Overview of the plague in the late Ming Dynasty and its prevention and control measures

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doi: 10.12032/TMR20200222166
Submit a manuscript: https://www.tmrjournals.com/tmr
Public Health
Overview of the plague in the late Ming Dynasty and its prevention and
control measures
Qiu-Hua Li1
, Yue-Hai Ma1
, Ning Wang1
, Ying Hu2
, Zhao-Zhe Liu3*
1
The Second Hospital of Liaoning University of Chinese Medicine, Shenyang 110034, China; 2
Shengjing Hospital of China
Medicine University, Shenyang 110004, China; 3
Northern Theater Command General Hospital, Shenyang 110016, China.
*Corresponding to: Zhao-Zhe Liu. Northern Theater Command General Hospital, 83 Wenhua Road, Shenhe District,
Shenyang 110016, China. E-mail: lzz_summer@126.com.
Highlights
The purpose of this paper is to review the medical system and measures of prevention and control instituted
for the plague that occurred during the late Ming Dynasty (1551–1644 C.E.), with the aim of providing
guidance for the prevention and control of plague in the present day.
Traditionality
Early records of plague in Chinese medicine can be traced back to the Shang Dynasty (1600–1046 B.C.E).
In the late Eastern Han Dynasty (184–220 C.E.), natural disasters and wars led to a wide breakout of plague.
Deeply touched by the suffering of people under the plague, the famous doctor Zhang Zhongjing (150–219
C.E.) recorded many classical ancient prescriptions in his medical monograph Shanghanlun (Treatise on
Exogenous Febrile Disease) (219 C.E.). Subsequently, as a result of imperial corruption, natural disasters,
and frequent wars, the plague that occurred during the late Ming Dynasty was the second greatest plague in
Chinese history after the outbreak of plague at the end of the Han Dynasty. During the many struggles that
occurred during the plague, a group of great medical experts emerged and devised a series of prevention and
control measures, which have the potential to play a key role in the prevention and control of plague today.

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Abstract
The plague of the late Ming Dynasty (1551–1644 C.E.) was long lasting, affected a wide range of the population,
and had serious consequences. The purpose of this study is to review the medical system in place at the time and the
measures instituted to prevent and control the plague during the late Ming Dynasty. Information on the history of
the Ming Dynasty (1368–1644 C.E.), local chronicles, and related research literature were consulted and analyzed
in terms of duration, geographical area, and other dimensions of the epidemic. Because of the abnormal climate,
wide range of natural disasters, and the impact of war, the epidemic spread over a wide area during the late Ming
Dynasty. The government’s epidemic prevention measures were affected by war and other factors, resulting in poor
control of the outbreak. However, in terms of the medical system in place during the Ming Dynasty, some of the
thinking and methods of prevention and control of the plague were historical and progressive. Some outstanding
physicians such as Wu Youke (1582–1652 C.E.) appeared during this period. His theory of plague prevention and
control had a profound influence on the formation and development of pestilence deterrence in later generations. In
the late Ming Dynasty, rich experiences and measures of prevention and control were accumulated in the struggle
against the plague. These methods and experiences also have a significant, positive guiding influence on the
prevention and control of plague in the present day.
Keywords：Late Ming dynasty, Plague, Infectious diseases, Traditional Chinese medicine, Prevention and control
Acknowledgments:
The study is supported by 2017 Liaoning Province Traditional Chinese Medicine Clinics (Specialized) Branch
Capacity Building Project and 2018 Liaoning Doctoral Start-up Foundation (20180540043).
Competing interests:
The authors declare that they have no conflict of interest.
Citation:
Qiu-Hua Li, Yue-Hai Ma, Ning Wang, et al. Overview of the plague in the late Ming Dynasty and its prevention
and control measures. Traditional Medicine Research 2020, 5 (3): 136–144.
Executive Editor: Nuo-Xi Pi.
Submitted: 7 February 2020, Accepted: 20 February 2020, Online: 29 February 2020.

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Background
There have been many plagues in Chinese history, all
of which have caused great losses to the people during
the time. The records of plague in Chinese medicine
can be traced back to the Shang Dynasty (1600–1046
B.C.E). As recorded in the Shanhaijing (The Classic of
Mountains and Rivers) (publication year unknown) of
the Qin Dynasty (221–207 B.C.E.), people at the time
determined the severity of epidemics through
divination. In the late Eastern Han Dynasty (184–220
C.E.), natural disasters and wars led to a great plague
of “countless bodies lay exposed in the fields, and
there’s no crow for miles around.” Deeply touched by
the suffering of people under the plague, the famous
doctor Zhang Zhongjing (150–219 C.E.) studied
ancient books to find a cure for typhoid fever. In 210
C.E., he completed his famous medical monograph
“Treatise on Exogenous Febrile Disease” (219 C.E.).
After the establishment of the Ming Dynasty
(1368–1644 C.E.), the medical system underwent
constant improvement. The imperial hospital and the
prestige medical center set up by the central
government and the Welfare Pharmacy set up by the
local government carried out a variety of prevention
and control measures against the epidemic. However,
as a result of imperial corruption, natural disasters, and
frequent wars, the plague that occurred during the late
Ming Dynasty (1551–1644 C.E.) became the second
greatest plague in Chinese history after the outbreak of
plague at the end of the Han Dynasty.
During the multiple struggles with the plague, a
group of great medical experts emerged and devised a
series of prevention and control measures as well as
some advanced technologies that were very effective
for the prevention and control of plague. The present
manuscript reviews the general situation and control
measures of the plague during the Ming Dynasty, with
the aim of providing a basis and reference for the
prevention and treatment of plagues in the present day.
Overview of the plague during the late Ming
Dynasty
According to historical records, an extremely cold
weather disaster occurred during the late Ming
Dynasty of China, which meteorologists refer to as the
“Little Ice Age of the Ming Dynasty” [1]. At that time,
the annual average temperature of China was well
below the normal level. In summer, drought was
followed immediately by flooding. The winters were
extremely cold, and heavy snowfall occurred in Hebei,
Fujian, and Guangdong Provinces. The severe cold in
the north regions caused the widespread southward
movement of rainfall areas, which reduced the
production of food significantly. Especially in the
northern regions, long-term droughts accompanied by
widespread famine occurred frequently, which led to
disasters throughout the Ming Dynasty (1368–1644
C.E.) [2]. According to available statistics, there was
one or more kinds of natural disaster every year from
the Wanli reign (1573–1620 C.E.) to the Chongzhen
reign (1628–1644 C.E.). From the first year to the 17th
year of the Chongzhen reign (1628–1644 C.E.), there
were floods, droughts, snowstorms, and locust plagues.
In particular, drought often coexisted with other natural
disasters [3].
Based on a statistical analysis of plague occurrence
over various periods of the Ming Dynasty, as well as
analysis of the major distribution areas and the number
of years affected by plague, the occurrence of plague
increased to once a year or more, with the number of
affected counties reaching 1,878 in the later period of
the Ming Dynasty (Table 1). We analyzed the
provinces with the highest number of major plagues
and found that the number of years affected by plague
in these provinces also showed an increasing trend
(Table 2).
The great plague of the late Ming Dynasty was
mainly concentrated in northern China and was not a
national outbreak like the plague of the late Eastern
Han Dynasty. The population of the Ming Dynasty was
characterized by smaller numbers of people in the
north and greater numbers in the south. The loss of
population in the late Ming Dynasty was mainly due to
the large-scale famine caused by the Little Ice Age and
the destruction caused by war [4]. In addition to the
natural disasters mentioned above, a nationwide
drought occurred over a period of four years beginning
in 1641. In 1643 C.E., “knotty disease” occurred in
Beijing, a term that was used to describe bubonic
plague patients suffering from lymphadenopathy.
Bubonic plague was transmitted by the bacterium
Yersinia pestis from parasites such as fleas on mice,
and the hallmark of infected humans was
lymphadenopathy [5].
The immediate effect of drought was the presence of
large numbers of refugees who fled the country
because of food shortage. The people and the rats
moved around together, which resulted in the
bacterium Y. pestis to be passed on to the refugees and
spread to wider areas. During the plague at the end of
the Ming Dynasty, “most of children died of the plague,
and more than 200,000 dead people were carried out
through the city gates.” Between August and
December in 1643 C.E., the conservatively estimated
death toll was one-fifth of population of Beijing. In
April 1644 C.E., the rebel leader Li Zicheng faced a
city of pestilence and terror when his army invaded
Beijing, the capital of the Ming Empire. Some studies
have suggested that the death toll from the plague at
the end of the Ming Dynasty would be on a 10 million
scale [6–7].
To sum up, the successive natural disasters caused
by the climate of the Little Ice Age were the main
natural factors of the plague epidemic during the late

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Ming Dynasty. We divided Ming Dynasty into three
time frames: the first was 1368–1451 C.E., with a total
of 83 years; the second was 1451–1550 C.E., with a
total of 100 years; and the third was 1551–1644 C.E.,
with a total of 94 years. It was reported that during
1551–1644 C.E., there were 78 recorded cases of
plague. The number of counties with plague reached
1878, which was more than the summary of the early
and middle Ming Dynasty [8]. The data in Table 1 and
Table 2 were extracted from the studies of Yao xueyin
et al. and Zhang Tao et al. [7, 8].
The medical system of the Ming Dynasty
The medical system of the Ming Dynasty was basically
inherited from that of the Yuan Dynasty (1271–1368
C.E.). During the Yuan Dynasty, medical management
and the medical system relied on the imperial hospital
to handle medical affairs. Various medical officers of
the Yuan Dynasty performed their duties respectively,
and they developed and perfected the original systems
of the Song Dynasty (960–1279 C.E.) and Jin Dynasty
(1115–1234 C.E.) in terms of the selection,
examination, and reward systems. In particular, the
medical officers of the Yuan Dynasty enjoyed a special
social status with more opportunities for promotion.
Many Confucian scholars also abandoned literature to
practice medicine [9]. The founding emperor Zhu
Yuanzhang overthrew the Yuan Dynasty and
established the Ming Dynasty. He constructed his own
medical system based on the original system of the
Yuan Dynasty (Figure 1A). In addition, there were
many deaths as a result of frequent floods, droughts,
and plagues. These disasters had very serious
consequences, including severe socioeconomic
damage. In ancient China, the social economy was
dominated by agriculture, and the role of the
population as an agricultural labor force could not be
replaced. Massive loss of life inevitably led to the
desolation and idleness of a large number of lands,
resulting in regression of the economy. At the same
time, people promoted a better medical system and
response measures in the struggle against natural
disasters [10].
Zhu Yuanzhang (1328–1398 C.E.) formulated a
series of welfare policies to assist the civilians. He set
up welfare homes to take in poor and homeless
individuals, which were built with government funds.
He also established the Welfare Pharmacy, where poor
civilians could obtain free medicines when they were
ill. In addition, he was particularly concerned about the
funeral arrangements of poor families. The government
paid for the burials of poor families who could not
afford to bury the dead.
The medical system of the Ming Dynasty was
mainly composed of four parts: a central medical
institution, imperial medical institution, local medical
institution, and folk medical organization. The central
medical institution mainly set up imperial hospitals,
which were divided into the Nanjing subdivision and
Beijing subdivision. There were drug storages in the
imperial hospitals, with one ambassador and one
deputy ambassador each in charge of drugs. Each year,
the distribution of medicinal materials was
administrated by the place of origin and was classified
by the quality of medicinal materials, processing
methods, degree of dryness, and dampness [11].
Table 1 Summary of plague occurrence during different periods of the late Ming Dynasty
Table 2 Major distribution of provinces and disaster years of the plague
Time stage 1368–1450 C.E. 1451–1550 C.E. 1551–1644 C.E.
Outbreak, number (n) 30 72 78
Frequency (times/year) 2.77 1.39 1.21
Annual occurrence probability (%) 36.1 71.9 83.0
Ratio of total times (%) 16.7 40.0 43.3
Number of plague counties (n) 234 478 1878
Major province 1368–1451 C.E. 1451–1550 C.E. 1551–1644 C.E.
Northern Zhili 1 17 38
Hubei and Hunan 6 30 38
Jiangxi 7 27 24
Southern Zhili 6 46 50
Shanxi 4 17 26
Zhejiang 6 27 27
Fujian 7 44 26

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The drugs were checked and put into the storehouse
by the imperial physician and ambassador of the
imperial hospital. The ceremony department sent a
person to supervise and register the drug, and two
copies were made of all records. The prince’s residence
established prestigious doctors’ hospitals, in which a
sixth-ranked medical officer, a seventh-ranked medical
officer, and several eighth-rank medical officers treated
the patients together. The medical officers were
recommended by the imperial hospital and appointed
by the Ministry of Administration. The outstanding
pharmacist Li Shizhen (1518–1593 C.E.) served as a
medical officer in a prestigious doctors’ hospital
[12–13].
There were doctors, medical assistants, and medical
officers in the local, state, and county governments
and/or border guard station as well as in the places
where people gathered. In the medical affairs system of
the Ming Dynasty, specific regulations were devised
by medical scientists from the content, method, and
attitude of studying to the ideological quality, moral
quality, and attitude of treating patients [14].
The imperial hospital was responsible not only for
medical work but also for the teaching and training of
doctors. In addition, the imperial hospital participated
in the government’s rescue work in the event of
plague.
At the local region, the Welfare Pharmacy existed
mainly to cure the poor, sick, and socially vulnerable
groups during peacetime and was responsible for
disaster relief in during a plague outbreak [15]. The
original intention of the Welfare Pharmacy was to
benefit the people and to help poor and sick
individuals afford the cost of seeing a doctor or to buy
medicine. Therefore, the imperial court implemented a
subsidy policy for drug administration in the Welfare
Pharmacy. In this way, the price of drugs was far lower
than that in the market, making medicine more
affordable for people in the lower classes [16]. The
Welfare Pharmacy would also distribute medicine free
of charge to poor individuals and disaster victims if
they really had no ability to pay (Figure 1B). The
Welfare Pharmacy was mainly created to aid ordinary
people and was subsidized by the government to
promote public welfare. This picture is excerpted from
Qiu Ying’s picture “Riverside Scene at Qingming
Festival” from the Ming Dynasty.
Understanding of measures to control plague
in the Ming Dynasty
For hundreds of years during the reign of the Ming
Dynasty, the relevant systems and countermeasures
instituted by various individuals during the struggle
against plague played a positive role.
Isolation and burial measures
Isolating the sick helps prevent the spread of infectious
diseases. Xiao Daheng (1532–1612 C.E.), a politician
of the Ming Dynasty, pointed out in his book Yisuji
(Tatar Folk Record) that “people suffering from
infectious disease should be isolated from their parents,
brothers, wives, and children.” Burying the bones of
the dead is also an indispensable measure in the
treatment of plague [17]. The lethality of plagues often
leads to large numbers of deaths, and severe plagues
often lead to the desolation of villages and the spread
of dead bodies. The decomposition of bodies that are
not buried in time and the breeding of mosquitoes and
flies worsen environmental hygiene, which in turn
exacerbate the disasters, creating a vicious circle. The
government of the Ming Dynasty actively buried the
dead bodies of plague victims to prevent further
deterioration of the environment [18].
Figure 1 The founding emperor of the Ming Dynasty and Welfare pharmacy in the Ming Dynasty. A.
The founding emperor of the Ming Dynasty (1368–1644 C.E.); B. Welfare pharmacy in the Ming Dynasty.

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In 1643 C.E., after the Beijing plague occurred, the
government released light criminals to avoid jail
crowding, allocated funds to treat epidemics, and
buried the dead [19]. When the rebel leader Li Zicheng
(1606–1645 C.E.) arrived in Beijing at the end of the
Ming Dynasty, the Ming Army in the city was so badly
quarantined by the plague that more than half of them
died. There were not even 10,000 soldiers who could
defend the walls of the capital. Every day, soldiers,
peddlers, and laborers died in droves, and there was
even no beggar in Beijing city [7].
Medicine delivery and disease control
The imperial hospital had an important responsibility
to participate in the government’s treatment strategies
when encountering a plague. Treatment methods
included the preparation of drugs, soup liquids, pills,
and plasters. However, the main objects of rescue were
the royal nobles in the capital city [14]. In 1560 C.E.,
there was a famine in the suburb of Beijing. People
who had no place to live swarmed into Beijing because
of the disaster. After the emperor summoned the
ministers for deliberation, he allowed the imperial
hospital to undertake the treatment of the sick civilians
[20]. At the time of the plague, it was easy for people
to become panicked when faced with the danger of
infection. Therefore, the Ming government arranged
for the medical officers of the Welfare Pharmacy to
quantify the epidemic situation, diagnose and treat the
patients, and distribute medicine when plague was
prevalent. They also set up special medical stations to
receive homeless patients and selected highly skilled
doctors to take care of the sick [20].
In 1581 C.E., plague occurred in Jiaocheng County
of Shanxi Province. Many civilians were infected with
the fungus, and their health was in serious danger. The
county magistrate collected doctors and medicines
from the Welfare Pharmacy to treat the infected
civilians [21].
After analyzing and summarizing the measures
taken by the Ming government to cure the plague, we
find that the local government would immediately
report the situation to the central government when
plague is prevalent. Then, the central government
issued corresponding measures and directives,
allocated the funds, opened the granaries, dispatched
the doctors, distributed medicines, and curtailed the
cost of official travel to help the affected residents.
Local governments organized workers to bury bodies
and isolate people and rewarded or punished officials
and doctors involved in treating the epidemic. Because
of traditional clan and blood relationships, some
people helped each other and shared medical resources
spontaneously. In addition, some prominent gentry and
good Samaritans offered to assist the government in
activities such as giving medicine and food, raising
funds, burying bodies, adopting orphans, and so on.
These people were commended by the government and
were even awarded some honorary positions. In some
remote villages, people prayed not to be harmed by the
plague by the way of worship and prayer (Figure 2)
[22–24].
However, in the middle and late Ming Dynasty, the
Welfare Pharmacy was not well managed, and its
activities were inefficient because of war, shortage of
funds, and regime corruption.
Prevention and treatment
The Jiajing reign (1522–1566 C.E.) of the Ming
Dynasty also personally wrote prescriptions and made
them into “small decoction for epidemic relief.” He
requested the Ministry of Rites to distribute the
prescriptions to the civilians. In addition, the Ming
Dynasty invented the process of variolation to prevent
smallpox. This became a precursor of artificial
immunity and thus occupies an important position in
the history of medicine [25] (Figure 3). In Bencao
Gangmu (Compendium of Materia Medica), the
outstanding pharmacist Li Shizhen instructed that the
clothes of the infected should be fumigated at high
temperature so as to reduce the probability of
transmission to the family in the event of a plague [26].
The owner of a famous bookstore in Hangzhou, Hu
Zhengxin (birth and death years unknown) also
mentioned the method of steam disinfection in his
book Jianyibeiyanfang (Simple Method of Preparing
and Checking Prescription, 1641 C.E.) [27]. In his
book Shoushibaoyuan (Prolonging Life and Preserving
the Origin, 1615 C.E.), Gong Tingxian (1368–1644
C.E.) of the Ming Dynasty listed the ingredients of “Tu
Su wine (a wine consumed during ancient Chinese
Spring Festival), with the Houpo (Magnoliae
officinalis cortex), Jiegeng (Platycodonis Radix),
Fangfeng (Saposhnikoviae Radix), Guizhi (Cinnamomi
Ramulus), Baizhu (Atractylodis Macrocephalae
Rhizoma), Cangzhu (Rhizoma Atractylodis), Chuanwu
(Aconiti Radix), Baizhi (Angelicae dahuricae Radix),
Dahuang (Rhei Radix et Rhizoma), Chenpi (Citri
Reticulatae Pericarpium), Tanxiang (Santali Albi
Lignum), Doukou (Amomi Rotundus Fructus), Huajiao
(Zanthoxyli Pericarpium), Huoxiang (Pogostemonis
Herba), Weilingxian (Radix et Rhizoma Clematidis),
Gancao (Glycyrrhizae Radix et Rhizoma), Liquor and
Spirits.” He pointed out that this kind of wine could
block the plague, and he suggested that patients ignited
moxa pillar at the corner of the bed to produce moxa
smoke, which could be used as an antibacterial and
antiviral agent [28–29]. Mingshilu (Record of Ming
Dynasty) recorded that in the late Ming Dynasty, an
official in Fujian Province invented bloodletting
therapy to treat the plague. Nearly 10,000 people were
treated with bloodletting every day during that period
[30]. It was recorded in “Jingyuequanshu (Jing-yue's
Complete Works)” (1624 C.E.), written by Zhang
Jingyue (1563–1640 C.E.), that the use of “Fujian tea
cake” (agalloch eaglewood, symplocos paniculata,

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cattail pollen, liquorice, musk, and bottle brush herb
were collected together and ground into a fine powder
and then modulated by glutinous rice soup and shaped
to a pill cake) was helpful for oral disinfection and for
preventing diseases that entered through the mouth
[31]. Wu Youke (1582–1652 C.E.) pointed out in his
Wenyilun (Treatise on Epidemic Febrile Diseases) that
pestilent Qi (a class of exogenous pathogens with
strong pathogenicity and infectivity) did not definitely
occur in a contagiously epidemic situation. Therefore,
the doctrine of pestilent Qi was not convincing [32].
Whether a person contracted the epidemic disease
depended on the existence of pestilence. Pestilence is
one of the miscellaneous Qi, which existed every year.
The pestilence caused infection of old and young
people. Wu Youke doctrine speculated on the presence
of pathogens and further emphasized the infectious
nature of the plague, on the basis of the work by Zhang
Zhongjing (150–215 C.E.). Wu Youke also pointed out
that the plague was contracted by the mouth and nose
and spread by inhalation. He stressed the importance
of isolating patients and invented a rather effective
treatment of plague, the “Dayuan decoction,” which
consisted of Binglang (Arecaesemen), Houpo
(Magnoliae officinalis cortex), Caoguo (Fructus
Tsaoko), Zhimu (Anemarrhenae Rhizoma), Shaoyao
(Paeoniae Radix Alba), Huangqin (Scutellariae radix),
and Gancao (Glycyrrhizae Radix et Rhizoma). He was
proved to be a master pioneer in the treatment of
febrile diseases in China [33] (Figure 4).
Modern studies have confirmed that Dayuan
decoction has a good curative effect in the treatment of
some acute infectious diseases, such as typhoid fever,
malaria, and influenza [34]. The use of Dayuan
decoction 3 to 10 days after the onset of severe acute
respiratory syndrome is associated with good clinical
efficacy [35]. Dayaunyin has a significant antipyretic
effect by decreasing the levels of interleukin-6 and
tumor necrosis factor-  in serum and reducing the
activity of myeloperoxidase in liver tissue.
Conclusion
During the Ming Dynasty, the medical system as well
as some of the thinking and methods of prevention and
control of the plague were historical and progressive.
Some outstanding physicians such as Wu Youke
appeared in this period. His theory of plague
prevention and control have a profound influence on
the formation and development of pestilence treatment
in later generations. Wu Youke’s Wenyilun (Treatise on
Epidemic Febrile Diseases) plays a connecting role in
the academic development of epidemic febrile diseases
and lays a theoretical foundation for the establishment
and development of the school of epidemic febrile
diseases during the Qing Dynasty. However, because
of natural weather disasters, corruption, and war, the
government of the late Ming Dynasty failed to control
the plague. In the late Ming Dynasty, people
accumulated rich experiences and devised measures of
prevention and control in the struggle against plague.
These methods and experiences have also had a
positive guiding influence on the prevention and
control of plague in the present day.
Figure 2 Prevention and control measures of plague

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Figure 3 Variolation was invented in the Ming Dynasty to prevent smallpox. To prevent smallpox, a smallpox
scab was ground to a fine powder and blown into the nostrils of children. This method was widely used because of
its simplicity.
Figure 4 Treatise on Epidemic Febrile Diseases (1642 C.E.). The Wenyilun (Treatise on Epidemic Febrile
Diseases) written by Wu Youke is the first monograph on epidemic febrile diseases in the history of medicine in
China. The treatise creates a new guidance for the prevention and treatment of exogenous diseases in traditional
Chinese medicine, establishes a relatively complete theoretical system of epidemic febrile diseases and has an
epoch-making impact on the development of epidemic febrile diseases.
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