farquhar objects processes & female infertility in chinese medicine

JUDITH FARQUHAR

Department of AnthropologyUniversity of North Carolina at Chapel Hill

Objects, Processes, and Female Infertiljty inChinese Medicine //

/Focusing on the diagnosis and treatment of female i1f:rtility in tradi-tional Chinese medicine's "women's specialty" (fu ke), I examine the

relationship between anatomical objects or substances qnd physiologicalprocesses in Chinese medical analysis. After considering the significanceof gender in medical perception, I cite field observations,\extbook expla-nations, and published cases to illustrate a bias toward the temporal andthe processual in Chinese medicine. Continuities between illness expe-riences and understandings of women's bodies are explored in relationto these clinical modes of knowing.

No one would deny that the body is an object. Yet scholars have assertedthe objecthood of bodies to many different ends in the service of widelyvarying projects (Kuriyama 1987:64-65; O'Neill 1986; Turner 1984). In

contemporary biomedicine, for example, the gross anatomy upon which clinicalpractices have long been grounded has been supplemented by refined technologiesfor visualizing bodily structure. Even such relatively gentle developments as com-puterized tomography (CT) and ultrasound imaging continue to trouble those pa-tients and medical critics who complain of a radical objectification of the personin clinical practice. In using (often invasive) laboratory tests to discover condi-tions of the body which are outside the experience of the patient yet exist deepwithin him, the body is separated from the lived discomforts of the ill person (Cas-sell 1982;Saunders 1988). However "humanistic" biomedical practices become,however kind the bedside manner of doctors, their mode of knowing and servingoften renders the body a foreign terrain of visualized structures, an object that canultimatelybe known only through technologies over which the patient has no con-trol (Taussig 1980).

In the discussion that follows, I will consider similar problems of object-hood, experience, knowledge, and time in the clinical practice of Chinese medi-cine as a way of assessing the extent to which all medical analysis requires someform of objectification through abstracting a structural state from the ongoing ex-perience of illness. As a way of approaching the category of "the body" (Sche-,per-Hughes and Lock 1987), I will inquire into the nature of objects in "tradi-tional" Chinese medicine. I Perhaps a clearer understanding of the bodily objectsand substances recognized in Chinese medicine (e.g., visceral systems, Bloodand Qi, circulation tracts),2 as well as of its more abstract objects (i.e., the entitiesthat result from extensive analysis such as syndromes and prescriptions), can lead

FEMALE INFERTILITY IN CHINESE MEDICINE J/I

us to a view of Chinese bodiliness that need make few concessions to Cartesian-ism and "the medical gaze" (Foucault 1973).3It may also suggest ways in whichstyles of knowing can color clinical encounters independent of the social skills ofindividualdoctors.

The anthropological investigation of styles of Chinese medical knowing isaided by a vast contemporary literature in the Peoples Republic of China. Text-book knowledge, the sorts of things that contemporary Chinese doctors are taughtin 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 andlegislate the accumulated technical wisdom of a healing discipline and where aprofession of experts is reproduced through formal training in well-supervised in-stitutions, the complex politics of the clinic diverge from expectations fostered bythe printed page. Furthermore, the illness experiences of patients articulate moreor less awkwardly with the language and manipulations of their doctors. At thesame time, both doctors and patients are subject to the structuring economic andpolitical exigencies of' 'health care delivery," the limitations of which they havedifficulty escaping. These differing registers of reality crisscross the field of ill-ness and healing, making every statement significant in several different ways(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-tive disciplines to transplantation and dialysis; for the patient it invokes a mundanebut continuous experience of urination, lower back pain, menstrual cramps, andvaginal discharges. For both, a (possibly highly charged) history of personal clin-ical experience connects to many such items of knowledge. Moreover, both doc-tor and patient respond in practice to the institutional fact that kidney disordersare treated differently in the "Western medicine" and "Chinese medicine" de-partments of hospitals. These are considerations that have no obvious place in"the professional literature" of textbooks and research reports, but they do sur-face in the clinic and are implicit in published cases. An anthropological study ofa style of knowing must therefore draw from all these sources.

I will focus this study on the clinical problem of infertility as it is treated infu ke, women's medicine.4 Recalling how often American women complain ofbeing treated like objects in gynecological practice, and perhaps because we areIe€!to believe that certain objects (e.g., uteruses and vaginas) must be significantto any medicine that makes a specialty of women, I bring motives and common-sense expectations from the life-world of female patients in the United States toan interrogation of the literature and practice of contemporary Chinese women'smedicine. In any such procedure there is a danger of finding orientalist "answers"to our own cultural questions, producing an idealized Chinese medicine as we go.Obviously, I wish to avoid such cross-cultural romanticism while still finding apath to &pecificChinese versions of what Shigehisa Kuriyama has called the "un-known realm" that is the body (1987:64).

The foil for this comparison is not the systematized and constantly reexam-ined knowledge of cosmopolitan biomedicine; rather it is a certain lumpy, taken-for-grantedness that still clings to our concept of "body." Anatomy may be dis-integrating fast as a foundation of biomedical knowledge and practice (Haraway

372 MEDICAL ANTIIROI'OLOGY QUAlflEKLY

1989), but it still serves as the chief metaphor through which nonspecialist West-erners think about their bodies. The persistent analysis of material existence interms of visible structural features of discrete things has been both a triumph anda limitation of the Western medical worldview. I hope in this article to show that'!Chinese medical analytics are radically different.

After discussing the clinical context of women's medicine as I have observedit in the course of fieldwork5and reporting explanations of infertility gatheredfromjil ke textbooks (Anonymous 1983;Chengdu College of Traditional ChineseMedicine 1985; Hu 1990; Shanghai College of Traditional Chinese Medicine. '

Gynecology Research and Training Unit 1983;Sheng, Yang,/~nd Sheng 1990), )'review 19 published cases of infertility, analyzing two of tqtm in some detail. ) .

have chosen these cases neither at random nor very sYstemat

~

ibaIlY; they are simplyall the cases of infertility appearing in the Chinese medical c se anthologies I havebeen collecting since 1982 (see Appendix). The two I hav chosen to discuss in

detail cannot be considered to be typical, but they do share fertain features withall other case reports in Chinese medicine. Few cases that fail to result in a cureor significant alleviation of symptoms are published, for example, and all havedidactic points to m\lke about clinical practice and medical analysis (Farquhar1991). The reading that I shall attempt here could be done with any of the 19 casessummarized in the Appendix and would lead to diverse insights about contem-porary Chinese medical discourse. Published cases mix many forms of experienceand knowledge, and they can be unpacked and analyzed in endless ways. Myfocus in this article will be on physiological knowledge-in-practice and its rela-tionships to the life-worlds of patients; other dimensions of medical experiencewill also be addressed in order to render the case histories intelligible.

Chinese Clinics of Fu Ke

In 1983I spent one afternoon observing the practice of a doctor of traditionalmedicine, a man just above middle age who was famous for treating infertility.Married couples desperate to have children came to him, many from a great dis-tance, most of them veterans of many different treatments for infertility. All themen had undergone fertility tests, and some of them were being treated with her-bal prescriptions to remedy a low sperm count or low motility. If husbands hadtested normal, their wives were treated for various depletions and deficiencies (afew examples of which I will analyze below). The clinic was crowded, tense, andoriented to the technicalities of prescription design. Many of the couples wouldkeep in touch with the doctor by mail, reporting changes in the patient's symp-toms and receiving written alterations in the prescription.

In strong contrast to this scene, I observed on several occasions (1983-84and 1988), the regular gynecology clinic of my friend Liu Jufang in the sameGuangzhou hospital. Liu practiced with another experienced woman gynecolo-gist, Dr. Ma, in a small room with a large table in the center. Each senior doctor,sat on one side of the table, with junior associates, also women, at her side. Withthe help of their associates they were able to interview and examine several pa.tients at once, which was often necessary since they were usually very busy. Mostof their patients were women; the occasional husband or father who attended theclinic seemed reluctant to enter a room so full of females. Many kinds of female

FEMALE INI'ERTILITY IN CHINESE MEDICINE 373

disorders, as well as male infertility, were treated here. Pelvic examinations wereconductedas needed in the room next door. Doctors often had whispered consul-tations with patients who didn't want to be overheard by the many bystanders; atthe same time there were frequent joking exchanges among the doctors and pa-tients, often involving complicated narratives of women's lives and illnesses. Ad-vice about sexual practices, hygiene, and self-care was given and discussed withlittle embarrassment. The atmosphere was one of both intimacy and openness. Inits relative exclusion of men, however, it was almost conspiratorial.

The last scenariodiffers from both these urban clinics. In a subsidized villageclinic near a Shandong county town, a locally well-known senior Chinese doctor,retired from the county hospital of traditional medicine, ran a thriving generalmedicine and fu ke practice. Patients came to see Zheng Chengfeng when theycould spare time from their work in the fields or get away from their jobs in localfactories. Though there were times when he was very busy (just after the wheatharvestand at the height of the winter upper respiratory infection season), he oftenhad the leisure to write lavish case histories, which he filed by surname and kepton many clipboards hanging in rows on the wal1.6When a patient came in, Zhengwould first find her case record and study it before collecting information on hercurrent condition. The patient did most of the talking, and many produced longnarratives while Zheng jotted down a few notes and asked a few clinical ques-tions. In the cases of women who had been coming to see him for a long time andbrought relatives to see him as well, he knew much more about their family andsocial situations than the overworked urban doctors I have described above.

I have also observed three other doctors ofjil ke at work in Beijing clinics,as well as numerous clinics of other Chinese medical specialties. The social stylesof these various doctors were highly diverse: some, like Liu, were sympatheticand attentive in a sisterly or fatherly way; others were taciturn, abrupt, or evenharsh with patients. All, however, shared a commitment to the use of clinicalmethods and therapies which are unique to Chinese medicine.

All contemporary Chinese doctors work in a complicated relationship to theforms of practice typical of Western medicine. In all the .fil ke clinics describedabove, for example, the results of pelvic examinations derived frolll Westernmedical practices may be noted and considered, but pelvics are very seldom per-formed. Most infertility patients arrive at clinics of traditional medicine after hav-ing been treated in Western medical clinics; they often can report the results ofsuch examinations or provide them in a previous case record. In such cases treat-ment proceeds with reference to these earlier findings. In the two urban clinics Ihave described, it was very rare for an infertility patient to be given a pelvic exam;in Zheng's rural clinic he sometimes asked a female associate to do an examina-tion if none had ever been done before. In Liu's clinic pelvic examinations weredone to confirm pregnancy, to determine fetal development, or if the patient com-plained of lesions or localized pain. Patients removed or pushed aside only theparts ohheir clothing necessary for the examination, and were never asked tofully disrobe. In contrast to the centrality of the pelvic examination in the Westernpractice of gynecology, with its fetishized arrangement of drapes over a disrobedbody and assymetrical placement of doctor and patient, the prototypical spatialarrangement of Chinese medical actors (their disposition in Bourdieu's sense ofthe word) is seated face to face atacornerof thetable, talking.

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The results of pelvic examinations and other Western medical procedures(ultrasound, for example) are recorded and considered within the larger frame-work of the clinical encounter, which is guided by the "four examinations" oftraditional medicine. These are "looking" (at the tongue and features of the pa-tient's general appearance), "asking" (the history of the disorder), "hearing!smelling" (for altered voice, coughs, foul odors) and "palpating" (the pulse). Ithas been clear in all my observations of clinical encounters in the institutions ofChinese medicine that doctors subsume the results of "objective" Western-styletests and examinations within the more impressionistic and subjective methodsoftraditional medicine. The "four examinations" focus on the patient's own ac-count of her symptoms and on signs that are perceptible on tbe-\)oaj's surface

(e.g., tongue color, pulse quality). Together, doctor and pa)lent produce an un-derstanding of the illness from the ingredients of her memory and noninvasive"readings" of her body. This understanding not only supe~sedesinformation de-

rived from Western medical methods but also replaces a !estern medical diag-nosis with a (theoretically, at least) more treatable Chine~e medical syndrome(zheng). Doctors neither strive to achieve "objectivity" no~dwell upon objects.Their subjective grasp of pathological process builds largely upon the patient'sreport of her history, treating both signs observed in the clinic (pulse, tongue im-ages) and Western medical test results as moments that are of little significancein themselves.7

This process of privileging the methods and entities of Chinese medicine isclear in both of the cases analyzed below. Though hospital case records and pub-lished cases are phrased in a somewhat specialized medical language, I will try toshow how the Chinese medical syndrome-a summary of pathological process-is arguably more consonant with the patient's experience of her illness than"Western medical" diseases of hidden anatomical irregularities and microscopicpathogens.

Chinese Medicine and Female Infertility

"Failure to become pregnant" (buyun zheng) as a disorder is invariably dis-cussed near the end of contemporary textbooks and collections of fu ke case his-tories.8 It is preceded by all the disorders that can afflict "menstruation, dis-charges, pregnancy, and childbirth."9 Infertility is often not present as a pathol-ogy at all, at least according to the usual means of detecting disorder in Chinesemedicine; it is a failure to achieve a desired bodily change, rather than an unde-sired change that must be brought under control. Further, like most Chinese med-

ical syndromes, it results not from a permanent structural abnormality of the bodybut rather from an (often subtle) deficiency of normal physiological functions.(The cases discussed below will illustrate this.)

Failure to become pregnant may be one of the most frequently treated dis-orders in contemporary Chinese medicine, and it is certainly one that evokes des-perate anxiety on the part of its sufferers. Much of this anxiety is due to the' 'onechild policy," which an American friend of mine in South China has bitterly de-scribed as "the policy that every woman must have one child." He was referringto the pressures that working women in China face to put motherhood first whilecombining household management with wage-earning and, in some cases, career

.J/J

advancement. In many administrativejurisdictions, prior authorization is requiredfor planned pregnancies; clearance to reproduce is awarded on the basis of com-plex rules designed to give everybody their chance at one healthy child. 10 It isoften strategically necessary to become pregnant with split-second timing: birthcontrol in this case actually means minute control of when there will be a birth,and "family planning" is no euphemism.

Before turning to the treatment of infertility, I will attempt to locate the sub-discipline of women's medicine within traditional medicine as a whole. Text-books both argue and demonstrate thatfu ke is basically the same as Chinese med-icine'scentraldisciplineof internalmedicine(nei keY,abodyof knowledgeandpractices that concerns itself with all physiological and pathological processes.Until the very recent entry of numbers of women into the profession of traditionalmedicine, male practitioners who were known for skill infil ke seldom confinedtheir work to this area. Male doctors who are developing the infant fieldof' 'men'sspeciality" (nankeYusually also have other specialties as well. Subdisciplinarydivisions tend to be very fluid in the contemporary institutions of Chinese medi-cine.11

One textbook points out that Western medical obstetrics and gynecology dif-fer from fu ke in that their origins are in surgery, a set of practices that neverdeveloped in premodern China (Chengdu College of Traditional Chinese Medi-cine 1985:1). This distinction is made in the context of a long critique of tradi-tional Chinese medical approaches to childbirth, which are seen as endlessly re-producing errors from an early classic, with only a few worthwhile insights scat-tered throughout the history of the field. Classical discussions of the disorders of"menstruation, discharges, and pregnancy," on the other hand, are said to havea more noble history by virtue of being part of the rich internal medicine tradition.

The 7th-century scholar Sun Simiao is often cited to the effect that "thosewho have prescriptions for women's distinctiveness (hie) take the differences ofpregnancy, childbirth, and [internal] bursting injuries as their basis" (cited inChengdu College of Traditional Chinese Medicine 1985:2).This remark is typicalof many distinctions made in classical medicine: a small set of characteristic phys-iological and pathological processes rather than anatomical structures mark"women's distinctiveness" within the general run of medical concerns. Theseprocesses take their place alongside a host of other physiological and pathologicalprocesses, all of them implicating each other in the functional relations of thevisceral systems. Sun's emphasis on reproductive functions remains important incontemporaryfu ke; recently published texts focus on maintaining normal men-struation, pregnancy, and childbirth, devoting almost no attention to sexuality ormenopause. Though there is a parallel interest in reproductive health for menwithin internal medicine, until very recently no separate specialty has been con-cerned with such problems (Zhang 1990:i). It appears thatfzl ke as medical sub-discipline is clearly all about assuring the wholesome production of babies. Thedisorders of "women's distinctiveness" that it treats are those that interfere withreproductive success.

It would be a mistake, however, to infer from this bias of a traditional med-ical specialty that "women," unlike "men," are uniquely significant as produc-ers of babies. For both men and women, reproductive physiology is strongly as-sociated with the roots and origins of many processes necessary to normal health.

376 MEDICAL ANTHROPOLOGY QUARTERI.Y

Male and female seminal essence (jing)12and the congenitally endowed "sourceQi" of both sexes are governed by the Kidney visceral system. (See Table I fora summary of the functions and characteristics of the five yin visceral systems offunction.)13

When an external heteropathy invades the body and initiates a pathologicalprocess, it most often affects the higher and more "outer" visceral systems first,especially the Lung system (which is hardly mentioned infu ke) and the Spleen-Stomach system. As an external pathology ramifies through the five linked vis-ceral systems and the circulation tract system, it may eventually begin to affectKidney system functions. This is a sign of a long-standing and deep-seated pa-thology, hard to cure and implying permanent damage. Pathological processesthat extend to the Kidney system attack the seat of irreplaceabl "source Qi."This form of Qi, which is necessary to healthful respiration and irculation, maybe slowly depleted through sexual activity, menstruation, and ch Idbirth. Womenare advised to rest for a month after childbirth lest they incur skel tal injuries frompremature activity, and a wide array of therapies are available t men who sufferfromthe serioussymptomsof prematureejaculationor nocturnal missions.Path-ological attacks on the center of source Qi are thus very serious i deed.

Affiliated with

Small intestine

Large intestine

Stomach

Gall bladder

Urinary bladder

FEMALE INFERTILITY IN CHINESE MEDICINE 377

It appears, then, that Chinese medicine, in placing the reproductive functionsfor both sexes at the terminus of a sequence of increasingly serious vulnerabilities,incorporates a strong telos of reproduction. A person with an impaired ability tohave a child is very ill indeed, at least in theory. Chinese medical knowledge hasthroughout its long history been used in the service of continuing' 'Confucian"lineages through the production of children. In medicine reproductive functionsare central to health just as in social life having children is central to selfllOod.'4Gender difference ("women's distinctiveness") appears to count for medicinemainly with regard to problems that arise in one moment of a dual-gendered pro-cess of reproduction.

Textbook Knowledge about Infertility

There are a few main types of female infertility. Textbooks differ somewhaton their number, some subdividing "Kidney Depletions" into two or three typesand some lumping all Kidney Depletions together. But the usual explanations forfailure to conceive are quite standard and can be summarized as six syndrometypes (Table 2).

. Giventhe complexityof Chinesemedicalphysiology,it is interestingthatinfertility syndromes should be so few. Practitioners, who are well aware of themanifold ways in which disorder in anyone system can ramify to all others, tendto explain the relative simplicity of short lists like this in terms of accumulatedclinical experience. These are the "often seen" (chang jian) syndromes, whoseperceived redundancy over centuries of observation has allowed them to be in-cluded in handbooks as lists which link typical symptoms (important for differ-ential diagnosis) with recommended treatment principles and effective drugs. Cli-nicians are likely to consider these syndromes first as explanations for the symp-toms presented by patients, but in practice infertility can have causes that deviatefrom such standard lists. Of the cases appended here, only one, # 17, is a syn-dromemarkedlydifferentfromthoselisted.IS Injil ke. as in traditionalmedicineas a whole, syndromes are patterns of disorder rather than fixed disease entities;the list of possibledisordersis thus theoreticallyinfinite,as the one exceptionreminds us.

The standard list of infertility syndromes undoubtedly arises from historicalexperience of some kind, but certain features of these "often seen" syndromesare easily remembered because they are reasonable in terms of normal physiol-ogy. It appearsfrom the "illness mechanisms"summarizedin Table2 that theirregularity most proximate to symptomatic expression is of the Highway andConceptioncirculationtracts.Thesearetractsof the"extraordinary" (qijingba-mai) class, usable for acupuncture treatment of various disorders in both men andwomen but especially crucial to female reproductive functions. In other words,though a visceral system (Kidney, Spleen, Liver), a bodily substance (Qi, Blood,Jingkor a formof heteropathicQi (Phlegm,Damp, Heat)is held to bechiefiyresponsible ("taken as the root," doctors would say), the Highway and Concep-tion tracts "downstream" from such sources invariably malfunction and producethe characteristic symptoms of irregular menstruation and infertility. In keepingwith 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

TABLE 1

Thefive visceral systems offunction.

System Acts on Stores Manifestations

Heart Blood Shell Unfolds in vessels;

(vitality) manifests in face;

vents at tonguc

Lung Qi; Unfolds in skin and

breathing; body hair; regulatesclears away, the "watercourse";carries downward vents at nose

Spleen transmission and Unfolds in flesh;transformation; four limbs;elevates clear vents at mouth;fluids; manifests in lipsin charge ofblood flow

Liver dispersion Blood Unfolds in sinews;

upward and vents at eyes;downward manifests in nails

Kidney fluids; lillg Unfolds in bones,Bladder; (semen) source Qi. "Bloodmarrow; reservoir"; manifestsaccepts Qi in hair; vents at ear,

genitals, anus

TABLE2

Main ca/lse~'and treatmentsof infertility.

Syndrome Type

Spleen and Kidneyyang depletion

Liver and Kidneyyin depletion

Blood depletion

Phlegm Damp

Liver

oppression

Damp Heat

Illness Mechanism

Body depleted and weakKidney Qi inadequateHighway and Conception

tracts cannot control ling toconceIve

Same as above

Withering or hemorrhage ofblood induces vacuity,

Depletion of Highway andConception tracts, whichcannot control ling to con-ceive

Obese constitution or indulg-ence in fatty and stickyfoods produces PhlegmDamp internally so that Qimechanisms don't flowsmoothly,

Highway and Conceptiontracts develop obstructionsand produce infertility.

Negative feelings lead to ten-sing and knotting in Liversystem

Qi and Blood go out of synchHighway and Conception

tracts lose regularityConception is affected.

Damp Heat accumulates andobstructs the lower pro-cessing locus, so the Qi andBlood of the Uterus chan-nels are blocked in their

tlow, inducing infertility

Treatment

Build up Spleen

Warm KidneyNourish Blood

Regulate menstrual periods

Nourish and replenish Liver

and Kidney/'Nourish Blood

RegUlate/lensesNourishl Blood to harmonize

with~onstructiveQi .Supplef\1ent and replenish

Live< \Kidn"Transform Phlegm and dry up

DampBuild up Spleen to regulate

menses

Relax Liver to resolve oppres-sion and clear out sluggish-ness

Clear Heat and drain DampRelax Liver to open tracts

SOl/Tee:Shanghai College of Traditional Chinese Medicine (1983:164-167).

specificsfor one or another visceral system and act on the Qi-Blood relationship.Their efficacy on the tracts of the reproductive system is not mentioned in themateriaemedicae except in terms of their results, regulation of menstrual periods.

All six infertility syndromes are characterized by irregular or absent men-struation. The importance accorded to regulating menstrual periods in curing in-fertility is evident in the treatment principles listed: three specify menstrual reg-ulation and the other three imply it in their emphasis on eliminating blockages andsluggishness and on reharmonizing Qi and Blood. In published cases like the twodiscussed below, pregnancy often follows quickly upon the attainment of regularmonthly periods.

Medical textbooks are organized to make symptom complexes associatedwith each of the syndromes listed in Table 2 easy to find. In fit ke, menstrualirregularitiesare 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-tient is relied upon to report these symptoms accurately, along with a great manymanifestations that are more widely significant within traditional medicine:moods, digestion, elimination functions, sleep patterns, aches and pains, localswellings, fevers or unusual feelings of cold, and degree of interest in sex. Theonly symptoms that can be correctly perceived by doctors exclusively are altera-tions in the pulse and quality and appearance of the tongue. These technical symp-toms are very important but seldom meaningful apart from their relationship toreported symptoms.

Syndrome differentiation, at least as it is taught in contemporary schools ofChinese medicine, proceeds from these symptoms, classifying them with evermore refined modes of analysis until many closely related possibilities have beeneliminated and one useful characterization has been achieved. To illustrate thisprocess with an overly simple example of just one symptom, a large volume ofbright red menstrual blood indicates pathological Heat arising from a state of re-pletion; small amounts of bright red blood suggest pathological Heat due to a de-pletion. Repletion and depletion refer less to the physical amount of blood thanto complex dysfunctions of the visceral systems.

After these general rules have been combined with analyses which target spe-cific visceral systems and spatiotemporal sectors of the body, 16 the informationcan be used to design an intervention. For example, once it has been determinedthat the problem is one of depletion of Cold of an internal sector, no drugs whicheither further chill or deplete (e.g., through draining) the affected visceral systemswill be chosen.

The syndrome names in column one of Table 2 suggest the various dimen-sions focused on in conventional diagnosis. Of the cases in the Appendix, six (I,6,7, 10, II, and 18)are clear cases of Spleen and Kidney Yang Depletion. Cases2, 4, 12, 13, and 15 are simultaneous depletions of Kidney and Liver. Cases 3,5, and 9 are simply seen as Kidney Depletion. Three of the 19 cases (8, 14, 19)are analyzed in Qi-Blood terms and would require a close reading of the prescrip-tions used to determine what visceral systems were primarily treated, thoughSpleen and Liver systems are the usual targets of such therapy. And in additionto the exception to all rules mentioned above (Case 17), Case 16 focuses ratherunconventionally on the Highway and Conception tracts themselves, naming nomore systemic root to the disorder. 17

Several general observations can be made on the basis of this review of text~book knowledge and published cases. First, doctors' own explanations of illnessetiology are consistent with textbook generalizations, though they may departfrom them when concrete symptoms warrant. This is true not only in formal texts,such as published cases, but also in the explanations doctors have provided to meabout cases I have observed in clinics. Second, these explanations focus on dis-ordered processes which ramify through the whole body. They do not localize thedisorder within the body, rather they distinguish it from other possible patterns ofpathological process affecting the whole body. Even the notion of depletion, aninadequate translation of the Chinese word xu, refers not so much to inadequateamounts of substance as it does to weakened forces of bodily flow. Where healthyprocesses flag or transgress usual limits, substances will not be produced with theproper timing and in the proper volume. The diagnosis and regulation of men-strual disorders (and the closely related condition of infertility) in fit ke thus ty-pifies the relations between processes and objects in Chinese medicine.

Two Cases of Infertility in Women

Of the 19cases appended here, cases 2 and 7 are translated in full for a closerreading; in what follows I will refer to them rather than paraphrase. In the viewof Chinese doctors, Case 2 is useful mainly to make a very clear point: a chroni-cally ill woman is diagnosed in a Western medicine clinic to be infertile becauseof obstructed fallopian tubes. An experienced doctor of Chinese medicine, per-ceiving long-standing functional disorders of many systems, ignores the repro-ductive organs per se. Instead he restores strength and regularity to functionalsystems which are more basic than any specific abnormalities of reproductivefunction. As a result, a healthier patient is able to conceive and bear a healthychild. In the published case, the fallopian tubes and whatever was obstructingthem are apparently irrelevant to the case.

The narrative of this case takes a familiar form for contemporary Chinesemedical case histories. It notes the anatomically founded "diagnosis" of Westernmedicine, then demonstrates the superiority of Chinese medical "dynamic andholistic" methods of analysis with the considerable polemic force of an actualcure and, in this case, a healthy baby. The discrete transplantable objects of West-ern medicine, characterized with such loving care in pathological anatomy andperceived at the cost of such expensive imaging technology, are seen as mereproducts of powerful processes that govern the tife of the body.

I can make this point clearer by explicating the treatment principles used inthis case. They fall into three categories. First, with respect to visceral systems,the plan is to "warm the Kidney system and nourish the Liver system." The Kid-ney system tends toward being "Cold" (i.e., more yin than yang), and this pa-tient's symptoms are strongly suggestive of a state of chronic Interior Cold. Con-ception and fetal development rely upon a balance of yin and yang in the Kidneysystem; therefore drugs which "Warm" or "yang" the Kidney will tend to reo,store this system to normal.

Turning to the Liver system aspect of Case 2, we should note that the rela-tionship of the Liver system to conception and pregnancy has to do both with itsBlood storage function and with its characteristic activity of Qi dispersion. With

respect to Blood, the most general classical principle governing conception is that"[male] Semen and [female] Blood join to become Ifetal] form." For women,then, an inadequate Blood supply to the Highway tract (also called the Blood res-ervoir, of which more below) because of reduced Liver function renders men-struation scant and infrequent and conception unlikely. If the Qi dispersion func-tions of the Liver system become disordered, there are immediate consequencesfor Blood flow, since Qi drives Blood. Menstrual irregularities are therefore al-most as often blamed on Qi disorders as on Blood.

Mrs. Sun, the patient, may grasp almost nothing about the activities of theKidney and Liver visceral systems, or she may be the sort of sophisticated patientwho has elaborate and well-informed ideas on the subject. But given her symp-toms of cold and weakness, pain and scant menstrual flow, it seems likely thatshe would see the sense of a therapy identified as "warming" and "nourishing."

The Kidney and Liver each "rule" (ZhU)18complex systems of function andusually are seen to have priority over the functions of the circulation tracts. Thusthough the Highway and Conception tracts are often implicated in menstrual dys-functionand infertility, their "regulation and replenishment" in this treatment arementioned after the more basic treatment of visceral systems. Though they haveotherfunctions,both tracts are crucial to reproduction.The Highwaytract, orBlood reservoir, fills and drains monthly, supplying regular menstrual flow. TheConception tract controls this periodicity, and its flow (of Qi, presumably) mustbe smooth and even. Thus both tracts depend especially on the Liver system asnot only a source of Blood but also a primary agent in the dispersion of Qi throughthe tract system. The two tracts also have a close interdependency of the yin-yangtype: the Conception tract plays the role of "active" yang Qi to the Highwaytract's "struetive" yin Blood. 19 They must be "regulated and replenished" to-gether. The chief means of doing so in this prescription is to foster Liver systemfunctions.

The third dimension of intervention in this case directly addresses Blood andQi, the closely interdependent yin-yang couple that crosscuts both visceral sys-tems and circulation tract functions. In other words, the yin-yang relationship ofBlood and Qi (Qi drives Blood while depending on Blood as its fluid medium) isthe most general dynamic of the body, the fluid and mobile resource of all bodysubstance and activity. The symptoms reported in Case 2 betray depletions of bothQi and Blood and give a clear picture of Blood stasis, a condition that often resultsfrom simultaneous Qi and Blood depletions. Because Qi drives Blood, Bloodstasis is often treated by stimulating Qi movement. In this case, four of the 15drugs in the prescription either replenish or regulate Qi, and four of them enlivenor replenish Blood (see Table 3). Treatment directed at the Liver system willeventually address problems of Blood stasis as the Qi dispersion functions of theLiver improve.

Few patients know much about the functional roles of the herbal medicinesincluded in their prescriptions. But they have little difficulty in correlating some-thing called "Blood stasis" with symptoms of menstrual irregularity and generalcoldness and weakness. Most people also know that in Chinese medicine Qidrives Blood; patients can see the logic of remedying a condition manifesting inBlood inadequacy with a method that simultaneously regulates Qi. With the doc-tor, theycan feelthathe is "seeking the root."

382MEDICAL ANTHROPOLOGY QUARTERLY

TABLE3Analysis of prescription for case 2.

"Treatmentprinciples are specified in the published case. No drugs were specific for"rcglliatin!! and repIenishin!!the Hi!!hwayand Conception tracts."

FEMALE iNFERTILITY IN CHINESE MEDICINE j1\j

The therapy for Case 2, then, is very broad. No effort is made to isolate thesingle most crucial system or substance, least or all something as trivial as tubeblockage. Instead, every aspect of Sun's chronic illness is addressed at once, witha strong emphasis on drugs that strengthen and nourish.2OIn a sense, a reproduc-tive anatomy that is capable of conceiving and bringing a pregnancy to term isbuilt almost ab initio by replenishing the productive functions of three cross-cutting bodily processes (visceral systems of function, circulation tracts, andBlood and Qi). 21 This is not to say that the relevant structures, such as the ovaries,tubes, and uterus, are denied; they are simply local and contingent phenomena ina medicine in which fetuses are conceived and nurtured by global (i.e., whole-body) processes.

Case 7 appears to be a good deal more complicated, even though the patient,herself a doctor, presents much less evidence of chronic illness than had Sun. Inthis case Luo Yuankai's editors have helpfully provided a syndrome differentia-tion(i.e., a Chinesemedicaldiagnosis)of "Spleen and Kidneysystemsbothde-pleted, accompanied by Liver system Qi stasis." This is a combination of two ofthe categories listed in Table 2 and yields eventually to the standard strategy re-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."

The case narrative makes the usual polemic point: the patient had long soughta cure for her infertility from institutions of Western medicine but without suc-cess. Their final gesture was to perform an invasive procedure unimaginativelyfocused on one part of one organ (a biopsy of endometrial tissue) which enabledthem to diagnose only a very subtle dysfunction. Luo's editors wish us to notethat he saw the problem in diametrically opposed terms: by reading the manifestsigns of the illness, he analyzed functional debility in three of the five major vis-ceral systems governing the health of the whole body. His herbal prescriptionreflects this wide-ranging analysis (Table 4). Since he was able to produce first asignificant alteration in menstruation and then a pregnancy in less than a year, hisreading of the problem (the case report suggests) was vindicated in practice.

Case 7 is one of those interesting Chinese medical documents in which thewhole sequence of the clinical encounter is indicated. Luo saw this patient over aperiod of more than a year; he not only recorded her changing symptoms duringthis 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 factonly three formulae involved, and all are variations of one master formula. Thefourth prescription is an exact duplicate of the first, which (the wording of thetreatment principle notwithstanding) takes replenishing and nourishing Kidneyand Liver functions to be primary and invigorating Spleen functions to be sec-ondary. The deviations from this master formula in the second and third prescrip-tions emphasize invigorating Spleen function; this is interpretable as a responseto 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-strual periods were beginning to regularize (fourth examination), Luo was able toreturn to his original prescription. Apparently the patient's condition had pro-gressed satisfactorily throughout, and no serious revision of the initial syndromedifferentiation was required.

Treatment Principles'

Enliven

Blood, RegulateTracts Warm Nourish expel Qito

Drug name affected Kidney Liver stasis stop painFoxglove Liver X X

KidneyDodder seed Liver X X

KidneyDeer horn Liver X

glue KidneyPlacenta Lung X X

Liver

Kidney

Angelica Heart X XLiver

Spleen

Sweetgum Liver X Xfruit Stomach

Jiazhll (not found in materia medica)

Sage HeartLiver X

Epimedium Liver XKidney

NUI-gruss Liver X XHare's ear Liver X

root GallBladder

Frankincense Heart X XLiver

Spleen

Myrrh Liver

Broomrape Kidney XLarge

Intestine

Ginseng SpleenLung

3M MEDICAL ANTIIROPOLOGY QUARllJJtL1

TABLE 4

Actions of precriptions for case 7.

Drug Name

Dodder seedCherokee rose

Treatmcnt Principlcs'

Rclax Liverto rcsolve

opprcsslon,XX

ReplenishKidney

XX

Build

SpleenTracts Affectcd

Kidney, LiverKidney, Urinary

Bladder, LargeIntestine

Kidney, LiverSpleen, LungKidney, Liver

Cornbind

Dal1g~'hetl

Matrimonyvine

Angelica

X

X

Heart, Liver,Spleen

Kidney, LiverLiverLiver, Gall

Bladder, Pericardium

X

RaspbelT)'Nut-grassLovage

XX

"Treatment principles arc specified in the published case.

The fact that no pelvic examination was considered necessary until a curehad almost certainly been achieved, and then only to confirm pregnancy, is inter-esting. This form of case management invites us to conceive of Chinese medicaldiagnosis as a different mode of apprehending illness from that which has char-acterized Western medicine. What are Luo (and possibly Rao, his patient) imag-ining on the basis of the phenomena they observe and record? Given that most ofthe pertinent phenomena are aspects of the illness's "history" (i.e., the patient'sperceptions of events prior to her clinic visit, collected in the course of the' 'ask-ing" examination), it appears that an illness process is more centrally at issue thana 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 stablestructure that can suffer from "substandard glandular secretion," as it is a livedlife of irregularperiods, lower back pain, cold extremities, etc. In Luo's approachto the illness, the diachrony of symptom history almost completely overwhelmsthe synchrony of an internal bodily defect, and the patient's knowledge of hersymptoms outweighs the results of the endometrial biopsy in diagnostic impor-tance.

The fu ke conceptualization of illness is not idealistic. All the symptomsnoted, including those derived from examinations performed in the clinic (pri-marily pulse and tongue images) are quite concrete and material. But they do notlead to the perception of an abnormal bodily structure. Consider the symptomslisted in Case 2:

FEMALE INFERTILITY IN CIIINESE MEDICINE385

Menarche was at age 15, menstrual periods tend to be delayed, volume of nowsmall and color pale, containing blood clots. Between periods her body is cold,lower back pain and weak legs, pain and swelling lofllower abdomen, largevolume of discharge. Breasts swell premenstrually, her mental state is ex-hausted, she lacks strength, and has little interest in sex. Urination clear allliprolonged, feces not firm.

These symptoms reported by the patient are supplemented by pulse and tongueimages observed by the doctor and, in this case, by the results of a laboratory testfrom another clinic. Together they form a pattern of disorder in which no singlephenomenon is significant in itself. For the doctor all the symptoms together be-tray a pathological process with a trajectory and key points at which interventionwill be efficacious. He understands the normal activities and standard pathologies

of visceral systems, circulation tracts, and body substances (Blood and Qi) andthinks about this illness history in those terms. For the patient the process in ques-tion perhaps never departs far from the vicissitudes of her general debility andcontinuing disappointment in her failure to conceive. Chinese medical analysis,however, by finding the significance of her symptoms in a temporal dimension, aweakened process rather than an invisible structural defect, may resonate with thepatient's lived experience of debility. 22 No wonder the confidence of these doctorsis not shaken when it takes months or years to bring about a major change in thepatient's condition: where therapy seeks to inl1uence natural trajectories of thewhole body so that a reliable continuation of general health and strength can beachieved, a certain amount of time is required. As both patients and doctors ofChinese medicine constantly point out, traditional medicine is slow but thorough.

Conclusion

In this reflection on two published cases I have devoted considerable spaceto a mode of medical analysis that is difficult to understand and foreign to our"Western" common sense, while pointing out that it may have important contin-uities with the experience of Chinese patients. If we fail to come to terms withthese complex analytics, field observations of the type included at the beginningof this article can only be misleading. In Chinese medicine, the illness experienceswomen confide in the clinic are the basic ingredients from which a treatable syn-drome becomes perceptible. Both doctor and patient work in the medium of time

. and experience, attending to the objective manifestations of disease as signs of aprocess. Seated not opposite from each other, but differently oriented around thecorner of the table, they can bring their differing expertise to bear on one illness.There may be struggles over many things in this relationship (e.g., the expenseof the drugs, the timing of return visits, the need for a work excuse or a hospitalstay), but there does not seem to be much disagreement over the nature of theillness.

One could argue that Western medical thinking has traditionally been mostI clear when anatomical objects and intellectual objects are the same thing. An ob-struction of the fallopian tubes, for example, is an explanation for a failure toconceive which posits both a thing with a structure and a notion that can ration-alize either an intervention or a practical decision not to intervene. Chinese med-icalthinkingis notnaturallymurky,itjust getsthatwaywhenoneattemptsto fill

XX

X

X

X

386 MEOICAL ANTlIROPOLOGY QUARTERLY

its intellectual objects (patterns of pathological function) with anatomical con-tent.23 This kind of translation is a shift of a particularly sweeping kind, an attempt;to translate the diachronic into the synchronic and processes into structures.

Others have made this point before about Chinese medicine (Porkert 1974),but our commonsense commitment to a materialism which must reduce phenom-ena to synchronically observable collections of objects is difficult to overcome. 'The visceral systems of function which organize so much of Chinese medical per-,tception need not be thought of as primitive anatomy, with the Kidney organs asJ:the "material substrate" of (immaterial?)reproductivefunctions.24Ratherit is ~.

signs and symptoms, experiences and perceptions, which are the material foun- ..i;dationof medicalperception.Theyare not lessconcretethananatomicalorgans, .

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 weacknowledge that these things are trivial from the point of view of diachronicChinese medical analysis.

Many attempts to demystify Chinese medicine have foundered on this par-ticular confusion, I think. Translators have failed to distinguish between the real- ,-,1ities of space, which are most powerfully apprehended through vision and depic- .tion, and the equally concrete realities of time, which must be remembered, in-scribed, and embodied. In popular works on Chinese medicine we have seen toomany translations of Chinese medical knowledge into a failed anatomy or a vagueand over-general "holism." To give both Chinese medicine and Western medi-cine their due requires finer discriminations of the specific relations between ob-jects and processes, products and relations of production, spatial and temporalmaterialities.

To conclude with a question that has motivated some of this discussion: arewomen made to feel like objects in Chinese medicine? Are they alienated fromtheir own experience in clinical practice? Though I have talked with some Chinesewomen about this, I cannot claim to know how they "really" feel when they visitdoctors of traditional medicine. The evidence here suggests, however, thatChinese medicine accords a certain importance to quotidian self-perception; whilenever denying the object-nature of bodies, it privileges processes of change thattake place in personal time, which can only be entered into medical considerationvia the patient's own narrative.

All this has taken us far from Chinese medical gynecology and infertility asspecific topics. Let me close then, with an observation made some time ago byJack Potter on the basis of his fieldwork in the New Territories of Hong Kong:"When a woman conceives a child, a heavenly flower is planted in one of thesmall gardens, and a seed is sent down from Heaven into the uterus of the woman.The villagers liken the uterus to a flower that begins to enlarge and open afterconception" (Potter 1974:214). Reported as a quaint folk belief, this image of thefragile, contingent, and short-lived womb has long fascinated me. As metaphor,it sums up in the relationship of flowers to seeds (zi, the same word as for sons),the most general yin-yang of reproduction. Families are a temporal continuityfounded not on the permanence of anyone thing or person but on a well-nurturedgenerativity and a wholesome alternation of potential and actual. Where repro-ducing endows life with much of its meaning, especially for women (as Potter'sother material suggests), the bodily things needed to have a child come into being

FEMALE INFERTILITY IN CHINESE MEOICINE 387

only as a result of the reproductive process itself. Whatever the official attitude ofmodern Chinese doctors might be toward the independent structural existence ofinternal organs, such as the uterus, in their way of analyzing and treating womcn'sillnesses they can be agnostic on the subject of anatomy. Doctors and their clientscan focus together on manifestations of disturbed processes, supplementing orrelaxing, dissolving or draining, to build a physiology that can have a child.

Appendix

The 19 cases summarized below are drawn from four collections of clinicalcases published in the Peoples Republic of China between 1980 and 1987. Twoof these volumes collect the cases of well-known senior doctors and two are de-voted to lu ke cases. I used my own collection of case anthologies (20 volumes,most published in the 1980s) and simply chose every case of infertility for thisanalysis.

Cases 1, 3-6, and 8-19 are summarized below with a brief list of key char-acteristics; Cases 2 and 7 are translated in ful1.25Certain technical terms (e.g., forpulse qualities) have been rendered following Sivin (1987) and capitalized. Syn-drome names are also capitalized.

Case J

Soum:: He and Liu (1987:166).Wang X X, F-29. Married six years without a pregnancy. Uterus abnormally

small, delayed menses, volume of menstrual blood small, color pale. Abdominalpain during menses, excessive discharge, lower-back pain. Poor appetite, coldextremities, clear and excessive urination, loose stools. Facial color dark, tonguepale with sticky white coating, pulse Subtle and Small.

Syndrome: Spleen and Kidney Yang Depletion with downward concentra-tion of Cold-Damp, infertility due to Uterine Cold.

Therapeutic principle not stated.After about three months of treatment there was a normal pregnancy and

delivery.

Case 2

Source: He and Liu (1987:166-167).. Sun X X, F-3I. Examined December 4, 1980.

Menarche was at age 15, menstrual periods tend to be delayed, volume offlowsmalland color pale, containingbloodclots. Betweenperiodsher body iscold, lower back pain and weak legs, pain and swelling on both sides of the lowerabdomen, large volume of discharge. Breasts swell premenstrually, her mentalstate is exhausted, she lacks strength and has little interest in sex. Urination clearand prolonged, feces not firm. Tongue pale with thin coating, pulse Sunken andSmall. Married eight years without a pregnancy. In 1978 at another hospital io-dized oil radiography (iodolography) was done of the uterus and fallopian tubesand the report was: "obstruction of both Fallopian tubes." Therapeutic plan is towarm the Kidney visceral system and nourish the Liver visceral system, regulateand replenish the Highway and Conception tracts, enliven Blood to eliminatestasis, regulate Qi to stop the pain.

JISISMEDICAL ANTHROPOLOGY QUARTERl.Y

Prescription:ginseng, 6 gm; Chinese foxglove (steam-dried), 30 gm; dodderseed, 15 gm; deer horn glue, 10 gm (scalded); human placenta, 10 gm (scalded);Chinese angelica, 10gm; Chinese sweetgum fruit, 10 gm; roastedjiazhu, 10gm;red-rooted sage, 10gm; epimedium, 10 gm; nut-grass, 10 gm; hare's ear root, 10gm; frankincense, 10 gm; myrrh, 10 gm; broomrape, 10 gm.

After 18 doses of this prescription had been administered, all the varioussymptoms had improved. The prescription was made up into pills, each dose 10gm; two doses daily. After it had been taken for three months, she got pregnant.Pregnancyanddeliverynormal;motherand childbothwell.

Case 3

Source: He and Liu (1987:167).Guo X X, F-32. Constitution weak, spirits low, vertigo. Irregular menses,

volumeof menstrual blood small and color pale. Dizziness and ringing in theears,severe lower back pain, abdominal pain. Tongue pale with fine coating, pulseSunken and Weak. Has been married 10 years without a pregnancy. L

Syndrome: Kidney Qi Depleted and Weak, Highway and Conception TractsIrregular.

Therapeutic principle: bolster Kidney Qi and regulate the Highway and Con-ception tracts. .

Treatment period 50 weeks, whereupon patient became pregnant.

Case4

Source: He and Liu (1987:167).Sun X X, F-32. Married eight years without a pregnancy. Delayed menses,

volumeof menstrual blood small; color pale, consistency thin. Vertigo, heart pal-pitations, facial color greenish white. Diagnosed at a Western medical hospital ascongenital infertility due to nonovulation. Pulse Sunken and Small, tongue palewith white coating.

No syndrome or treatment principle stated, probably Kidney and Liver De-pletion.

Menstruation regularized after eight treatments. Pregnancy occurred after 12treatments, carried to term, normal delivery.

Case 5

Source: He and Liu (1987:167-168).Zhang X X, F-29. Chronic menstrual pain. Married eight years without a

pregnancy. Delayed menses, volume of blood small and color pale, intense men-strual pain which can be lessened with heat and massage. Facial color greenishwhite. Discharge yellow. Lips pale. Vertigo. Skin and flesh dry and flaccid.Lower back pain and generalized weakness, little interest in sex. Urination clearand prolonged, stools loose. Tongue coating sticky white, pulse Small and Re-tarded. Patient has been treated with both Chinese and Western medicine withoutobvious improvement. .

Syndrome: Kidney Depletion brought on by Lack of Nourishment to theHighway and Conception Tracts.

FEMALE INFERTIUTY IN CHINESE MEDICINE 389

Treatment principle: Strengthen yang to warm the Uterus.Treatment period three months, pregnancy occurred before treatment com-

plete. Normal pregnancy and delivery.

Case 6

Source: Guangzhou College of Traditional Chinese Medicine, Gynecology andObstetrics Research and Training Section (1980:217-218).

Hu X X, F-31, factory medical services worker. Married six years withouta pregnancy. Menses slightly irregular, color light red, volume normal. Westernmedical tests report hormonal insufficiency but unobstructed fallopian tubes. Lastthree years patient has suffered from lower back pain, dizziness, weakness, andpoor appetite; recently has had abnormal hair loss, chills, and insomnia. Urinationand defecation normal, facial color greenish white, lips pale, tongue mottled andswollen with white coating, pulse Sunken and Small.

Syndrome: Spleen and Kidney Yang Depletion.Treatment Principle: warm Kidney, invigorate Spleen, bolster Blood.Treatment period 14 months showing steady improvement, followed by a

normal pregnancy.

Case 7

Source: Guangzhou College of Traditional Chinese Medicine, Gynecology andObstetrics Research and Training Section (1980:218-220).

Rao X X, F-36, a physician, first examined April 15, 1978.Patient married and living together [with her husband] more than five years

but still has no children. Husband has been examined and is normal. Patient hasundergone a thorough examination and is largely normal; she has sought out doc-tors in four places, still without the desired result. At the beginning of this year,at anotherhospital in Guangzhou, she had an endometrial biopsy (three hours afteronset of menses), and the pathology report was "during endometrial secretionperiod, substandard glandular secretion." Menarche at 15 years, periods approx-imately monthly. But from the time of her marriage in 1973the onset and lengthof her periods has not been predictable, onset being frequently delayed, some-times having only one period in two or three months; volume of menstrual nowis small, even to the extent that [the period will amount to] one day of spottingthen be clear; color dark red; breasts swell premenstrually. She has used artificialmeans to induce periods several months, which were effective when used, butafter ceasing this medication the situation was as before. Frequent dizziness, fa-tigue and lassitude, marked pain in the lower back, urination clear and prolonged,cold extremities, normal digestion, somewhat excessive white discharge. Facialcolor darkish yellow, with blackheads, tongue pale and spotted with white coat-ing, pulse Sunken and Small, Weak at the foot sections.

[Western medical] diagnosis: (I) delayed periods with small volume, (2) in-fertility (buyun zheng).

[Chinese medical] syndrome differentiation: Spleen and Kidney systemsboth depleted, accompanied by Liver system Qi stasis.

Treatment principle: primarily replenish Kidney and strengthen Spleen, sec-ondarily relax Liver to resolve Qi stasis.

J7V

MEDICAL ANTHROPOLOGY QUARTERLY

Prescription: dodder seed, 25 gm; Chinese raspberry, 10 gm; Chinese ma-trimony-vine (fruit), 15 gm; Cherokee rose (fruit), 25 gm; Chinese angelica, 12gm; Sichuan lovage, 6 gm; Chinese cornbind, 25 gm; dangshen, 20 gm; nut-grass, 10gm. Take once a day.

Second examination, April 26: After administering the above prescriptionwith some modifications more than 10 times, the lower back pain had lessenedbut the other symptoms were as before.

Prescription: dodder seed, 25 gm; epimedium, 10 gm; dangshen 20 gm;baishu,15gm;millettia,30 gm;Chineseangelica,6 gm;nut-grass,10gm. Takeonce a day.

Third examination, May 3: After this medication menstruation commencedwithout swollen breasts; spirits markedly improved from before. Continue to use[principles of] replenishing Kidney, strengthening Spleen, and nourishing Bloodto treat the condition.

Prescription:dodder seed, 25 gm; epimedium, 10gm; Sichuan teasel, 20 gm;chain fern, 20 gm; dangshen, 20 gm; baishu, 15 gm; Chinese cornbind, 30 gm;Chinese angelica, 10 gm.

Fourth examination, June 25: returned to the hospital to inform us that, tak-ing the above prescription after meals, her periods had become more regular, thelast one having started on June 23 and cleared after one day, the volume being abit more than before; dizziness and back pain improved, extremities warmer,digestion okay; tongue pink with white coating, pulse Small and Sunken.

Prescription: dodder seed, 25 gm; Chinese raspberry, 10 gm; dangshen, 20gm; Chinese matrimony-vine (fruit), 15 gm; Cherokee rose (fruit), 25 gm;Chinese cornbind, 25 gm; Sichuan lovage, 6 gm; Chinese angelica, 12 gm; nut-grass, 10gm. Advised to take four doses each month after the period clears, reus-ing the sediment. Return for a check-up after two or three months of use.

Fifth examination, September 23: Having taken the above prescription ac-cording to our advice, all the various symptoms appeared to be improved, timingof menstrual periods normal, [one having] begun on July 23 and lasted four days,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 twomonths. She is dizzy and nauseous, digestion is not good, there is fatigue, and aurine test for pregnancy in her home unit was positive. Tongue pink with white,slightly oily coating, pulse Sunken, Small, and Smooth.

Physical examination: External genitalia and vagina normal, cervix soft withchanged color [Chadwick's sign?], uterus tilted forward and soft, enlarged con-sistent with second month of pregnancy, bilateral attachments normal, diagnosedas early pregnancy. Treatment is to replenish Kidney, strengthen Spleen, and sta-bilize the fetus; plan is to use Fetal Longevity Pills and modified Four Lords De.coction.

At this writing patient has been pregnant six months. [Editor: ZhangBaozhen]

Case 8

Source: Guangzhou College of Traditional Chinese MediCine(1980:220-222).Li X X, F-29, worker. Married three years without a pregnancy, diagnosed

at a Western medical clinic with "congenital uterine insufficiency." Since onset


of menses at age 15 has suffered from premenstrual abdominal swelling, as wellas nausea, cold sweats, dizziness, cold extremities, and severe abdominal painduring menstruation. After a therapeutic dilation and curettage two months agoher periods regularized somewhat. Tongue dark red with fine yellowish-whitecoating, pulse Strung, Small, and Rapid.

Syndrome: Blood Stasis with Qi CongestionTherapeutic Principle: enliven Blood to transform stasis, mobilize Qi.Treatment interrupted for six months. Pregnancy achieved ten months after

first clinic visit, two months after resumption of treatment. Carried to term withnormal delivery.

Commentary (by Zhang Baozhen) on Cases 6, 7, and 8: Although the basiccause in the above listed few cases of infertility disorders is Kidney Depletionsuch that it cannot.control ling (seminal essence) and produce a pregnancy, the"branch" illnesses are different in each case; if the branch illnesses are not elim-inated it is difficult to settle on the root. . . . Case [7] was one in which Spleenand Kidney were both depleted, along with premenstrual tension disorders ofLiver system Qi stasis, so it was appropriate to take replenishing Kidney andstrengtheningSpleen as the main [therapeuticprinciples1, secondarily relaxing theLiver to resolve Qi stasis; when Liver Qi ramifies outward wholesomely [tiaoda]Blood and Qi are harmoniously regulated, and when Kidney, Spleen, and Liverare all properly synchronized, this makes the menstrual periods have a regulartiming-then it's easy to become pregnant. . . . When Chinese medicine treatsillnesses it always emphasizes combining illness differentiation and syndrome dif-ferentiation; thus it can get immediate results. [Editor: Zhang Boazhen]

Case 9

Source: Guangzhou College of Traditional Chinese Medicine (1980:222-224).He X X, F-29, worker. Married 3\12years without a pregnancy. Irregular

menses, menstrual pain, volume of blood normal, dizziness and lower back painwhen fatigued, little interest in sex, light sleep with frequent dreams. Diagnosedat another hospital as "immature uterus." A recent test reported "proliferationof endometrial tissue." Body weak and wasted, facial color dark yellow, tonguepink with normal coating, pulse Sunken and Small.

Syndrome: Insufficiency of "Prior Heaven" Kidney Qi, Depleted Highwayand Conception Tracts.. Treatment Principle: moisten and bolster Kidney Qi, invigorate Spleen to

regulate Blood and menstruation.After five months of treatment, patient became pregnant and delivered a baby

girl normally.

Case 10

Source: Guangzhou College of Traditional Chinese Medicine (1980:224-225).) WangX X, F-32,doctor.Marriedmorethanfouryearswithoutapregnancy.

Delayed menses, variable volume of blood, abdominal swelling and pain, andlower back pain during menstruation. Pelvic examination normal. Tongue hassmall red lesions and little coating, pulse is Sunken and Small.

Syndrome: Infertility due to irregular menstruation.

392 MEDICAL ANTHROPOLOGY QUARTERLY

Treatment principle: bolster Kidney, nourish Blood, mobilize Qi and regu-late menstruation.

Treatment period: 10 months, whereupon there was a normal pregnancy anddelivery of a baby girl.

Case 11

Source: Wang (1986:215-216).Zeng X X, F-36. Teacher at Sichuan University. Married more than ten years

without a pregnancy. Diagnosed at another hospital as "blocked fallopian tubes.one side has an accumulation of fluid due to inflammation." Obese, spirits low.lower back pain and ringing in ears, cold extremities, feelings of congestion inchest, swollen breasts, poor appetite and diarrhea, discharge clear and thin in con-sistency. menstrual periods very irregular, blood scanty and discolored. PulseSunken and Weak. tongue pale with moist and slippery coating.

Syndrome: Spleen and Kidney Yang DepletedTreatment principle: warm Kidney and stimulate Spleen transformation, reg-

ulate the Highway tract and transform Damp to drive out local stasis.Treatment period fivemonths, followed by pregnancy resulting in birth of8.

pound baby.

Case 12

Source: Wang (1986:216-217).Duan X X, F-42. Design technician. Married 17 years without a pregnancy.

Volume of menstrual blood small, discharge yellow and foul-smelling. Diag-nosed at another hospital as "endometrial inflammation, fallopian tubesblocked." Surgery failed to open tubes effectively. Has chest pain and insomnia.dizziness and ringing in ears, sweaty palms, low-grade fever in afternoon, thinand weak body, dry throat and bitter taste in mouth, constipation. Pulse Strung,Small, and Rapid. Tongue red with dry yellow coating.

Syndrome: Liver and Kidney Yin Depleted.Treatment principle: drive out stasis.Treatment period: six months, followed by normal pregnancy and delivery

of a 71/2pound baby.

Case 13

Source: Wang (1986:217-218).Feng X X, F-32. Military. Married five years without a pregnancy. Diag-

nosed at another hospital as blocked fallopian tubes. Dizziness and ringing in ears.sweaty palms, low fever and periodic sweating, excessive sexual desire, and ir-ritability. Headaches and insomnia, feelings of chest congestion and pain in sides.bitter taste in mouth, dry throat, constipation, irregular menstruation with smallvolume of blood. Pulse Strung and Rapid, tongue red and without coating.

Syndrome: Yin Depletion with Yang Excess.Treatment principle: regulate Liver and moisten Kidney, nourish Yin to reo

store fluids.Treatment period: seven months, followed by nonnal pregnancy and deliv-

ery of a baby girl.


Case 14

Source: Wang (1986:218-219).Zhou X X, F-42. Staff person at Sichuan Engineering College. Married

many years without a pregnancy. Diagnosed at another hospital as "severe ane-mia. proliferation of endometrial tissue." Suffers cold extremities, cold lowerabdomen, sallow facial color, weak body, poor appetite. insomnia. shortness ofbreath, slow speech, lower back pain. poor bladder control, long menstrual pe-riods with high volume of blood, and excessive white discharge. Pulse Retardedand Moderate, tongue pale with thin white coating.

Syndrome: Qi and Blood both Depleted.Treatment principle: bolster Qi and Blood, moisten Liver and Kidney, reg-

ulate menstruation to transform stasis.Treatment period: three months, after which she became pregnant and deliv-

ered normally. Later she became pregnant again.

Case 15

Source: Liu (1986:240-241).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-ously periods were nonnal. Volume of blood small, color dark; pain with men-struation. Obese. Tongue normal, pulse Sunken and Slippery.

Syndrome: Kidney Qi Inadequate, Liver Tract Congested and Sluggish.Treatment principle: moisten Kidney and relax Liver, enliven Blood to mo-

bilize stasis.After four months of treatment there was a normal pregnancy and delivery.

Case 16

Source: Liu (1986:241-242).Zhang X X, F-25, a relative. Irregular menstruation, married four years

without a pregnancy. Menstrual symptoms: volume of blood small, color dark.Premenstrual back and abdominal pain and generalized weakness. Frequentswelling of lower abdomen, reduced appetite. Tongue dark red with fine whitecoating, pulse Strung and Small.

Syndrome: Highway and Conception Tracts Inadequate, Depletion Cold ofthe Uterus.

Treatment principle: warm Uterus and expel Cold, regulate and bolster High-way and Conception tracts.

Pregnant after two months of treatment.

Case 17

S~urce: Liu (1986:242-244).Wang X X, F-29, a cadre. Married three years without a pregnancy. Men-

struation every 40 + days, volume of dark blood very great. Recently has expe-rienced agitation, pimples on face and lips, and constipation. Tongue coating dryand yellow, pulse Sunken and Slippery.

.., ...,,~. ~~~v. '<'U'"'" I ""'.1

Syndrome: Fire Excess of Stomach and Heart, Highway and ConceptionTracts Irregular.

Treatment principle: clear Heart and drain Stomach, moisten and bolsterHighway and Conception tracts.

After seven months of treatment she became pregnant.

Case 18

Source: Liu (1986:244-245).Chen X X, F-29, worker. Menstruation had ceased for 40 days on patient's

first visit to clinic, and she displayed other signs of early pregnancy. But preg-nancy was ruled out upon examination. She had been married six years without apregnancy.

Syndrome: Depletion Cold of Spleen and Kidney, Infertility Due to UterineCold.

Treatment principle: assist yang and supplement Qi, warm and bolsterSpleen and Kidney.

After six months of treatment she attained a normal pregnancy and full-term Udelivery.

Case 19

Source: Liu (1986:245-247).Lu X X, F-35, farmer. Married 12 years without a pregnancy. Diagnosed as

'uterine insufficiency at another hospital. Menstrual symptoms: periods short andvolumesmall; color of blood dark; pain in abdomen, lower back, and extremities.Tongue mottled, pulse Tardy and Moderate.

Syndrome: Cold Depletion of Uterus, Irregularity of Highway and Concep-tion Tracts.

Treatment principle: supplement Qi and nourish Blood, warm Uterus todrive out Cold.

Pregnancy achieved after 18 months of treatment.

NOTES

Acknowledgments. The fieldwork on which this study partly draws was funded by aseries of generous grants from the Committee on Scholarly Communication with the Peo- ",-pIesRepublicof Chinaof theNationalAcademyof Sciences.Versionsof thisarticlehave I~benefitedfrom the comments of participants in the following meetings: Southern California ~'China Colloquium, January 1990; Department of Humanities and Social Studies of Med- ~~

icine Colloquium, McGill University, January 1990;and the annual meeting of the Amer- ~1

ican Ethnological Society, Atlanta, April 1990. Special thanks are due to Tani Barlow, -,Jean Comaroff, Charlotte Furth, James Hevia, Margaret Lock, Allan Young, and twoanonymous readers for MAQwho made helpful suggestions based on careful readings.

Correspondence may be addressed to the author at the Department of Anthropology,University of North Carolina at Chapel Hill, 301 Alumni Building, CB3115, Chapel Hill, 'NC27599-3115. h.

'In the Peoples Republic of China, "traditional" medicine,is called Chinese medicine ci;

(zhongyi), and biomedicine (what Charles Leslie [19751has called cosmopolitan medicine) .is referred to as Western medicine (xiyi). My use of the term Western medicine in this /,


'"

article is meant to recall this indigenous practice, which constantly contrasts the two med-ical systems. Though the standard translation for zhol/gyi is "traditional Chinese medi-cine" (TCM), the traditionalism of this rapidly modernizing field in the contemporaryP.R.C. is arguable.

2Qi(ch' i) is translated by Nathan Sivin as vitalities or energies, depending on medicalcontext (1987:46-53). See his useful historical discussion of this fundamental medicalforce and substance for a clarification of its many contexts and connotations. For purposesof this article it is especially important to note the intimate interdependence of Qi andBlood. Qi drives Blood;Blood is the condition of existence for certain types of physiolog-ical Qi. In this article I use many of Sivin's standard translations of medical terms (Cir-culation tracts is an example) and capitalize technical terms that could be misleading,especially those referring to complex entities such as Blood and Qi and the five yin and sixyang visceral systems offunction (Spleen, Kidney, etc.). I hope in capitalizing these termsto remind readers that these entities do not correspond in any simple way to the anatomicalobjects described by the English words. Where an otherwise capitalized word such asBlood appears uncapitalized, it can be taken to refer to the red fluid of our commonsenseexperience.

31do not mean to separate objects into two types, one real (bodily) and the other an-alytic (mental). Rather the intention here is to consider them together, one argument of thisarticle being that objects given in Chinese medicine, such as visceral systems, are as muchthe result of intellectual activity as are disease categories. The converse also holds: anotheraim of this article is to show that categories such as the syndrome in Chinese medicine(zheng), though unrecognized in biomedicine, are not purely ideal or vapid.

'The obstetrics and gynecology specialties of Western medicine in China arc usuallyorganized together in departments calledfucha/lke. Because there is almost no scholarlytradition of obstetrics in traditional Chinese medicine, fil ke (women's specialty) is theusual term which both organizes textbook knowledge and provides the name for clinics andteaching-research units of this subdiscipline of traditional medicine. All the material in thisarticle, from both field observations and written works in Chinese, is drawn from this spe-cialty within traditional Chinese medicine.

'The field observations which follow were made in the course of three research visitsto the P.R.C. in 1982-84, the summer of 1988, and 1990-91, totalling more than twoyears of fieldwork. In all cases I was invited to sit in the clinics concerned, listening toconversations among doctors, patients, and bystanders in Cantonese and more or less stan-dard MandarinChinese. I kept notes and occasionally tape-recorded what transpired. I alsoread and sometimes copied the case histories of patients visiting the clinics. In some casesI was able to follow the management of a case over a period of several weeks through bothclinic observations and the written case history. This work was done without the help of atranslator. In the Guangzhou clinics the doctors and their assistants sometimes translatedthe'remarks of Cantonese-speaking patients into standard Mandarin for me, and in Shan-dong for a brief period local associates kindly transcribed tapes I had made, using Mandarinto explain unclarities of local language as needed. For this latter assistance I am indebtedto Li Zhongyong and Wang Jun.

61nthe outpatient clinics of the Guangzhou hospital, where the scenes previously de-scribed took place, patients kept their own case-record booklets with them, bringing themevery time they visited the clinic. Dated notes were added until it was full (or became lost),whereupon a new one was started. The clinics collected these booklets only if they had aresearch project under way and needed to code them for analysis.

'Most of the senior doctors I have interviewed about philosophical issues in Chinesemedicinespontaneously insist upon the essential "subjectivity" (z}llIgua/lxing)of Chinesemedicine. Their feelings on this issue are mixed, as they fear that the future lies with the"objective" sciences, especially in a socialist China where official policy has recently em-phasized "seeking truth from facts."

~~I'i!

m

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"There are, however, numerous specialized works devoted to the treatment of infer-tility. Two recently published examples are Sheng, Yang, and Sheng (1990) and Hu(1990).

"Thisfour-character phrase,jing dai yun chan. is used repeatedly in thefu ke literatureto label the special concerns of the field. A similar phrase both labels and characterizestraditional medicine as a whole, .'theory, methods, formulae, and drugs." Four-characterphrases are not confined to medical usage; witness the often-seen characterization of lifein general: "birth, aging, illness, and death."

"'Control over the timing of legal births is most fundamentally exerted by controllingthe time of marriage. In most urban and rural areas childbearing is allowed immediatelyafter marriage registration at the legal age. In many rural areas a second child may beapproved for parents whose first child is a girl, but this is possible only some years later,after others have had a chance at a first baby. The infertility treated infu ke clinics is oftenof late onset, following previous successful or aborted pregnancies. Rural women desiringa second child and who felt they had to take advantage of an administrative clearance whiletheyhadit, werefrequent visitors to such clinics.

IIA recentinfiuentialarticlebyThomasLaqueur(1986)tracestheemergenceinearlymodem Europe of beliefs that women are essentially different from men. He describes <I.shift from gender seen as positions on a qualitative continuum to gender represented asabsolute difference founded in anatomy and links this shift with problems arising from18th-centurydebates on equality and human nature. His work has raised interesting ques-tions about the universality of .'natural"genderdifferenceswhich this article in part takesup. Hence my interest in the relationship of a medical subdiscipline called "women's spe-cialty" to the clinical concerns of general Chinese medicine.

"The complex term ling can be properly translated in a variety of ways; it is perhapsmore context sensitive than any other central term of Chinese medicine. Three major com-mon uses of the term are transitional Qi (i.e., in a moment of transforming between twoother substantial forms), refined essences of food and drink, and seminal essence or semenitself. See Sivin (1987:164-165) and Porkert (1974:176-180).

"The yinand yangvisceralsystemsof function,eachof whichis namedwith refer-ence to an internal organ, are very complex. Limitations of space prevent a full explanationof their characteristics beyond the formulaic presentation in Table I. See Sivin (1987) andPorkert (1974) for extensive discussions.

14Thoughthis is an unoriginal insight in Chinese studies, few authors have framed therelationship of filiality and selfhood in just this way. John Hay (1983) and Tu Wei-ming(1985) are among the exceptions. .

"Case records maintained in hospitals and clinics often fail to specify the causes orsyndromes of infertility. When they do, simply noting "Kidney depletion" or "Liveroppression" is often felt to be enough. For experienced clinicians, diagnostic refinementsmay be inferred from prescriptions, so there is no need to specify the syndrome more com-pletely. When cases are published, though, editors must identify the syndrome beingtreated by either analyzing the prescription or checking with the doctor who wrote the orig-inal case record.

'6Thespatiotemporal sectors referred to are part of the methods and theoretical frame-works of two major schools of thought in Chinese medicine, the Warm Illnesses schooland the Six Warps school. In the diagnosis of exogenous illnesses one or the other methodis almost always used.

11 Analysis of this case would inevitably implicate larger-scale disorders, however. Aspointed out previously, the literature of therapy has few techniques that address disordersof the circulation tracts directly.

'"Zhll can also be translated as "ramifies as," "is chief among," or "unfolds in"(Farquhar 1989).


.,.

'''The terms "active" and "structive" are Porkert's (1974). The yin-yang relationshiphas been the subject of extensive discussion in Sinology and anthropology from MarcelGranet forward. For purposes of this article it is important to note that Blood as materialrealization and Qi as the active vitality driving it exist in a classic yin-yang relationship.But yin and yang logics are not confined to medicine; they still exist to some extent inordinary language and social life, and patients undoubtedly grasp something of the tech-nical significance of terms like Qi and Blood by analogy to the yin-yang of wcather, thecalendar, and other mundane concerns.

2"Though I have no way of exactly calculating the cost of this prescription in 1980, Ihave the strong impression that it was not only symbolically evocative but also very ex-pensive. The use of Frankincense and Myrrh (Tantric codes for blood and semen) to "buildmuscle," and of deer horn glue, human placenta, and ginseng, which are also expensive,implies that Sun's family was willing to pour considerable wealth into her in the hope ofproducing their own child.

2'One can imagine how Chinese doctors view a Western medical regimen that cancontemplate surgical intervention to correct a structural problem, thus permitting a prcg-nancy in a woman whose physiology is not strong enough to carry and nourish a fctusproperly. The procedure must seem highly irresponsible.

221nsupport of this somewhat speculative point, it is worth noting that herbal medi-cines and food are commonly confiated in modern Chinese practicc. Many types of food,especially expensive "gift" foods important in holiday festivities, arc known for their me-dicinal qualities and described in the language of Chinese medicine. Ideally Chinese herbalmedicine is administered in a "soup" (tang) which is cooked at home from ingredientsassembled in a pharmacy according to a doctor's prescription. Since so many illnesses inChinese medicine arc conditions of debility and depletion, it would not be far-fetched to seeChinese medical therapy as a mode of nurturing. Families draw upon the expertise of doc-tors for refined prescription design, but they remain in control of the actual therapy bypreparing and administering the medicine. Patients' comments about their relations toChinese doctors and Chinese medicine suggest a strong continuity between technical ideasabout such therapies as "warming and nurturing" and the mundane processes in whichpeople care for each other.

23This opinion is very much my own and is not shared by most of my Chinese medicalacquaintances, many of whom believe (perhaps correctly) that eventually Chinese medicalknowledge will become comprehensible in Western medical terms.

24"Substrate" is Porkert's term. In the early 1980s there was much concern in theworld of Chinese medicine with characterizing the "material foundations" (wlIzhi jichll)of many functions described by Chinese medicine. Though I have not yet done substantialresearch on this topic, I believe that this interest has subsided in recent years.

"Translations for Chinese herbal medicine are taken from Hu (1980). Medicines forwhich Hu finds no suitable translation are rendered in the Wade-Giles romanization systemin her book. For the sake of consistency within this article I use Pinyin romanization forChinese drug names, as for all other Chinese terms.

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