Obstetrics and Gynecology in Chinese Medicine

CHAPTER 1 History of Gynecology in Chinese Medicine

Like all branches of Chinese medicine, traditional gynecology has a long history. The earliest records of gynecological medical writings date from the Shang dynasty (1500–1000 BC): bones and tortoise shells have been found with inscriptions dealing with childbirth problems. The text Book of Mountains and Seas from the Warring States period (476–221 BC) describes medicinal plants to treat infertility.

The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen) has many references to women’s physiology, anatomy, diagnosis and treatment of gynecological problems. It describes the function of the Uterus and states its connection to the Heart and Kidneys via the Bao Mai (Uterus Vessel) and Bao Luo (Uterus Channel) respectively. For example, the Simple Questions in Chapter 33 says:

In amenorrhoea, the Uterus Vessel is shut. The Uterus Vessel pertains to the Heart and communicates with the Uterus; when Qi rebels upwards to press towards the Lungs, Heart-Qi cannot flow downwards and amenorrhoea results.¹

In Chapter 47 it says: “The Uterus Channel connects with the Kidneys; the Kidney channel reaches the root of the tongue.”²

The very first chapter of the Simple Questions describes the hormonal changes occurring in women at 7-year intervals and attributes these to the waning and waxing of the Directing and Penetrating Vessels. The Simple Questions also describes the aetiology and treatment of amenorrhoea and menorrhagia.

The first chapter of the Simple Questions mentions for the first time the important substance Tian Gui. Tian Gui is a transformation of Kidney-Essence that occurs at puberty. In men, it is sperm; in women, it is menstrual blood and ova. Chapter 1 of the Simple Questions says: “When a girl is 14, the Tian Gui arrives, the Directing Vessel is open and the Penetrating Vessel flourishing, the period arrives and she can conceive.”³

That gynecology already existed as a speciality during the Warring States period is recorded in the Historical Annals (Shi Ji) which refers to the famous doctor Bian Que as one who ‘treats diseases under the skirt belt’ (Dai Xia Yi), i.e. a gynecologist. During the Han dynasty (206 BC–AD 220), a gynecologist was called a ‘breast doctor’ (Ru Yi) or ‘women’s doctor’ (Nu Yi). The earliest recorded gynecologists under that name were two doctors called Yi Xu and Chun Yu Yan who treated one of the empresses during the Western Han dynasty (206 BC–AD 24).

The famous doctor Zhang Zhong Jing refers in his work Discussion on Cold-induced Diseases (Shang Han Lun) to a previous book entitled Series of Herbs for Obstetrics (Tai Lu Yao Lu) which proves that even before the Han dynasty there were books dealing exclusively with gynecology, but all of these have been lost. The Discussion of Prescriptions of the Golden Cabinet (Jin Gui Yao Lue Fang Lun) by the same author has three chapters on gynecology, i.e. ‘On pregnancy’, ‘Post-partum diseases’ and ‘Women’s miscellaneous diseases’. These chapters discuss disorders of menstruation, leucorrhoea, pregnancy, miscellaneous diseases and post-partum problems. Over thirty gynecological formulae are discussed, e.g. Wen Jing Tang Warming the Menses Decoction, Jiao Ai Tang Donkey’s Hide Glue-Artemisia Decoction, Dang Gui San Angelica Powder, Gan Jiang Ren Shen Ban Xia Wan Zingiber-Ginseng-Pinellia Pill, Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill, etc. All these formulae are still widely used nowadays. These three chapters on gynecology represent one of the earliest gynecological treatises and they formed the model upon which subsequent books were based.

The Pulse Classic (Mai Jing, AD 280) by Wang Shu He, a famous doctor of the Jin dynasty (265–420), describes pulse pictures and differentiation of women’s diseases in Volume 9. This book constitutes an assimilation and systematization of the gynecological material from earlier texts, notably the Yellow Emperor’s Classic of Internal Medicine, the Classic of Difficulties and the Synopsis of Prescriptions from the Golden Cabinet. Wang Shu He also added a wealth of comment from his personal experience in the gynecological field. For example, he says that “The Kidneys govern the Uterus, and its condition is reflected at the Rear position of the pulse. If the pulse at this region does not fade on pressure, it indicates pregnancy.”⁴ In another passage he says that “A superficial pulse accompanied by abdominal pain referred to the midline of the lower back, indicates impending labour.”⁵ The book also describes the qualities of the pulse before an imminent miscarriage, normal and abnormal pulses during the post-partum stage and pulses in women with abdominal masses in relation to prognosis.

During the Sui dynasty (581–618), Chao Yuan Fang wrote the General Treatise on the Symptomatology and Aetiology of Diseases (Zhu Bing Yuan Hou Zong Lun, AD 610) which deals with gynecology and obstetrics in Volumes 37 to 44. The book describes 283 syndromes covering diseases of menstruation, leucorrhoea, pregnancy and post-partum diseases.

The Thousand Golden Ducat Prescriptions (Qian Jin Yao Fang, AD 652) written by Sun Si Miao during the Tang dynasty (618–907) has three volumes dealing with gynecology, including the differentiation and treatment of infertility, diseases of pregnancy, menstruation, leucorrhoea, etc., with hundreds of formulae for these diseases. Sun Si Miao made the interesting observation that a metal knife should never be used to cut the umbilical cord: from a modern perspective, this was an important recommendation as, if dirty, a metal instrument could easily provoke a tetanus infection.

The Treasure of Obstetrics (Jing Xiao Chan Bao), written during the Tang dynasty, is the earliest obstetrics book. The book contains 12 chapters on diseases of pregnancy, 4 chapters on difficult labour and 25 chapters on post-partum diseases. Diseases of pregnancy discussed include morning sickness, bleeding, threatened miscarriage, miscarriage, urinary problems and oedema. The discussion on labour problems includes formulae for promoting labour, and on dealing with a dead fetus, prolonged labour or retention of placenta. The discussion on post-partum diseases includes tetanus, puerperal infections, abdominal pain, persistent bleeding, retention of urine, insufficient lactation and mastitis.

During the Song dynasty (960–1279), the imperial medical college was staffed by 300 people; there were nine departments, one of which was obstetrics and gynecology. This was probably the earliest medical school department dedicated entirely to gynecology and obstetrics. The specialization fostered by the division of the imperial medical college into different departments stimulated the development of the various specialties, among which was gynecology. This led to the publication of many books specializing in obstetrics and gynecology, an important one being the Great Treatise of Useful Prescriptions for Women (Fu Ren Liang Fang Da Quan, 1237) written by Chen Zi Ming during the Southern Song dynasty. The book comprises 24 volumes including 20 chapters on menstrual diseases, 91 on miscellaneous diseases, 10 on infertility, 8 on ‘fetal education’, 9 on pregnancy problems, 70 on post-partum diseases and 10 on boils and ulcers. More than 260 diseases are discussed in all with various formulae for each. This book exerted a profound influence on the development of obstetrics and gynecology in subsequent dynasties.

During the Jin and Yuan dynasties (1115–1368) many different medical schools of thought flourished, among which the main ones were those headed by Liu Wan Su, Li Dong Yuan, Zhu Dan Xi and Zhang Zi He. Liu Wan Su (1120–1200) maintained that Fire is the primary cause of disease and he therefore advocated the use of cold herbs in gynecological problems. For example, he attributed amenorrhoea to Heart-Fire. He also advocated treating the Kidney channel in girls before puberty, the Liver channel in young women and the Spleen channel in post-menopausal women. He also paid attention to modifying gynecological formulae according to the seasons. Recognizing the influence of the seasons on medical conditions, he advocated doubling the dosage of Chuan Xiong Radix Chuanxiong within the formula Si Wu Tang Four Substances Decoction during springtime, doubling Bai Shao Radix Paeoniae alba in summertime, doubling Shu Di Huang Radix Rehmanniae preparata during the autumn and doubling Dang Gui Radix Angelicae sinensis in wintertime. He also suggested adding Fang Feng Radix Saposhnikoviae in springtime, Huang Qin Radix Scutellariae in summertime, Mai Men Dong Radix Ophiopogonis in the autumn and Gui Zhi Ramulus Cinnamomi in winter.

Li Dong Yuan (1180–1251) was the founder of the ‘School of Stomach and Spleen’ which emphasized a disharmony of these two organs as the main aetiology and pathology of diseases. He therefore advocated tonifying the Stomach and Spleen as the main method of treatment in gynecology too. In his book Secret Record of the Orchid Chamber (Lan Shi Mi Cang), he says that prolonged deficiency of the Stomach and Spleen leads to amenorrhoea, and that to treat this, one needs to clear Stomach-Heat, generate Stomach fluids and tonify Qi and Blood. He says that uterine bleeding is due to deficiency of the Stomach and Spleen, arousing Minister Fire of the Kidneys and causing Damp-Heat to infuse downwards: to treat this he advocates tonifying the Stomach and Spleen and raising Qi.

Zhu Dan Xi (1281–1358) maintained that “Yang is often in excess and Yin is often deficient” and therefore advocated nourishing Yin as one of the most important treatment principles. For example, for problems before childbirth he advised clearing Heat and nourishing Blood. He also indicated Huang Qin Radix Scutellariae and Bai Zhu Rhizoma Atractylodis macrocephalae as two important herbs to prevent miscarriage.

Zhang Zi He (1156–1228) treated diseases by the three methods of sweating, vomiting and moving downwards. He used tonics only after first using herbs that eliminate pathogenic factors, since one cannot tonify when these are present. He applied this method to gynecological diseases as well, often advocating that the patient be made to vomit and using downward-moving methods of treatment to eliminate Phlegm and Water in menstrual problems.

The doctors of the Ming dynasty (1368–1644) consolidated and integrated the theories of these four great schools of medical thought. Many important gynecological books were written during the Ming dynasty, e.g. Standards of Diagnosis and Treatment of Women’s Diseases (Zheng Zhi Zhun Sheng – Nu Ke, 1602) by Wang Ken Tang, Summary of Gynecology and Obstetrics (Nu Ke She Yao, 1548) by Xue Ji, Summary of Fertility (Guang Si Ji Yao) and Women’s Secrets (Fu Ren Mi Ke) by Wan Quan. He said that, in order to conceive, the man should clear his Heart and control his sexual desire to nourish the Essence, while a woman should calm her Mind and settle Qi to nourish Blood. The above-mentioned Standards of Diagnosis and Treatment by Wang Ken Tang summarized the experience of doctors of previous generations in the treatment of gynecological diseases. His book dealt with menstrual problems, miscellaneous diseases, pregnancy problems and post-partum diseases. Wu Zhi Wang adopted this book as a chief source to write his Compendium of Therapy of Women’s Diseases (Ji Yin Gang Mu, 1620) which became an authoritative text for subsequent generations of gynecologists. The Complete Works of Jing Yue (Jing Yue Quan Shu, 1624), by Zhang Jing Yue, has an extensive section on gynecology and obstetrics discussing the treatment of problems of pregnancy and labour, leucorrhoea, breast diseases, fertility, abdominal masses and menstruation. Zhang Jing Yue recommended paying particular attention to regulating menstruation in gynecological diseases. He said that the key to regulate menstruation is to nourish Blood by tonifying the Stomach and Spleen and calming the chamber of Blood by tonifying the Kidneys. On the question of whether the Spleen or the Kidneys was the more important organ, he decided in favour of the latter.

During the Qing dynasty (1644–1911) many gynecological treatises were written. The three most important ones were Fu Qing Zhu’s Gynecology (Fu Qing Zhu Nu Ke) by Fu Qing Zhu (1607–1684), the Golden Mirror of Medicine (Yi Zong Jin Jian, Vol. 3, 1742) by Wu Qian and the Treatise on Obstetrics (Da Sheng Bian, 1715) by Ji Zhai Ju Shi (a pseudonym meaning ‘the Buddhist of Ji House’).

Fu Qing Zhu’s Gynecology is unlike any other gynecology book insofar as the author proposes his own personal, and often unorthodox, ideas on the pathogenesis and treatment of gynecological diseases and his formulae are unlike any of those from previous gynecological books. One of the central theses of Fu Qing Zhu’s book is that the Kidneys are the most important organ for the menstrual function as they are the origin of menstrual blood. According to him, menstrual blood is unlike normal ‘Blood’: it is a precious fluid derived from the Kidney-Essence. His book discusses the differentiation and treatment of menstrual problems, pregnancy, post-partum diseases, infertility, leucorrhoea and labour, with the different patterns and formulae for each.

The gynecology volume of the Golden Mirror of Medicine by Wu Qian discusses the pathology and treatment of menstrual problems, leucorrhoea, pregnancy, labour, post-partum diseases, abdominal masses and miscellaneous diseases. One particular feature of this book is that it is written in a style that is easy to read.

The Treatise on Obstetrics focuses on diseases of pregnancy, management of normal and difficult labour, and post-partum diseases.

During the late Qing dynasty, Western medicine was introduced to China and integrated with Chinese medicine. The two principal doctors who advocated the integration of Chinese and Western medicine were Tang Zong Hai (1862–1918) and Zhang Xi Chun (1860–1933). These doctors did not write specialized books on gynecology but they did discuss gynecological and obstetric problems in their works. For example, in his book Discussion on Blood Syndromes (Xue Zheng Lun, 1885), Tang Zong Hai discusses the treatment of menstrual problems, uterine bleeding, stasis of Blood, accumulation of Blood, amenorrhoea, etc. Zhang Xi Chun paid special attention to regulating Spleen and Kidneys and invigorating Blood in treating gynecological diseases. He formulated several important prescriptions such as Li Chong Tang Regulating the Penetrating Vessel Decoction, An Chong Tang Calming the Penetrating Vessel Decoction, Gu Chong Tang Consolidating the Penetrating Vessel Decoction and Shou Tai Wan Fetus Longevity Pill in his book Records of Combined Chinese and Western Medicine (Yi Xue Zhong Zhong Can Xi Lu, 1918).

Since 1949, the combination of Western and Chinese medicine has been emphasized and many innovative treatments have been devised. For example, ectopic pregnancy is often treated with acupuncture and Chinese herbs without recourse to surgery; acupuncture is used in breech presentation of the fetus; Chinese herbs are used in the treatment of myomas and cervical carcinoma, etc. Since the major colleges of traditional Chinese medicine were established in 1956, many modern gynecology textbooks have been published and the ancient ones reprinted.