Smallpox in China,
History of a Disease and its Response.
From: https://www.historyofvaccines.org/index.php/content/chinese-smallpox-inoculation
Historically smallpox has been one of the most devastating diseases to affect mankind. Therefore it should be no surprise that throughout history not only has there been great fear of smallpox, but that there has also been a great interest in identifying, treating and protecting from the disease. This paper covers the history of smallpox in pre-modern China and the response to the disease.
WHAT IS SMALLPOX?
Before
one can cover the history of smallpox in China, it would help to give some
background on the disease itself and its effects and status in today’s world.
Today
smallpox is considered eradicated in nature, but since stockpiles are known to
exist in the United States and Russia, and since it is possible that there may
be secret stockpiles elsewhere,[1]
there is still a great fear of the disease.[2]
Smallpox is
caused by a virus called the variola virus. It is related to cowpox, monkeypox
and vaccinia and a member of the family poxviridae and the genus orthopoxvirus.[3]
This
virus is spread by person-to-person contact, primarily by either droplets
expelled from the oropharynx of an affected person or by direct contact with
skin lesions or respiratory secretions. The disease can also be spread by
contact with contaminated laundry or clothing, a common vector of transmission
during historical outbreaks.[4]
When
the virus infects a person, incubation lasts about twelve days, at which time
the affected person develops the following signs and symptoms: abrupt fever,
malaise, rigors, headache, backache and vomiting. Fifteen percent of those
affected develop changes in mental status and often exhibit delirium. Two to
three days after this event, a rash appears on the face, hands and forearms.
Later the rash spreads, reaching the lower extremities. In eight to fourteen
days the rash begins to scab and heal, often leaving scars.[5]
This rash first appears in the mucosa of the mouth and pharynx.[6]
The
rash is marked by eruption of papules at first, these then progress into
vesicles, then pustules and eventually change into pock marks.[7] In the days before the eradication of
smallpox, when the disease was endemic, these scars were common and greatly
feared. In ancient China, it was reported that such scars usually lasted one
year.[8]
Today
the primary means of dealing with smallpox is through prevention done through
widespread immunization programs. Should the disease reappear, however, perhaps
through a terrorist attack, emergency personnel are trained to provide
respiratory and contact isolation of all affected or potentially affected
persons. These patients should also be quarantined for seventeen days.[9]
Although the time that the virus can live outside of a human body is unknown
with certainty, it is probably several months.[10]
Hypochlorite solutions inactivate the
smallpox virus outside of a person, reducing its chance of spread, but
treatment of infected people is mostly supportive since once affected
anti-biotics will not kill smallpox as it is caused by a virus. It is estimated
that thirty percent of those affected will die, and that even though
immunization is recommended, immunization is considered to be only 97%
effective in preventing the disease from developing in those exposed.[11]
It
is a deadly virus and undoubtedly it is significant that it not just provoked
fear historically, but that it continues to provoke fear today.
SMALLPOX IN CHINESE HISTORY
There
is great debate over the date of the first smallpox outbreak in China. Although
the first known report of an outbreak dates from the late third or
fourth century A.D., the report is of a historical nature and there is great
debate as to the time period it refers to when describing the outbreak.[12]
Many Chinese believed the disease to have arrived in China carried by foreign
soldiers.[13]
From
the fourth century, Chinese were able to clinically identify smallpox. It was
referred to as "bean lesion" or "bean eruption." At this
time the Chinese believed that the disease was caused by a poisonous form of qi.[14]
Despite this belief, in China from this time
onward, there were many theories about how smallpox was spread. The 610 A.D.,
medical text, the Zhu bing yuan hou lun, states that smallpox was caused
by an over-accumulation of heat toxin and that it originated from being hurt in
the winter or else from unseasonable qi.[15]
From the fifth century
onwards, however, there was a shift in the perception of smallpox in China.
Since the disease was endemic, and since people were usually affected only
once, as exposure and survival conferred immunity upon the survivors, the
majority of people who caught smallpox were children. This was because while
most adults had been exposed, children had often not yet been exposed. Because
of this, from the Five Dynasties period and the Song and Yuan Dynasties period,
smallpox was widely regarded as a children’s or pediatric disease.[16]
After
the Song period, these two ideas became combined and it was widely believed
that smallpox was caused by “fetal toxins” (zang fu) passed from the
mother during pregnancy whose effect was then triggered by certain external
factors.[17]
Treatments and preventative measures varied widely as did belief in the details
of the causes of the disease.[18]
During the Ming dynasty
(1368-1644), smallpox was rare among the peoples to the north of China, so rare
that most Chinese considered the disease to be non-existent among them.[19]
Among Chinese, however, the disease was still common. Theories about the
disease and its spread shifted further, and the disease and its spread became
interpreted with the concepts of systemic correspondence such as described in
the Huang-ti nei Ching, including the five phases of matter and a
complex system that described the spread and effects of the disease using a
cycle of 60 days and other correspondences.[20]
Nevertheless, it was
still believed that even if there were predetermining factors, an external
agent was needed to provoke the onset of smallpox. For instance, if a child
were to become frightened, angry or fall down, or eat an unhealthy, overly
spicy diet, or be nursed by a woman who ate an overly spicy diet, then these,
as well as other factors, were believed to cause the disease to erupt.[21]
It was theorized that
since there was no evidence of people in China in ancient times having
smallpox, the early Chinese were wiser and had lived lives of careful
moderation and had thus avoided provoking the onset of the disease.[22]
As for the northerners, although they too were seen as having been exposed to “fetal toxins,” they were also seen as not having been exposed to “hot qi” prior to having entered the southern regions such as China.
As for the northerners, although they too were seen as having been exposed to “fetal toxins,” they were also seen as not having been exposed to “hot qi” prior to having entered the southern regions such as China.
Prior to the late Ming
dynasty, smallpox was so widespread as to be seen as natural, and this
perception of smallpox as a natural thing affected treatment decisions. As
Chang Chia Feng wrote in his essay “Dispersing the Foetal Toxin of the Body:
Conceptions of smallpox aetiology in Pre-Modern China”:
Since most of the population had
undergone this predictable development, people gradually became convinced that
contracting smallpox was an inevitable fate. Smallpox was seen as a common
event in life, and was considered as a crucial turning point in determining
whether or not a child would grow up successfully. Developing smallpox was
thought to be as natural and usual a phenomenon as a snake shedding its skin.
It inspired physicians to assert that smallpox should be allowed to run its
course spontaneously, and did not need medical treatment at all. Providing
treatment to those with “shang deng dou” (first class smallpox)
or “zhuang yuan dou” (grade one smallpox) could be dangerous or even
fatal. The pox of such were seen as normal and good. Those which demanded medical treatment were exceptional
types of smallpox, whose pox were considered abnormal in appearance, and which
were attributed to various causes, such as having received too much tai du
[fetal toxins], or having disobeyed the restriction of touching any filth or
stinking substance in the course of the disease. [23]
Needham states that
during this time people would pray not to avoid smallpox but instead simply to
ask for a mild attack, a happy recovery and not too much scarring.[24]
VARIOLATION AND
IMMUNIZATION ARE INVENTED IN CHINA
In the late Ming dynasty, however, the situation changed when the Chinese invented variolation.[25] Variolation was a technique for inducing a small attack of the virus in a person in a controlled or semi-controlled fashion. When this was done the body would develop anti-bodies to fight the virus and from then on the chances of infection were greatly reduced.
The Chinese of the time however, unaware of
anti-bodies or germ theory, naturally had their own explanation as to why
variolation worked. The believed the process was designed to rid the body of the “fetal
poisoning” and accompanied it with various rituals that were supposed to help
with effectiveness.[26]
Although at first variolation was only practiced by a small group of radical
healers, it ultimately became more accepted as the secrecy surrounding the
technique broke down.[27]
Chang Chia-feng states
that there were five different forms of variolation, although he does not give
the details.[28]
One method was to take
the scabs from a child with a mild case of smallpox, grind the scabs into a
powder, mix the powder with water or wine, dip a cotton ball into the mixture,
and then place the cotton ball inside a person's nasal passage thus exposing
them to the disease.[29]
Needham provides a detailed
passage describing the technique:
Method of storing the incolum
(Tshang Miao Fa).
Wrap the scabs carefully
in paper and put them into a small container bottle. Cork it tightly so that
the activity (chhi) is not dissipated. The container must not be exposed to
sunlight nor warmed beside a fire. It is best to carry it for some time on the
person so that the scabs dry naturally and slowly. The container should be
marked clearly with the date on which the contents was taken from the patient.
In winter the
material has Yang chhi within it, so it remains active even after being kept
from thirty to forty days. But in summer the Yang chhi will be lost in
approximately twenty days. The best inoculum is that which has not been left
too long, for when the Yang chhi is abundant it will give a ‘take’ with nine
persons out of ten; but as it gets older it gradually loses its activity,
giving perhaps a ‘take’ with only five five out of ten people –and finally it
becomes completely inactive, and will not work at all. In situations where new
scabs are rare and the requirement is great, it is possible to mix new scabs
with the more aged ones, but in this case more of the powder should be blown
into the nostril when the inoculation is gone.[30]
Needham also states that
in the Chung Tou Chih Chang, and eighteenth century text, the
“innoculum” (material for inoculating”) was either lymph or scabs and was
carried in a bamboo tube, carefully corked. The material was supposed to be
carried in the physician’s pocket where it could “receive qi” unless the
weather was quite hot in which case it
should be stored in a cool place.[31]
Some pre-modern Chinese
physicians also advocated the sharing of clothing between persons affected with
smallpox and those unaffected in order to provoke an onset of the disease and
confer immunity upon a person, although others argued that this was not an
effective method of immunization. Naturally this was explained in terms of
transferring qi.[32]
Since the Manchus came
from an area where smallpox was rare, they tended to catch the disease in large
numbers when exposed and thus had a particularly great fear of the disease. [33]
During the reign of
Kangxi during the Ching dynasty, Zhu Chunghu was sent to practice variolation
among the Mongols.[34]
In the seventh year of his reign, the Emperor Kang-xi implemented a program to
begin the variolation of the imperial family. He then also began variolation
among the Mongols.[35]
THE SPREAD OF VARIOLATION
The exact origins and spread of variolation are uncertain, but the Turks also used the practice.[36]
Although Needham admits
the Europeans learned of immunization from the Turks, he also argues that not
only could the Europeans have learned it earlier if they had paid more
attention to the Chinese, but he also argues that the Turks actually did
learn the practice from the Chinese in the first place.[37]
For instance, Needham says that Europeans first learned of immunization and
variolation “just before 1700 A.D.” in letters from China to the “Royal
Society.”[38]
Although there’s
controversy and swirling claims over the exact course of events, one generally
accepted view is that Europeans learned of immunization when the wife of an
eighteenth century Turkish ambassador learned of Turkish “smallpox parties.” At
these parties persons would expose themselves to smallpox in a controlled
fashion in order to induce a mild case of the disease. Once having survived a
mild case of the disease they knew the likelihood of catching smallpox in the
future was miniscule.[39]
Edward Jenner is credited
with having invented an early form of modern inoculation in 1798 in England.[40]
Jennerian Vaccination was
introduced into China by Dr. Alexander Pearson in 1805. It was taken up only
slowly. There were many technical problems involving the preservation and
obtaining of vaccines.[41]
Free vaccinations were offered by charitable organizations and institutions.
[42] One
response was to sinicize the theory of the Jennerian vaccine, finding its roots
or justification within Chinese tradition:
Because the cow is an animal which belongs to Earth, Human spleen belongs to Earth. Using Earth, the same Qi will mutually stimulate, the same category will mutually breed. Therefore, it can have such an effect.[43]
One 1817 Chinese
discussion mentioned vaccination being done through acupuncture points.[44]
Although inoculation had many advantages over variolation, such as a better
theoretical base, easier delivery and improved safety, all of which facilitated
the mass inoculations that led to the conquest of smallpox, variolation
continued in China, particularly in rural areas, well into the twentieth
century. Naturally economics was one reason for this but there were also many
who simply preferred variolation, considering it to cause less suffering and
produce less pockmarks than inoculation.[45]
CONCLUSION
In conclusion, smallpox was historically one of the most feared and deadly of diseases, both inside and outside China. The Chinese interpreted this disease through their own cultural framework and explained its spread through the same theoretical framework. Treatments were also done through this framework. Eventually the disease became endemic and was seen as a normal part of life, particularly childhood. Surviving smallpox was seen as one of the challenges a child passed through on their way to adulthood, should they live to do so (and, obviously, in pre-modern China, few assumed that a child would live to adulthood.) In the mid-Ming dynasty, the situation changed with the development of variolation, an immunization method created by the Chinese. The process spread and became more popular over the next few centuries. Ultimately, the West learned about immunization techniques, largely from the Turks and some, such as Needham, argue that the Chinese may have learned the technique from the Turks. The West improved the technique, however, and brought it back to China. Today smallpox has been eradicated in nature, and only exists in laboratories. Nevertheless, it still inspires fear and interest in smallpox immunization techniques is still widespread.
ENDNOTES
[1] Pages
4-6, Johnathan B. Tucker, editor and
author of the introduction, “Introduction”to Toxic Terror –Assessing
Terrorist Use of Chemical and Biological Weapons, 2000, Monterey Institute
of International Studies, MIT Press,
Cambridge MA.
[2] Although
it lies far outside the scope of this paper, since smallpox is a potential
bioterrorism weapon, and since terrorists have been known to use suicide
attacks as a tactic, one means by which a terrorist organization might induce
an outbreak of smallpox upon a target is to simply infect a person, presumably
a volunteer willing to die for “their cause,” and then have that person travel
to the area where they wish an outbreak to occur.
See Page 65,
E.Bush-Petersen, “Smallpox- Preparing for the Emergency,” pages 57-67,
in Ellipse, 18(3):57-68, 2002. found on-line at http://www.baxter.de/fachkreise/bioterrorismus/Baxter_Ellipse_Smallpox.pdf
[3] Stephan
L. Foster and L.Brian Cross, 11/05/02, “Smallpox ---the immunization
connection,” in Welcome to U.S.Pharmacist,
on line publication at http://uspharmacist.com/index.asp?show=article&page=8_997.htm
[4] Page
58, E.Bush-Petersen, “Smallpox-
Preparing for the Emergency,” pages 57-67, in Ellipse, 18(3):57-68,
2002. found on-line at http://www.baxter.de/fachkreise/bioterrorismus/Baxter_Ellipse_Smallpox.pdf
[5] Pages
70-71, Robert A. DeLorenzo and Robert S. Porter. 2000. Weapons of Mass
Destruction –Emergency Care, Brady,Prentice Hall Health, Upper Sadddle
River, New Jersey.
[6] Page
59, E.Bush-Petersen, “Smallpox-
Preparing for the Emergency,” pages 57-67, in Ellipse, 18(3):57-68,
2002. found on-line at http://www.baxter.de/fachkreise/bioterrorismus/Baxter_Ellipse_Smallpox.pdf
[7] Stephan
L. Foster and L.Brian Cross, 11/05/02, “Smallpox ---the immunization
connection,” in Welcome to U.S.Pharmacist,
on line publication at http://uspharmacist.com/index.asp?show=article&page=8_997.htm
[8] Page 24,
Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[9] Pages
70-71, Robert A. DeLorenzo and Robert S. Porter. 2000. Weapons of Mass
Destruction –Emergency Care, Brady,Prentice Hall Health, Upper Sadddle
River, New Jersey.
[10] Page
58, E.Bush-Petersen, “Smallpox-
Preparing for the Emergency,” pages 57-67, in Ellipse, 18(3):57-68,
2002. found on-line at http://www.baxter.de/fachkreise/bioterrorismus/Baxter_Ellipse_Smallpox.pdf
[11] Pages
70-71, Robert A. DeLorenzo and Robert S. Porter. 2000. Weapons of Mass
Destruction –Emergency Care, Brady,Prentice Hall Health, Upper Sadddle
River, New Jersey.
[12] Page
23, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[13] Page
30, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[14] Page
24, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[15] Page
24, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[16] Page 24,
Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[17] Page 25,
Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[18] Page 24-27,
Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[19] Page
177, Chang Chia-feng, 2002. "Disease and its impact on Politics,
Diplomacy, and the Military: The Case of Smallpox and the Manchus
(1613-1795)," in "The Journal of the History of Medicine," Vol.
57, April 2002,. Pages 177-197.
[20] Page
30-31, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions
of smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[21] Page
30, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[22] Page
31-32, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions
of smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[23] Page
36, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[24] Page 2,
Joseph Needham, 1980. China and the origins of immunization, Centre of Asian Studies, University of Hong
Kong.
[25] Page
36, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
[26] Page 7, Dominik Wujastyk no date, “The reception of Western Medicine in
China.” Online essay
[27] Page
6-7, Joseph Needham, 1980. China and the origins of immunization, Centre of Asian Studies, University of Hong
Kong.
[28] Page
178, Chang Chia-feng, 2002. "Disease and its impact on Politics,
Diplomacy, and the Military: The Case of Smallpox and the Manchus
(1613-1795)," in "The Journal of the History of Medicine," Vol.
57, April 2002,. Pages 177-197.
[29] Page
178 ff, Chang Chia-feng, 2002. "Disease and its impact on Politics,
Diplomacy, and the Military: The Case of Smallpox and the Manchus
(1613-1795)," in "The Journal of the History of Medicine," Vol.
57, April 2002,. Pages 177-197.
[30] Page
18, from “Chung Tou Hsin Shu” by Chang Yen quoted in Joseph Needham, 1980. China
and the origins of immunization,
Centre of Asian Studies, University of Hong Kong.
Needham states that this book was written in 1941 A.D.
but this may be a typo. On the same page he compares this to “other eighteenth
century texts” and states that the description is quite close to that of many
eighteenth century texts that describe variolation practices
[31] Page
18-19, Joseph Needham, 1980. China and the origins of immunization, Centre of Asian Studies, University of Hong
Kong.
[32] Page
36, Chia-feng Chang, ”Dispersing the Foetal Toxin of the Body: Conceptions of
smallpox aetiology in Pre-Modern China,” in Contagion –Perspectives from
Pre-Modern Societies, Edited by Lawrence I Conrad and Dominik Wujastyk,
2000, Ashgate, England.
.
[33] Page
180, Chang Chia-feng, 2002. "Disease and its impact on Politics,
Diplomacy, and the Military: The Case of Smallpox and the Manchus
(1613-1795)," in "The Journal of the History of Medicine," Vol.
57, April 2002,. Pages 177-197.
[34] Page 178,
Chang Chia-feng, 2002. "Disease and its impact on Politics, Diplomacy, and
the Military: The Case of Smallpox and the Manchus (1613-1795)," in
"The Journal of the History of Medicine," Vol. 57, April 2002,. Pages
177-197.
[35] Page
178, Chang Chia-feng, 2002. "Disease and its impact on Politics,
Diplomacy, and the Military: The Case of Smallpox and the Manchus
(1613-1795)," in "The Journal of the History of Medicine," Vol.
57, April 2002,. Pages 177-197.
[36] Page
410, Sayili, Aydin M. Turkish Medicine, Turkish Medicine, by Aydin M. Sayili
Isis © 1937 The History of Science Society
Published by The University of Chicago Press
Isis © 1937 The History of Science Society
Published by The University of Chicago Press
Pages 403-414. Sayili, Aydin M. Turkish Medicine, Turkish Medicine, by Aydin M. Sayili
Isis © 1937 The History of Science Society
Published by The University of Chicago Press
Isis © 1937 The History of Science Society
Published by The University of Chicago Press
[37] Page
28-19, Joseph Needham, 1980. China and the origins of immunization, Centre of Asian Studies, University of Hong
Kong.
[38] Page 3,
Joseph Needham, 1980. China and the origins of immunization, Centre of Asian Studies, University of Hong
Kong.
[39] Page 4,
Joseph Needham, 1980. China and the origins of immunization, Centre of Asian Studies, University of Hong
Kong.
This is a widely repeated story and is also found, with
more details, at Page 60,
E.Bush-Petersen, “Smallpox- Preparing for the Emergency,” pages 57-67,
in Ellipse, 18(3):57-68, 2002. found on-line at http://www.baxter.de/fachkreise/bioterrorismus/Baxter_Ellipse_Smallpox.pdf
[40] Page
4-5, Joseph Needham, 1980. China and the origins of immunization, Centre of Asian Studies, University of Hong
Kong.
[41] Page 6, Dominik Wujastyk no date, “The reception of Western Medicine in
China.” Online essay
[42] Page 6, Dominik Wujastyk no date, “The reception of Western Medicine in
China.” Online essay
[43] Page 6, Dominik Wujastyk no date, “The reception of Western Medicine in
China.” Online essay
Wujastyk does not state where this quote originally
came from and I was not able to learn myself before deadline.
[44] Page 6, Dominik Wujastyk no date, “The reception of Western Medicine in
China.” Online essay
[45] Page 7, Dominik Wujastyk no date, “The reception of Western Medicine in
China.” Online essay
