Medical missionaries to China and the reformation of anatomy

Abstract

The earliest record of human anatomy in chapters of the Yellow Emperor’s Inner Classic is likely to be based upon proper dissections. The first incident of human dissection for medical purpose documented in the History of Han Dynasty occurred in AD 13. During the Sung dynasty, a physician prepared illustrations of internal organs of executed criminals, published in 1113 as the Images of Truth. Successive Chinese medical treatises have plagiarized but preserved the anatomical diagrams without improvements or modifications. China had to wait till the mid-19th century for Anglo-American Protestant medical missionaries to bring about a complete and permanent reformation of anatomical science.

Keywords

Anatomy Chinese medicine history of medicine missionaries

Human dissection in ancient China

The scarcity of human dissection has been attributed to the traditional teachings of Confucius (551–479 BC) and other religious leaders.¹ Anatomy could not progress and consequently glaring errors were found in the knowledge of the structure of the human body.²

The earliest reliable record of human anatomy in extant historical texts is interspersed in chapters of the Huang-ti Nei-ching (Yellow Emperor’s Inner Classic).³ This work, compiled between 400 BC and AD 260 is the basis of traditional Chinese medicine.^4,5 A comparison of the anatomical measurements in the ancient texts with modern measurements shows a reasonable correlation.⁶ From such exact assertions made in the Inner Classic it follows that they are based on measurements as a result of dissections performed by anonymous persons.⁷ The term ‘anatometrics’ has been coined to denote this branch of anatomical study that assumes the human body exists in regular proportions and obeys quantitative laws. It also assumes that human organs can be quantified to clarify problems in diseases.⁷ Physical anthropometry is clearly of Chinese origin.⁸

The earliest authentic record of human dissection is in the History of the Han Dynasty – Biography of Wang Mang:

Wang captured the leader of the rebel forces. [Wang] ordered his court physician aided by a skilful butcher to open up the body. Measurements of the internal organs were made. Bamboo rods were inserted into the blood vessels to trace their origins and terminations. [Wang] said that [this knowledge] could be used for the purpose of curing illnesses.⁹

This event in AD 13 can be considered the first professional dissection with a medical intention. Wang Mang (45 BC–AD 23), a relative of the Empress, had placed an infant on the throne in AD 8 with himself as regent and was barely concealing his desire to become the new Emperor of the Hsin interregnum (AD 9–23). Wang, infamous as usurper of the Han dynasty, seemed to have an interest in anatomy. Had he remained in power for a longer period, more light might have been shed on this subject. As it was, Chinese historians merely cited this incident as proof of Wang’s misrule and condemned each of his acts.^10,11

During the Northern Sung dynasty (960–1126), human dissection occurred in the Southern province of Kwang-si around 1045. A bandit named Ou was killed and 56 of his followers were dissected. The local magistrate carefully inspected the bodies and made diagrams of them.¹¹ The event is recorded in contemporary records:

A provincial governor secured the surrender of Ou, Meng, and scores of his men. All bandits were executed, their bellies opened, and the intestines and kidneys removed. A physician and an artist were ordered to examine and make illustrations …¹²

In Memoirs of the authorities of ancient books by Ch’un Chai, the scholar Chao (flourished 12th century) referred to a lost work, the Ou Hsi-fan’s illustrations of the five viscera:

During the Sung dynasty many bandits were executed at Soo-Chow prefecture. The prefect accompanied by physicians and artists examined the internal organs and made detailed pictures of them. They compared these with the older Ou Hsi-fan Illustrations and found them to be superior to Ou’s. Their work is valuable to the medical profession.¹²

From 1102 to 1106, a physician prepared illustrations of the internal organs of executed criminals captured after another insurrection. His work was published in 1113 as the Images of Truth. The first section was described as containing 10 anatomical illustrations with annotations, incorporating previous work based on dissection on Ou and his gang.¹³ No longer extant, some of its illustrations were plagiarized and reproduced ad nauseum in later Chinese medical treatises (Figure 1).¹⁴

Figure 1.

Traditional illustrations of inner organs believed to be derived from dissections on the rebel bandit Ou Hsi-fan and gang. From Ku’s Treatise of Trauma, 18th century. (Facsimile copy in the author’s collection).

Figure 2.

The urinary system (left); the intestines (right). From Hobson’s Outline of anatomy and physiology, 1850. (Facsimile copy in the author’s collection).

Figure 3.

The arterial system (left); the heart and great vessels (right). From Hobson’s Outline of anatomy and physiology, 1850. (Facsimile copy in the author’s collection).

Figure 4.

Abdominal organs (left). Respiratory system (right). From Hobson’s Outline of anatomy and physiology, 1850. (Facsimile copy in the author’s collection).

Figure 5.

Myology (left); Osteology (right). From Osgood’s translation of Gray’s Anatomy, 1881. (Facsimile copy in the author’s collection).

Figure 6.

The cerebrum (left); the cerebellum (right). From Osgood’s translation of Gray’s Anatomy, 1881. (Facsimile copy in the author’s collection).

As bandits were used as subjects, it gave rise to the impression that dissection was a form of criminal punishment. As a result, nobody in China would donate dead bodies for medical purposes.¹¹ Post-mortems and dissections were not recognized as a branch of study and were disregarded by the medical profession. Another reason for the lack of development of anatomy in ancient China is the notoriety of the persons initiating this practice and the subjects dissected, namely, the notorious Wang, and the bandit Ou.¹⁰

Legacy of the Protestant medical missionaries

The opening of Chinese ports to Europeans consequent upon the First Sino-British War (Opium War) of 1839–1841 brought with it influx of missionaries. Anglo-American Protestant missionary societies saw opportunities for evangelical work. Among them medical missionaries introduced Western medical practice and education. One important aspect was medical education with the translation of standard English medical textbooks. Some medical missionaries who were already heavily burdened conducted medical education in hospitals. The pupils learned while assisting their teachers.^11,15

Dr Benjamin Hobson, MRCS (1816–1873), a graduate of University College London, was sent to China under the auspices of the London Missionary Society. Arriving first in Macao in 1839, he worked at a hospital there, then at Hong Kong in 1843. He returned home two years later because of his wife’s illness, who died on the voyage. In 1847, on return to China he married Mary Rebecca (1812–1902), daughter of the Father of China missions, Reverend Dr Robert Morrison (1782–1834). He moved with his family to Canton in 1848 and opened a hospital. Hostilities eventually leading to the Second Sino-British War of 1856–1858 resulting in destruction of this hospital by fire. He settled in Shanghai until 1859 when failing health necessitated his retirement to England.¹⁶ Hobson was the author of the first series of books on Western medicine published in the Chinese language, a tremendous achievement considering the difficult linguistic and political circumstances. Deploring the erroneous concepts of anatomy and physiology in China, he deemed it

Very desirable to introduce the well-established principles and facts of Western medical science to prepare the way for changes in the present system in China. Under this conviction a work was prepared in Canton on the subject of anatomy and physiology, avoiding all theoretical consideration. This has been extensively read and very favourably received, and has proved a good foundation for what was to follow.¹⁷

The six books that he wrote are:

Outline of anatomy and physiology, 1850. This commences with the bones and a comparison of the skeleton of animals, the muscles and ligaments; followed by a description of the nervous system. Optics, acoustics and the organs of senses are treated. The viscera and their functions are illustrated; the heart and the circulatory system and their actions occupy the most important chapter. The genitourinary organs and embryology complete the text (Figures 2 to 4).¹⁸

Natural philosophy and natural history, 1851.

First lines of the practice of surgery in the West, 1857.

Treatise on midwifery and diseases of women, 1858.

Practice of medicine and materia medica, 1858.

Medical vocabulary in English and Chinese, 1858.^11,16

Hobson’s books remained for many years the standard works in China and were reprinted many times there and in Japan. They were of incalculable benefit and value to the profession.

Dr John Glasgow Kerr (1824–1901) of Duncansville, Ohio, was sent to China by the American Presbyterian Mission to Canton in 1855.¹⁹ Between 1871and 1899, he translated no fewer than 34 volumes of medical books into Chinese including Vocabulary of diseases based on Thomson’s vocabulary and Whitney’s anatomical terms.^20,21

With the establishment of Western-style medical schools in Canton (1866), Peking (1869) and elsewhere, there came a pressing need for proper updated textbooks. An Edinburgh graduate Dr John Dudgeon (1837–1901) came to Shanghai in 1863 under the London Missionary Society. The next year he took charge of the Peking Missionary Hospital (precursor of Peking Union Medical College). He was appointed Professor of Medicine at the Imperial College in Peking and also one of the Imperial Customs Medical Officers. Despite his pressing duties, he found time to pursue Chinese studies and began translation of medical work. His most important achievement was his contribution to medical works in Chinese. Among his nine publications are

Anatomy, 16 volumes, illustrated.

Anatomical atlas, one volume folio with coloured plates.

Miscellaneous medical essays.

Medical vocabulary, six volumes.^11,22

A University of New York graduate Dr Dauphin William Osgood (1845–1880) sailed for China in 1869 as a medical missionary under the American Board of Commissioners for Foreign Missions. Arriving in the southern coastal city of Foo-chow (one of the five treaty ports designated by the Treaty of Nanking of 1842), he started a small hospital in the city, an asylum for opium addicts and two dispensaries in the suburbs.²³ In addition to his multiple duties, Osgood undertook a translation of Gray’s Anatomy descriptive and surgical (based on the New American Edition of Gray’s Anatomy) in accordance with the desire of the Committee on Textbooks appointed by the Shanghai Conference in 1877^{2
4} (Figures 5 to 7). For more than three years and already in failing health, he devoted all the time there was to this work. He secured 98 copper plates from the publisher, HC Lea of Philadelphia, and wood engravings furnished locally and he had 167 electrotype plates prepared at the Presbyterian Press in Shanghai by which all the important parts of the body are illustrated. Osgood finished composition of the book, the first and second volumes with the Vocabulary were already in press when he died suddenly of sun-stoke on 17 August 1880.^23,25 The unfinished manuscript was completed by his associate Dr Henry Whitney (died 1924).²³

Figure 7.

Top: the male genital system. Bottom: the female genital system. From Osgood’s translation of Gray’s Anatomy, 1881. (Facsimile copy in the author’s collection).

Anatomy in Chinese medical schools

Amid the multifarious duties of these pioneer medical missionaries, endeavours were made to train Chinese assistants. Gradually the idea of replacing this apprentice system developed. An editorial in the North China Daily News in September 1863 advocated the cause of medical schools. Chairs of chemistry, natural history and natural philosophy would group around the chairs of anatomy, physiology, medicine and surgery. Medicine and surgery should be the first subjects taught and the rest would follow.^11,26 It was not until 1866 that a medical school was founded that was attached to the Canton Missionary Hospital.¹⁹ As recorded in the Medical Missionary Society’s Report:

Immediately after the occupation of the new Hospital [1 October], a course of medical instructions was commenced in which Dr Kerr is assisted by Dr Wong Fun [MD Edinburgh, 1828–1878, the first Chinese to graduate abroad] … it was proposed that Wong should teach anatomy, physiology, and surgery, Kerr material medica and chemistry, while other specialties would be given all possible attention.¹¹

Kerr deplored the slender facilities for practical anatomical work:

The superstitious regard of the Chinese for the dead would seem to be an insurmountable obstacle to the prosecution of this important branch of study. An endeavour has been made to prepare the way for this by holding postmortem examinations in cases where patients without friends die in the hospital. Opportunity is taken also to dissect an arm or leg in a hasty way, and thus the most important regions of the body have been shown to the pupils. These examinations and dissections have been held without any effort at secrecy, and so far as I have been able to observe, have produced no unfavourable influence on the minds of patients or others who have been cognizant of the proceedings.

The fact that the Chinese have little or no regard for the corpse of a child has been taken advantage of, and in one instance the body of a child which was given to me was dissected in the hospital yard. I am satisfied that with due caution and without any attempt at secrecy, the public mind may be gradually familiarized with dissection as an essential part of education.¹¹

Vivisection on cats and dogs was sometimes resorted to.²⁷

The dawn of the 20th century saw a new era in anatomy. Before then autopsies were rare. In 1883, an autopsy was performed on a Chinese who died of bladder stones at the Canton Hospital. Another attempt in 1893 to use the body of a man found dead at Shanghai was made but gave rise to manifold rumours.¹¹ Elsewhere at Harbin and Mukden in Manchuria, numerous dissections were performed at times of bubonic plague epidemic from 1901 to 1911 with the tacit consent of the authorities. Possibly the first proper human dissection for purposes of medical education in Chinese history was made at the Harvard Medical School in the International Settlement in Shanghai around 1911, shortly before official sanction of the practice by the new Republic of China.²⁸

In 1913, dissection of a criminal was performed at the Kiang-su provincial Medical School at Su-chow Prefecture with the permission of the Governor. The occasion was one of great formality. Some 65 guests were invited to attend including local officials, judges and foreign physicians. A group photograph concluded the day and a commemorative pamphlet was issued describing the occasion as the first dissection in China for 4000 years.¹¹

On 22 November 1913, a Presidential Mandate was issued legalizing and regulating dissection of dead bodies:

Order of the board of interior number 51:

A physician, in case of death from disease, may dissect the body and inspect the diseased part to determine the origin of the disease, but he must obtain the consent of the relatives of the dead person and clearly inform the local magistrate before proceeding.

The police and inspectors, in case of mysterious death, the cause and origin of which cannot be accurately be ascertained without dissection, may appoint a physician to dissect the corpse.

The bodies of all those meeting death by punishment or dying in prison from disease, without relatives or friends to claim their bodies, may be given by the local magistrate to a physician for dissection, to be used for the purpose of experimentation in medical science, but after dissection the body must be sewed up and buried.

If any are willing for the benefit of science to offer their bodies for dissection and leave word to that effect before death, they may do so, but the whole body must be sewn up and returned to his or her family after dissection.^11,29

Additional Order of the Board of Interior number 85 of April 1914:

Giving the right of dissections to all medical colleges and hospitals in good condition by local authorities and recognized beforehand by the Board of Education or established by the public;

Conferring under certain restrictions the right to retain parts of a dead body if such were necessary for medical demonstrations.^11,29

The Rockefeller Foundation Commission Report of 1914 aptly summed up the situation:

Up to the present time the number of dissections and autopsies that have been done in China is practically negligible. One hears very rarely of a foreign doctor who has performed an autopsy, or more likely a partial autopsy. These have always been done with the utmost secrecy, for if news of them got abroad, the public might become inflamed and the doctor and the hospital are in grave danger. At one government school we were told that dissections had been carried on – that moribund patients were brought to the hospital from the jail, and after death their bodies were dissected. Outside inquiry revealed that the fact that this has happened, but it is doubtful if it has happened frequently. At another school it was said that bodies had been dissected, but the number is very questionable. At Shanghai a limited number of bodies had been obtained for dissection at the Harvard Medical School, and about six autopsies have been performed in the school. Conditions are of course very favourable in Shanghai where there is a large foreign Concession and a foreign Health Officer.¹¹

In Hong Kong, a British territory, the situation is quite different. The medical school can obtain all the material it needs for dissection and about 2000 autopsies are performed annually by order of the authorities. Some students at medial schools in Canton come to Hong Kong in the summer for a special course in anatomy.^11,27,30

In medicine, it was essential for a new scientific vocabulary to be standardized and established if China were to assimilate Western medicine. These medical missionaries had laid the foundations for a new medical literature and terminology in China.

Although there is no clear evidence of the existence of Chinese anatomical illustrations before the Han dynasty (202 BC–AD 9),³¹ Chinese anatomy was definitely based upon actual dissection of the human body.^7,32 Traditionally, anatomy and surgery used to occupy the lowest grade in Chinese medicine. A few ancient and imperfect diagrams existed and a couple of European anatomical works have been translated.^33,34 Because there was no further interest in anatomy, the measurements of the viscera and skeleton that appeared in the Yellow Emperor’s Inner Classic and its derivatives were repeated verbatim and neither challenged nor revised. The history of ancient Chinese anatomy has parallels with that in the pre-Renaissance West.³⁵ By contrast, thereafter in Europe the awakening of intellectual ideas resulted in overcoming religious obstacles and the subsequent emancipation and flowering of the Renaissance.³⁶ No further interest in topographical and surgical anatomy such as of the kind one encounters in the West developed in China until the efforts of Protestant medical missionaries of the mid-19th century that resulted in complete modernization of medical science.^6,37

Conclusion

The efforts of the pioneer missionaries were augmented by successive generations of far-seeing men and women who devoted their lives not only to the propagation of the Gospel but also to developing the highest interest of medicine. They were the founders who brought the healing art of body and soul to the Chinese, prompted by a Christian spirit of love and service without thought of personal gain.³⁸ Time is not the destroyer of truth. In the not-too-distant past, Chinese historians, especially Marxists, had regarded the introduction of Western medicine to China as a tool of ‘invasion by Anglo-American Imperialism under the banner of medicine’.^29,38,39 Scathing attacks had been made against the missions as spies in the vanguard of military as well as cultural invasion, branding them as ‘wolf in sheep’s clothing’.²⁹ Current views have admitted that Western medicine as a scientific discipline has been of benefit for the advancement of knowledge in China, a more balanced and objective reappraisal of the role of the medical missionaries has been made.^40,41

Comparisons between ancient and modern dimensions of organs (length of the stomach and intestines)
	Huang-ti Nei-ching (400 BC–AD 260)	Chou measure (1030–221 BC)	Hsin measure (AD 9–23)	modern measure
Stomach	64 cm	53 cm	60 cm	40 cm (greater curve)
Small bowel	796 cm	637 cm	737 cm	700 cm
Large bowel	[sic]522 cm*	[sic]418cm**	[sic]484cm***	200 cm

*Halved to 274 cm, **halved to 219 cm, ***halved to 253 cm.

Footnotes

Author biography

Louis Fu is a retired Consultant Orthopaedic Surgeon who has developed an interest in medical history and medical biography. He has contributed eight previous papers to the Journal of Medical Biography (Pien Chueh – the Chinese god of medicine (2002; 10: 92–99); Hua Tuo – the Chinese god of surgery (2002; 10: 160–166); Sung T'zu and medical jurisprudence in ancient China (2004; 12: 95–104); William Arbuthnot Lane and Kenelm Hutchinson Digby: a tale of two universities (2008; 16: 7–12); Music and medicine: a note on John Hunter and Joseph Haydn (2010; 18: 115–122); Medical missionaries to China: the Jesuits (2011; 19: 73–79); The Protestant medical missions to China: the introduction of Western medicine with vaccination (2013; 21: 112–117); The Protestant medical missions to China: Dr Thomas Richardson Colledge (1796–1879) and the founding of the Macao Ophthalmic Hospital (2013; 21: 118–123). Presently he is an Honorary Associate Professor in Orthopaedic at the Chinese University of Hong Kong.

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