We are excited to announce a new title in the Studies of the Weatherhead East Asian Institute book series: Forgotten Disease: Illnesses Transformed in Chinese Medicine, published by Stanford University Press. The book’s author is Hilary A. Smith, an assistant professor of history at the University of Denver.
Around the turn of the twentieth century, disorders that Chinese physicians had been writing about for over a millennium acquired new identities in Western medicine—sudden turmoil became cholera; flowers of heaven became smallpox; and foot qi became beriberi. Historians have tended to present these new identities as revelations, overlooking evidence that challenges Western ideas about these conditions. In Forgotten Disease, Hilary A. Smith argues that, by privileging nineteenth century sources, we misrepresent what traditional Chinese doctors were seeing and doing, therefore unfairly viewing their medicine as inferior. Drawing on a wide array of sources, ranging from early Chinese classics to modern scientific research, Smith traces the history of one representative case, foot qi, from the fourth century to the present day. She examines the shifting meanings of disease over time, showing that each transformation reflects the social, political, intellectual, and economic environment.
We thank Professor Smith for taking the time to discuss her book with us. Please read the following Q&A to learn more about the research and questions that drove her project.
Could you tell us about the significance of the title “Forgotten Disease?” What do you think has often been forgotten in existing Western scholarship about Chinese medicine?
The title has three meanings. Narrowly, it refers to the particular disease that is the focus of the book: foot qi, which meant different things to people in different time periods and from different walks of life. Some foot qi sufferers experienced a kind of chronic pain disorder, possibly something like arthritis or gout, while others had an itchy skin condition, while still others had a deadly disease that involved heart palpitations and killed them in a matter of days. All of these diverse illnesses were called “foot qi” in pre-modern sources. But in the late nineteenth and early twentieth centuries, modernizers in East Asia linked the name with the vitamin B deficiency disorder known in English as beriberi, a disease that was rampant then. At the same time, scientists began to understand what vitamins were and how to synthesize them, so before long beriberi wasn’t a problem of epidemic proportions like it had recently been. The result is that today foot qi is remembered only as a past problem solved by the advance of medical knowledge. Its previous diversity of meanings has been forgotten. That’s a shame, because if they bothered to look at the pre-modern literature on foot qi, doctors today might find that it offers insight into treating chronic pain disorders that still cause a lot of suffering.
More broadly, because of the way Chinese and Western medicine have evolved in the modern period to become foils of one another, we’ve forgotten that Chinese medicine ever dealt with “disease” as we understand it today. Contemporary practitioners of Chinese medicine insist that it’s all about “disorder,” holistic and personal understandings of illness, and is therefore totally different from Western medicine (also called biomedicine). Things in pre-modern Chinese sources that look like diseases—things like foot qi that have a specific cause, a predictable clinical course, and are recognizable across diverse sufferers—don’t fit that image of Chinese medicine and so are now ignored.
Finally, thanks to a widespread belief that modern medicine has an exclusive claim to truth, we tend to dismiss as unsophisticated how people in the past perceived illness, and not to make much effort to understand their perspectives. So in that sense all pre-modern disease concepts have been forgotten. In the book I try to recover some of those lost perspectives.
How did you come to focus on the specific disease “foot qi” in order to explore the changing understandings of disease over many centuries?
I didn’t set out to explore changing understandings of disease. Instead, what I initially wanted to explore was changing understandings of nutrition. And because I initially took for granted the modern definition of foot qi and thought it was a vitamin deficiency disorder, I thought tracing the history of foot qi would be a good way to get a handle on how Chinese ideas about nutrition changed over time.
But when I was in China doing research I started having casual conversations with people about foot qi and they had a really different understanding of what it was—to them, it meant athlete’s foot! So that was perplexing. And then once I started reading the primary sources it became clear that beriberi didn’t fit a lot of what doctors and patients identified as foot qi. So I started to wonder how this peculiar modern definition developed, and where the colloquial athlete’s foot meaning came from, and why the impression that modern histories give of foot qi’s past is so much simpler than the sources actually suggest. As I dug into foot qi’s layers of meaning I began to realize that what had happened to this one traditional disease concept had happened to others too. Just as foot qi had been turned into beriberi, “flowers of heaven” had been turned into smallpox, “sudden turmoil” into cholera, “cold damage” into typhoid, and so on. So foot qi seemed like a good case study to highlight how Chinese disease concepts have changed over time, and how their modern definitions can obscure their historical complexity.
What kinds of sources and archives did you consult in the course of your research?
My main sources were medical texts, everything from a little fourth-century book of drug formulas to the major encyclopedia of disease produced by government officials in the seventh century to articles in scientific journals in the nineteenth and twentieth centuries. Historians have tended to ignore what observers in the late imperial period wrote about foot qi, I think because it really doesn’t conform well to the symptoms of beriberi, so I paid special attention to those sources, which included eighteenth- and nineteenth-century manuscripts held at the Chinese Academy of Medical Sciences and the Peking Union Medical College in Beijing.
Could you discuss some of the challenges you faced in trying to trace a disease’s history from the fourth century through the present? How did you deal with those challenges?
One challenge was resisting the temptation to fall back into retrospective diagnosis. That temptation is strong, even when you’re committed to the idea that ancient medical ideas need to be understood on their own terms. At one point I wrote a long section arguing that late imperial foot qi seems an awful lot like gout, but I finally realized that I was overriding the late imperial writers’ judgment with my modern biomedical ideas, exactly what I’m trying to get historians to stop doing. I took it out.
The chronological scope of the project was also a major challenge. Trying to understand the changes I was seeing in the context of the time required lots of reading about the social, intellectual, political, and epidemiological circumstances of medieval, early modern, and modern East Asia. Those are completely different scholarly literatures. It’s impossible to master the relevant literature to the degree that you could if you were writing about a discrete set of events that happened over a ten-year span. I sometimes described the project as “big picture, low resolution” for that reason. I was lucky, though, to have feedback on drafts from scholars who are experts in the different periods the book discusses. They alerted me to places where they thought I was mischaracterizing the context or the current state of scholarship, and affirmed the parts that jibed with their more deeply informed understanding.
How would you like Forgotten Disease to expand or challenge our understandings of the history of Chinese medicine–and the history of medicine in general?
Today there is a belief that Chinese and Western medicine are categorically different from one another. You often hear things like: Western medicine is good for acute infectious diseases while Chinese medicine is good for chronic conditions. Western medicine excels at describing the structure of the body while Chinese medicine excels at describing energy. Western medicine is reductionistic while Chinese medicine is holistic. Whether they’re presented as complementary (both are good in different ways) or oppositional (one is better than the other) depends on the observer, but there’s general agreement that they are very different kinds of systems. And the implicit assumption is that it was Western medicine’s nineteenth- and twentieth-century progress that created those kinds of differences. That is, while Western medicine was mastering anatomy and infectious disease, Chinese medicine was staying more or less the same as it had always been. Only Western medicine is dynamic in this narrative; Chinese medicine is just a fixed backdrop that sets off Western medicine’s amazing transformation. Forgotten Disease shows that Chinese medicine had always been changing, and that it continued to change in the modern period. The fact that it is now understood as holistic and focused on chronic disorders has as much to do with how it has changed in the past century as with any sort of fundamental characteristics.
The book also presents an alternative to the kinds of histories of disease that are common today. One is what I call the “disease that changed the world” narrative, showing how, for example, yellow fever helped determine who won and who lost in struggles for power in the Americas. The other is the biography of disease. You can easily find “biographies” of everything from anthrax to anxiety—a well-known popular version is Siddhartha Mukherjee’s Emperor of All Maladies: A Biography of Cancer. I actually enjoy reading these kinds of books, and I think it’s great that more scholars are looking at the role of disease in world history now.
But both of these genres reinforce a modern way of understanding disease and make it harder for us to escape our own tunnel vision. Today, people talk about fighting wars against cancer, AIDS, malaria, and so on as if these were enemies that existed somewhere outside of our bodies. But none of these diseases exist without a body. A cancer cell isn’t cancer; the HIV virus isn’t AIDS; the Plasmodium that causes malaria isn’t malaria. Only when you have a living body burning with fever, shaking with chills, wasting away, and so forth can you say that the disease exists. Besides that, there is no road to diagnosis that doesn’t go through human culture. Only a person can declare that an illness someone is experiencing is disease X, whether the sufferer is a patient in a clinic today or a fourteenth-century figure. And whether the observer declares that the sufferer has a disease at all, or that it’s X instead of Y, depends on what symptoms she prioritizes, how she understands the relationship between the body and its environment, what her social and intellectual world is like. So a disease is both a physiological phenomenon and a social invention. But since the nineteenth century, when scientists discovered that microbes can cause disease, we’ve increasingly come to think of it as external to ourselves, something we can fight and defeat and eradicate. That’s a perspective that would have been nonsensical to doctors before germ theory. Sure, you can cure a disease in a single person, but the idea of waging war against disease or eradicating it would have been mystifying.
The “disease that changed the world” and “biography of disease” histories don’t typically question that contemporary perspective. Forgotten Disease does. It refuses to approach foot qi as an ancient foe of humankind, and instead looks at it as both a physical experience and a concept that people created, re-created, and argued about.
What research findings surprised you the most when working on this project?
It surprised me that contemporary understandings of the same disease name are so different across East Asia. In China, as I mentioned, most of the people I talked to thought foot qi was “Hong Kong foot,” meaning athlete’s foot. But in Japan and Korea foot qi is beriberi. In Taiwan it’s sometimes understood as beriberi and sometimes as athlete’s foot. When you think about it, this makes sense, because Chinese and Western medicine developed very differently in each of these societies over the course of the twentieth century. But it puzzled me at first.
Official and colloquial understandings also mingled and overlapped in ways that surprised me. In mainland China, sometimes people would conflate beriberi and athlete’s foot because both go by the same name: on online chat boards someone would write in complaining about his terribly itchy and stinky feet, and a well-meaning respondent would write, “You should take some vitamin B.”
It was fun to disentangle some of the complicated contemporary understandings in the final chapter of the book.
Could you tell us briefly about your next book project?
I’m still interested in the history of nutrition, so I’m looking at how ideas about healthy and pathological eating changed over time in China. I’m especially interested in ideas about nutrition that emerged in the late nineteenth and early twentieth centuries. There was a persistent tension between scientific dietary recommendations—which were presented as universal but had mostly developed around Caucasians of northern European descent—and the sense that Chinese bodies were different and therefore had different food requirements. As new ways developed to measure the healthfulness of diets, they began to interact with older Chinese ways of understanding nourishment, and that contact produced some difficult questions. For example, did Chinese people require fewer calories than Europeans? Should everyone drink fresh milk, or was dairy inappropriate for Chinese bodies? Could adopting a Western diet foster in the Chinese population the positive characteristics that some people perceived in Western populations (things like strength and height and even things like ambition and ingenuity)? Was their preference for rice holding Asians back? I’m exploring how people in China answered these questions and navigated these kinds of tensions.