The Discontinuity and Reconstruction of the Concept of Cholera in Modern Times – Based on An Epitome of the Reports of the Medical Officers to the Chinese Imperial Maritime Customs Service, from 1871 to 1882

1 Introduction

Since modern times, the gradual formation and completeness of the world has enabled a variety of infectious diseases to spread along with the growth of trade and exchange activities. Meanwhile, the process of multi-cultural interaction has also enabled many ancient diseases to possess new characteristics and connotations of epidemics. Cholera is one of them. This ancient disease has become an actual epidemic of the mankind as the gradual formation of the world concept. In the process of its global expansion, cholera opened up more variants as “Asian cholera”, “Indian cholera” and “British cholera”, which can all be regarded as the medical evidence of knowledge transfer and convergence by the development of imperialist science. In the meantime, the definition of cholera was also completed the transition from a pre-modern disease to a modern epidemic through breaking and remodeling its old connotations. In order to study the forming process of the modern cholera concept, this article takes An Epitome of the Reports of the Medical Officers to the Chinese Imperial Maritime Customs Service, from 1871 to 1882, hereafter referred as the Epitome, a medical history work co-authored by professional medical men in 19th century as reference, and reconstructs the process by which the definition of cholera was connected with science in 19th century and thus was gradually separated from traditional cosmology.

2 The Epitome and its Cholera Records

The Epitome’s prototype was the first 24 issues of Medical Reports from 1871 to 1882. Ever since the middle of 19th century, the treaty ports authorized by the Qing government have become the space for the extraterritoriality and the settlement, the continuous influx of foreigners’ health needs in each port made the maritime customs of service recruit a group of medical officers with professional background of western medicine to maintain the health of foreigners, ensure the ship quarantine inspection, and improve environmental hygiene of ports. In 1870, the inspector-general of Chinese imperial maritime service, Robert Hart (1835–1911), decided to set up a medical journal Medical Reports dedicated to collecting information on diseases and environmental conditions, which regularly submitted in the form of half-year reports by medical officers. Later, more and more reports began to cover geography, diet, climate and other aspects, thus made Medical Reports not only a historical database of the development of modern medicine and epidemiology, but also a comprehensive document of social and cultural history. The Epitome compiled and arranged by the surgeon-general Charles Alexander Gordon (1820–1899) in 1884 was a 12 year summary derived from the essence of the first 24 issues and the further research on certain valuable subjects based on forefront European medical theories then.

With reference to Cholera in the Epitome, there were a total of 44 regular reports, which written by 22 medical officers from 18 Chinese treaty ports, and a 30-page special report Cholera Epidemics in Japan: With a Monograph on the Epidemic by Dr. Duane Buckbee Simmons (1832–1899), who was a physician and surgeon to the Ken Hospital, one of the physicians to the Cholera Lazaret, and Chairman of the Yokohama Foreign Board of Health in 1879 (Simmons, 1879, pp. 1–30). Therefore, the study on the history of modern cholera based on the Epitome can better show the evolution, transmission, treatment and information exchange of this disease in the Chinese cultural circle from a cross-cultural perspective, so as to provide evidence and reference for the study on the evolution history of cholera concept.

3 The Pre-modern Conditions of Cholera

Cholera has been known in China, as in India, from time immemorial. The earliest reference can be traced back to 2500 B.C. Huang Di Nei Jing, which considered that something huddled up in a confused manner inside the body. Neijing believed that jing, qi and shen were the three treasures for human bodies, and three pent-up qis leaded to vomiting and purging. In other words, the gastrointestinal symptoms were only the external manifestations of cholera, the real source of the disease was the internal obstruction of human bodies. Since then, this theory has become the basic view of cholera in TCM. In the age when doctors were still not distinguished from wizards, there were also someone who assigned the source of cholera to the evil spirits released by the god of plague. Misbehavior of the patient or the king’s moral failure would lead evil spirits to the body. Because of the influence of Daoism (Taoism), the solution at that time included confession, prayer, exorcism and quarantine, etc. Temples to the Yaowang, or Princes of Medicine, are everywhere to be met with in China. The earliest of those to whom such were erected was Bian Que (407 B.C.–310 B.C.), then Hua Tuo (145–208). Reference occurred to the appearance of a plague in the A.D. 591, and to the simultaneous appearance in the sky of the five mighty ones. During that dynasty the Sui and the Tang temples were dedicated to ceremonies for averting the pestilential wrath of these mighty ones, now styled supernatural (Macgowan, 1881, p. 30). At the same time, Sun Simiao (581–682) of the Tang Dynasty re-attributed the cause of cholera to the abnormal abdominal qi caused by improper diet, and no longer related to demons in his Beiji Qianjin Yaofang (652). In Yuan Dynasty, Zhu Zhenheng (1281–1358) inherited Sun’s views in his Danxi Xin Fa (1347) and ascribed the cause to retained ingesta, aided by certain external influences such as cold, by which the male principle (yang) ceases to ascend, and the female (yin) to descend, and the diaphragm is drawn down. Then in the Ming Dynasty, Li Ting (?–?) ascribed the disease principally to heat in Yixue Rumen (1575), but his contemporary Zhang Jiebin (1563–1640) showed in Jingyue Quanshu (1624) that it was because of the prevalence of the summer and autumn heat, people did not control the ingestion of cold things, which were more likely to stimulate chill. It was not until the Qing Dynasty that Zhang Lu (1617–1699) Zhangshi Yitong (1695) took into account the fact that cholera was also found in the cold season, and thus considered the factors of soil and water as other potential causes. In other words, it wasn’t until the Qing Dynasty that environmental factors were finally incorporated into the cause of cholera. However, environment was still only a small part of the whole cholera theory, and the fixed view that cholera was an intestinal disease caused by qi has not been shaken.

Before the middle of 19th century, the spread of cholera rarely went beyond the national borders or the range of the Asians, it to a certain extent only led to the simple symptoms of patients, the small possibility of new complications and the relevant theories which were rarely changed, thus the etiology and pathology of cholera always maintained its pre-modern situation. Driven by the view of cholera as a minor intestinal disease, Chinese doctors continued believing that if there was premonitory diarrhoea it could be checked by opium, astringents and carminatives. When the disease has manifested itself, they gave stimulants to forestall the collapse. They employed shampooing by skillful pinshers (Manson, 1877, p. 31). The focus on the relief of diarrhoea symptoms has also led to a proliferation of folk remedies. At Fuzhou during the epidemic in the summer and autumn of 1877, a number of prescriptions for the disease were posted about the city. The most of them recommended external irritation, and hot medicine, i.e., ginger, pepper, etc. For the most part the natives, during an epidemic, take refuge in gong-beating, paper-burning, and sing-songs (Somerville, 1877, p. 85). In general, Chinese doctors’ therapies in 19th century were still in the pre-modern state, which not only followed the traditional means of diagnosis and treatment, but also combined characteristics of both spiritual and nature philosophical medical models, though what they did sometimes seemed more like inaction. At Wenzhou, during the summer of 1877, cholera prevailed about 10 to 14 days. Little or no treatment appeared to be received by the natives. As soon as a native doctor made out the nature of the case he departed, and the domestic offices for the dead were begun (Myers, 1878, p. 41). It seemed like the best ways to ward off disease then were isolation and death. However, it was undeniable that there were still a variety of “modern” diagnosis and therapies in TCM when treating diarrhoea caused by cholera. Therefore, it is more appropriate to consider the new cholera concept that emerged in 19th century as the result of adding many new knowledge that had never appeared before, so that the modern concept of cholera gradually separated from the traditional cosmology and finally constructed a connection with the modern science.

4 Discontinuity and Reconstruction of Cholera Concept

Since the mid-19th century, the late Qing customs recruited a group of professional medical officers in the name of customs staff. These medical officers generally were independent practitioners qualified as pharmacists, surgeons or physicians. They had high social status, common qualifications to independently undertake medical responsibilities and universal potential to carry out medical research. They could provide their long-term and stable research results regularly for western medical colleagues to share and exchange relative knowledge under the requirements of the late Qing customs. In other words, these officers were the direct witnesses and recorders of the change of various diseases’ characteristics including cholera at that time. The following are the concept of modern cholera reconstructed by medical officers in terms of therapies, space, theories, and prevention based on the cholera records from the Epitome.

5 The Cholera Concept Applied in Japan before and after the Reconstruction

Before the end of the Ming Dynasty, China and Japan had frequent exchanges, and there was only an interval of 20 or 30 years between the popularity of important Chinese medical knowledge and their spread to Japan. In Japan, as in China, the early history of cholera was quite obscure. With regard the history of the disease in Japan, Dr. Simmons gave particulars as follows from a native treatise on cholera: In the summer of 2376 era of Jimmu, i.e., A.D. 1718, a fatal illness, under the name of fever, prevailed in the city of Great Yedo; the mortality by exceeding 80,000 per month; the dead so numerous that, interment being impossible, the bodies were buried in the bay adjoining (Simmons, 1879, p. 4). The prevailing disease was quite different from ordinary fever, and was considered to have been the first occurrence of the cholera in Japan.

After the middle of the Ming Dynasty, Chinese culture, which has been less influential, was replaced by western culture, which gained increasing importance in Japan. Compared to China, Japan’s contact with western culture was a century earlier. By the middle of 19th century, when China was transferring from an importing country to an exporting country of cholera epidemics, the ratio of western and Chinese doctors has reached 1:4. The cholera pandemic of 1877, which affected many countries, could be regarded as a direct example of the reconstructing connotations of cholera in Japan, where was jointly influenced by the role transition and ideological transformation in China and the west.

In 1877, a cholera epidemic broke out in Xiamen, and by the end of August it has practically ceased. In March of the following year, Dr. David Manson (1848–1878), the medical officer of Xiamen Customs, wrote: “why did cholera first appear in one corner of the comparatively small town of Amoy, and then spread over the whole town, and then to the large cities in its immediate neighbourhood, and afterwards make its appearance successively at different ports on the coast, reaching at present as far as Japan? The answer is easy enough. Amoy town itself is the port for the great cities in its neighbourhood, and the centre of a great Chinese passenger traffic (Manson, 1877, p. 31).” Therefore, Xiamen can be both the receiver of cholera epidemics and the beginner of transmission of the disease, and the most direct impact in the process of transmission was its neighbour Japan. But strictly speaking, in the 1870s, the source of cholera in Japan was not only Xiamen, British and Dutch merchant ships were also suspected.

Although the great epidemic of 1817 had its origin in India in that year, it did not reach Java until 1819, China till 1820, and Japan in 1821–1822 (Simmons, 1879, p. 3). However, because of the experience of half a century earlier, in 1877, when the outbreak occurred again in Xiamen due to the imported cases, Japan raised its vigilance in advance. On 7th of July, 1877, the Japanese consul in Xiamen telegraphed to his Government the existence of cholera in that port from about the 27th of June. In reply to a telegram from the British minster at Tokyo, Chinese Hong Kong stated that they did not consider the disease in Xiamen sufficiently severe to justify the declaration of quarantine. Yet the Japanese authorities, bearing in mind the great severity of previous epidemics, took precautions to stay its progress in the event of the disease entering that country. The existence of the Satsuma rebellion, then at its height, rendered it impossible to carry out efficiently quarantine regulations, or inspection of ships. And so, sometime in August, the disease appeared in a small village half a mile from Nagasaki, and then quickly spread among ships in the port. The precise manner and means by which cholera reached Japan remained undiscovered (Simmons, 1879, pp. 7–8). There was only an opinion that when showers were falling slowly, no marked change was noticeable in the disease ratio; when rain was heavy for a few successive hours a rapid rise in that ratio always followed on the fourth or fifth day afterwards – a circumstance accounted for by the excess of water bringing about contamination of the wells. Throughout this epidemic in Japan the recorded cases of cholera were 12,378, of which number 6508, equal to 52.58 per cent., died. The attacks to population were 3.79 per 10,000. On 11 November, 1878, a case occurred in that portion of the town where the epidemic of the previous year had prevailed; this was followed by a serve outbreak. With few exceptions the scourge remained in the district in which it had revived. The last instance occurred on 23rd January, 1879; the total cases from its recurrence 33, death 25 (Simmons, 1879, p. 14). During the year the general statistics of the epidemic in Japan gave 975 cases, deaths 532, equal to 54.56 per cent. The cases to population not stated (Simmons, 1879, p. 15).

The circumstance that cholera was absent from Japan from 1861 to 1862 to 1877 was noticed as demonstrating that it is not endemic in that country. On the last occasion it was considered that the disease spread along the great routes of travel; that the water-supply was the immediate cause of its extended prevalence; and that the towns which suffered most were those situated near the foot of mountains, where the custom of directing streams of water through the streets was followed. With regard to the results of treatment, the statement occurred that where, as in many of the infected places, a vast majority of the medical men still followed the Chinese system, the mortality has but little exceeded the average of that in more enlightened countries. The manner in which the Japanese dispose of their night-soil was also considered to favour the spread of cholera: their system was very similar to that followed in China (Gordon, 1884, p. 137). Some scholars believed that it was the similarity in public facilities and medical theories in Japan that led to the comparability in the prevalence of cholera between China and Japan.

However, different from China where western medicine were separated from Chinese medicine, as early as the Edo period, Japan had learned western medicine through the trade port Nagasaki and formed ran gaku who were independent of Chinese medicine. In the 1870s, ran gaku and Chinese medicine have been coexisting for a 100 years in Japan. Therefore, the methods of treating cholera showed a mixture of traditional connotations and early modern scientific hygiene. First of all, the disease was attributed to diabolical agency, hence the people gave it the name of “fox, wolf and badger”. Everyone adorned his gate with branches of pines and bamboo, and straw ropes; at the same time some of them offered prayers to the kami, others to Buddha. It was believed that all water and all fish were poisoned, so that people dared not draw water from the pure stream of the upper Tamagawa, nor eat any fresh fish, even when it was brought alive to their doors (Simmons, 1879, p. 5). Secondly, certain instructions were issued by the Bakufu, having reference to the prevention of cholera, and to the treatment of patients suffering from that disease. They were nearly as follows: In the way of precaution, avoid of patients exposing your body to cold air; wear a cotton belt round your abdomen; be careful to avoid gluttony and excessive drinking, and the eating of indigestible food. In the way of treatment: If symptoms appear, go to bed: be extremely careful what eat and drink; keep the whole body warm, and take the medicine hoko-san, prepared by mixing yekichi and dried ginger in equal quantities, and boil; drink at intervals one or two cupfuls at a time. If you vomit and purge much, and your body becomes cold, put 2 monme of refined camphor into 2 go of spirit (sho-chiu), warm the mixture over the fire, dip a cotton cloth in it, and rub the body and limbs briskly. The application over the stomach of a mustard plaster composed of powdered mustard-seeds, wheaten flour and vinegar is also recommended; or, in urgent cases, mustard only mixed with hot water. Another form of medicine is this: Into a certain measure of tea pour about one-third the quantity of spirit; add a little sugar, and drink. The patient to be placed in a hot room, and his body rubbed with a cotton cloth soaked in spirit; if the extremities are cold, hot stones to be applied (Simmons, 1879, pp. 5–6).

At first glance, it seems that the demonic conjecture and the prayer have not yet gotten rid of the traditional structural views. However, in fact, after the middle of the Ming Dynasty, the influence of Chinese culture in Japan has gradually shrunk and been replaced by increasingly valued western culture, therefore the traditional knowledge of cholera in Japan still remained in the pre-Qing state and made no progress at that time. And the core of the treatment, which concentrated on diet, warmth, and the use of aromatic powder, was no longer associated with the Chinese cosmology of qi, but, as medical officers believed, did not materially differ in kind from such as might, if need were, be issued in 9th month, 47th year of Victoria, A.D. 1883 (Gordon, 1884, pp. 134–135), and thus possessed the essential characteristics of scientific legitimacy. For example, Ogata Hongan (おがた こうあん, 1810–1863) once mentioned that taking quinine, rubbing the body with warm water for muscle spasms, or using opium and morphine for vomiting and diarrhoea were all the latest treatments for cholera at that time. However, although Japanese medicine in the 19th century was westernized through constant, centuries-long contact with Dutch – among them also many German – doctors, this type of medicine – ran gaku – was still hardly “modern” from the overall perspective of medical history, but was rooted in the medicine of the 18th and early 19th centuries. What is modern in relation to cholera is just the scientific integration of modern science into hygiene from the cholera epidemic of the 1850s onwards. Therefore it could only be called as the mixture of traditional connotations and early modern scientific hygiene rather than modern science.

6 Conclusions

Yu Xinzhong and Wang Xu believe that the great plague that broke out in the early 19th century was the first time for China to experience the cholera epidemic. And a great social and economic change which was unprecedented in history has been experienced in the meantime since the plague also carried with it profound and complex social and cultural implications from both global and Chinese historical perspectives (Yu & Xu, 2020, p. 205). If modern medical officers had their way, they would not approve of the continuous use of the old name “Huo Luan” to refer to modern epidemics that have broken with the Chinese cosmology in both structure and scope. However, given the “collective” and “inevitable” nature within the term, and the desire to describe the epidemic characteristics and susceptibility of cholera after the conceptual reconstruction, the idea of “Huo Luan” was step by step accepted into the structure of modern medical hygiene. Western medicine in general and hygiene and health protection in particular have chosen the modern experimental sciences as their reference disciplines. Environmental or conditional hygiene emerged from the early 19th century, choosing meteorology, epidemiology, chemistry and physics as reference disciplines, while microbiological and bacteriological hygiene applied experimental methods to biological phenomena in the 1860s and 1880s. In the eyes of western doctors, the new expression “Huo Luan” has already been separated from the traditional field, and been incorporated into the modern structure by expressing the high epidemic and pathogenic connotations of a more modern “cholera” concept. Through a process of discontinuity and reconstruction, “Huo Luan” became synonymous with a more “modern cholera”, representing the western way of cholera of conditional hygiene, and relevant research began to shift to scientific experimental laboratory thinking and away from the old cosmology. This “birth” of medical modernity, and esp. modern hygiene not only appeared in China. But it also linked the cholera-related philosophy and the spatial orientation, national customs, and group culture behind it through the existence of the pre-modern Chinese cultural circle. As a result, the construction of modern natural and cultural landscape has brought about structural and essential changes to concepts of various diseases, including cholera, during the reconstructing process in modern times. With the rise of various diseases as modern manifestations of diseases, although traditional theories and treatment based on the Chinese cosmology still have room to flourish, most of them have become independent of scientifically recognized medical fields. And the line of discontinuity formed by distinguishing the traditional cosmology and the modern medical narrative framework should be traced back to the imperialist line of scientific pressure, which divided tradition and modernity into two categories in 19th century.