Women’s Health in Medieval Manuscripts
(prepared for a panel on “Medieval Chinese Medicine in Dunhuang Manuscripts” for the 11th International Conference on the History of Science in East Asia, Munich, Germany, Aug 15-20, 2005)
Introduction
In contrast to the beginnings of classical Chinese medicine in the Han period, our knowledge of early medieval medicine is still sketchy. This is due largely to a lack of sources. Of the more than 100 medical texts recorded in the Old Tang History (Jiùtángshū 《舊唐書》, 945 CE), only four have survived in the received literature from the early medieval period: Cháo Yúanfāng’s 巢元方 Zhūbìng yuánhòu lùn 《諸病源候論》 (On the Origins and Symptoms of the Various Diseases, 610 CE), Sūn Sīmiǎo's 孫思邈 Bèijí qiānjīn yào fāng 備急千金要方 (Essential Formulas worth a Thousand in Gold for Every Emergency, 652 CE, in the following discussion abbreviated as Qiānjīnfāng), his Qiānjīn yìfāng 千金翼方 (Supplementary Formulas worth a Thousand in Gold, 682 CE), and Wáng Xī’s Wàitái mìyào 外台秘藥 (Essential Secrets From the Palace Library, 752). Other texts are known only from quotations in compendiums like the Japanese Ishimpō 醫心方 (Prescriptions from the Heart of Medicine, 984 CE), a collection of early medieval Chinese medical literature by a Japanese court acupuncturist. The other great source for medical literature from this period is the corpus of medical manuscripts found in Dūnhuáng 敦煌, which date mostly to the Suí and early Táng periods.
Since early Chinese gynecology is not a commonly known topic, let me provide some background to the Dūnhuáng material by summarizing the treatment of women in the received literature: Here, the difference between Hàn period formularies like the Jīnguì yàolǜe 《金匱要略》 and the medieval sources mentioned above is striking. In light of this, we might be tempted to celebrate a medical author like Sūn Sīmiǎo as a “king of medicinals” (藥王 yàowáng), a physician with super-human accomplishments who composed his encyclopedia with over 5000 entries on the basis of a heroic lifetime of medical practice and the intuitive healing skills of a genius. Especially in the context of women’s medical treatment, Sūn is often acknowledged as the founder of Chinese gynecology. He was indeed the first to stress the need for a gender-specific treatment of women with his famous statement: “Women are ten times more difficult to treat than men.” Recognizing the pivotal role women’s bodies played in the continuation of the family lineage, Sūn placed the section on “formulas for women” first in his encyclopedia. The three scrolls on this topic, roughly ten percent of the whole text, show how male elite doctors viewed the female body as suffering from the effects of menstruation, the burdens of reproduction, subsequent vacuity and taxation that allowed for an invasion of wind or cold, and, to top it off, from deeply lodged emotions and passions that far exceeded their husbands' and made their disorders “ten times more difficult to treat.” The formulas themselves suggest that the pinnacle of elite medical practice as envisioned by Sūn consisted of complex prescriptions for decoctions, pills, and powders with literally dozens of medicinal ingredients. These addressed highly specific constellations of symptoms that were based on a thorough diagnosis of a woman's emotional and physical condition. Similarly, the slightly earlier etiological treatise on the origins and symptoms of disease by Cháo Yuánfāng also contains several scrolls on women’s conditions that focuse particularly on the disorder of dài xià 帶下 (lit. “below the girdle”), in the technical sense of vaginal discharge.
I will spare you the details of early Chinese gynecological theory, but briefly want to emphasize three points: 1. the significance of the symptoms of vaginal discharge and irregular menstruation for diagnosing women’s health, 2. the etiology of childbirth-related taxation and vacuity, susceptibility to wind and cold, and resulting problems of stagnation and lack of free flow, whether spelled out explicitly or implied in the choice of medicinals, and 3. the resulting focus in treatment on gentle and slow-working yáng- and blood-supplementing formulas, in conjunction with warming and blood-moving treatments. These factors allowed gynecology to emerge as a respected professional medical specialization by the early Sòng period (see my translation of Qí Zhòngfǔ’s Hundred Questions of Gynecology, the first part of which was published in 2019 as Channeling the Moon for an eminent example of this literature).
A closer look at the remedies for women in the Dūnhuáng manuscripts, which reflect a more popular and less orthodox level of medical practice, suggests that this picture is in need of some revision. Here, I introduce you specifically to two representative texts that reflect the range of gender-specific etiologies and therapies.
Manuscript P2666 v, Dānyàofāng《單藥方》(Formulas with a Single Medicinal)
The manuscript known as P2666v, which modern Chinese editors[1] have named Dānyàofāng (Formulas with a Single Medicinal), was most likely produced during the Táng period, but its author and exact date of composition are unknown. As the title implies, it is a collection of medicinal formulas with only a single ingredient each, or in one instance, one moxibustion point. Indications range from internal and external medicine to gynecology and pediatrics and include side-by-side and in no apparent order treatments for conditions like wind strike, dysentery, poisoning, insanity, burns, having a fishbone stuck in the throat, and snake bites.
Let me give you a sample of the advice found in this text: For heart pain, mix soot from the underside of a pan with infant’s urine and ingest that; for wealth, take earth from the field of a rich household, make mud and spread it on the stove, or , as another formula advises, burn an oxhorn in the central hall; treat pediatric cholera and vomiting of milk by pouring ginseng decoction in the infant’s mouth; treat malaria by ingesting your own urine; and for wisdom and freedom from disease, rise at dawn on the first day of the eighth month and remove the dirt from the middle of your navel.
Out of 84 formulas, 22 specifically address female disorders. Of these, 80% are directly related to reproduction: Five treat infertility, loss of children, or giving birth to girls, one is a contraceptive formula, and twelve treat childbirth-related conditions like postpartum abdominal pain, retained placenta, or stalled labor. The remainder is made up of one formula for incessant menstrual flow, one for vaginal discharge, and two for making a woman who is having an affair reveal the man’s identity in her sleep: by secretly adding dirt from under an oxen's hoof to her food and drink, or by hiding dirt from under a white horse’s hoof under her bed. Less than one third of the formulas for women involve what we would consider clinical medical advice in the stricter sense of treatments with medicinal efficacy, such as ingesting hemp seeds, pine rosin, oven earth, lycium berries, three soybeans, or the flowers from a hundred herbs dried in the shade, or burning moxa on the first horizontal line below the navel (that is, Yīnjiāo, REN-7). The others contain advice along such lines as the following: ingest charred rat heads for stalled labor or a bowl of hot dog blood for retained placenta; make a mud figure with birth blood and bury it at the birth place to avoid future loss of children, tuck money inside the placenta and bury it for contraception; accelerate labor by ingesting seven pills made from dirt that many people have urinated on; and insert milk from a white dog into the vagina and have intercourse to treat chronic infertility.
Three points are most striking about these formulas: First, childbirth- and fertility-related treatments far outweigh the other conditions treated in the contemporaneous received literature, most notably menstruation and vaginal discharge, as well as general formulas for boosting and supplementing. Second, several remedies that are not found in the received literature are also found in other Dūnhuáng manuscripts in often almost literal versions.[2] Third, we look in vain for basic medicinal ingredients commonly associated with women’s treatment such as dāngguī, shāoyào, xiōngqióng/chuanxiong or gāncǎo that must have certainly been available in a border town at the intersection of important trade routes. We might be tempted to relate these particularities to the uniqueness of this manuscript, as it confines itself to formulas with only a single ingredient. To get a broader impression of the nature of women’s treatment in the Dunhuang manuscripts at large, let us look at a second manuscript.
Manuscript S4433v, Qiúzǐfāng 《求子方》 (Formulas for Fertility)
My second example is manuscript S4433v, which modern Chinese editors because of its content have titled Qiúzǐfāng (Formulas for Seeking Offspring, or in other words, for Fertility). Its author and date of composition are also unknown, but it most likely predates the Táng period. A somewhat unrelated essay on drug preparation is followed by 27 formulas that are all related to fertility, reproduction, and techniques for sexual intercourse. Let me give you a quick summary of the formulary section of this text:
The first entry after the materia medica essay is a complex formula with 24 ingredients for treating male infertility due to weakness of essence and Qì. This formula is also quoted in the Qiānjīnfāng, Wàitái mìyào, and Ishimpō. It stands out in the Qiānjīnfāng as the very first formula in the section on women´s treatments, in the first chapter on 求子 qiúzǐ (seeking offspring, or fertility). Why is this formula found among treatments for women? Let me return to the Dunhuang text for a possible answer:
The following two remedies treat a condition called cold in the genitals (陰冷 yīn lěng) by inserting heating drugs like shízhūyú or sulphur pills into the vagina. Again, these formulas are found in the Qiānjīnfāng, where they are, however, not included under fertility treatments but under “women’s miscellaneous treatments.” This is an interesting category in early gynecological literature that serves as a grab-bag for women’s disorders that do not fit into any of the standard categories of pregnancy, childbirth, postpartum, menstrual disorders, and vaginal discharge. Among the “miscellaneous treatments,” we find remedies for conditions ranging from mammary problems to dreams of intercourse with ghosts and genital disorders, like prolapse of the uterus or anus, vaginal sores, or pain, injury, and bleeding as a result of sexual intercourse. Treatments for genital cold obviously fit into this category.
Overlapping with this constellation of conditions, the Dūnhuáng manuscript continues with a group of aphrodisiac and fertility-enhancing formulas: treatments for a widened vagina by rinsing the vagina with heating medicinals;[3] a formula for a man to “make him big,” that is, for enlarging the penis, by applying a medicinal paste to the tip;[4] and instructions for “making women happy and men strong,” by applying a stimulating medicinal powder to the tip of the penis and inserting it deeply into the vagina, which after a while will result in “great heat and happiness.”[5] A systematic comparison between treatments for men and treatments for women transcends the frame of this paper, but in general, men’s treatments aim at strengthening Yīn and supplementing Qì and essence while women’s formulas include more heating and Yáng- and blood-supplementing drugs, reflecting etiological notions of vacuity cold and resulting lack of free flow. The remainder of the scroll contains formulas of a magical flavor for treating infertility and for a successful pregnancy that will result in the birth of a healthy, intelligent, and ideally male child: To treat infertility, for example, the man is instructed to hold two times seven rice beans in the left hand during intercourse and then pass them on to the woman’s right hand and have her swallow them.
The last group of formulas contains directions for the woman to follow during pregnancy: to ensure the birth of a male fetus, she should wear a girdle made from a bow string from the first month of pregnancy on; to change a female into a male fetus and ensure its future wealth, she should eat two carp heads. A diet of ox heart causes wisdom, and of beef liver wealth, facing south during the third month of pregnancy will make the fetus restless; and so on. In contrast to the surprising overlap of other sections of the manuscript with other texts, I have not been able to find close textual parallels for this last section of pregnancy prohibitions. This is particularly surprising when we consider the consistency of literature on nurturing the fetus, referred to as 養胎 yǎng tāi “nurturing the fetus” in other texts, such as from the Mǎwángduī 馬王堆 Tāichǎnshū 《胎產書》 to the Qiānjīnfāng and Ishimpō.[6]
What can we learn from this manuscript about fertility formulas and the treatment of women? Literature on “seeking offspring” included formulas for both men and women on a wide range of subjects, such as genital and reproductive disorders; aphrodisiacs; sexual cultivation; fertility-boosting medicinal decoctions, pills, and powders; and instructions for pregnancy, delivery, and postpartum care. The Mǎwángduī manuscripts have shown that much responsibility for fertility and procreation was originally placed on the male partner and the specifics of conception. In the context of elite medicine of the highest standard in the early Táng, as reflected in Sūn Sīmiǎo’s work, we can see how the emphasis shifted gradually to the female partner. Here, physicians focused on her general health, supplementing and increasing the flow of her blood and Qì, on preparing her womb for pregnancy by warming it and cleansing it of old, stale blood, and lastly on the gradual nurturance of the fetus during the ten months of gestation. The information found in earlier texts on sexual cultivation and fertility that were directed at both men and women, was now subdivided under strictly medical terms into sexual cultivation, in the section for men, and, in the section for women, into “seeking offspring” (treatments for enhancing fertility for women), pregnancy (formulas to nourish the fetus once pregnancy was established), and miscellaneous treatments (concerned with disorders of the genitals, sexual malfunction, and the like).
Conclusion
I will conclude this paper with a few general observations on formulas for women in the Dūnhuáng medical manuscripts. Several facts stand out in contrast to the received formulary literature:
Formulas for complex decoctions prepared from numerous medicinally efficacious ingredients are remarkably rare in these manuscripts, as are formulas that are intended to gradually supplement and strengthen the female body over a long period of time, and treatments for vaginal discharge and menstrual disorders. Treatments that address anything but life-threatening emergencies or conditions related to procreation are virtually absent. Also lacking is the diagnostic specificity with which contemporaneous elite writers like Cháo Yuánfāng and Sūn Sīmiǎo categorized and treated the disorders of the female body. This is most likely related to the fact that the population of Dūnhuáng as a remote military outpost had little access to elite professional physicians devoted to the regular and long-term care of wealthy court ladies. Thus, these texts address life-threatening emergencies, and the most dangerous event in any woman’s life of this period was undoubtedly the moment of childbirth and its related obstetrical and postpartum complications.
Formulas for women were not yet considered in a separate category but were randomly included under general treatments, perhaps in specialized contexts like single-ingredient formulas, formulas related to fertility and reproduction, or in P3930, where childbirth treatments are grouped with treatments for head and eye disorders. Nevertheless, the textual overlap among different Dūnhuáng manuscripts and with the received literature proves that this literature was transmitted in writing. This also shows that elite authors like Sūn Sīmiǎo did not compose their formularies on the basis of personal experience and individual genius, but at least to a large extent by compiling and synthesizing existing formulary literature.
In contrast to the received literature, the treatments in the manuscript literature stand out for their frequent use of animals, pointing perhaps to a popular tradition specifically related to fertility and childbirth complications: charred rat heads or two times seven pieces of male rat feces treat stalled labor, dog blood treats a dead fetus in abdomen, white dog's feet and milk are employed in the context of fertility, and retained placenta is expelled with charred ox tail. Even more striking and most likely repulsive even to early Táng sensitivities, are treatments involving human bodily fluids, such as urine and birth blood, the latter of which is to my knowledge not found in orthodox and received medieval literature. The fact that these substances appear in different texts and different combinations suggests that this information was also transmitted orally. Manuscripts are thus important in the history of medicine for reflecting a more popular level of medical practice or unorthodox contents that an individual copyist might have compiled as a personal collection of useful treatments.
In conclusion, the Dūnhuáng medical manuscripts demonstrate the vast gulf that existed between elite medicine as practiced, recorded, and transmitted at court, and the medical care provided at the remote border community of Dūnhuáng. The received literature from this period, the texts that were soon to become classics in the emerging specialty of gynecology, emphasize a gentle, gradual, and long-term approach to the female body with complex supplementing medicinal preparations, on the basis of subtle cues gained in the diagnosis of vaginal discharge and menstrual irregularities. We look in vain for this type of gender-specific diagnosis or therapy in the Dūnhuáng texts. Here, men’s interest in women’s health is limited to sexuality, reproduction, and to life-threatening conditions.
NOTES
[1] Cóng Chūnyǔ 叢春雨, Dūnhuáng zhōngyīyào quánshū1 《敦煌中醫藥全書》 (Complete Text of the Dunhuang Medical Manuscripts).
[2] S6177v., for example, also contains instructions for treating incessant postpartum pain in women by burning seven cones of moxa on the first horizontal line below the navel, treating incessant menstruation by ingesting a charred winnowing basket tongue, ingesting 3 shēng of lycium berries to expel a dead child from the abdomen, and treating infertility by charring grass growing in the hole of a mulberry tree and ingesting the ashes.
[3] E.g., fùzǐ, guìxīn, and gāncǎo.
[4] This notably contains cōngróng and shíhú, both of which are already in the Shénnóng běncǎo jīng 《神農本草經》, a Hàn period materia medica text, described as strengthening Yīn, treating taxation damage, and supplementing the center, essence, and Qì.
[5] Another formula for a similar aphrodisiac, which is found in an identical version in the “miscellaneous treatments” of the “formulas for women” in the Qiānjīnfāng, is used on the seventh day of the first month, with the effect of shrinking the vagina so that after 50 days it will be like that of a virgin.
[6] The Qiānjīnfāng contains a lengthy section on a “method for nurturing the fetus month-by-month,” that is identified specifically as a quotation. It is an almost literal citation of the month-by-month account of fetal development and related instructions for the mother that is first found in the Mǎwángduī text, supplemented with medicinal formulas and information on channels prohibited in each month for treatment with acumoxa. The same text is found in the Ishimpō, again with striking textual parallels and accompanied by yet more information. It is here identified as a quotation from yet another text that has not been transmitted down to the present.
