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Glocalizing Medicine in the Canton–Hong Kong–Macau Region in Late Qing China

Published online by Cambridge University Press:  10 December 2019

ANGELA KI CHE LEUNG
ANGELA KI CHE LEUNG*
Affiliation:
University of Hong Kong Email: angela-leung@hku.hk
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Abstract

This article looks at how globalization in the nineteenth century was inextricably entangled with localization in the Canton–Hong Kong–Macau nexus on the southern fringe of China by tracing the growth of its unique medical culture. It explains the ‘glocalizing’ process by tracing the development of this medical culture, which consists of knowledge construction and institution building, in the context of highly volatile epidemiological conditions aggravated by increasingly heavy inter-regional trade and migration. It traces the dynamic circulation of people, materials, ideas, and practices in this southern edge of China, which was traditionally connected to southeast Asia and shared ecological backdrops that produced similar epidemiological experiences. The Canton nexus in the nineteenth century saw the growth of native medical knowledge that focused less on theoretical innovation than on the efficacy of therapeutic strategies. These ideas were likely to have been informed or reinforced by new anatomical knowledge disseminated by Western medical missionaries on the ground early in the century. The medical culture in the region was also marked by the formation of a series of local institutions that were fusions of Western-style hospitals and native merchant-run charity halls where diseases were studied and treated, and new public health management negotiated and implemented by experts from different traditions.

Type
Forum Article
Information
Modern Asian Studies , Volume 54 , Issue 4 , July 2020 , pp. 1345 - 1366
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Copyright
Copyright © Cambridge University Press 2019

Introduction

The nineteenth-century Canton–Hong Kong–Macau nexus is an excellent site for exploring the idea of ‘glocalization’ ‘as a refinement of the concept of globalization’, highlighting the ‘universalization of particularism and the particularization of universalism’, as argued by Roland Robertson.Footnote 1 Being on the southern fringe of China, and in a region where, in the nineteenth century, Europeans increasingly dominated trade activities, this locality was doubly ‘peripheral’. It was precisely in this peripheral site that, unsurprisingly, the connectivity generated by global movements of things, ideas, and people was most visible.Footnote 2 By tracing the development of a unique, local medical culture that merged indigenous, Chinese, and Western elements in this nexus, this study reveals the historical process of the ‘invention’ of locality as a key aspect of nineteenth-century globalization.Footnote 3 This globalized locality, initially positioned on the periphery, would later acquire new political and economic centrality—a process that is, however, beyond the scope of this study.Footnote 4

China as an empire was closed to external trade in the eighteenth century, which meant that the Canton–Hong Kong–Macau nexus on its southern fringe was the only place where global trade could continue. The nexus's pivotal place in early modern global maritime trade is a well-told story.Footnote 5 On the other hand, this southern region, which retained many non-Han ethnic languages and customs, was culturally and politically problematic to the Chinese empire in that it was a latecomer to the ‘civilized’ world order defined by state Neo-Confucian ideals and institutions.Footnote 6 It also stubbornly resisted Manchu conquest for several decades in the late seventeenth century.Footnote 7 By this time, its local culture had drawn strength both from a distant, inward-looking Neo-Confucian governance centred at the north and from a worldview moulded by centuries of commercial and migrational activities along sea and land routes connecting South and Southeast Asia. The ‘metropolitan language culture’—a term Glen Dudbridge uses to qualify centrally positioned Neo-Confucian culture,Footnote 8 which finally penetrated South China in the sixteenth century, did not exactly displace pre-existing local practices and customs, but rather reframed them to fit Neo-Confucian prescriptions.Footnote 9 Later, new materials, knowledge, and practices introduced by global traders and travellers since the eighteenth century would further enrich the complexity of this culture. What was seen as ‘local’ about this region was therefore not only in relation to the modern European cosmopolitan culture brought by maritime trade,Footnote 10 but also to the Chinese cultural universalism embodied by the imperial state. By the nineteenth century, this culture was simultaneously cosmopolitan, metropolitan Chinese, and uniquely and locally Cantonese.

This article traces the development of the unique medical culture in this locality shaped by the globalizing process in which traders, doctors, scholars, bureaucrats, publishers, and religious experts from different cultures mediated the flow of medical materials, knowledge, and practices. It also follows the movements of old and new, border-crossing, and local diseases that created epidemiological situations which prompted specific medical knowledge-construction and institution-building.Footnote 11 This study thus highlights the entanglement of human and non-human actors within this glocalization process of the nineteenth century.

Knowledge construction

Two developments converged in the nineteenth century to produce new medical knowledge in this region: the boom in the study of indigenous ailments by native medical experts and the direct interaction between native and Western doctors. Since China did not have any formal institutional structure to standardize medical knowledge and practice like that which existed in modern Europe, such as universities or academies, medical knowledge was created, edited, and integrated by practitioners and medical writers actively networking within a region. In the Cantonese region, the rapid growth of woodblock printing houses in the mid-nineteenth century producing medical texts of all genres also played a key role.Footnote 12

In earlier periods, knowledge on the climate, ecology, and health situation in China's deep south was provided by travellers from the north. What they saw there was a particularly unhealthy environment with excessive and year-round warmth and damp, made worse by a low-lying landscape that produced miasmatic and pathogenic zhang 瘴 qi which was the cause of some of the ugliest endemic diseases such as leprosy.Footnote 13 These observations culminated in an important collection of medical recipes for southern ailments in the late thirteenth century—Recipes for Protecting Life in the Lingnan Region (嶺南衛生方 Lingnan Weisheng fang),Footnote 14 collated by a Buddhist monk from northern China. Authors included travelling magistrates and doctors from middle and northern China. By this time the Lower Yangzi (Jiangnan) region was emerging as a centre of medical knowledge production. This text on Lingnan diseases was notable for highlighting the environmental impact on somatic vulnerabilities and the notion of the contagiousness of disease, which would have its full impact on mainstream medical studies in the seventeenth century.Footnote 15 However, it did not distinguish between the specific clinical patterns observed in this region, it simply grouped them under the umbrella of zhang miasma.

From the early nineteenth century, medical writers and practitioners in the Canton region began to elaborate on their insiders’ accounts of southern diseases. This happened in a period when the Canton–Hong Kong–Macau nexus was becoming the centre of a rapidly deteriorating global epidemiological situation caused both by increased inter-regional trade and migration, and worsening public health governance. Native experts in the nexus were the first to observe and provide new knowledge on the situation, soon followed not by medical elites to their north, but by Western experts newly arrived in this southern region.

Cantonese doctors found in an ancient, popular medical genre a format most suited to the expression of their ideas and findings: collections of ‘efficient’ recipes (yanfang 驗方, based on local experience and often indigenous pharmaceutical products) as distinct from ‘classical’ recipes (jingfang 經方) from classical texts.Footnote 16 Local Cantonese recipe books shared certain common features: the want of theoretical elaboration was more than compensated for by highly practical information on ‘efficient’ recipes, often favouring native pharmaceuticals, based on concrete clinical experience, often illustrated with cases of diseases with indigenous names. These texts were popular and cheap, sometimes freely distributed in temples and chemists as an act of charity, or compiled and used internally by households. One early example was Yanfang xinbian (驗方新編 New Compilation of Efficient Recipes), first published in Guangxi in 1846, a province to the west of Guangdong, with numerous subsequent re-editions and enhanced editions.Footnote 17

From the 1880s onwards, indigenous recipe collections on acute and chronic endemic diseases with high mortality such as smallpox, syphilis, or ailments with symptoms suggestive of influenza, diphtheria, vomiting, diarrhoea, or cholera, and various kinds of fevers, proliferated. The symptoms of ‘boils’ (locally called ding 疔 or ban 癍) were frequently mentioned and analysed as manifestations of internal blockages caused by toxic heat or the conflicting chills and fevers peculiar to this region.Footnote 18 With the use of vernacular medical terms, new, devastating epidemics in the extreme south now became more visible and recognizable. At the turn of the century, and continuing well into the twentieth century, popular printed recipe collections on new or re-emerging epidemics, often in combination with recipes for other ailments, proliferated in Guangdong province.Footnote 19 These closely observed pathological conditions also called for more diversified therapeutic strategies.

The extreme toxicity generated by the protracted warmth (redu 熱毒), damp, and pollution qi (zhuoqi 濁氣) of this region was considered too severe to be alleviated by common, mild Jiangnan recipes. The body of the southern patient, typically characterized as depleted of yang, was described as requiring strong remedies. The measured use of ‘hot’, toxic aconite (附子) or powerful toxin-clearing antelope or rhino horn and strong purgatives, for instance, were the main features of southern therapeutics that intriguingly positioned southern doctors closer to the classical Cold-Damage school of prescription. After the domination of Qing medical culture for some two centuries by Jiangnan literati who favoured tonics and mild recipes, they played a key role in the school's revival.Footnote 20

Most notable among these publications were those on ‘re-emerging’ or new epidemics in this region. Two outstanding monographs speak for this development, the first of which was a modern monograph on an old epidemic called jiaoqi (腳氣 leg-qi) in 1887 by the Cantonese doctor Zeng Chaoran 曾超然. Jiaoqi, characterized by swollen lower limbs and numbness, and leading to a fatal heart attack if untreated, was described in early classics as an ailment of internal blockages caused by damp and cold emerging from the ground or by excessive intake of alcohol and rich foods.Footnote 21 Mainstream Jiangnan medical texts post-thirteenth century had lost interest in jiaoqi, but southern doctors identified it as re-emerging rapidly among Chinese emigrants in Hong Kong and Southeast Asia in the nineteenth century. Zeng's book was later recognized in Republican China as the most important modern work on the ailment.Footnote 22 While Zeng continued to refer to old classics for his analysis of jiaoqi, he added important new information, for example, that the disease was more rampant in the warm and wet months, and in the miasmatic ‘Southern Seas’ (Nanyang, Southeast Asia).Footnote 23 Zeng's book was also characterized by a therapeutic strategy of ‘flexible’ implementation (huofa 活法) of standard recipes, increasing doses, and adding strong purgatives when necessary to dissolve internal blockages. The book was significant also because it was published before jiaoqi was problematically used to translate ‘beriberi’, a ‘new’ biomedical disease of nutrition deficiency, classified by European doctors as a tropical epidemic affecting rice-eating populations in Southeast and East Asia.Footnote 24

The second representative work was the medical recipe book on the bubonic plague, Collated Texts on the Rat Epidemic, published in 1891, in which the disease name ‘shuyi’ (鼠疫 rat epidemic) was coined in Chinese for the first time in history. The epidemic was then recurrent in South and East Asia following human and material flows, with a dramatic outbreak in Canton–Hong Kong–Macau in 1894. The book was compiled by a Cantonese doctor called Luo Rulan 羅汝蘭 and was re-edited throughout the 1890s, with an accessible publication in 1897 reprinted at least five times until 1901.Footnote 25 The disease was described as a product of severe toxic heat (熱) that could enter the blood vessels—a new anatomical concept—through the pores of the skin, congealing blood with qi and causing blood blockages (xueyu 血瘀) in the form of bubos, sometimes also called ding (疔 boils) by native doctors. Like Zeng, who had written on jiaoqi, Luo preferred strong ingredients and big dosages to treat patients: ‘It will be hopeless if we treat severe diseases with mild medicines.’Footnote 26 He recommended strong ‘dissolvants’ such as safflower, rhubarb, the horn of an antelope or rhino, and bear's bile for those who could afford it.Footnote 27 At a time when the bubonic plague had no biomedical ‘cure’, missionary doctors working in Canton were not in a position to advise, even though they were keen observers. One of them noted in 1894 the efficacy of bear's bile administered by Chinese doctors in saving a dying plague patient.Footnote 28 The epidemic in this locality, however, created conditions that facilitated the acquisition of new knowledge by bacteriologists: in the same year, the French Pastorian Alexandre Yersin (1863–1943) and Japanese Kochian Kitasato Shibasaburo (北里柴三郎, 1852–1931) identified the plague bacillus in colonial Hong Kong (see below).

What global maritime trade also produced was direct interaction between Cantonese and European medical experts on the ground, which proved to be interestingly productive. The first such direct encounter in the region was the collaborative implementation of the Jennerian vaccination shortly after its invention in Europe. The Spanish royal maritime vaccination voyage, known as the Balmis expedition, arrived from Manila in September 1805, bringing the vaccine to Macau and Canton.Footnote 29 An illustrated pamphlet on the technique of vaccination was prepared for the occasion by Alexander Pearson (1780–1874), an East Indian Company physician in Macau, who translated it into Chinese in the same year and published it with the endorsement and financial support of leading Cantonese hong merchants. The reception and use of this translation were instant and wide, but initially limited to the Canton region. Qiu Xi 邱熺, Pearson's assistant in Macau, became a key figure in the dissemination of vaccination in China by indigenizing the technique: he increased the number of incisions on the arm and positioned them to accommodate acupunctural meridian points to ‘release’ the innate ‘foetal toxin’ that was traditionally believed to cause smallpox. This new indigenized technique, also understood as an improved version of traditional variolation methods using human pox, was readily accepted in Canton. Qiu's descriptions of the indigenized technique, first published in 1817 together with traditional smallpox recipes, were republished, copied, edited, collated many times, and circulated all over China.Footnote 30 The first vaccination house he established in Canton was a lucrative business, relying on arm-to-arm transmission of the vaccine, as fresh cow pox was hard to come by. The model was also copied by other vaccinators, many of whom were former variolators. Soon other technical innovations like cultivating vaccine from native animals, such as buffaloes, were also recorded in a series of local vaccination tracts throughout the nineteenth century.Footnote 31

Among the many new things brought by European maritime travellers to the attention of nineteenth-century Cantonese doctors, none was more intellectually engaging than Western anatomy and surgical art, which culminated in the translation of Outline of Anatomy and Physiology 全體新論 by the missionary doctor Benjamin Hobson (1816–1873) and published in 1850 when he was working in Canton.Footnote 32 The first edition quickly sold out and republication was financed by Canton's viceroy later in the 1850s.Footnote 33 The anatomical drawings and descriptions in this book inspired generations of native Chinese and Cantonese doctors, providing them with a new imagination of the viscera and the circulation of blood and qi, and with it, new ideas on the causes of diseases. In the 1860s, John Kerr (1824–1901), then director of the Canton hospital, openly practised post-mortem dissections in the hospital yard,Footnote 34 further stimulating Chinese curiosity about Western anatomy, as shown by the many re-editions of Hobson's text and the frequent reproduction of anatomical drawings in Chinese medical texts. John Kerr himself reported in 1862 that a native doctor who had read Hobson's book wrote to consult him on the possibility of doing a blood transfusion for a client who was suffering from a severe, chronic disease.Footnote 35

With this newly publicized anatomical knowledge, more ambitious Cantonese doctors attempted to follow in the footsteps of Wang Qingren (王清任, 1768–1831), the first Chinese doctor to question the classical descriptions of the viscera, based on his own observations of corpses, to bring into line Chinese and Western concepts of the body. This ambition was later fully developed by Tang Zonghai (唐宗海, 1851–1908), the founding father of ‘integrated’ medicine.Footnote 36 Another outstanding example is the Chen medical lineage. In the early nineteenth century, Chen Dingtai 陳定泰 began the research. Inspired by Wang Qingren's illustrations of the viscera, he searched for an answer with the help of a ‘Western doctor’, who showed him Western anatomical drawings that he reproduced in a book he published in 1844.Footnote 37 Some unexplained differences between the two sets of drawings and a lack of information on ‘channels’ (jing luo 經絡) in them, however, left him unsatisfied. His grandson Chen Zhenge 陳珍閣continued the investigation by travelling to Singapore in 1886 to observe autopsies of the bodies of Chinese, Westerners, and people of different races in the ‘royal hospital’. He spent three years in Singapore, recording his observations in a book called Yigang zongshu (醫綱總樞 Key Pivot of the Medical Framework), published in Canton in 1890. In this text, Chen noted in particular that people of different races in fact had the same anatomical structure, as illustrated in Western anatomical drawings, and that Wang's illustrations of the viscera were erroneous in the detail.Footnote 38

What seems to have interested Chen most, however, were the channels along which blood and qi flowed. He provided great anatomical detail on blood vessels and the nervous network of ‘weijin’ (衛筋 defensive sinew). Such interest prompted him to highlight the various pathological manifestations of blood stagnation (xueyu 血瘀).Footnote 39 He claimed to have witnessed, in one of the autopsy sessions in Singapore, blood vessels, intestines, and the bladder stuck with black blood.Footnote 40 This observation might have impacted on the diagnosis and therapeutics of the bubonic plague that struck Canton in the 1890s. Bubos that developed on a plague victim's body were then explained as a result of heat-induced blood/qi stasis in a channel, a clinical pattern explained by Chen Zhenge as ‘external cold damage being transformed into internal blocked heat’ (shanghan zhuan shire 傷寒轉實熱).Footnote 41 Large doses of strong heat-clearing ingredients, such as rhinoceros horn, were now recommended on top of Wang Qingren's original plant-based ‘decoction for dissipating toxin and activating blood’ for dissolving stagnation in a ‘blood vessel’ (xue guan 血管).Footnote 42 Later, Kong Peiran 孔沛然 (1854–1945), a Cantonese doctor trained at the Canton Hospital before he started a successful career as a traditional doctor at the turn of the century, also became well known for applying anatomical knowledge to his practice. He was notably one of the first to evoke the nervous system to reinterpret qi and consider neurasthenia as an ailment caused by the depletion of qi.Footnote 43 Clearly, Cantonese doctors were actively integrating new anatomical concepts into traditional medical study, not simply as an intellectual pursuit, but especially for clinical application.

New institutional setting

The example of Kong Peiran illustrates the importance of the Canton Hospital in facilitating the rapid and intensive circulation of Western anatomical information and practice in the nineteenth century. This institutional set-up, a unique product of nineteenth-century global trade, like those that came after it, was a peculiar fusion between a Western clinic/hospice and a Chinese charity hall, a venue where medical experts from different traditions would interact and learn from each other to create new knowledge.

American trader David Olyphant (1789–1851) brought Yale-trained doctor and Presbyterian medical missionary Peter Parker (1804–1888) to Canton in 1834, and Howqua (1769–1843), a leading Cantonese hong merchant, provided the building for Parker to start the Canton Hospital in 1835. It would go on to become a long-lived and influential institution in both Canton and China.Footnote 44 While it is commonly celebrated by both Chinese and Western historians of medicine as the first Western-style hospital set up on Chinese soil for the dissemination of Western medicine in China, its function as an unprecedented arena for inter-fertilization between nineteenth-century Western and Chinese medical practices in Canton has been largely overlooked. As a pre-Opium War institution designed by Protestant missionaries to lure the Chinese to Christianity by showcasing the superiority of Western surgical arts, the hospital also provided unique opportunities for missionary doctors to acquire first-hand experience of Chinese medical practice.

The initial success of the hospital was the result of shrewd strategies: the hospital prioritized surgery—first treating eye ailments like entropia, cataracts, ophthalmia, later expanding to the removal of tumours, bladder stones, bullets, dead foetuses, genitals affected by syphilis—which was thought to be the weak part of Chinese medicine. The strategy quickly attracted patients of all social classes to the hospital. Some 470 native ‘patients of the literary class’ visited the hospital in 1836, its first year in Canton, among them local officials, hong merchants, and their families. Two years later, in 1838, the hospital received patients from other parts of China, from as far away as Peking and the ‘borders of Tartary on the West’.Footnote 45 In other words, missionary doctors quickly realized that the Cantonese and Chinese considered foreign medical practice with great curiosity, especially the educated classes. By the 1860s, the Canton Hospital had successfully found its niche in a market dominated by indigenous medicine: the Chinese now sought treatment at the hospital for chronic ailments, especially those requiring surgery, while ‘febrile and inflammatory diseases [were] treated by native physicians, because the people [had] much more confidence in their own practice for what [were] called internal diseases’.Footnote 46

Peter Parker's strategic step to incorporate a training programme for local students also proved to be wise. Three native assistants, aged 16–19 from a good family background, some of whom children of successful native doctors, were recruited as early as 1837.Footnote 47 By the end of the 1860s, the number of trainees in the hospital had increased to a dozen. John Kerr, director from 1858 to 1899, further enhanced the teaching programme with the translation of medical textbooks into Chinese,Footnote 48 while Cantonese artisans began to make Western medical instruments used by the students. By the 1890s, at least eight pharmacists in Canton were selling foreign medicines.Footnote 49

What needs to be emphasized here is that the success of the teaching programme in the hospital also had to do with the missionary doctors’ acceptance of native medicine as a parallel practice even inside the hospital: Peter Parker allowed his patients to continue to be treated by ‘native doctors’ and take Chinese drugs, especially ginseng. He even studied their prescriptions. John Kerr more or less continued Parker's policy and we can see that some of the medical cases were diagnosed by the hospital's native students using Chinese methods as late as the 1860s. Kwan Ato, one of Parker's best students, described himself as having learned medical methods from Dr Parker but as being competent in Chinese methods as well.Footnote 50 By the early 1870s, a number of former students trained at the hospital were running their own private practice, probably in some hybrid form, in the Cantonese region. Kwan Ato, for example, owned a lucrative practice that was famed for treating eye diseases.Footnote 51 Canton was very much where the first generations of Chinese practitioners of Western medicine were trained and where treatment by some version of Western medicine blended with indigenous practice became part of daily life, well before the establishment of the first national medical school for Western medicine—the Viceroy Hospital Medical School—in 1881 in Tianjin by Li Hongzhang (1823–1901), viceroy of Zhili. In fact, the first batch of Chinese students recruited by this state school were exclusively Cantonese.Footnote 52

The Canton Hospital was also a source of inspiration for Cantonese philanthropists of the post-Taiping restoration of the 1870s, when medical relief, generally marginal in traditional charity, became a key charitable offer.Footnote 53 Local hospitals practising traditional medicine established in this later period played a critical role in identifying, studying, and managing new and re-emerging epidemics of the time. The management of endemic diseases by these institutions in a period of limited public health resources was particularly instrumental in the production of new epidemiological knowledge in both the Chinese and biomedical traditions in the nineteenth century. The construction of knowledge on the jiaoqi/beriberi phenomenon well illustrates the central role of native charitable hospitals.

The key player was the Tung Wah Hospital in colonial Hong Kong, established in 1872 by Chinese business elites to provide, among other social services, Chinese medical care to the native population, who distrusted Western medicine. The hospital was one of the first models of an institutional fusion between a traditional Chinese charity hall and a modern hospital.Footnote 54 While British doctors were trying to find out more about what was known to them as the beriberi epidemic in the region at the turn of the twentieth century, Chinese doctors had already been treating native patients of jiaoqi at Tung Wah Hospital since at least the 1880s. We have seen above how Zeng Chaoran, a Cantonese doctor at the hospital, specialized in the treatment of jiaoqi and published the first modern Chinese text on the disease in Canton in 1887 based on his clinical experience in Hong Kong. Tung Wah Hospital not only provided in-patient treatment to jiaoqi victims, it also organized the regular repatriation of jiaoqi patients from Southeast Asia or other parts of the world back to their native Canton, from around 1903 until the early 1940s. In Canton, these patients were received and treated in the Fangbian (Expediency) Hospital, another charitable hospital set up in 1899 by native and overseas Cantonese merchants.Footnote 55

Prominent British doctors in Hong Kong, Patrick Manson (1844–1922), father of tropical medicine, and his protégé James Cantlie (1851–1926), on the other hand, only began to study beriberi and other ‘unknown’ ‘tropical diseases’ in 1887 when the private charitable Alice Memorial Hospital was established by a prominent Chinese community leader to provide Western medical care to underprivileged Chinese in the colony.Footnote 56 Manson said in 1888, ‘It was not until last year, when the Alice Memorial Hospital was opened, that the general medical practitioners of Hong Kong had a proper opportunity to see and study native diseases and that we began to learn a little definite about our endemic Beri-beri.’Footnote 57 James Cantlie looked up the European literature on beriberi only after seeing many outpatients suffering from the disease in the same hospital; this resulted in his 1893 translation into English of a Dutch medical text on beriberi.Footnote 58 This hospital was also the place where British doctors learned from Chinese experts and texts on jiaoqi, thinking that they were talking about what they considered to be beriberi. How and when exactly that translation was made is unclear but the British doctors recorded that they learned from the Chinese that beriberi was caused by the ‘overenjoyment of ease during early life, too much sitting, addiction to alcohol, relishing rice, accumulating bad humours or heat, and catching miasma in a foreign place which the patient has visited’. They noted that Chinese doctors treated their patients in three main ways: sending the patients back to their native place or moving them to sleep on an upper floor to avoid damp, changing their diet from rice to beans or potatoes, and prescribing medicines consisting of ‘(1) purgatives, not tonic drugs (2) rice worms … eaten with leeks and orange peel (3) turtles… (4) cocherowpowder, betel nut, orange nut, orange peel, ginger and cinnamon …’.Footnote 59 These were mostly translated extracts from Zeng Chaoran's 1887 book on jiaoqi. It was in the same charitable Alice Memorial Hospital, the teaching hospital of the Hong Kong College of Medicine for Chinese, that James Cantlie taught his Cantonese student Sun Yat-sen with whom he travelled to Guangdong province to observe leprosy,Footnote 60 and Yersin did his research on the bubonic plague bacillus in 1894 in the makeshift laboratory set up in the grounds of the hospital.Footnote 61

Epidemiological context

Old, ‘re-emerging’, and new epidemics like leprosy, jiaoqi/beriberi, cholera, influenza, and the bubonic plague connected South China and Southeast Asia to form an epidemiological region that both Chinese and biomedical doctors of the time considered, for different reasons, to be coherent. The study of these diseases here became part of the emerging field of ‘tropical medicine’ in Europe, while Cantonese doctors considered these diseases typical of the locality, caused by toxic heat rooted in the ground of this region that they called Lingnan, ‘south of the five ranges’, now more closely connected than ever to Nanyang, the ‘Southern Seas’. The multiple framing of jiaoqi/beriberi and the bubonic plague illustrates well how the Canton–Hong Kong nexus was gradually conceptualized as the core of a larger epidemiological region.

Beriberi, newly ‘discovered’ by biomedical experts as a tropical Asian endemic disease in the late nineteenth century, was a central issue in health governance in Monsoon Asia and contradicting views on the epidemic by doctors of different traditions were frequently debated in the congresses of the Far Eastern Association of Tropical Medicine (FEATM), a transnational organization established in 1910 and which continued until 1938.Footnote 62 In China, elite traditional doctors, such as Xie Guan (謝觀 1885–1950), who worked in Shanghai, considered jiaoqi to be an old, defunct ailment ‘re-introduced’ to China from Southeast Asia.Footnote 63 This point was already emerging in Zeng Chaoran's 1887 text on jiaoqi as he believed the epidemic to be product of the zhang miasma emanating from Southeast Asian land and islands, while Vietnamese betel nuts were considered the natural antidote to this indigenous miasmatic disease.Footnote 64 Hong Kong was thought to be a place with ‘water and soil’ more harmful to the body than that in mainland China, but it was the ‘Southern Seas’ that had the worst natural environment. A Chinese doctor residing in Hong Kong refused to take up a position at a Kuala Lumpur hospital in 1920 because, as he explained in a letter to the hospital, ‘The “water and soil” of the Southern Ocean [Malaya] is not as stable as that in Hong Kong, most [who go to Malaya] will develop jiaoqi and bone pain.’Footnote 65 His view was statistically supported by a 1928 list of jiaoqi patients to be repatriated from Hong Kong to Canton which shows that more than a third were transients who had stayed in Hong Kong for less than two years, mostly returning from Southeast Asia.Footnote 66 The great anxiety that existed around contracting severe miasmatic diseases in colonial Southeast Asia, where work opportunities abounded, was vividly expressed in popular songs and ballads lamenting the southern Chinese migrants’ wretched lives in Southeast Asia during this period.Footnote 67

The bubonic plague that devastated Southeast Asia and Southern China in the 1890s, on the other hand, was an even more dramatic global pandemic. It was believed to have originated in a region bordering Yunnan and northern Vietnam, and reached southeastern China via land and sea trade lines.Footnote 68 Luo Rulan was fully aware of the regional context of the plague pandemic: ‘The epidemic began in the 1870s, in Annam (northern Vietnam), it then spread to Guangxi province, then to coastal cities (Leizhou, Lianzhou) along the southern coast of Guangdong, reaching Gaozhou of southwestern Guangdong. More than 2000 to 3000 died every day… patients brought the ailment to the villages when they returned home …’.Footnote 69 He further developed the notion that, similar to jiaoqi, the pathogen came from the ground: ‘Rats dwell in holes in the soil and are the first to be infected by the qi of the ground’ and ‘when the epidemic attacked, hot qi arose from the ground …. people in contact [with the qi] would feel dizzy, their eyes would turn red and they became agitated …’Footnote 70 The important thing therefore was to avoid direct and prolonged contact with the ground or soil. This notion of an epidemic rooted in the soil of an affected region was intriguingly similar to what some contemporary Western doctors called ‘soil infection’ which they believed to be the cause of the bubonic plague in India.Footnote 71

In the 1890s, with the flow of more than 11,000 weekly inter-city travellers, the plague spread rapidly from Canton into Hong Kong. Thousands died, triggering a series of drastic public health reforms in the colony after 1894, including extensive urban renewal and biomedicine being imposed as an option at the Tung Wah Hospital.Footnote 72 In Canton, the growing awareness of a dangerous epidemiological situation prompted the establishment in 1910 of new charity halls and hospitals in the last decade of the nineteen century. Of these, the Expediency Hospital, mentioned above, would cooperate with Tung Wah and Kiang Wu hospitals in Macau to manage the repatriation of southern Chinese migrants working in South and Southeast Asia who fell victim to serious diseases in this epidemiological region. Decades before the establishment of FEATM, which conceptualized ‘tropical Asia’ as an epidemiological region that required globally coordinated biomedical health governance, local hospitals/charity halls in the Canton–Hong Kong–Macau nexus, a major hub of human and material flows, had already been networking to study new epidemics, produce new knowledge, and derive trans-regional public health management in the same ecological context.

Conclusion

Knowledge production and trans-national public health management in the Canton–Hong Kong–Macau nexus in the nineteenth century involved ideas and practices emerging from native, metropolitan Chinese and Western biomedical traditions that were all facing threats from a rapidly deteriorating epidemiological environment and an unstable political situation. These ideas and practices formed a complex medical culture, much of which was embodied in unique institutions in this special locality shaped by the globalization of the time. This culture thrived in a region where the political centre was distant and unstable but trans-regional trading and migration activities were unprecedentedly intensive. The permeability of new political boundaries from the mid-nineteenth century onwards, allowing greater inter-fertilization of different traditions, further enriched a culture that could not be characterized simply as Cantonese, Chinese, or Western.

The Canton nexus in the nineteenth century saw the growth of native medical knowledge that focused less on theoretical refinement or innovation and more on the practicability and efficacy of therapeutic strategies to deal with existing and emerging epidemics. These ideas and practices had roots in classical medicine, but were likely to have been informed or reinforced by new anatomical knowledge disseminated by Western medical missionaries on the ground early in the century. At least new anatomical vocabulary was now freely integrated into medical recipe texts on local epidemics, revealing a new and mixed imagination structure of the body. The medical culture in the region was also marked by the formation of a connected network of local institutions that were fusions of Western-style hospitals and native merchant-run charity halls where diseases were studied and treated, and new public health management was negotiated, invented, and implemented with considerable flexibility by medical experts and public figures from different traditions.

This history also highlights the danger of narrowly conceptualizing local cultures within China's imperial or national boundaries as ‘Chinese’, because this idea reinforces the bias that such cultures were monolithic, thus perpetuating misleading and rather unproductive dichotomies such as China/Europe and China/West. Chinese medicine itself was a constantly evolving body of knowledge constructed around a ‘classical’ core that was revised and informed by vernacular knowledge in different epidemiological contexts, and even by traditions outside the Han Chinese cultural sphere. The case of the Canton–Hong Kong–Macau region in the late imperial period clearly demonstrates the multiple historical processes in which different systems of knowledge and practices were entangled and subsisted as integral parts of a native culture that was at the same time local, Chinese, and global.

Footnotes

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This article is a partial output of project no. 745613, ‘The construction of nutritional knowledge in modern China (circa 1850–1950)’, funded by the Hong Kong Research Grants Council.

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67 I would like to thank Wilt Idema for drawing my attention to a genre of modern Hakka and Minnanese Songs and Ballads about Overseas Migration (guofan ge 過番歌 ‘Songs on traveling to foreign land’) from late-Imperial and early Republican China that highlight the dread of catching all kinds of strange diseases in the Southern Seas.

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