Chapter 5: Late Qing China through the Lens of Medicine

and Disease

This chapter builds on the previous one. Here we take a closer look at China during the last decades of the Qing dynasty, a time when imperialist pressures were intense. Much can be learned about societies by examining their medical practices and reactions to disease, especially epidemic disease. In the case of late Qing China, this general topic is especially worthy of study because China was the site of a major clash of cultures. Within this clash, medicine and disease played a prominent role. A study of medicine and disease also sheds light on broad changes that took place in many modern societies, such as the rise of direct state intervention into the private lives of its citizens. Today we tend to take such intervention for granted, and indeed, often demand it. The active, interventionist state, however is a recent development, dating to the late nineteenth century. Medicine and disease played a major role in this development for reasons that we will see.

Today even people with no formal medical training generally know the causal agents of most diseases: microorganisms, commonly called “germs.” Those who remember their high school biology know that these microorganisms consist mainly of bacteria and viruses. There are other disease-causing organisms, of course, mainly a wide variety of single-cell and multi-cell parasitic organisms. Furthermore, a small number of diseases appear to be caused by unusual agents such as prions, the culprit in Creutzfeldt-Jakob Disease, the human form of “mad cow disease” (Bovine Spongiform Encephalitis). Bacteria, viruses, and parasitic organisms cause the vast majority of disease. Because these organisms are using the human body to reproduce themselves (with the disease symptoms being a side effect of their reproductive effort), in a sense, they can all be called “parasites.”

Some further reading in the extensive literature on the history of disease and the co-evolution of humans and microbes will clarify some basic principles. Bacteria, for example, are the most successful life form on the planet owing to their adaptability. More relevant for our purposes here is the principle that whenever a group of people inhabits and disturbs a new physical environment, this move is likely to give rise to outbreaks of disease. In a very general sense, agriculture is the best example of this phenomenon. Digging up the soil, combined with humans living in the same place in a fairly dense concentration, along with domesticated animals and the by-products of these humans and farm animals, was an ideal situation for new diseases to use the human body as a place to spread their genes (i.e. to reproduce). Settled agriculture provided humans with many advantages and provided the economic basis for cities, but one severe cost was higher levels of disease. More specific examples of this principle include Lyme Disease in the United States (human encroachment on the habitat of deer ticks), cholera in major urban areas along trade routes during the nineteenth century, bubonic plague in China’s Yunnan Province during the nineteenth century, and pneumonic plague in Manchuria between 1910 and 1911.

Another general point to bear in mind is that many organisms that cause disease in humans have a complex life cycle. There are often one or more vectors that transmit the disease-causing organism to humans. For example, in South China, the yellow-chested rat is the main organism in which the bacteria that causes bubonic plague lives. Under certain conditions, the plague-causing bacteria in these rats become especially virulent and kills many of the rats. If humans are living in or near this rat’s habitat, the fleas that normally feed on the rats shift to humans. The fleas thus serve as a disease vector, transmitting plague bacteria into humans. Humans are much less able than rats to deal with this type of bacteria, and more often than not died from such the encounter, at least during the nineteenth century.

The reason most human victims of bubonic plague died during the nineteenth century is that there were no effective treatments. The reason there were no effective treatments is that nobody really understood the cause of the disease, its path(s) of transmission, and the precise manner(s) in which plague damaged the human body. The same could be said for most other diseases. Today, for example, the treatment for *cholera* is to drink large quantities of water or similar fluids (cholera causes death by rapid dehydration). This treatment is nearly 100% effective if started fairly soon after the onset of symptoms. There is no need to attempt to kill the cholera bacterium because it passes through the body so quickly. When cholera raged through parts of London in the summer of 1854, however, nobody knew what caused the disease or how to treat it.

At the time, most British physicians thought that most disease was caused by miasmas. In other words, they thought that the main cause of disease was a toxic atmosphere. In Britain, especially, the alleged toxicity of the atmosphere was thought to be directly proportional to how bad the air smelled. The public health crusader Edwin Chadwick, for example, was famous for asserting that bad odors cause disease: “All smell is, if it be intense, immediate acute disease; and eventually we may say that, by depressing the system and rendering it susceptible to the action of other causes, all smell is disease.” (from testimony before a parliamentary committee, 1846. Quoted in Steven Johnson, The Ghost Map: The Story of London’s Most Terrifying Epidemic—and How It Changed Science, Cities, and the Modern World [New York: Riverhead Books, 2006], p. 114.) When did European scientists and physicians begin to acknowledge the role of microorganisms in disease? Not until the end of the nineteenth century, and not universally until the early twentieth century, did the miasma theory of disease give way to a germ-based theory of disease. In other words, at the time British, French and American imperialists were setting up shop in China, their physicians were generally unaware of the role of microorganisms in disease.

The Western miasma-based theories of disease were roughly similar in underlying concept to Chinese understandings of disease. There were many differences in details, of course (some of which we will examine), but the basic idea was that some pestilential aspect in the environment was transmitted to the human body via the air. The result was that those especially susceptible became sick. The manner of the sickness depended on the type of pestilential agent and the particular constitution of the individual patient. In this general way, Chinese and Western medicine conceived of disease similarly in, say, 1860. At the time, however, virtually nobody understood or appreciated this similarity in medical outlook. Western physicians, often owing simply to terrible translation of key terms, were convinced that Chinese medicine was absurd, and Chinese physicians (and often the general public) viewed Western medicine similarly. When bubonic plague struck Hong Kong in 1894, for example, the main treatment in British-administered hospitals was to drink large quantities of brandy. From the 1840s through the 1890s, advocates of Western-style medicine (which was itself constantly changing) and advocates of Chinese-style medicine (of which there were several different schools) each regarded the other as incompetent.

Other factors came into play within this field of mutual dismissal of each other. The Westerners had better guns and better ships. In other words, they were militarily superior. This military superiority enabled the forced implementation of Western-style medicine in certain areas of China, often including such coercive measures as destroying the homes of the sick and forcing them into hospitals where they faced the prospect of almost certain death. Furthermore, because of the dominance of the miasma model of disease, most Westerners of all walks of life regarded the presence of unpleasant odors in Chinese cities as proof of a “filthy” or “un-hygienic”—and thus diseased—way of life. European or American cities were, by almost any objective standard, just as filthy and smelly as Chinese cities at this time. But the imperialists were not objective. To them, Qing military weakness was a sure sign of cultural and moral decay. Moreover, cultural and moral decay went hand-in-hand with a lack of hygiene. Sure enough, to the noses of most Europeans, Chinese cities lacked hygiene. Outbreaks of disease—often the same diseases ravaging European cities at the time—became further proof of Chinese inferiority. The realms of medicine and disease were closely interconnected with the realms of cultural politics and imperialism.

Finally, bear in mind the importance of religion in perceptions if disease and related matters. Both Europeans and Chinese tended to regard disease outbreaks as being at least partially under the control of higher cosmic powers. The details of those beliefs, however, were quite different. When Chinese prayed to their gods of disease and wellbeing, Europeans regarded such actions as superstitious folly. When nuns and other religious personnel attempted to cure the sick in China, the local view of their activities was similar. Indeed, in 1870 an angry crowd in Tianjin murdered several nuns from the Sisters of Charity for allegedly stealing the souls of the sick entrusted to their care (the practice of baptizing dying infants appeared especially suspicious).

The Cold Damage and Warm Factor Schools of Chinese Medicine

Terms like “Western-style medicine” suggest that there was a single basic view of health, disease, and treatment among “Western” physicians. Putting aside the impossible question of figuring out what “the West” was, we should bear in mind that even within a single county, England for example, there were a wide range of medical views during the nineteenth century. At certain times and in certain circumstances one or another view tended to be dominant, so it is sometimes possible to make cautious generalizations—for example the tendency to link foul odors with disease. Still, we should bear in mind that there were several different forms of “Western” medicine.

The same is true for “Chinese” medicine. There were some basic underlying concepts common to all forms of Chinese medicine, especially the idea of qi (the most basic force or matter in the universe, sometimes translated with such terms as “ether,” “matter,” or “material force”). But a variety of different medical paths diverged from a few very basic concepts. Here we consider two of these paths that were especially prominent during the nineteenth century: the Cold Damage school (shanghan pai 傷寒派) and the Warm Factor school (wenbing pai 瘟病派). Some physicians specialized in one or the other of these two schools, but many medical practitioners (more so than theoreticians) used both approaches, depending on circumstances.

The bedrock idea in classical Chinese cosmological thought was that a subtle physical substance called *qi* 氣 constituted all things in the universe. Although there is no perfect English translation for qi, the term "material force" is sufficiently close that we will use it here. This concept of material force is roughly similar to the concept of matter in contemporary science, but the Chinese material force was more subtle and fluid, much like eighteenth-century European theories of ether or phlogiston. For Han Chinese, material force permeated the universe and manifested itself in a variety of specific physical forms. The presence of material force throughout the universe tied the cosmos together into a vast web. All existence, therefore, was interconnected.

The idea of material force alone was insufficient to explain the workings of nature in all its complexity. Classical Chinese thinkers, therefore, developed additional theories and explanations. Material force unified the cosmos, making it into a vast, complex, interconnected web. Chinese intellectuals devoted much of their attention to exploring the composition and operational laws of this web. Through these investigations, Chinese scholars developed theories of cosmic correspondence or correlation. In such theories, all things affect all other things, but some things are more directly connected to each other than are others. Scholars employed numerological formulae to quantify these degrees of correspondence. During the Song dynasty, one scholar even attempted to connect every known thing and phenomenon via a complex network of mathematical correspondences. We need not go into any further detail here.

The main point to bear in mind is that material force unites all phenomena in the cosmos and thus understanding these phenomena was largely a matter is matter of understanding the correlations between them. For Chinese physicians, therefore, neither the human body nor pathology were fixed entities that could be classified into universal categories. Instead, each case of illness was unique. Of course, physicians did rely on general guidelines and the study of past cases, but factors such as the patient’s personality, diet, general living environment, the season of the year, and so forth were essential for identifying the nature of the imbalance of material force and determining the proper treatment to restore that balance. This concern with environmental factors was at least partially in accord with the miasma view of pathology among European doctors. On the other hand, the contingent, fluid nature of the body in the eyes of Chinese physicians tended to retard advances in surgery. By the nineteenth century, Chinese forms of medicine tended to excel in drug therapy that included hundreds of types of medicinal compounds, whereas the main drug in the European physician’s arsenal was strong liquor. On the other hand, European physicians often performed fairly sophisticated surgical procedures unknown in China. For epidemic diseases, of course, surgery was useless. Outside of surgical procedures, European medicine of the mid nineteenth century (in any of its forms) had no obvious advantage over native Chinese practices.

Schools of Chinese medicine were rooted in the basic views described above, and they had a few other points in common. All schools of medicine advocated a lifestyle free of excesses. Excess emotion, excessive or unbalanced eating and drinking, sudden and extreme changes in temperature, and excessive sexual activity could all lead to illness. The reason was that such extremes of stimulation upset the rather delicate balance of material force. Nearly all schools of Chinese medicine understood illness as a material force imbalance, but they often differed in their theories of how such imbalances came to be.

The Cold Damage school is based on the notion of six normal climatic configurations of material force (liuqi 六氣) and six excesses (liuyin 六淫), which can lead to six different pathology syndromes (liujing 六經). The normal climactic configurations are wind, cold, heat, moisture, dryness, and fire. When these configurations occur in the proper seasonally cycle and to the proper degree, they cause no harm. Out of sequence, or if present to an abnormally excessive degree, any of these configurations could become a pathological “excess.” Such excesses are abnormal material force (xieqi 邪氣) that enters the body through the pores of the skin. At that point, it may or may not cause harm. A person with a healthy balance of material force is unlikely to become ill, but it the excess in the external atmosphere exacerbates a weakness or imbalance of material force in someone’s body, illness will result. There is no standard cure, however, even for people afflicted by the same pathology syndrome, because the manner in which illness manifests itself in someone and the best way to restore a proper balance of material force depends on many factors specific to that person’s circumstances. Medicine that cures one person might kill someone else with the same symptoms because of individual differences.

Although in theory, any of the six climatic configurations could, as excesses, lead to pathology, the Cold Damage school was especially concerned with cold and wind. The reason two excesses were such cause for concern was that they tended to afflict large numbers of people within a geographical area. In other words, cold and wind tended to cause epidemics. Moreover, Cold Damage physicians tended to regard any seasonal material force that harmed the body as a “cold” in nature. The inherently “cold” nature of disease carried important implications for treatment. Indeed, for the practicing physician, determining whether hot or cold imbalances were to blame for a specific patient’s illness was the primary consideration for proper diagnosis and treatment. Additionally, there were other factors such as whether the pathology was mainly the result of external forces or internal imbalances. Another key consideration was the location within the body of the pathology, since imbalances of material force typically moved through various regions of the body.

As an example, consider the following case described by the physician Wang Shixiong 王士雄 in 1838. The illness in question is huoluan 霍亂, which means “sudden chaos.” In most cases, it referred to cholera, but it could also include other severe gastrointestinal diseases:

A person [male] came down with huo luan. Since he had been sweating, his limbs were cold and his pulses weak. He generally ate cool things and drank cool beverages, so everyone thought this was a Cold Syndrome and wanted to treat it with extremely Hot medicines. Then I examined him. Although his face was white, it was sunken and crimson red around the periphery. He was extremely thirsty and had a severe headache. It could not be that the cold and cool had become illness. [Those who argued for treating this with Hot drugs] had not detected the hidden Summer Heat within him. (Quoted in Ruth Rogaski, Hygienic Modernity: Meanings of Health and Disease in Treaty-Port China [Berkeley: University of California Press, 2004], p. 97.)

In this case, had the patient been treated with hot drugs, the treatment might have killed him. The diagnosis was “invading summer heat,” and the treatment was as follows: “cooling drugs, a Five-Herb Poros cocos Fungus Formula (wu ling san) with added cooling ingredients such as magnolia bark, quince, and broad beans.” (Rogaski, Hygienic Modernity, p. 97.) Consider another of Wang’s cases of patients afflicted (most likely) with cholera:

A young man, of plump constitution and hot stomach, with an extreme personality. On a hot afternoon he laid naked on a mat placed on a brick floor and stuffed himself with several pounds of watermelon. That evening, he felt his head grow heavy, and a Cold malaise filled his body. Later that night he began to vomit and excrete feces in great quantity. His limbs were stiff. He sweated lightly. Occasionally he would become extremely agitated. His pulses were sinking and weak. (Quoted in Rogaski, Hygienic Modernity, p. 97.)

In this case, the patient became ill from seasonal excesses because of his neglect of the general principles of moderation in lifestyle. Notice also that although the extreme weather was in the form of summer heat, it manifest itself in the patient as “a Cold malaise.” The treatment consisted of “warming drugs such as cassia bark, dried ginger, and aconite.” (Rogaski, Hygienic Modernity, p. 97.)

Not only did Wang treat these two cases differently, in the second case his diagnosis and treatment were in accord with the Cold Damage school, and in the first case Wang followed a course of treatment that resonated with the Warm Factor school. Many Chinese physicians sought to do precisely what Wang did by combining the best insights of both schools.

The Warm Factor school held that pestilent material force (li qi 厲氣 or za qi 雜氣) was unconnected with seasonal cycles, and was thus unpredictable. Such malevolent material force could arise suddenly in an area and cause many people to become ill. This scenario was the Warm Factor explanation for epidemics. Moreover, this damaging material force was not cold in nature. Instead, it did its damage by manifesting excessively warm properties. According to Warm Factor theory, pestilent material force typically entered the body through the nose and mouth, not by seeping into the pores as the Cold Damage school maintained. In other words, the most common scenario by which people become diseased is by breathing in pestilent material force, or sometimes by drinking it. In practice, this understanding was very close to the prevailing mid nineteenth-century British view that breathing in miasmic vapors was the main cause of disease.

How might Warm Factor theory explain an outbreak of epidemic disease such as bubonic plague, commonly known in nineteenth-century China as shuyi 鼠疫, or “rat epidemic?” Repeated observation had established that outbreaks of bubonic plague in human populations were preceded by large die offs of rats. Carol Benedict describes one medical text’s explanation of the pestilent material force that causes plague as:

. . . an earthly (di qi) rather than an atmospheric qi (tian qi). This distinction provides an explanation for why rat epizootics [die offs] occur before the outbreak of the disease among humans: Because the pestilential qi rises from the ground, it passes through rat burrows on its way to the surface. The rats are driven from their nests by the intense “heat” of the pestilential qi. Seeking relief, the animals drink from water cisterns or even unattended teacups. When humans unwittingly drink from the same containers, they receive the pestilential qi. (Carol Benedict, Bubonic Plague in Nineteenth-Century China [Stanford: Stanford University Press, 1996], p. 107.)

To contemporary readers, such a causal mechanism, sharing teacups with rats, may seem absurdly contrived. It did, however, identify the main animal source of the plague, something Chinese physicians knew well before such knowledge became common among European physicians. Furthermore, what we have here is a common phenomenon in human thought: upholding the theory. If a theory seems convincing or powerful (or if it is simply the accepted knowledge of the time), people tend to twist the details to accord with the theory. After the theory loses its standing, then these twisted details seem absurd. Let is consider a British example of precisely the same thing. During the London cholera epidemic of 1854, Dr. John Snow concluded that cholera was a water-borne illness. Because in hindsight, we know he was correct, we tend to assume that his conclusion was very influential at the time he advanced it (and it did have some impact). Snow’s view, however, was completely out of step with mainstream miasma-based thinking, and the official report on the epidemic dismissed it with contempt. Nevertheless, the official report did have to explain one odd fact: water drawn from a particular pump that Snow identified as the source of the cholera was taken by carriage across town and delivered to Susannah Eley, who drank it and died of cholera. Nobody else in her area became sick. According to the official view:

The water was undeniably impure with organic contamination; and we have already argued that if, at the times of epidemic invasion there was operating in the air some influence which converts putrefiable impurities into a specific poison, the water of the locality, in proportion as it contains such impurities, would probably be liable to similar poisonous conversion. (Quoted in Johnson, Ghost Map, 186.)

This piece of circular reasoning claims that poisonous air (miasma) seeped into the (well) water, thus causing it to take on the same diseased qualities of the air. It is no less strange than the notion of thirsty rats spreading pestilent material force by drinking from people’s unattended teacups. In both the Chinese and the British cases, the writers were, in effect, defending the prevailing disease theory of the day—miasmas and destructive hot material force—by explaining away inconvenient facts. The construction of theories is essential for the advancement of knowledge. We should always be aware, however, that theories can be mistaken, and sometimes adhering to them holds back advances in knowledge that would otherwise occur. Eventually the accumulated weight of contrary evidence and alternative explanations causes mistaken theories to collapse, thus ushering in what historians of science and others often call a “paradigm shift.” Paradigm shifts are uncomfortable. Typically, the experts are heavily invested in the prevailing theories of their day. Unwilling to let their beloved theories collapse, they work hard to shore them up, explaining away facts and observations that do not seem to fit.

An Early Imperialist Attempt at Sanitary Engineering

Recall from the previous chapter the major phases of the Second Opium War or Arrow war, which waxed and waned between 1857 and 1860. Owing to the Conventions of Beijing, the city of Tianjin (#map#) became a treaty port. During the last phase of the fighting in 1860, the Anglo-French invaders left a British garrison of over 2,000 behind in Tianjin while the rest of the force went on to Beijing and then north to burn down the emperor’s summer palace.

A large part of this garrison set up camp at two different temples, one in the north of the city and one in the south. From these two points, the soldiers sent out surveying and reconnaissance teams that began mapping the city and recording other relevant, important, or interesting information. One British officer, quartermaster Colonel G. J. Wolsey, recorded detailed observations. He sometimes wrote of the odors that assailed his nostrils as he visited various environments. At a picturesque temple, for example, he recoiled at a pile of occupied coffins out in the open unburied. The reason for this situation was that the temple officials were waiting for an auspicious time to conduct the burial. In contrast with the British practice at the time of fertilizing agricultural fields with crushed bones or bird droppings, farmers around Tianjin generally used human waste. Wolsey pointed out that amidst such fields, “the olfactory organs are so rudely assailed by the variety of stenches.” (Quoted in Rogaski, Hygienic Modernity, p. 84.) To nearly any educated British observer in 1860 bad smells, especially unusual, exotic, and unexpected bad smells was a sure sign of a lack of proper hygiene and sanitation, which in turn would lead to disease. Rogaski explains how this fear of smells played out in Tianjin:

Wolsey and his fellow British officers were convinced that the smells and vapors they sensed rising from the Chinese landscape were not harmless but had the potential to inflict severe illness, particularly if the vapors were emanating from a groundwater source. One of the first engineering tasks the British forces undertook in Tianjin was the elimination of stagnant water from areas around their camps. The worst offending spot was the moat that ran the entire course of the city wall. Convinced that vapors from the moat would visit pestilence upon the troops, the British (or rather, the Cantonese laborers employed by the British) moved tons of soil from higher ground and used it to fill in the part of the moat that stood between the city wall and their headquarters at Qianlong’s Ocean-Viewing Pavilion. (Rogaski, Hygienic Modernity, p. 84.)

This early attempt by foreigners to impose their notions of public sanitation onto Chinese geography proved to be a debacle. The moat was part of Tianjin’s drainage system. Runoff from the city streets collected in the moat, which periodically overflowed into the Hai River. By the next winter, there was a foot of standing water in most Chinese residential districts throughout the city thanks to the British “improvement.” The British response was not to restore the old system, which would have been costly and embarrassing. Instead, the British forces moved into accommodations on higher ground in the city.

Specifically, these soldiers commandeered the Empress of Heaven Temple, a major center of religious rites in the city. The temple’s courtyards and buildings were an almost ideal residence for the soldiers except for one problem: the buildings were full or altars, statues, and other religious objects. Of course, to the British soldiers Chinese religious practices were obviously false, deluded, and superstitious. As residents of the city watched in anger, the soldiers set about destroying all of the objects cluttering the space in which they intended to live. Among the deities destroyed were those responsible for guarding the city’s health. Viewed from the standpoint of the residents of Tianjin, the British presence was a health disaster. Much of the city was covered with standing water, and the major deities responsible for health had been destroyed. Indeed, from almost any perspective it is hard to see any benefit in this early European attempt at sanitary engineering.

Plague in Yunnan, Hong Kong, and Manchuria

Yunnan Province (#map#), on China’s border with Southeast Asia, was sparsely populated until the eighteenth century. At that time, copper mining and an expanding population throughout the Qing empire caused human communities in Yunnan to intrude into the habitats of the semi-wild yellow-chested rat, a rodent that carries the plague bacillus. Recall the general principle whereby human intrusion into new natural environments frequently results in disease outbreaks. Plague in Yunnan would have been merely a local phenomenon in late Qing China, had it not been for economic expansion. Yunnan became linked to the rest of southern China via an expanding network of roads and coastal transportation networks. Via these networks, a vigorous exchange of goods and people between Yunnan and other parts of the region flourished during the nineteenth century. Civil disorder of during the 1850s diverted opium trade routes in Yunnan directly through areas inhabited by the yellow-chested rat. This change of trade routes caused bubonic plague to spread from Yunnan province to other areas. Regional trade and transportation networks spread the disease throughout much of southern China. This case illustrates the spread of disease not because of economic stagnation or decay but because of economic expansion and vitality.

Notice the date. The spread of plague took place at the same time that British and other foreign imperialists were becoming entrenched in Chinese treaty ports. Moreover, the Island of Hong Kong, which was in the plague zone, had become British territory in 1842. Bearing in mind that in fact, the spread of plague reflected not Chinese decay and decline but rather Chinese economic expansion and population growth throughout much of the south, consider the following points by Carol Benedict about Western perceptions of disease in China. They should sound familiar, based on what we have already seen:

In many ways, the image of a decaying China presented in earlier [academic] analysis of the late Qing epidemics reflects nineteenth-century Western preconceptions and prejudices about China and the Chinese. During an era of intensive imperialist expansion and unshaken belief in the superiority of Western science, Europeans and North Americans used scientific and technological achievement as a measure of civilization . . . . For many, China was a “barbaric” and “semi-civilized” country that had advanced early on but had then stagnated and declined. As their comments during the plague epidemics indicate, nineteenth-century colonial physicians, administrators, and missionaries viewed Chinese responses to plague from this vantage point. They condemned Chinese officials for their supposed indifference to the plight of victims and ridiculed the masses for their “superstitious” religious festivals and processionals. (Benedict, Bubonic Plague, p. 168.)

One showcase of such attitudes was the plague epidemic of 1894 that struck Hong Kong. British authorities there imposed a severe, state-supervised regimen of isolation of victims in hospitals (where the treatment consisted mainly of drinking strong liquor, and where approximately 90% of patients died) and the destruction of the homes of victims (on the grounds that they must have been unsanitary and thus a menace to public health). British health authorities also attempted to quarantine the whole island with respect to its Chinese residents—the one measure that actually might have helped—but local resistance was too strong. Indeed, the local Chinese population bitterly resented the entire program, which, in their eyes, was as cruel as it was ineffective. Western accounts at the time, and later, interpreted this local Chinese resistance as backward, superstitious opposition to scientific progress. In fact, however, Western scientific “progress” in 1894 had not advanced to the point where anyone understood the how plague was spread (e.g., rats to fleas to humans) or how to treat it effectively. Moreover, Chinese medicine at time was quite vigorous, as Cold Damage and Warm Factor theorists engaged each other in spirited debates in an effort to explain the recent epidemics. In 1894, European “public health” and medicine had proven no more effective against plague than native Chinese responses, and the foreign measures were much more socially disruptive.

At the time, however, the British colonial authorities were convinced of the superiority of their methods. And they had the guns. As a direct result of the Hong Kong epidemic, British and other imperialists began to pressure the Qing government to enact stringent, European-style public health measures. Moreover, several influential Chinese reformers began to argue in favor of European-style public health measures as essential components of a “modern” and “progressive” society. Starting in 1902, important Qing officials began to establish police-directed public health bureaus within individual provinces. Remember, “progressive,” “Western-style” public health measures at this time, generally meant arresting the sick at gunpoint and herding them together in isolation wards.

A good showcase of this change was the outbreak of pneumonic plague in Manchuria in 1910-1911. Pneumonic plague is caused by the same bacterium as bubonic plague (Yersinia pestis). In its bubonic form, the bacteria infect the lymph system. In its pneumonic form the bacteria spread from person to person via coughing and infect the lungs directly. Pneumonic plague is fatal in nearly 100% of the cases. In Manchuria, too, the basic principle we have already seen applied: human settlement in new natural environments often results in disease outbreaks. *Click here* for more details and for photographs. Moreover, like bubonic plague in south China, the 1910-1911 Manchurian epidemic was the result of economic and social expansion, not stagnation. In the Manchurian case, both Qing officials and Russian military officials (Manchuria was in the Russian “sphere of influence”—more on that later in the course) acted quickly to round up anyone suspected of being ill with the disease. This was not a good time to come down the common cold or some other lesser illness, or you might well have found yourself in a boxcar full of pneumonic plague sufferers. Such an environment would have meant certain death.

In short, by the time the Qing dynasty fell, the western-style apparatus of police-directed public health had become widely accepted in China. (Indeed, in recent years we have seen it in action in response to SARS and bird flu.) Notice, however, that even at the turn of the century, there was no compelling evidence that this foreign model was superior from a purely medical standpoint. It was the power of the imperialists’ guns, more than anything else, that propelled their public health measures forward.