Miscellaneous Records of a Female Doctor

"Miscellaneous Records of a Female Doctor written by Tan Yunxian and translated by Lorraine Wilcox with Yue Lu, is the earliest known writings by a female doctor in China. It consists of one volume with 31 cases surrounded by two prefaces and three postscripts. Tan Yunxian primarily treated women in her practice, and these records reflect insights into the pathology of female patients that male practitioners might not have been privy to. At this time, a wealthy woman could not see a male doctor without having a male relative such as her father, husband, or son present. Modesty was the utmost female virtue. The male doctor questioned the husband, not the woman herself. He might not be allowed to see her face. He needed to ask for permission to feel her pulse. Therefore, because Tan was a woman, she was allowed by her female patients to do things that a male doctor could not, and this intimacy in turn led to a better diagnosis of the patient's problems. Lorraine Wilcox has annotated and explained Tan's original cases by both telling us the source text of the formulas Tan used, and what the probable diagnosis was from both Western and Eastern viewpoints. The complete formulas used by Tan have been added, and have been compared to the original formulas with a complete explanation of Tan's modifications. Wilcox, then discusses the reasons for such a diagnosis, and illustrates a number of other details that help us better understand each case. There were undoubtedly many other women doctors in ancient China but they left no record or the record was not preserved. Women doctors are occasionally mentioned in case studies written by men or in other types of literature. Therefore, we are lucky that Dr. Tan Yunxian's manuscript survived through the ages, as it helps us to understand the challenges and illnesses that women of the Ming faced."

Miscellaneous Records of a Female Doctor (女醫雜言, Nǚ Yī Zá Yán) is the earliest known text by a female doctor in China, and could not be found electronically nor in print until now. This is the first publication of this text with an English translation. It provides a window into the lifework of Dr Tán Yŭnxián, a female physician from the Ming Dynasty, through a sample of 31 of her clinical cases. As none of the males in her father's generation nor her generation were interested in pursuing medical studies, Tán became the recipient of medical knowledge passed down from her grandparents, both of whom were doctors themselves. As a woman of the wealthy classes, Tán's life had many restrictions with regards to her interaction with the world outside of her household, in a cultural context where the existence of a female physician, let alone the publishing of her work, was virtually unheard of. Her case studies were only published on her insistence that her son publish them.

Over the centuries, Tán's case studies were lost, then rediscovered and then lost again. Even Tán's grand-nephew did not know of the existence of her 1511 publication until he came across his grandfather's preface to it. He then began the search for a copy of the book. Finally, a single copy was located in a nearby town. He then managed to publish the 2nd edition - a woodblock print - of Miscellaneous Records of a Female Doctor in 1585. Whilst conducting research in the rare books library of the Beijing Institute of Traditional Chinese Medicine, author Charlotte Furth managed to obtain photos of each page of that same remaining 2nd edition woodblock print from 1585. These appeared in her 1999 book, A Flourishing Yin. Later, via a friendship with Charlotte Furth, TCM practitioner and teacher Lorraine Wilcox obtained photocopies of Tán's 31 cases and began translating some of them, initially incorporating the material into the classes she was teaching, and in so doing realised how engaging the patient stories were. In 2007, The Traditional Chinese Medicine Classics Press (Zhongyi guji chuban she) in Beijng printed 200 copies of the surviving 1585 2nd edition. As these copies are not currently in circulation, they are practically impossible to come across other than via rare book collections in libraries in China. Through this translation of Miscellaneous Records of a Female Doctor published by the Portland-based publisher The Chinese Medicine Database, translators Lorraine Wilcox and Yue Lu have made Tán's medical expertise accessible to, and relevant for, the greater community of practitioners of TCM.

Wilcox writes of herself that, as a practitioner with scholarly tendencies, she 'functions at the cusp' between academia and the practice of Chinese medicine, and her commentary of each of Tán's 31 case histories does indeed provide a critical bridge that renders Tán's medical expertise accessible to the practitioner. Were the modern clinician of Chinese medicine to try to read the photocopies of the 1585 edition of Tán's case histories, not only would they likely struggle with the translation of the medical Chinese, but they would require further scholarly knowledge of the history of Chinese medicine in order to track down the classical antecedents of the formulas – including which classical text, which ingredients, which dosages and which preparations are being referred to. Lorraine Wilcox's painstaking research has provided all of this. Tán wrote her case histories indicating the formula and the text it came from, as well as any modifications to the formula; however, she wrote assuming that the reader would be familiar with the classical texts and the formulas therein, which were written in the centuries preceding her life. In fact, in the preface to her case histories Tán wrote that one of her goals was to be able to use the case histories to ask advice from other doctors, so she wrote her case histories with her medical contemporaries in mind. Understandably Tán could not foresee how many of those texts so familiar to her would one day be lost or available only in rare book collections in China. Thankfully, many of the formulas and classical sources she cites are still in common use today.

Wilcox accomplished the monumental task of researching Tán's formulas thanks in great part to the guidance and assistance of Yue Lu. The following illustrates the process that Wilcox went through in order to generate the commentary for each of Tán's 31 cases. For source texts that were no longer available, Wilcox went through other texts that she suspected Tán would have had at her disposal to try to find the formula indicated by Tán. Failing that, she went to Zhu Dan-Xi related sources (as Tán was fond of his formulas). Wilcox then considered other texts printed prior to the 16th century, knowing that these were books with which Tán was likely to have been familiar. If this did not prove successful, Wilcox would look at later texts published after Tán's lifetime to see if the formulas from earlier times were cited therein. Sometimes Wilcox uncovered two or more different formulas bearing the same name, in which case she had to use her own TCM training and clinical experience to decipher which of the formulas seemed more appropriate for the patient case under discussion, and/or provide the reader with a choice of two possible formulas.

To comment on each of Dr Tán's cases, what was required was not just a translation of the formulas but also a deep familiarity with the cultural context of life in the Ming Dynasty. As a female doctor, Dr Tán was in a unique position to see and speak to her female patients. She was also in a unique position to be able to take the pulses of her patients. When male doctors in the Ming Dynasty saw female patients, they were usually accompanied by a husband, father or son, and it was usually the male who would reply to the questions the doctor had regarding the woman's health. The woman was often out of sight, behind a veil. The doctor would have to ask the male chaperone for permission to take her pulse. Because Dr Tán had better access to her female patients than her male counterparts, both in terms of physical access to take the pulse as well as the opportunity to ask questions that would be 'off limits' to male doctors, Tan's cases are arguably more clinically relevant than other Ming dynasty publications by male doctors

Miscellaneous Records of a Female Doctor is not the typical fertility and pregnancy textbook that modern TCM practitioners might have come to expect. Though it contains clinically relevant herbal formulas and moxibustion point prescriptions for presentations such as nausea and vomiting in pregnancy and post-partum complications, Tán's book does not stop there. The female patients in Tán's cases range in age from six to 69, serving as a reminder that TCM has a wealth of knowledge accumulated over the millennia that is relevant for the treatment of female patients at all ages and stages in their lives.

Reading Dr Tán's cases is akin to shadowing her in clinic as an apprentice, with the additional benefit of being accompanied by a medical translator in Wilcox who is able to decipher the cultural context of the diagnoses, internal and external (topical) herbal formulas and moxibustion acupuncture point prescriptions. Dr Tán's tone is one of informality and humility, whilst being directive and decisive, characteristics which must have created rapport and trust with her patients, but which also create rapport with the modern reader of her cases.

Having made your way through the 25 pages of introduction, 136 pages of main text, plus an additional 20 pages of appendices, you will emerge with a richer understanding of the heritage behind traditional Chinese medicine. This is not merely a translation of a single classical book - it provides insight into the application of Song and Ming Dynasty formulas from the multiple classical texts cited by Tán. To be precise, Dr Tán makes reference to 12 different classics over the course of her case histories, preface and postscripts. Over the 31 case histories, Lorraine Wilcox includes content from 37 different books ranging from 49 CE to 1626 CE in her translator's notes.

As a TCM practitioner myself, having read Dr Tán's book, I have renewed awareness of the curative power of moxibustion. For example, for a case of repetitive stress injury with hand numbness, akin to the modern presentation of carpal tunnel syndrome, Tán's treatment is moxibustion at Lieque LU-7, Zhigou SJ-6, Quchi L.I.-11 and Jianyu L.I.-15. I found this an interesting use of Jianyu L.I.-15, as the modern application would tend to be more when the shoulder area was affected. Of note is that moxa sticks were not used in Tán's time; Wilcox suggests that direct moxa was likely Tan's method of choice. For diarrhoea due to deficiency of the Stomach and Spleen, Tán chooses moxibustion at Zhongwan REN-12, Xiawan REN-10, Tianshu ST-25 and Zusanli ST-36. However she also chooses two points which for moxibustion which I would not have considered: Gaohuangshu BL-43 and Dazhui DU-14 - the former of which does indeed treat deficiency of Spleen and Stomach but the latter of which in modern textbooks is indicated to treat malarial infections.

This book has also give me new new insights into the use of herbal formulas, particularly for acute cases such as vomiting, diarrhoea, threatened miscarriage, insomnia, food stagnation and menstrual flooding. As a proponent of Zhu Dan-Xi's formulas, Tán encouraged considering the use of cold medicinals such as Huang Qin for restless foetus/threatened miscarriage, rather than always choosing warming medicinals as was traditional at the time (although she also recommends the warmth of Sheng Jiang [Zingiberis Rhizoma recens] where needed). Her example serves as a good reminder of the omnipresent TCM concept of 'one condition, many treatments' - treatment truly tailored to the individual

The book also contains instructions for the preparation and application of useful external herbal medicinals for conditions such as the intense itching of lichen planus, and the red nodules of rosacea. The cases on neck scrofula (relevant in modern day to the treatment of tuberculosis), abdominal lumps, malaria, parasites and flatworms will have less relevance to the modern practitioner. In addition, some of the ingredients will be unobtainable due to their aristolochic acid content or their animal or mineral derivation. That said, the vast majority of Tán's formulas can be reproduced today and should be useful for the TCM practice of the modern practitioner.<br><br>Lorraine Wilcox's commentary brings alive the cultural context of treating women at the time of the Ming Dynasty and has made me realise what a huge bearing the cultural context has on case histories, whether modern or historical. Examining case histories from the Ming Dynasty exemplifies how pivotal the patient/doctor interaction is in terms of the information that can be elicited from the patient, which in turn has a knock-on effect on diagnostic accuracy and therapeutic effectiveness. Lorraine has inspired me to better understand the historical and cultural underpinnings of the classical formulas on which so many of the formulas still used by the modern TCM practitioner are based. On that note, I am now off to study my newly acquired copies of Charlotte Furth's A Flourishing Yin, Yu-Li Wu's Reproducing Women: Medicine Metaphor and Childbirth in Late Imperial China and Paul Unschuld's Medicine in China – A History of Ideas.

Christina Goldoni