionally, Chinese physicians hadseen sickness in terms of the dichotomy of somatic vulnerabil-ity and climatic intrusion. Rather than subscribe to the nega-tive influences of invasion by pathogenic wind cold, he attrib-uted the contagious epidemics of his time to be the result of zaqi or specific kinds of disease induced by specific types ofpathogens. This break with what Kuriyama has termed 'mete-orological orthodoxy' posited a new ontological conceptionof illness which attributed it to the intrusion by certain alienpathogens (Kuriyama, 2000).

This new theory of disease causation was engendered bythe appearance of acute, epidemic febrile diseases, which,from the biomedical nosological perspective, included small-pox, scarlet fever, and the various forms of plague. The prin-cipal clinical manifestations of thirst, pyrexia, skin eruptions,and delirium, were to challenge the orthodox medical frater-nity imbued with the doctrines of cold febrile disease. Of the113 herbal formulas contained in the Shang Han Lun, onlytwo specifically addressed the complications of endogenouspathogenic heat. Both prescriptions, Bai Hu Tang and DaCheng Qi Tang, were formulated in response to repletion heatin yang mingo The therapeutic response to epidemic fevers inthe mid to late Qing era was to result in a schism with theadherents of the older theories of external pathogenic colddisorders. This breach with therapeutic tradition was engen-dered from historical circumstances and is exemplified by thecontributions of the best known successors to Wu You Xing,being Ye Tian Shi and Wu ju Tong.

Ye Tian Shi (167-1746j

However, although the therapeutic contributions of YeTian Shi and Wu Ju Tong in late Imperial China were instru-mental in facilitating (outlining) Warm Febrile Disease Theo-ry as an independent system, it was the novel and innovativemedical concepts formulated in the Jin and Yuan dynasties

16 The European Journal of Oriental Medicine

(1115 - 1368 CEl which provided the impetus and initiatedthe schism with the earlier proponents of the School of ColdDamage. In this respect, the medical theories of both Li DongYuan (1180 - 1251 CEl and Zhu Dan Xi (1281 - 1358 CElwere seminal. Their therapeutic predilection for both ronify-ing the earth and nourishing the yin respectively, were formu-lated in direct response to changing historical circumstancesand exemplify new medical responses engendered by the dele-terious incursions of warm contagious fevers. As the medicalscholar Zhang Yuan Su, who also became the mentor of theyoung Li Dong Yuan, was to write 'No movements of Qi areidentical, and ancient times and modern times differ. Hencethe ancient formulas are helpless for treating modern disease'(Yang and Li, 1993).

These 'modern' diseases as such, were also the result ofchanging historical circumstances in late medieval China. In1276, the grandson of the great Mongol leader GhenghisKhan (1162 - 1227 CE), Kublai Khan (1216 - 1294 CEl

No movements of Oi are identical,and Jlncient times and moderntimes differ. Hence the ancient

formulas are helpless for treatingmodern disease

sacked the capital of the Southern Song dynasty at Hangzhou.By 1279, he was proclaimed Emperor of the Yuan dynastywhich was to rule China until the Ming finally defeated the socalled 'barbarians' in 1368. The defeat of the sophisticatedempire of the Song (960 - 1279 Cli) by an alien, nomadic trib-al people must have had severe repercussions in the minds ofcontemporary medical literati. However, while the psycholog-ical effects of external conquest may help to explain the ther-apeutic diversification exemplified by the [in Yuan Si Da [a,or the Four Great Schools of the Jin and Yuan dynasties, itwas the exigencies of the ensuing military struggles and result-ing bloodshed which must have impacted most on the thera-peutic outlook of the contemporary Chinese medical fraterni-ty. The widespread occurrence of famine, sickness, and deathwhich followed in the wake of the internecine conflict demon-strated, I believe, the therapeutic inappropriateness of earliertreatment strategies formulated in response to climatic intru-sion as exemplified in the Shang Han Lun.

The depletion which resulted from the irregular ingestionof food, manifesting as nei shang or internal damage as LiDong Yuan phrased it, necessitated a new therapeuticresponse. His Pi Wei Lun (Treatise on the Spleen and Stomach)of 1249 CE placed emphasis on the ronificarion of the Centre,employing sweet, warm medicinals like ren shen (Radix Gin-seng) and bai zhu (Rhizoma Atractylodis) to invigorate centreqi, and using cool, pungent herbal agents like chi hu (RadixBupleuri) and sheng ma (Rhizoma Cimicifugae) to raise theclear ymtg qi. His most well known formula, Bu Zhong Yi QiTang is the apotheosis of this therapeutic strategy.

To his historical successor, Zhu Dan Xi, the medical focuswas to shift to nourishing the yin, which he posited in his trea-tise Dan Xi Zhi Fa Yin Yao (The Heart and Essence of DanXi's Method of Treatment, 1347 CE) as always tending to bevacuous. This natural disposition of yin to become depletedwas further exacerbated by the ravages of warm pestilentialfevers, endemic in much of late medieval and early ImperialChina. Shifting the therapeutic focus from climatic intrusionto preserving the yin, Zhu Dan Xi and the proponents of theZi Yin Pai (Nourish the Yin School) advocated the employ-ment of bitter, cooling herbs like huang bai (Cortex Phel-lodendri) and zhi mu (Radix Anernarrhenaj) to clear vacuityheat and nourish yin. This approach is exemplified in his for-mula to nourish yin and down bear fire, being Da Bu YinWan. In addition to the two cooling herbs already mentioned,the formula also contains shu di huang (Radix RehmanniaeGlutinosae) and gui ban (Plastrum Testudinis).

This new therapeutic response to contagion is evident inthe medical strategies of his successors, demonstrating furtherhow changing disease patterns have helped shape medicalnotions and determine new therapeutic responses. The mostwell known of these successors, and a major proponent ofWen Bing Xue, Ye Tian Shi lived in the early Qing period, atime when epidemic disease was widespread throughout theChinese empire. In his compilation of epidemics in China,Joseph Cha lists a total of 33 visitations occurring from 1667,when Ye Tian Shi was born, until his death in 1746 (seeMcNeill, 1976). Many were of the warm, pestilential form,including smallpox, scarlet fever, and plague.

Contemporary medical debate however, often centred onthe contagious/non-contagious dichotomy in the Wen BingXue nosology. Some scholars considered that warm pestilenceshould be distinguished from warm disease per se by the con-tagious nature ofthe former. To Wu You Xing, they were oneand the same. Writing in his Wen Yi Lun (Theory of Epi-demics) he stated that 'hot diseases are the same as warm dis-eases, bur are also called warm pestilence because they gofrom door to door, recruiting everyone, like the forced labourcampaign from which no one is immune' (quoted in Wen andSeifert, 2000). As many of the warm diseases do include acutecontagious disorders such as smallpox and scarlet fever, andas the treatment strategies are similar, perhaps the therapeuticdistinction is rather arbitrary.

In response to the incursions of warm pestilence, it was YeTian Shi who completed the break with traditional ColdDamage Theory by the publication of the Welt Re Lim (Trea-

The Therapeutic Response to Contagion

tise on Wann Febrile Disease) in 1746. Written in response tothe deleterious impact of pestilential fevers on contemporaryChinese society, this important work detailed his quadripar-tite explanation for the pathogenesis of warm disease throughlevels of wei, qi, yiltg, and xue. The medical exigencies of thenew threat to good health in early modern China requiredcontemporary physicians to either adjust old treatmentregimes, or as in the case of Ye Tian Shi, develop new ones.Observing the effects of pathogenic endogenous heat on thebody, he emphasised the importance of nourishing the yin andpreserving the iin ye or body fluids. This therapeutic approachis best exemplified by his formula Yi Wei Tang which containssweet and cool herbal medicines including sba sben, (RadixGlehniae Littoralis) mai dong, (Radix Ophiopogonis) and yuzhu (Rhizoma Polgonati Odorati) to preserve the yin, moistendryness, and allay thirst.

hot diseases are the same aswarm diseases, but are also calledwarm pestilence because they go

from door to door, recruitingeveryone, like the forced labourcampaign from which no one is

immune

This same therapeutic orientation to nourish yin and clearvacuity heat resulting from the incursions of warm febrilecontagion was continued by his historical successor Wu JuTong. During his lifetime, the continuing menace of epi-demics, including scarlet fever and smallpox, ravaged humansettlements in southern China. He continued the further elab-oration of the effects of warm febrile pestilence by developinga system for the differentiation of syndromes according to theSan [iao, expounding his theories in the Wen Bing Tiao Bian,or Detailed Analysis of Warm Diseases published in 1798.This important work, being a cornerstone of Wen Bing Xue,contains many important formulas used today for incursionsof warm febrile disease. These include Yin Qiao Salt, Sang [uYin, Zeng Ye Tang, and Sba Sben Mai Mett Dong Tang.

In this paper I have attempted to elucidate the impact offebrile disease on shaping medical opinion, both in China andthe West, assessing, as a corollary, its influence in determiningnew therapeutic strategies. As Guenter Risse pointed out,physicians need to 'understand that diseases are notimmutable realities bur temporary conceptual constructions

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used to account for patterns of distress recognised and accept-ed by society' (Risse, 1979).

Certainly in historical times, this distress has often mani-fested as extreme anguish and despair following the devastat-ing effects of acute, infectious contagion. Demonstrating theuniversal frailty of human existence in this respect, the wordsof Agnolo di Tura seem pertinent here. Writing on the ravagesof the plague of Siena in 1348, he was to lament that 'I, Agno-lo, also called the Fat, buried my five children with my ownhands. And there were also those who were so sparsely cov-ered with earth that the dogs dragged them forth anddevoured many bodies throughout the city. There was no onewho wept for any death, for all awaited death. And so manydied that all believed it was the end of the world' (quoted inAberth,2001).

Today, the plague has lost much of its mystery and horror.The success of scientific medicine in the eradication of virtual-ly all acute infectious diseases which afflict human societieshowever, has now been paralleled by an increase in the chron-ic, degenerative illnesses including multiple sclerosis and can-cer. These new patterns of disease, reaching global propor-tions in the case of AIDS, have had profound effects onmedical theory and practice, challenging further the need forpractitioners of both biomedicine and traditional therapies toadjust their treatment strategies to meet the demands of morerecent threats to human well-being. Complementary medicinedoes have an important role in this respect.

With the acculturation of the traditional medicine of Chi-na into western societies in the 21st century, we as practition-ers need to be cognisant of necessary modifications in bothour theory and practice to meet the challenges of modern,industrialised societies. Perhaps the future directions of tradi-tional Chinese medicine, both in China and the West, will beguided by lessons from the past. Its leading proponents in his-torical times, including Ye Tian Shi and Wu Ju Tong, weresuccessful in treating current diseases because they were ableto adjust strategies of intervention to confront the new healthchallenges of contemporary Chinese society. The strength ofChinese medicine lies in its historical durability which, in part,relates to the inherent therapeutic flexibility of its paradigm.

As Lester King once wrote on the nature of illness in aphilosophical sense, 'disease is the aggregate of those condi-tions which, judged by the prevailing culture, are deemedpainful or disabling' (King, 1954). Differing socio-economic,climatic, and cultural factors have, in historical perspective,manifested in a wide variety of human disorders, both in Chi-na and the West. The continued academic inspection of possi-ble connections between disease, medical theory, and treat-menr strategies will contribute not only to an understandingof the evolution of medical paradigms, but it may indicatefuture directions for their further growth and expansion. Inthis respect, traditional Chinese medicine is no exception.

A shorter version of this paper was read at the 4th Aus-tralian Acupuncture and Chinese Medicine Association Con-ference held in Adelaide, South Australia on May 18,2002.

The Therapeutic Response to Contagion

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