What we refer to as infertility treatments in modern medicine was in early China included in the medical category of qiu zi (), literally “the quest for children.” For cultural, social, and philosophical reasons, the significance of this topic in the historical Chinese context can hardly be overstated. It was therefore discussed not only in technical medical literature, but also in philosophical and cosmological texts, from both a Daoist and a Confucian angle.

On the one hand, what we traditionally identify as the Confucian perspective is a prescriptive set of ideas that is concerned with life in this world, in a socially meaningful and productive way that takes the cultivation of the self, the family, and the state as its goal. Harmony, balance, moderation, and order within and between these spheres of existence are necessary to ensure survival and continuity in the ever-changing cycle of life. In this context, women were recognized as essential participants for their role of producing and rearing male offspring, to guarantee the continuation of the family line from the past through the present into the future.

In contrast to the social, moral, and political orientation of Confucianism, Daoist texts and authors focused on the natural world and the cosmic order as it was reflected not in the human realm but in the larger scheme of things. In that context, human reproduction was a mirror image, a metaphor, a window into the obscure processes of cosmogenesis and of birth, maturity, decay, and death that occurred in unceasing succession in all realms of the natural world.

Understanding this process of change was essential to the ultimate goal of Daoism, namely to exist in harmony with the dao ( “way”), the way of the universe, which was expressed in the ideal of wu wei ( “non-action,” but more accurately perhaps “not acting against the dao”).

Considering the interpretation of reproduction in all early Chinese philosophical traditions, we understand why we find detailed references to the processes of conception, gestation, and childbirth in texts that we would otherwise classify as philosophical or cosmological. This multifaceted interest in the “quest for children” by male elite writers in early China should be kept in mind when we look at the information presented in the following paragraphs.

The following description of early medieval Chinese practices is drawn from a 7th-century text: the Bei Ji Qian Jin Yao Fang (), composed by Sun Simiao () around 652 CE. The title can be translated as Essential 1000-Gold Formulary for Emergencies and is in the following paragraphs abbreviated as Qian Jin Fang.

In this groundbreaking medical encyclopedia of over 5000 entries, the three volumes titled Formulas for Women form the first major section in the text, followed by pediatrics, general medicine, and, lastly, life-prolonging self-cultivation techniques. The information found in this text is of a clinical nature and was clearly intended for practical application. In addition to its intended use as medical knowledge on diagnosis, etiology, and therapy, it can also tell us indirectly about early Chinese culture, particularly in regard to views on gender.

“The reason why women have special formulas is that they are different because of pregnancy, childbirth, and flooding damage (i. e., abnormal vaginal bleeding). Therefore, women’s diseases are ten times more difficult to treat than men’s. It is a classic saying that ‘women are copious accumulations of yin and are constantly inhabited by dampness.’

From the age of fourteen on, [a woman’s] yin qi floats up and spills over, [causing] a hundred thoughts to pass through her heart. Internally, it damages the five viscera; externally, it injures the outward appearance. The discharge and retention of menstrual fluid is alternatingly early or delayed, stagnant blood lodges and congeals, and the central pathways are interrupted and cut off. It is impossible to discuss the entirety of damages and losses among these [conditions]. The raw and the cooked are deposited together [during digestion], vacuity and repletion intermingle with each other in confusion, malign blood leaks internally, and the qi in the vessels is injured and exhausted. [The woman’s] intake of food and drink might have been intemperate, causing not just a single injury. Or she may have had sexual intercourse before [vaginal] sores have healed. Or she may have squatted over the privy without proper care, [allowing] wind to enter from below and thereby giving rise to the twelve intractable diseases. For these reasons, special formulas have been established for women. In cases where the nodal qi over the four seasons has caused illness and where vacuity or repletion of cold or heat have caused worry, then [women are treated] the same as men, the only exception being that if they fall ill while carrying a fetus in pregnancy, you must avoid toxic medicines!

In cases where their miscellaneous diseases are identical to men’s, [the treatments] are dispersed throughout the various volumes and can be known from there. Nevertheless, women’s predilections and desires exceed men’s and they contract diseases at twice the rate of men. In addition, when they are affected by compassion and attachment, love and hatred, envy and jealousy, and worry and rancor, these become firmly lodged and deep-seated. Since they are unable to control their affects by themselves, the roots of their diseases are deep and it is difficult to obtain a cure in their treatment.’

In these paragraphs, Sun Simiao constructs a multifaceted explanation for the medical need to recognize the female body as different. His discussion takes into consideration not only physiological factors, but also psychological and even cultural ones, all of which cause the diseases of women to be “ten times more difficult to treat than men’s.” This essay is a powerful appeal to physicians’ humanitarian duty to heal female bodies, which are seen as particularly vulnerable for several reasons.

Because of the stresses of pregnancy, childbirth, and resulting hemorrhaging, they are prone to vacuity (xu ), which could lead to any number of physical and psychological problems. In addition, women’s excess of yin qi associated with sexual maturation causes emotional instability, damage to the internal organs, menstrual disorders, and problems with the flow of blood and qi in the channels. When we read the essay above in conjunction with the individual formula entries that follow, the etiologies expressed by Sun Simiao reflect the notion that a vacuous female body, forced open in the process of childbirth, is liable to an invasion by cold and wind. Sneaking in through the vagina, these external pathogens can attack and block blood and qi in the channels and from there wreak havoc in any of the internal organs for years to come. Moreover, it turns out that the most dangerous pathology for women, in Sun’s eyes, is the lingering presence of a substance called “malign dew” (e lu ).

To this day, a traditional Chinese woman’s postpartum recovery is often covered by a host of taboos aimed at protecting her from premature contact with society and the natural environment. Postpartum taboos in the early gynecological literature express, on the one hand, the authors’ paternalistic concern for the mother’s extremely depleted and vulnerable physical state. On the other hand, though, the numerous references to magicoreligious etiologies and treatments reflect a simultaneous awareness of the pathogenic powers of the blood of childbirth and the risks of handling this substance.

To cite just one example, several centuries after the Qian Jin Fang, Chen Ziming () (ca. 1190–1270 CE) compiled the Fu Ren Da Quan Liang Fang (Comprehensive Good Formulas for Women ) in 1237. In particular, the section on childbirth contains a large percentage of religious treatments like invocations, talismans, astrological calculations, divinations, and various rituals to prevent offending the spirits during childbirth. Found in the lengthy discussion of postpartum taboos is even a strict warning that laundry that has been stained by the fluids of childbirth must not be dried in the sunlight, or one will risk injury by evil spirits.

To return to Sun Simiao’s introductory essay, the effects of women’s reproductive functions range from a general state of vacuity to specific conditions like emotional volatility during menstruation or the presence of rotting blood in the uterus for years after childbirth. This underlying and often invisible vulnerability can then lead to severe injuries from fairly harmless secondary causes like an immoderate diet, sexual intercourse during menstruation or too soon after childbirth, or an invasion of wind by an innocent visit to the outhouse.

After stressing that “women’s cravings and desires exceed their husbands’…they contract illness at twice the rate of men and…because they are unable to control their emotions, the roots of their disorders are deep,” the essay concludes by emphasizing the importance of childbearing for society at large. In the course of this argument, Sun first states that reproduction plays a central role in women’s lives since “bearing children is the adult role in women’s destiny and fate.” Going further, he even advises that “specialists in the art of nurturing life (yang sheng zhi jia ) should particularly instruct their sons and daughters to study these three volumes of women’s recipes until they comprehend them thoroughly” to prepare for any “harvests of unexpected surprises” and “to prevent premature and wrongful death.” Even servants involved in childcare “cannot afford not to study them. Thus, they should routinely write out a copy and carry it on their person, clutched to their bosom, in order to guard against the unexpected.”

In a subtle but highly significant twist, Sun Simiao hereby extends the elite practice of macrobiotic hygiene, that is, physical cultivation with the purpose of prolonging one’s life, to cover not only the practitioner’s individual body but to also include past and, most importantly, future generations. The importance of female bodies in this context becomes immediately obvious, a fact that the ancient sages had already recognized. Protecting and preserving women’s health was therefore an essential task for any elite gentleman, since it could, if neglected or ignored, result in potentially grave consequences for society as a whole. This respect for the female body was doubtlessly further strengthened by Sun Simiao’s personal and active involvement as a Daoist priest and practitioner of religious cultivation. In stark contrast with the negative association of the female body with impurity, transgression, and material desire in Buddhism, it was celebrated in Daoism for its identification with yin as complementary to yang, and with motherhood and the ability to give and nurture life.

Before offering treatments though, Sun Simiao 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 phases) and the astrological constellations at the time of conceiving the fetus are inauspicious. If their birth signs are in harmony, however, they will still need to pay heed to Sun Simiao’s medical advice and also guard against breaking taboos against sexual intercourse at inauspicious times, in order to ensure their own and their offspring’s future health and good fortune. Editors of the Qian Jin Fang from the Song period insert a reference here that methods for determining the right time and day for “receiving a fetus” (shou tai ) are found further back in the Qian Jin Fang in Volume 27 on “nurturing life” (yang sheng ). It is interesting to note that these “methods for taboos and restrictions [on sexual intercourse]” are in a manuscript edition of this text cited in the category for “the quest for children” and were therefore considered part of the Formulas for Women. This would suggest that methods of sexual intercourse aimed at safeguarding and improving the result of conception (i. e., the fetus) were in early China sometimes considered under the category of fertility treatments and sometimes under the category of longevity practices.

In other contemporaneous medical literature, such as the Wai Tai Mi Yao (Arcane Essentials from the Imperial Library) and Ishimpo (in Chinese, Yi Xin Fang), considerable space is devoted to these taboos and prognostications about the child’s and parents’ future in the section on “the quest for children.” In a slight shift of emphasis, Sun Simiao offers a purely medical etiology of infertility in the next essay. Here, he states:

“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 in contrast to the popular notions of his time, most notably the Zhu Bing Yuan Hou Lun (On the Origins and Symptoms of the Various Diseases ), which states:

“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 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 benefit.”

Similar sentiments are expressed in the calendrical and astrological sections on childlessness in the Wai Tai Mi Yao, Ishimpo, and Qian Jin Fang cited above. Following this reference to non-medical causes of childlessness, Sun Simiao 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 Sun Simiao’s Formulas for Women:

In order to prevent or treat the medical cause of infertility, which Sun Simiao has previously identified as the “five taxations and seven damages and the hundred illnesses of vacuity and emaciation,” the author 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 qi, by supplementing his insufficiencies with Qi Zi San ( Seven Seeds Powder). The famous Yuan dynasty physician Zhu Zhenheng () (alternatively, Danxi ) later developed this formula into Wu Zi Yan Zong Wan ( Five Seeds Pills for Abundant Descendants), which is still used today as a treatment for infertility.

The treatment should be concluded with Zi Shi Men Dong Wan ( Fluorite and Asparagus Pills), to be taken until the sensation of heat in the abdomen indicated a successful completion of the treatment.

Next, Sun Simiao 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 36 diseases of the lower burner, the myriad diseases of vaginal discharge, and the 12 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 [man’s] 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, it appears that in Sun Simiao’s eyes, infertility was caused by an accumulation of cold blood in the uterus that was treated by expelling it via 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 Sun Simiao’s times. The first one treats the husband for insufficiency of yang qi 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. Sun Simiao 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, Sun Simiao’s choice of medicinal 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 Tang period. Thus, I follow the descriptions in materia medica literature roughly contemporaneous to the date of composition of the Qian Jin Fang. For this purpose, I have relied on a critical edition of the Shen Nong Ben Cao Jing ( Divine Farmer’s Classic of Materia Medica), a Han period medicinal text that was edited and annotated by Tao Hongjing () in the early 6th century.

This text can therefore serve as an accurate reflection of materia medica knowledge slightly prior to the time when the Qian Jin Fang was composed. According to the descriptions of the actions of medicinals in this text, the formulas for treating infertility in the Qian Jin Fang contain medicinals like po xiao (impure mirabilite ), mu dan (moutan ), and tao ren (peach kernel ) that eliminate evil qi, break up accumulations, and treat blood stagnation. These are combined with other medicinals: xi xin (asarum ), gan jiang (dried ginger ), jie geng (platycodon ), and shu jiao (zanthoxylum ). These are warming, treat wind, dampness, cough, and counterflow qi ascent, and precipitate qi. They are also combined with medicinals like tian men dong (asparagus ), niu xi (achyranthes ), wu wei zi (schisandra ), and shan zhu yu (cornus ) that extend life and supplement insufficiencies, treat taxation damage and emaciation, nourish yin, and boost essence and qi, in addition to the above characteristics of warming, moving blood, or eliminating wind and dampness.

This choice of ingredients suggests a notion of infertility as caused by the inhibited movement of qi and blood due to vacuity, which in turn leads to cold stagnation and accumulations in the abdomen of a substance that Sun Simiao refers to as “this malign substance.” The frequent use of medicinals like fang feng (asarum and saposhnikovia ) also indicates the notion that infertility might be caused by externally contracted wind-cold, which had to be dispersed and expelled by increasing the flow of blood and qi with supplementing, warming, and down-draining preparations.

• 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
  
• red and white leakage

Except for one use of ran gu ( Blazing Valley), which is located on the ankle, the other points are all located in the area between the navel and the pubic bone: guan yuan ( Pass Head), bao men ( Uterine Gate), qi men ( Qi Gate), and quan men ( Spring Gate). These are for the most part still used today for the treatment of infertility.

Appended to the chapter on fertility is a short but significant section on manipulating the fetus’s gender. As a brief introductory essay explains, the fetus is created by the interaction and mutual stimulation of yin and yang.

According to the standard medical notions of the time, the shape of the fetus was not settled until the end of the third month of pregnancy, and the mother’s behavior and environment could therefore affect the fetus’s physical and psychological characteristics. This was the basis for the popular practice of “fetal education” (tai jiao ), discussed by Sun Simiao in the following chapter on pregnancy-related formulas. Regarding the fetus’s gender, early medieval theories of conception and pregnancy are sometimes contradictory, suggesting either that the gender of the fetus was not yet fixed or that it could be transformed until the third month of pregnancy.

By the Song period, sexual differentiation had become identified with conception in medical literature, and instructions for changing the fetus’s 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, become more important. Being a formula text with only short essays, the Qian Jin Fang 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 yang, qi, blood, and essence, Sun Simiao 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 method 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. Interesting in this section is the curious combination of medical and magical thinking, but even the medicinal formulas include such ingredients as dog testicles and the head of a rooster from the top of the eastern gate.

The second major category of the Formulas for Women volumes in the Qian Jin Fang covers pregnancy and comprises almost a quarter of the entire gynecological section. It is divided into three sections: “malign obstruction in pregnancy,” “nurturing the fetus,” and “the various diseases of pregnancy.”

The comparatively short section on “malign obstruction in pregnancy” (ren shen e zu ) contains two long essays and four formulas. The first essay describes a method for determining whether a woman is pregnant and for predicting the gender of the fetus and the time of birth, by diagnosing the pulse. Several important ideas about conception, pregnancy, and fetal development can be deduced from this advice:

• The fetus is created through the harmonious intermingling of blood and qi, yin and yang.
  
• Pregnancy is diagnosed by detecting increased movement and blood flow in the pulse of either the heart vessel, which governs the flow of blood, or of the kidney vessel, which governs reproduction.
  
• By the fourth month, the fetus’s gender is fixed and can be diagnosed by the characteristics of the pulse (deep and replete for a boy, big and floating for a girl).

Sun Simiao also mentions several simpler methods for diagnosing the gender, such as:

• inducing the woman to spontaneously turn to the left (for a boy) or right (for a girl) or
  
• finding lumps in the right or left side of the husband’s chest.

This section is reminiscent of folk advice given all over the world. It is significant that Sun Simiao chose to transmit this advice alongside and as equal to what we would consider more properly medical and sophisticated methods of pulse diagnosis, which were by necessity the domain of an educated physician with sufficient training and experience to distinguish such subtle differences.

The remainder of this chapter concerns the etiology and treatment of “malign obstruction” in pregnancy in strictly medical terms. It defines the condition as a combination of physical and psychological symptoms caused by the presence of wind-cold, a pathological accumulation of fluids below the heart, as well as a general stagnation of qi and blood. These are in turn ultimately due to the quintessentially feminine problems of vacuity and emaciation from taxation damage, insufficiency of qi and blood, and additional weakness of kidney qi, potentially aggravated by exposure to wind.

The next section on “nurturing the fetus” (yang tai ) begins with an essay on “fetal education” (tai jiao ). This practice is aimed at creating a model descendant who is “long-lived, loyal and filial, humane, righteous, intelligent, wise, and free of disease.”

This information is standard and similar to advice cited in many other early texts. Following these instructions on fetal education, the Qian Jin Fang contains a varied list of prohibited foods, with the more mundane goal of preventing miscarriage, childbirth complications, or physical deformities.

Then, Sun Simiao quotes “Xu Zhicai’s Monthby-month Formulas for Nurturing the Fetus,” a text that is also cited in many other early medical texts: from the Tai Chan Shu ( Book of the Generation of the Fetus), early Han period, to the Zhu Bing Yuan Hou Lun (On the Origins and Symptoms of the Various Diseases), early seventh century, and the Ishimpo (Formulas from the Heart of Medicine), tenth century, where it is identified as a quote from yet another text.

At times almost literally identical to the Ishimpo version, the quotation in the Qian Jin Fang describes the monthly progress in the fetus’s gestation and notes the foods and acupuncture channels prohibited in each month. It also includes two decoction formulas for each month, one for the treatment of pathologies likely to occur during that month and the other for the treatment of damage to the fetus.

The last subsection of pregnancy treatments consists of “medicines for lubricating the fetus” (hua tai yao). This is an important category of prescriptions, taken during the final stage of pregnancy to prepare the mother and fetus for childbirth and to ease labor, which is still used today. As a whole, this section stands out for the nuanced descriptions of symptoms and the specificity and complexity of the formulas. This suggests that prescribing medicinal decoctions for nurturing the fetus and in preparation for delivery were two areas of women’s medical care that educated medical practitioners, whether professional or amateur, were actively engaged in during the time of the composition of the Qian Jin Fang.

The last chapter in this section, on the “various diseases of pregnancy” (ren shen zhu bing ), presents a more diverse treatment style: it contains 10 sections on the conditions of stirring the fetus (tai dong ) and repeated miscarriage; leaking uterus; child vexation; heart, abdominal, and lumbar pain and intestinal fullness; cold damage; malaria; (vaginal) bleeding; urinary diseases; diarrhea; and water swelling: a total of 89 formulas and three moxibustion methods.

The treatments in this section run seamlessly from complex medicinal formulas, often with more than half a dozen ingredients, to simple home remedies such as drinking infant’s urine or water in which the husband’s leather boots have been washed. Ingesting pulverized cow manure, grease from a cart’s linchpin, or charred fingernails and matted hair are recommended side-by-side with physical manipulations such as applying abdominal compresses of roasted buffalo manure mixed with vinegar, or burning moxa on qi hai ( Sea of Qi, CV-6), a point still used today for the treatment of abdominal pain, painful or irregular menstruation, and vaginal discharge. Much to our regret, it is impossible to determine yet whether these different treatment modes—as well as the etiologies they were based on—reflected the practices of different types of practitioners who were differentiated by gender, economic or social status, education, professionalization, family ties, or other factors.

All in all, though, the chapters on fertility and pregnancy in the Qian Jin Fang offer us a comprehensive glimpse into the sophistication, multiplicity, and variety of early Chinese notions regarding the causation as well as treatment of medical problems related to fertility, conception, and pregnancy. The level of attention and care, with which the woman was apparently treated throughout this process, shows yet again how high the Qian Jin Fang author Sun Simiao valued women’s contribution in the efforts of the state, family, and individual to “nourish life” and safeguard the continuity between past, present, and future.

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