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FEMALE INFERTILITY IN CHINESE MEDICINE J/I

JUDITH FARQUHAR us to a view of Chinese bodiliness that need make few concessions to Cartesian-
Department of Anthropology ism and "the medical gaze" (Foucault 1973).3It may also suggest ways in which
University of North Carolina at Chapel Hill styles of knowing can color clinical encounters independent of the social skills of
individual doctors.
The anthropological investigation of styles of Chinese medical knowing is
Objects, Processes, and Female Infertiljty in aided by a vast contemporary literature in the Peoples Republic of China. Text-
book knowledge, the sorts of things that contemporary Chinese doctors are taught
Chinese Medicine // in modern schools and on which they draw in doing clinical work, is readily ac-
/ cessible and admirably clear. It should be noted, however, that medical knowl-
edge is nowhere pure (Farquhar 1987). Even where textbooks systematize and
legislate the accumulated technical wisdom of a healing discipline and where a
Focusing on the diagnosis and treatment of female i1f:rtility in tradi- profession of experts is reproduced through formal training in well-supervised in-
tional Chinese medicine's "women's specialty" (fu ke), I examine the
stitutions, the complex politics of the clinic diverge from expectations fostered by
relationship between anatomical objects or substances qnd physiological the printed page. Furthermore, the illness experiences of patients articulate more
processes in Chinese medical analysis. After considering the significance or less awkwardly with the language and manipulations of their doctors. At the
of gender in medical perception, I cite field observations,\extbook expla- same time, both doctors and patients are subject to the structuring economic and
nations, and published cases to illustrate a bias toward the temporal and political exigencies of' 'health care delivery," the limitations of which they have
the processual in Chinese medicine. Continuities between illness expe- difficulty escaping. These differing registers of reality crisscross the field of ill-
riences and understandings of women's bodies are explored in relation
ness and healing, making every statement significant in several different ways
to these clinical modes of knowing.
(Allan Young, personal communication).
The statement, for example, that the Kidney visceral system governs repro-
ductive functions invokes for the doctor a literature ranging from Taoist medita-

N o one would deny that the body is an object. Yet scholars have asserted
the objecthood of bodies to many different ends in the service of widely
varying projects (Kuriyama 1987:64-65; O'Neill 1986; Turner 1984). In
contemporary biomedicine, for example, the gross anatomy upon which clinical
tive disciplines to transplantation and dialysis; for the patient it invokes a mundane
but continuous experience of urination, lower back pain, menstrual cramps, and
vaginal discharges. For both, a (possibly highly charged) history of personal clin-
ical experience connects to many such items of knowledge. Moreover, both doc-
practices have long been grounded has been supplemented by refined technologies tor and patient respond in practice to the institutional fact that kidney disorders
for visualizing bodily structure. Even such relatively gentle developments as com- are treated differently in the "Western medicine" and "Chinese medicine" de-
puterized tomography (CT) and ultrasound imaging continue to trouble those pa- partments of hospitals. These are considerations that have no obvious place in
tients and medical critics who complain of a radical objectification of the person "the professional literature" of textbooks and research reports, but they do sur-
in clinical practice. In using (often invasive) laboratory tests to discover condi- face in the clinic and are implicit in published cases. An anthropological study of
tions of the body which are outside the experience of the patient yet exist deep a style of knowing must therefore draw from all these sources.
within him, the body is separated from the lived discomforts of the ill person (Cas- I will focus this study on the clinical problem of infertility as it is treated in
sell 1982;Saunders 1988). However "humanistic" biomedical practices become, fu ke, women's medicine.4 Recalling how often American women complain of
however kind the bedside manner of doctors, their mode of knowing and serving being treated like objects in gynecological practice, and perhaps because we are
often renders the body a foreign terrain of visualized structures, an object that can Ie€!to believe that certain objects (e.g., uteruses and vaginas) must be significant
ultimately be known only through technologies over which the patient has no con- to any medicine that makes a specialty of women, I bring motives and common-
trol (Taussig 1980). sense expectations from the life-world of female patients in the United States to
In the discussion that follows, I will consider similar problems of object- an interrogation of the literature and practice of contemporary Chinese women's
hood, experience, knowledge, and time in the clinical practice of Chinese medi- medicine. In any such procedure there is a danger of finding orientalist "answers"
cine as a way of assessing the extent to which all medical analysis requires some to our own cultural questions, producing an idealized Chinese medicine as we go.
form of objectification through abstracting a structural state from the ongoing ex- Obviously, I wish to avoid such cross-cultural romanticism while still finding a
perience of illness. As a way of approaching the category of "the body" (Sche-, path to &pecificChinese versions of what Shigehisa Kuriyama has called the "un-
per-Hughes and Lock 1987), I will inquire into the nature of objects in "tradi- known realm" that is the body (1987:64).
tional" Chinese medicine. I Perhaps a clearer understanding of the bodily objects The foil for this comparison is not the systematized and constantly reexam-
and substances recognized in Chinese medicine (e.g., visceral systems, Blood ined knowledge of cosmopolitan biomedicine; rather it is a certain lumpy, taken-
and Qi, circulation tracts), 2 as well as of its more abstract objects (i.e., the entities for-grantedness that still clings to our concept of "body." Anatomy may be dis-
that result from extensive analysis such as syndromes and prescriptions), can lead integrating fast as a foundation of biomedical knowledge and practice (Haraway
372 FEMALE INI'ERTILITY IN CHINESE MEDICINE
373
MEDICAL ANTIIROI'OLOGY QUAlflEKLY

1989), but it still serves as the chief metaphor through which nonspecialist West- disorders, as well as male infertility, were treated here. Pelvic examinations were
erners think about their bodies. The persistent analysis of material existence in conducted as needed in the room next door. Doctors often had whispered consul-
terms of visible structural features of discrete things has been both a triumph and tations with patients who didn't want to be overheard by the many bystanders; at
a limitation of the Western medical worldview. I hope in this article to show that'! the same time there were frequent joking exchanges among the doctors and pa-
Chinese medical analytics are radically different. tients, often involving complicated narratives of women's lives and illnesses. Ad-
After discussing the clinical context of women's medicine as I have observed vice about sexual practices, hygiene, and self-care was given and discussed with
it in the course of fieldwork5 and reporting explanations of infertility gathered little embarrassment. The atmosphere was one of both intimacy and openness. In
fromjil ke textbooks (Anonymous 1983;Chengdu College of Traditional Chinese its relative exclusion of men, however, it was almost conspiratorial.
Medicine 1985; Hu 1990; Shanghai College of Traditional Chinese Medicine. ' The last scenario differs from both these urban clinics. In a subsidized village
Gynecology Research and Training Unit 1983; Sheng, Yang,/~nd Sheng 1990), )' clinic near a Shandong county town, a locally well-known senior Chinese doctor,
review 19 published cases of infertility, analyzing two of tqtm in some detail. ) . retired from the county hospital of traditional medicine, ran a thriving general
have chosen these cases neither at random nor very sYstemat ibaIlY; they are simply medicine and fu ke practice. Patients came to see Zheng Chengfeng when they
all the cases of infertility appearing in the Chinese medical c se anthologies I have could spare time from their work in the fields or get away from their jobs in local
been collecting since 1982 (see Appendix). The two I hav chosen to discuss in factories. Though there were times when he was very busy (just after the wheat
~
detail cannot be considered to be typical, but they do share fertain features with harvestand at the height of the winter upper respiratory infection season), he often
all other case reports in Chinese medicine. Few cases that fail to result in a cure had the leisure to write lavish case histories, which he filed by surname and kept
or significant alleviation of symptoms are published, for example, and all have on many clipboards hanging in rows on the wal1.6When a patient came in, Zheng
didactic points to m\lke about clinical practice and medical analysis (Farquhar would first find her case record and study it before collecting information on her
1991). The reading that I shall attempt here could be done with any of the 19 cases current condition. The patient did most of the talking, and many produced long
summarized in the Appendix and would lead to diverse insights about contem- narratives while Zheng jotted down a few notes and asked a few clinical ques-
porary Chinese medical discourse. Published cases mix many forms of experience tions. In the cases of women who had been coming to see him for a long time and
and knowledge, and they can be unpacked and analyzed in endless ways. My brought relatives to see him as well, he knew much more about their family and
focus in this article will be on physiological knowledge-in-practice and its rela- social situations than the overworked urban doctors I have described above.
tionships to the life-worlds of patients; other dimensions of medical experience I have also observed three other doctors ofjil ke at work in Beijing clinics,
will also be addressed in order to render the case histories intelligible. as well as numerous clinics of other Chinese medical specialties. The social styles
of these various doctors were highly diverse: some, like Liu, were sympathetic
Chinese Clinics of Fu Ke and attentive in a sisterly or fatherly way; others were taciturn, abrupt, or even
harsh with patients. All, however, shared a commitment to the use of clinical
In 1983I spent one afternoon observing the practice of a doctor of traditional methods and therapies which are unique to Chinese medicine.
medicine, a man just above middle age who was famous for treating infertility. All contemporary Chinese doctors work in a complicated relationship to the
Married couples desperate to have children came to him, many from a great dis- forms of practice typical of Western medicine. In all the .fil ke clinics described
tance, most of them veterans of many different treatments for infertility. All the above, for example, the results of pelvic examinations derived frolll Western
men had undergone fertility tests, and some of them were being treated with her- medical practices may be noted and considered, but pelvics are very seldom per-
bal prescriptions to remedy a low sperm count or low motility. If husbands had formed. Most infertility patients arrive at clinics of traditional medicine after hav-
tested normal, their wives were treated for various depletions and deficiencies (a ing been treated in Western medical clinics; they often can report the results of
few examples of which I will analyze below). The clinic was crowded, tense, and such examinations or provide them in a previous case record. In such cases treat-
oriented to the technicalities of prescription design. Many of the couples would ment proceeds with reference to these earlier findings. In the two urban clinics I
keep in touch with the doctor by mail, reporting changes in the patient's symp- have described, it was very rare for an infertility patient to be given a pelvic exam;
toms and receiving written alterations in the prescription. in Zheng's rural clinic he sometimes asked a female associate to do an examina-
In strong contrast to this scene, I observed on several occasions (1983-84 tion if none had ever been done before. In Liu's clinic pelvic examinations were
and 1988), the regular gynecology clinic of my friend Liu Jufang in the same done to confirm pregnancy, to determine fetal development, or if the patient com-
Guangzhou hospital. Liu practiced with another experienced woman gynecolo- plained of lesions or localized pain. Patients removed or pushed aside only the
gist, Dr. Ma, in a small room with a large table in the center. Each senior doctor, parts ohheir clothing necessary for the examination, and were never asked to
sat on one side of the table, with junior associates, also women, at her side. With fully disrobe. In contrast to the centrality of the pelvic examination in the Western
the help of their associates they were able to interview and examine several pa. practice of gynecology, with its fetishized arrangement of drapes over a disrobed
tients at once, which was often necessary since they were usually very busy. Most body and assymetrical placement of doctor and patient, the prototypical spatial
of their patients were women; the occasional husband or father who attended the arrangement of Chinese medical actors (their disposition in Bourdieu's sense of
clinic seemed reluctant to enter a room so full of females. Many kinds of female the word) is seated face to face at a cornerof thetable,talking.
"'--'~"-' '''''U'~' ~-~". "1U""'l"\l.' .J/J

The results of pelvic examinations and other Western medical procedures advancement. In many administrativejurisdictions, prior authorization is required
(ultrasound, for example) are recorded and considered within the larger frame- for planned pregnancies; clearance to reproduce is awarded on the basis of com-
work of the clinical encounter, which is guided by the "four examinations" of plex rules designed to give everybody their chance at one healthy child. 10 It is
traditional medicine. These are "looking" (at the tongue and features of the pa- often strategically necessary to become pregnant with split-second timing: birth
tient's general appearance), "asking" (the history of the disorder), "hearing! control in this case actually means minute control of when there will be a birth,
smelling" (for altered voice, coughs, foul odors) and "palpating" (the pulse). It and "family planning" is no euphemism.
has been clear in all my observations of clinical encounters in the institutions of Before turning to the treatment of infertility, I will attempt to locate the sub-
Chinese medicine that doctors subsume the results of "objective" Western-style discipline of women's medicine within traditional medicine as a whole. Text-
tests and examinations within the more impressionistic and subjective methods of books both argue and demonstrate thatfu ke is basically the same as Chinese med-
traditional medicine. The "four examinations" focus on the patient's own ac- icine's centraldisciplineof internalmedicine(nei keY,a body of knowledgeand
count of her symptoms and on signs that are perceptible on tbe-\)oaj's surface practices that concerns itself with all physiological and pathological processes.
(e.g., tongue color, pulse quality). Together, doctor and pa)lent produce an un- Until the very recent entry of numbers of women into the profession of traditional
derstanding of the illness from the ingredients of her memory and noninvasive medicine, male practitioners who were known for skill infil ke seldom confined
"readings" of her body. This understanding not only supe~sedesinformation de- their work to this area. Male doctors who are developing the infant fieldof' 'men's
rived from Western medical methods but also replaces a !estern medical diag- speciality" (nan keYusually also have other specialties as well. Subdisciplinary
nosis with a (theoretically, at least) more treatable Chine~e medical syndrome divisions tend to be very fluid in the contemporary institutions of Chinese medi-
(zheng). Doctors neither strive to achieve "objectivity" no~dwell upon objects. cine.11
Their subjective grasp of pathological process builds largely upon the patient's One textbook points out that Western medical obstetrics and gynecology dif-
report of her history, treating both signs observed in the clinic (pulse, tongue im- fer from fu ke in that their origins are in surgery, a set of practices that never
ages) and Western medical test results as moments that are of little significance developed in premodern China (Chengdu College of Traditional Chinese Medi-
in themselves.7
cine 1985:1). This distinction is made in the context of a long critique of tradi-
This process of privileging the methods and entities of Chinese medicine is tional Chinese medical approaches to childbirth, which are seen as endlessly re-
clear in both of the cases analyzed below. Though hospital case records and pub- producing errors from an early classic, with only a few worthwhile insights scat-
lished cases are phrased in a somewhat specialized medical language, I will try to tered throughout the history of the field. Classical discussions of the disorders of
show how the Chinese medical syndrome-a summary of pathological process- "menstruation, discharges, and pregnancy," on the other hand, are said to have
is arguably more consonant with the patient's experience of her illness than a more noble history by virtue of being part of the rich internal medicine tradition.
"Western medical" diseases of hidden anatomical irregularities and microscopic The 7th-century scholar Sun Simiao is often cited to the effect that "those
pathogens. who have prescriptions for women's distinctiveness (hie) take the differences of
pregnancy, childbirth, and [internal] bursting injuries as their basis" (cited in
Chinese Medicine and Female Infertility Chengdu College of Traditional Chinese Medicine 1985:2).This remark is typical
of many distinctions made in classical medicine: a small set of characteristic phys-
"Failure to become pregnant" (buyun zheng) as a disorder is invariably dis- iological and pathological processes rather than anatomical structures mark
cussed near the end of contemporary textbooks and collections of fu ke case his- "women's distinctiveness" within the general run of medical concerns. These
tories.8 It is preceded by all the disorders that can afflict "menstruation, dis- processes take their place alongside a host of other physiological and pathological
charges, pregnancy, and childbirth."9 Infertility is often not present as a pathol- processes, all of them implicating each other in the functional relations of the
ogy at all, at least according to the usual means of detecting disorder in Chinese visceral systems. Sun's emphasis on reproductive functions remains important in
medicine; it is a failure to achieve a desired bodily change, rather than an unde- contemporaryfu ke; recently published texts focus on maintaining normal men-
sired change that must be brought under control. Further, like most Chinese med- struation, pregnancy, and childbirth, devoting almost no attention to sexuality or
ical syndromes, it results not from a permanent structural abnormality of the body menopause. Though there is a parallel interest in reproductive health for men
but rather from an (often subtle) deficiency of normal physiological functions. within internal medicine, until very recently no separate specialty has been con-
(The cases discussed below will illustrate this.) cerned with such problems (Zhang 1990:i). It appears thatfzl ke as medical sub-
Failure to become pregnant may be one of the most frequently treated dis- discipline is clearly all about assuring the wholesome production of babies. The
orders in contemporary Chinese medicine, and it is certainly one that evokes des- disorders of "women's distinctiveness" that it treats are those that interfere with
perate anxiety on the part of its sufferers. Much of this anxiety is due to the' 'one reproductive success.
child policy," which an American friend of mine in South China has bitterly de- It would be a mistake, however, to infer from this bias of a traditional med-
scribed as "the policy that every woman must have one child." He was referring ical specialty that "women," unlike "men," are uniquely significant as produc-
to the pressures that working women in China face to put motherhood first while ers of babies. For both men and women, reproductive physiology is strongly as-
combining household management with wage-earning and, in some cases, career sociated with the roots and origins of many processes necessary to normal health.
376 MEDICAL ANTHROPOLOGY QUARTERI.Y FEMALE INFERTILITY IN CHINESE MEDICINE 377

Male and female seminal essence (jing)12and the congenitally endowed "source It appears, then, that Chinese medicine, in placing the reproductive functions
Qi" of both sexes are governed by the Kidney visceral system. (See Table I for for both sexes at the terminus of a sequence of increasingly serious vulnerabilities,
a summary of the functions and characteristics of the five yin visceral systems of incorporates a strong telos of reproduction. A person with an impaired ability to
function.) 13 have a child is very ill indeed, at least in theory. Chinese medical knowledge has
When an external heteropathy invades the body and initiates a pathological throughout its long history been used in the service of continuing' 'Confucian"
process, it most often affects the higher and more "outer" visceral systems first, lineages through the production of children. In medicine reproductive functions
especially the Lung system (which is hardly mentioned infu ke) and the Spleen- are central to health just as in social life having children is central to selfllOod.'4
Stomach system. As an external pathology ramifies through the five linked vis- Gender difference ("women's distinctiveness") appears to count for medicine
ceral systems and the circulation tract system, it may eventually begin to affect mainly with regard to problems that arise in one moment of a dual-gendered pro-
Kidney system functions. This is a sign of a long-standing and deep-seated pa- cess of reproduction.
thology, hard to cure and implying permanent damage. Pathological processes
that extend to the Kidney system attack the seat of irreplaceabl "source Qi."
Textbook Knowledge about Infertility
This form of Qi, which is necessary to healthful respiration and irculation, may
be slowly depleted through sexual activity, menstruation, and ch Idbirth. Women There are a few main types of female infertility. Textbooks differ somewhat
are advised to rest for a month after childbirth lest they incur skel tal injuries from on their number, some subdividing "Kidney Depletions" into two or three types
premature activity, and a wide array of therapies are available t men who suffer and some lumping all Kidney Depletions together. But the usual explanations for
fromthe serioussymptomsof prematureejaculationor nocturnal missions.Path- failure to conceive are quite standard and can be summarized as six syndrome
ological attacks on the center of source Qi are thus very serious i deed. types (Table 2).
. Giventhe complexityof Chinesemedicalphysiology,it is interestingthat
TABLE 1 infertility syndromes should be so few. Practitioners, who are well aware of the
Thefive visceral systems offunction.
manifold ways in which disorder in anyone system can ramify to all others, tend
to explain the relative simplicity of short lists like this in terms of accumulated
clinical experience. These are the "often seen" (chang jian) syndromes, whose
System Acts on Stores Manifestations Affiliated with
perceived redundancy over centuries of observation has allowed them to be in-
Heart Blood Shell Unfolds in vessels; Small intestine cluded in handbooks as lists which link typical symptoms (important for differ-
(vitality) manifests in face; ential diagnosis) with recommended treatment principles and effective drugs. Cli-
vents at tonguc nicians are likely to consider these syndromes first as explanations for the symp-
Unfolds in skin and toms presented by patients, but in practice infertility can have causes that deviate
Lung Qi; Large intestine
from such standard lists. Of the cases appended here, only one, # 17, is a syn-
breathing; body hair; regulates
clears away, the "watercourse";
dromemarkedlydifferentfromthoselisted.IS Injil ke. as in traditionalmedicine
carries downward vents at nose as a whole, syndromes are patterns of disorder rather than fixed disease entities;
the list of possibledisordersis thus theoreticallyinfinite,as the one exception
Spleen transmission and Unfolds in flesh; Stomach reminds us.
transformation; four limbs; The standard list of infertility syndromes undoubtedly arises from historical
elevates clear vents at mouth; experience of some kind, but certain features of these "often seen" syndromes
fluids; manifests in lips are easily remembered because they are reasonable in terms of normal physiol-
in charge of ogy. It appearsfrom the "illness mechanisms"summarizedin Table 2 that the
blood flow irregularity most proximate to symptomatic expression is of the Highway and
Liver dispersion Blood Unfolds in sinews; Gall bladder Conceptioncirculationtracts.Thesearetracts of the "extraordinary" (qijingba-
upward and vents at eyes; mai) class, usable for acupuncture treatment of various disorders in both men and
downward manifests in nails women but especially crucial to female reproductive functions. In other words,
though a visceral system (Kidney, Spleen, Liver), a bodily substance (Qi, Blood,
Kidney fluids; lillg Unfolds in bones, Urinary bladder Jingkor a form of heteropathicQi (Phlegm,Damp, Heat)is held to be chiefiy
Bladder; (semen) source Qi. "Blood responsible ("taken as the root," doctors would say), the Highway and Concep-
marrow; reservoir"; manifests tion tracts "downstream" from such sources invariably malfunction and produce
accepts Qi in hair; vents at ear, the characteristic symptoms of irregular menstruation and infertility. In keeping
genitals, anus with a strong diagnostic bias toward more systemic disorders (i.e., toward "seek-
ing the root"), all drugs for regulating the Highway and Conception tracts are
TABLE2
specifics for one or another visceral system and act on the Qi-Blood relationship.
Main ca/lse~'and treatmentsof infertility. Their efficacy on the tracts of the reproductive system is not mentioned in the
materiaemedicae except in terms of their results, regulation of menstrual periods.
Syndrome Type Illness Mechanism Treatment
All six infertility syndromes are characterized by irregular or absent men-
struation. The importance accorded to regulating menstrual periods in curing in-
Spleen and Kidney Body depleted and weak Build up Spleen fertility is evident in the treatment principles listed: three specify menstrual reg-
yang depletion Kidney Qi inadequate Warm Kidney ulation and the other three imply it in their emphasis on eliminating blockages and
Highway and Conception Nourish Blood sluggishness and on reharmonizing Qi and Blood. In published cases like the two
tracts cannot control ling to Regulate menstrual periods discussed below, pregnancy often follows quickly upon the attainment of regular
conceIve monthly periods.
Liver and Kidney Same as above Nourish and replenish Liver Medical textbooks are organized to make symptom complexes associated
yin depletion with each of the syndromes listed in Table 2 easy to find. In fit ke, menstrual
and Kidney/'
Nourish Blood irregularities are focused on most attentively; not only the timing but also the vol-
ume, color, consistency, and odor of menstrual flow are carefully noted. The pa-
RegUlate/lenses tient is relied upon to report these symptoms accurately, along with a great many
Blood depletion Withering or hemorrhage of
Nourishl Blood to harmonize manifestations that are more widely significant within traditional medicine:
blood induces vacuity, moods, digestion, elimination functions, sleep patterns, aches and pains, local
with~onstructiveQi .
Depletion of Highway and Supplef\1ent and replenish swellings, fevers or unusual feelings of cold, and degree of interest in sex. The

\
Conception tracts, which only symptoms that can be correctly perceived by doctors exclusively are altera-
cannot control ling to con- tions in the pulse and quality and appearance of the tongue. These technical symp-
ceive
Live< Kidn" toms are very important but seldom meaningful apart from their relationship to
Phlegm Damp Obese constitution or indulg- Transform Phlegm and dry up
reported symptoms.
ence in fatty and sticky Damp Syndrome differentiation, at least as it is taught in contemporary schools of
foods produces Phlegm Build up Spleen to regulate Chinese medicine, proceeds from these symptoms, classifying them with ever
Damp internally so that Qi menses more refined modes of analysis until many closely related possibilities have been
mechanisms don't flow eliminated and one useful characterization has been achieved. To illustrate this
smoothly, process with an overly simple example of just one symptom, a large volume of
Highway and Conception bright red menstrual blood indicates pathological Heat arising from a state of re-
tracts develop obstructions pletion; small amounts of bright red blood suggest pathological Heat due to a de-
and produce infertility. pletion. Repletion and depletion refer less to the physical amount of blood than
Liver to complex dysfunctions of the visceral systems.
Negative feelings lead to ten- Relax Liver to resolve oppres-
oppression After these general rules have been combined with analyses which target spe-
sing and knotting in Liver sion and clear out sluggish- cific visceral systems and spatiotemporal sectors of the body, 16 the information
system ness
can be used to design an intervention. For example, once it has been determined
Qi and Blood go out of synch that the problem is one of depletion of Cold of an internal sector, no drugs which
Highway and Conception either further chill or deplete (e.g., through draining) the affected visceral systems
tracts lose regularity will be chosen.
Conception is affected. The syndrome names in column one of Table 2 suggest the various dimen-
Damp Heat Damp Heat accumulates and Clear Heat and drain Damp sions focused on in conventional diagnosis. Of the cases in the Appendix, six (I,
obstructs the lower pro- Relax Liver to open tracts 6,7, 10, II, and 18) are clear cases of Spleen and Kidney Yang Depletion. Cases
cessing locus, so the Qi and 2, 4, 12, 13, and 15 are simultaneous depletions of Kidney and Liver. Cases 3,
Blood of the Uterus chan- 5, and 9 are simply seen as Kidney Depletion. Three of the 19 cases (8, 14, 19)
nels are blocked in their are analyzed in Qi-Blood terms and would require a close reading of the prescrip-
tlow, inducing infertility tions used to determine what visceral systems were primarily treated, though
Spleen and Liver systems are the usual targets of such therapy. And in addition
SOl/Tee:Shanghai College of Traditional Chinese Medicine (1983:164-167). to the exception to all rules mentioned above (Case 17), Case 16 focuses rather
unconventionally on the Highway and Conception tracts themselves, naming no
more systemic root to the disorder. 17
Several general observations can be made on the basis of this review of text~ respect to Blood, the most general classical principle governing conception is that
book knowledge and published cases. First, doctors' own explanations of illness "[male] Semen and [female] Blood join to become Ifetal] form." For women,
etiology are consistent with textbook generalizations, though they may depart then, an inadequate Blood supply to the Highway tract (also called the Blood res-
from them when concrete symptoms warrant. This is true not only in formal texts, ervoir, of which more below) because of reduced Liver function renders men-
such as published cases, but also in the explanations doctors have provided to me struation scant and infrequent and conception unlikely. If the Qi dispersion func-
about cases I have observed in clinics. Second, these explanations focus on dis- tions of the Liver system become disordered, there are immediate consequences
ordered processes which ramify through the whole body. They do not localize the for Blood flow, since Qi drives Blood. Menstrual irregularities are therefore al-
disorder within the body, rather they distinguish it from other possible patterns of most as often blamed on Qi disorders as on Blood.
pathological process affecting the whole body. Even the notion of depletion, an Mrs. Sun, the patient, may grasp almost nothing about the activities of the
inadequate translation of the Chinese word xu, refers not so much to inadequate Kidney and Liver visceral systems, or she may be the sort of sophisticated patient
amounts of substance as it does to weakened forces of bodily flow. Where healthy who has elaborate and well-informed ideas on the subject. But given her symp-
processes flag or transgress usual limits, substances will not be produced with the toms of cold and weakness, pain and scant menstrual flow, it seems likely that
proper timing and in the proper volume. The diagnosis and regulation of men- she would see the sense of a therapy identified as "warming" and "nourishing."
strual disorders (and the closely related condition of infertility) in fit ke thus ty- The Kidney and Liver each "rule" (ZhU)18 complex systems of function and
pifies the relations between processes and objects in Chinese medicine. usually are seen to have priority over the functions of the circulation tracts. Thus
though the Highway and Conception tracts are often implicated in menstrual dys-
Two Cases of Infertility in Women function and infertility, their "regulation and replenishment" in this treatment are
mentioned after the more basic treatment of visceral systems. Though they have
Of the 19cases appended here, cases 2 and 7 are translated in full for a closer otherfunctions, both tracts are crucial to reproduction.The Highwaytract, or
reading; in what follows I will refer to them rather than paraphrase. In the view Blood reservoir, fills and drains monthly, supplying regular menstrual flow. The
of Chinese doctors, Case 2 is useful mainly to make a very clear point: a chroni- Conception tract controls this periodicity, and its flow (of Qi, presumably) must
cally ill woman is diagnosed in a Western medicine clinic to be infertile because be smooth and even. Thus both tracts depend especially on the Liver system as
of obstructed fallopian tubes. An experienced doctor of Chinese medicine, per- not only a source of Blood but also a primary agent in the dispersion of Qi through
ceiving long-standing functional disorders of many systems, ignores the repro- the tract system. The two tracts also have a close interdependency of the yin-yang
ductive organs per se. Instead he restores strength and regularity to functional type: the Conception tract plays the role of "active" yang Qi to the Highway
systems which are more basic than any specific abnormalities of reproductive tract's "struetive" yin Blood. 19 They must be "regulated and replenished" to-
function. As a result, a healthier patient is able to conceive and bear a healthy gether. The chief means of doing so in this prescription is to foster Liver system
child. In the published case, the fallopian tubes and whatever was obstructing functions.
them are apparently irrelevant to the case. The third dimension of intervention in this case directly addresses Blood and
The narrative of this case takes a familiar form for contemporary Chinese Qi, the closely interdependent yin-yang couple that crosscuts both visceral sys-
medical case histories. It notes the anatomically founded "diagnosis" of Western tems and circulation tract functions. In other words, the yin-yang relationship of
medicine, then demonstrates the superiority of Chinese medical "dynamic and Blood and Qi (Qi drives Blood while depending on Blood as its fluid medium) is
holistic" methods of analysis with the considerable polemic force of an actual the most general dynamic of the body, the fluid and mobile resource of all body
cure and, in this case, a healthy baby. The discrete transplantable objects of West- substance and activity. The symptoms reported in Case 2 betray depletions of both
ern medicine, characterized with such loving care in pathological anatomy and Qi and Blood and give a clear picture of Blood stasis, a condition that often results
perceived at the cost of such expensive imaging technology, are seen as mere from simultaneous Qi and Blood depletions. Because Qi drives Blood, Blood
products of powerful processes that govern the tife of the body. stasis is often treated by stimulating Qi movement. In this case, four of the 15
I can make this point clearer by explicating the treatment principles used in drugs in the prescription either replenish or regulate Qi, and four of them enliven
this case. They fall into three categories. First, with respect to visceral systems, or replenish Blood (see Table 3). Treatment directed at the Liver system will
the plan is to "warm the Kidney system and nourish the Liver system." The Kid- eventually address problems of Blood stasis as the Qi dispersion functions of the
ney system tends toward being "Cold" (i.e., more yin than yang), and this pa- Liver improve.
tient's symptoms are strongly suggestive of a state of chronic Interior Cold. Con- Few patients know much about the functional roles of the herbal medicines
ception and fetal development rely upon a balance of yin and yang in the Kidney included in their prescriptions. But they have little difficulty in correlating some-
system; therefore drugs which "Warm" or "yang" the Kidney will tend to reo, thing called "Blood stasis" with symptoms of menstrual irregularity and general
store this system to normal. coldness and weakness. Most people also know that in Chinese medicine Qi
Turning to the Liver system aspect of Case 2, we should note that the rela- drives Blood; patients can see the logic of remedying a condition manifesting in
tionship of the Liver system to conception and pregnancy has to do both with its Blood inadequacy with a method that simultaneously regulates Qi. With the doc-
Blood storage function and with its characteristic activity of Qi dispersion. With tor, theycan feelthat he is "seeking the root."
382 MEDICAL ANTHROPOLOGY QUARTERLY FEMALE iNFERTILITY IN CHINESE MEDICINE j1\j

TABLE3 The therapy for Case 2, then, is very broad. No effort is made to isolate the
Analysis of prescription for case 2. single most crucial system or substance, least or all something as trivial as tube
blockage. Instead, every aspect of Sun's chronic illness is addressed at once, with
Treatment Principles' a strong emphasis on drugs that strengthen and nourish.2OIn a sense, a reproduc-
Enliven tive anatomy that is capable of conceiving and bringing a pregnancy to term is
Blood, Regulate built almost ab initio by replenishing the productive functions of three cross-
Tracts Warm Nourish expel Qito cutting bodily processes (visceral systems of function, circulation tracts, and
Drug name affected Kidney Liver stasis stop pain Blood and Qi). 21 This is not to say that the relevant structures, such as the ovaries,
Foxglove Liver X X tubes, and uterus, are denied; they are simply local and contingent phenomena in
a medicine in which fetuses are conceived and nurtured by global (i.e., whole-
Kidney
body) processes.
Dodder seed Liver X X Case 7 appears to be a good deal more complicated, even though the patient,
Kidney herself a doctor, presents much less evidence of chronic illness than had Sun. In
Deer horn Liver X this case Luo Yuankai's editors have helpfully provided a syndrome differentia-
glue Kidney tion(i.e., a Chinesemedicaldiagnosis)of "Spleen and Kidneysystemsbothde-
Placenta Lung X X
pleted, accompanied by Liver system Qi stasis." This is a combination of two of
Liver the categories listed in Table 2 and yields eventually to the standard strategy re-
Kidney ferred to in the commentary attached to the published case: "This makes the men-
strual periods have a regular timing-then it's easy to become pregnant."
Angelica Heart X X The case narrative makes the usual polemic point: the patient had long sought
Liver
a cure for her infertility from institutions of Western medicine but without suc-
Spleen cess. Their final gesture was to perform an invasive procedure unimaginatively
Sweetgum Liver X X focused on one part of one organ (a biopsy of endometrial tissue) which enabled
fruit Stomach them to diagnose only a very subtle dysfunction. Luo's editors wish us to note
Jiazhll (not found in materia medica) that he saw the problem in diametrically opposed terms: by reading the manifest
signs of the illness, he analyzed functional debility in three of the five major vis-
Sage Heart
ceral systems governing the health of the whole body. His herbal prescription
Liver X reflects this wide-ranging analysis (Table 4). Since he was able to produce first a
Epimedium Liver X significant alteration in menstruation and then a pregnancy in less than a year, his
Kidney reading of the problem (the case report suggests) was vindicated in practice.
NUI-gruss Liver X X Case 7 is one of those interesting Chinese medical documents in which the
Hare's ear Liver whole sequence of the clinical encounter is indicated. Luo saw this patient over a
X
root Gall period of more than a year; he not only recorded her changing symptoms during
Bladder this time but also his tinkerings with the prescription, down to the amount of each
..drug in each formula. Though four prescriptions are recorded, there are in fact
Frankincense Heart X X only three formulae involved, and all are variations of one master formula. The
Liver fourth prescription is an exact duplicate of the first, which (the wording of the
Spleen treatment principle notwithstanding) takes replenishing and nourishing Kidney
Myrrh Liver and Liver functions to be primary and invigorating Spleen functions to be sec-
Broomrape X ondary. The deviations from this master formula in the second and third prescrip-
Kidney
tions emphasize invigorating Spleen function; this is interpretable as a response
Large
Intestine to the fact that Kidney and Liver symptoms cleared up sooner than Spleen symp-
toms did. Once the various symptoms had been brought under control and men-
Ginseng Spleen strual periods were beginning to regularize (fourth examination), Luo was able to
Lung return to his original prescription. Apparently the patient's condition had pro-
gressed satisfactorily throughout, and no serious revision of the initial syndrome
"Treatmentprinciples are specified in the published case. No drugs were specific for differentiation was required.
"rcglliatin!! and repIenishin!!the Hi!!hwayand Conception tracts."
3M 385
MEDICAL ANTIIROPOLOGY QUARllJJtL1 FEMALE INFERTILITY IN CIIINESE MEDICINE

TABLE 4 Menarche was at age 15, menstrual periods tend to be delayed, volume of now
Actions of precriptions for case 7. small and color pale, containing blood clots. Between periods her body is cold,
lower back pain and weak legs, pain and swelling lofllower abdomen, large
volume of discharge. Breasts swell premenstrually, her mental state is ex-
Treatmcnt Principlcs' hausted, she lacks strength, and has little interest in sex. Urination clear allli
Rclax Liver prolonged, feces not firm.
Replenish Build to rcsolve
Tracts Affectcd These symptoms reported by the patient are supplemented by pulse and tongue
Drug Name Kidney Spleen opprcsslon, images observed by the doctor and, in this case, by the results of a laboratory test
Dodder seed Kidney, Liver X X from another clinic. Together they form a pattern of disorder in which no single
Cherokee rose Kidney, Urinary X X phenomenon is significant in itself. For the doctor all the symptoms together be-
Bladder, Large tray a pathological process with a trajectory and key points at which intervention
Intestine will be efficacious. He understands the normal activities and standard pathologies
Cornbind Kidney, Liver X X of visceral systems, circulation tracts, and body substances (Blood and Qi) and
Dal1g~'hetl Spleen, Lung X thinks about this illness history in those terms. For the patient the process in ques-
Matrimony Kidney, Liver X X tion perhaps never departs far from the vicissitudes of her general debility and
vine continuing disappointment in her failure to conceive. Chinese medical analysis,
Angelica Heart, Liver, X X however, by finding the significance of her symptoms in a temporal dimension, a
Spleen weakened process rather than an invisible structural defect, may resonate with the
RaspbelT)' Kidney, Liver X patient's lived experience of debility. 22 No wonder the confidence of these doctors
Nut-grass Liver X is not shaken when it takes months or years to bring about a major change in the
Lovage Liver, Gall X patient's condition: where therapy seeks to inl1uence natural trajectories of the
Bladder, Pericardium whole body so that a reliable continuation of general health and strength can be
achieved, a certain amount of time is required. As both patients and doctors of
"Treatment principles arc specified in the published case. Chinese medicine constantly point out, traditional medicine is slow but thorough.

The fact that no pelvic examination was considered necessary until a cure Conclusion
had almost certainly been achieved, and then only to confirm pregnancy, is inter- In this reflection on two published cases I have devoted considerable space
esting. This form of case management invites us to conceive of Chinese medical to a mode of medical analysis that is difficult to understand and foreign to our
diagnosis as a different mode of apprehending illness from that which has char- "Western" common sense, while pointing out that it may have important contin-
acterized Western medicine. What are Luo (and possibly Rao, his patient) imag- uities with the experience of Chinese patients. If we fail to come to terms with
ining on the basis of the phenomena they observe and record? Given that most of these complex analytics, field observations of the type included at the beginning
the pertinent phenomena are aspects of the illness's "history" (i.e., the patient's of this article can only be misleading. In Chinese medicine, the illness experiences
perceptions of events prior to her clinic visit, collected in the course of the' 'ask- women confide in the clinic are the basic ingredients from which a treatable syn-
ing" examination), it appears that an illness process is more centrally at issue than drome becomes perceptible. Both doctor and patient work in the medium of time
a stable disease lesion or local functional defect. The field in which such mani-
festations of illness process are significant is not so much a body, seen as a stable
. and experience, attending to the objective manifestations of disease as signs of a
process. Seated not opposite from each other, but differently oriented around the
structure that can suffer from "substandard glandular secretion," as it is a lived corner of the table, they can bring their differing expertise to bear on one illness.
life of irregular periods, lower back pain, cold extremities, etc. In Luo's approach There may be struggles over many things in this relationship (e.g., the expense
to the illness, the diachrony of symptom history almost completely overwhelms of the drugs, the timing of return visits, the need for a work excuse or a hospital
the synchrony of an internal bodily defect, and the patient's knowledge of her stay), but there does not seem to be much disagreement over the nature of the
symptoms outweighs the results of the endometrial biopsy in diagnostic impor- illness.
tance. One could argue that Western medical thinking has traditionally been most
The fu ke conceptualization of illness is not idealistic. All the symptoms Iclear when anatomical objects and intellectual objects are the same thing. An ob-
noted, including those derived from examinations performed in the clinic (pri- struction of the fallopian tubes, for example, is an explanation for a failure to
marily pulse and tongue images) are quite concrete and material. But they do not conceive which posits both a thing with a structure and a notion that can ration-
lead to the perception of an abnormal bodily structure. Consider the symptoms alize either an intervention or a practical decision not to intervene. Chinese med-
listed in Case 2: icalthinkingis notnaturallymurky,itjust getsthat waywhenoneattemptsto fill
386 MEOICAL ANTlIROPOLOGY QUARTERLY FEMALE INFERTILITY IN CHINESE MEOICINE 387

its intellectual objects (patterns of pathological function) with anatomical con- only as a result of the reproductive process itself. Whatever the official attitude of
tent.23 This kind of translation is a shift of a particularly sweeping kind, an attempt; modern Chinese doctors might be toward the independent structural existence of
to translate the diachronic into the synchronic and processes into structures. internal organs, such as the uterus, in their way of analyzing and treating womcn's
Others have made this point before about Chinese medicine (Porkert 1974), illnesses they can be agnostic on the subject of anatomy. Doctors and their clients
but our commonsense commitment to a materialism which must reduce phenom- can focus together on manifestations of disturbed processes, supplementing or
ena to synchronically observable collections of objects is difficult to overcome. ' relaxing, dissolving or draining, to build a physiology that can have a child.
The visceral systems of function which organize so much of Chinese medical per-,t
ception need not be thought of as primitive anatomy, with the Kidney organs asJ: Appendix
the "material substrate" of (immaterial?)reproductivefunctions.24Ratherit is ~.
The 19 cases summarized below are drawn from four collections of clinical
signs and symptoms, experiences and perceptions, which are the material foun- ..i;
dationof medicalperception.Theyare not lessconcretethananatomicalorgans, .
cases published in the Peoples Republic of China between 1980 and 1987. Two
of these volumes collect the cases of well-known senior doctors and two are de-
but they are not conceivable outside of lived time. The materiality of the syn- ~.
chronic body, its contents and its boundaries, can be unproblematic as long as we voted tolu ke cases. I used my own collection of case anthologies (20 volumes,
acknowledge that these things are trivial from the point of view of diachronic most published in the 1980s) and simply chose every case of infertility for this
Chinese medical analysis. analysis.
Cases 1, 3-6, and 8-19 are summarized below with a brief list of key char-
Many attempts to demystify Chinese medicine have foundered on this par-
acteristics; Cases 2 and 7 are translated in ful1.25Certain technical terms (e.g., for
ticular confusion, I think. Translators have failed to distinguish between the real- ,-,1
ities of space, which are most powerfully apprehended through vision and depic- . pulse qualities) have been rendered following Sivin (1987) and capitalized. Syn-
tion, and the equally concrete realities of time, which must be remembered, in- drome names are also capitalized.
scribed, and embodied. In popular works on Chinese medicine we have seen too Case J
many translations of Chinese medical knowledge into a failed anatomy or a vague
and over-general "holism." To give both Chinese medicine and Western medi- Soum:: He and Liu (1987:166).
cine their due requires finer discriminations of the specific relations between ob- Wang X X, F-29. Married six years without a pregnancy. Uterus abnormally
jects and processes, products and relations of production, spatial and temporal small, delayed menses, volume of menstrual blood small, color pale. Abdominal
materialities. pain during menses, excessive discharge, lower-back pain. Poor appetite, cold
To conclude with a question that has motivated some of this discussion: are extremities, clear and excessive urination, loose stools. Facial color dark, tongue
women made to feel like objects in Chinese medicine? Are they alienated from pale with sticky white coating, pulse Subtle and Small.
their own experience in clinical practice? Though I have talked with some Chinese Syndrome: Spleen and Kidney Yang Depletion with downward concentra-
women about this, I cannot claim to know how they "really" feel when they visit tion of Cold-Damp, infertility due to Uterine Cold.
doctors of traditional medicine. The evidence here suggests, however, that Therapeutic principle not stated.
Chinese medicine accords a certain importance to quotidian self-perception; while After about three months of treatment there was a normal pregnancy and
never denying the object-nature of bodies, it privileges processes of change that delivery.
take place in personal time, which can only be entered into medical consideration Case 2
via the patient's own narrative.
All this has taken us far from Chinese medical gynecology and infertility as Source: He and Liu (1987:166-167).
specific topics. Let me close then, with an observation made some time ago by . Sun X X, F-3I. Examined December 4, 1980.
Jack Potter on the basis of his fieldwork in the New Territories of Hong Kong: Menarche was at age 15, menstrual periods tend to be delayed, volume of
"When a woman conceives a child, a heavenly flower is planted in one of the flowsmalland color pale, containingblood clots. Betweenperiodsher body is
small gardens, and a seed is sent down from Heaven into the uterus of the woman. cold, lower back pain and weak legs, pain and swelling on both sides of the lower
The villagers liken the uterus to a flower that begins to enlarge and open after abdomen, large volume of discharge. Breasts swell premenstrually, her mental
conception" (Potter 1974:214). Reported as a quaint folk belief, this image of the state is exhausted, she lacks strength and has little interest in sex. Urination clear
fragile, contingent, and short-lived womb has long fascinated me. As metaphor, and prolonged, feces not firm. Tongue pale with thin coating, pulse Sunken and
it sums up in the relationship of flowers to seeds (zi, the same word as for sons), Small. Married eight years without a pregnancy. In 1978 at another hospital io-
the most general yin-yang of reproduction. Families are a temporal continuity dized oil radiography (iodolography) was done of the uterus and fallopian tubes
founded not on the permanence of anyone thing or person but on a well-nurtured and the report was: "obstruction of both Fallopian tubes." Therapeutic plan is to
generativity and a wholesome alternation of potential and actual. Where repro- warm the Kidney visceral system and nourish the Liver visceral system, regulate
ducing endows life with much of its meaning, especially for women (as Potter's and replenish the Highway and Conception tracts, enliven Blood to eliminate
other material suggests), the bodily things needed to have a child come into being stasis, regulate Qi to stop the pain.
JISIS
MEDICAL ANTHROPOLOGY QUARTERl.Y FEMALE INFERTIUTY IN CHINESE MEDICINE 389

Prescription: ginseng, 6 gm; Chinese foxglove (steam-dried), 30 gm; dodder Treatment principle: Strengthen yang to warm the Uterus.
seed, 15 gm; deer horn glue, 10 gm (scalded); human placenta, 10 gm (scalded); Treatment period three months, pregnancy occurred before treatment com-
Chinese angelica, 10 gm; Chinese sweetgum fruit, 10 gm; roastedjiazhu, 10gm; plete. Normal pregnancy and delivery.
red-rooted sage, 10 gm; epimedium, 10 gm; nut-grass, 10 gm; hare's ear root, 10
gm; frankincense, 10 gm; myrrh, 10 gm; broomrape, 10 gm. Case 6
After 18 doses of this prescription had been administered, all the various
symptoms had improved. The prescription was made up into pills, each dose 10 Source: Guangzhou College of Traditional Chinese Medicine, Gynecology and
gm; two doses daily. After it had been taken for three months, she got pregnant. Obstetrics Research and Training Section (1980:217-218).
Pregnancyanddeliverynormal;motherand child both well. Hu X X, F-31, factory medical services worker. Married six years without
a pregnancy. Menses slightly irregular, color light red, volume normal. Western
Case 3 medical tests report hormonal insufficiency but unobstructed fallopian tubes. Last
three years patient has suffered from lower back pain, dizziness, weakness, and
Source: He and Liu (1987: 167). poor appetite; recently has had abnormal hair loss, chills, and insomnia. Urination
Guo X X, F-32. Constitution weak, spirits low, vertigo. Irregular menses, and defecation normal, facial color greenish white, lips pale, tongue mottled and
volume of menstrual blood small and color pale. Dizziness and ringing in the ears, swollen with white coating, pulse Sunken and Small.
severe lower back pain, abdominal pain. Tongue pale with fine coating, pulse Syndrome: Spleen and Kidney Yang Depletion.
Sunken and Weak. Has been married 10 years without a pregnancy. L Treatment Principle: warm Kidney, invigorate Spleen, bolster Blood.
Syndrome: Kidney Qi Depleted and Weak, Highway and Conception Tracts Treatment period 14 months showing steady improvement, followed by a
Irregular.
normal pregnancy.
Therapeutic principle: bolster Kidney Qi and regulate the Highway and Con-
ception tracts. .
Case 7
Treatment period 50 weeks, whereupon patient became pregnant.
Source: Guangzhou College of Traditional Chinese Medicine, Gynecology and
Case 4 Obstetrics Research and Training Section (1980:218-220).
Rao X X, F-36, a physician, first examined April 15, 1978.
Source: He and Liu (1987:167). Patient married and living together [with her husband] more than five years
Sun X X, F-32. Married eight years without a pregnancy. Delayed menses, but still has no children. Husband has been examined and is normal. Patient has
volume of menstrual blood small; color pale, consistency thin. Vertigo, heart pal- undergone a thorough examination and is largely normal; she has sought out doc-
pitations, facial color greenish white. Diagnosed at a Western medical hospital as tors in four places, still without the desired result. At the beginning of this year,
congenital infertility due to nonovulation. Pulse Sunken and Small, tongue pale at another hospital in Guangzhou, she had an endometrial biopsy (three hours after
with white coating. onset of menses), and the pathology report was "during endometrial secretion
No syndrome or treatment principle stated, probably Kidney and Liver De- period, substandard glandular secretion." Menarche at 15 years, periods approx-
pletion. imately monthly. But from the time of her marriage in 1973 the onset and length
Menstruation regularized after eight treatments. Pregnancy occurred after 12 of her periods has not been predictable, onset being frequently delayed, some-
treatments, carried to term, normal delivery. times having only one period in two or three months; volume of menstrual now
is small, even to the extent that [the period will amount to] one day of spotting
Case 5 then be clear; color dark red; breasts swell premenstrually. She has used artificial
means to induce periods several months, which were effective when used, but
Source: He and Liu (1987:167-168).
after ceasing this medication the situation was as before. Frequent dizziness, fa-
Zhang X X, F-29. Chronic menstrual pain. Married eight years without a tigue and lassitude, marked pain in the lower back, urination clear and prolonged,
pregnancy. Delayed menses, volume of blood small and color pale, intense men- cold extremities, normal digestion, somewhat excessive white discharge. Facial
strual pain which can be lessened with heat and massage. Facial color greenish color darkish yellow, with blackheads, tongue pale and spotted with white coat-
white. Discharge yellow. Lips pale. Vertigo. Skin and flesh dry and flaccid. ing, pulse Sunken and Small, Weak at the foot sections.
Lower back pain and generalized weakness, little interest in sex. Urination clear [Western medical] diagnosis: (I) delayed periods with small volume, (2) in-
and prolonged, stools loose. Tongue coating sticky white, pulse Small and Re- fertility (buyun zheng).
tarded. Patient has been treated with both Chinese and Western medicine without [Chinese medical] syndrome differentiation: Spleen and Kidney systems
obvious improvement. .
both depleted, accompanied by Liver system Qi stasis.
Syndrome: Kidney Depletion brought on by Lack of Nourishment to the Treatment principle: primarily replenish Kidney and strengthen Spleen, sec-
Highway and Conception Tracts.
ondarily relax Liver to resolve Qi stasis.
J7V
MEDICAL ANTHROPOLOGY QUARTERLY FEMALE INFERTILITY IN CHINESE MEDICINE 391

Prescription: dodder seed, 25 gm; Chinese raspberry, 10 gm; Chinese ma- of menses at age 15 has suffered from premenstrual abdominal swelling, as well
trimony-vine (fruit), 15 gm; Cherokee rose (fruit), 25 gm; Chinese angelica, 12 as nausea, cold sweats, dizziness, cold extremities, and severe abdominal pain
gm; Sichuan lovage, 6 gm; Chinese cornbind, 25 gm; dangshen, 20 gm; nut- during menstruation. After a therapeutic dilation and curettage two months ago
grass, 10 gm. Take once a day. her periods regularized somewhat. Tongue dark red with fine yellowish-white
Second examination, April 26: After administering the above prescription coating, pulse Strung, Small, and Rapid.
with some modifications more than 10 times, the lower back pain had lessened Syndrome: Blood Stasis with Qi Congestion
but the other symptoms were as before. Therapeutic Principle: enliven Blood to transform stasis, mobilize Qi.
Prescription: dodder seed, 25 gm; epimedium, 10 gm; dangshen 20 gm; Treatment interrupted for six months. Pregnancy achieved ten months after
baishu,15gm; millettia,30 gm;Chineseangelica,6 gm; nut-grass,10gm. Take first clinic visit, two months after resumption of treatment. Carried to term with
once a day.
normal delivery.
Third examination, May 3: After this medication menstruation commenced Commentary (by Zhang Baozhen) on Cases 6, 7, and 8: Although the basic
without swollen breasts; spirits markedly improved from before. Continue to use cause in the above listed few cases of infertility disorders is Kidney Depletion
[principles of] replenishing Kidney, strengthening Spleen, and nourishing Blood such that it cannot.control ling (seminal essence) and produce a pregnancy, the
to treat the condition.
"branch" illnesses are different in each case; if the branch illnesses are not elim-
Prescription: dodder seed, 25 gm; epimedium, 10gm; Sichuan teasel, 20 gm; inated it is difficult to settle on the root. . . . Case [7] was one in which Spleen
chain fern, 20 gm; dangshen, 20 gm; baishu, 15 gm; Chinese cornbind, 30 gm; and Kidney were both depleted, along with premenstrual tension disorders of
Chinese angelica, 10 gm.
Liver system Qi stasis, so it was appropriate to take replenishing Kidney and
Fourth examination, June 25: returned to the hospital to inform us that, tak- strengthening Spleen as the main [therapeutic principles1, secondarily relaxing the
ing the above prescription after meals, her periods had become more regular, the Liver to resolve Qi stasis; when Liver Qi ramifies outward wholesomely [tiaoda]
last one having started on June 23 and cleared after one day, the volume being a Blood and Qi are harmoniously regulated, and when Kidney, Spleen, and Liver
bit more than before; dizziness and back pain improved, extremities warmer, are all properly synchronized, this makes the menstrual periods have a regular
digestion okay; tongue pink with white coating, pulse Small and Sunken. timing-then it's easy to become pregnant. . . . When Chinese medicine treats
Prescription: dodder seed, 25 gm; Chinese raspberry, 10 gm; dangshen, 20 illnesses it always emphasizes combining illness differentiation and syndrome dif-
gm; Chinese matrimony-vine (fruit), 15 gm; Cherokee rose (fruit), 25 gm; ferentiation; thus it can get immediate results. [Editor: Zhang Boazhen]
Chinese cornbind, 25 gm; Sichuan lovage, 6 gm; Chinese angelica, 12 gm; nut-
grass, 10 gm. Advised to take four doses each month after the period clears, reus- Case 9
ing the sediment. Return for a check-up after two or three months of use.
Source: Guangzhou College of Traditional Chinese Medicine (1980:222-224).
Fifth examination, September 23: Having taken the above prescription ac-
He X X, F-29, worker. Married 3\12years without a pregnancy. Irregular
cording to our advice, all the various symptoms appeared to be improved, timing
menses, menstrual pain, volume of blood normal, dizziness and lower back pain
of menstrual periods normal, [one having] begun on July 23 and lasted four days,
when fatigued, little interest in sex, light sleep with frequent dreams. Diagnosed
with increased volume. After this period she continued to take the above prescrip-
tion in the same manner until August 20. Now there has been no period for two at another hospital as "immature uterus." A recent test reported "proliferation
months. She is dizzy and nauseous, digestion is not good, there is fatigue, and a of endometrial tissue." Body weak and wasted, facial color dark yellow, tongue
urine test for pregnancy in her home unit was positive. Tongue pink with white, pink with normal coating, pulse Sunken and Small.
slightly oily coating, pulse Sunken, Small, and Smooth. Syndrome: Insufficiency of "Prior Heaven" Kidney Qi, Depleted Highway
Physical examination: External genitalia and vagina normal, cervix soft with and Conception Tracts.
changed color [Chadwick's sign?], uterus tilted forward and soft, enlarged con- . Treatment Principle: moisten and bolster Kidney Qi, invigorate Spleen to
regulate Blood and menstruation.
sistent with second month of pregnancy, bilateral attachments normal, diagnosed
as early pregnancy. Treatment is to replenish Kidney, strengthen Spleen, and sta- After five months of treatment, patient became pregnant and delivered a baby
bilize the fetus; plan is to use Fetal Longevity Pills and modified Four Lords De. girl normally.
coction.
Case 10
At this writing patient has been pregnant six months. [Editor: Zhang
Baozhen]
Source: Guangzhou College of Traditional Chinese Medicine (1980:224-225).
Case 8 ) WangX X, F-32,doctor.Marriedmorethanfouryearswithouta pregnancy.
Delayed menses, variable volume of blood, abdominal swelling and pain, and
Source: Guangzhou College of Traditional Chinese MediCine(1980:220-222). lower back pain during menstruation. Pelvic examination normal. Tongue has
Li X X, F-29, worker. Married three years without a pregnancy, diagnosed small red lesions and little coating, pulse is Sunken and Small.
at a Western medical clinic with "congenital uterine insufficiency." Since onset Syndrome: Infertility due to irregular menstruation.
392 FEMALE INFERTILITY IN CHINESE MEDICINE 393
MEDICAL ANTHROPOLOGY QUARTERLY

Treatment principle: bolster Kidney, nourish Blood, mobilize Qi and regu- Case 14
late menstruation.
Source: Wang (1986:218-219).
Treatment period: 10 months, whereupon there was a normal pregnancy and Zhou X X, F-42. Staff person at Sichuan Engineering College. Married
delivery of a baby girl.
many years without a pregnancy. Diagnosed at another hospital as "severe ane-
Case 11 mia. proliferation of endometrial tissue." Suffers cold extremities, cold lower
abdomen, sallow facial color, weak body, poor appetite. insomnia. shortness of
Source: Wang (1986:215-216). breath, slow speech, lower back pain. poor bladder control, long menstrual pe-
Zeng X X, F-36. Teacher at Sichuan University. Married more than ten years riods with high volume of blood, and excessive white discharge. Pulse Retarded
without a pregnancy. Diagnosed at another hospital as "blocked fallopian tubes. and Moderate, tongue pale with thin white coating.
one side has an accumulation of fluid due to inflammation." Obese, spirits low. Syndrome: Qi and Blood both Depleted.
lower back pain and ringing in ears, cold extremities, feelings of congestion in Treatment principle: bolster Qi and Blood, moisten Liver and Kidney, reg-
chest, swollen breasts, poor appetite and diarrhea, discharge clear and thin in con- ulate menstruation to transform stasis.
sistency. menstrual periods very irregular, blood scanty and discolored. Pulse Treatment period: three months, after which she became pregnant and deliv-
Sunken and Weak. tongue pale with moist and slippery coating. ered normally. Later she became pregnant again.
Syndrome: Spleen and Kidney Yang Depleted
Treatment principle: warm Kidney and stimulate Spleen transformation, reg- Case 15
ulate the Highway tract and transform Damp to drive out local stasis.
Treatment period five months, followed by pregnancy resulting in birth of8. Source: Liu (1986:240-241).
pound baby. Wang X X, F-28, a relative. Married seven years without a pregnancy, re-
cently menstrual periods five to ten days premature, with swollen breasts. Previ-
Case 12 ously periods were nonnal. Volume of blood small, color dark; pain with men-
Source: Wang (1986:216-217). struation. Obese. Tongue normal, pulse Sunken and Slippery.
Syndrome: Kidney Qi Inadequate, Liver Tract Congested and Sluggish.
Duan X X, F-42. Design technician. Married 17 years without a pregnancy.
Volume of menstrual blood small, discharge yellow and foul-smelling. Diag- Treatment principle: moisten Kidney and relax Liver, enliven Blood to mo-
bilize stasis.
nosed at another hospital as "endometrial inflammation, fallopian tubes After four months of treatment there was a normal pregnancy and delivery.
blocked." Surgery failed to open tubes effectively. Has chest pain and insomnia.
dizziness and ringing in ears, sweaty palms, low-grade fever in afternoon, thin
Case 16
and weak body, dry throat and bitter taste in mouth, constipation. Pulse Strung,
Small, and Rapid. Tongue red with dry yellow coating. Source: Liu (1986:241-242).
Syndrome: Liver and Kidney Yin Depleted. Zhang X X, F-25, a relative. Irregular menstruation, married four years
Treatment principle: drive out stasis. without a pregnancy. Menstrual symptoms: volume of blood small, color dark.
Treatment period: six months, followed by normal pregnancy and delivery Premenstrual back and abdominal pain and generalized weakness. Frequent
of a 71/2pound baby. swelling of lower abdomen, reduced appetite. Tongue dark red with fine white
Case 13 coating, pulse Strung and Small.
Syndrome: Highway and Conception Tracts Inadequate, Depletion Cold of
Source: Wang (1986:217-218). the Uterus.
Feng X X, F-32. Military. Married five years without a pregnancy. Diag- Treatment principle: warm Uterus and expel Cold, regulate and bolster High-
nosed at another hospital as blocked fallopian tubes. Dizziness and ringing in ears. way and Conception tracts.
sweaty palms, low fever and periodic sweating, excessive sexual desire, and ir- Pregnant after two months of treatment.
ritability. Headaches and insomnia, feelings of chest congestion and pain in sides.
bitter taste in mouth, dry throat, constipation, irregular menstruation with small Case 17
volume of blood. Pulse Strung and Rapid, tongue red and without coating.
Syndrome: Yin Depletion with Yang Excess. S~urce: Liu (1986:242-244).
Treatment principle: regulate Liver and moisten Kidney, nourish Yin to reo Wang X X, F-29, a cadre. Married three years without a pregnancy. Men-
store fluids. struation every 40 + days, volume of dark blood very great. Recently has expe-
Treatment period: seven months, followed by nonnal pregnancy and deliv- rienced agitation, pimples on face and lips, and constipation. Tongue coating dry
ery of a baby girl. and yellow, pulse Sunken and Slippery.
.., ...,,~. ~~~v. '<'U'"'" I ""'.1 FEMALE INFERTILITY IN CHINESE MEDICINE 395

article is meant to recall this indigenous practice, which constantly contrasts the two med-
Syndrome: Fire Excess of Stomach and Heart, Highway and Conception
ical systems. Though the standard translation for zhol/gyi is "traditional Chinese medi-
Tracts Irregular. cine" (TCM), the traditionalism of this rapidly modernizing field in the contemporary
Treatment principle: clear Heart and drain Stomach, moisten and bolster P.R.C. is arguable.
Highway and Conception tracts. 2Qi(ch' i) is translated by Nathan Sivin as vitalities or energies, depending on medical
After seven months of treatment she became pregnant. context (1987:46-53). See his useful historical discussion of this fundamental medical
force and substance for a clarification of its many contexts and connotations. For purposes
Case 18 of this article it is especially important to note the intimate interdependence of Qi and
Blood. Qi drives Blood; Blood is the condition of existence for certain types of physiolog-
Source: Liu (1986:244-245). ical Qi. In this article I use many of Sivin's standard translations of medical terms (Cir-
Chen X X, F-29, worker. Menstruation had ceased for 40 days on patient's culation tracts is an example) and capitalize technical terms that could be misleading,
first visit to clinic, and she displayed other signs of early pregnancy. But preg- especially those referring to complex entities such as Blood and Qi and the five yin and six
nancy was ruled out upon examination. She had been married six years without a yang visceral systems offunction (Spleen, Kidney, etc.). I hope in capitalizing these terms
pregnancy. to remind readers that these entities do not correspond in any simple way to the anatomical
objects described by the English words. Where an otherwise capitalized word such as
Syndrome: Depletion Cold of Spleen and Kidney, Infertility Due to Uterine Blood appears uncapitalized, it can be taken to refer to the red fluid of our commonsense
Cold.
experience.
Treatment principle: assist yang and supplement Qi, warm and bolster 31do not mean to separate objects into two types, one real (bodily) and the other an-
Spleen and Kidney. alytic (mental). Rather the intention here is to consider them together, one argument of this
After six months of treatment she attained a normal pregnancy and full-term U article being that objects given in Chinese medicine, such as visceral systems, are as much
delivery. the result of intellectual activity as are disease categories. The converse also holds: another
aim of this article is to show that categories such as the syndrome in Chinese medicine
Case 19 (zheng), though unrecognized in biomedicine, are not purely ideal or vapid.
'The obstetrics and gynecology specialties of Western medicine in China arc usually
Source: Liu (1986:245-247). organized together in departments calledfucha/lke. Because there is almost no scholarly
Lu X X, F-35, farmer. Married 12 years without a pregnancy. Diagnosed as tradition of obstetrics in traditional Chinese medicine, fil ke (women's specialty) is the
'uterine insufficiency at another hospital. Menstrual symptoms: periods short and usual term which both organizes textbook knowledge and provides the name for clinics and
volume small; color of blood dark; pain in abdomen, lower back, and extremities. '" teaching-research units of this subdiscipline of traditional medicine. All the material in this
article, from both field observations and written works in Chinese, is drawn from this spe-
Tongue mottled, pulse Tardy and Moderate. ~~ cialty within traditional Chinese medicine.
Syndrome: Cold Depletion of Uterus, Irregularity of Highway and Concep- --,'I'i!
"
,
'The field observations which follow were made in the course of three research visits
tion Tracts. m ~.!
to the P.R.C. in 1982-84, the summer of 1988, and 1990-91, totalling more than two
Treatment principle: supplement Qi and nourish Blood, warm Uterus to ~ years of fieldwork. In all cases I was invited to sit in the clinics concerned, listening to
';;i
drive out Cold. conversations among doctors, patients, and bystanders in Cantonese and more or less stan-
Pregnancy achieved after 18 months of treatment. dard Mandarin Chinese. I kept notes and occasionally tape-recorded what transpired. I also
read and sometimes copied the case histories of patients visiting the clinics. In some cases
NOTES I was able to follow the management of a case over a period of several weeks through both
clinic observations and the written case history. This work was done without the help of a
Acknowledgments. The fieldwork on which this study partly draws was funded by a translator. In the Guangzhou clinics the doctors and their assistants sometimes translated
series of generous grants from the Committee on Scholarly Communication with the Peo- ",- the'remarks of Cantonese-speaking patients into standard Mandarin for me, and in Shan-
pIesRepublicof Chinaof the NationalAcademyof Sciences.Versionsof thisarticlehave I~ dong for a brief period local associates kindly transcribed tapes I had made, using Mandarin
benefitedfrom the comments of participants in the following meetings: Southern California ~' to explain unclarities of local language as needed. For this latter assistance I am indebted
China Colloquium, January 1990; Department of Humanities and Social Studies of Med- ~~ to Li Zhongyong and Wang Jun.
icine Colloquium, McGill University, January 1990; and the annual meeting of the Amer- ~1 61nthe outpatient clinics of the Guangzhou hospital, where the scenes previously de-
ican Ethnological Society, Atlanta, April 1990. Special thanks are due to Tani Barlow, -, scribed took place, patients kept their own case-record booklets with them, bringing them
Jean Comaroff, Charlotte Furth, James Hevia, Margaret Lock, Allan Young, and two every time they visited the clinic. Dated notes were added until it was full (or became lost),
anonymous readers for MAQ who made helpful suggestions based on careful readings. whereupon a new one was started. The clinics collected these booklets only if they had a
Correspondence may be addressed to the author at the Department of Anthropology, research project under way and needed to code them for analysis.
University of North Carolina at Chapel Hill, 301 Alumni Building, CB3115, Chapel Hill, ' 'Most of the senior doctors I have interviewed about philosophical issues in Chinese
NC27599-3115. h. medicine spontaneously insist upon the essential "subjectivity" (z}llIgua/lxing)of Chinese
'In the Peoples Republic of China, "traditional" medicine,is called Chinese medicine ci; medicine. Their feelings on this issue are mixed, as they fear that the future lies with the
(zhongyi), and biomedicine (what Charles Leslie [19751has called cosmopolitan medicine) . "objective" sciences, especially in a socialist China where official policy has recently em-
phasized "seeking truth from facts."
is referred to as Western medicine (xiyi). My use of the term Western medicine in this /,
396 MEDICAL ANTHROPOLOGY QUARTERLY FEMALE INFERTILITY IN CHINESE MEDICINE 397

"There are, however, numerous specialized works devoted to the treatment of infer- '''The terms "active" and "structive" are Porkert's (1974). The yin-yang relationship
tility. Two recently published examples are Sheng, Yang, and Sheng (1990) and Hu .,. has been the subject of extensive discussion in Sinology and anthropology from Marcel
(1990). Granet forward. For purposes of this article it is important to note that Blood as material
"This four-character phrase,jing dai yun chan. is used repeatedly in thefu ke literature realization and Qi as the active vitality driving it exist in a classic yin-yang relationship.
to label the special concerns of the field. A similar phrase both labels and characterizes But yin and yang logics are not confined to medicine; they still exist to some extent in
traditional medicine as a whole, .'theory, methods, formulae, and drugs." Four-character ordinary language and social life, and patients undoubtedly grasp something of the tech-
phrases are not confined to medical usage; witness the often-seen characterization of life nical significance of terms like Qi and Blood by analogy to the yin-yang of wcather, the
in general: "birth, aging, illness, and death." calendar, and other mundane concerns.
"'Control over the timing of legal births is most fundamentally exerted by controlling 2"Though I have no way of exactly calculating the cost of this prescription in 1980, I
the time of marriage. In most urban and rural areas childbearing is allowed immediately have the strong impression that it was not only symbolically evocative but also very ex-
after marriage registration at the legal age. In many rural areas a second child may be pensive. The use of Frankincense and Myrrh (Tantric codes for blood and semen) to "build
approved for parents whose first child is a girl, but this is possible only some years later, muscle," and of deer horn glue, human placenta, and ginseng, which are also expensive,
after others have had a chance at a first baby. The infertility treated infu ke clinics is often implies that Sun's family was willing to pour considerable wealth into her in the hope of
of late onset, following previous successful or aborted pregnancies. Rural women desiring producing their own child.
a second child and who felt they had to take advantage of an administrative clearance while 2'One can imagine how Chinese doctors view a Western medical regimen that can
theyhadit, werefrequent visitors to such clinics.
contemplate surgical intervention to correct a structural problem, thus permitting a prcg-
II A recentinfiuentialarticleby ThomasLaqueur(1986)tracestheemergenceinearly nancy in a woman whose physiology is not strong enough to carry and nourish a fctus
modem Europe of beliefs that women are essentially different from men. He describes <I. properly. The procedure must seem highly irresponsible.
shift from gender seen as positions on a qualitative continuum to gender represented as
221nsupport of this somewhat speculative point, it is worth noting that herbal medi-
absolute difference founded in anatomy and links this shift with problems arising from
cines and food are commonly confiated in modern Chinese practicc. Many types of food,
18th-centurydebates on equality and human nature. His work has raised interesting ques-
especially expensive "gift" foods important in holiday festivities, arc known for their me-
tions about the universality of .'natural"genderdifferences which this article in part takes
dicinal qualities and described in the language of Chinese medicine. Ideally Chinese herbal
up. Hence my interest in the relationship of a medical subdiscipline called "women's spe-
cialty" to the clinical concerns of general Chinese medicine. medicine is administered in a "soup" (tang) which is cooked at home from ingredients
assembled in a pharmacy according to a doctor's prescription. Since so many illnesses in
"The complex term ling can be properly translated in a variety of ways; it is perhaps Chinese medicine arc conditions of debility and depletion, it would not be far-fetched to see
more context sensitive than any other central term of Chinese medicine. Three major com-
Chinese medical therapy as a mode of nurturing. Families draw upon the expertise of doc-
mon uses of the term are transitional Qi (i.e., in a moment of transforming between two
other substantial forms), refined essences of food and drink, and seminal essence or semen tors for refined prescription design, but they remain in control of the actual therapy by
preparing and administering the medicine. Patients' comments about their relations to
itself. See Sivin (1987:164-165) and Porkert (1974:176-180).
"The yin and yangvisceralsystemsof function,eachof whichis namedwith refer- Chinese doctors and Chinese medicine suggest a strong continuity between technical ideas
about such therapies as "warming and nurturing" and the mundane processes in which
ence to an internal organ, are very complex. Limitations of space prevent a full explanation people care for each other.
of their characteristics beyond the formulaic presentation in Table I. See Sivin (1987) and
Porkert (1974) for extensive discussions. 23This opinion is very much my own and is not shared by most of my Chinese medical
14Thoughthis is an unoriginal insight in Chinese studies, few authors have framed the acquaintances, many of whom believe (perhaps correctly) that eventually Chinese medical
knowledge will become comprehensible in Western medical terms.
relationship of filiality and selfhood in just this way. John Hay (1983) and Tu Wei-ming 24"Substrate" is Porkert's term. In the early 1980s there was much concern in the
(1985) are among the exceptions. .
world of Chinese medicine with characterizing the "material foundations" (wlIzhi jichll)
"Case records maintained in hospitals and clinics often fail to specify the causes or
of many functions described by Chinese medicine. Though I have not yet done substantial
syndromes of infertility. When they do, simply noting "Kidney depletion" or "Liver
research on this topic, I believe that this interest has subsided in recent years.
oppression" is often felt to be enough. For experienced clinicians, diagnostic refinements "Translations for Chinese herbal medicine are taken from Hu (1980). Medicines for
may be inferred from prescriptions, so there is no need to specify the syndrome more com-
which Hu finds no suitable translation are rendered in the Wade-Giles romanization system
pletely. When cases are published, though, editors must identify the syndrome being in her book. For the sake of consistency within this article I use Pinyin romanization for
treated by either analyzing the prescription or checking with the doctor who wrote the orig- Chinese drug names, as for all other Chinese terms.
inal case record.
'6Thespatiotemporal sectors referred to are part of the methods and theoretical frame-
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