The Silent Killer of the Wèi Imperial Family?
A Theory on the Early Deaths of the Wèi Emperors
Edit September 13:
It has been pointed out to me that describing the deaths of the Wèi Emperors as "early" is potentially misleading, as there are many, many more Emperors who died of illness at even younger ages, to the point that Emperors Wén and Míng could be said to be relatively long lived in comparison. Therefore, please understand that the use of "early" in this article is meant to mean "unexpected," in reference to the common historiography judgment that the Wèi-Jìn transition was heavily influenced by the unexpected deaths of Wén and Míng. It is not to be understood as referring to their absolute ages.
I would also like to clarify that the diabetes theory has been put forward by many, many others over the years, and that my lack of an explicit citation was meant to refer to the commonality of the idea, not to claim originality. In general, do not assume that anything I say is original. If in the future I ever claim that I came up with an idea myself, I will do so explicitly.
Wèi Emperor Wén, Cáo Pī, died quite suddenly at forty (or thirty-nine to use the modern counting system).1 His son and successor the Emperor Míng died in his early thirties.2 The early deaths of its first two Emperors fatally injured the young Wèi dynasty and ultimately led to the Wèi-Jìn transition.
Now, some moralist commentators might (and have3) argued that the short span of the Wèi dynasty is proof of the regime’s evil, and the short lives of the first two Emperors proof of their personal evil, but if we accept that, we should probably also bring up the fact that Cáo Pī’s younger brothers Zhāng and Zhí, who are often treated as the unfortunate victims of Pī’s aforementioned evil rather than being personally evil themselves, also died in their thirties to forties. Zhí died at forty-one (so forty in modern counting).4 We unfortunately do not know Zhāng’s exact birth year or age at death, but we do know his age was between Pī and Zhí, and that he died in 223,5 so this bounds his age to between thirty-five and thirty-one.
A group of closely related men all dying at around the same age. Now isn’t that suspicious? Sounds awfully like a disease running in a family. But what disease?
The Affine Connection6
Cáo Cāo, father of Pī, Zhāng, Zhí, and grandfather of Ruì, died at sixty-six (or sixty-five in modern counting),7 which is a fair bit longer than his descendants, so perhaps he was not a carrier of this hypothetical disease. So let us then take a look at the other side of the family, the family of the Dowager Biàn, wife of Cáo Cāo, mother of Pī, Zhāng, Zhí, and paternal grandmother of Ruì.8 The Dowager herself lived to seventy,9 but she could perhaps have been a carrier for an X-linked recessive inherited trait.
Genetics Review
Quick and dirty crash course on what X-linked recessive inheritance is for those unfamiliar with it; feel free to skip ahead if you remember your biology class lessons.
Oversimplified, humans carry two copies of most genes, one inherited from each parent. These can differ from one another, and for certain genes, one variant of gene can be expressed over the other. So, an individual inherits version A from one parent and a from the other, having Aa genes, but A is dominant in expression, so individuals with Aa, aA, and AA all show the A trait, while only aa show the a trait. Individuals with Aa or aA (I use the order difference to indicate them coming from the different parent) can therefore be carriers of the a trait, since it is not immediately obvious that they have the a trait from gene expression, but they can pass on the a trait to their offspring.
Certain genes tend to get passed along together, due to being on the same chromosome. In humans, whether an individual is male or female is determined by the so-called sex chromosomes, labeled X and Y. Individuals with XX are female, with XY are male.
Now suppose some other gene is found on the X chromosome, with a dominant variant R and a recessive variant r. In a female, with two X chromosomes, they can end up with Rr, rR, and RR all masking expression of the r. Males however have only one X chromosome, if their mother is an Rr or rR carrier and they inherit the r trait, they will automatically express it.
Biàn Lán
So the Dowager Biàn could have been a carrier for an X-linked recessive trait inherited by her sons, and if so, perhaps some of her male relatives expressed such a trait. Well, we happen to have some hints of that in the account of Biàn Lán, the son of the Dowager Biàn’s younger brother Biàn Bǐng.10
Wèilüè records:
Later Lán suffered alcohol-induced wasting thirst, at the time the Emperor [Cáo Ruì] trusted in a witch woman using water techniques, and had someone bring the water to bestow on Lán, Lán would not agree to drink it. Imperial Order asked: “What is your reason?” Lán said: “Treating illness should use drug techniques, why trust in this?” The Emperor because of this changed color, but Lán to the end would not submit. Later the thirst became more extreme, so that he died.11
What exactly was this alcohol-induced wasting thirst that Biàn Lán suffered from, and which likely led to his death?
We can only speculate, but severe unexplained weight loss and excessive thirst can be symptoms of diabetes,12 especially when alcohol is reported to aggravate symptoms.13
That witch women with the magic water mentioned in the Wèilüè account about Biàn Lán also gets a mention in the Standard Histories in the annals of Cáo Ruì:
Previously, during Qīnglóng Third Year [235], a Shòuchūn farmer’s wife said she had been sent down by the heavenly spirits, ordered to become an ascended woman, to guard and protect the Emperor’s household, to enjoy a comfortable life. Of those that drank her water and used it to wash wounds, many healed. Therefore installed a building in the Rear Palace, sent down Imperial Order praising her, and she extremely met with exceptional favor. When the Emperor was ill, he drank the water to no effect, and therefore she was killed.14
Did Cáo Ruì perhaps suffer a similar affliction as his father’s cousin Biàn Lán?
A Possible Silent Killer
Diabetes.15
Well, maybe a different kind of diabetes than what you might be thinking. There is the more common version and how most people understand it (diabetes mellitus), but the possibility of an X-linked recessive inheritance suggests a less commonly known alternative condition, diabetes insipidus.
The two diseases are not related, but both are termed diabetes because of the outward similarities in symptoms,16 namely frequent urination: “diabetes” comes from the Greek term for “passing through.”17 The distinguishing terms mellitus and insipidus connect to the differing causes of the disease: “mellitus” meaning “sweetness” or “honey,” “insipidus” meaning “without taste.” In diabetes mellitus (the more commonly known diabetes), inability to maintain normal blood sugar levels leads to frequent urination with excess sugar appearing in the urine, hence the urine have a sweet flavor. In diabetes inspidus, inability to maintain proper hormone balance leads to frequent and dilute urination, hence the urine being tasteless.
Yes, the urine used to be tasted.18
Diabetes mellitus is known to have a genetic component, but without a clear pattern. Meanwhile, one version of diabetes insipidus, Nephrogenic diabetes insipidus, is known to have an X-linked recessive inheritance pattern:
Nephrogenic diabetes insipidus is a disorder of water balance. The body normally balances fluid intake with the excretion of fluid in urine. However, people with nephrogenic diabetes insipidus produce too much urine (polyuria), which causes them to be excessively thirsty (polydipsia). Affected individuals can quickly become dehydrated if they do not drink enough water, especially in hot weather or when they are sick.
When nephrogenic diabetes insipidus results from mutations in the AVPR2 gene, the condition has an X-linked recessive pattern of inheritance.19
Alcohol consumption can aggravate diabetes insipidus as well as the more commonly known diabetes mellitus.20 Diabetes, both mellitus and insipidus, can lead to further complications such as kidney damage, cardiovascular damage, and brain damage.
The Deaths
Cáo Zhāng is recorded as having died rather suddenly, by one account due to his rage upon being deliberately snubbed by his elder brother Cáo Pī.21 Ongoing damage to his cardiovascular system or brain due to fluid imbalances from diabetes (whether mellitus or insipidus) could have contributed to a sudden death in an anger-induced stroke.
Cáo Zhí is recorded as having abused alcohol in his younger years,22 which could have aggravated any hypothetical diabetes condition and contributed to his relatively early death if he continued to abuse alcohol into his early forties.
Cáo Pī had nine recorded sons total. Excluding Cáo Ruì for now, four of those eight sons seem to have died too young for their fiefs to be maintained after their deaths, and three more had to have successors adopted over from the sons of Cáo Zhāng’s son Kǎi. Cáo Ruì had at least three sons who all seem to have died in infancy or early childhood.23 If some underlying genetic disease ended up having an early onset in those children, it could have contributed to the short lifespans of the sons of Pī and Ruì.
Of course, these can only be speculations, since there is not enough evidence remaining to be absolutely sure of such guesses, but at the very least, these speculations of a genetic disorder are a potential counter-argument to the usual claims that the short lives of Pī and Ruì were due to their supposed immorality and wanton lifestyles.
In his biography of Cáo Cāo, de Crepsigny commented on Cáo Pī’s early death:
Had Cao Pi lived longer—and his final, fatal illness appears to have been sudden and unexpected—he could have established a long-lasting state.
In this regard, we may consider one last “might-have-been:” had Cao Cao died at the same age as his son Cao Pi, he would have met his end in 195, when he was still engaged with Lü Bu in the struggle to recapture Yan province, and before he had brought Emperor Xian under his control. Guandu, White Wolf Mountain, the Red Cliffs and the kingdom of Wei were still ahead of him, as were his civil reforms and much of his poetry: he would have been remembered, if at all, as a minor warlord in a ruinous time. There is much to be said for longevity.24
If the short lives of Cáo Pī and Pī’s son Ruì, which led to the downfall of Wèi, had a genetic component inherited from Pī’s mother the Dowager Biàn, then perhaps there is much to be said for carefully choosing one’s spouse. Perhaps the downfall of Cáo Cāo’s legacy came not from any particular decision he made on the battlefield or in the political arena, but from his choice of a favorite consort.
SGZ 2: 丁巳,帝崩于嘉福殿,時年四十。In the ancient systems, counting years of age started at one rather than zero at birth.
SGZ 3: 即日,帝崩于嘉福殿,時年三十六。As pointed out by the annotation of Péi Sōngzhī, thirty-six must be an error, as this would mean Cáo Ruì would have been born too early to be Cáo Pī’s son. This has, unfortunately, led to all sorts of conspiracy theories regarding Cáo Ruì’s paternity, but the easier explanation is that thirty-six is indeed an error. I will cover the Cáo Ruì age-paternity problem elsewhere.
I’m looking at you Sūn Shèng.
SGZ 19: 遂發疾薨,時年四十一。
SGZ 2: 六月甲戌,任城王彰薨于京都。SGZ 19: 四年,朝京都,疾薨于邸,諡曰威。
Get it? Because “affine” can mean a relative by marriage, but in differential geometry an affine connection is also a geometric object on a smooth manifold that connects nearby tangent spaces.
SGZ 1: 庚子,王崩于洛陽,年六十六。
SGZ 5: 武宣卞皇后,琅邪開陽人,文帝母也。
Wèishū annotated to SGZ 5: 魏書曰:后以漢延熹三年十二月己巳生齊郡白亭,有黃氣滿室移日。SGZ 5: 至太和四年春,明帝乃追謚太后祖父廣曰開陽恭侯,父遠曰敬侯,祖母周封陽都君及敬侯夫人,皆贈印綬。其年五月,后崩。
SGZ 5: 初,太后弟秉,以功封都鄉侯,黃初七年進封開陽侯,邑千二百戶,為昭烈將軍。秉薨,子蘭嗣。
Wèi lüè annotated to SGZ 5: 後蘭苦酒消渴,時帝信巫女用水方,使人持水賜蘭,蘭不肯飲。詔問其意?蘭言治病自當以方藥,何信於此?帝為變色,而蘭終不服。後渴稍甚,以至於亡。故時人見蘭好直言,謂帝面折之而蘭自殺,其實不然。
https://www.nhsinform.scot/illnesses-and-conditions/nutritional/thirst Quote: “If you feel thirsty all the time, it could be a sign of diabetes – particularly if you also have other symptoms such as needing to urinate frequently, extreme tiredness (fatigue) and unexplained weight loss.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761899/ Quote: “Alcohol consumption by diabetics can worsen blood sugar control in those patients. For example, long-term alcohol use in well-nourished diabetics can result in excessive blood sugar levels. Conversely, long-term alcohol ingestion in diabetics who are not adequately nourished can lead to dangerously low blood sugar levels. Heavy drinking, particularly in diabetics, also can cause the accumulation of certain acids in the blood that may result in severe health consequences. Finally, alcohol consumption can worsen diabetes-related medical complications, such as disturbances in fat metabolism, nerve damage, and eye disease.”
SGZ 3: 初,青龍三年中,壽春農民妻自言為天神所下,命為登女,當營衛帝室,蠲邪納福。飲人以水,及以洗瘡,或多愈者。於是立館後宮,下詔稱揚,甚見優寵。及帝疾,飲水無驗,於是殺焉。
Yes, calling diabetes “the silent killer” is a thing. For example: https://www.meritushealth.com/media-center/news/2019/january/diabetes-the-silent-killer/
https://www.webmd.com/diabetes/diabetes-insipidus-vs-diabetes-mellitus
https://www.canr.msu.edu/news/how_diabetes_got_its_name
https://www.everydayhealth.com/diabetes/understanding/diabetes-mellitus-through-time.aspx
https://medlineplus.gov/genetics/condition/nephrogenic-diabetes-insipidus/
https://www.pituitary.org.uk/media/339898/diabetes-insipidus_email-ver.pdf
Annotated to SGZ 17: 魏氏春秋曰:初,彰問璽綬,將有異志,故來朝不即得見。彰忿怒暴薨。
SGZ 17: 而植任性而行,不自彫勵,飲酒不節。
SGZ 3, SGZ 20.
de Crespigny, Imperial Warlord, p. 462.
It has been pointed out to me that describing the deaths of the Wèi Emperors as "early" is potentially misleading, as there are many, many more Emperors who died of illness at even younger ages, to the point that Emperors Wén and Míng could be said to be relatively long lived in comparison. Therefore, please understand that the use of "early" in this article is meant to mean "unexpected," in reference to the common historiography judgment that the Wèi-Jìn transition was heavily influenced by the unexpected deaths of Wén and Míng. It is not to be understood as referring to their absolute ages.
I would also like to clarify that the diabetes theory has been put forward by many, many others over the years, and that my lack of an explicit citation was meant to refer to the commonality of the idea, not to claim originality. In general, do not assume that anything I say is original. If in the future I ever claim that I came up with an idea myself, I will do so explicitly.