By Eric Brand

Gynecology is considered to be one of the most successful fields within Chinese medicine. The importance of fertility in traditional Chinese culture made gynecology a focal point for centuries, so the literature and expertise within the field of gynecology is particularly well-developed. By looking at the evolution of ideas from the earliest classical texts to the modern era, we can gain valuable insight into the fundamental theories and refinements that made Chinese medical gynecology into the advanced field that it is today.

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The literature on gynecology goes back into antiquity. Fertility is mentioned in Chinese oracle bones, the earliest recorded form of Chinese writing. Early classical texts such as the Jin Gui Yao Lue (“Essential Prescriptions of the Golden Coffer”) devoted entire chapters to women’s health, and several of the formulas described within remain in common use today. By examining the traditional literature of gynecology, we can trace the development of Chinese medical theory on important topics such as obstetrics, sexually transmitted diseases, and conception.

The arrival of Western medicine has had a major impact on the field of Chinese medical gynecology. While Chinese medicine is an excellent resource for effective treatment, the specificity of biomedicine in terms of diagnosis and prognosis is critically important for patient care. Things like ovulation and the phases of the menstrual cycle were relatively poorly understood in Chinese medicine until the arrival of Western medicine, and modern innovations such as treatment based on the phases of the menstrual cycle are products of the integrative approach that characterizes the field of TCM gynecology today.

To understand the state of Chinese medical gynecology prior to the arrival of Western medicine, some of our best resources are texts from the Qing dynasty (China’s final dynastic period, which lasted from 1616-1911 CE). Of particular interest are the gynecology sections of the Yi Zong Jin Jian (“The Golden Mirror of Orthodox Medicine”) and the book Fu Qing Zhu Nu Ke (“Fu Qing-Zhu’s Gynecology”). Both of these titles are available in English; the former is published by Paradigm Publications and the latter is published by Blue Poppy Press.

Many readers are doubtless already familiar with Fu Qing-Zhu’s Gynecology. As an individual author, Fu Qing-Zhu's contribution to gynecology was profound and his work is essential reading in the field of Chinese medical gynecology. His book emphasized the importance of the spleen, liver, and kidney, as well as the importance of qi and blood and the chong (penetrating) and ren (controlling) vessels. It contains both theory and formulas, and is a particularly good source for discussions on vaginal discharge. Famous formulas from Fu Qing Zhu’s book include Sheng Hua Tang (Engendering Transformation Decoction), Wan Dai Tang (Discharge-Ceasing Decoction), and Yi Huang San (Transforming Yellow Powder).

By comparison, the Yi Zong Jin Jian (“The Golden Mirror of Orthodox Medicine”) is less familiar to most Western practitioners. While its full set of texts is extremely comprehensive in scope, the entire work is too huge to translate. The Yi Zong Jin Jian is a 90-volume compendium of medical theory and practice that was compiled by court physicians in 1742. It was used as a textbook for the Imperial Medical School in the Qing dynasty, and it was one of the last major Imperial compilations in the history of Chinese medicine.

In the 18th century, Chinese medical literature was vast but somewhat disorganized. Many ancient texts were obscure and riddled by errors in transmission from centuries of copying and reconstruction. Thus, the Chinese Emperor Qian Long commissioned officials at the Imperial Academy of Medicine to “compile a medical book to rectify medicine,” with the intention of surveying the literature to identify consensus and to correct errors in transmission. Top physician-scholars were given unlimited access to the Imperial library and supplies, and together they produced one of the most meaningful works in Chinese medical history, the Yi Zong Jin Jian. Its relatively late arrival and scholastic rigor offers us a unique look into the state of Chinese medicine just prior to the arrival of Western medicine.

In the six-volume gynecology section, the most common topics related to women’s health are presented. Chapters are structured with verses followed by annotations and are dedicated to menstruation, fertility, pregnancy, childbirth and postpartum care. In many historical texts, annotations were written by later generations of physicians in an attempt to clarify ambiguities arising from the terse, formal writing style of the original work. The Yi Zong Jin Jian stands out because its annotations were written by the original authors themselves, so the expanded explanations within are particularly reliable.

Looking at the content of the Yi Zong Jin Jian, we see many places where the modern understanding in Chinese medicine parallels the viewpoint during the Qing dynasty. For example, the modern TCM pattern breakdown and treatment for conditions such as infertility, menstrual pain, and other disorders of menstrual irregularities are often quite similar to the descriptions in the Yi Zong Jin Jian.

In addition to seeing the smooth evolution of the fundamental theories that define our modern treatment strategies, looking at traditional texts allows us to see which concepts endured and which ones did not withstand the test of time. In other instances, we can see the authors reflecting on the classics and offering perspectives that illustrate the consensus opinion of their era. Far from being clinically irrelevant, traditional texts like the Yi Zong Jin Jian show us the long, gradual development of consensus and critical assessment of theory that brought Chinese medicine to where it is today.

For example, in the Yi Zong Jin Jian we see the concept of “invisible worms” mentioned in the pathology and treatment of genital sores in women. The concept of worms is often mentioned in the context of skin diseases in historical Chinese medicine, and the link between worms and genital sores dates back at least to the Zhu Bing Yuan Hou Lun (“The Origin and Indicators of Disease”), written in 610 CE. Indeed, many medicinals in use today for skin diseases were traditionally ascribed a “worm-killing” action. However, even though we use similar medicinals and we may attempt to draw parallels between “worms” and various fungi, bacteria, and parasites that cause disease, few practitioners today believe that genital sores are actually caused by invisible worms (the original text says that “sores form as the worms feed”). Furthermore, it is likely that some of the severe presentations of genital sores described in pre-modern literature were cancerous lesions, so our current understanding tends to trump the ancient literature when it comes to decisions affecting patient care.

The Yi Zong Jin Jian demonstrates conscious critical assessment of ancient knowledge, and it devoted great space to both preserving and analyzing material from classics such as the Shang Han Lun (“On Cold Damage”) and the Jin Gui Yao Lue (“Essential Prescriptions of the Golden Coffer”). For example, plum-pit qi was initially thought to be a disease that affected women exclusively. It was first described in the Jin Gui, which stated that women suffered from this condition and Ban Xia Hou Po Tang (Pinellia and Magnolia Bark Decoction) governed its treatment. (This is also the first historical mention of the pathomechanism that would later become known as liver depression with phlegm binding in the throat.) Over 1500 years after the Jin Gui was written, the Yi Zong Jin Jian explicitly pointed out that this pattern existed in men as well as women, an idea that has remained with us to the present day.

By examining the traditional literature, we can gain unique insight into the culture that created Chinese medicine. Many sections of the Yi Zong Jin Jian allow us to better understand the state of Chinese medicine as it was practiced centuries ago. Of particular interest are attitudes on topics like sexuality and gender, which are often difficult to assess in pre-modern medical texts.

It is difficult to generalize about sexual attitudes in China over the long history of Chinese medicine; some dynastic periods were quite conservative and others were comparatively open. In the Qing dynasty when the Yi Zong Jin Jian was written, China was relatively sexually conservative, and we can see the influence of this conservatism on medicine.

For example, consider the following quote from a section entitled “Women’s Illnesses are Difficult to Treat.” The text states: “Kou Zong-Shi said that he would rather treat ten men than one woman, meaning that women’s disorders are usually not easy to treat. Because women are sequestered, they are melancholic, anxious, indignant, suspicious, and confused about their preferences. They do not get what they want, and they are stubborn and obstinate. Even during consultation, physicians are not allowed to observe a woman’s physical appearance, inspect her complexion, listen to her voice, or inquire of her illness. In an affluent family, a woman stays behind a curtain in her private room and covers her hands with a handkerchief. Not only is inspecting the complexion impossible, but a thorough pulse examination technique is also impossible. If a doctor must ask about the details of the illness, the patient will feel the questions are overly complicated, suspect him of not being an expert in medicine, and then will not trust him enough to take the prescribed medicine…”

The passage above illustrates how conservative sexual mores complicated diagnosis by excluding direct palpation and observation in elite families. In addition, it allows us to see historical physicians’ reflections on gender roles and the perceived health effects of social issues such as gender inequality. In another example, this time from the section on internal causes of menstrual disorders, the text states: “Women must follow others and do not control all aspects of their own lives. The resulting anxiety, thought, rage, anger, and depressed qi can all cause damage. Thus, most menstrual disorders are due to damage from the seven affects.” These quotes show us about the cultural circumstances surrounding medical practice in the Qing dynasty, and they offer us unique insight into the theories and therapies that physicians developed in response to these circumstances.

Interestingly, we see other sections of the text that suggest that the absence of sexual activity needs to be considered when assessing pathology in certain patient populations. In the Yi Zong Jin Jian’s gynecology section, we see that celibate women (grouped as Taoist nuns, Buddhist nuns, maidens, and young widows) were considered to require different therapy than normal women. The text states: “[Require] different therapy means treatments for such women are different from those for ordinary women. If the pulse examination on the wrist reveals a stringlike pulse, then you will know the woman’s mind has unfulfilled emotions, and the disease is from an emotional cause. No matter what menstrual disorder one aims to regulate, if this cause is not recognized, then one cannot understand the complicated emotions and miscellaneous difficult diseases. Treatment of this pattern should harmonize the liver, rectify the spleen, open depressed qi, and clear heart fire. Treating according to the pattern, one naturally will succeed.”

Throughout the Yi Zong Jin Jian, we see a heavy emphasis placed on proper diagnosis and pattern-based treatment. This remains an essential feature of Chinese medicine up to the present day. By studying traditional medical texts, we learn more about Chinese medicine’s cultural roots. Our unique vantage point in history allows us to have more classical texts available than even the Emperors had in days gone by, and the study of these texts gives us a special opportunity to examine the evolution of ideas within Chinese medicine. It is amazing how much timeless wisdom has endured, and it is also highly insightful to see the ways in which Chinese medicine has advanced and adapted to the modern world. Many top experts have a profound appreciation for classical texts, and I hope that the new generation of practitioners will help maintain this tradition of scholarship, preservation, and research that has characterized our field for centuries.