Sun Simiao on Fertility
Originally published April 25, 2019
The following is an excerpt from the 75-page historical introduction to my new publication Channeling the Moon, a translation and discussion of the first fourteen questions of Qí Zhòngfǔ’s 齊仲甫 Nǚ Kē Bǎi Wèn 女科百問 (“Hundred Questions of Gynecology,” published in 1220 CE). This excerpt includes a brief introduction to the Bèi Jí Qiān Jīn Yào Fāng 備急千金要方 (composed by Sūn Sīmiǎo 孫思邈 in 652) and a survey of Sūn Sīmiǎo’s ideas on fertility. These may be of interest especially to some of the people attending the IFS symposium in Vancouver, CA, which is starting today! For more on early Chinese gynecology and fertility, see the information page for my book Channeling the Moon in my ONLINE BOOKSTORE HERE. The photographs below, most of which have also made it into the book, are from around my home on Whidbey Island, but here you get the colored version.
…After this brief summary of early Chinese classical sources on gynecology, we have finally arrived at the text that many Chinese medicine physicians to this day consider the earliest classic of gynecology: Volumes Two to Four in Sūn Sīmiǎo’s Bèi Jí Qiān Jīn Yào Fāng. The introductory essay of these three volumes on “Formulas for Women” (婦人方 fù rén fāng) begins with this oft-cited statement:
The reason why women have special formulas is that they are different because of pregnancy, childbirth, and landslide collapse damage (i.e., heavy vaginal bleeding). Therefore, women’s diseases are ten times more difficult to treat than men’s.
Placed at the very beginning of the main body of the Bèi Jí Qiān Jīn Yào Fāng, the significance of this statement cannot be overrated. The following information attempts to shed light on it from various angles:
I present a summary and brief interpretation of Volumes Two to Four, which includes a case study that analyzes the formulas for “seeking a child” in more detail, in order to give the reader an impression of the general nature and major themes and issues of the text. Comparing the content and structure of Sūn Sīmiǎo’s “Formulas for Women” with earlier and later texts allows us to situate this text in the history of the development of gynecology in medieval China. In addition, it sheds light on Sūn Sīmiǎo’s various roles as an innovative author, as a preserver and transmitter of literary medical traditions, as a cosmologically-inclined practitioner of yǎng shēng (nurturing life) with a personal stance in promoting women’s health, and even as an advocate for oral traditions that transcended class or gender boundaries.
Although the categorical confusions, overlap between formulas, and contradictory statements found in these pages indicate the preliminary state of knowledge about women’s health in early medieval China, the material introduced here also points toward the sophisticated understanding of a gendered body with gender-specific etiologies and treatment needs that emerges full-blown in the following Sòng dynasty. Sūn Sīmiǎo’s understanding of women’s weaknesses and vulnerabilities can already be seen as more comprehensive than what is included in a typical modern biomedical dictionary definition of obstetrics and gynecology as the “medical care of pregnant women (obstetrics) and of female genital diseases (gynecology).” As he wrote in the sentence that follows the introductory statement quoted above, which also reflects the organization of formulas in the Bèi Jí Qiān Jīn Yào Fāng, Sūn Sīmiǎo interpreted female difference under the categories of reproduction (consisting of fertility, pregnancy, childbirth, postpartum conditions, and lactation), miscellaneous treatments (including treatments for female genital diseases), supplementing and boosting, and a large section on menstruation and vaginal discharge.
It is impossible to discern at this point the extent to which Sūn Sīmiǎo’s placement of the “Formulas for Women” at the very beginning of the Bèi Jí Qiān Jīn Yào Fāng was motivated by a humanitarian concern for what he clearly perceived as the greater vulnerability and weakness of the female body, in both its physical and psychological aspects. It also appears that he consciously composed and organized the Bèi Jí Qiān Jīn Yào Fāng with the ultimate intention of preserving and prolonging life in the elite tradition of “nurturing life” (養生 yǎng shēng). Therefore, he placed women’s health, interpreted as the foundation for the creation of life, at the beginning of the text, followed by pediatrics, and only then by general medicine. This leads up to instructions for the preservation and prolongation of life based on diet, lifestyle, Qì cultivation, and sexual cultivation, appended with technical instructions for pulse diagnostics and acumoxa therapy. Supporting this argument, he states in his introduction to volume five on pediatrics:
For this reason [I have arranged] these formulas [by placing] those on women first, then those on children, and afterwards those on men and the elderly. This is the meaning of venerating the root.[1]
Whatever Sūn Sīmiǎo’s motivations were, his treatment of women went far beyond ensuring their reproductive capabilities and reflects a genuine concern with what he saw as the special burdens suffered by the female body for the sake of continuing the family lineage.
Fertility
Sūn Sīmiǎo’s formula collection on women starts with the treatment of reproductive problems. As the introductory statement quoted above shows, Sūn Sīmiǎo considered the effects of childbearing to be the single most important factor in the etiology of women’s diseases. The remainder of this first essay in the “Formulas for Women” refines this statement considerably. As additional causes for women’s weak health, it mentions the onset of menstruation at the age of fourteen and external causes like immoderate food and drink, inappropriate sexual intercourse, and most notably, wind entering from below, or in other words, through the vagina. To complicate matters further, he states that “women’s cravings and desires exceed their husbands’ and they contract illness at twice the rate of men.” Next, Sūn Sīmiǎo lays out the significance of childbearing as “the adult role in women’s destiny and fate.” Because childbearing was “the basis of human affairs and the foundation of enlightened rule,” the volumes on women should be “inspected by gentlemen of like intention” and “routinely copied and carried by servants engaged in childrearing.”
Sūn Sīmiǎo has now laid the foundations from which to launch the first aspect of his “Formulas for Women”: a treatment program for “seeking a child” (求子 qiú zǐ), i.e., enhancing fertility. Containing six essays, fourteen medicinal formulas, six moxibustion methods, and three “methods for converting a female [fetus] into a male,” it comprises about six percent of the gynecological material. Before offering treatments, though, Sūn Sīmiǎo warns that even the best medicine is useless if the couple’s basic destinies are mismatched, meaning that their birth signs do not follow the order of generation in the progression of the Five Dynamic Agents, or if the astrological constellations at the time of conceiving the fetus are inauspicious. If their birth signs are in harmony, however, they still must pay heed to Sūn Sīmiǎo’s medical advice and also guard against breaking taboos against sexual intercourse at inauspicious times to ensure their own and their offspring’s future health and good fortune.
The Sòng editors insert a reference here to methods for determining the right time and day for “receiving a fetus” (受胎 shòu tāi), found later in the Bèi Jí Qiān Jīn Yào Fāng in volume 27 on “Nurturing the Inner Nature” (養性 yǎng xìng). It is interesting to note that these “methods for taboos and restrictions [on sexual intercourse]” are, in a manuscript edition of the text, cited in the category for “seeking a child” and therefore considered part of the “Formulas for Women.” Similarly, the Wài Tái Mì Yào 外台秘要 and Ishimpō 醫心方 both devote considerable space to these taboos and prognostications about the child’s and parents’ future in the section on “seeking a child.”
In a slight shift of emphasis, Sūn Sīmiǎo lastly offers a purely medical etiology in the next essay, stating that “whenever people are childless, it is caused by the fact that both husband and wife suffer from the Five Taxations and Seven Damages and the hundred illnesses of vacuity and emaciation, with the disastrous result that the line of descendants is cut off.” This seems to contrast the popular notions of his time, as expressed most notably by the Zhū Bìng Yuán Hòu Lùn 諸病源候論, which states at the very end of Volume Thirty-Eight:
When women are without child, there are three reasons:
First, that the tombs have not been worshipped;
second, that the husband’s and wife’s yearly fate (a reference to their astrological constellations) are in a relationship of mutual conquest;
and third, the husband or wife’s illness.
All of these cause childlessness. If it is a case of tombs not having been worshipped or the yearly fates conquering each other, there are no medicines that can be of benefit.
Similar sentiments are expressed in the calendrical and astrological sections on childlessness in the Wài Tái Mì Yào, Ishimpō, and Bèi Jí Qiān Jīn Yào Fāng cited above.
Following this reference to non-medical causes of childlessness, Sūn Sīmiǎo then proceeds to discuss options for medical treatments. These are summarized here in a detailed case study to illustrate the treatment style and underlying etiological reasoning found in Sūn Sīmiǎo’s “Formulas for Women”:
Case Study: An Interpretation of Volume Two, Section One on “Seeking a Child”
In order to prevent or treat the medical cause of infertility, which he has previously identified as the “Five Taxations, Seven Damages, and hundred diseases of vacuity emaciation,” Sūn Sīmiǎo proposes a complex treatment plan: First, the husband is treated for lack of offspring in conjunction with wind vacuity, clouded vision, and weakness and shortage of essential Qì by supplementing his insufficiencies with Qī Zǐ Sǎn 七子散 (Seven Seeds Powder), a formula consisting of twenty-four ingredients in total! The famous Yuán dynasty physician Zhū Zhènhēng 朱震亨 (style-name Dānxī 丹溪) later developed this formula into Wǔ Zǐ Yǎn Zōng Wán 五子衍宗丸 (Five-Seeds Pill for Abundant Descendants), which is still commonly used today as a treatment for infertility. To return to the Bèi Jí Qiān Jīn Yào Fāng, the wife is next treated for lifelong inability to give birth with a “uterus-rinsing decoction,” to be ingested by the patient while she is kept warm by being wrapped in blankets and, in cold weather, placed on top of a brazier. This complex preparation consists of eighteen ingredients that are decocted in equal parts rice wine and water and taken in four doses throughout the day. This treatment is supposed to induce sweating and cause the discharge of the illness in the form of accumulated blood, which will appear as “cold red pus.” Referred to as “this malign substance” in the womb, the root of the illness is identified as an accumulation of cold blood that has caused pain below the navel, irregular menstruation, and inability to receive the fetus. Sūn Sīmiǎo stresses the importance of consuming an entire preparation of this medicine, if at all possible, because the illness might otherwise not be completely eliminated. On the next day, the woman should be treated with a suppository consisting of pulverized drugs (zàojiá, shānzhúyú, dāngguī, xìxīn, wǔwèizǐ, gānjiāng, dàhuáng, fánshí, róngyán (rock salt), and shǔjiāo) filled into a finger-sized silk bag and inserted into the vagina. This is to be applied repeatedly throughout the day while the patient is to remain in her chamber and rest until she discharges a “cold malign substance” in the form of a green-yellow cold liquid, which again represents the illness being expelled below. The treatment should be concluded with Zǐshí Méndōng Wán 紫石門冬丸 (Fluorite and Asparagus Pill), to be taken until the sensation of heat in the abdomen indicates a successful completion of the treatment.
Next, Sūn Sīmiǎo lists a number of fairly complex medicinal formulas for the treatment of infertility in conjunction with symptoms such as heat above and cold below, inhibited menstruation, the thirty-six illnesses of the Lower Jiāo, the myriad illnesses of vaginal discharge, and the twelve abdominal conglomerations. While the formulas differ based on the reason for infertility, such as the above-mentioned indications or a “blockage of the uterus that is preventing it from receiving the essence,” they all share the goal of inducing a certain type of discharge below that indicates the expulsion of the illness, whether in the form of “long worms and green-yellow liquid,” or “bean juice or snivel.” Thus, in Sūn Sīmiǎo’s eyes infertility was caused by an accumulation of cold blood in the uterus that was treated by expelling it through the vagina, sometimes in combination with a “scrubbing” of the uterus or internal organs. In the midst of these formulas, we find two formulas with significantly less ingredients, said to be “used by the ancients,” but fallen out of use in Sūn Sīmiǎo’s times. The first one treats the husband for insufficiency of Yáng Qì and inability to cause transformation (i.e., in the woman’s womb) or, if transformation did occur, failure to complete it. The second one seems like a rather standard treatment for women’s infertility. Sūn Sīmiǎo precedes these with the caveat that he has no personal experience using them, but has included them because of their popularity in ancient times.
Throughout this section, Sūn Sīmiǎo’s choice of drug ingredients reveals his underlying etiological ideas as well as treatment strategies. The following discussion of medicinal actions is based on the understanding of a substance’s efficacy during the early Táng period. Thus, I follow the descriptions in materia medica literature roughly contemporaneous to the date of composition of the Bèi Jí Qiān Jīn Yào Fāng. For this purpose, I have relied on a critical edition of the Shén Nóng Běn Cǎo Jīng 《神農本草經》 (Divine Farmer’s Classic of Materia Medica), a Hàn period classic that was edited and annotated by Táo Hóngjǐng 陶弘景 in the early sixth century.[2] The edition used here includes this commentary, while attempting to reconstruct the original appearance of the text and can therefore serve as an accurate reflection of materia medica knowledge slightly prior to the time when the Bèi Jí Qiān Jīn Yào Fāng was composed.
According to the descriptions of the medicinal actions of drugs in this text, the formulas for treating infertility in the Bèi Jí Qiān Jīn Yào Fāng contain ingredients like pòxiāo, mǔdān, and táorén, which eliminate evil Qì, break up accumulations, and treat blood stagnation.[3] These are combined with drugs like xìxīn, gānjiāng, jiégěng, and shǔjiāo, which are warming and treat wind, dampness, cough, and counterflow qì ascent, as well as precipitate Qì. We also see drugs like tiānméndōng, niúxī, wǔwèizǐ, and shānzhūyú, which extend life and supplement insufficiencies, treat taxation damage and emaciation, nourish Yīn, and boost Essence and Qì, in addition to the above characteristics of warming, moving blood, or eliminating wind and dampness. This choice of ingredients suggests an understanding of infertility as caused by the inhibited movement of Qì and blood due to vacuity, leading to cold stagnation and accumulations in the abdomen of something that Sūn Sīmiǎo refers to as “this malign substance.” The frequent use of drugs like xìxīn and fángfēng also indicates the notion that infertility might be caused by externally contracted wind-cold, which must be dispersed and expelled by increasing the flow of blood and Qì with supplementing, warming, and down-draining preparations.
In addition to medicinal formulas, the text lists several moxibustion techniques for treating women’s infertility. The choice of moxibustion points is quite carefully differentiated by the particulars of the condition, such as general infertility, inability to have children because the mouth of the uterus is blocked, inability to complete a pregnancy due to miscarriage with abdominal pain and leaking of red discharge, blockage of the uterus so that she is unable to receive the [male] essence, or red and white leakage. Except for one use of Rángǔ 然谷 (KI-2), which is located on the ankle, the other points are all located in the area between the navel and the pubic bone: Guānyuán 關元 (REN-4), Bāomén 胞門 (KI-13), Qìmén 氣門 (EX-7), and Quánmén 泉門 (“Spring Gate,” an otherwise unattested point location). For the most part, these locations are still used today in the treatment of infertility.
Appended to the chapter on fertility is a short but significant section on manipulating the fetus’ gender. As a brief introductory statement explains, the fetus is created by the interaction and mutual stimulation of Yīn and Yáng. Following the standard medical notions of the time, Sūn Sīmiǎo emphasizes that the outer form of the fetus is not settled until the end of the third month of pregnancy and that the mother’s behavior and environment in pregnancy can therefore affect the physical and psychological characteristics of the future child. This notion is the basis for the popular practice of “fetal education” (胎教 tāi jiào), discussed by Sūn Sīmiǎo in the following chapter on pregnancy-related formulas. Regarding the fetus’ gender, early medieval theories of conception and pregnancy were sometimes contradictory, suggesting that until the third month of pregnancy the gender of the fetus was either not fixed yet or that it could be transformed. By the Sòng period, sexual differentiation had become identified with conception in medical literature, and instructions for changing the fetus’ gender were therefore eliminated from elite doctors’ gynecological texts. On the other hand, instructions for influencing the gender of the fetus during the act of intercourse, as for example by timing it in relationship to the woman’s menstrual cycle, became more important.
Being a formula text with unfortunately only short essays, the Bèi Jí Qiān Jīn Yào Fāng fails to provide a conclusive statement on this issue. Nevertheless, the formulas obviously reflect the belief that gender could be manipulated up to the third month of pregnancy, which, in most cases, meant converting a female fetus into a male. Besides a complex formula of medicinals that mostly boost Yáng, Qì, blood, and Essence, Sūn Sīmiǎo also lists several instructions of a decidedly magical flavor, such as the advice to “take a crossbow string, place it in a crimson bag and have the pregnant woman carry it on her left arm” or to tie it around her waist below the belt. Another piece of advice calls for an ax to be hidden under the woman’s bed. All of these actions needed to be performed secretly, a common feature in magical formulas.
To conclude this brief survey of the information on fertility in the Bèi Jí Qiān Jīn Yào Fāng, the following points should be noted:
This section includes formulas for treating male insufficiency of Yáng Qì, as well as a reference to formulas in the section on “nurturing life” that is aimed at men. This shows that responsibility for the inability to generate new life was not placed exclusively with the woman, but was shared between husband and wife. The creation of the fetus was seen as an act performed by two equal partners, with Yīn and Yáng intermingling and stimulating each other. As the essay states, “Yīn and Yáng blend in harmony, the two Qì respond to each other, and Yáng bestows and Yīn transforms.” Jender Lee has shown that in early medieval Chinese medicine, the treatment of infertility was shifted from sexual cultivation texts directed at men, called “texts of the bedchamber” (房中書 fáng zhōng shū), to medical formula literature on women’s health. In this context, more and more attention focused on ensuring the woman’s reproductive health before and during pregnancy with medicinal formulas, rather than on the avoidance of calendrical and other taboos at the time of conception.
While the male cause for infertility is here simply diagnosed as insufficient Qì (and treated in more detail in the section on “supplementing and boosting through sexual intercourse”), the woman’s condition is carefully differentiated on the basis of a sophisticated diagnosis that takes into consideration the appearance of abdominal masses, sensation of cold, menstrual abnormalities, white or red vaginal discharge, and the anatomical shape of her reproductive organs.
In all cases, treatment was directed at causing the discharge of cold blood, sometimes in connection with heat therapy, and the cleansing of the uterus with cold-expelling and precipitating medicinals. The stagnation and accumulation of pathogenic cold in the body’s center was seen as caused by either the invasion of external wind-cold or a deep-lying insufficiency of Yīn, blood, and Qì, which in any case predisposed the patient to the former.
The complexity of the medicinal formulas, requiring numerous non-household medicinal ingredients, suggests that this sphere of women’s healthcare was not limited to care provided by other female household members or local drug peddlers and midwives, but clearly received the attention of concerned male literati like Sūn Sīmiǎo.
In addition to medicinal formulas, Sūn Sīmiǎo also included magical treatments as well as references, in the very first paragraph, to the superior power of astrology and fate, against which even the finest physician was helpless. Thus, Sūn Sīmiǎo recognized that, in this significant area of women’s health, medicinal formulas did not satisfy his readers’ need for different treatment modalities.
[1] Volume 5 of Sūn Sīmiǎo’s Bèi Jí Qiān Jīn Yào Fāng on pediatrics is available in English in my translation as Venerating the Root, Parts One and Two, published by Happy Goat Productions in 2013 and 2015.
[2] For an English translation of this important classic, see Sabine Wilms, The Divine Farmer’s Classic of Materia Medica.
[3] See the Materia Medica Index in the Appendix for a list of medicinal names, alphabetized by Pinyin with characters and common English and Latin identifications.
